Plenary, 17 Jan 2001

Meeting date: Wednesday, January 17, 2001

Official Report 439KB pdf

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Health and Social Care Bill

The next item of business is a debate on motion S1M-1529, in the name of Malcolm Chisholm, on the UK Health and Social Care Bill.

The first part of the motion seeks Parliament's approval for the Westminster Parliament to legislate to end the system of preserved rights and to bring those people with preserved rights into the mainstream community care arrangements. The second part proposes the introduction of enabling powers that may be authorised under the Medicines Act 1968 in respect of new groups of prescribers.

Preserved rights are the rights to higher rates of income support for some people who have been living in residential accommodation since before 1 April 1993. When the current community care arrangements were established in 1993, people already resident in independent sector nursing or residential homes acquired those preserved rights. That was a means of reassuring and protecting existing care home residents by continuing to give them a higher rate of income support so that the choice that they had already made about their residential accommodation continued to hold sway. It also ensured that local authorities were not faced with the considerable task of assessing the care needs of existing residents.

There are two principal concerns about the system of preserved rights. First, a significant number of people with preserved rights, such as younger people with learning disabilities, are locked into residential care when their needs could be more appropriately met in supported accommodation. Secondly, there are concerns about a shortfall between the fees charged by homes and the weekly benefit income of residents.

The Royal Commission on Long Term Care for the Elderly considered those concerns and recommended that we should consider whether preserved rights payments in social security should be brought within the post-1993 system of community care. In our response to the royal commission on 5 October 2000, we accepted that recommendation and announced our intention to transfer funding and responsibility for the assessment and care management of everyone with preserved rights to councils in April 2002.

Will the minister give way?

I have five minutes. If I have time left, I will give way when I have got through my speech.

A mixture of reserved and devolved legislation is required to make the transfer of responsibility from the Department of Social Security to local authorities. In those circumstances, there are clear benefits to having a single bill to cover England, Scotland and Wales. A single bill will make it much more straightforward to ensure that the transfer is clear and consistent across the United Kingdom. Were we aiming for separate Scottish legislation on the devolved aspects, we would have to wait for the outcome of the DSS provisions in the Westminster bill. Achieving the transfer in a single UK bill ensures that there is no possibility of a gap between the end of DSS preserved rights and the commencement of new responsibilities for local authorities. That will avoid disadvantage to those people with preserved rights in Scotland. Otherwise, we would have to ask the DSS to continue the scheme in Scotland only for the interim period. I therefore ask the Parliament to agree that the provisions for those devolved aspects of the preserved rights transfer be made through the Health and Social Care Bill.

The second strand of the motion proposes the introduction of enabling powers in respect of new groups of prescribers that may be authorised under the Medicines Act 1968, which is reserved. Extending prescribing rights to health care professionals other than doctors, dentists and some nurses is in line with the recommendations of a UK review that was carried out in 1997. The "Review of Prescribing, Supply and Administration of Medicines" concluded, after wide consultation, that the introduction of new groups of prescribers would benefit patients.

The proposed enabling amendments provide the legal framework for such an extension. Amendment of the National Health Service (Scotland) Act 1978, as proposed in clause 44 of the bill, will enable Scottish ministers, through regulations, to give newly authorised prescribers NHS prescribing rights in Scotland.

The Medicines Act 1968 and the National Health Service (Scotland) Act 1978 are being amended in parallel so that the changes that they make possible are available for implementation throughout the UK. It will be for the Executive to decide whether and to what extent that legislation should be enacted in Scotland. The first and most important consideration will be the absolute need to ensure patient safety. Moreover, we must ensure continuity of care, avoid fragmentation of services and safeguard patient choice and convenience.

Before any new health care groups are designated as NHS prescribers, ministers will have to be satisfied that there is a clinical need, that any new prescribers are properly trained and that their skills can be kept up to date. Health care professions that might be considered for prescribing rights include pharmacy, chiropody and physiotherapy.

The motion also provides for Scottish ministers to determine the medicines and appliances that each group of prescribers may prescribe. That is a commonsense measure, given the very different areas of health in which the new groups of potential prescribers practice. With all those safeguards in place, I believe that extending the right to prescribe will help to break down the divisions between health professions and will play an important role in the introduction of more flexible team working across the whole of the UK.

Will the Deputy Presiding Officer let me give way to Alasdair Morgan now?

Yes—for one question only.

What we are doing is in effect deciding that we agree with the principles of the bill as it applies to Scotland and asking the Westminster Parliament to carry on with it. The Westminster Parliament has already given it a second reading, so the principles are now unexaminable even for that Parliament. Why was the motion not brought before the Scottish Parliament before the bill was given its second reading?

The critical factor is that we should deal with the motion before it is dealt with in committee at Westminster. Because of the time scale, it was not possible to deal with it here before the bill was given its second reading at Westminster—the bill was introduced just before Christmas and had its second reading in the first week back after Christmas.

I move,

That the Parliament endorses the principle of transferring to local authorities in Scotland the responsibility for the funding and care management of people in residential care and nursing homes with preserved rights to higher levels of income support as set out in the Health and Social Care Bill; also endorses the principle of introducing enabling powers to extend recognition to specific groups of healthcare professionals for the purposes of dispensing NHS prescriptions written by them and of determining the list of medicines and appliances which they may prescribe and which NHS community pharmacists may be paid for dispensing, and agrees that the relevant provisions to achieve these ends in the bill should be considered by the UK Parliament.

The SNP does not oppose the provisions of the Health and Social Care Bill that relate to Scotland. The provision on preserved rights implements one of the recommendations of the Sutherland commission and I look forward to further announcements on the implementation of the Sutherland recommendations over the next few days.

I also welcome the proposal to enable Scottish ministers to extend to certain categories of registered health professionals the power to prescribe medicines, and to determine what each group is able to prescribe. That is a step forward, although I ask the Deputy Minister for Health and Community Care to give an assurance that there will be full consultation with health professionals before those powers are exercised. Collaboration between different groups of health professionals will be needed, as they may all be prescribing medicines to the same individuals. It is important that arrangements are in place to ensure that prescription policies do not conflict at the individual level.

In the remainder of my comments, I will concentrate on the important point that Alasdair Morgan made about the Parliament's procedures. I hope that the deputy minister will address it in more detail and with greater conviction than he did in his response to Alasdair Morgan.

I am sure that all of us in this Parliament would agree that Westminster should legislate on devolved matters only in very limited circumstances and after this Parliament has fully considered and approved the proposals. That approval should be sought as early as possible in the process and it should never be assumed, as it appears to have been in this case. The Sewel motion asks us to agree

"that the relevant provisions to achieve these ends in the bill should be considered by the UK Parliament."

The motion is about a bill that was introduced at Westminster on 20 December and that received its second reading on 10 January. In other words, MPs were asked to agree it in principle, including the provisions relating to Scotland, before this Parliament had the chance to consider whether it wanted to cede legislative competence in those areas to Westminster.

To add insult to injury, the explanatory notes to the bill give a clear impression that the Scottish Parliament had already asked Westminster to legislate. On clause 49, the explanatory notes say:

"At the request of the Scottish Executive and by the approval of the Scottish Parliament clause 49 amends devolved legislation concerning Scotland".

MPs who agreed the bill in principle did so under the impression that this Parliament had already asked them to legislate for Scotland. That is presumptuous, to say the least. I would like Malcolm Chisholm to give an assurance this afternoon that that will never happen again and that Sewel motions will be considered as early as possible in the procedures so that this Parliament is not taken for granted. It is for this Parliament and no other body to decide when and if Westminster should legislate on devolved matters.

The Conservatives are pleased to accept the bill as it relates to Scotland. We welcome the end of preserved rights, which will ensure consistency and equality of funding based on appropriate health care.

I will flag up some issues on prescribing. Given that many of them are devolved and are in line with long-term planning and the successful implementation of the bill, I think that it is appropriate to raise them at this stage.

There is a need for absolute clarity about who retains clinical responsibility. My colleague David Davidson—a pharmacist—has given me some advice on the matter. It is important that the control of a patient's management and care is fully known and integrated. One person must hold a full record of all prescribing. How will all the new prescribers be aware of a patient's clinical history and care? Will that require the use of smart cards and a fully integrated information technology system, as mentioned in the health plan? The success of the initiative seems to depend on that.

The extension of prescribing rights leads us to seek further reassurance on training. I understand that ophthalmic opticians are trained in prescribing drugs and therapies in relation to their professional obligations. However, will dental auxiliaries be given full training before the new prescribing regime is implemented? David Davidson raised with me the point that osteopaths and chiropractors do not tend to prescribe medicines as part of their care. The new prescribing rights would be quite a departure from that conventional line of care. Again, that raises issues about training, clinical responsibility and knowledge of a patient's history.

I fully endorse Nicola Sturgeon's point about consultation. The question of liability is also crucial, particularly in relation to the side effects of drugs. How will liability of the prescriber be determined, given that one patient can be prescribed drugs by several health care professionals? We seek assurances on who is ultimately responsible for the patient's health.

Much has been said about nurse prescribing. The Royal College of Nursing has pointed out that all those who gain prescribing powers will already have undergone professional education—they will be on a professional register and they will be expected to comply with a code of professional conduct. However, are we not asking nurses to take full responsibility for prescribing without full and adequate training? Given that nurses have a broad input into health care, how can we limit the number of drugs on the list and the disciplinary action that can be taken in the event of a lack of judgment?

The Scottish Liberal Democrats support the motion and the principles of the bill. I agree with the minister about preserved rights income support. In certain areas, there have been problems with the shortfall in funding between the fees charged by homes and the benefit that is available to the people who are resident in them. There is also a shortfall in funding between fees and benefit when people have to move from residential homes to nursing homes. I hope that the new system will cover that. There should be assessment across the board and everyone should be treated equally.

We support in principle the proposal to widen the categories of groups who can prescribe, although we have some concerns. The need for co-ordination between different professionals prescribing different drugs is clear. Often, the patient may not be fully aware of, or may forget, what they have been prescribed. Recently, I was in hospital and was yet again asked for my clinical history, which I am glad to say is not that long. However, I forgot certain things from the past, which I later let the doctor know about. Patients may forget relatively recent prescriptions and it is important that the person who is writing a prescription knows about those. There is an argument for having a card or some kind of record of prescriptions that can be given to patients, so that they can pass it on to specialists, consultants and even those in the extended groups.

I have been lobbied by registered osteopaths and chiropractors—as I am sure other members have—who would like to be able to prescribe certain steroids without having to send their clients to general practitioners, who then anyway send them back to the osteopaths, chiropractors and physiotherapists to inject the steroids. Steroids are a controversial issue and can raise difficulties, particularly when patients—depending on their clinical history—are on them for too long. It is important that the new groups are properly trained and that there is close co-ordination between what they are doing and what much more experienced GPs know.

With those provisos, we support the bill. I hope that the minister will be able to respond to the brief points that I have made. There was a debate on this subject in the House of Commons last week; I disagree with what the SNP has said about that, because I am glad that the debate took place—it has been interesting to read the report of it. We know that the Executive will deal with the issue of free personal care in a positive manner when the Minister for Health and Community Care makes her statement shortly.

I should begin by declaring that I am a director of a nursing home company that operates in England. I am probably more concerned about the bill in the English context. However, I welcome this Sewel motion and the proposal to transfer preserved rights, which makes sense and is simply the implementation of the Sutherland recommendation. As Keith Raffan said, we await the announcements on the rest of the recommendations next week.

The extension of powers to prescribe medication is welcome and long overdue. The groups mentioned in the reference papers have for some time been straining at the bit to be able to prescribe. However, it is important that prescribing is properly controlled and managed and that those who prescribe are properly qualified and trained. The section of the Scottish NHS plan that deals with information refers to the accessibility of clinical history information to the various prescribing groups. Confidentiality will have to be managed in a highly effective way. That is an important issue.

I hope that the minister will extend the range of prescribing that nurses undertake, which is currently severely limited. There are specialist nurses in diabetes, epilepsy, asthma, colostomy care and a number of other areas, but they cannot prescribe the drugs for the care area in which they operate. I particularly welcome the extension to pharmacists of powers to prescribe, because pharmacists are partners in health care who have been seriously underutilised.

My one concern is that we may have missed an opportunity with this Sewel motion. The Scottish Executive is not taking up the references to care trusts in clauses 45 and 46 of the Health and Social Care Bill because they implement paragraphs 7.9 to 7.12 of the English NHS plan. The Health and Community Care Committee of this Parliament, in its recent report on community care, referred to problems between social services and the NHS, which those clauses will address in an extremely positive way, so I wonder whether we have missed an opportunity. I acknowledge that the Scottish NHS plan states that the Executive will at a later date deal with any impediments to appropriate accommodation between the NHS and social services in terms of pooled budgets, for example, but the Sewel motion would have provided an opportunity for us to piggy-back on the much more advanced measures that are being taken in England.

However, I welcome the motion and hope that it will be supported.

The SNP is happy to support the principles of the bill, although we have concerns about the process. The proposal to end the preserved rights system is welcome, as it leaves residents at a disadvantage, both financially and in not having their care needs properly met.

The widening of the categories of registered professionals who are allowed to prescribe is also welcome. Clearly, widening prescribing rights will reduce the need for routine visits to GPs, which will, we hope, free up time for GPs to spend with patients.

However, two questions remain for the minister to answer. First, will he confirm that there will be a rigorous and validated education and training programme and closer links between professionals to protect the patient and professional accountability? Secondly—as Mary Scanlon asked—will safeguards be developed to ensure communication between multi-prescribers and so avoid potentially harmful interaction of drugs that have been prescribed by different health professionals? I look forward to hearing the minister's response to those questions.

As I said, the content of the bill is to be commended, but the process by which this and other Sewel motions are presented to the Parliament leaves a lot to be desired. The memorandum that is attached to the bill says:

"Parliament's approval is sought to include devolved issues in the UK Bill."

The motion seeks the agreement of the Parliament that

"the relevant provisions to achieve these ends in the Bill should be considered by the UK Parliament."

However, it is presumptuous to introduce a Sewel motion for approval so late in the bill's process at Westminster. What if this Parliament were not minded to support the bill?

As Nicola Sturgeon said, the explanatory notes that accompanied the bill at Westminster say:

"At the request of the Scottish Executive and by the approval of the Scottish Parliament clause 49 amends devolved legislation concerning Scotland so that preserved rights can cease across the whole of Great Britain on the same day."

To me, that suggests that approval had already been given when the bill had its second reading last week. That is misleading to MSPs and to MPs. It might be appropriate for the Procedures Committee to consider suitable timetabling of Sewel motions. I look forward to the response of the committee's convener to that.

I will deal mainly with the substance of the debate, but I must refer to what Nicola Sturgeon and Shona Robison said about procedure. I think that Nicola Sturgeon answered her own point by reminding us that the bill was introduced at Westminster on 20 December and received its second reading on 10 January—the dates on which this chamber adjourned for Christmas and returned after the break. Normally, debates such as this one will take place before a bill's second reading at Westminster. In this case, that was not possible.

Richard Simpson also made a comment that was off the main topic. He made an interesting point about care trusts. What he said may be his view, but it was not that of the Health and Community Care Committee. The Executive is determined to go forward through joint working and pooled budgets.

I remind members that it is up to us to decide who prescribes. Patient safety will be paramount when we consider whether to grant prescribing rights to any professional group. It is also up to us to decide what is prescribed. We hope to follow Richard Simpson's suggestion of including extra prescribing rights for nurses.

Members asked about one person holding the records for prescribing. The answer to that comes from information technology systems—smart cards are not necessary.

Mary Scanlon and Shona Robison talked about training. Before any new category of prescriber is designated, ministers will have to be convinced that all new prescribers will be fully trained and competent to fulfil the responsibility.

Nicola Sturgeon mentioned consultation. Proposals for granting prescribing rights for some medicines to a group of health professionals will be subject to wide consultation with relevant organisations.

Extending the right to prescribe will help to break down the divisions between health professions and will play an important role in the introduction of more flexible team working throughout the NHS. It is in line with the commitments in "Our National Health: A plan for action, a plan for change", which proposed change to the traditional ways of delivering services to patients.

I am pleased that members have welcomed the change to preserved rights. Keith Raffan asked about the shortfall in funding. I assure him that approximately £8.9 million of the proposed funding that will be transferred is included to top up shortfalls and to meet existing home care charges. No one will be disadvantaged under the arrangements. No one will have to change their accommodation. Some people will for the first time be able to obtain appropriate care in the community. I therefore once again ask the Parliament to agree to the motion.

We saved five minutes on that debate, which I hope will be added to the debate on convenerships. Likewise, perhaps we can make good speed in the next debate.