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Baroness Thomas of Walliswood: I thank the noble Lord, Lord Harris of Haringey, for making some points on my behalf with which I entirely agree. I did not do so because I felt that time was moving on. I thank him all the same. I thank the Minister for a very careful answer. I must confess that I do not find myself entirely at ease with all the points she made. We are talking here about a partnership with local authorities which involves joint commissioning of services. It involves commissioning services from each other, or the possibility that that should happen. If one comes at that from a different standpoint, one could be getting oneself into trouble. However, I do not want to dispute every point that the noble Baroness raised, as that would take another three-quarters of an hour. I shall read carefully what she said. I shall withdraw the amendment at this stage but may come back with another version of it at a later date. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Clement-Jones moved Amendment No. 130:

After Clause 18, insert the following new clause--

Standing conference

(" .--(1) The Secretary of State shall establish a standing conference (referred to in this Act as the Standing Conference) which shall have the duty of--
(a) conducting an annual review of, and the making of reports and recommendations to the Secretary of State on, treatment priorities and funding in the NHS after consultation with the National Institute for Clinical Excellence; and
(b) establishing a clear set of values and guidelines to clarify the decision-making process to be applied by Health Authorities, Special Health Authorities, Primary Care Trusts and NHS Trusts to ensure that patients are entitled to equal and consistent treatment, to be given clear treatment options and reasons where treatment is denied.
(2) The reports of the Standing Conference shall be published annually and shall take account inter alia of--
(a) the views of the public on the priority of treatments;
(b) the efficacy of treatments;
(c) the cost benefit of treatments; and
(d) the affordability of treatments.
(3) The members of the Standing Conference shall be appointed by the Secretary of State and shall consist of an equal number of lay members and members involved in the delivery of health care.

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(4) In exercising his functions under the 1977 Act, the National Health Service and Community Care Act 1990 or this Act, the Secretary of State shall have regard to the reports and recommendations of the Standing Conference.").

The noble Lord said: Several of our debates have touched on rationing. At this time of night I have no intention of instigating a long debate on the subject. Indeed, we alluded to so-called post-code rationing when discussing the commission for health improvement and NICE. However, it is clear that rationing occurs in a number of different ways. It occurs where health authorities have decided that treatments are core and non-core healthcare services; it occurs where health authorities, while generally being favourable to a treatment which may be provided in another district, insist on more evidence than is reasonable in order to ensure that their bills are not unduly inflated; and it occurs where health authorities have run out of money for particular treatments.

When one looks at the whole area of rationing, one sees that there are huge variations in how communications take place with patients about treatments that are being denied. That is a matter of particular concern. The amendment attempts to tackle the first kind of rationing. The second type, we hope, will be dealt with by the combination of NICE and CHIMP. The third is a matter of year-on-year resources as provided to health authorities and NHS trusts. We believe that the first type will be dealt with by our amendment. It seeks to set up a standing conference along the lines of the Dunning Committee which was set up in Holland to provide a public forum in which rationing issues could be debated.

For instance, what is core healthcare? Noble Lords may have seen an interesting article in The Times of 23rd February which looked at the detail of IVF treatment. The article was headed "IVF treatment and the lottery by postcode". Clearly, IVF treatment is not provided on a consistent basis across the country and health authorities have very different views about it. Members of the Committee may have heard on the radio this morning a discussion about chemotherapy and the kinds of so-called chemotherapy cocktails which consultants wish to make but which are denied them by their health authorities. Who in a health authority decides on what is core and non-core? Is the Viagra example the model? Do we expect the Secretary of State to descend in a chariot of fire to make a decision on a single drug; or is there another model? We suggest that there is another model. We are not proposing an executive body or anything that actually takes the decision on what is core and what is non-core. We are suggesting simply a forum available to the Secretary of State to advise him. The pattern of differences between health authorities is enormous.

Nowadays, health authorities, to their credit, are being much franker about whether tattoo removal or infertility treatment is or is not included in their menu of treatments. However, by itself, that is dangerous. It means that potentially we no longer have a national health service. We have a series of health authorities deciding on what treatment is available in their localities. That means, in the words of the Question that

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has been tabled for tomorrow by the noble Baroness, Lady Knight of Collingtree, that people literally have to move house in order to find different treatments. That cannot be desirable. We are trying to ensure that there is at least a forum for a national debate on the subject that is long overdue. I beg to move.

9 p.m.

Baroness Hayman: The noble Lord has argued persuasively that we need to take measures to ensure that we have less unacceptable variation in standards of care in different parts of the country. I do not in any way disagree. What I believe the Committee should consider is whether the establishment of a national standing conference--a national priority-setting body--would be helpful in the process that we have set out in order to ensure a more nationally accountable NHS.

We are already setting up two new national bodies--the national institute for clinical excellence, in order to assess treatments, to examine their clinical and cost effectiveness, and to make the best possible evidence available to local health authorities, trusts and individual clinicians; and the commission for health improvement, whose role we have just discussed, to monitor the implementation not only of NICE's recommendations but of the national service frameworks, which will be aimed at reducing unacceptable variations and ensuring national standards of quality for patients wherever they are.

In some ways the arguments for a national standing council seem persuasive. The noble Lord alluded to the Dutch experience. Other countries have trodden that path but have not found it as easy or as successful a process as he suggests or they perhaps imagined it would be.

To reiterate, we have made it clear that we are committed to high quality, comprehensive services. We discussed earlier the need to ensure equality of access to those services and to ensure that there is not discrimination on the grounds of race or age. It is the Government's responsibility to decide on priorities within the resources that are available. That is not a responsibility that we wish to abdicate. In setting out national priorities, which we did in the national priorities guidance for 1999-2001 that we issued to the service last September, we made that clear.

We have set out our plans for ensuring a clearer national framework within which decision-making by local clinicians and commissions should take place. That involves setting up the national service frameworks, the commission and the national institute, and ensuring that there are clinical guidelines and advice on treatments that should be routinely available within the NHS. That will be underpinned by local clinical governance and the new performance assessment frameworks. There are also the health improvement programmes at local level. All those bodies and undertakings will need to engage the community and the interests of users and carers at appropriate levels. Earlier, we discussed the appropriate lay input into the commission for health improvement.

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We want to ensure a more consistent approach across the country. However, at the same time we must recognise not only that individuals have different needs, to which clinicians will respond, but that local services need to reflect local needs and take account of local views. We recognise that health authorities and primary care groups are in the best position to make judgments as to which services and which treatments are required, but we want them to do that within a stronger national framework. We are setting about creating that stronger national framework after the fragmentation of the past. I hope that on that basis the noble Lord will accept that the aims that he intends to promulgate with this amendment are being addressed by various measures from the Government.

Lord Clement-Jones: I thank the Minister for that interesting reply. In a sense, it attempts to offer the best of both worlds--strong local views and a stronger national framework. I am not sure which bit is going to give at the end of the day.

Interestingly, the Minister did not mention Greg Dyke's NHS charter, which clearly has a role in this provision. If the Government accept any or all of the Greg Dyke formula, I should have though that subsection (1)(b), dealing with establishing a clear set of values and guidelines to clarify the decision-making process to be applied by health authorities, would be attractive. One does not quite understand the status of the Greg Dyke exercise; however, he has made some interesting suggestions. They fit in with the local decision-making aspect mentioned by the Minister.

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