NHS: Private Companies

Lord Winston Excerpts

Monday 11th February 2013 Lords Chamber

Asked by

[Lord Winston]

To ask Her Majesty’s Government whether they have plans to exempt private companies providing services to the NHS from corporation tax.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, the Government will not be exempting private sector providers of NHS services from corporation tax. The purpose of Monitor’s fair playing-field review is to ensure that any providers, be they NHS, for-profit, community or voluntary sector organisations, that are able to improve the services offered to patients are given a fair opportunity to do so.

[Lord Winston]

I am grateful to the noble Earl for that reply and deeply reassured that corporation tax will not be in the equation. Given that the NHS is not good at costing out its treatments, how can he be sure that the private sector will not charge what it thinks the market will bear rather than the actual cost of the treatment it is delivering?

[Earl Howe]

My Lords, the Government’s policy is that competition should never be deployed for competition’s sake but only in the interests of patients. Furthermore, competition should be on the basis of quality and not price. The answer to the noble Lord’s question is that we need to arrive progressively at a system of tariffs that fairly reflect the value and cost of the work that providers do, and that all providers should compete equally on that basis.

Health: Medical Innovation

Lord Winston Excerpts

Wednesday 16th January 2013 Lords Chamber

[Lord Winston]

My Lords, it is both a responsibility and a privilege to be the first speaker after the deeply moving speech from the noble Lord, Lord Saatchi. He carries the respect of the whole House for tabling this debate and has our thanks for the way that he phrased what he said. I feel that my own contribution will be paltry by comparison, but I thought that it would be interesting to look quickly at my own career and think of seven points in it where innovation was an issue. Our excellent Minister sitting on the Front Bench cannot be expected to be responsible for trying to improve innovation in the health service. This is a colossally difficult issue; I will explain why I think so.

The first thing I want to refer to briefly is my involvement in the early days of microsurgery of the fallopian tube. First, that project, which led to about 50 publications, would not have been possible today because the Medical Research Council grant that I got would not be awarded with the current competition. Secondly, it is fair to say that I would not have got an animal licence to practise a surgical procedure, rather than to do it experimentally. There is a neat difference now in how the regulation is. Throughout, there are at least eight issues that conflict to make innovation difficult. One is regulation; one is infrastructure; one is governance; one is industry and its involvement; one is the internal market, supported by both the Labour Party and the Conservative Party; one is clinical training; another is teamwork. Lastly and most importantly, there is the cultural environment. I will come to one other issue at the end, if I may.

The infrastructure for my work with the fallopian tube would not be possible now because I had access then to a workshop in a district general hospital, where Dennis Melrose was producing extracorporeal circulation pumps to improve heart surgery. That is almost unthinkable now. One of the greatest difficulties I had was in getting industrial support for making the microsurgical needles. I could not find a single industry in this country that would make the needles. We made needles with our own hands, under a microscope, that were so fine and delicate that they did not fall to the ground. Unlike the noble Lord’s papers, they actually floated on the air. Eventually, we found a German company which then captured one-third of the world’s ophthalmic market with those needles. There is a message in that innovation.

With regard to trying to translate that surgery into the female pelvis, the big problem now would be governance. What also followed was the issue of having training in teamwork around, to persuade surgeons to work as a team. That has become more difficult now because of the internal market. It is very difficult to prove that a surgical procedure works and is innovative, because it is more difficult to collect the cases together within a health service structure. We have all faced this difficulty for quite a long time. It is not the responsibility of any one Government.

The same thing applies, to some extent, to laparoscopic surgery. I think I was one of the first people to operate using a laparoscope in this country. There would now be a problem with governance; it would be considered risky and unwise, and would take much longer to innovate.

With the present regulatory system, it would also be impossible to see in vitro fertilisation—your Lordships probably know that I have certainly more than dabbled in that—on the books in the way that it is now. It would be very difficult to transfer an egg that you fertilise outside the body into a human patient. It would certainly take much longer to get permission to do that. That is one of the issues. In my own unit, we made a whole series of improvements. We improved the culture media. We demonstrated, for example, the given knowledge that glucose in the medium was poisonous to human embryos but not to any other animal that was experimented on. We could not change those media now, given the current regulatory framework. Even the little changes that one could make—the fact that tungsten light is dangerous to embryos, for example—become increasingly difficult.

I could go on and on but I do not want to spend more than a few minutes and my time is almost up. It would now take much longer to get permission for things such as embryonic detection of genetic defects. I have to declare an interest as somebody who launched a biotech company. One of the problems with that company, which might change the whole field of transplantation with the use of pigs’ kidneys, hearts and livers, and possibly pigs’ lungs, is that it took us more than a year and a quarter to get an animal licence to practise and do the work on just six pigs. It was quite difficult to get the rodent licence before that as well.

I want to say one final thing. The first experiment I ever did was as a result of fraud in my unit. I was asked to go in and troubleshoot by repeating an experiment. It was pure serendipity that we found that there was probably something wrong, with an infection in the vagina of women that might lead to the possibility of a virus being involved. We now know, of course, that the virus is very well established but I did not know what it was at the time. That was a long time ago but one of the issues with true innovation is that serendipity is extremely important. What we can perhaps best all do together is to see how we might improve the culture in which we do our medicine.

NHS: Reconfiguration of Services

Lord Winston Excerpts

Tuesday 15th January 2013 Lords Chamber

[Earl Howe]

I am grateful to my noble friend and I can give the confirmation that he seeks. Monitor’s advice was sought and obtained by the OFT. He is quite right that that it is one of the benefits from the Health and Social Care Act. In situations of this kind we expect Monitor and the NHS Commissioning Board to engage with the Competition Commission on FT mergers but before that with the OFT because Monitor, as a health-specific regulator, has the insight into the considerations that bear most closely on the interests of patients.

[Lord Winston]

My Lords, does the noble Earl agree that, whatever the explanation, the involvement of the OFT suggests an increasing privatisation of the health service? Given that the health service so often does not cost out individual treatments per patient very successfully, that raises the issue of competition between private providers in such areas as this. Would the noble Earl be kind enough to comment on that?

[Earl Howe]

I do not agree with the noble Lord. Competition issues arise within the health service and the matter in the noble Lord’s Question is specifically a health service issue. There are, of course, competition issues involving the independent sector and the charitable sector as well but that is not the focus here. It was the previous Government who recognised the benefits of competition for patients. Our attitude to it is very pragmatic. The key objective for commissioners is to ensure that patients receive the best possible services irrespective of whether they are from the public, voluntary or private sectors. It is for commissioners working with patients to decide where competition is appropriate. It is a means rather than an end in itself.

NHS: Research and Development

Lord Winston Excerpts

Monday 17th December 2012 Lords Chamber

[Earl Howe]

My Lords, every NHS trust or foundation trust has to oversee the governance of the research taking place within it. That is an inescapable part of the process. I do not think there is any confusion in anyone’s mind between support for research governance and the actual research itself, which is done by academics and clinicians working in academic and clinical departments. It is up to each trust to determine how its budget for research is allocated, but I can reassure my noble friend that the money is getting to where it needs to go.

[Lord Winston]

My Lords, would the Minister agree that since Sally Davies took charge of how research is done within trusts, there has been a significant improvement in insuring that more of this money actually goes to serious translational research, which is an area that the health service really needs to concentrate on? I hope that the Minister will agree that that job has been done rather effectively.

NHS: Health Workers

Lord Winston Excerpts

Thursday 19th July 2012 Lords Chamber

[Earl Howe]

My Lords, the noble Lord’s Question addresses the central issue facing the NHS, which is how to deliver the best outcomes for patients and do so in the most cost-effective way. He is right to single out the role of Health Education England because I believe that, in conjunction with local providers who will be feeding in their view of what the workforce priorities are in their local areas, together with the Centre for Workforce Intelligence, which has a horizon-scanning capability, we can at last crack a nut that has been so difficult to crack in the past, that of good workforce planning in the NHS to make the workforce as productive and effective as we can. He is also right to single out the CQC because in areas such as staff ratios, the commission has a role in making sure that providers have thought about the right way to deliver care in individual settings.

[Lord Winston]

My Lords, in order to produce a skilled workforce with wide diversity in the health service, one of the real needs is that of attracting more young people into this very large workforce. At the present time, as I think the noble Earl may be aware, there is massive resistance to having young people on work experience in the health service. All sorts of barriers are put up—risk of infection, lack of privacy and so on—most of which are absolute nonsense. Could the Minister do more to encourage the university trusts in particular to ensure that more young people can gain work experience in our hospitals?

[Earl Howe]

My Lords, the noble Lord has made an extremely creative and important point, and I will gladly take it back to the workforce colleagues in the department.

NHS: Primary Care Trusts

Lord Winston Excerpts

Tuesday 17th July 2012 Lords Chamber

[Earl Howe]

My Lords, I do not have the figures for North Yorkshire in front of me but, as the noble Baroness is aware, there is a process for patients to make an exceptional case application to their primary care trust where the circumstances are deemed to be exceptional. We had a short debate about this matter the other day. However, there will inevitably be variation around the country in the extent to which treatments are seen as a priority for the local population in a given area.

[Lord Winston]

My Lords, it is a question not just of treatment but of investigations for treatment. Only last week, I saw a couple complaining of long-standing infertility who were refused a laparoscopy or an X-ray of the uterus on the grounds that they were not permissible as investigations under the National Health Service. It was limited by their primary care trust. Would the noble Earl care to comment on that?

[Earl Howe]

My Lords, if that case was a consequence of the primary care trust taking a blanket decision over a clinically valid investigation process then I would be very concerned and should be interested to hear the details from the noble Lord.

NHS: Definition of Exceptional Case

Lord Winston Excerpts

Monday 2nd July 2012 Lords Chamber

[Earl Howe]

My Lords, no, that is not the reason. My noble friend is quite right that this treatment has been around for a little while. However, it is not yet in mainstream practice. It is expensive, it is not routinely available in the NHS, and indeed NICE has published interventional procedure guidance which concludes that it,

“shows some short term efficacy, although most patients require insulin therapy in the long term”.

That does not seem to me to be a resounding endorsement of this treatment.

[Lord Winston]

My Lords, will the Minister be kind enough to help us by defining what is meant by exceptional clinical needs?

[Earl Howe]

There is no clear-cut answer to that question. A patient might be suffering unusually severe symptoms from a given condition, or they might suffer from some comorbidity, with the result that in the absence of treatment his or her quality of life would be unusually severely affected. The underlying principle should be that the patient has some exceptional characteristic which would justify more favourable treatment being given to them than to the average patient with that condition.

Health and Social Care Bill

Lord Winston Excerpts

Monday 19th March 2012 Lords Chamber

[Lord Greaves]

My Lords, this has been an extraordinary parliamentary process. When this Bill was introduced, I said at Second Reading that it was a bad Bill. It was a bad Bill when it came here; there has been a growing tide of opposition to it and concern throughout the process while it was in the Commons and the Lords. There was the pause in the Commons and the Future Forum, which resulted in a large number of changes, and at that time Nick Clegg said that no Bill is better than a bad Bill. What we all individually have to do now—I speak very much for myself and not my party—is to assess whether it has now moved over from being a bad Bill to perhaps being, as Nick Clegg said last week, a much better Bill.

There is no doubt at all that on a spectrum of bad to good, it has shifted very considerably. It shifted in the Commons; it shifted far more here in the House of Lords. I believe that the process in your Lordships’ House has been the House of Lords at its best. This House can be proud of the work that it has done throughout the gruelling Committee stage, then during Report and again today. I regret that I could not take a detailed part in much of that, because I was then spending time as a patient of the NHS, but I have been watching it all and I believe that the work this House has done has been absolutely superb.

If I can make a party political point here for a moment, the work that our team has done on the Bill, led by my noble friend Lady Jolly with all my other noble friends who have taken part, has contributed well. I refer not only to the Liberal Democrats but to Cross Benchers and everybody around the House. Tribute has been paid to the Minister. I pay particular tribute as a Liberal Democrat to our person on the ministerial team, my noble friend Lady Northover, who from our point of view has played a very important part by being a link into the Government and getting many of the changes which have taken place.

It is about not just the changes to the Bill but the implementation—the work that starts after this Bill has been passed, as no doubt it will be today. A huge number of ministerial assurances have been made, which may or may not be put upon people’s bedroom walls as the noble Baroness, Lady Cumberlege, wants to do with hers. Nevertheless, this is a Bill which has had more outside scrutiny and involvement from people out there, as far as the House of Lords is concerned, than any other Bill I can remember in 12 years in your Lordships’ House. That will continue with the implementation, and it is absolutely crucial how the Government now implement this Bill. Will it be gung-ho privatisation, which is what people were very frightened of when the Bill was first introduced and many are still frightened about, or will it be implemented in a cautious and careful way to allow the health service to breathe and to cope with the changes? This will be absolutely crucial, and we will know the answer to that in a year or two’s time.

The noble Earl, Lord Howe, said that we have had debates of unparalleled length and scope, and that is true. However, as I have just said, the public interest and lobbying on this from outside has been unprecedented. One of the lessons that we all have to learn is that we—whether the House of Lords, members of the Government or our party—have not coped with that very well. I do not think that the Opposition coped with it terribly well either because, even this morning, I was getting e-mails telling me what the Bill did, some of which was absolutely untrue. They were still telling me that the Bill removes the duty on the Secretary of State to provide health services. We are still getting that, and the amount of education or information which goes out from debates within this Chamber to the outside world is pretty poor.

Several people have said, “We have been trying to follow this Bill. We have been trying to follow your Marshalled Lists, having discovered where to find them on the internet. We have been trying to follow the parliament channel, and we haven’t understood a word of it. It is interesting, but we can’t understand it”. I have to tell them that that applies to quite a lot of Members of your Lordships’ House while the Bill is going through.

[Lord Winston]

Could the noble Lord tell us whether he intends to vote for or against the amendment?

[Lord Greaves]

I am coming to that. So having said all this, why am I going to vote for the amendment moved by the noble Baroness, Lady Thornton? I will do so very unhappily because I do not like voting against my noble friends, particularly when they have done so much hard work and achieved so much. I do not like voting against the party anyway but, having looked at it, it seems to me that the safeguards which have been achieved are not sufficient. Having read the latest version of the Bill which we got at Third Reading, I think it is inevitable that this Bill will lead to greater commercialisation. It will lead to a greater emphasis on competition rather than integration, and to a continuing incursion of private sector-based companies into the provision of NHS services. It is undoubtedly a radical top-down restructuring, in direct contradiction of the coalition agreement that I signed up to. That is being imposed on the health service at the same time as it is struggling with the biggest financial problems that it has had for many years. This is all in the face of the overwhelming opposition of NHS staff, professional groups, patient groups, public opinion and, indeed, a majority of people in my own party and of people who vote for us.

I believe that the new structures at local level will be no less bureaucratic, less open and accountable—

Health and Social Care Bill

Lord Winston Excerpts

Monday 27th February 2012 Lords Chamber

[Lord Turnberg]

My Lords, As someone who taught medical students for many years that it is very important to be absolutely open and candid with your patients, and that, if something has gone wrong, to explain it in full to the patients and their relatives—explaining that that is not necessarily an admission of guilt in some way—I am very keen on the sort of sentiment that is being expressed in this amendment. I am particularly keen on the GMC imposing on doctors the duty of being open. I am all behind the sentiments of this amendment. I have some anxiety, though, about how this can be put into law. How can you legislate for someone to be candid? How will it work? How do you know that someone has been candid or not? There is a great deal of subtlety about this candour and about putting it into law as a duty on every occasion. I am slightly apprehensive about the amendment, even though I support everything about the principle.

[Lord Winston]

My Lords, I find it very difficult, as I have said before, to accept or support this kind of amendment, but I strongly believe in candour and I totally support what many noble Lords, including my noble friend Lord Turnberg, have said around the House. However, there are major problems with putting this kind of amendment into legislation, which would make it extremely difficult to be reasonable. There would be real risks of serious psychological harm to quite a lot of patients. One of the last things we want to do is to involve patients in a perceived injustice or perceived negligence which turns out to fail miserably in the courts of law. I have seen that as horribly damaging with patients I had in the past when I was a medical practitioner, which I am of course no longer.

The other issue not adequately dealt with in this amendment is that of time. At what stage is it justified no longer to be candid? Should somebody who, let us say, sees something from that same health authority a year or two later, or three or four, still be candid about what they think may have gone wrong, or where they are not absolutely certain that it has gone wrong? There is a colossal difficulty in trying to enforce this. Far better is the idea of having some kind of code of practice, to which I think my noble friend Lord Turnberg referred, which ought to be acceptable to doctors.

When I was a trainee surgeon, we did innumerable partial gastrectomies. We now know that that operation was really mutilating and totally wrong; it actually resulted in many people losing weight and not being able to hold down a proper diet. Subsequently, of course, peptic ulceration could be treated by a simple antibiotic therapy. Now, at what stage does that treatment become established or a gastrectomy become a negligent operation? These are very difficult things to define, and I urge that we should not write this proposal into law in the way that is proposed.

[Baroness Wheeler]

My Lords, we had a long debate on this very important issue of the duty of candour before the Recess, and I do not intend to take up very much of the House’s time on this amendment by responding to the issues that we covered then, or by repeating our views on why we are concerned that the Government’s current proposal for a contractual duty will not address the need for the huge cultural change in the NHS that has to take place in order to ensure openness and honesty when things go wrong in the care and treatment of patients.

Nevertheless, I hope that the Minister will accept the case for regulations on including the duty of candour in commissioning contracts. We on these Benches emphasise our commitment to trying to help to make the contractual duty work. I therefore place it on record that we welcome the Minister’s reassurance during the previous debate that he will come back to the House on the outcome and actions resulting from the current government consultation on the contractual duty. I also hope that he will be magnanimous in the victory that he had before the Recess in the vote rejecting statutory requirement by standing by his assurances on a future review of the effectiveness of the contractual duty, after an appropriate period, and whether its effectiveness is being held back by the lack of statutory provision. My third hope is that the NHS Commissioning Board will issue clear and strong guidance to assist CCGs in this matter, and I look forward to the Minister’s response.

--- Later in debate ---

[Lord Patel]

My Lords, I support the amendments relating to conflict of interest and I agree that there needs to be something in the Bill. I will give an example to indicate why I believe that more strongly following a seminar that we attended before the Recess. For those noble Lords who were not there, we had a presentation from a GP who told us, first, that he was salaried, and I therefore presume he did not have a standard general medical services contract, and that his salary came from somewhere else—it may well have come from another general practitioner. He said, secondly, that he was involved in commissioning and, thirdly, that the commissioners had found that the provision of some services in his area was not satisfactory or of the quality that they had asked for—particularly, in relation to hand surgery. They therefore set up an independent provider of surgical services, of which the GP was a non-executive director. The conflicts of interest are quite obvious: here is a commissioner who is a salaried doctor, and that raises a question. If the commissioning board is to hold the contracts of primary care providers, will they not include those who have a general medical services contract, or will they include those who are salaried? More and more primary care providers are salaried GPs employed by other practitioners. We therefore also need to clarify who will be asked to be a member of the commissioning group: will it be only those who hold the general medical services contract, or will it be all those who provide primary care services? The conflict of interest here is many-fold, and therefore we need to address how it is to be resolved.

While I was, and still am, very attracted to the amendments of the noble Baroness, Lady Barker, because I had not seen those of the noble Lord, Lord Hunt, the question of sanctions needs to be addressed more clearly. I agree with the noble Lord, Lord Hunt, on the need for this question of sanctions to be clarified so that those who may be involved in conflict know from the very beginning how those sanctions will apply to them.

[Lord Winston]

My Lords, perhaps I may deal very briefly with one area of medicine with which the noble Lord, Lord Patel, and I are particularly familiar. One problem raised is that increasingly general practitioners are doing minor surgical procedures; increasingly in practice, often in groups. I know of one large practice in south-east England, for example, that is now carrying out a procedure called a hysteroscopy, which is an endoscopic or telescopic examination of the inside of the uterus. This is quite a specialised procedure designed to identify cancers of the uterus at an early stage. The problem is that general practitioners may well be able to carry out this procedure somewhat more cheaply than gynaecologists in a practising group. Of course, there is clearly a conflict of interest here, because they may well be in the very practice that is also commissioning this procedure, and a patient might perhaps be wrongly given a particular treatment when a slightly more expensive treatment, done elsewhere, may be more effective and reduce the risk of the cancer.

[Baroness Finlay of Llandaff]

My Lords, this group of amendments and this debate has focused on conflicts of interest. For clinical commissioning groups, conflict of interest will arise where the leaders of the groups have financial interests, but also where private companies which may have separate provider arms competing as a qualified provider are contracted to provide commissioning support. The other area of conflict which has not been addressed is where quality rewards for commissioning are linked to financial performance of clinical commissioning groups. Further, there are cases where local medical committee officers are key officials in a clinical commissioning group.

The clinical commissioning group is meant to represent the constituent practices. Indeed, there have been articles in the press about commissioning support and commissioning support organisations. Many of those have raised alarm among clinicians who have become increasingly concerned by the talk revealed in the press about the profit to be made by commissioning support organisations. There has also been a realisation that profit going to the commissioning support organisations will reduce the amount of money going into the provision of core NHS services at any level—whether in the community or in secondary care and the hospital sector.

Several amendments are tabled here. The amendment in the name of the noble Lord, Lord Hunt, is very comprehensive and deals with an area which the other amendments do not. There is also an amendment, on which my name is the first, regarding conflict of interest. I can see that Amendment 79A is more detailed than the amendment which I have tabled, and therefore goes further and would be better. However, I am concerned that it does not go quite as far as the amendment in the name of the noble Lord, Lord Hunt, and that some of the principles in there need to be incorporated into Amendment 79A if the Government are minded to accept that amendment. We may have to come back to amend the amendment should it be accepted and incorporated.

--- Later in debate ---

I hope that that provides sufficient reassurance to the noble Lord, Lord Warner, that the emphasis on integration is there, but that he will accept that trying to pin down in words what it should look like may be counterproductive. This is not an argument about the Government’s commitment to integration or what we are doing on the ground to achieve it; it is an argument about a specific mechanism designed to achieve it. I think that it is a mechanism that is ill-advised. I hope that the noble Lord will agree to withdraw his amendment.

[Lord Winston]

I have a short question for the Minister because I feel that it is an important issue. Perhaps I may very briefly tell him about something that I learnt of last week. A friend of mine went to a very famous ENT hospital after a month with a fractured nose—

[Noble Lords]

Order!

--- Later in debate ---

[Baroness Northover]

My Lords, the Minister has sat down, so it is for the mover of the amendment to respond.

[Lord Winston]

I am sure that the Minister will want to answer my question because it is not aggressive or political; it is really to find out how this Bill will work. When somebody goes to casualty after a month with a broken nose and complains, “Look, my main problem is the pain in my sinuses which I have had for a long time”, and is told by the doctor when they had already waited six hours, “I’m afraid the sinuses are a different department. You’ll have to make another appointment”, that is a problem with integration. How does the Minister think we might accomplish better integration with this Bill?

[Earl Howe]

It is a very interesting question from the noble Lord. When I visited Oldham a few weeks ago, I saw for myself how they were getting around that problem in the context of musculoskeletal services. Instead of patients being shunted from pillar to post, they had a system whereby the patient could move seamlessly and immediately from one specialist to another. They did not have to be referred; they could ring up the centre and ask to see a particular person. That is the kind of integrated model that we need to see rolled out more generally in other services. I recognise the issue that the noble Lord raises, but it is one that we are seeing inventive solutions arising to address. I hope that the work being done will do that.

Health and Social Care Bill

Lord Winston Excerpts

Monday 27th February 2012 Lords Chamber

[Baroness Jolly]

My Lords, I had not intended to speak because everything had been said. However, the noble Lord, Lord Walton of Detchant, made a point that I think is worth picking up on. I declare an interest as chairman of the Specialised Healthcare Alliance, which works with people with rare and complex conditions. These conditions are commissioned by the NHS Commissioning Board, while the conditions referred to by the noble Baroness, Lady Finlay, in Amendment 63A are intended to be commissioned by CCGs. Clearly, people are really anxious about these commissioning arrangements. They are based on geography; they are relatively small in number, but not tiny; they are geographically sparse; and very often GPs will not actually see these conditions very frequently.

The noble Lord, Lord Walton, asked whether any thought had been given to sweeping these conditions in with the rare and complex conditions, and to have them commissioned by the NHS board. I am not suggesting whether this is a good or a bad thing, but I think that those with these conditions and the organisations that represent them might be glad to engage in a dialogue on this to see whether it is the appropriate way forward. There is certainly a lot of anxiety about what is currently happening. If my noble friend would give us some indication of whether that could be looked at, that might alleviate some concern.

[Lord Winston]

My Lords, I hope that in summing up the Minister will address the general issue of genetic disease. The noble Lord, Lord Walton, referred to one specific single gene defect but there are some 6,000 single gene defects and they are often very complex. Most of them are fatal diseases and many of them affect children. A few sufferers of single gene defects live to a young age and some occasionally live into middle age. However, one problem that we already find in the health service is that provision for the care, treatment and diagnosis of these patients and for the counselling of their families is often very deficient, depending very much on whether funding is available.

An example is the work that has been going on in pre-implantation genetic diagnosis, which can prevent a child who might die from one of these diseases being born through the selection of a suitable embryo. Of course, this is not a cheap procedure but in terms of financial efficiency for the health service it is very much less expensive than the complex care that might be involved for a child with, for example, advanced male-type muscular dystrophy. Hitherto there has been a huge difficulty in getting these services through individual PCTs because they think in the short term and are on a budget from year to year. Therefore, collaboration seems extremely important not only in relation to these rare cancers, which of course are immensely important, but for a great number of diseases which are extremely distressing. I am sure that the Minister will fully understand and be greatly sympathetic to the fact that the families involved are immensely distressed by these diseases. They are often very puzzled that they may be carrying one of these gene defects and they find it very difficult to get answers to what are quite complex problems. There really does need to be proper provision for them through collaboration with other authorities.

[Lord Turnberg]

My Lords, I should like to comment on Amendment 64ZA. I am sorry to inflict yet another medical opinion on the House but there is one factor which has not been mentioned in the planning of emergency services—that is, the fact that the vast majority of patients in medical wards are admitted through the emergency department, coming in as acute emergencies. This is quite unlike the situation in surgical wards. They, too, have their ration of emergencies but the majority of patients are admitted from waiting lists, and this is where the waiting list initiative and so on come in. However, when planning for medical beds, one has to think in terms of the accident and emergency department being the major route by which these patients enter the hospital and, in planning for emergency services, one has to think of the bed needs associated with that.