Examination of witnesses (Questions 60 - 79)
WEDNESDAY 15 JULY
MR C REEVES,
MR A BARTON
and MR R DOUGLAS
60. I am not clear quite how
you responded to the issue of how you targeted poor performance.
Can you expand on that because I have not fully understood how
you have done that?
(Mr Reeves) A good example is the waiting list money,
the allocation of £417 million. There is a breakdown of those
monies but the predominant amount of money, £220 million,
is intended to be spent directly on cutting waiting lists. What
we have decided to do is to allocate £288 million direct
to health authorities from April with a view to them ensuring
that their waiting list targets are achieved by the end of this
financial year. That is important in terms of making sure that
the waiting lists reduce from their current figure of 1.3 million
to the figure of 1.16 million by the end of this financial year.
Obviously Ministers put a great deal of emphasis on that. If history
is anything to go by, some health authorities will overachieve,
some will underachieve. What the view of Ministers was on this
specific initiative was to hold some monies back and in this case
10 per cent of the available £320 million was held back to
act almost as an incentive and sanction fund to specific health
authorities. For those who were overachieving there is a chance
for them to receive an additional 10 per cent of their allocation
to improve their waiting lists still further. The reverse of this
is that for those who underachieve, if we feel it is because of
poor management or poor efficiency, there is a possibility for
instance of the regional office bringing in the regional task
force, seconding in experts, either managerial or clinical, with
a proven track record to ensure that those health authorities
start to achieve. That was the logic of holding back some monies
in terms of the waiting lists.
61. What about the issue of a winter pressure
area? The point I was making to you was that the policy intention
was to target poor performance and I accept your comments in respect
of the waiting list question. I am looking at how that applied
in relation to the winter beds initiative.
(Mr Reeves) The answer is that we did not. We adopted
a different approach in terms of the allocation of the winter
pressures monies compared with the waiting list monies. That might
have been something to do with the timescale because the winter
pressures monies were allocated in October for a period of six
months. If we had held back monies at that stage they would not
have been spent. The waiting list monies are quite different.
They have been allocated in April for the full 12 months and our
approach in terms of this 10 per cent of monies is to allocate
that money in year, probably round about September, when we know
it will be spent. The only difference in approach is because of
the timing of the announcement of these in-year monies.
(Mr Douglas) The other point to make on that is that
each health authority is required to put together plans which
we would agree and targets which we would agree. Even if the money
itself is not allocated to take into account poor performance,
you can agree plans with people which deal with particular aspects
of their performance. The individual plans would focus on aspects
of performance with which the regional office were not happy.
62. When the Department originally issued press
releases on the winter pressures question, they talked about improving
waiting lists, that the additional monies could be used to improve
waiting lists. Have you any evidence that this proved to be the
case? Do you have any examples of where we could see the winter
crisis funds impacting upon waiting lists in any particular area?
(Mr Reeves) Certainly I can say at this stage, in
terms of the original plans which were submitted round about October
in connection with this figure of £159 million, broadly half
was used to reduce waiting lists, the other half was to respond
to emergency care, either keeping people out of hospital or making
sure they were discharged at the appropriate time, working very
closely with social services. We have not as yet got the final
report back on what was actually spent in 1997-98 either as an
amount or the quality of care it produced. The intention will
be to receive their report on that. In the light of that report
I can probably give you an answer then.
63. We are more concerned with the impact on
waiting lists rather than the expenditure. It is fair to say that
the Committee have had substantial anecdotal evidence of this
scheme impacting upon individual circumstances. We have travelled
the country and we have some good examples of the way in which
this scheme has helped people. What I am trying to establish is
what hard facts you have in relation to the impact on waiting
lists, bearing in mind that it was suggested initially that waiting
lists would be improved.
(Mr Reeves) At this stage we do not have that information
and it is impossible without that report to try to determine what
specific winter pressures monies enabled us to respond to waiting
lists as opposed to health authorities using their general allocations.
64. May I push you a bit further on this issue?
Can you indicate the extent to which winter pressures emerge in
terms of measurable factors, for example by comparing the increase
in admissions in the winter of 1997-98 with that in previous winters,
or the increase in demand for A&E services? It may be that
these are figures which will emerge along with the impact on waiting
lists. Are there any other concrete measures which you have available
at the present time in respect of this particular initiative?
(Mr Reeves) I should like to await the report but
your points are well taken. One of the things we have looked at
in another measure is how activity has been re-profiled during
the year. A number of health bodies are working towards putting
through their elective inpatients during the first seven months
of the year and then leaving the day case work to the year end
and that allows a ward switch, to be converted from surgical to
elderly medicine in the winter. There is a lot of anecdotal evidence
of that happening and I have a whole list of about 30 things which
have also happened in a number of areas. I cannot actually put
a quantitative figure on it at the moment but I am happy to respond
once you have received this report.
65. Is it also difficult for you to describe
any information, any ways in which you are aware of the winter
pressures initiative impacting on local authority personal social
services? Certainly the Secretary of State has given a clear impression
on a number of occasions, when he has been asked specifically
by people including myself why he does not allocate directly to
local authorities, that his view has been that he has a guarantee
of getting this money spent in a certain arena by allocating it
through health authorities. The implication of that response was
that that money is in some ways finding its way into the personal
social services framework. Is that your impression or have I misunderstood
what he has said?
(Mr Reeves) It is certainly my impression and it certainly
fits in with the plans. I come back to the £159 million plans
which we determined in October; a figure in excess of £35
million was actually allocated to local authorities through section
28A grants. It is my personal belief that we will see a lot more
of this happening in the future; the whole idea through the White
Paper of pooled budgets will encourage this as well. In many ways
this might be a forerunner of something we shall see a lot more
of in the future. To what extent that £35 million was actually
spent and the way it was spent, I am afraid I cannot tell you
about until I have received this report.
Mr Walter
66. I want to pursue this point, if I may, even
though it is probably a little early. The Secretary of State quite
clearly said that he wanted this money distributed to local authorities
via the health authorities for specific projects so he was sure
that the money was being spent on what it was intended for. You
have answered that partially but I wondered whether I could draw
you a little on the comments you made a second ago as to whether
you saw that as a model for the future, that more money would
be allocated to social services departments for specific projects
coming via the health authority rather than coming through the
SSA.
(Mr Reeves) I genuinely think it would be wrong for
me to comment on that at this stage. It is important to read the
comprehensive spending review to determine the allocations both
to local authorities and to the NHS. It is important in terms
of Ministers coming together to decide how the approach will be
adopted in the future. There is no doubt that we are encouraging
the links between health and social care. It would be premature
for me to speculate on the precise funding mechanisms at this
stage.
67. May I rephrase it then? Do you think this
was a more efficient way of distributing those resources?
(Mr Reeves) Subject to the report, and all my comments
are going to be subject to the report, certainly there was a lot
of support, and again this is anecdotal evidence, both from local
authorities and from NHS bodies in terms of the approach being
adopted. My personal view—and it is a personal view—is
that I suspect we shall see a lot more of this approach in the
future; whether it be through the mechanism of Section 28A or
the mechanism of pooled budgets is something that remains to be
seen.
68. May I look at the attempts to reduce waiting
lists? The Secretary of State has indicated that waiting lists
have started to fall. I am not sure that we have seen any evidence
of that. Do you have some more up-to-date figures than the ones
which have already been published?
(Mr Reeves) The Secretary of State did make a comment
in response to an oral PQ at the end of June and that comment
was based on our own fast track unvalidated data which suggests
that waiting lists rose again in April 1998 but they levelled
off in May and are now coming down in June and that is the evidence
we were able to provide to the Secretary of State to enable him
to make that statement.
Mr Gunnell
69. Do you have any forecasts for July?
(Mr Reeves) Not at this stage but I am very confident
that having set the waiting list targets for this financial year
it will achieve what we are trying to do which is to get back
to the March 1997 national figure on waiting lists. The Secretary
of State also made the point very clearly in the response that
we would not know the final position until the validated data
was produced and that would be data for the end of June which
should be available the week commencing 17 August. Then we will
know whether the waiting lists are coming down or not.
70. It is just an impression from some of your
fast track data.
(Mr Douglas) It is more than an impression. It is
what the fast track data is saying to us, but we do need to make
sure that we do validate that data before publication.
71. It has been suggested that hospitals are
working overtime, working at weekends, to get this reduction which
they have been asked to get. Do you think this is resulting in
greater unit costs than previously when they were just working
on a normal timetable?
(Mr Reeves) May I answer that by trying to put this
in perspective? In national terms we are trying to come from a
position where waiting lists stood at 1.3 million at the end of
1997-98 and the intention is to reduce them to a figure of 1.06
million by the end of parliament. In other words, we are trying
to reduce waiting lists by 240,000 at a time when GP referrals
are increasing at the rate of at least 3.5 per cent per annum.
It is a major initiative. The figures for the waiting list targets
I spoke about before would result, if they are achieved, in elective
activity increasing by 9.7 per cent. this financial year. To achieve
the initiative over a three-year period suggests that elective
activity would have to increase by not dissimilar amounts over
that three-year period. Having said that, we do need to think
of a variety of approaches to respond to this, some are short
term and some are longer term. Certainly very much at the moment,
we are focusing on some of the short-term measures which sometimes
involve weekend and evening surgery being introduced, more theatre
time and treatments being extended, which in themselves do have
implications in terms of unit costs. The answer in the short term
is yes, there are some implications for unit costs. Having said
that, we need to think much more in terms of a three-year strategy,
which is partly about providing more beds, partly about providing
more wards and also about staff being taken on. That might have
cost implications but without predicting what the comprehensive
spending review says, I am hopeful we will be funding in the system
to respond to those additional components of this initiative.
72. I should like to come back on the more general
point about waiting lists in a second. Going back to the figures
in your evidence, the distinction has been drawn in those between
£320 million for direct action on waiting lists and £65
million for whole systems action. Each health authority has been
set an individual target for March 1999 against which the use
of the £320 million will be assessed. Can you supply those
target figures? Are they available to the Committee?
(Mr Reeves) All I can say at this stage about the
waiting list monies is that we have allocated the £288 million
in April. The £32 million of incentives and sanctions which
the Chairman referred to is likely to be allocated mid year, which
then leaves two broad areas to be considered. One is the figure
of £65 million which Mr Walter refers to and that money is
focused on the winter pressures approach which we adopted in October
last year. The allocations to health authorities is likely to
be announced the week commencing 13 July from the £65 million.
To complete the jigsaw, the final piece is the specific initiative
of £32 million. The Secretary of State announced on 1 July
£5 million for booked admissions and then on 5 July £14
million in respect of the NHS direct initiative. There is also
a view that some extra money will be put into account though that
announcement is yet to be made formally.
73. May I come on to a general point about waiting
lists, a mathematical problem I have? Except for an emergency
admission, by definition you are on a waiting list if you are
going to go into hospital. Therefore the more people you treat,
the more people you have on waiting lists. If you are measuring
the efficiency of the service, would it not be more realistic
to measure health authorities and trusts by waiting times rather
than the aggregate total of a waiting list. It has been put to
me by a chief executive of a NHS trust that if he is treating
5 per cent more people each year, but his waiting times are not
really changing, by definition waiting lists are going to go up,
therefore you would suggest that he was failing and therefore
he ought to be doing something about it. If you bring waiting
lists down, and they become shorter and shorter, then there may
be a greater incentive to people to present themselves for elective
surgery. Before they might have said if it was going to take two
years and they were really not bothered about getting on the list,
whereas if the waiting list was only six weeks, then perhaps they
would go and have that toenail removed or whatever. That is going
to increase the waiting lists. Just a little anecdote which was
put to me by that chief executive: would you measure the efficiency
of a bus company by the number of people waiting at the bus queue
or would you measure it by the length of time they had been waiting
in the bus queue. If there were lots of people waiting at the
bus queue it meant it was a popular service.
(Mr Reeves) I take the analogy. There is a concern
and a view that supply creates demand and the actual size of the
waiting list has a reflection in terms of the demand it creates
from those people wanting inpatient and day case care. That is
one very clear point and we are trying to do more analysis on
that. The written evidence shows that we think it important to
focus not just on waiting numbers on the list itself but also
in terms of waiting times. We have provided this evidence to the
Committee for a number of years. Having said that, certainly the
focus in the current Government's manifesto was very clearly to
achieve a waiting list initiative in terms of hitting a specific
target and that was to reduce the numbers on the waiting list
nationally by 100,000 compared with the figures in May 1997. That
is something the Government is focused on doing. What we have
been discussing before in terms of the approach to health authorities
is a reflection of that initiative. That is not to say that it
is not also important to make sure that we can see waiting lists
and waiting times from other perspectives and the point you made
is well made. We do need to focus on waiting times as well. I
would not disagree with your chief executive at all.
74. When we get these figures which you have
talked about on 17 August, will we also get figures for that period
for mean and median waiting times?
(Mr Reeves) No, that will not be possible. The information
will focus purely on the quarterly achievement of the waiting
list target for 1998-99. At this stage we will not be providing
detailed quarterly information about medians and means for waiting
lists and waiting times. That is an annual exercise.
Audrey Wise
75. Looking at matters to do with public health,
you told us, and indeed the Department has often told us, that
there will be a much broader approach to health. This then means
that the Our Healthier Nation green paper or the things which
flow from that are going to be supported by initiatives across
departments. Health is not to be regarded any longer just as a
matter of concern for the Department of Health. I must say I agree
with this approach but I did wonder whether there had been any
discussion, perhaps at the initiative of other departments, about
how much this would cost other departments. Has anybody done any
work on this? If they do, can it be ensured that work is equally
done on savings which will ensue from this kind of approach?
(Mr Reeves) Our view on the cost is that implementing
the proposals in Our Healthier Nation is not planned to lead to
additional expenditure in other government departments, nor indeed
in the Department of Health either. Therefore there are no plans
to estimate costs. We believe the information should be achieved
by refocusing on existing resources and that is based on the fact
that we do believe that Our Healthier Nation sets new goals for
improving health which recognise all the impact which poverty,
poor housing, unemployment, can have on health. Therefore it is
for the greater good of all government departments to be associated
with this initiative and that is happening. I can name five initiatives
on discussions with other departments where these discussions
have taken place: first the DETR on integrated transport policy;
in education the initiative on excellence in schools; third, the
working with the social exclusion unit, particularly looking at
poorer housing estates; the welfare reform green paper; the whole
initiative on tackling drugs. Five areas and by no means an exclusive
set of areas where we are working in tandem. I am sure all of
those initiatives will have huge implications for the achievement
of Our Healthier Nation. In answer to your second question about
it being important to work out what those savings are, whether
they be financial savings or improved healthcare, either way it
is important that we do try to monitor that. In terms of the costings,
no, we do believe it is important to redeploy existing resources
for the greater good of the health strategy of the UK.
76. You are saying it is not actually going
to cost them more, it is just going to help them to focus on being
genuinely efficient in transport policy for instance.
(Mr Reeves) What I am saying is that all departments
need to look again at their expenditure programmes, bearing in
mind that Our Healthier Nation is a very high Government priority.
I am sure all departments will be thinking, for example in transport,
that what they do in transport needs to be very closely associated
with the objectives of Our Healthier Nation. All departments we
have spoken to would take that line and agree with that.
Dr Brand
77. It would be very helpful if, when you publish
sequential figures, you gave some indication of what the main
initiatives have been which may have resulted in that change.
There are clearly initiatives which are costing money and taking
resources. Looking at cancer care, the two weeks waiting list,
the extra emphasis on that, our expenditure on mental health which
is a big area, our expenditure on lipid lowering agents in circulatory
disease. It would be nice to know whether there has been a policy
change and a resource shift and whether that has translated itself
into a change in mortality rates. May I ask a second question
to do with local targets? I appreciate that at the moment you
do not have them yet. Do you not think you ought to have the aggregated
local targets made available to us in the meantime, so basically
carrying on collecting the same data we can compare what happened
to the Health of the Nation targets with the Healthier Nation
targets? It concerns me that we are beginning to lose those. There
have been enormous resource shifts in pregnancy advisory centres
and family planning clinics and we are not monitoring what the
result of that is. A lot of these services have had resources
stripped from them in many areas.
(Mr Reeves) I understand Dr Brand's point and my answer
is going to be that we are working towards this in the longer
term. If I may link together the data both input and outcomes
which will accompany Our Healthier Nation, that needs to fit very
closely with what we are trying to do in the national performance
framework. The national performance framework will take time to
get off the ground. At the moment we are focusing on six major
themes, one of which is outcomes and trying to provide a variety
of data. Unfortunately, data being what it is, we are having to
rely on very limited sources at the moment but we have plans to
expand that. Only by increasing the data sources will we be able
to see the various clinical links you have mentioned. I am afraid
that is not going to take place overnight. There is going to be
quite a bit of work to be done to ensure the performance framework
can measure clinically what is happening in terms of Our Healthier
Nation.
78. I am sorry but some specific costed initiatives
have been declared by the Secretary of State in the Chamber and
it would be nice to see whether they have actually made any impact
on outcomes as measured in mortality rates. When do you expect
to see a result from this activity.
(Mr Reeves) We can certainly measure mortality rates.
In three of the four Our Healthier Nation indicators we have to
use death rates in accidents as a proxy. I was really trying to
make a response in terms of what we talked about earlier: mortality
data not necessarily being the best data to judge outcomes. I
think the answer is that we can provide data on measurements for
Our Healthier Nation on mortality. I thought the point you were
making was very much that there need to be much clearer measures
of outcome besides mortality if we are going to determine whether
Our Healthier Nation is working or not.
79. Can we have a quick comment on the local
targets and why we cannot, until we have got those, carry on with
at least what is happening nationally? We had an assurance that
although we are concentrating on four national targets the other
ones were as important but they were better set as local targets
because they would be more meaningful. We are now six months on
from that statement and you do not have a baseline yet.
(Mr Reeves) The views of Ministers will be that it
would be quite wrong to jettison Health of the Nation and replace
it with Our Healthier Nation. I see it as a spectrum of change
and we will gradually move away from the Health of the Nation,
which after all focuses on 27 targets, to focus on Our Healthier
Nation which focuses on four major targets.
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