HL Deb 18 December 1991 vol 533 cc1433-56

8.39 p.m.

Baroness Masham of Ilton rose to ask Her Majesty's Government what action they propose to take to safeguard specialist hospital units, which provide centres of excellence within the National Health Service.

The noble Baroness said: My Lords, at Christmas time we think of goodwill towards each other. I hope that the Government will have a satisfactory reply to the Question I now bring to your Lordships.

Many countries envy our National Health Service. Some of our centres of excellence provide the only lifeline patients have. Some conditions caused by accidents or illness need exceptional centres. They need specially trained doctors, nurses, therapists and technicians who have come together and, with their common interest and discipline, have found ways of treating conditions which are difficult and often cause insurmountable problems and run into complications if the only choice is that of a general ward in a district general hospital.

These centres of excellence have been built up over the years by dedicated teams of trained hospital personnel. They are not only treatment centres for patients; they are also centres of post-graduate teaching and centres of research and development in respect of health care and the monitoring of new drugs and techniques. It would be a tragedy if the marketing of health care turned into the fragmentation and downgrading of our centres of excellence.

I am most grateful to all noble Lords and noble Baronesses who will speak in the debate tonight. I congratulate the noble Baroness, Lady Hooper, on having visited the spinal unit of Stoke Mandeville Hospital while she was on an official ministerial visit to another part of that hospital. She took the time and trouble to visit the spinal unit. The noble Baroness was shown a horrific pressure sore, the sight of which will no doubt remain with her for ever as a vivid memory. Those terrible pressure sores are common occurrences if paraplegics and tetraplegics who lose sensation from a point of injury are treated in general hospitals that do not implement a routine turning procedure.

I have seen many people whose lives were saved due to the treatment they received in many different centres of excellence. My life was saved in a specialist unit. Many other Members of your Lordships' House have had similar experiences in centres such as St. Mark's Hospital in City Road. That hospital is world famous for treating the gut. I do not believe that Government Ministers want to see such centres disappear. However, unless some safeguards are established forthwith, Ministers, along with everyone else, may be impotent to do anything about the position.

If the money runs out and districts do not transfer patients, units may have to close down. It would be a tragedy if the only solution remaining to patients, their next of kin or voluntary organisations was to resolve the lack of correct treatment through the courts. If the supra-regional funding is to stop at the end of March, there is not much time left.

The many voluntary support organisations that represent various patient groups know what correct treatments should consist of. Many of those organisations are concerned that the recent Patient's Charter omits any mention of the right to a tertiary referral. That omission was one of the reasons I felt there was an urgent need to bring this matter to the attention of your Lordships.

There are many complicated disabling conditions which need specialist treatment, not only when they reach an acute stage but throughout the lives of the patients concerned. The expectations of the public are growing all the time. I am sure that if the late Lady Lane-Fox had been with us this evening she would have spoken in the debate. Across the river at St. Thomas's Hospital is the Lane-Fox unit. That unit is unique in Great Britain. It cares for people who suffer from high respiratory conditions. It is a lifeline for a small but important group of people. If noble Lords were to visit that unit, they would be amazed at what treatment can be offered by people who know how to offer that treatment.

Eighteen years ago, as I had dealt with some desperate cases of people with spinal injuries who had not been sent to spinal units—most of those patients came from social class 5, medically speaking—I, with colleagues, founded the Spinal Injuries Association. I now have the honour to be the life president of the association.

During the passage of the National Health Service and Community Care Bill I raised on behalf of the association a number of points of concern regarding the Government's proposals on supra-regional specialties. Although we received assurances from the Government that the specialties would be protected, it is now over a year since those assurances were given. In less than four months the new contracting system will begin in full. Our concerns are as great as ever.

In Committee on that Bill the Minister, the noble Lord, Lord Henley, said: In short, regional and supra-regional specialty units are likely to be in a stronger position under the proposals in this Bill than they are now".—[Official Report, 24/4/90; col. 520.] The evidence is that this is not the case and there are fundamental problems with the proposals. The Spinal Injuries Association is in constant and close contact with the spinal injuries units. I wish to highlight our main areas of concern.

I shall deal with the matter of the new contracts. Of fundamental concern to units is the Government's decision to change their status from supra-regional to regional units from April 1992. That will mean a loss of central government funding with serious consequential difficulties for units. It flies in the face of assurances given by the noble Lord, Lord Henley, again in Committee on the National Health Service and Community Care Bill when he said that, spinal units and, for that matter, all supra-regional services will be protected by a proportion of the costs being met centrally and the balance regionally".—[Official Report, 3/4/90; col. 1385.]

Although many units take a large proportion of their patients from within their own regions, some take a significant proportion of clients from outside their regions. Stoke Mandeville Hospital, for example, takes 80 per cent. of its patients from outside its region and the Midland Spinal Injuries Unit takes 35 per cent. of its patients from outside its region. Even where the figures are not so high, there are always ex-patients and a handful of new patients requiring the services of the specialist unit who come from outside that unit's region.

There is great concern that any lull in income while contracts are negotiated with the districts will have devastating consequences for some units. The lack of contracts may also prevent future and existing clientele from receiving the specialist care provided by a spinal injuries unit. One unit received official notification of the new arrangements for contracting only last week. Another unit estimates a three year time lag while the districts sort out their simpler, more routine and less expensive contracts.

The Spinal Injuries Association's recommendation to the Government to prevent units from closing under the consequent financial shortfall is that central funding should be provided for at least an interim period of, say, three, years. The continuation of central government support should be reviewed after that period.

There are difficulties in costing treatment for clients. Due to the large variation in the extent of each individual's injury, it is difficult to cost out a standard package for individual patients. Apart from the initial diagnosis of cord damage and neurological sparing, factors such as the previous state of health of the person, the delay in referral, the presence or absence of complications and associated injuries and the provision of support in the community afterwards affect the total cost of providing for each person.

Hospital stays can vary from an initial period of two months to six months or longer. How do the Government envisage such variations being accommodated in the drawing up of contracts? The Spinal Injuries Association recommends that assured central government support is provided to cushion any shortfall.

Units have developed as centres of excellence and offer a policy of "crash to coffin" support that enables patients to live in the community. It is essential to the future health of a person with a spinal cord injury that he or she is able to return to the specialist unit for regular check-ups. Lack of expert assessment can lead to unnecessary complications. There is considerable anxiety that ex-patients will be required to go for check-ups at their local district hospitals, which lack the necessary expertise but which are cheaper in the short term until complications arise. The result is that complications arise for individual patients, causing a significant shortfall in funds for the spinal unit. One unit estimates that 35 per cent. of its clients and funds are at risk from such a policy.

There is real anxiety in specialist units that districts will not refer new patients to spinal units because of the additional expense. That may well lead to inappropriate and poor treatment, resulting in long-term complications for the patient concerned and an on-going drain on financial resources. It can take months in hospital to repair an avoidable pressure sore.

There is significant evidence that some district health authorities are considering the possibility of establishing their own centres for treating people with spinal cord injuries. It is clear that they will not be able to provide the necessary expertise which is provided by the specialist units. The Spinal Injuries Association would like unreserved assurances from Ministers that new and former patients will have readily available access to specialist units. We are fearful that unless those issues are addressed now there will be insurmountable problems in April 1992, with devastating consequences for units and future and existing patients with spinal cord injuries.

As this subject is not understood fully by many people who have not had first hand experience of spinal cord injuries, I should like to summarise the position. The modern treatment of spinal cord injuries was pioneered at Stoke Mandeville Hospital. The principle of early admission to a specialised spinal injuries centre with comprehensive rehabilitation and lifelong follow-up was adopted by all the spinal injury centres in the United Kingdom and has now been copied in many countries worldwide. The network of dedicated spinal injury centres in the United Kingdom is the most advanced and comprehensive in the world.

Because of the rarity of spinal injuries—one new case per 100,000 of the population per annum—it is not possible to provide functional spinal injury centres on a district or regional basis. It was for that reason that spinal injuries became one of the first supra-regional specialties. The sudden removal of spinal injuries from supra-regional funding poses grave threats to the continuation of the service although in the long term it gives spinal injury centres an opportunity to develop further. The market which has been introduced into the health service is barely capable of coping with routine large specialties. There is a grave danger that spinal injuries, a small specialty necessarily organised on a supra-regional basis, may suffer in the next year or two. It is essential that adequate interim measures are introduced to ensure the continuation not only of the admission, of the newly injured patient to the spinal injury centre but also the continuation of the essential lifelong follow-up. The spinal injury service is one of the great successes of the National Health Service and should not be sacrificed and lost for the sake of new reforms.

The Spinal Injuries Association wrote to all the spinal injury units before the debate. One unit commented: None of our potential purchasers have any knowledge of the proposed de-supraregionalisation of spinal injury units. We have been having regular meetings at a hospital level with the purchasers of our services. I have raised the spinal injury unit issue with each of them. None of them have had prior information and all of them say that they cannot handle this matter at district level". Another wrote: Frankly, the whole matter seems to have been handled with much haste and little planning … postponement of the proposals for de-designating spinal injury units would undoubtedly help to avoid what is likely to be chaos next year". Another unit said that its greatest concern was that former patients would be unable to return to the unit for specialist treatment. That has already occurred.

I should like to obtain more information and send it to the Minister.

As Christmas draws near it is difficult not to think of the many children who will be in hospital. One has only to look through the directory of Contact a Family to see how many specific conditions and rare syndromes there are with long-term consequences, such as juvenile chronic arthritis. There is nothing so frustrating and worrying for parents as not being able to reach the services of experts who can give their child, who is suffering from a complex condition, the best available treatment. There are many people in all parts of the country raising money and striving to help provide equipment for hospitals so that patients can have the best possible treatment.

Not to have the centres of excellence with their concerted team approach, driven by a special interest in a specific condition, would mean the fragmentation and watering down of treatment. The expertise comes from seeing and treating many cases of a similar condition, knowing what the patient responds to, the benefits of treatment and how to achieve success. The aim of a centre of excellence is to understand how to overcome what seem insurmountable problems. A general ward so often cannot achieve that because the staff lack the specialised training and the dedication to find a cure for, or to alleviate, a specific condition.

It would be a tragedy if we were left with no national or supra-regional units. Not to have the freedom to send patients to the centre where their condition can best be treated and understood will only cause immense problems for everyone concerned in the long run. It cannot be allowed to happen. We should be rightly proud of our centres of excellence in the National Health Service. They are not only of paramount importance to the patient; they are cost effective in the long run for everyone.

8.58 p.m.

Lord Butterfield

My Lords, I congratulate the noble Baroness, Lady Masham, on her strong statement about the need for the maintenance and continuity of our specialist units. I find it hard to believe that the noble Baroness, Lady Hooper, could possibly have a hard enough heart to jeopardise the future prospects of those important centres. I like to believe that when it comes to her turn to speak she will be able to give us encouragement that there will be some funding so as to ensure that the dreadful prospect that the noble Baroness, Lady Masham, has put before us can be dispelled. It is most important that the people who work in those units are helped by such encouragement as we can give them, particularly at this time.

I do not need to convince the House that some of our most important innovative and pioneering specialist units are concerned with the so-called NHS supra-regional specialties, and not only those that are so designated. Others which used to be supra-regional specialties, such as renal transplantation units, have now been absorbed in the warp and weft of the health service.

I understand that at present about £76 million a year is spent on supra-regional specialties which include chorion carcinoma services, cranio-facial surgical services, heart transplantation, liver transplantation and specialised liver services, neo-natal and infant cardiac surgery, primary bone tumours, psychiatric services for deaf people, spinal injury units, to which the noble Baroness made important reference, retinoblastoma and stereotactic radio surgical units. I have no doubt that the people in those services will need protection and, I suspect, more money. I hope that we shall hear that they will be cosseted.

However, there are diseases that produce disabilities which can be seen out and about and which are also helped by specialist research units. These are the specialist research units for heart disease, strokes, rheumatism and diabetes, about which I shall speak for a short while. Those special units for more widespread diseases are to a considerable extent supported by funds from the medical research charities, of which the most powerful and influential are those concerned with the study, treatment and, we hope, prevention of cancer.

However, there are many charities, ranging from those large ones—for example, the Heart Foundation and the British Diabetic Association, with which I have been associated—right down to quite small charities that have been established by citizens, frequently from their wills. I am conscious of the importance of those small charities because, when I did a survey in Bedford with my colleagues from Guy's Hospital in 1962, the only reason that we could proceed with and fund that survey was that a solicitor in Bedford discovered a charity which had been established by a patient with diabetes who had gone blind and wanted her residual estate to be spent on diabetic research. We were fortunate enough to receive a grant from the charity to help us go ahead.

That survey in 1962 showed that about 2 per cent. of people in this country have diabetes. That is a million people in round numbers. Of those, about 130,000 are paid up members of the British Diabetic Association which each year raises between £6 and £7 million. It has a policy of putting 40 per cent. of that money into social and educational services. It has a strong education service to teach children to inject themselves with insulin and to provide summer camps for them. It has a strong research grant system which distributes funds to specialised units of the kind to which the noble Baroness referred which are scattered over the country, from Belfast, Glasgow, Edinburgh, Newcastle, Manchester, Sheffield and Nottingham, down into the South and London. Those units are almost exclusively located in university settings because that is where one can attract people to take time in a career to become familiar with a disease and to make a research contribution.

I am anxious to take the opportunity created by the noble Baroness to ask the Minister to consider a point about charitable dispensations for medical research in specialised units. So great is the generosity of our people that the medical research charities can spend over £100 million on all the different diseases that are represented, including muscular dystrophy and diabetes.

However, a problem arises in that in future, because of the new arrangements, it is inevitable that the hospitals that carry the specialist units will have to charge overheads. The research councils have a dispensation from the Government to the effect that the Government will carry their overheads. University centres receive £60 million to £80 million a year from the Medical Research Council and, I understand, will have their overheads met from central funds.

Our worry is that the £2.5 million that is spent in the units to which I have referred will be reduced by 20 per cent. due to the need for overheads to be paid under the new arrangements. Let us be quite honest about it: in the past a large amount of research was done on the NHS without anyone noticing it. When I was Professor of Experimental Medicine at Guy's Hospital, I did trials of new medicines and new techniques under the NHS. We did not ask for money because no one did any accounting. We would now ask for funds from pharmaceutical companies, particularly the 40 per cent. overheads from overseas pharmaceutical companies. However, to date the men who work on charitable research units have been able to carry that work forward and hospitals have been pleased to have them in their midst and to support them and find ways and means of losing their expenses. That cannot happen any more.

I should therefore like to ask the Minister whether she will give sympathetic consideration to phasing in the imposition of the overheads to be loaded on the specialist units which do the research that is the lifeblood of the specialist units. If one takes a period of five years it would mean £4 million extra next year, then £8 million and so on, until £20 million was found.

I believe that the charities will be able to absorb that but it would be a nice gesture to the public, to the people working there and to the young people who give up their jobs mid-career to work in the units if they have some expectation of security over the next five years while those changes are coming about. I realise that the noble Baroness cannot give assurances tonight but I am sure that she will give sympathetic consideration to the matter. It is one of the ways in which the public is able to make sure that they receive the best possible treatment through research in the specialist units to which the noble Baroness, Lady Masham, referred.

9.8 p.m.

Lord Ennals

My Lords, I want first to thank the noble Baroness, Lady Masham, for raising this issue. She can always be relied upon to raise urgent medical issues. We are much indebted to her once again.

I want to support in general terms what she said on behalf of the Spinal Injuries Association with which I am concerned and to which I have a commitment. I also want to echo the disquiet expressed by the noble Lord, Lord Butterfield, and add that I fear that it will not be just the units which are supported by large charities that suffer. I believe that there are a number of cases in which small units are now very much in peril.

Before I go on to specifics, I should like to ask the noble Baroness whether her department would he prepared to look at the situation in which some specialist units now find themselves on the brink of closure. Once a well established unit is forced to close for financial reasons and the team of doctors and researchers involved with it is broken up, it becomes very difficult to get that particular research going again.

I want to mention a particular research project with which I happen, in a sense by accident, to be involved. In the 1960s the B-12 research laboratory was established at the Westminster Children's Hospital. Rapid diagnosis and treatment of B-12 disorders in children were made possible by a new method developed by the laboratory. A dozen serious diseases of B-12 metabolism are now recognised and many young lives have been saved by timely intervention and B-12 treatment. One might ask why single out B-12? Vitamin B-12 is vital for the proper functioning of every cell in the human body. The total amount of B-12 in an adult would probably do no more than cover a pin head. A minute quantity in every human cell is able to control cell functions, the growth and development of nerves, muscles, the brain and every vital organ.

In 1982 that work was in peril. 1982 was a time when university funding was reduced, as the noble Lord, Lord Butterfield, may well recall. I remember visiting the unit in the Westminster hospital and being told by the doctor in charge that unless a charity was established that could raise funds, the unit would simply disappear. I remember saying, "It will disappear over my dead body". Ever since 1982 I have remained alive.

The children's medical charity was established to help save the lives of sick children by the better understanding of disorders such as diabetes (which was referred to by the noble Lord), cot death, malnutrition and leukaemia, which have clear or possible links with Vitamin B-12. The charity has sustained the work for nine years now. It has been able to do so because of generous donors, to whom I am very grateful.

The B-12 unit in Westminster Children's Hospital is the only specialist, diagnostic and research unit in the United Kingdom that can estimate active Vitamin B-12 in tiny new born babies for rapid diagnosis and treatment of those crippling diseases. Over 400 premature babies and sick infants have been referred to the unit in the past decade. The closure of that unit will have grave implications not only for the lives of children now at risk but in the future for many others.

Recent pioneering research in the unit has shown that there may be other diseases of childhood in which Vitamin B-12 may play an important role. There are already positive links between the vitamin and diabetes, cystic fibrosis and cancer. Unless the closure of the unit is averted, further work on those important developments is unlikely and some parents will suffer hardship and needless distress.

I emphasise that this unit is one of only five comparable units in the world. It has world-wide recognition and approval. Three years ago the researchers in the unit organised an important seminar. The work of the unit is now at risk. I have written to the Secretary of State for Social Services, Mr. Waldegrave, to ask whether the department can consider the project because unless funds are raised in the next three months the work will stop. I believe that it is not in the interests of the country or children, let alone the department, that this work should go by the board. I therefore hope the Minister will look into the matter to see what the department can do to help.

I shall continue to do what I can, as will many other noble Lords in this House. The noble Lord, Lord Walton, was president of the charity. The noble Lord, Lord Goodman, has been associated with it. I am very proud of the response. However, there is now a grave danger that the unit may close.

I wish to refer too to the Hilda Lewis House at the Bethlem Royal Hospital which is now threatened with closure from January 1992. It is a money saving operation. The money saved will be used to buy a scanner. If Hilda Lewis House is closed there will be no place at Bethlem Royal Hospital for children with severe learning disabilities. Hilda Lewis House provides an intensive short-term in-patient assessment and intervention service for children with severe learning difficulties and extreme behavioural problems such as extreme aggression to others or injuring themselves so severely that they cause permanent damage. The aim is to help those children to live as normal a life as possible. Interventions are aimed at discouraging dangerous and difficult behaviours while fostering the development of constructive and less harmful behaviours. Treatment needs to be carried out consistently throughout 24 hours. That requires among other things a very high staff ratio.

The unit is well respected. It is a unique national resource offering residential treatment to children up to 16 years of age who have such severe problems that they cannot be helped in the community and whose needs local services cannot meet.

On 6th August 1980 the then Secretary of State, Mr. Kenneth Clarke, acknowledged Hilda Lewis House's international reputation as a centre of excellence. He stated, I am confident that Hilda Lewis House will continue to provide the unique service which it offers". He continued: There is absolutely no intention to close the unit". I suppose that the use of those words means that there was no intention then. But there is an intention now. Despite the assurance given by Mr. Clarke, Hilda Lewis House is to be closed to buy some equipment which the health authority cannot otherwise afford. Such a choice is grossly unsatisfactory.

I hope that the Minister will also consider that project. The great benefit of the noble Baroness, Lady Masham, having moved such a debate is that it enables those of us with specific experience to bring forward projects that are in danger. I know the thoughtful and caring approach of the noble Baroness, Lady Hooper. I hope that she will consider the two units that I have brought to her attention.

9.18 p.m.

Lord Wise

My Lords, the noble Baroness, Lady Masham, described forcefully the work of the special units and their problems, especially in relation to spinal cord injuries. As a layman I have no great knowledge of the work of the units. However, one of my sons leads a special unit and from time to time I have had discussions with him. Perhaps I may tell the noble Lord, Lord Butterfield, that my son worked for a period some time ago at Manchester Royal Infirmary. That was under a university appointment. He conducted much research then into diabetes.

As with all the National Health Service's problems, the main difficulty relating to the safeguarding of the special hospital units is the need for continuing and adequate finance. I believe that the Government may wish to encourage an area of competition between the specialist units. I feel a little unhappy about that. The inevitable consequence would be the closure of some units. That surely cannot be good for patient care. Could that involve a desperately ill patient having to travel many miles for treatment at another specialist unit? Money has to go with the patient. I do not understand what will happen if a district authority has overspent and does not have the money to send with the patient. Could such a situation arise? If so, what will happen to the patient? Who makes the decision? Will he receive inferior treatment, the best that can be provided locally or elsewhere, or will he merely suffer through lack of treatment? Who makes the decision? There is bound to be a conflict of interests and possibly acrimonious arguments between the consultant who is dealing with the case and knows what the patient needs and the administration which is having to try to find the money. The poor patient is just the pig in the middle who is suffering.

I suppose that if the patient has the money to pay there will be no problem; he will receive the treatment that he needs and his suffering will be alleviated. However, if neither he nor the district authority has the money, I presume that he will not receive the treatment. Surely that must not be allowed.

District health authorities can be short of money for all manner of reasons. They may even be badly managed, who knows? However, the number of our truly excellent special units must not fall. They are in jeopardy if there are insufficient funds to send patients to them. How will the Government ensure that district managers have enough funds to refer patients to special units whenever that is needed? If the patients do not get to them, the units must fold as a result of lack of cash.

9.22 p.m.

Lord Rea

My Lords, I too thank the noble Baroness, Lady Masham, for raising this important issue. I also congratulate her on her moving and extremely well-informed speech. The internal market involving the separation of purchaser and provider, which is the central change brought about by the National Health Service and Community Care Act 1990, was based on an idea put forward by Professor Alan Enthoven, the economist of Stanford University. His monograph was based on a study that he carried out on the National Health Service. It was not meant to be incorporated into legislation, as it has been, in one tranche and applied throughout the National Health Service. Indeed, he has since expressed in an interview and to relatives, friends and colleagues his embarrassment that his ideas were not introduced gradually in stages in different areas and at different levels with evaluation at each stage. He, among many others, has pointed out that the market in health care has sometimes had disastrous effects in the United States.

We must accept that the internal market is now here, al least for a while, and we must make the best of it. The principle of having a purchasing authority assessing and buying health care for the needs of its population is to me theoretically attractive. If it can be shown to work it is likely that it is here to stay. However, I say that advisedly because we have yet to see the internal market working in its full force. Until now it has been a cushioned operation of the system.

The type of units to which the noble Baroness's Question refers cater for the needs of a small and rather fluctuating proportion of the population of any single health district. It is very difficult to predict on a district or even regional level how many spinal injuries, rare bone tumours, or cases which need special psychiatric units because of deafness there are likely to be in any one year. Thus, referrals to specialist units at regional or supra-regional level will in most cases be extra-contractual—ECRs. Other noble Lords have pointed out that those ECRs are the bêtes noires of district purchasing managers, the more so because of the difficulty in specialist cases of costing each admission or referral since each case may be different in complexity and length of stay required.

I hope that the noble Baroness will be able to explain whether and how regional reserve funds will be created and operated to help or bail out district health authorities which have overspent and which cannot afford as many extra-contractual referrals as they would like. Are those funds to be set up and how will they be administered? Is it known how large will be the funds at their disposal and whether the funds will be subtracted from the sums allocated to districts, or will they be earmarked for legitimate overspends on ECRs hours when the regions are funded centrally? The specialist hospital units, as many noble Lords have pointed out, need more secure funds than they can expect from fluctuating extra-contractual referrals.

As the noble Baroness pointed out extremely clearly, anyone who has been a patient in a specialist hospital unit or has had a relative treated there, or who, like myself, has treated patients who have received care in such a unit, will be very much aware of the extremely high level of expertise which has been built up in those units over many years. As my noble friend Lord Ennals and the noble Lord, Lord Butterfield, pointed out, those centres of excellence use their unique experience to train teams of doctors, nurses and therapists. That training cannot be obtained elsewhere; nor can the research which is often conducted on very rare conditions, as has been explained in some detail by those noble Lords, be carried out so well elsewhere. The staff trained at those units can spread their expertise when they take up jobs in other units, quite apart from forming part of a team in the units themselves. For example, they can help to teach others to avoid the kind of unpleasant experience, which the noble Baroness described, of the badly neglected pressure sore. There are many other examples of different conditions which can go wrong if not given special care.

We are all anxious to hear from the noble Baroness how the Government intend to safeguard these unique units from the vagaries of the market system. Can she assure the House that the units will be able to rely on earmarked secure funding for at least the next two or three years until we see how the internal market settles down?

The Patient's Charter does not include the words "patient choice". That is rather strange when the National Health Service and Community Care Bill was preceded by a White Paper called Working for Patients. The units which we are discussing are the enthusiastic choice of those who use them. The system at present does not assure those units of a secure future. I hope that the noble Baroness can provide them with that assurance.

9.30 p.m.

Baroness Gardner of Parkes

My Lords, I am grateful to the noble Baroness, Lady Masham, for introducing this topic to the House tonight. I have always supported supra-regional hospitals from the time when I was on the board of the Brompton National Heart Hospital. This House listened to the problems that existed then and did much to help solve them. Now, like all other postgraduate hospitals, it will again face problems of funding. However, again like other special health authorities, it is standing back waiting to see what happens. Therefore tonight I do not intend to speak about that hospital but about the Royal National Ear, Nose and Throat Hospital, which is in a slightly different position.

I must declare an indirect interest in that my husband is the chairman of the hospital, which was one of the first wave national health hospital trusts. It is interesting that it is mainly postgraduate. However, it does not come in as a special health authority in the same way as the others—the Royal Marsden, the Brompton and the Hammersmith. There are so many that are special health authorities. A general practitioner said to me the other day that one is allowed to send patients to any of those special health authorities and the cost does not come out of the district health authority's allocation.

Unfortunately, the Royal National Ear, Nose and Throat Hospital does not have the benefit of being in that position. The cost of sending a patient there comes out of the district allocation and therefore it has to be in a competitive position in regard to funds. It is doing quite well in that it has run efficiently for almost its first full year. It lived within its means, it improved the waiting time on the waiting lists, it is continuing a high level of valuable research and it has introduced a master's degree in audiological science which the first students will take in 1992. There is already a master's degree in audiological medicine.

The difficulty arises from the fact that all the money given for undergraduate teaching is separate from the money given for postgraduate teaching. There is a lack of funds for postgraduate teaching. This year, it being its first year as a national health hospital trust, it was perceived that it would have special difficulties and it was given an unnaturally high amount of undergraduate teaching money. That provided £1 million, plus the £.3 million postgraduate funds. On that £1.3 million it managed well.

I was particularly interested in the speech of the noble Lord, Lord Rea, when he explained that the proposer of those ideas believed that they should be introduced gradually. We are seeing many things introduced gradually in this new restructured National Health Service. But it certainly must be a gradual process. It is only as it goes along that little difficulties appear which previously no one realised existed. They make themselves apparent and suddenly one realises that something must be done about them. The Government assured us that they will allow the changes in the health service to evolve. They are not planning to destroy the system. I believe that the changes are working well. But that is one of the difficulties that has become apparent.

The audiology department is unique in the country. There is also an excellent standard of ear, nose and throat treatment. One may receive ear, nose and throat treatment in other areas, but the audiology department is unique. The hospital includes the Institute of Laryngology (throats) and Otology (ears). I point that out because there is nothing worse than reading all those names in Hansard and thinking, "What on earth was that all about?" It has the National Chair in audiological medicine and also a Chair in audiological science. It is therefore of importance to people with hearing difficulties.

Some Members of this House—I feel I am rapidly becoming one of them—are aware that time produces hearing difficulties for many of us. Perhaps nowhere could we be speaking about a subject more dear to our hearts.

I appeal to the Minister to put to the Secretary of State and the department that the same formula for funding for postgraduate hospitals should be introduced in the same way as in the undergraduate hospitals. There should not be the great difference that exists now.

While thought is being given as to how that can be done and how to recognise the special needs of postgraduate teaching —because that must be recognised—can the Minister assure us that the status quo will be maintained and that at least we shall not see any reduction in funding to these hospitals which are conducting postgraduate teaching but which are not in the position of special health authorities? Because they are not in that category they are more visible than the other postgraduate hospitals which are waiting and watching to see what happens. Will the Minister assure me that she will look carefully into the position as regards postgraduate teaching? It is vitally important.

I strongly support all the supra-regional and highly specialised hospitals. We all wish to see our centres of excellence continued. We hope to see good hospitals doing routine work everywhere so that people can have treatment close to home. It would never be in the national interest to have highly specialised units everywhere because one would not have enough cases requiring that kind of work. Therefore, there would never be the degree of expertise that exists when the units are retained as supra-regional centres of excellence.

9.37 p.m.

Lord McColl of Dulwich

My Lords, I too would like to thank the noble Baroness, Lady Masham, for raising this issue and also apologise for not putting my name on the list of speakers. I believe that what we are talking about tonight is the problem of bringing in any kind of change. Changing anything in this country is an uphill task: changing anything in the National Health Service is even more of an uphill task. All changes inevitably bring problems. Changes have to be modified, as has already been said, when unforeseen difficulties arise.

The Government have taken a great deal of trouble to try to ensure a smooth take-off of these reforms. Perhaps noble Lords remember the dire warnings that were given in this House a year or so ago as to how the NHS would collapse on 1st April 1991. It is interesting to note how smooth the take-off has been. It is perfectly natural for hospitals like Stoke Mandeville with its spinal injuries unit to be worried about what is going to happen in April of next year. The patients are taken from about six or seven different regions. The hospital could have £4 million to £5 million to collect in extra-contractual referrals. In the first year that could lead to instability.

It has been proposed—it is perfectly reasonable and within the bounds of possibility—that a unit like Stoke Mandeville could negotiate with the four Thames regions in the way that it has already negotiated with the Oxford region and have a contract with them. If that were done with those five regions it would ensure between 75 per cent. and 80 per cent. of its income. That would seem to be a reasonable proposition, certainly in the first year.

The noble Baroness, Lady Masham, said that she was worried that the district health authorities would not refer the needy, paralysed patients to the proper place in order to save money. If a hospital within a district health authority were to do that it certainly would not save any money; it would increase the total expenditure. An average district health authority will see only five new paralysed people a year. There is no way that a hospital will set up a unit to treat just five patients, so that is very unlikely to occur.

The spinal injuries unit takes patients from British dependencies such as the Falklands Island and Gibraltar, and no doubt some system will be put in place to make sure that money follows patients there. The unit also takes quite a number of patients from Her Majesty's Armed Forces. Clearly, that factor too will have to be catered for. The Stoke Mandeville unit is one of the front windows of the National Health Service on the world scene. It has done marvellous work in the past and I know that the Government are anxious that that work should continue undiminished.

9.40 p.m.

Baroness Robson of Kiddington

My Lords, I join other noble Lords in thanking the noble Baroness, Lady Masham, for raising this subject tonight. We have: heard some excellent speeches, in which concern has been expressed about the future of specialist units. I am delighted that we are able to discuss this subject coolly and calmly and that there is no political angle attached to it. We are all taking part in the debate because we feel desperately concerned.

The noble Baroness, Lady Masham, referred to problems that will in a way increase from now on. When the contract system, if one can call it that, between purchaser and provider was introduced last April it was based completely on historical facts. There was no proper costing in the sense that there will be from 1st April 1992. The specialist units will be faced with a proper contractual programme and their status will be changed from supra-regional units to regional units. Both those developments worry them deeply. They are worried, as the noble Baroness said, that the districts and regions will deal first with the simpler, general, standard services. The districts and regions have problems to face too. It will not be easy for them to get the contracting system working properly on the right economic basis. The specialist units are therefore feeling threatened. As the noble Baroness said, they would like central funding to remain at least while this transitional period is going on.

The noble Lord, Lord McColl, said that the Stoke Mandeville Hospital, having made a contract with the Oxford region, could make a contract with the other regions and that its income would therefore be safeguarded. I find it difficult to see how a specialist unit can make a meaningful contract when its patients may be there for a week, a month or two months, or may even be there for between six and 12 months. Under those conditions, entering into a contract with a district health authority is a complicated process. The specialist units will have to rely largely on extra-contractual arrangements. That must put them in a most frightening situation at present, as they do not know what their income will be and how they will plan their services for the next one, two or five years. That feeling of instability is what worries all of us, together with the danger that it presents in itself that some of the units may go to the wall.

The noble Baroness, Lady Masham, referred to the unit at St. Thomas' Hospital which deals with high respiratory conditions, and to our late friend, Lady Lane Fox. I knew her from 1952; indeed, I knew her for most of her life. I know how delighted she was when that unit finally got off the ground and how important it was to her. Her visits on a regular basis to it enabled her to function in this House and to live a normal life.

Many people use the Lane Fox Unit. I talked to Dr. Spencer, who runs it. He told me that the number of referrals has not gone down, because he accepts patients regardless of whether there is a guarantee of payment. He said that about 97 per cent. of his patients are extra contractual and, so far, 30 per cent. of them are not paid for. That is the situation this year but it will be even more difficult next year when the financial constraints will become meaningful.

I am sure that all of us would hate to see that unit, which is unique and which serves so many people all around the country, run into difficulties. It not only helps people in the unit itself; it also provides technicians who visit people's homes to ensure that the breathing machinery which they have there and which prevents them from taking up a hospital bed—for example, artificial lungs—is kept in good order. It is a most valuable unit which should, in my opinion, be safeguarded especially carefully. I know that Dr. Spencer is most concerned about its future.

The other point raised by the noble Baroness, Lady Gardner of Parkes, was that postgraduate education was of the greatest importance. If specialist treatment is to be provided, it is dependent upon appropriately trained staff. Among the most important members of the staff in such units are the nurses. Tragically, we know what happened when there were not enough specialist, trained nurses when we had the problem with the Birmingham babies in 1987. The planning as regards the number of special paediatric care nurses who were needed went wrong.

As the Minister knows, because we discussed the matter when we debated the Nurses, Midwives and Health Visitors Bill, we are still concerned about ring fencing for postgraduate training. It is important that adequate investment is made in post-registration education. Therefore, it is important that the Government should, so long as it is possible and especially as regards postgraduate education, ring fence that sum of money.

I sincerely hope that, as a result of this debate we shall receive some guarantees about the future of all the specialist units. There are many of them—not just the spinal injury or respiratory units—around the country. They contribute enormously to the well-being of people who are much less fortunate than we are. I should like their future guaranteed.

9.50 p.m.

Lord Desai

My Lords, first let me join all other noble Lords in thanking the noble Baroness, Lady Masham of Ilton, for having brought this Question to our notice. She speaks on the subject with knowledge and passion. I welcome the opportunity to speak on the subject. Let me also join the noble Baroness, Lady Robson of Kiddington, who said that this is not a party matter; it is a matter in which we all wish to do the best that we can. My contribution will be made in that spirit.

Many noble Lords have spoken with great knowledge—a knowledge which I lack—as doctors or users of the services. Let me start by emphasising certain points about which we all agree. There are many specialist units, not just the spinal injuries unit which was mentioned by the noble Baroness, Lady Masham. They are unique. They make a great contribution which is appreciated. We all agree that we should save as many of them as possible. We are also agreed that we are currently going through a period of reform. As the noble Lord, Lord McColl, pointed out, there are always difficulties in implementing reforms. We should learn from experience what to do.

I am sure that no one, including the Government, wants the organisational problems involved in getting money from here to there to stand in the way of good treatment being meted out to patients. If there are any institutional problems to be smoothed out we should try to do so. In that respect I note the remarks of my noble friend Lord Rea, who pointed out the principles involved in the new NHS reforms relating to purchasers and providers.

Economics is a subject about which I know something. As so often happens, the bulk of the services provided by the NHS can be taken care of by the purchaser/provider arrangement. To give an analogy, that is like off-the-shelf buying. We know about the cases which are not routine. We know roughly what they cost and what the length of treatment is likely to be. One can estimate the costs of such treatments within a certain range. The specialist units—as we have heard there are many of them—operate what I shall call made-to-order or Cinderella technology. Something has to be fitted separately to each patient. Patients, as has been said, may need different kinds of treatments and different lengths of stay. Those specialist units cater for treatments which are hard to cost routinely. The market for them cannot be the same as the market for what I call standard routine illnesses.

Another problem is that because the institutions are unique their markets are national. Their catchment area is national rather than district. Any financing arrangement that looks at the district only cannot cater for institutions that have a national market. Without wanting to criticise what has been going on, I urge the Government to consider whether a distinction can be made in the structural reforms between matters that can be taken care of at district level through the purchase/provider arrangement and matters which need a wider geographical coverage and a different kind of financing. As we have noticed this evening, district budgets or GPs' budgets are overstrained by the one-off, odd or difficult to estimate large expenditure. The difficulty is one of transition in reforms. The bulk of problems can be taken care of in the purchaser/provider arrangements, but these units have a different kind of problem.

In the light of these observations, I should like to ask the noble Baroness, Lady Hooper, whether there is any prospect of interim funding for, say, three years while we iron out the problems which arise both in the implementation of the new reforms and in the specialist units. That is one kind of problem. There are obviously individual cases of specialist units, as has been pointed out by other noble Lords. They should be examined in detail.

A further problem is that the specialist units produce not only health care and health cure but also research and training. Those are vital ingredients for future health care and health cure. I know from the university sector that there are problems in financing postgraduate training and research in any case. They seem to be heightened by the fact that the National Health Service is going through these reforms. Teaching in that sector has problems of financing education and health.

It may be that the postgraduate education provided by the specialist units needs some other kind of special treatment, some other kind of arrangement. Without in any sense disrupting the flow of change, it will enable the units to preserve their essential contribution. I know from my experience that good research units are hard to build up; they are easily destroyed and hard to rebuild. It takes many years to build up good research teams and they are important.

I do not wish to delay the House any longer except to say that I am sure there is much good will on all sides. We desire the preservation and enhancement of the specialist unit, ironing out the problems of transition. Let us hope that the comments expressed by noble Lords are taken on board by the Minister.

9.57 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Hooper)

My Lords, there can be no doubt about the importance and value of the services which specialist units and centres of excellence provide. We have heard of some excellent examples of developing these services from the noble Baroness, Lady Masham, and the noble Lord, Lord Butterfield, who spoke of the diabetic units and the work of the Lane-Fox Unit. The noble Lord, Lord Ennals, mentioned the B-12 Unit.

I wish to emphasise that I believe that there can be no doubt about the Government's recognition of the vital role that the units play in providing for the overall well-being and health of the nation. It may be in service terms, providing specialist care to a wide catchment population; in research terms, as centres in pushing back the frontiers of medical advancement and achievement; or in educational terms in developing and training the future generation of clinical specialists both at undergraduate and at postgraduate levels.

I realise that uncertainty can be created by change. As my noble friend Lord McColl said, people do not always welcome change. However, I would, not wish anyone to think that the effect of the reforms will be negative for these special units. On the contrary, the principles of the reforms have put in place the foundation which will enable such units to thrive. It may therefore be appropriate if I begin by referring to the reforms and then explain how the specialist services fit into them.

With the implementation of the reforms, district health authorities are now responsible for assessing the health needs of their residents and for securing access to a comprehensive range of services which aim to meet those needs. They are therefore becoming more aware and better informed about the health needs of their residents and they are in a better position to make judgments about what services are required and where to purchase them to meet the needs and wishes of their residents.

The noble Baroness, Lady Robson, referred to the system of contracting. The separation of the role of the DHA from hospitals and units providing services has given hospitals and units greater control over their own affairs. It has enabled them to manage themselves and organise their services in ways which are more responsive to patients' needs. The contracts provide the mechanism for securing and ensuring the delivery of a high quality, consumer-responsive health service. Hospitals will increasingly get paid for the number of patients they treat rather than, as in the past, being funded to provide access to facilities irrespective of usage. The principles which the reforms have put in place tackle the efficiency trap and units providing high quality services—such as the units we have heard about this evening—can only stand to gain.

Within this overall framework created by the reforms, we have been particularly concerned to ensure that proper funding arrangements are made for specialist services. Those arrangements will need to be flexible enough to reflect the diversity of services provided, and indeed who they are provided for. The breadth of the examples referred to this evening underline that need for flexibility.

Of course we have never pretended that all services could be contracted for on a local DHA basis. Because of their catchment population, or because of research or teaching aspects, there will be specialist services which need to be funded on a regional or national basis. Indeed, the White Paper Working for Patients underlined the importance we attach to the continued existence of specialist services and our commitment to secure an environment which will enable them to prosper in line with their popularity and the need for them.

The framework under which the majority of specialist services are currently delivered therefore reflects their particular characteristics. Special Health Authorities continue to be centrally funded by the department. There are also services which are only available in a small number of units throughout the country. These supra-regional services are also funded centrally. There are too services where it is sensible to continue funding on a regional basis and those where DHAs have a role to play in representing the interests of their residents more closely.

There is no centrally dictated straitjacket that the Government are imposing. However, the department's management executive, together with the regions concerned, is keeping these issues under review as part of its ongoing review process. Our policy in implementing the reforms has always been one of managing change in a planned and sensible way. The continued provision of specialist services is no exception to this policy.

The London Postgraduate Special Health Authorities—eight in all—are just one example of the way in which we have sought to provide a sound base for centres of excellence to function. These national centres of clinical excellence provide the foci for research and development, medical education and training, and non-medical education and training within their fields. We have recently reconfirmed our commitment to the special health authorities as national centres for research and development and we intend to maintain central funding and management for the next two years.

The noble Baroness, Lady Masham, raised a number of anxieties concerning the supra-regional services and those anxieties were echoed by other speakers. The department's funding of supra-regional services is another example of the importance we attach to the provision of specialist services. In the current financial year we have provided central funding worth £100 million. I can therefore correct the somewhat lower figure quoted by the noble Lord, Lord Butterfield. In those cases the department is acting directly to secure care through contracts and all residents are able to benefit from the services. The contracts cover the provision of high profile services such as heart and liver transplants together with less well known but equally pioneering services such as cancer services for eye and bone tumours.

Where services develop to the stage where they are largely provided on a regional basis—spinal injury services are an example—it is only equitable that designation as a supra-regional service ceases and that health authorities contract for their provision in the same way as for other mainstream health services. De-designation has been planned and prepared for. It is clearly important that the transition from supra-regional service status is handled in a managed manner.

Funding will no longer be from the centre but will be distributed to regions to secure services for their residents. However, regions will be expected to use that funding in 1992–93 on a "smooth take off, no surprises" basis. We would not expect any major changes. Therefore, contracts will be entered into on a historic basis but there will be scope for amending and improving them as time goes on.

In coming to its decision to recommend de-designation of spinal injury services the supra-regional services advisory group noted that in most cases the services are provided largely to patients from the host region. The group believes that it would be in the best interests of units and their patients for the service to be organised on a regional rather than a supra-regional basis. Districts and regions have adopted a number of approaches to ensure that similar valuable services continue to prosper.

The noble Baroness, Lady Masham, raised a question about assurances given by my noble friend Lord Henley during the passage of the National Health Service and Community Care Bill. He gave an assurance that spinal units would continue to be funded in part by central government. It was later decided that supra-regional services would not be part funded but would be 100 per cent, funded by the centre. That was a change for the better.

It has always been the case that supra-regional services are de-designated when the case for designation has passed. One example which was welcomed concerned the end stage renal failure services for children in 1988. Spinal units are now in that firmly established position in which designation could not and need not continue.

Another point raised by the noble Baroness concerned the difficulties in relation to the continuation of contracts because costs are so variable. A contract already exists between the Department of Health and the spinal injuries units. For next year, the money will pass to regions to make appropriate funding arrangements for the services. The approach to contracting will be evolutionary as better information on costs and quality becomes available. Therefore regions are well aware of the importance of ensuring a smooth transition.

Baroness Masham of Ilton

My Lords, perhaps I may ask a question. What happens if there is a large train crash in one region and 10 people break their necks and have to stay in hospital for a year? Is money transferred from a region which may have no patients to that region with 10 new patients? The matter is complicated because you cannot tell what will happen.

Baroness Hooper

My Lords, it is complicated, but there are special arrangements for major emergencies of that kind. I believe that sufficient flexibility is built into the system to enable such a case to be well covered.

The noble Baroness and the noble Lord, Lord Desai, both asked for a delay in implementing those changes. I believe that the noble Lord suggested a three-year delay. In February of this year the Secretary of State announced that spinal units would transfer to the regions next April. All health authorities were informed at the time, so there have been many months to plan for the smooth transition and regional health authorities are leading discussions with units in a number of cases. Obviously, the Department of Health's management executive is following the matter keenly and it all appears to be proceeding satisfactorily. We have issued guidance on contracting and specialist guidance on this particular area of contracting.

The supra-regional funding has allowed spinal units to develop firm foundations of quality, expertise and, above all, the universal reputation for their services—underlined by the noble Lord, Lord Rea. All are safeguarded. Any new unit trying to start a service would need to be confident of at least matching the existing standards.

The Stoke Mandeville spinal injuries unit is a shining example. I am glad that the noble Baroness, Lady Masham, gave us the background to the unit. I thank her for ensuring that on my visit I was able to see all that I should see, both to appreciate the needs of the patients and the scope of the services there. The Oxford region is well appraised of the importance of the issue and is working with other regions. I understand that, historically, four regions in particular have used the services of the Stoke Mandeville unit and they are working together to agree on appropriate funding arrangements.

As I said, the management executive is also in close touch with regions on this issue, but I do not believe that there is anything to be gained by exaggerating any anxieties that might exist about a system that we have every reason to believe will be in place and working smoothly from April next year. There is no reason to suggest or believe that patients will not have as good or better access to those specialist services.

Contracting on a national basis is not sensible for services which are provided in a number of units around the country. Those who are closest to patients are inevitably more informed about their needs and more able to reflect the variations in demand in their contracting arrangements. Regions and districts have, therefore, developed their own approaches to contracting for specialist services which reflect their local needs. We expect developments to continue in that evolutionary way.

Some regions continue to fund regional specialties through regional contracts. Others have taken a more developmental approach whereby funding comes from both the region and those districts whose residents are using the service. That allows districts a greater say in ensuring that the needs of their residents are reflected in the agreement with the unit, while providing that unit with a greater degree of security as to its funding.

There are a number of examples of ways in which the regions and districts are using the contracting process to achieve improvements in the care available to their residents. I quote an example in which one region—the West Midlands—has taken a two-fold approach to contracting for specialist services. Some of those services are being funded through regional contracts while others are being funded through what they call a subscription service. That is where each district pays a proportion of the cost of providing the service to the district in which the unit is located. That district acts as manager on behalf of all the purchasers. It negotiates and agrees the terms of contract and monitors the service being delivered. That means that the unit has a guaranteed income and clear quality standards to aim for. For purchasers it provides an effective way to fund often unpredictable and high cost referrals.

The noble Lord, Lord Rea, was concerned that contracting for specialist units does not work because of the small number of patients from each district. I welcome the noble Lord's support for the idea of districts and regions securing health services on behalf of their residents. But we have always made it clear that they cannot contract for all services at district level, especially the specialist services where there are just a few referrals from each district. That is why we have the supra-regional services in place and have provided the £100 million funding to which I have referred. We have made clear the responsibility on regions to ensure that residents have access to all appropriate specialist services.

My noble friend Lord Wise was concerned about the money question and we have to recognise that demand for health care will always exceed the money available. In acting on behalf of their residents to secure access to a comprehensive range of services, districts have to make decisions on priorities. But I hope that in the course of this evening I have given him sufficient evidence of our appreciation and keenness to ensure that the appropriate range of specialist services continues.

The noble Lord, Lord Butterfield, asked a particular question about research. I reaffirm the Government's commitment to the importance of research and the need to ensure that units facing extra costs as a result of collaborating with the medical charities' research programmes are not disadvantaged by doing so. It is an important issue and perhaps I could write to the noble Lord in a little more detail.

I have also noted the point made by my noble friend Lady Gardner of Parkes about the Royal National Ear, Nose and Throat Hospital. I am not aware of any problem about funding in respect of that unit but I shall look into the matter and come back to her.

With regard to Hilda Lewis House, which was an example raised by the noble Lord, Lord Ennals, of a centre of excellence in postgraduate research and teaching which caters mainly for mentally handicapped children, the special health authority, the Bethlem Royal and Maudsley Special Health Authority is considering the future of the unit and must ensure that its decision reflects both its overall strategic direction and other opportunities for priorities for research and service. But the future of the unit is being given very serious consideration.

Lord Ennals

My Lords, I am grateful. Does that mean that the unit will not close in two weeks' time?

Baroness Hooper

My Lords, certainly not so far as I am aware.

We are confident that effective arrangements are being developed and indeed are in place to enable specialist units to thrive and flourish in the reformed National Health Service. I believe that, as experience and expertise in contracting grows, other innovative ideas about how these services are best secured and delivered will evolve. We shall see money following patients more and more clearly so that units are properly funded for the work that they do. Where there is a need and a demand for specialist services, they will continue to play an important role in providing for the health and wellbeing of the nation.

I may not have answered all the points raised in the course of the debate. However, I shall look closely at Hansard and write to any noble Lord to whom I have not replied. Again, I add my thanks to the noble Baroness, Lady Masham, for giving me the opportunity to provide some reassurance.

Lord Ennals

My Lords, before the noble Baroness sits down, will she say that she will at least look into the second urgent case that I raised? The B-12 unit in Westminster Children's Hospital is gravely threatened at present.

Baroness Hooper

My Lords, yes. In saying that I shall look into all the points raised by noble Lords, I certainly include the noble Lord's B-12 unit.

House adjourned at twenty-two minutes past ten o'clock.