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Lord Turnberg: The problem that PCTs have in being responsible for commissioning specialist services may not be insurmountable but nevertheless will be a problem. The problem is that, by and large, the number of patients requiring specialist care is fairly small in the population for which they are responsible, of something like 100,000.

It poses particular problems for an individual PCT when there are so many more patients requiring its attention and having more pressing problems. For example, two or three patients with a rare, expensive disease such as haemophilia, moving into a new GP's

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practice can cause enormous problems and havoc for its budgeting. Patients needing renal dialysis or transplantation, for example, may be ill served in this system and such services may become threatened in the process.

The proposal that a lead PCT will act for several PCTs may work, but only if each PCT is willing to fund it. I have spoken to one or two non-executive PCT members and they tell me that there is considerable reluctance to fund in this way. I am not yet convinced, therefore, that specialist services should be the responsibility of PCTs, but rather should be the direct responsibility of strategic health authorities. At least there the population of a million or more provides enough patients with specialist services for them to take a particular interest.

Although I am not in favour of these particular amendments, I would look to a separate system for commissioning those services, which I think would be very much welcomed by the PCTs and by the NHS trusts. There may of course be other ways in which we can ensure that these important services are not damaged and are protected. I very much look forward to hearing how the Minister will reassure us on this.

Baroness Masham of Ilton: I would like to declare an interest. I would not be here today if I had not been treated in a specialised unit—a spinal unit which was classified as a supra regional unit, that is, going beyond the region. I was very grateful to the Minister, who came down to see one of the spinal units when it was experiencing some difficulties.

What will be the national overview with regard to these specialised units? Will Ministers still be able to be involved? I believe that some of the very complicated neurological conditions must be treated in specialised units. Can and will the patients be able to be sent anywhere in the country for treatment? Sometimes their needs are very unique, and there are but a few specialists dealing with such conditions.

I should like to tell the Committee how important it is to get the correct treatment quickly, and how cost effective it is. I had seen so many disasters in the spinal injury field with people receiving the wrong treatment and suffering from horrific pressure sores that I founded the Spinal Injuries Association. Some years ago, we undertook a survey on pressure sores, which cost the country millions of pounds of extra money that could be avoided. We found that the worst pressure sores arose in the intensive care units of teaching hospitals. That may seem surprising, but, while everything is monitored, the basic skin is forgotten. It is often the basic treatment that is so important. Therefore, the expert doctors, nurses, physiotherapists, and all the ancillary staff, have an important role to play.

I believe that such amendments are very significant. It will be interesting to hear what the Minister has to say, because many people throughout the country are worried about these very specialised services. I look forward to hearing his response.

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Baroness Finlay of Llandaff: Perhaps I may express my concern over the lack of protection of secondary and tertiary services, as outlined in the Bill at present. The problem is that tertiary services are integrally linked with secondary care services: they cannot be separated. We do not have enough resources to separate tertiary care completely from secondary care. Therefore, within the hospital sector and the specialist sector of the NHS we have the full range of services, of which I should like to give the Committee some specific examples. I should declare an interest here as I am married to a dermatologist. Building on the example of skin, as used by the noble Baroness, Lady Masham, I should point out that dermatologists function as generalists, but within that service there are also highly specialised fields, such as paediatric dermatology, surgery, viral disease, inflammatory diseases, and occupational dermatology clinics, as well as cancer clinics.

I should also declare an interest as I have just been a patient and been in receipt of Mohs surgery, which, until I was on the receiving end of it, I did not know existed. There are a handful of specialist dermatological surgical centres around the United Kingdom, as well as a few photo-dermatology centres; yet there are general services everywhere. The difficulty with not protecting the whole of the secondary care sector in commissioning is that you may well find that you are simply buying a generalist service, and losing the highly specialised expertise that is required in the process.

I also have a concern that we might return to some of the nightmares that occurred under fund holding. At that time, it was an administrative nightmare to find that some fund holders had contracted for certain services while other fund holders had not done so. Therefore, you would have two patients from different areas under separate GPs who, under the commissioning arrangements, were able to access different parts of services. That inequity was terrible for those functioning in the secondary care or tertiary care service sectors.

My other concern is that there may be a misguided view that primary care trust commissioning will somehow act as a form of rationing and control expenditure in secondary and tertiary care. However, there is evidence to show—although it is anecdotal—that unmet needs are revealed where GPs and those in primary care are better educated about conditions. The result is more appropriate referrals, not fewer referrals. There is a need to ensure that the spectrum from high quality primary care into secondary care and on to tertiary care is protected right the way through, thereby securing the highest standard of care for patients who need it at the time that they need it; in other words, not too late when problems have to be undone. I look forward to hearing the Minister's reply.

7.15 p.m.

Baroness Northover: When the internal market was first proposed, I remember a high level civil servant from the Department of Health being asked how the new arrangements would ensure that specialist services

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would be preserved. She replied that she did not know, and that 15 years would show whether or not they would go to the wall—by which time, of course, it would have been too late. It struck me then, and still does now, that that was a most cavalier approach. Indeed, since the NHS was introduced, specialist services have often sat uneasily in a service that tries to provide everything everywhere and ends up by not doing so. Unless this area of concern is properly addressed in the way outlined, yet again, a civil servant at the Department of Health might, truthfully, be able to say that he or she does not know; and, indeed, such services might well go to the wall.

We all know how important it is to retain specialist units given the huge variation of outcomes according to whether or not people are treated in such units. I was not reassured during the briefing meeting before the Committee stage, which was otherwise most helpful, when the Minister seemed quite unsure as to how decisions would be taken as regards which PCTs would lead in each specialist area. I trust that the Minister will be able to give more concrete guarantees today.

Lord Hunt of Kings Heath: The matter of specialist services is one that has always been of great interest to noble Lords, and rightly so. I am the first to accept that it is important not just to patients but also to the NHS—and to the wider issues of teaching and research in this country—that we support our specialist services with the right kind of resources, and the right kind of agreements, in terms of ensuring that there is appropriate patient referral.

I echo a point made by the noble Baroness, Lady Finlay. My general view on the matter is that part of the approach of getting this right is to recognise the inter-relationship between primary, secondary and tertiary care rather than treating specialist services as an isolated service to be resourced and dealt with in a completely different way from that applied to other services that will be commissioned by PCTs in the future. The care networks under development in a number of important areas involve an integrated approach through from primary to secondary and then to tertiary care. They are very often roughly aligned with the strategic health authority boundaries. I certainly hope that they will provide the sensible approach in terms of commissioning, funding, and the referral of patients that we all seek.

By their very definition, specialist services are those with small patient numbers. Quality can be achieved only by bringing together a critical mass of patients in each specialist centre. Inevitably, relatively few centres will be able to offer treatment, and there will not be a specialist centre in every locality. By concentrating specialist services in a few centres, we hope to achieve the best outcomes, maintain clinical competence, sustain the training of specialist staff, support high-quality research programmes, and ensure that services are cost effective, while making the best use of scarce resources, including expertise, high technology equipment, research and development.

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As the noble Lord, Lord Clement-Jones, suggested earlier, typical specialised services include drug treatments for HIV and AIDS, rare cancer services, children's intensive care services, neuro-surgery, secure mental health services, renal services, and so on. Where those services are for exceptionally rare conditions, and where service provision would otherwise be vulnerable, the National Specialist Commissioning Advisory Group will be asked to commission the services on behalf of the whole country. I have a list with me of the designated national services in 2001, which includes over 20 services. Again, I shall be very happy to place a copy of this list in the Library of the House for the convenience of noble Lords.

It is important to stress that national commissioning can and should occur only where local solutions are impossible to achieve. That is why under Shifting the Balance of Power, which contains the principles under which the Bill is brought before the Committee, primary care trusts will be responsible for commissioning health services for their local populations. That principle applies also to specialist services.

However, we recognise that where it makes sense to organise services on a larger population base, so those services will be organised on a larger population base. That is why primary care trusts will be expected to work together on a consortium basis to secure specialised services, except for that list of highly specialised services which will continue to be commissioned at national level.

The noble Baroness, Lady Northover, felt that I was not explicit enough on how a PCT would be selected at local level if it was decided that one PCT would undertake specialist commissioning in relation to one service and another PCT would take on specialist commissioning for another service. I do not believe that I should be explicit, nor that it is my position to be. The point is that this is the kind of arrangement—

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