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Earl Howe: My Lords, once again, on this side of the House, we are grateful to the Minister for an extremely helpful set of amendments and for the way in which she has spoken to them. I do not believe that at the outset of her remarks she mentioned Amendment No. 73, but it is one of the key amendments in the group. For the sake of clarity, perhaps I should ask her to confirm that she was speaking to it.

Baroness Hayman: My Lords, I specified Amendments Nos. 72 to 74 which I took to include Amendment No. 73. I am glad to clarify the point.

Earl Howe: My Lords, I am grateful.

Lord Clement-Jones: My Lords, I also thank the Minister for what I agree is a helpful set of amendments. That refers particularly to resolving the "may or must" issue throughout all stages of the Bill. I thank her also for dealing with a problem which the Professions Allied to Medicine was keen to see cured. It is grateful to have its

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best, most optimistic hopes being realised in terms of the way that section has now been changed in the 1977 Act. That is extremely helpful.

The only remaining aspect on which the Minister could be even more helpful--and this is somewhat of a side wind in the context of level 4 PCTs--is that the department definitely expects the PCT executives at level 4 to involve and, in some cases, consist of Professions Allied to Medicine. That would be a positive sign to those professions that their involvement would be actively supported. In the meantime, we very much welcome the set of amendments.

Lord Skelmersdale: My Lords, I add my thanks to the noble Baroness for this comprehensive set of amendments, especially Amendment No. 73 which I am delighted to see is list-free.

On Question, amendment agreed to.

Baroness Masham of Ilton moved Amendment No. 7:

Page 12, line 24, 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 was most encouraged at Report stage by the support which your Lordships gave for my amendment on out-of-area treatment. For that reason I move Amendments Nos. 7 and 18 today. The Minister said that the fragmentation of responsibility in the past made it difficult to ensure co-ordinated planning and commissioning of specialised services. The Minister also said that the Government were giving regional offices clear responsibilities for ensuring that proper arrangements were in place and would require all health authorities, primary care groups and primary care trusts to participate in that.

Many bodies are involved. The noble Lord, Lord Walton of Detchant, said during Report stage that in some instances specialist units were uncertain as to the future flow of patients and consequently their future funding arrangements. To have these amendments written into the Bill places emphasis on the importance of out-of-area treatments. Amendment No. 7 deals with the general powers of the Secretary of State to issue directions to National Health Service 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. 18 provides that the duty of co-operation should extend to OATs, making sure that they are covered in the Bill. Specialised medical conditions do not always fit into the flow patterns that health authorities might have arranged. Sometimes there are very difficult and complicated cases. Flow patterns might have been arranged with a hospital, such as the one at Bristol, where doctors and parents had lost confidence in the clinical results. I am pleased to hear that with a new surgeon Bristol has now improved, but that is an example of how matters can change. There should be flexibility and choice for patients, carers and doctors.

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It is cost-effective in the long run to provide the correct diagnosis and treatment quickly with a fully trained medical team who have knowledge and expertise and who can solve difficult problems. Sometimes sophisticated and expensive equipment is needed for difficult diagnoses. Often it is found only in select hospitals that deal with complicated conditions. To advance in medical research and development patients need to be treated in units that have an interest in and are motivated by their conditions and, ideally, have links with universities.

We live in a fast-changing world and must not fall behind. In last Saturday's Daily Express the case of Helen Smith, aged 24, was highlighted. She had her arms and legs amputated after contracting meningitis. So far officials at Addenbrooke Hospital in Cambridge will not pay for bionic hands and lightweight artificial legs to help her walk properly. On her arms she has a stump and a claw. I gave the Minister notice that I may bring up this case. This young woman has a university degree in molecular and cellular biology and wants to return to independent living and work. She needs the expertise of an orthopaedic limb-fitting centre. Why do severely disabled people have to fight so hard for what should happen smoothly and efficiently through the NHS so that they can get on with their lives and overcome human tragedies with help and support rather than bureaucratic injustice?

The British Medical Association says that there is lack of clarity and detail in the Bill about the way in which health services will work at district and regional levels and how services commissioned by primary care trusts will fit into this process. The Bill does not make clear how the formal mechanisms for joint working will be achieved and how the existing procedures for commissioning, which are now not working adequately, can be improved. What mechanisms will be in place to achieve an overview of the planning at regional level of services commissioned by primary care trusts? What mechanisms will there be to involve hospital consultants in the decision-making process of PCTs?

Although the Bill makes provision for the functions of primary care trusts, there is no clear direction for joint working between all relevant local health and social service agencies. I believe that Amendment No. 18 will help to achieve this. Currently, some services are commissioned by a lead health authority on behalf of the other health authorities in the region. Some services are provided on a regional or supra-regional basis. What will be the effect of the Health Bill on those services? What reassurances can the Minister give that those services will be protected? This service includes many vital specialties.

The College of Health, which is a body dedicated to patient-centred care, is also concerned about these issues. On "Newsnight" on Tuesday night the need for out-of-area treatment was highlighted. It showed adolescent and young adult patients who needed vital heart treatment at Brompton Hospital. Some patients said that if they had not received the treatment with the help of GUCH (Grown-Up Children's Heart Charity)

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they would have died. Dr. June Sommerville, a world-renowned heart specialist, said that because some young people had not been transferred they had died.

I thank both the noble Baroness, Lady Hayman, and the noble Lord, Lord Hunt of Kings Heath, for their communications. Both Ministers have great knowledge of the National Health Service, but this is a new Bill. I believe that out-of-area transfers should be on the face of the Bill. I hope your Lordships will agree that this is a matter of life and death for many people. I beg to move.

4.45 p.m.

Earl Howe: My Lords, I rise to support these amendments, to which I have added my name. The Minister was kind enough to write to me earlier this week following our debates at Report stage. I am grateful for her explanation in that letter of how out-of-area treatments are to be commissioned and funded. However, I share the perception of the noble Baroness, Lady Masham, that there is still a good deal of uncertainty within the health service as to how these commissioning arrangements will work and, in particular, what mechanisms will operate at district and regional levels to enable a proper strategic view of specialisms, such as cardiac and renal services, to be taken and to ensure that the advice of the specialists themselves is taken into account. What joint working arrangements will there be between all those who have a professional interest in the planning of services?

I should like to ask the Minister about the range of specialisms that health authorities and PCTs will be expected to commission under long-term service agreements. How many specialisms typically will these agreements cover? What will happen when there is a need for a certain specialist service for which there is no agreement in place? The worry that has been expressed to me is that none of this bodes very well for patients because the decisions of regional specialist commissioning groups will be binding. Yet there will be no patient or carer involvement in those decisions, as there will be for public health and health authority managers.

Nor are there any structures in place for the views of patients and carers to be heard and acted on at regional level. Even more importantly there is no provision for an appeals mechanism against refusals to fund out of area treatments. CHCs have no rights of representation at regional level. There is no provision for patient and carer feedback into the commissioning process and the subsequent monitoring and evaluation of provision. Nor does there appear to be any mechanism for patients to find out what specialised commissioning arrangements apply to their areas.

I turn to a different aspect of the issue. I wonder why it is that when waiting lists are so long, as they are at present, limits are now being imposed on the referral of patients from overstretched hospitals to those which may have spare capacity. There is a need for greater flexibility, not less, in the way the system operates. The Government need to explain more fully how the proposed arrangements will not work in practice to the detriment of patients.

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I share the view of the noble Baroness, Lady Masham, that these are important questions. I look forward to hearing what the Minister has to say.

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