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Baroness Masham of Ilton: My Lords, before the Minister leaves that point, will she say whether there will be a right to appeal for patients if they are not sent to the appropriate place of treatment?

Baroness Hayman: My Lords, perhaps I may deal with that issue in a moment. The way in which the right of appeal is defined and implemented in terms of clinical judgments about what is an appropriate referral is a difficult issue. However, we want the new regional reports to cover the interface between specialised commissioning arrangements and the arrangements for ad hoc, out-of-area treatment. In that respect, patients could consider that they fall between two stools.

The report will identify, for example, where an increase in the number of ad hoc referrals suggests the need to move to a planned long-term service agreement within the specialised commissioning arrangements. This will enable all concerned to reach clear understandings about the pace at which the service will develop and the types of case that it will treat.

Each annual report will of course be available to health authorities, primary care groups and trusts, NHS trusts and patient groups in the region concerned. But, recognising the interest in your Lordships' House, I can confirm that we shall ensure that a full set of these regional reports is available in the Library. The year 1999-2000 is the first for the development of the new arrangements and we therefore anticipate the first reports being available next summer.

It will also be important to take stock of national lessons emerging from these regional arrangements and ensure that good practice is shared; and we wish to ensure that the interface between the national and regional commissioning arrangements is working smoothly. The National Specialised Commissioning Advisory Group, which deals nationally with some of the most specialised services of all--for example, specialised psychiatric services for the deaf--already produces an annual report. We believe that the right way forward is likely to be to ask this group to extend its annual report to cover national lessons emerging from the regional arrangements so that there is a comprehensive and readily accessible account available. Again, copies will be placed in the Library.

Finally, I should like to reaffirm the importance we attach to ensuring that the users of these services are involved in the development of the new arrangements and have confidence in them.

Our debates have highlighted the need to look at strengthening user and carer involvement, not just in local commissioning arrangements, but in the new regional arrangements and indeed in the arrangements for the National Specialised Commissioning Advisory

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Group. In the light of our debates, I shall want the department to explore with patient groups and the NHS how best to secure greater user and carer input into the new arrangements; for example, through involvement in service reviews.

I return to the issue of a patient being unhappy with the decision not to refer. Of course, all patients can discuss with their GP a decision not to refer where the GP considers it clinically appropriate. If a patient is not happy, the GP can arrange a second opinion and the GMC guidance is very clear that it is good professional practice to arrange for that second opinion if the patient asks. However, in response to the issue raised by the noble Earl, Lord Howe, the principle that GPs have the clinical freedom to refer in the best interests of their patients remains. There is now greater scope than ever before for PCGs to align the available resources with those GP judgments. They are now involved explicitly through their PCGs in discussions about priorities and cost effectiveness to ensure that they achieve the best for their patients with the total resources available.

The basic principle for all the new commissioning arrangements is to promote the development of services that best match the needs of patients as identified by their GPs. As regards referrals where, for other reasons, patients are not met by the PCGs' service agreements, general practitioners can use the out-of-area treatment mechanism. Unlike the previous arrangements, there is no formal prior approval mechanism for out-of-area treatments, so we have a simplification of the situation rather than making it more difficult. There is nothing to stop a PCG, for example, making a service agreement to refer patients outside their own areas where that makes sense.

The noble Earl, Lord Howe, asked about the funding arrangements. They are designed to ensure that the issues are resolved while ensuring that patients receive the treatment they need. Clearly, it is key that over-performance within service agreements for more specialised services should not prejudice the delivery of more routine and locally based services. In managing their portfolio agreements, NHS trusts, health authorities and PCGs should ensure that that does not happen. Additional work is in hand in some areas to develop risk pools to which health authorities and PCGs will contribute to help manage in-year fluctuations under the OAT arrangements. Clinical units under short-term pressure could have access to cash brokerage in the usual way. That helps trusts both with their financial management and in imposing a measure of financial discipline as regards commissioners. The guidance we are issuing on those will encourage such pooling developments.

If there were a significant increase in referrals, the units concerned would need to explore with the referring PCG whether this trend was likely to continue. In that case, it would be better handled through a planned service agreement using the usual specialised arrangements if appropriate rather than continued use of out-of-area treatment and having to deal with the financial consequences.

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In our earlier debates, including our debate at Third Reading when the House voted through amendments moved eloquently then, as again today, by the noble Baroness, Lady Masham, my sense was that the House wished to register the importance it attached to ensuring proper access to high quality specialised services for those who need them. That, rather than the specific terms of the amendments, formed the substance of our debate. Perhaps I may repeat that the Government share the views of the House and that the arrangements we will put in place are designed to achieve that end. I cannot pretend that they will be achieved overnight because we start from a position in which there is unequal access to some services.

I believe that the right response to the view your Lordships have expressed so strongly today is not to be found in fine-tuning the drafting of the Bill. I have explained that it already contains the necessary powers and duties and that there are no legal obstacles to referrals to specialist centres. I believe that in legislative terms there are dangers in leaving the Bill as it is and not agreeing with another place in their amendments. I believe that the right way forward is to ensure that the new arrangements fulfil their potential and that they command the confidence of the patients who depend on these services and the clinicians who provide them.

I pay tribute to the noble Baroness, Lady Masham, for the way in which she has kept our attention focused on these important matters as the Bill has proceeded. I believe that together the developments I have described represent a serious and constructive response to the debates we have held. I hope that the House will understand why the Government do not consider that the amendments passed in your Lordships' House at Third Reading offer the right way forward. But I hope that the noble Baroness and other noble Lords who have spoken, and those who have listened, will accept that the Government have listened and responded and that we intend to continue to listen and respond to the views of patients and clinicians as the arrangements develop further and that the commissioning of specialised services will be better as a result.

Baroness Masham of Ilton: My Lords, I thank all noble Lords who have supported the Motion and I thank the Minister for her full answer. However, I am concerned because often the tertiary referrals are from hospital to hospital and the GP is not even involved. I hope that that aspect is included.

We have had a useful debate. It was well worthwhile tabling the Motion because we have prised more information out of the Government. We will keep watching carefully, as will the bodies outside your Lordships' House and another place. I know that Members of Parliament are under pressure from their constituents over this matter.

It would not be right to divide the House on this issue. We have been able to put our views forward and to say how strongly we feel over this matter. We will go on feeling strongly. With that, I beg leave to withdraw the Motion.

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Motion, by leave, withdrawn.

Baroness Hayman: My Lords, I beg to move that the House do agree with the Commons in their Amendment No. 18.

Moved, That the House do agree with the Commons in their Amendment No. 18.--[Baroness Hayman.]

On Question, Motion agreed to.



Clause 10, page 17, line 1, leave out ("45(2) or (3)") and insert ("45(1C) to (4)").


Page 17, line 7, at end insert--

("or a function referred to in section 28EE(1)(a) to (d) below").

Page 17, line 33, leave out ("11,").


Page 17, line 40, leave out ("11,").

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