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Earl Howe: My Lords, I welcome these amendments, in particular Amendment No. 15. I welcome especially the scope of that amendment. I understand that a government amendment on this issue was tabled in Committee in another place almost at the last moment. The clause as then framed was deficient, at least in the eyes of the Opposition, in that it did not cover, as the noble Baroness rightly said, the 7,000-plus non-principal GPs who have the right to expect their views to be represented in their local representative committees, if those committees are to perform their very important statutory functions in an effective manner. I am delighted that the Government tabled further amendments in Standing Committee to meet the concerns expressed. The very satisfactory result is what we now see on the Marshalled List as Amendment No. 15. I thank the Minister for her comments.

Lord Clement-Jones: My Lords, in very similar terms I add my thanks to the Minister for the amendment. I know that the amendment is very broadly welcomed by the medical profession.

On Question, Motion agreed to.



Clause 10, page 16, line 7, at end insert--

("( ) The Secretary of State may direct a Special Health Authority to exercise any functions of a Health Authority or a Primary Care Trust which are specified in the directions.").

Page 16, line 8, after ("specified") insert ("in directions under this section").

Baroness Hayman: My Lords, I beg to move that the House do agree with the Commons in their Amendments Nos. 16 and 17.

Moved, That the House do agree with the Commons in their Amendments Nos. 16 and 17.--(Baroness Hayman.)

On Question, Motion agreed to.

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Page 16, leave out lines 19 to 23.


That this House do disagree with the Commons in their Amendment No. 18.

4.30 p.m.

Baroness Masham of Ilton: My Lords, I beg to move that the House do disagree with the Commons in their Amendment No. 18. As your Lordships will remember, the House agreed two amendments referring to out-of-area treatments where appropriate for the purpose of receiving specialist hospital treatment and after-care. The second amendment stressed the need for co-operation over this matter. There was a great deal of support for OATs to be written on the face of the Bill in another place, but the Government want them taken out.

I thank the Minister for her communication. The noble Baroness knows so well the need to be able to access the correct medical treatment when illness strikes. In the past few days I have been implored by patient organisations to table a Motion disagreeing with the Commons amendment. On Wednesday 9th June in your Lordships' House there was an Unstarred Question on the subject of artificial limbs. There is a great need for improvement in many National Health Service specialised services.

In the past few days every time I open a newspaper I read of some avoidable health disaster. The case of the Treasury official who was refused admission to a psychiatric hospital and then killed his wife illustrates the need for better communication between junior doctor and consultant and, with the shortage of beds, between health authorities. If there is not a bed in one area there should be easy access out of a person's home area so that he gets the correct treatment quickly. The Government will realise that serious illness can come to anyone at any time. I believe that the general public regard access to correct health treatment as a top priority.

Referring to the bottom of page 11 of the Notes on Commons Amendments to the Health Bill, perhaps the Minister can explain the following statement:

    "adding wording of that sort ... may have the unfortunate and unintended consequence of being construed as limiting the scope of the power". Having discussed this matter with expert advice from your Lordships' House, the matter needs clarification.

In the modern world people who suspect complicated medical conditions turn to the Internet to see what treatments exist. The Patients Forum believes that longer-term service agreements replacing ECRs (extra contractual referrals), based on past referral patterns, will reinforce existing inequalities. Some areas will not plan to provide services at all. The transition from ECRs to the out-of-area treatments (OATs) is confusing users and practitioners.

The lack of clarity and poor communication run counter to the NHS code of openness, which emphasises the importance of users,

    "having access to available information about the services provided by the National Health Service. The cost of these services, quality, standards and performance against targets ... authorities must ensure that people know whom to ask for information".

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    There seems to be no clear accountability.

Denying access to specialist services, through limiting OATs referrals, risks denying access to greater independence and other opportunities such as Welfare to Work and the New Deal. Referrals out of area should be made on clinical need. Refusals of OATs referrals must be monitored to ensure that they are not based on non-clinical factors such as PCG, PCT or health authority pressure.

Can the Minister give an assurance that rural health authorities, which often do not have many of the specialised hospital units within their local hospitals, will not be at a disadvantage when they have to send patients out of their local areas? The cost-inefficiency of losing specialist centres of excellence must be avoided.

Disability organisations, the College of Health and the National Consumer Council all support this matter and know the importance of getting expert treatment when needed and will continue to press the government on behalf of patients. To have OATs written into the Bill is a very reasonable request and I believe that it is the Government who are being unreasonable over this matter. I beg to move.

Moved, That the House do disagree with the Commons in their Amendment No. 18.--(Baroness Masham of Ilton.)

Lord Ashley of Stoke: My Lords, I speak in support of the noble Baroness, Lady Masham, and about genuine miracles. My concern is about the future of specialist services for deaf people. I wish to speak also about the provision of cochlear implants.

I declare a personal interest, but that does not mean that anything in the Bill will affect me because I already have a cochlear implant. A person with such an implant knows that it miraculously transforms his or her life if they have been, as I was, totally deaf. I am in no doubt that anyone who could benefit should get one. That is a very simple proposition, but it is one which is impeded and sometimes obstructed by health authorities. Cochlear implants are still relatively new and rare. Many people, including health professionals, simply do not appreciate that they are medical miracles.

Any loss of hearing can be a problem as many noble Lords in this House will know, but the complete loss of hearing is of a very different order. To hear nothing is a terrible deprivation because it ends easy conversation. It means that there is no music, no meaningful television, no radio, no birdsong and no children's laughter. It means exclusion and isolation.

To a large extent a cochlear implant remedies much of that. It is not perfect, but it returns a deafened person to near normal social living. The number of implants being carried out now is falling especially for adults. In 1997 there were 180, and 155 in 1998. The number of refusals is rising. For adults there were 27 refusals in 1997 and 65 in 1998.

Health authorities have discovered a shabby trick. If they refuse an initial assessment, that can stop a deaf person protesting, and that is being done. Out of 65 adults, 41 were refused assessments in 1998. That is the

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kind of shabby behaviour of some of our health authorities. That is a depressing and deplorable outlook facing people deprived of a major sense.

The first cochlear implants were funded by charities. Then came three-year central NHS funding, coupled with Medical Research Council research, which established that they are safe and cost effective. Then funding became a health authority responsibility and the problem started. I did a personal survey of all health authorities in January 1997. It showed a great variation in understanding of total deafness and willingness to relieve it. Since then I have received countless letters from deaf people despairing of ever getting an implant. Many health authorities have responded to my letters about this medical miracle and some have now agreed to fund. Even the most rigid health authority in Britain, which is Oxfordshire, was refusing to implant adults in the foreseeable future, but it has now relented. I congratulate that authority on its change of mind.

But it is still guerrilla warfare. Many health authorities are good; some are slow but tolerable; and others are deplorable. That is no way to treat the hearing needs of totally deaf people. As my noble friend the Minister knows, there were high hopes that we would get regional commissioning. Cochlear implants fulfil all the conditions in Annexe A of the HSC circular Commissioning Services, but they are not named in Annexe B, as are bone-anchored hearing aids. There is only a reference to "communication aids". Not naming cochlear implants gives scope for argument and disagreement and deaf people want and need certainty.

The new procedures of out-of-area treatment mentioned by the noble Baroness, Lady Masham, and service agreements may sound sensible to my noble friend and other Ministers and civil servants. All of them are trying to be helpful. But they are linked--at least initially--to previous levels of referrals. That is the weak element which needs to be remedied. There is a strong smack of lip service backed up only by promises that remedial action will be taken if necessary. That is a "wait and see" strategy when we can already see a highly visible problem for deaf people. I urge the Government to think again. I know that my noble friend will do what she can to ensure that cochlear implants are firmly based on the regional commissioning list. If they are not, the funding bodies will be able to duck, weave and swerve, and some deaf people will be left knowing that help is possible, but they cannot have it. If my noble friend can meet this provision she will have struck a major blow for the totally deaf. I support my noble friend.

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