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Lord Renton: My Lords, before the noble Lord sits down, perhaps I may say how grateful I am to him for putting me right. What the noble Lord has said supports the amendment and what I said about what can be done in one particular area also supports the amendment because it shows that such transfers take place elsewhere.

Lord Winston: My Lords, I feel that I hardly need to answer that point.

Baroness Fookes: My Lords, I feel equally strongly about this. At different times, both my parents benefited from being referred to a specialist service outside the area in which they were living, so I have some personal reason to be grateful for that.

More recently, I intervened, if that is the right word, on behalf of a lady of my acquaintance who I felt needed specialist treatment which she was not receiving in her local area. However, it proved quite difficult. Her GP was not anxious to refer her. She was not the kind of lady who was in a position to make herself felt. That was partly because of the illness from which she had suffered, which was a massive stroke. I tried to make representations to the doctor myself and in the end, very successfully, the case was referred to a specialist unit. That was to her great benefit because after a considerable number of tests something was discovered to be wrong which had not been discovered at the local level.

However, such problems should not arise. I would like an assurance from whoever answers on behalf of the Government tonight that, where a patient is anxious to have treatment out of area, no undue blocks will be placed in his or her way. Indeed, not everyone has someone to speak up for them. If there is to be equality of provision, which this Government set great store by, then it is most important that people should have equal access to the very best specialist treatment that is available.

Baroness Sharp of Guildford: My Lords, I, too, should like to express my support for the amendment.

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In my own district health authority, which is struggling at present with a large deficit, there is considerable pressure to limit the number of extra-contractual referrals. Therefore, what the noble Lord, Lord Winston, has said is totally true.

When we discussed another amendment earlier, we talked about the position of research and development in this country. The expertise that we have in our teaching hospitals is amazing. It is ludicrous that we are not making use of such expertise at present. If we are to maintain state-of-the-art capabilities in medicine, it is essential that we maintain the expertise here. We must make use of these out-of-area referrals. Indeed, we have centres of excellence and we must build upon them.

Lord Skelmersdale: My Lords, as someone who might have died had I not had an out-of-area referral, I was horrified by the speech made by the noble Lord, Lord Winston. The idea that specialist units are under employed in the health service when there is so much need out there in the country fills me not only with horror but also with dismay and disquietude. The nub of this debate is to ask the Minister what provision will continue to be made--if necessary, a new provision--to ensure that the description provided by the noble Lord, Lord Winston, will no longer pertain. It is absolutely disgraceful.

Baroness Berners: My Lords, I support the amendment moved by the noble Baroness, Lady Masham. I strongly agree with referrals to specialist hospitals. Indeed, it makes very good sense. I hope that the Government feel able to consider the amendment.

Baroness Gardner of Parkes: My Lords, I support the principle of being able to refer people to specialist hospitals. That is absolutely right. However, I draw the line when it comes to the speech made by the noble Lord, Lord Winston. For years everyone was referred to hospitals in London. It would be a great pity if there was in any way a feeling that we were making a special plea for people to come back to London. I say that because it has been beneficial for people to have centres of excellence in many different parts of the country. I hope that that will continue. Of course I would be delighted if the noble Lord, Lord Winston, were to have full occupation all the time in his hospital, but not if that disadvantaged some other equally good centre of excellence in another part of the country.

Lord Winston: My Lords, I should point out to the noble Baroness that what I said would apply equally if I were living in Leeds. It is a pure accident that I happen to work at Hammersmith Hospital. Nevertheless, the principle of what I said pertains across the country and it is true in different parts of the country. It is ludicrous to suggest that I am special pleading for London; indeed, I am certainly not.

Lord Hunt of Kings Heath: My Lords, the noble Baroness, Lady Masham, has raised a very important matter. I certainly understand the concerns that lie behind her amendments. Indeed, other noble Lords who

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have spoken in this debate have experienced problems which some specialist units have encountered with the operation of the internal market. I hope that I can convince the House that the arrangements which the Government are now putting in place will meet some of the concerns expressed. Of course, one needs to start by saying that it is absolutely essential that all patients have ready access to specialised treatment and care.

We are committed to promoting fair access both to NHS services generally and in particular to specialised services. In The new NHS White Paper we said explicitly that an aim of our new arrangements for planning and commissioning specialised services was to develop the more systematic approach needed if fair access is to be guaranteed.

It may be helpful if I explain in a little more detail how the new arrangements will work. Each health authority, and increasingly, each primary care group and primary care trust, will be responsible for commissioning services for their population. There is of course nothing to restrict them to commissioning services from hospitals in their own immediate area. Many will have service agreements with hospitals in neighbouring health authorities to reflect established flows of patient referrals, and many more will also enter into agreements with more distant hospitals, for example to reflect patterns of treatment for cardiac or cancer patients.

As regards specialist centres, I make it clear that funding for those services will come through long-term service agreements. The main funding route will be through the specialised commissioning arrangements. NHS Executive regional offices will be responsible for ensuring that health authorities and their primary care groups and primary care trusts come together with the clinical units concerned to agree the future pattern of services. As we said in The new NHS, the intention is to balance the population perspective of health authorities, primary care groups and primary care trusts as regards addressing questions of fair access with the need to support clinical units and their staff in developing the most suitable and effective care.

In their health improvement programmes, health authorities and their partners will set specialised commissioning issues alongside their local priorities. They will need, as ever, to form a balanced judgment about areas for development along a number of broad fronts. One of the criticisms of the internal market was that fragmentation of responsibility made it difficult to ensure co-ordinated planning and commissioning of specialised services. The comments of a number of noble Lords in this debate have reflected this problem of fragmentation. The noble Lord, Lord Walton, is not present at the moment, but as he pointed out earlier this evening, in some instances specialist units were uncertain as to the future flow of patients and, consequently, their future funding arrangements. The new specialised commissioning arrangements we are putting into place will offer a much more coherent and purposeful way forward. We are giving regional offices clear responsibility for ensuring proper arrangements are

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in place, and will require all health authorities and all primary care groups and primary care trusts to participate in that.

Having said that, I cannot, of course, go so far as to say that every specialist centre will receive the funding it would like as a result. I do not think any system in the NHS has, or could, ensure that. There will still be a need for difficult judgments to be made and difficult priorities to be set, but in future there will be a clear and ordered system for ensuring that the concerns that are expressed are properly and collectively addressed by all the partners in a health region or in smaller areas respectively.

To complete the picture, the new arrangements for out-of-area treatments will cover cases which cannot readily be brought within a primary care group or trust's planned service agreements, for example, emergency admissions away from home or a rare case needing specialised treatment. Where a hospital receives referrals of this kind, that pattern will be reflected in the allocation of the health authority which is its main local commissioner. That health authority will build this funding into its own service agreements with the hospital to cover these ad hoc cases. There is no constraint here on the freedom of a GP to refer a patient in such circumstances.

I believe that these arrangements should, between them, meet the concerns of the noble Baroness. I can also confirm that the powers of direction in Clause 7 are wide enough to enable directions to be issued on this point. The scope and duty of partnership in Clause 19 is similarly broad enough to cover these arrangements. As I said in Committee, the co-operation in the commissioning and provision of specialist services is precisely the kind of issue that we see coming within the scope of that duty. In the light of my explanation and assurances I hope that the noble Baroness will consider withdrawing her amendment.

9.30 p.m.

Baroness Masham of Ilton: My Lords, I wish to thank all the supporters of the amendment. I believe it is necessary to have the out-of-area treatments written on the face of the Bill. It does not matter where they may be--Leeds, London, Liverpool, Glasgow, Belfast, Middlesbrough or anywhere else--but if the specialised services are not written on the face of the Bill, which is, after all, a health service Bill, a strong emphasis is put on primary health care in the Bill, and secondary healthcare--tertiary healthcare--will seem to be forgotten.

I think that I speak for many outside the Chamber who would like our National Health Service to be the best in the world. We cannot be the best in the world unless, as the noble Lord, Lord Winston, said, there is the clinical material necessary to carry out research and to advance in treatments. We live in a fast-advancing world. I shall read very carefully what has been said. I will go back to the supporters of the amendment and we will wait for Third Reading. The Government should

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take this matter seriously. I consider it to be the most important matter for the advancement of our medical service. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

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