My Lords, this has been another excellent debate. It is worth saying at the outset that I fully appreciate the importance of the board and CCGs paying due attention to the way they commission specialised services and services for less common conditions and indeed emergency services. I fully endorse the importance of services being delivered in an integrated way when that is in the best interests of patients. I listened very carefully to the case put forward by the noble Baroness, Lady Finlay, on Amendment 50A. She made a very persuasive case about the importance of only ever commissioning specialised services with a close acquaintance with the relevant guidance and evidence base. I could not agree more with her on that. Commissioning of specialised services requires specialist skills and this is precisely why we feel that the Commissioning Board is the right body to commission such services. The board will be able to draw on a great deal of expertise in doing so. I hope the noble Baroness recognises our shared commitment in this area. Very shortly we will be publishing a consultation document as a UK response to the EC recommendation on rare diseases. We hope to be able to do that within a few days. The consultation document and responses will form the basis of the UK's plan. She will see in it that a great deal of thinking is going into how these services should be commissioned.
The noble Lord, Lord Walton, spoke with his customary authority about Duchenne muscular dystrophy. He may like to know that all regional specialised commissioning groups have undertaken reviews of neuromuscular services in their localities. Improvements to services are already being put in place. For example the NHS has invested in care co-ordinator posts which can reduce emergency admissions and readmissions. The national specialised commissioning group has also included neuromuscular disease as a priority in its 2012 work plans and it has been looking at emergency admissions as part of that work.
The noble Lord, Lord Winston, referred to rarer conditions, including those of genetic origins, as did the noble Baroness, Lady Masham, in relation to neuroblastoma. I identified closely with all that they said. Many of these conditions are extremely rare fortunately. It is not possible for all health professionals and carers to have detailed knowledge of conditions which they will see only very rarely in their working life. However, already we are addressing this through such initiatives as NHS Choices. It is one of a number of initiatives we have developed to provide comprehensive, clinically accredited information about health and health services. Comprehensive information to support clinical decision-making is also included on NHS Evidence, the new web-based portal hosted by the National Institute for Health and Clinical Excellence. It provides access to a range of information, including primary research literature, practical implementation tools and guidelines. I am not suggesting it is the total answer to this conundrum but it is certainly a demonstration of the direction of travel. We want to see much more information available to commissioners at a local level.
I think there has been consensus in this debate as to the need to think long and hard about how and at what level particular services should be commissioned. I completely agree with that. It is not always clear cut and it does require careful thought. The Bill says that certain services will be for the board alone to commission. We expect these to include certain highly specialised services-I direct that assurance particularly to the noble Lord, Lord Walton. Other services will be by and large for CCGs to commission, but in collaboration if need be with other CCGs and supported by the board.
I appreciate the keenness of the noble Baroness, Lady Finlay, to ensure that the board's commissioning of highly specialised services pays due regard to NICE guidance. However, we would prefer not to impose a blanket requirement on the board to exercise its functions in respect of specialised services, or any of its commissioning functions, in accordance with NICE guidance. NICE guidance will undoubtedly be relevant to specialised commissioning-that is obvious-but the amendment could well have the effect of requiring the board to have regard to it at the expense of other authoritative sources of advice. I have already referred to a couple. In exercising its duty to obtain expert advice, we would expect the board to draw on as wide a range of professional expertise as possible and not be constrained into prioritising that of NICE, valuable though that would be.
It is important for us to remember that CCGs must be competent to commission all services to meet the reasonable needs of all those for whom they are responsible. This includes services to meet the needs of patients with "less common" conditions, as Amendment 63A points out. CCGs will need to be well supported in developing as commissioners and the Bill provides a framework for just that. It provides for collaborative working, in Section 14Z1, between CCGs. The NHS Commissioning Board must publish guidance on commissioning, to which the CCG must have regard, which could also cover issues relating to commissioning for less common conditions.
The clinical senates and networks will be overseen by the board to ensure that CCGs can access specialist advice. Clinical commissioning, by giving responsibility for ensuring services meet the reasonable needs of patients to the very clinicians who deal with those patients daily and understand their needs, provides a far stronger basis for ensuring that commissioning caters to the needs of those with less common conditions than the current commissioning arrangements. GPs will be able through their membership of the CCG to seek to ensure that commissioning takes account of the less common conditions, which might not be of great significance across an entire geography but which are of great concern at the level of the individual GP practice.
I can assure the noble Baroness that the NHS Commissioning Board will be required to have a robust authorisation process to ensure that CCGs have made appropriate arrangements to discharge their functions competently, including consideration of the extent to which CCGs have collaborative arrangements for commissioning with other CCGs or local authorities as well as any appropriate commissioning support.
However, while I completely recognise the importance of commissioning services for this particular group of patients, I am afraid that I would prefer not to single out a requirement for authorisation to look at specific groups of conditions in the Bill. It would not make the NHS Commissioning Board's process any more effective, but it might lead emerging CCGs to add undue weight to this if it was the only part of the services that CCGs will be responsible for commissioning that was specified in relation to the authorisation process.
I hope it is recognised by your Lordships that in opposing Amendment 64ZA I do not wish to suggest that the concerns of that amendment, to ensure the quality of urgent and emergency care and the integration of its different elements to the benefit of patients, are unimportant-indeed, quite the opposite. The framework in the Bill for ensuring the competence of commissioners, securing continuous improvement in the quality of care and ensuring the promotion of integration applies to emergency and urgent care services every bit as much to as other areas of care. Commissioners will use the expert advice from senates and networks, and from other sources, to determine the best approach to commissioning integrated approaches to the delivery of urgent and emergency care, and within the context of a far-reaching national programme. As the House will know, we already recognise the importance of integration across the health service, particularly in urgent and emergency care. The introduction of NHS 111 will act as a driver for the redesign of local urgent and emergency care systems to create a more integrated system that is easier for patients to access and understand.
I understand the noble Baroness's concerns about competition in the context of emergency care and I should like to reassure her on that issue. We have been clear that competition should be used only where it is in the best interests of patients. For some services or parts of a pathway this may not be the case and commissioners will need to use their judgment as to what is in the interests of their patients and whether competitive tendering is appropriate. With some services, such as emergency care, it is surely highly unlikely that this test would be met. Indeed, we have always cited A&E as a prime example of where choice is usually irrelevant and competition will almost certainly be inappropriate.
I was asked by the noble Lord, Lord Warner, and the noble Baroness, Lady Finlay, about what will happen in the future to cater for the kind of reconfiguration of services that we have seen in London and how the new system will support a regional style of planning. Section 14Z1 enables CCGs to collaborate, as I have already said, in respect of the exercise of their commissioning functions. That is of particular relevance in the context of emergency care. In the same way as current PCTs operate, CCGs may choose to act collectively to co-ordinate care over larger geographical areas; for instance by adopting a lead commissioner model to negotiate and monitor contracts with urgent care providers. In instances such as that, I am sure that the strategic advice of clinical senates and the range of expertise of clinical networks will prove invaluable in continuously improving the quality of services and care for patients.
The noble Lord, Lord Hunt, spoke of the need for external expertise in this kind of decision-making. I agree with him. That will be essential in some cases. The clinical senates will be available as a source of specialist and strategic advice to health and wellbeing boards, in particular, providing a link between professionals and national leadership, although it is anticipated that senates are only likely to become involved in service changes or other issues occurring on a significant scale. However, very often emergency services will be on a significant scale.
My noble friend Lady Williams asked about improving out-of-hours services. We are taking work forward already on that front. Improvement of out-of-hours care will be taken forward as part of the development of a coherent 24/7 urgent care service. Two of the aims of this provision are, first, consistent high-quality integrated care led by clinical commissioning groups, delivering the best outcomes and experience 24/7, with no noticeable differences during or out of normal office hours; and, secondly, greater integration, with services working together to provide a seamless service irrespective of the provider organisations which operate them.
Our vision for urgent care is to replace the ad hoc unco-ordinated system that has developed over the past 13 years-which has been characterised, I am afraid, by poor quality and too much variation-with a system that patients better understand and can get them to the right place first time. Amendment 64ZA would not stimulate that. In fact, it could well distort the local freedoms which commissioners need to develop the best and most effective integration of care.
I hope that I have said enough to persuade the noble Baroness to withdraw her amendment.