§ 7.39 p.m.
§ The Lord President of the Council (Baroness Amos) rose to move, That the draft order laid before the House on 17 December 2003 be approved.
§ The noble Baroness said: My Lords, the purpose of the draft Primary Medical Services (Northern Ireland) Order 2004 is to make the legislative changes to allow the implementation in Northern Ireland of the new contract for the provision of general medical services by GPs. It amends the provisions of the Health and Personal Social Services (Northern Ireland) Order 1972 and replicates measures introduced in England and Wales by the Health and Social Care (Community Health and Standards) Act 2003 and in Scotland by the Primary Medical Services (Scotland) Bill.
§ The new contract represents the most radical change to the way in which general practitioner services are delivered since the inception of the National Health Service. The contract was negotiated with the profession in response to UK-wide demands from GPs for new working arrangements that would enable them to control their workload and achieve a better work/life balance. The new contract has the overwhelming support of the profession and the changes it will introduce to GPs' working arrangements should ensure that qualifying doctors continue to be attracted to general practice for the future.
§ As well as being good for the profession, the contract will deliver real benefits to patients, other health care professionals and to primary care as a whole. The emphasis it places on team working and the opportunities it offers to provide a wider range of services at the primary care level will facilitate the future development of primary care for Northern Ireland.
§ I shall comment briefly on the main provisions of the draft order. Article 3 inserts provision into the 1972 order to place a new statutory duty on health and social services boards to provide or secure the provision of primary medical services for persons in their area. The responsibility to provide such services currently rests with the general practitioners.980
§ Article 4 inserts into the 1972 order broad regulation—making powers which will be used to set out the detail of the terms and content of new contracts, including who may provide services and the rights and obligations under such contracts.
§ Article 5 introduces powers to make transitional arrangements in respect of persons who are providing services under the existing general medical services contract and for the resolution of disputes in relation to new contract. The measures are intended to ensure continuity of service in the period spanning the date of implementation.
§ Article 6 amends existing legislation to reflect the fact that the current changes have implications for those who are providing services under a personal medical services arrangement and Article 7 abolishes the statutory requirement to pilot such arrangements.
§ Article 8 provides regulation-making powers to prescribe the way persons providing general medical services under the new contract are to be listed. I beg to move.
§ Moved, That the draft order laid before the House on 17 December 2003 be approved.—(Baroness Amos.)
§ Lord Glentoran
My Lords, I thank the noble Baroness the Lord President of the Council for her clear explanation of the order. In paper terms it is quite large. However, as the introduction tells us, it takes Section 4 of the Health and Social Care (Community Health and Standards) Act and transfers it into law in Northern Ireland. My party had no dissent with Section 4 of the Act and hence I have no dissent in principle with the order.
I have some questions. I am a little concerned about costs. The Explanatory Memorandum tells us in paragraphs 19 and 20 that extra cost will be incurred. I am always somewhat suspicious when the Government admit that something they are doing will increase costs. My life experience tells me that significant change in most matters—certainly in business life—almost invariably incurs extra cost. I hope that those costs will prove to be a sound and profitable investment and the investment will be delivered in improved service. In principle, I support the order.
§ Lord Smith of Clifton
My Lords, I thank the noble Baroness the Lord President of the Council for introducing the order. Its aim is to replicate in Northern Ireland some of the PCT elements that pertain in England and Wales. The main provision is new GP contracts. That is a matter which the Liberal Democrats have supported.
However, there are concerns about the provision of out-of-hours services. Previously general practitioners were contracted to provide out-of-hours services that are now the duty of primary care trusts in England and Wales. PCTs there are having problems in providing services at night. That is a particular problem in rural areas, where there may be only one GP. Given that we are aware of the difficulty, can the Minister say what 981 steps the Government are taking to ensure that the problem does not arise in Northern Ireland, where there are many rural practices?
Furthermore, in England and Wales there is provision for lay members on PCTs. That is also true of the health and social services boards in Northern Ireland. But they cover large areas. Have the Government any plans to introduce a more local lay element, other than at the sub-regional level, of the health and social services boards?
§ 7.45 p.m.
§ Lord Rogan
My Lords, my colleagues and I welcome the new medical practitioner contract, but while I feel that the legislation comes not a moment too soon, the Government must be scrupulous in ensuring that the interests of both the patients and the general practitioners are protected.
I understand the difficulty of out-of-hours working, but will the proposals under the new legislation provide a better service when GPs are under contract and do not provide an out-of-hours service but instead register with some agency or body that does? Will the position be similar to that of the nursing profession? Ultimately, agency nurses cost the health service more than it can by directly employing them. Consequently, hospitals should be encouraged to build up their own nursing banks, rather than go through agencies, because otherwise they have to employ the agency staff above their permanent staff. The issue must be carefully considered regarding GPs.
Apparently, recruitment to GP training schemes in Northern Ireland is declining and if GP services are improved in Great Britain, there would be—I realise that I will sound selfish, but it is realistic—a movement of many Northern Ireland doctors to the mainland. I can understand why our recruitment is declining. In the past many of our young graduates from Queen's University doing their junior house and senior training found it exceedingly difficult to find GP training posts in Northern Ireland.
We must arrest that decline in recruitment to GP schemes in Northern Ireland. We are still producing medical graduates. If we do not produce more of our own GPs who will remain in Northern Ireland, particularly, as the noble Lord, Lord Smith, implied, in rural areas, we will have further difficulties in providing the service that the taxpayer has come both to expect and deserve.
The new legislation prescribes a practice-based contract, instead of a contract for individual GPs. Who will be responsible for seeing how that contract is implemented? Will a senior GP in a practice say what his staff should be paid or will the staff be employed directly by an outside service? Regarding finance, I welcome the guaranteed increase of 34 per cent over the next three years, but the Government must provide funding after that. Will sufficient funds be made available to maintain the changes after they have been put into place?
982 It is unclear why we are emphasising heart diseases, strokes, asthma—from which I suffer—diabetes, epilepsy, mental health problems and other chronic diseases as indicators to encourage our GPs to organise their practices better and to be more responsive to patients' needs. When we start especially prescribing like that, there is a temptation to focus on just those conditions. It is an issue that has not been properly thought through. Therefore, I ask that other important issues, particularly children's health, are not overlooked.
Access targets have been mentioned for childhood immunisation for flu vaccines; routine monitoring of anti-coagulant therapy and rheumatology drugs; patients with depression; dealing with drug, alcohol or homelessness problems; and providing services for patients with a history of violence. These all are enhanced services, but who will be the doorkeeper? Will it be the GP who refers patients? How long will it take to get through to the enhanced services?
There is an urgent need to reorganise the system and to do it as accurately as possible. I must remind the House that this is the first major shift in policy since 1948 and it might be well into the 21st century before we get a similar opportunity. We must get it right.
The Government must ensure that this legislation, when implemented, is targeted at making effective changes that penetrate the top-heavy system as it now exists and provides a better deal for both patients and general practitioners.
§ Baroness Amos
My Lords, I thank all noble Lords who have spoken and I shall try to address all the points that have been raised.
The noble Lords, Lord Glentoran and Lord Rogan, asked about costs. Funding for these arrangements will be guaranteed for five years. With respect to the specific question asked by the noble Lord, Lord Glentoran, I assure him that it will improve the range and quality that is available to patients and the importance of patients' views will be strengthened through the patient satisfaction element of the quality and outcomes framework. The noble Lord's concern about improvement in the monitoring service is dealt with.
The noble Lords, Lord Smith of Clifton and Lord Rogan, expressed concern about out-of-hours services. Where GPs exercise their right to opt out, the responsibility for providing services will rest with the health and social services boards which, at the request of the department, are currently working with colleagues and other bodies on the details of the most appropriate alternative arrangements to put in place. I can assure noble Lords that contracts will be implemented in such a way as to ensure no loss of access to out-of-hours services.
The noble Lord, Lord Smith of Clifton, asked about lay members on the PCTs. The department introduced new structures in 2002 in the form of local health and social care groups whose membership comprises primary care professionals and community representation. I hope that that addresses the noble Lord's concern.
983 The noble Lord, Lord Rogan, asked a number of questions with respect to recruitment, training and retention of GPs. The new contract is specifically designed to make general practice more attractive to aspiring doctors. On the movement of GPs, the contract is UK-wide and will provide the same benefits to GPs in Northern Ireland. This will ensure that difficulties with respect to recruitment and retention, which are current in Great Britain, will be prevented in Northern Ireland.
On payments to practice staff, which was also raised by the noble Lord, Lord Rogan, they will be provided within practices. On agency nurses, agencies are private companies which negotiate their rates with the boards. GPs will contract with the boards on the basis of terms and conditions set out in the contract and laid down by regulation.
The noble Lord, Lord Rogan, also asked about priorities with respect to services. A number of additional services will be covered. The noble Lord was particularly concerned about children. This will include child health surveillance. The enhanced services will be commissioned by health and social services boards as a need is recognised.
I hope that that addresses all the points which have been raised.
§ Lord Smith of Clifton
My Lords, before the Minister sits down, it was good to have her assurances about the health and social services boards making provision for night-time cover. Bearing in mind the rurality of Northern Ireland, can she give a hint of the kind of arrangements that the health and social services boards are looking at?
§ Baroness Amos
My Lords, I do not have the detail of that because the health and social services boards are currently looking at the kind of arrangements which could be put in place locally to provide a comprehensive service outside normal practice hours. If the noble Lord will permit me, I will happily write to him once we have more information about the matter. It is clear that any arrangements put in place must include a proper set of standards which must be met by the providers of such service. I commend the order to the House.
§ On Question, Motion agreed to.