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Lord Clement-Jones: My Lords, will there be different levels of cover for different types of practitioner?

Lord Hunt of Kings Heath: My Lords, the intention is to be flexible in the arrangements to reflect the situation as it is on the ground.

I should prefer to write to the noble Baroness, Lady Carnegy, on the matter which she raised.

Lord Colwyn: My Lords, before the noble Lord sits down, I believe that I heard him say that the indemnity of dental surgeons is paid for by the NHS. I believe that he will find that all general practitioners have to pay their own indemnity, whether they are working for one day or five days per week. It is not paid for by the NHS. It may well be covered indirectly by the fee structure, but they have to pay their own indemnity, whether they work for the NHS or privately.

Baroness Gardner of Parkes: My Lords, in answer to the noble Lord, Lord Clement-Jones, the Minister said that there would be flexibility. Is he suggesting that there may be a possibility of a no-claims bonus?

Lord Hunt of Kings Heath: My Lords, no. I was not suggesting that. The arrangements which are brought into play will need to reflect the points which the noble Lord made about the differing circumstances. I commend the amendment to the House.

On Question, amendment agreed to.

Clause 7 [Directions]:

Baroness Masham of Ilton moved Amendment No. 20:

Page 7, line 17, at end insert--
("( ) The power conferred by subsection (1) shall be exercised so as to enable patients resident in an area covered by a body referred to in that subsection to be referred out of that area where appropriate for the purpose of receiving specialist hospital treatment and after-care.").

The noble Baroness said: My Lords, I apologise to the Committee for not being present throughout the Committee stage of the Bill. The reason is that my noble kinsman, my husband, was not well and with the very

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serious medical conditions he has, I did not have carers who were adequately trained to deal with the situation. Therefore, I had to go back to Yorkshire.

That is the reason I now bring to your Lordships on Report what I consider to be most important amendments. Amendment No. 20 deals with the general powers of the Secretary of State to issue directions to NHS bodies. The intention of the amendment is to require the Secretary of State to issue directions to achieve out-of-area treatments where appropriate.

Amendment No. 48 provides that the duty of co-operation should extend to OATs, making sure that they are covered in the Bill. People are often suspicious of change. We have before us a Bill which deals with the new National Health Service. It has many changes within it. The National Health Service is something from which every family in the country benefits at some time in their lives.

I have had my life saved by the expertise provided at a centre of excellence which dealt with spinal injuries. I was transferred from an accident and emergency department of a general hospital to a spinal unit attached to a general hospital out of the area in which I was living. Because of that, I declare a personal interest in these amendments.

I founded the Spinal Injuries Association and I can tell your Lordships from first-hand experience that I have seen some terrible cases of patients who have not been transferred to a spinal unit and have been treated in a general ward of a general hospital. After many months, some of them have at last been transferred, looking like a person from Belsen--emaciated, with sepsis, pressure sores, urinary infections, contractions of the limbs and suffering from depression.

There are many supra-regional specialties which these amendments would cover such as those dealing with liver disease, cancers, HIV/AIDS, skin diseases, head and spinal injuries, special eye surgery and complicated fertility problems, to mention but a few. It is cost-effective for patients to receive correct treatment from experts who know what they are doing.

Nobody seems to know exactly who will be responsible for OATs. Will it be health authorities, primary care trusts or NHS trusts? Many doctors and patients do not trust those trusts. The Minister, the noble Baroness, Lady Hayman, has worked for the NHS as a hospital trust chairperson. The Minister knows how important it is for an individual patient to receive the correct treatment. My amendment refers to patients to be transferred only where appropriate.

Last Friday I had a most interesting visit to the vascular unit of St James's Hospital in Leeds. The expertise of the doctors and nurses at that specialising unit was excellent. The benefit to the patients was obvious. Very difficult conditions were being treated and the patients felt confident. The expert advice given to patients makes all the difference to them and their families. The benefit to teaching and research was also obvious. We live in a fast-developing technological age. Expensive medical equipment cannot be made available in every hospital. It is from such specialised units that the patients, universities and students can benefit.

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We must keep up with the advancement of medical expertise. We must keep up the morale of staff and patients. These amendments will help to recognise the wonderful work of the experts. I hope that the Government and your Lordships will accept them. I beg to move.

Lord McColl of Dulwich: My Lords, I rise to support the two amendments. I cannot imagine for one moment that the Government will not support them. As noble Lords will be aware, it is not just the medical personnel at the specialist centres who make the difference; it is the whole team, including the nurses, the physiotherapists and the much-maligned management. The whole atmosphere of such places is geared to providing a superb service. Of course, they treat a sufficient number of these injuries to be expert in them. If a clinician has only one such case a year at his hospital, there is no way that he can acquire the expertise that obtains in the specialist hospitals.

There are also many other problems, perhaps less acute, which nevertheless are so rare and difficult to treat that they need to be concentrated in a specialist unit. Everyone in London used to send cases of a tumour, chorionepithelioma--cancer of the womb--to the Charing Cross Hospital because the best person worked there. Ewing's tumour of bone is another rarity and such cases tend to congregate in the Middlesex Hospital where again there is the expertise.

It is essential that that practice is allowed to continue and is encouraged under the new arrangements. We believe that it is important to have a provision on the face of the Bill so that there is absolutely no doubt that the arrangements can operate when required.

Lord Clement-Jones: My Lords, I rise to support strongly the amendment in the name of the noble Baroness, Lady Masham. She brings a particular understanding and expertise to this area. She has cogently put the case for this provision to be on the face of the Bill.

We have had a discussion already in Committee on the question of out-of-area treatments and the way in which extra-contractual referrals move towards OATs. If we genuinely are to have a situation where referrals can continue to be made to specialist hospitals, that is a test as to whether or not the internal market is being done away with.

In her previous replies--if I did not misunderstand her--the Minister made it fairly clear that, although generally the commissioning contracts of PCTs and PCGs were to cover tertiary care and specialist care, where it was necessary and where it was in the patient's interest and at no cost to the PCT or the PCG, such a referral would take place. It is important that we have absolute confirmation of that as that is precisely the kind of treatment that the noble Baroness was talking about in terms not only of spinal injuries but also liver disease, cancer, head injuries, plastic surgery and so on, where tertiary referral will be vital.

We hope that the Government will support the spirit of the amendment, if not necessarily the precise wording. It is a litmus test. It is extremely important that

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the new system of commissioning does not confine GPs to taking services only from within their own area. It is vital that patients have full access to expertise of the highest order outside their particular area.

Lord Renton: My Lords, I apologise to the noble Baroness, Lady Masham. I did not hear the first two minutes of her speech but I have managed to pick up the threads. I am interested in this matter because I speak from personal experience. What is aimed at in these two amendments is already in operation in the area of England in which I live. I live five miles from Huntingdon, where there is a general hospital with a certain amount of specialist treatment available.

I now draw on experience within my family. One member of my family had to go to Addenbrooke's Hospital in Cambridge where she needed particular specialist treatment. She was operated on there and received that treatment there, but she could not have had that treatment in Huntingdon. Another member of my family, alas, had to go to a specialist unit in a hospital in Peterborough. Out-of-area treatments already take place. Under the new arrangements which the Government have in mind, I hope that that flexibility will be maintained.

9.15 p.m.

Lord Winston: My Lords, this is a matter about which I feel absolutely passionately and on which I have spoken in your Lordships' House in the past. Sadly, I fear that the noble Lord, Lord Renton, is not entirely correct when he says that this practice invariably goes on. It does not. It happens in some areas of the country but not, unfortunately and regrettably, in all areas.

There is growing concern, especially in the teaching and specialised hospitals, that there is an increasing problem with the reorganisation of the health service. Although I do not want to talk about different governments and their different reforms, I do think that this started in some way with the internal market and it is still causing increasing nervousness. Many specialists have seen a falling off in out-of-area transfers. I am sorry to return to reproductive services, but my hospital in Hammersmith has seen an astonishing fall in referral practice, so much so that we now have empty operating theatres, fully staffed, waiting for patients who are not there. I was talking this week to the director of leukaemia services there and he has found similarly that patients are now not so easily able to attend his expert unit for leukaemia treatment because they are not being referred.

I believe that that is completely counter-productive to the health service. First, it reduces the research base. When I first used to lecture in the United States about what we were doing at Hammersmith Hospital, the Americans were amazed at the wealth of clinical material which an individual clinician could build up. Whereas we were building up literally thousands of cases, American doctors would see tens or perhaps hundreds of cases. We were able to do that because of

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the remarkable pattern of referral across the nation inside the National Health Service.

Secondly, out-of-area transfers present great benefits in terms of teaching and training. That in turn allows the dissemination of excellent practice, which is very important for the training of specialists.

Above all, I hope that the Government will recognise that sensible out-of-area transfers can save money. There is no question in my mind but that at the moment we are spending more than we need. In my own area of reproductive medicine, for example, I am convinced that if we sensibly concentrated services in certain areas to which patients could easily travel, there would be a great benefit to the patients, a benefit in terms of training and research, and a saving of money. I feel strongly that there is sense behind the amendment and I hope that the Government will be able to give some kind of assurance--

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