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Baroness Masham of Ilton: My Lords, the Minister knows full well my interest in specialised services. Perhaps I should declare an interest: I broke my back and had my life saved at a spinal injury unit. Those units are spread across the country; there are seven in England. They go far beyond strategic regions; many of them are super-regional.
Primary care trusts can be parochial. Through the self-help group that I founded with the Spinal Injuries Association, I have come across many people who were not sent to spinal injuries units. My noble friend Lady McFarlane is well aware of the problems and costs of dealing with pressure sores, which can be prevented with good nursing. That involves not merely specialised medical people but also nurses, physiotherapists and occupational therapists. It is vital that those patients go quickly to a specialised unit; otherwise, the whole process becomes very expensive. They can spend up to an additional year getting the problems treated and solved through plastic surgery and all sorts of other measures. Urinary tract infections and the treatment of the bowels may be involved. I have previously discussed such issues in the House. I am aware of the case of a young man who went to Charing Cross Hospital with a broken neck. There was no free spinal unit. No nurse would evacuate his bowels. Noble Lords can imagine the distress that that caused a young man in his twenties. However, that is the sort of situation that arises.
The Minister visited a spinal unit, and we are grateful to him for that. He knows what I am talking about. There are many other highly specialised conditions, including neurological conditions. Some GPs may not have even heard of some of those conditions. Sometimes the training of medical students does not include specialised services; for example, in relation to haemophiliacs, HIV patients and, of course, cancer patients. One could go on. It is a disaster if such patients do not go to a specialised unit quickly.
Therefore, I want to ask the Government why they do not include this issue in the Bill in order to place some emphasis on its importance. I know perfectly well that many specialists want to hold on to interesting patients and then disaster happens.
7.15 p.m.
Lord Filkin: My Lords, if it is necessary, it may be worth returning to the central thrust of the Bill; that is, our commitment to establishing one body which is as close as possible to the public that it serves with a comprehensive responsibility for the health needs of the public in a particular area. For that reason, we see it as essential that the responsibility for commissioning specialist services rests with primary care trusts rather than being placed somewhere else in the system.
Whenever devolution or delegation is proposed, understandably there are always anxieties about whether one should devolve this or that function. I know that the Liberal Democrat Benches will join with us generally in resisting those arguments because frequently the benefits outweigh the risks that are advanced.
The general thrust is that jointly commissioning specialist services by agreement or through a lead PCT is very different from, and we believe vastly better than, having no power at primary care trust level for making judgments about the form of specialist services that are required best to meet the needs of the public.
Having said that, noble Lords have raised a number of concerns about specialised services. We know that in such services patient numbers are small and quality can be achieved only by bringing together a critical mass of patients in each centre. That means that relatively few centres will offer treatment and there will not be a specialist centre in every locality and every local hospital.
As has been mentioned, specialised services are defined by reference to the National Specialised Services Definitions Set, the first version of which was published in December last year. It was a major piece of work commissioned by the Government involving contributions from clinicians, managers, commissioners and patients. It has been published on the department's web site.
Under shifting the balance of power, primary care trusts are responsible for commissioning health services for their local populations. As I indicated, we believe that rightly that should include specialist services. Why do we believe that the anxieties that have perhaps properly been expressed in this debate will not be realised? First, PCTs will be expected to work together on a consortium basis to secure specialised services. That will be an expectation from the department and, more specifically, from the strategic health authority. If, against any bounds of common sense or argument, they are resisted, then ultimately the strategic health authority has the power of direction, although one does not expect or believe that that will be necessary.
However, there is no clarity in that respect. The strategic health authority has a duty to ensure that effective consortia arrangements are in place.Secondly, PCTs are expected to work together in order to maintain continuity and ensure stability. In the short term, clearly PCTs will be extremely busy in the next 12 months or so but they will be expected to honour existing agreements—financial and otherwise—that have, in the past, been negotiated by regional specialised commissioning groups.
Therefore, the existing systems will continue for at least the next year, allowing people to settle in and then, through discussion within a locality or strategic health authority, to hold discussions and make decisions about whether or not any changes in the past practice of commissioning might be desirable.
In order to support that process, regional specialised commissioning groups will continue for at least a further year, with PCTs replacing the former health authority members. RSCGs will have a specific role in developing PCT capacity to commission specialised services as part of a planned transition to successor arrangements. As part of that, in the context of specialised services it will be particularly important to ensure that enough people with the right skills continue in their role.
A number of encouraging reports—I believe that a survey was carried out in January this year—show that PCTs are already beginning to engage very successfully in discussions about taking on commissioning roles for specialised services. But it is not possible to come up with a single geographic model for specialised functions. In some cases, the only sensible commissioning unit will be at national level. In response to the question raised by the noble Earl, Lord Howe, the national level commissioning body will continue with its role, although, in time, the functions with which it deals will evolve because that is the nature of medical service and medical science.
However, it is not possible to say that the strategic health authority is the right body to take on responsibility in certain areas. I have given the principal reasons why we believe that PCTs should have the comprehensive responsibility for services for their public, including commissioning services. Functionally, the strategic health authority might be appropriate in relation to some functions but not in relation to others. There will be a whole pattern of service needs and service distribution which will vary from that. Therefore, there is no single "Holy Grail" answer in response to where all such specialised commissioning should take place.
As I indicated, the role of the strategic health authority will be to oversee the consortia arrangements, with regional directors of health and social care ensuring that the specialised services that go beyond strategic health authorities are also delivered properly within that region.
The Government are adopting a pragmatic approach to commissioning arrangements for specialised services. As I have signalled, current
commissioning arrangements will be continued for at least the next year. Local experience will then inform how they should evolve in the future.However, the Government have given serious consideration to the valid points raised by noble Lords during the Committee stage of the Bill. I am pleased to be able to inform the House that my right honourable friend John Hutton announced at a joint meeting of the all-party parliamentary group on 21st March that over the next six months he would head a review into commissioning arrangements for specialised services, in particular, for the regional-type services covering several strategic health authorities, with a view to issuing guidance in the autumn on arrangements beyond 2002-03.
The review will canvass views on how best to integrate the current RSCG arrangements with the new health and social care regional boundaries so as to ensure that highly specialised services covering large geographical areas are properly planned, funded and monitored.
Finally, I turn to a number of the questions raised by noble Lords during the debate. I have marked that the national commissioning body will continue. In answer to the question raised by the noble Lord, Lord Clement-Jones, as to who would be responsible for commissioning, for ensuring that the commissioning is carried out expertly or for monitoring the commissioning quality at PCT or at consortia level, the answer is clearly that it will be the strategic health authority or, if it is at the supra-SHA level, the regional director.
As to why regional directors should not continue, I believe that that was covered in the previous points that I made. The answer was that that was the case for two reasons: the first was devolution; and the second was that there is nothing perfect about a regional level.
The noble Earl, Lord Howe, indicated his concern about the risks of dismantling, as he saw it, well-developed and coherent plans for specialist services at regional level. But, of course, such structures may well not be dismantled. They will certainly continue for at least another year. One would then expect to see a process of evolution, as people felt that improvements could be made to them, rather than starting with a blank sheet of paper.
With regard to the question of patient and public involvement, I should have thought that that would need to take place at a number of levels. Clearly, the question of whether or not a patient considered that he was being properly served would always need to be dealt with at PCT level. I believe that the noble Baroness, Lady Masham of Ilton, gave a very human example of where one would expect a challenge to take place if a certain practice persisted. However, one would also expect there to be the potential to scrutinise a consortium arrangement and a specialised service arrangement. The nature of scrutiny will of course differ in each of those three places according to the functions they are pursuing.
The noble Earl, Lord Howe, also asked about pooled budgets. It is perfectly possible as part of a commissioning agreement for PCTs not only to commission jointly but to pool and share risk by putting funding into a pooled budget. One can well see circumstances in which that would be both sensible and desirable.
I am grateful for the many points raised in this debate and in Committee. We recognise that these are substantial changes. However, we fundamentally believe that they will in time lead to a better service for the public. That is why we resist the amendments.
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