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Lord Moynihan: My Lords, can the Minister, without anticipating the White Paper, assure the House that it will contain a repetition of British policy that there will be no compromise on sovereignty against the wishes of the people of Gibraltar and that it will therefore effectively be a rejection of the present Spanish proposals for joint sovereignty? Is the Minister prepared today to reject those proposals, which are so demonstrably against the wishes of the people of Gibraltar?

Baroness Symons of Vernham Dean: My Lords, I do not anticipate that the White Paper will be the vehicle for announcing any change in Her Majesty's Government's policy towards Gibraltar. I am sure that that does not come as a surprise to the noble Lord. Our policy towards Gibraltar remains the same as I have described in previous statements that I have made to your Lordships' House.

Lord Steel of Aikwood: My Lords, is the Minister at least able to assure the House that the White Paper will draw a clear distinction between those territories that are genuinely overseas, in the sense of being remote, and Gibraltar, whose future clearly can be determined within the ambit of the European Union?

Baroness Symons of Vernham Dean: My Lords, I believe it has already been pointed out that there are differences in the case of Gibraltar. When my right honourable friend announced the intention to publish a White Paper he made it clear that some of the issues would not have a direct bearing on Gibraltar. After all, the question of the right of abode for citizens of Gibraltar has already been decided. I do not wish to anticipate the terms of the White Paper; indeed, I am

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sure that noble Lords would be very cross with me if I did so. However, I believe that I can give the noble Lord the assurance that he seeks.

NHS: Access to Services

2.50 p.m.

Baroness Knight of Collingtree asked Her Majesty's Government:

    What steps they propose taking to ensure that patients do not have to move house to receive the medication they need.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Hayman): My Lords, we are determined to tackle unwanted variations in access to services. We are taking action to ensure that the most effective services are available more consistently across the country. We are putting in place mechanisms to develop clear national standards, to promote their implementation and to monitor progress.

Baroness Knight of Collingtree: My Lords, I am grateful for the response of the Minister. Is not rationing of health treatment by postcode freely acknowledged to be taking place by the majority of GPs and even the chief executive of the National Health Service Confederation, who advises people to move house to get better treatment? I assume that this rationing does not stem from malice but from the fact that some areas have the means to pay and others do not. I am aware that NICE will come into play, as the Minister said, but exactly how will it bring about equality? Are the Government to give more money to areas that do not presently have enough so that there is equality of treatment; will they withhold money from those areas that now have it so that there is equality in the sense of no treatment, or what?

Baroness Hayman: My Lords, we spent many happy hours discussing some of these issues yesterday in Committee. Whether a local health authority funds a particular treatment or gives priority to it is not simply determined by money. It is for the authority to assess the most important issue that faces its local community. To do that is particularly difficult when there is a dispute, as there are in many new drug treatments, about clinical effectiveness. The steps that we seek to take in drawing up national service frameworks for particular conditions and suggesting that the National Institute for Clinical Excellence sets guidelines for appropriate treatment for particular conditions are designed to ensure that every health authority receives the same reputable clinical and academic advice about the effectiveness of treatments. We must recognise that at individual patient level the doctor and patient will have an input as to the appropriate treatment and the local health authority will have to decide the priorities.

Lord Winston: My Lords, the noble Baroness has raised a most important question. Is my noble friend aware that it is not just a question of drugs but

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treatments and that in the case of reproductive medicine, for example, patients are forced to change address in order to receive equivalent treatment in a different area of Britain? Can my noble friend suggest what should be done to ensure that there is equality of treatment for these patients?

Baroness Hayman: My Lords, I recognise the issue to which my noble friend refers, particularly in regard to infertility treatment. We are, however, trying to tackle the variations in prescribing and availability of services that grew up because of the fragmentation of the health service and the two-tierism and variety implicit in GP fundholding. No one should assume that this is a new problem; it is one that we seek to reverse. As to access to NHS infertility treatment, particularly tertiary services involving reproductive techniques, the Government are commissioning a survey of health authorities to find out exactly what the variations are in provision. We hope to issue guidance towards the end of the year having examined the survey results and considered the policy and cost implications of the clinical guidelines on infertility that are being developed by the Royal College of Obstetricians and Gynaecologists.

Lord Clement-Jones: My Lords, apart from infertility treatment there are many other glaring examples of postcode rationing, such as beta interferon for the treatment of multiple sclerosis, Aricept for Alzheimer's and Taxol for breast cancer, to name but a few. Will the department be asking the new National Institute for Clinical Excellence to look urgently at those aspects of postcode prescribing? Will the institute have sufficient resources to do that?

Baroness Hayman: My Lords, the noble Lord is right to point out the crucial role that the institute will have in these kinds of areas and how it can speed access for patients more fairly to clinically effective treatments. These are not easy issues. Questions are raised about particular treatments. The noble Lord referred to Taxol. The department wrote to all regional directors of public health to draw to their attention the view of the JCCO and oncologists about the effectiveness of that treatment. The noble Lord may well be aware that in recent articles in The Lancet the results of a new trial, ICON II, have been produced which have questioned that advice. We are in a shifting area when new treatments are introduced. It is important that we have the strength of the national institute to assess clinical effectiveness.

Lord Pilkington of Oxenford: My Lords, is the Minister content that when a patient is being treated in another area health authority the home area authority rings the family of that person close to death and says that it can provide better treatment, rather like a tradesman who offers a magic cure? Is that helpful to the family? I can assure the Minister that that occurs.

Baroness Hayman: My Lords, if it occurs I shall be very grateful if the noble Lord can provide me with

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details of such a case. I undertake to investigate it because, as he describes it, that is a situation that is most concerning.

Lord Peston: My Lords, does my noble friend agree that, while it is reasonable for central government to take an interest in how resources are allocated, there must be permissible variations according to local services? Does he also agree that in an area where doctors prescribe less rather than more it cannot be taken for granted that it is indicative of wrong prescribing? I speak as chairman of the Office of Health Economics. Does my noble friend further agree that sometimes more prescribing is worse than less prescribing when it comes to assessing local priorities?

Baroness Hayman: My Lords, my noble friend is absolutely right to point out that these are not simplistic analyses in the sense that if more is spent on something higher quality can be achieved. The aim is to ensure that patients have access to high quality services. Members of your Lordships' House who have taken a great interest in the prescription of antibiotics, for example, recognise that high quality service does not suggest that there should be widespread prescription of unnecessary antibiotics.

Baroness Masham of Ilton: My Lords, are the Government working in full co-operation with the pharmaceutical industry to determine the effectiveness of various drugs for the benefit of patients?

Baroness Hayman: My Lords, obviously the role of the pharmaceutical industry in developing new and effective drug treatments is crucial. Recently we have issued a consultation document explaining to the industry how the new appraisal techniques that the National Institute for Clinical Excellence is to undertake will be used in order to assess the clinical and cost-effectiveness of new drugs as they are introduced.

Earl Howe: My Lords, how do the Government plan to achieve the levelling up in the availability of treatments that they say they want to achieve when for the first time in the history of the NHS the drugs budget is to be capped and the size of that budget is not to be increased substantially? Does it not imply that if health authorities increase the availability of some treatments inevitably they will restrict the availability of others?

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