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Lord Walton of Detchant: My Lords, I support the amendments. I wish to take this opportunity to express my sincere thanks--other noble Lords have also expressed their thanks--for the way in which the Minister has met so many of the concerns expressed throughout the Bill's passage. I know that I speak on behalf of noble Lords on these Benches. The pharmaceutical industry and the professional regulatory authorities also feel that virtually all their concerns have been met.

I support the views expressed by the noble Baroness, Lady Masham. I do not propose to redeploy the arguments I expressed at Second Reading and Committee and Report stages about the crucial importance of out of area referrals not only for those patients suffering from rare conditions but also those who suffer from common conditions. There is clear evidence that in the treatment, for instance, of diabetes a referral to a highly specialised centre brings greatly improved outcomes in relation to patient care. One could redeploy the arguments relating to the specialised treatment of cancer, to the highly specialised specialties such as cardiac surgery, cardiology, neurology and many more.

One of the great strengths of the old NHS--if I may speak about it in that way--was that regional planning made it possible to define those hospitals in which regional services would be provided. Primary care was provided by the general practitioners. Secondary care was provided in virtually every district hospital. But the more difficult problems were referred to regional or sub-regional centres which were carefully planned. One of the unexpected and unforeseen effects of the internal market introduced by the former government was that extra-contractual referrals diminished sharply. That meant that many patients deserving of highly specialised care were not referred to those specialised centres. Not only did that have a detrimental effect on the care of many individuals, it had a devastating effect on clinical academic medicine, which often depends on such referrals for its very existence.

For that reason alone, and for many of the others expressed by the noble Baroness, I strongly support the amendments. From what the Minister said when debating the last group of amendments, I understand that hospital consultants among others will be consulted about the activities of primary care trusts. That will greatly reassure the BMA. When the noble Baroness answered some of our questions on the topic in Committee and on Report she was able to give many reassurances. But the future of specialised patient care in the NHS and the future of clinical academic medicine depend upon having effective answers to the problems posed in the amendments.

Baroness Sharp of Guildford: My Lords, I support the amendment and endorse the reservations expressed from other Benches.

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As the Minister said at Report stage, health authorities and their partners will still need to set specialised commissioning issues alongside their local priorities. We accept that the new spirit of co-operation which will pervade the National Health Service in future means that the new arrangements can or may be more coherent and purposeful. But the fact remains that health authorities and primary care trusts will still be constrained by their budgets and will be under constant pressure to buy the cheaper local services rather than to go elsewhere for more expensive services. Therefore there is the tendency to ration by postcode.

My attention was brought last weekend to a patient who urgently needed a heart bypass operation. His cardiologist reckoned that he had only a week to live if he did not have one. However, it was January and his health authority had exhausted the quota of bypass operations that it had bought from a specialist hospital outside the area, and there was no way round that. That was despite the fact that the cardiologist estimated that he had only one week to live without the operation. The specialist hospital concerned had excess capacity; namely, both its operating theatres and its specialist staff were not being used at that time.

That picks up the problem raised at Report stage by the noble Lord, Lord Winston. The noble Lord, Lord Walton, reiterated it. He spoke about unused specialist facilities and specialist staff being laid off. Yet I confess that I see little in the proposals at present to alleviate the problem. We shall still be confronted by constrained budgets and the purchaser provider provisions which are at the centre of the internal market. As my noble friend Lord Clement-Jones said at Report stage, these are the litmus test of whether the internal market continues.

It is vital for patients in this country to have access to the most appropriate and best possible care, even if it is not available within their area. We should be glad to have assurances from the Minister that I have interpreted the matter wrongly and that those facilities will be available.

Baroness Fookes: My Lords, I warmly support the amendments in the name of the noble Baroness. I prefer not to rely on some nebulous spirit of co-operation, but to have a provision written firmly on the face of the Bill. I do not believe that there ever was a golden age in the NHS when it was easy to send people out of area. As a constituency MP, I recall having the greatest difficulty under previous reforms when trying to help someone who needed that out of area support. I therefore take a rather jaundiced view as to whether the concept will work if it does not get a good shove on the face of the Bill. I am sure the Minister will give us some reassuring words about what is planned. But I should still like to see the provision on the face of the Bill. In the absence of any proposal from the Minister, I warmly support the amendments in the name of the noble Baroness.

Lord Renton: My Lords, I, too, support the amendments. I revert to Report stage, when some of us mentioned specialised services that were already available. At first I doubted whether the amendment was necessary because I wrongly assumed that those services

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would be available throughout the country. However, in a powerful speech, the noble Lord, Lord Winston, put me right. He mentioned that the situation varies a great deal. We know that the Government have the good intention of wanting to make the services readily available everywhere--involving travelling, of course; that cannot be avoided.

I remind your Lordships of what the noble Lord, Lord Winston, said. The noble Baroness, Lady Sharp, referred to it. He stated:

    "I am convinced that if we sensibly concentrated services in certain areas to which patients could easily travel, there would be a great benefit to the patients, a benefit in terms of training and research, and a saving of money".--[Official Report, 15/3/99; col. 560.]
He then said that he strongly supported the amendments.

It is arguable that under the Bill there is power to provide these services, but there does not seem to be an obligation to do so. We know the Government want that to be done but surely it would be better to make it clear in the Bill that there is an obligation on the part of the Secretary of State and the various bodies which will be helping him in providing health care in the future. We should make it clear that there is an obligation to extend specialist services so that they are available all over the country. For that reason no harm could be done by accepting the amendments; indeed there would be a very great advantage.

5 p.m.

Lord Skelmersdale: My Lords, as I understand the position the proposed new arrangements for regional specialised commissioning centre upon an indicative list of specialised services. Health authorities will, as I understand it, only be expected to make arrangements for a limited number of specialisms each year. This is bound to continue the unfairness that has already been referred to at Report stage as treatment by postcode. For example, patients needing access--and here I declare an interest as chairman of the Stroke Association--to specialist stroke units will be able to have that if they are in the right area, otherwise not. Patients with rare diseases or complicated illnesses will find it much more difficult to have access to centres of expertise or specialist consultants.

Like my noble friend Lord Howe, I can find no provision for appeal against refusal to fund out-of-area treatments and community health councils have no rights of representation at regional level. All this leads me to conclude, like my noble friend Lady Fookes, that we need to refer to what my noble friend Lord Renton calls "this obligation" on the face of the Bill.

Lord Hunt of Kings Heath: My Lords, this has been a most important and interesting debate. I am most grateful to the noble Baroness, Lady Masham, for once again allowing us to discuss these important issues. I am very well aware of the concerns that many members of your Lordships' House have about the proper availability of specialist services within the National Health Service. It is a fact, as the noble

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Baroness, Lady Fookes, said, that there has never been a golden age. There has always been a tension between the proper provision of specialist services and the appropriate provision of local services. My own view is that the internal market added to the problems. No one should underestimate the challenge that the NHS faces in ensuring that we reach the right solutions in terms of a balance between specialist services and the services that one would expect to be provided in one's local area.

I believe that the action which the Government are taking in this area will enable us to meet many of the concerns that noble Lords have. Notwithstanding the ever present tension that I have already described, I believe that the arrangements that applied under the internal market were responsible for many of the problems that have been discussed.

It was certainly the case that fragmentation of responsibility within the internal market made it more difficult for specialised units to work together with all those who referred to their services, so as to agree how the service should develop, and how it could best be dovetailed with local services to ensure that there was a proper continuum of care that patients require. There was no mechanism for agreeing priorities for investment, so as to offer specialised centres a proper context in which to plan, to devise research programmes, and so forth. There was too much dependence on the system of "extra contractual referrals"--ECRs as they came to be known--which was designed for one-off cases, not to support the development of complex services. And for the patient and their clinician, the ECR system meant a bureaucratic obstacle, in the form of requirement to obtain "prior approval" from the health authority before referral to the specialist centre went ahead. So patients, clinicians and specialist units all had real cause for concern about the impact of these arrangements. I understand the anxiety of noble Lords to ensure that the arrangements we are putting in place will be better. I want to reassure the House on this point. There are two important strands to the action we are taking: first, that there are new, coherent arrangements to plan and commission specialised services; and secondly, new, less bureaucratic arrangements are being put in place to cover the small minority of cases where it is not possible to plan ahead.

The arrangements for specialised services commissioning recognise that these services form much too important an element of the NHS to allow their development to be left to chance, or to the goodwill of individual clinicians, units, or individual commissioning bodies or indeed to the urgings of patient groups. That is why we have charged NHS executive regional offices with ensuring there are proper, coherent arrangements in place to plan, commission and (through long-term service agreements) fund specialised services. This is essential both to ensure patients have fair and appropriate access to specialised services when they need them, and to enable the units concerned to plan ahead with confidence and, if I may say so, to provide the

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flexibility which the noble Baroness, Lady Masham, requested in what she aptly described as a "fast changing world".

As a first step, regional offices have been working with local NHS bodies to identify those collective arrangements to commission specialised services that already exist, and ensure that all health authorities and primary care groups are covered by these. There will then be a rolling programme of reviews to tackle national priorities and the priorities for attention identified in each region, and ensure that robust arrangements are in place. The result will be agreements between a group of health authorities and their primary care groups and a specialist centre, covering the service to be provided, the flow of funds, the quality standards to be expected, the intended outcomes of treatment, and other important aspects of the service. All GPs in the area covered will be free to refer patients to such a centre in line with the agreement concerned. I believe this is the best course wherever a pattern of need and referrals can be identified. But the Government also recognise that there will be a minority of cases which do not fit these arrangements, and for which provision must also be made; for example when a serious illness or injury occurs away from home, or where a patient has a rare condition and the health authority or primary care group's service agreements do not cover the specialist centre best equipped to help.

This is where the arrangements for out-of-area treatments (OATs) come in. The principle of out-of-area treatments is to make proper and non-bureaucratic provision for these unpredictable but pressing cases. Where a specialist centre can identify a pattern of receiving "one-off" referrals from outside their area in circumstances such as these, the arrangement is that the funding allocation to its "main commissioner" (usually the health authority in which it is located) will be increased to reflect this pattern of referrals. The main commissioner will then add this funding to its own service agreement with the trust. This will become an agreement against which "all comers" can be treated, admitted according to clinical priority by the specialist unit.

I believe that together, the arrangements for commissioning specialised services, and for out-of-area treatments, offer a secure framework within which specialist centres will be able to make their proper contribution to the NHS. It happens that this is an area where we can proceed without primary legislation. That is the reason that it does not appear on the face of the Bill, not because we attach any less importance to specialist services than to those matters where legislation is required.

The noble Baroness, Lady Masham, referred to the case of Helen Smith. I am most grateful to her for giving me advance notice of that. The clinicians in that case have offered what they consider to be the best possible artificial limbs for her condition, which they believe will be most comfortable and at the same time provide her with the greatest flexibility. Experts at Addenbrooke's Hospital which is a regional

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disablement centre, have suggested the coverings in the bionic-electric hands which would best suit her, but she has declined them. They have also offered the possibility of referral to another NHS specialist centre, the Royal National Orthopaedic Centre at Stanmore.

The noble Baroness, Lady Masham, also referred to a story in yesterday's "Newsnight" programme about the Brompton Hospital. Like other specialist services, those services should benefit from the systematic approach for the review and commissioning of specialist services to which I have referred. I cannot give a definitive answer today in relation to the specific issue she raised, but I can say that one of the national priorities we have identified for action during 1999-2000 on specialist service commissioning is a specialist cardiac service. I hope that that will ensure that some of the issues raised will be met.

The noble Earl, Lord Howe, referred to the definition of specialist services. There is no fixed definition and as the noble Baroness, Lady Masham, suggested, there needs to be flexibility, given the fast changing circumstances with which the NHS is often faced. In a circular issued by the Department of Health, a list of potential specialist services was set out, but it highlighted the difficulty in attempting to produce something definitive. I should be happy to send the list to the noble Earl because it offers a starting point that is being worked on by every regional office.

We are asking the regions and the NHS to concentrate, first, on some selected national specialties--for example, cancer and paediatric intensive care units--and during 1999-2000, medium-secure psychiatric services, cleft lip and palate services and issues of particular priority within each region, as each region faces different circumstances and different priorities. There will then be a rolling programme for examining other services.

That is practical because these matters require careful attention. It is sensible to take them through a rolling programme. The funding of specialist services not yet covered by such an approach will be covered by service agreements.

An important question was raised about the relationship between primary care groups and trusts and clinicians. We are stressing to those concerned that long-term service agreements must be based upon dialogue between clinicians in primary and secondary care. That same approach will inform the commission of specialist services, with input from those specialist commissions, which will be critical to effective discussions.

We recognise that it is important to get these mechanisms right. Regional offices will soon be reviewing the existing collective agreements and identifying the sharing of best practice. Issues of how best to assure the proper arrangements for input from clinicians, particularly in specialist services, will be covered in that review.

In relation to the important question of user and carer input, we are stressing to the service that this must be a feature of the new arrangements. Moving

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to a three- to five-year time scale in relation to service agreements will allow much more opportunity for the in-depth involvement of users and carers.

I noted with a great deal of interest the point made by the noble Lord, Lord Walton, about diabetes. That is identified as a future national service framework topic.

The noble Baroness, Lady Sharp, asked about resources. I can confirm that we must work within available resources, but I believe that moving to a stronger role for primary care groups and trusts in commissioning means that the balance must be struck between specialist and local services. It will be struck sensitively and appropriately and in an atmosphere in which the clinicians closest to the patients are very much involved in making those decisions.

The noble Lord, Lord Renton, referred to the variations in service availability throughout the NHS. I believe that the impact of the specialised commissioning arrangements to which I have referred--the development of service frameworks--will help to ensure a broad pattern of provision throughout the country. Of course, when one is dealing with specialist services at a regional level, one must reflect on the different priorities which will be set in different regions.

I wish to assure noble Lords that we are taking proper and careful account of these very important debates. We plan to issue guidance soon to the NHS setting out further details on the out-of-area treatment arrangements. We will ensure that it stresses the importance of pro-active planning around the development of new services, reserving the use of out-of-area treatment for those instances where a pre-arranged service agreement is impracticable. In commissioning guidance later this Spring--and I hope that this answers the point made by the noble Earl, Lord Howe, about the preparedness and awareness of the NHS--and in the light of debates in your Lordships' House, we shall pay careful attention to the proper balance between the different forms of commissioning, local service agreements, arrangements for specialised services and for out-of-area treatments so that together they best provide for the full range of patient needs.

I believe that those arrangements, combined with a duty of partnership, the crucial importance of the health improvement programmes which we developed within each area, the monitoring role of regional offices, and the close involvement of clinicians at all levels will ensure that we deal with these important matters in the appropriate way.

Finally, I assure the House that the new provisions in the Bill--the Secretary of State's powers of direction--will extend to specialised services. I hope that the House will feel reassured by my response and that the noble Baroness will feel able to withdraw her amendment.

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