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Baroness Cumberlege: My Lords, referrals are a matter for the consultants or the GPs concerned. With regard to tertiary referrals, which are referrals from one hospital to another, no prior agreement is necessary and those are dealt with as the patient's need requires and on the opinion of the clinical doctor involved.

Lord Walton of Detchant: My Lords, does the Minister agree that one of the greatest strengths of British medical research is the ability to carry out multi-centre clinical trials, often involving the treatment of rare diseases? Does she accept that there is now an increasing reluctance on the part of some district hospital managers to refer patients because of the need for extra-contractual referrals to centres of excellence? If the Culyer working party report is to be implemented by government, how do the Government propose to protect the position of these important tertiary referrals to major research centres?

Baroness Cumberlege: My Lords, the Culyer report has been accepted by my right honourable friend the Secretary of State for Health. We believe that it will safeguard and promote the very high reputation this country already has in medical research.

With regard to extra-contractual referrals, we believe that the Culyer report will address many of the issues. It will safeguard the funding for research and

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development, which I believe will please this House which has had such a very strong influence on the future of medical research in this country.

Baroness Robson of Kiddington: My Lords, can the Minister assure us that there are sufficient funds in local authority hospitals and in National Health Service trusts for extra-contractual referrals?

Baroness Cumberlege: Yes, my Lords. Such referrals are a tiny percentage of the total budgets of health authorities, amounting to between 1.5 and 3 per cent. Therefore, it is a very small sum of money. Usually these referrals are very important. Of course, all emergencies are dealt with immediately, but for extra-contractual referrals we no longer require prior approval before a patient is treated or even seen. That is much simpler.

With regard to resources, your Lordships will know that every year we put more funding into the National Health Service, as indeed the Chancellor did yesterday in the Budget.

Baroness Jay of Paddington: My Lords, can the Minister tell us whether the number of extra-contractual referrals across the country is going up or down? Is it not the case that the NHS market has almost created a Catch-22 situation in which, if the number of extra-contractual referrals goes down, the number of patients receiving specialist care is reduced, but if it goes up the ability of purchasing health authorities to keep within their budgets is also reduced?

Baroness Cumberlege: My Lords, for the very highly specialised units which in the past have had to rely on extra-contractual referrals we have instructed health authorities and regions that in future they should not use that system but should co-operate with one another so that there is a critical mass which is large enough to support these highly specialised units. Therefore, we are working away from the present system of extra-contractual referrals.

The Countess of Mar: My Lords, is the noble Baroness aware that in the case of people who are or who believe they are suffering from organophosphate poisoning there are particular difficulties? Is she aware that they are being refused extra-contractual referrals because they are told there is no treatment for the problems they are suffering from, and as the referral is for tests and research only they are not allowed to have them?

Baroness Cumberlege: My Lords, I appreciate that this is a very special need, which has recently emerged. As with many other new clinical conditions which may develop, it takes time to develop services.

Baroness Jay of Paddington: My Lords, I apologise for coming back and pressing the Minister on the point, but is it the case that the number of referrals is going up or going down at present? As I said, is it not therefore

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the case that, whatever the Government's intention in respect of moving away from the system, we are at the moment in a Catch-22 situation?

Baroness Cumberlege: My Lords, I think I answered that point fairly clearly. I said that we are trying to move away from extra-contractual referrals. Indeed, we have required regions to monitor the situation and ensure that there is a different way of purchasing these services.

Lord McIntosh of Haringey: My Lords, the Minister was asked a very simple question: is the number of extra-contractual referrals going up or down?

Baroness Cumberlege: My Lords, they will reduce in time.

Lord Monkswell: My Lords, is the Minister aware that public perception of referral for specialist treatment is that it is based on clinical need, which may be constrained by waiting lists? In her earlier Answer the noble Baroness referred to the "usual constraints". Apart from the points that I made about clinical need and waiting lists, are there any other usual constraints which the public should be aware of?

Baroness Cumberlege: My Lords, we are talking about very specialised services dealing with extremely rare diseases and conditions. They require a high degree of expertise. Sometimes that will also be a constraint in that that expertise will not be available.

Baroness Darcy (de Knayth): My Lords, does the Minister agree that delayed referral, for instance in the case of spinal injuries, can lead to many complications which will not only retard rehabilitation but also lead to frequent return visits to hospital, which is not only bad for the person concerned but also economically bad for the National Health Service? Can the Minister say whether there is anything she can do to encourage early referral to specialist units?

Baroness Cumberlege: My Lords, those are clinical matters. It is up to the doctors concerned to decide when somebody should be referred to a specialist unit. However, it is the duty of the regional health authorities to ensure that the facilities are available to meet those particular needs.

Baroness Masham of Ilton: My Lords, will the Department of Health take on the monitoring once regions disappear in one or two years' time?

Baroness Cumberlege: Yes, my Lords.

Iraq: Northern No-Fly Zone

2.56 p.m.

Lord Archer of Weston-Super-Mare asked Her Majesty's Government:

    Whether they can confirm that the no-fly zone over northern Iraq will be extended by the allies beyond December for a further six months.

The Earl of Arran: My Lords, the Government of Turkey are expected to discuss in December the extension of the basing agreement for aircraft patrolling

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the northern no-fly zone in Iraq. We have made clear that we attach importance to the continuation of the northern no-fly zone for as long as Saddam Hussein poses a threat to that area.

Lord Archer of Weston-Super-Mare: My Lords, I thank the Minister for that reply. Does he accept that Saddam Hussein would have crossed the border into Kuwait a second time if it had not been for fear of reprisal from the allies? Does he agree that exactly the same situation exists in northern Iraq and that, if he has no fear of reprisals, then Iraq will cross that border—I refer to the 36th parallel—and will kill the Kurds? Will my noble friend therefore ensure that he fights as hard as he can to ensure that the no-fly zone continues for another six months?

The Earl of Arran: My Lords, of course my noble friend is quite right. We can never rule out further threats from Saddam Hussein. We continue to watch the situation extremely carefully. We must maintain no-fly zones while the threat of repression remains. Operation Provide Comfort, which I am sure my noble friend knows well and which is based in southern Turkey, is crucial to the security and stability of northern Iraq. We strongly hope that the Turkish Government will agree to the extension of the operation when it expires at the end of December.

Lord Molloy: My Lords, is the noble Earl aware that the Kuwaiti people now believe that they live in reasonable safety with the protection of, primarily, the British and the Americans? Can he say that that protection will be forthcoming and that in no way will we take any risk that will allow Saddam Hussein to attempt to obliterate Kuwait as he did before?

The Earl of Arran: My Lords, I can give that assurance too. I am also glad to be able to inform the noble Lord, Lord Molloy, that the Speaker of the Kuwaiti Parliament is in London at this very moment. That is another symbol of the closeness of our bilateral relationship.

Baroness Blackstone: My Lords, can the Minister comment on reports that the UN Special Commission on the Disarmament of Iraq is so short of funds that it has begun contingency planning to close its operations? Does he agree that that is entirely unacceptable? Can he tell the House what action the UK Government are taking to rectify that situation?

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