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Secondly, the noble Earl, Lord Howe, was right that we are in urgent need of data on incidence, frequency and, most of all, location. Let us be absolutely honest: we shall not have a specialist unit in every district general hospital; there will always need to be a small number of highly specialised units which filter out their knowledge and expertise into secondary and primary care. The question is where they should be. The location of our current services is an accident. I do not know, and I would like somebody to tell me, whether there is a case for a new unit in Birmingham, because the new military hospital is there, which I imagine is seeing an awful lot of people with spinal injuries and is perhaps developing an area of expertise. Particular sports might attract a unit. For example, I imagine that if you were going to choose a location for a national centre in Scotland, you would want to find a location that was not only within a short distance of the largest centre of population but also within reach of people who have climbing accidents, who have a high number of spinal injuries.
Thirdly, the noble Lord, Lord Walton of Detchant, was leading us to the right point on the collocation of those services with others. In this day and age, with research as it is, there is an increasingly convincing case for having spinal injury and neurological units, if not together, then in close proximity. I do not wish to take the Committee into territory that might be contentious, but some of the researchfor example, on stem cellsis going on in neurology and will have applications to those with spinal injuries.
When the Minister comes to respond to the debate, she may feel that her department is unable to accept the amendment. However, perhaps she can take those points from this debate and indicate whether and how the department would be willing to review and update the overall provision of these badly needed services.
Baroness Cumberlege: First, a debate like this shows the tremendous strength, expertise and personal experience in the Committee; I have found it very moving. To take
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I like the idea of the noble Baroness, Lady Emerton, that we should perhaps have an interim solution. I see the Minister looking more and more glum as she replies to the debate. I suspect that she will say that she is very sorry but she cannot go with a national bed bureau, so we will have to try to think of other ways of resolving some of these problems. As I have said, we must do it through commissioning.
The other area is awareness. I am appalled by some of the statistics. Just 19 per cent of new injuries were admitted on the day of injury, yet we have heard from people with enormous expertise that speed is of the essence; I know that the noble Baroness, Lady Masham, has got her society going and tried to increase awareness of the issue. Can the Minister, thinking forward, say in her reply what the Government can do to ensure that there is much greater awareness of that, especially in accident and emergency units but also throughout the country? It is important that people are admitted within four hours of the injury if at all possible.
Baroness Meacher: I do not want to detain the Committee. I want to make a couple of points and, in particular, add my support to this incredibly important amendment. I was impressed by the contribution of the noble Earl, Lord Howe. It seems to me that we have a win-win situation here.
I do not altogether accept that we cannot expand capacity. The foundation trusts, in general, build up considerable cash reserves and the capacity to borrow for capital projects. In the years ahead, however, after the following two years, there will be the most incredible squeeze on resources in the National Heath Service for revenue for ongoing expenditure. The Department of Heath probably cannot afford not to have the amendment, or something rather similar to it. We will be unable to spend at the same level as we have in the past. Here we have a possibility of improving the quality of services for severely injured or unwell peopleof course, we all want to see thatwhile cutting the overall revenue spend, so I hope that the Minister will be able to support the amendment.
My final point is about bed occupancy. In mental health, we have always worked to 100 per cent bed occupancy and under government targets, we are being driven to a lower level: 85 per cent bed occupancy. I find it hard to imagine that other bits of the NHS are driving bed occupancy up to 100 per cent, so I hope the department can clarify that point because it is extraordinarily important.
Baroness Thornton: Amendment 126, moved by the noble Baroness, Lady Masham, would establish in statute a new national bed bureau to oversee the commissioning of services for spinal injuries. I am grateful to the noble Baroness for raising the important
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I found the contribution made by the noble Lord, Lord Tebbit, very moving. He will not remember, but we had a conversation some years ago when he was campaigning on behalf of Stoke Mandeville Hospital. I expressed my support for his campaign because my grandfather returned from the war and was put back together at Stoke Mandeville. He lived for 25 years in a wheelchair and visited Stoke Mandeville Hospital two or three times a year, so I may have been six years old when my noble friend had her accident, but at that time, I was sitting on the knee of a grandfather in a wheelchair, so I am very sympathetic to this.
I wrote to the noble Baroness on this matter last week, and I hope she will forgive me if I repeat for the record some of the points I made in that letter. I fully sympathise with the situation she described but, at the moment, we are not convinced that primary legislation is the best route to achieving her objectives. In May 2006, Sir David Carter published his Review of Commissioning Arrangements for Specialised Services in response to a request from the noble Lord, Lord Warner, then Minister of State at the Department of Health. This report resulted in the establishment of the National Specialised Commissioning Group, the National Commissioning Group, and 10 new specialised commissioning groups, including one for spinal injuries. The noble Baroness, Lady Cumberlege, is correct that commissioning is the answer.
The new arrangements offered significant improvements in the organisation and governance of specialised services commissioning at local and national level. Specialised commissioning groups plan collectively, share risk through pooled budgets and co-ordinate strategic commissioning across PCT boundaries. No primary legislation was needed to establish them, and one of our concerns is that to place the arrangements for spinal injury services on a statutory footing might undermine the work being undertaken across the breadth of specialised services. That is not to say that we are by any means where we wish to be on this matter.
I understand that the Spinal Injuries Association sits as a partner on the south of England board for the commissioning of spinal injury services. The board has discussed making proposals to the National Specialised Commissioning Group for an English forum for spinal injuries, in similar terms to the proposed amendment, which could help set a strategic direction and address concerns across organisational boundaries.
No formal approach has yet been made to the National Specialised Commissioning Group or its support team. I am pleased to inform noble Lords and the noble Baroness that the director of national specialised commissioning is keen to meet representatives from the Spinal Injuries Association to discuss these proposals. The director is currently in consultation with the south of England board to explore how its existing collaborative arrangements are working, what wider applications they might have and a range of other options for improving commissioning arrangements, all of which has the potential to improve the experience
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The noble Earl, Lord Howe, and my noble friend Lady Wilkins both mentioned the lack of data about the number of spinal injuries. We recognise that this is a problem. The clinical coding for spinal injuries is weak, but the NHS is making bids for new codes which will better identify spinal injury patients and the severity of their cases.
There is a strong case for improving the co-ordination of the commissioning of spinal cord injury services and we are looking to the National Specialised Commissioning Group to lead that. We want to facilitate the meeting as soon as possible to take those arrangements forward. I hope that this offer of further consideration within the existing structures and further discussion with the noble Baroness will go some way towards reassuring her, and that she will withdraw her amendment.
Baroness Masham of Ilton: I thank all Members of the Committee who have taken part in this debate for their support. I also thank the Minister, who is always helpful, for which I am very grateful. The Spinal Injuries Association recently received a letter from a consultant in Oldham who had had a spinal cord injured patient. He had contacted Middlesbrough to get the patient a specialised spinal bed, but he was told by Middlesbrough that it takes only patients from its own area. Recently, I was told that five tetraplegics are on respirators, waiting for beds in a spinal unit, in the intensive care unit of the Royal London Hospital. What is that if it is not blocking beds?
On Sunday night, I spoke to the sister of a tetraplegic who has been in the Norfolk and Norwich University Hospital for 12 weeks on a respirator, awaiting a bed in a spinal unit. He has already had a pressure sore. A few years ago, the Spinal Injuries Association did a survey of how patients get pressure sores. It found that most of them occur in intensive care units where everything is monitored, but basic skin is forgotten. How many more such patients in general hospitals across the country are getting into difficulties? How many paraplegics, who get just as many problems and get just as depressed, are in general hospitals?
Some Members of the Committee may have read about the tragic case of the young rugby player mentioned in this weeks Sunday Times. He was treated incorrectly, which made a disaster of his life. My noble friend Lady Wilkins has referred to this young man. I am told that there is an upsurge in rugby accidents. Many sports, such as diving, riding and mountaineering, incur spinal cord injuries, as do driving and industrial injuries, as well as even falling down the stairs and getting stabbed or shot. A tetraplegic in the Royal London Hospital was shot in the neck.
We cannot let this situation get worse. I am sure that this amendment will help. For many years, this problem has been talked about. The noble Lord, Lord Carlile of Berriew, who has put his name to this amendment, said that 20 years ago he was discussing the lack of treatment places for spinal cord injury patients. We must have a better, transparent system of admitting patients across the country. We cannot wait
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Baroness Wilkins: Before the noble Baroness withdraws the amendment, will the Minister clarify my understanding of her answer? Are the Government considering putting spinal cord injury into the national commissioning group as opposed to the regional commissioning group, where it is at the moment? In that way, the Government could make the proposed changes in the amendment to provide a national commissioning body without the need for legislation or for making spinal cord injury a special case.
(1) Where an individual makes a payment in resepct of a premium under a contract of private medical insurance, it shall be deducted from or set off against his income for the year of assessment in which it is made for the purposes of calculating his liability to income tax.
(a) a premium, in relation to a contract of insurance, is any amount payable under the contract to the insurer,
(b) a contract is a contract of private medical insurance where
(i) it either provides indemnity in respect of all or any of the costs of all or any of the treatments, medical services and other matters for the time being specified in regulations made by the Secretary of State, or in addition to providing indemnity of that description provides cash benefits falling within rules for the time being so specified,
(ii) it does not confer any right other than such a right as is mentioned in sub-paragraph (i) above, and
(iii) the premium under the contract is reasonable.
Lord Palmer: I am aware of the time. We have spent over an hour debating the important amendment proposed by my noble friend, and we are now on the seventh day of Committee. Some Members of the Committee will no doubt remember that I tried to persuade Her Majestys Government that this amendment had great merit during the last Health Bill in 2006. I am introducing it again for the same reasons as last time. It would simply greatly encourage individuals and companies to invest in private medical insurance, which in turnthis is the important partwould greatly reduce the National Health Service waiting lists. That is the sole purpose of
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Lord Walton of Detchant: I know that I shall be unpopular with the Government for giving warm support to the amendment. When I became a consultant neurologist in 1958, I chose at the outset to be part-time in nine sessions, and I spent two half-days a week in private practice. That was an interesting experience and one which I greatly enjoyed, though I was absolutely meticulous in making certain that my nine NHS sessions were more than fulfilled, often amounting to over 60 hours a week.
At that time, I had a neurological ward with 28 beds, and of those 28 beds in the Newcastle General Hospital there were eight single rooms and two bays, one of 10 beds for women and one of 10 beds for men. Of the eight single rooms, two could be used at any time, if the situation so arose, for the care of private patients. I have no doubt whatever in my mind that, as time went by, the situation became very difficult because, under pressure from the trade unions at the time when Mrs Castle, subsequently Lady Castle, was Secretary of State for Health, slowly but surely private beds were withdrawn from NHS hospitals. We ended up with the ridiculous situation that there were in Newcastle three private beds, one in each of the main general hospitals.
I had by then become a full-time academic, and I was no longer undertaking private practice, after several years as a consultant in part-time practice. I had built up a major research unit for research into neuromuscular disease, for which I developed such a reputation that we had patients referred from other parts of the world to come to that unit for investigation. Very properly, it was the law that any patient coming directly to the UK for treatment from overseas had to be a private patient. That was absolutely right, because it was not the case for people who were visitors from overseas who happened to fall ill. Those who came specifically who were referred from overseas had to be private patients.
That decision by Mrs Castle gave the greatest impetus to the development of private hospitals outside the NHS of any decision of any Government. Before that time, many consultants in part-time private practice were geographically full-time: they looked after their NHS patients and their private patients in the same hospitalthey were private wards, all of which were closed. I was thereafter compelled to refuse patients referred to me from the United States, Australia and other countries. I could not take them into hospital because no specialist facilities such as were required for the investigation of neuromuscular disease existed in any private hospital. I found that situation intolerable.
I have always believed that a partnership between the public and the private sectors is a benefit to the National Health Service provided that part-time consultants give their services, as they must for the time for which they are contracted, to the NHS. Individuals with private health insurance have paid their taxes and have in the same way as everyone else contributed to the costs of the NHS. The proposal would benefit the National Health Service by allowing
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Baroness Thornton: I shall address Amendment 127, tabled by the noble Lord, Lord Palmer. It is a long and well established principle that most personal private expenditure is not eligible for tax relief. Our tax system has to be fair to a very large number of people and relief is given only where it supports specific government priorities. Premiums paid for private medical insurance are treated in the same manner as other personal expenses and are not liable for income tax relief.
Alongside general tax principles, there are several reasons why the Government do not allow tax relief for individuals paying private medical insurance premiums and why they do not support the amendment. The Government do not believe that public money should fund private healthcare. It is a longstanding and fundamental principle of the NHS that it provides a comprehensive, universal health service which is free to all at the point of use. For the Government to subsidise a minority of people who choose to take out private medical insurance would undermine the fundamental principle of equity in the NHS. It would reduce the money available to fund the NHS and other public services. I hope that noble Lords would agree that there must be no question of using tax breaks to subsidise a two-tier health system, which would discriminate against those who were not able to pay for their care. In addition, the level of coverage offered by private medical insurance plans varies widely. For example, it is very rare for them to cover emergency care and access to a private GP, and therefore no one taking advantage of the proposed amendment would be able to opt out of the NHS completely.
We do not believe that the proposal would be a cost-effective use of taxpayers money. We have been sparing in our use of tax exemptions and have introduced them only where we are convinced that they offer the best-targeted and most cost-effective support for our objectives. If tax relief was given to the 1.7 million individuals who currently pay for private medical insurance, the cost to the Exchequer would be £810 million.
It is also highly likely that the amendment would cause a behavioural change, with many individuals who currently receive taxable corporate care changing to pay for it personally to gain the benefit. If a quarter of those who currently receive corporate private medical insurance moved, it would increase the cost of the amendment to £1.32 billion. I hope that noble Lords agree that this would not be the best way of using funds available for health.
As with all tax exemptions, the most benefit from the introduction of this proposal would be gained by higher-rate taxpayers, who would get 40 per cent tax relief on the premium paid. It would give little or no benefit to those on the lowest incomes who most need the support of our healthcare system, and those who are not taxpayers would obviously gain no benefit from the amendment whatever.
It would be hard to justify granting relief for this expenditure and not for other expenditure which some might think equally deserving. Notwithstanding the support for the amendment of the noble Lord, Lord Walton of Detchant, I hope that, on reflection, the noble Lord, Lord Palmer, will feel able to withdraw it.
With the greatest possible respect the noble Baroness has forgotten that the point behind this is to reduce NHS waiting lists. The new 48-hour directive from Europe will present terrible problems of prolonging the waiting lists for operations such as artificial hips, limbs or whatever. I knew that I would get absolutely nowhere and that the noble Earl, Lord Howe, would be sitting firmly without rising to his feet, as indeed would the noble Baroness, Lady Barker, but we ought not to lose sight of the amendment. I am particularly grateful to my noble friend Lord Walton of Detchant for saying that the idea behind this is to reduce the waiting lists in the NHS for hip replacements and so on.
Baroness Meacher: I emphasise at the outset that this is a probing amendment. The aim is to initiate a discussion and explore how best to reform the private patient cap in such a way as to uphold the following fundamental principles. First, private patient work will not change the public service nature of foundation trusts; secondly, private patient work will in every case benefit NHS patients and will not cause detriment to NHS patients. It is not good enough in my view to benefit some NHS patients if you cause detriment to others. One needs both safeguards. Thirdly, the approval of boards of governors will be required for any significant new private patient expenditure, to ensure that the fundamental principles and specified safeguards are adhered to. That would fulfil the requirement for local
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