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Lord Clement-Jones: My Lords, I am sorry to interrupt the Minister, but does she really believe that the current guidelines represent the consensus established during the consultation? As many of us read it, the consultation requested a much greater degree of upward devolution, if you like, from the PCTs on a firmer and more compulsory basis than is currently the case.

Baroness Andrews: My Lords, if the noble Lord allows me to develop my argument, I think that I can satisfy him. The guidance does follow the spirit of the consultation, especially in relation to the development of regional specialist community groups. Essentially, the guidance ends the uncertainty of commissioning arrangements—as the noble Earl said, it is extremely important to build certainty into the commissioning arrangements, alongside clear thinking.

From the responses to the report, it was especially clear that the work of the regional specialist commissioning groups was highly valued, but that they were still developing organisations. That accorded with the Government's view of the continuing importance of maintaining strategic responsibility at that level. So let me emphasise, as does the guidance, that where such regional and local specialised commissioning groups and arrangements are working effectively in line with the guidance, there is no need to change them.

To address the specific question raised by the noble Lord, Lord Clement-Jones, who cited my honourable friend Hazel Blears in another place as saying that the RSCGs would continue only, by implication, for another year, when she spoke, she meant 2002–03; she was not talking about the future. So I can certainly put the noble Lord's mind to rest on that point.

I hope that I can also reassure him on another matter. As the Government believe that planning must take place at the appropriate level, and given the population for which the regional groups have always been responsible and their success as developing strategic bodies, their work and the response that we have received—we are certainly considering developing regional specialist commissioning groups in future. There is a definite continuing role for them.

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To continue my argument about regional commissioning for a moment, the guidance places an explicit value on the continuity of commissioning and strategic development at regional level.

Lord Clement-Jones: My Lords, this is too good an opportunity to miss to probe further. Who decides whether those arrangements are working sufficiently effectively for the RSCGs to continue? It is so qualified in the guidance that they are to carry on, but only where they are working effectively. Who decides on that? That will mean that there is a patchy network.

Baroness Andrews: My Lords, again, to continue with my argument, the guidance will guide the RSCGs. We are asking them to build on their experience and knowledge of specialist services; to develop their capacity; and, concerning the guidance's advice on the nature of commissioning, to put in place the clear strategic process that will guarantee that commissioning is working at regional and local level.

To turn to my second point, the guidance essentially aims to ensure that all RSCGs and local commissioning groups meet the level of the best. We want them to put in place agreed remits and powers, clear accountability and public and patient involvement that can be approved by the strategic health authority, so that the relationship between the collaborative tiers is clear and appropriate.

We have made clear that what we mean by the proper functioning of commissioning groups is that there is a clear and agreed structure that enables them to develop clear referral guidelines, access criteria and treatment protocols; and to follow the National Institute for Clinical Excellence guidelines, appropriate data-monitoring, clinical and financial risk-assessment procedures and service-specific commissioning consortia.

Those are the pillars of good practice. They are spelled out in the guidance and CCGs that follow the guidance will be well on their way to intelligent and successful commissioning. We envisage the regional groups as fulfilling an extremely important role—as they have—and developing that role in future.

I turn to some questions that the noble Lord, Lord Clement-Jones, asked about the role of PCTs. He and the noble Earl, Lord Howe, asked whether their decisions were binding and, if so, what the nature of that binding arrangement. We expect that the remit, the powers and the rules of engagement will be agreed by the member PCTs. It is up to them to decide the nature of the binding agreement that they will enter into. There will be scope for development. We are agreed that the decisions taken are binding on all PCT members and that the commissioning process is transparent, so that providers and the public are clear who is commissioning. There is a clear direction for the PCTs to engage seriously with the process of commissioning.

Noble Lords have asked what is the role of the SHA. It is up to the SHA to ensure that that takes place. The SHAs have the oversight of PCTs. They will have the

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responsibility for ensuring that the guidance in the respect that I am describing is followed. It is a developing arrangement and a developing reform. We have provided additional and clear signposts for the standard of performance that we expect, and how PCTs can avoid the risks that have been identified. For example, we want to see a dedicated commissioning team in every PCT. They have already demonstrated their value. We want to put the PCTs in the driving seat. We have emphasised the need for coherence and integration in the overall approach. We have asked the PCTs to incorporate plans for specialised services in their future local delivery plans. Those plans are at present being evaluated by the Department of Health.

We have linked commissioning into education and training for specialist services, so that workforce confederations are including considerations in their work programmes. We have emphasised the need to build local and public confidence through a transparent process, so that PCTs are expected to make public the remit and rules of engagement. The noble Earl, Lord Howe, talked about the importance of the involvement of the users of the service. Indeed they will be involved. PCTs should ensure that their views and experience are fed into the commissioning process, and that certainly involves the user groups, who have the greatest experience.

Noble Lords have raised the issue of capacity. I must stress that PCTs have already been in place for a year. They are still developing systems. They are developing their expertise, but they are developing a history of continuity in workforce and practice that I hope will reassure the noble Baroness, Lady Masham, who raised that question. The evidence that we have suggests that after a year they are developing the systems to deliver local services. There is a growing understanding of their roles and the size of the agenda. We have no evidence to date of the PCTs failing to commission properly, and now they have the guarantee of more certainty, because they have three-year allocations so that they can plan more effectively. We believe that the capacity will be built through mature collaborative behaviour.

That is not all. We are providing support around the PCTs, and that may address the noble Earl's question about why we have not supported the idea of a national group. We have a support system which includes the training and support programmes offered through the national primary care trusts. They are finalising a self-assessment tool for commissioning competencies. That will include specialised services. There is the overall responsibility which the SHAs hold for performance. That is the key to successful arrangements.

The commissioning process is underpinned by the national frameworks, which guide best practice and treatment in areas such as CHD and diabetes, which cross over with specialist services. NICE gives clear guidelines on prescriptions.

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We have built certainties and reassurances into the system. The PCTs will have already developed the competence in line with successful commissioning arrangements, which will continue and will be aided by the guidance.

I shall briefly answer a few of the questions that other noble Lords have raised. The noble Baroness, Lady Masham, asked about spinal units. It is extremely important that people with spinal injuries are able to access spinal units, for all the reasons that she mentioned, particularly the issue of pressure sores and so on. A new review into spinal services is being conducted by three RSCGs in the south of England, including Stoke Mandeville hospital. It will look at provision and performance of services in relation to commissioning and spinal units. A report will be finished by May to be presented at a conference. We hope that generalised good practice will come out of that, which others can access and develop. That is good news.

The noble Lord, Lord Chan, referred to the fact that black and ethnic minorities suffer disproportionately from some forms of disease. We are very conscious of that. We have addressed the genetics issue in different ways. We expect the Green Paper on genetics very soon. A specialist committee of commissioners has been addressing genetic issues. We issued detailed guidance on sickle cell some time ago and we hope that universal neonatal screening for every child will be

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available within the next three years. In different ways, we are looking at the issues that seem particularly to disadvantage black and ethnic minority families.

The noble Earl, Lord Listowel, asked about young people in childcare homes in particular. One issue that they particularly have to contend with is mental health services. RSCGs have a particular responsibility to address issues of mental health of children. In addition, a lot of support is coming through Quality Protects and the new child and mental health services with additional funding, which makes it essential that people who look after children are aware of the need to take advantage of what is coming their way. That is why training is very important and why the voice of the child and the staff in the PCT commissioning process is particularly important. We should certainly look out for that.

I have gone well beyond my time and I am conscious that I have not addressed many of the detailed questions that have been raised. I am very sorry that I have not been able to deal with them. I shall have to write to noble Lords and pick up the points of detail. I hope that the guidance will be welcomed and supported across the House.

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