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Baroness Northover: I thank the Minister for giving way. I was concerned at the briefing meeting about what would happen if no PCT wanted to take a lead in this matter. I would be happy if a PCT wanted to take a lead. That would obviously show an interest and an incentive to do that. However, it seemed to me in the briefing meeting that it was not clear what would happen if no PCT wanted to take a lead.

Lord Hunt of Kings Heath: That is where my "banging of heads" comes together. I shall come to that in a moment in response to the noble Baroness, Lady Noakes.

A number of noble Lords asked about the existing agreements. Perhaps I may state clearly that primary care trusts will be expected to honour existing agreements, financial and otherwise, negotiated by regional specialised commissioning groups and current specialised service commissioners. In future, specialised services will continue to be defined by

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reference to the national specialised services definitions set. I shall place that information alongside the designated services information in the Library.

In the financial year 2002-03, regional specialised commissioning groups, which will continue in existence for the moment, will have a specific role in developing primary care trust capacity to commission specialised services as part of a planned transition to successor arrangements. We are retaining for the moment the regional specialised commissioning groups to ensure that their capacity and skills can be handed over to primary care trusts as part of a planned transitional arrangement. Although continually in our debate today doubt has been passed on both the capacity and willingness of PCTs to take up that challenge, that is not my experience. From speaking to many primary care trusts, I know that work is already taking place in terms of deciding which PCT will take on a particular role on behalf of other PCTs in developing the specification and in the commissioning of such specialist services.

We expect primary care trusts to work together to ensure that specialised services will be effectively commissioned. If appropriate, that might cover the population size of the strategic health authority or involve going across one strategic health authority boundary to another. I understand the concerns being expressed. I can assure noble Lords that it will not be a question of a haphazard approach with some primary care trusts clubbing together and others staying out. We shall expect primary care trusts to form consortia to take collective decisions about the commissioning of specialist services, and that consortia decisions will be binding on all parties.

My noble friend Lord Turnberg spoke of non-executives who said, "We are not really interested in funding specialist services". However, the reality is that the whole structure we are putting into place will not work if that "head in the sand" approach is taken. Seventy-five per cent of the budget of the National Health Service will be at PCT level. The quid pro quo of that kind of resource being devolved to that level is for primary care trusts to accept that they have a wider responsibility than simply their own primary care trust.

In our debate last Thursday, I said to the noble Baroness, Lady Noakes, that if ultimately a particular primary care trust refused to go into such a consortium arrangement—I do not expect that to happen—I would expect the strategic health authority to call it to order. Perhaps I may say to the noble Baroness that her doubts about the effectiveness of banging heads surprised me. Her reputation in the department as a most effective banger of heads is still as strong as ever within the walls of Richmond House. Surely, the new leadership skill of the strategic health authorities is not to second-guess primary care trusts nor to attempt to micro-manage, but to have an ability to intervene where necessary if there is a problem.

Perhaps I may say to the noble Baroness, Lady Masham, that I am well aware of the issues concerning spinal injury units. Indeed, I would regard the well-being of such units as a test of the new commissioning

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arrangements in two ways. First, it is to show that PCTs have the ability to commission such specialist services. Secondly, I took the point she made about patients who may have been cared for in such units being further treated in local general hospitals where their specialist needs may not be fully understood. One of the great advantages of primary care trusts is that they can leverage pressure at local level on those district general hospitals.

I have spoken at some length. I am confident that the new arrangements can work effectively. I do not agree with my noble friend Lord Turnberg that to top-slice specialist service commissioning at strategic health authority level is a good thing. I believe that it detracts from both the competence and authority of primary care trusts. I believe that the arrangements I have described with the performance management role of strategic health authorities is the best way to get us through this issue.

Baroness Noakes: I thank the Minister for that response. Indeed, I thank all other noble Lords for taking part in the debate on the amendment. I hear the Minister explain how this will work in practice, but we keep coming back to the fact that he has one view of the world—that is, that there will be PCTs which will do these things and strategic health authorities which will do certain things, largely called "performance management"—and that he seems unwilling to accept that there may be better ways to do things at different levels. He said, for example, that where it would make sense to organise commissioning on a larger population base than for PCTs, the answer—which most of us would think logical—would be to say, "Let's do it at the strategic health authority level or with a group of strategic health authorities, if necessary"—

Lord Hunt of Kings Heath: I am grateful to the noble Baroness for giving way. That was not quite what I said. The responsibility would still be with primary care trusts, but the specialist commissioning might go across strategic health authority boundaries and therefore engage a wider group of primary care trusts.

Baroness Noakes: I thank the Minister for that. I was aware of it. The point was that if the noble Lord was saying that commissioning should be done on the basis of a larger population area the logical answer is to say that several PCTs should do it. The logical answer is to ask whether there is another tier in the service that more naturally can fit with the commissioning need. Yes, there happens to be another layer called the strategic health authority. So it is logical. The Minister starts from the proposition that everything must be put down to PCTs and then be lifted back up again. Some of us see the matter as being much more logical, secure and safer in terms of commissioning coherence and robustness if it was not pushed down and then brought up but was left at a higher level.

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7.30 p.m.

Lord Clement-Jones: Will the noble Baroness agree with me that we are now in the second of two debates where we get these rather precarious organisations. We have this consortium of PCTs in the case of commissioning and with regard to public health we have these rather amorphous public health networks. It seems to me that we are building rather a lot of responsibility into organisations which are highly precarious.

Lord Hunt of Kings Heath: Could I—

Baroness Noakes: I completely agree, but the Minister may want to say more than that.

Lord Hunt of Kings Heath: That is why I rose, to try to deal with the issue before the noble Baroness felt that she had to respond. The point is that as dedicated de-centralisers the Government are investing a great deal of faith in primary care trusts. I make no apology whatever for that. Of course there are some areas where commissioning needs to go wider than primary care trusts. I agree with the noble Baroness that we could have taken a different approach. We could have said to strategic health authorities, "You do all the difficult things. Top-slice the money and leave primary care trusts with the routine stuff". But that would have detracted from what we are really trying to do, which is to get decision making down to the primary care level. If one goes down the Government's route, you do—

Baroness Finlay of Llandaff: I express a grave concern. The Minister has expressed that he has great faith. I would call for evidence to support the changes, and evidence that patients' care will not be jeopardised. I have a real concern that while the changes go through—we know that it takes two years for organisations to bed down and find new ways of working—there will be ill patients who miss out on the services they need. There will be arguments between who is commissioning what. In the process of that, services will be destabilised. Destabilised services do not function well.

Lord Hunt of Kings Heath: The evidence that I would pray in aid is: first, I have already described how the current regional specialised commission arrangements will hold for another year while the regional specialised groups work with primary care trusts to ensure that in the future they have the capacity to undertake specialised commissioning.

Secondly, we are working already with primary care trusts which have been in existence for some time. The evidence I have to hand is that they have worked very well indeed. They have delivered improvement to patients. They have not led to huge gaps, risks or failures to commission certain services. In fact, they have shown that it is perfectly possible to deliver and commission services at the primary care level while at the same time recognising that they are part of a fully

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integrated national system. It is that balance that gives me a great deal of confidence that primary care trusts will rise to the challenge being set for them.

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