Examination of Witnesses (Questions 160
- 179)
WEDNESDAY 22 JULY 1998
RT HON
FRANK DOBSON
MP, TESSA JOWELL
MP, MR ALAN
MILBURN MP, MR
PAUL BOATENG
MP, AND MR
COLIN REEVES
160. You have mentioned things which I agree
with quite a lot about examining, training, training value, costs,
all of that kind of thing. Could I draw your attention to the
fact that the community children's nursing training places apparently
are bought from the same pot of money as district nurse training
places and health visitor training places and that this has meant
because community children's nursing is a newer specialisation
they have come off worse. Could you make sure in your examination
that you look at costs and needs and you try to get less competition
in this particular field as you are doing in others?
(Mr Dobson) To go back to the point I made, what we
want to be able to do is to try, and it is always an imprecise
science or imprecise art, to identify what the particular personnel
needs of the Health Service will be right across the board over
a few years hence and then try to meet those needs and then that
having been decided we have got to try and recruit people who
are willing to be trained for those purposes and if we do it that
way the only competition then is really in terms of resources.
There will always at some point be a problem about finding the
resources to provide the training that everybody needs.
161. I gather from your answer, Secretary of
State, that you do put some importance on having the necessary
information on which to base sensible decision-making. Can I therefore
suggest that you might like to look more thoroughly at the kind
of information that the Department collects. For example, in January
I tabled a very simple written question: "In which regions
are the numbers of school nurses going up and in which regions
are the number of school nurses going down?" I did not even
ask for numbers you will note. That was in January. In May I got
an answer which was that the Department does not know. I do not
think that you can have a coherent policy on school nursing or
indeed on anything else on which there is an equivalent level
of knowledge in the Department while this is the case. So can
I gather from your answers that you will be attending to this
in order to ensure that this lovely money is actually going to
produce the best possible value?
(Mr Dobson) Of the things that have most astonished
me since I have had this job the two that have astonished me most
have been the almost total absence within the National Health
Service of any machinery for spreading best practice of any sort
of practice, clinical, managerial or anything else and we are
taking steps to deal with that. The other is the appalling state
of that data that is or is not available. I think one of the reasons
for that is that under the previous regime they did not seek to
manage the National Health Service or get it managed by the headquarters
or the regions because virtually all decision-making had been
devolved to the health authorities and trusts and it is the devil's
own job trying to get information even current information let
alone information from previous years with which to compare it.
For instance, I find it very difficult to find out in a systematic
way about the huge cost overruns of hospitals in the past. Some
of the ones I know are spectacular from my own memory do not appear
in tables that are presented to me.
162. So if I retable my question on school nurses
could I assume that the Department will manage to write to the
regions to find out whether their number of school nurses has
gone up or down and perhaps supply them by Christmas?
(Mr Dobson) This year? Tessa?
(Tessa Jowell) Chairman, I would like to let Mrs Wise
know that I have commissioned a survey of precisely that information
in relation to health visiting. It is important we not only have
the figures but we also know what the likely trends are in terms
of health authority decisions. I would be delighted to undertake
that exercise to cover school nursing as well as health visiting
so if she would like to table that question again round about
Christmas we will make sure that there is an answer.
163. I will table it before then.
(Tessa Jowell) I thought you might say that.
Audrey Wise: I want my answer back by Christmas.
Mr Walter
164. I have a quick question on training particularly
as it related to nursing in the community and health visitors.
In February, Secretary of State, when you addressed the Royal
College of Nursing conference you mentioned a sum of £14
million available for training for nurse prescribing. Where have
we got to on that?
(Mr Dobson) Truthfully I do not know. As far as I
know it was approved and it is going ahead.
Mr Walter: In which year, the current year?
Chairman
165. You can perhaps find the information.
(Mr Milburn) We think it is the current year. We just
approve the money!
(Mr Dobson) I think it is in the current year that
that money is now committed.
Mr Walter
166. Good. I am going to move on to a different
topic now which is the question of waiting lists and waiting times.
I wondered first of all what information you have got on the impact
on unit costs of your drive to push down the overall size of waiting
lists. We have heard anecdotal evidence about doctors and nurses
being paid as much as two or three times the normal rate to work
on Saturdays and Sundays and various overtime bills. I wonder
if you have got any information on that at the moment?
(Mr Dobson) We have not got systematic information
on it. It is fair to say that some nurses would say that some
doctors are getting rather substantial sums for working on Saturday
mornings and the nurses are not getting comparable increases and
that is a source of some dissatisfaction but I do not have systematic
information available. I am a great believer in letting Parliament
have information as soon as I have got it. I can tell this Committee
in relation to waiting lists that yesterday evening I received
a report on the waiting lists at the end of June—they have
not been what is called validated but validation does not usually
make very substantial changes—and I can report that at the
end of June there had been a fall on the invalidated figures of
21,000 in the number of people waiting compared with the number
of May which confirms what I said in the House two or three weeks
ago that the figures are coming down and coming down substantially.
167. I was conscious of the fact that you had
indicated you had some information on that although we have not
got any figures on it. I wonder if I could look at the nature
of waiting lists. There are two ways of looking at it. One is
the overall number of people over on the list and the other is
the length of time that they have been on the list. Last week
I used a little anecdote put to me by a Chief Executive of a trust
which has got a very good record of numbers of patients going
through which was would you measure the efficiency of a bus company
by the number of people waiting at the bus stop or would you measure
it by the time they were waiting at the bus stop? The increase
in the number of people waiting at the bus stop in terms of overall
size could in fact be a reflection of the efficiency of the service
and more people wanting to use it. In terms of bringing down waiting
times that can in fact in itself be an incentive to people themselves
to join the waiting list. It might be something they might have
put off of an elective nature and they might now have decided
to do it. I wonder whether we could have more detailed information
about waiting times. The indication we got last week was that
this information was only available on an annual basis.
(Mr Dobson) There are all sorts of aspects of the
dynamics of waiting lists and various theories about what happens
in what circumstances but in the run-up to the General Election
we concluded that waiting lists were too long and we promised
that we would get them down because they were too long and that
is a promise that we intend to keep. I know that some people say
the number of people on the list does not matter, but if I can
move from your bus station to your supermarket, next time you
are in the supermarket will you join the long queue or the short
queue at the check out? The length of the queue will have something
to do with the amount of time you wait and the reduction in numbers
on the waiting list which we are contemplating are on such a scale
that the times people wait will also be reduced and we have also
insisted on the 18 month backstop because no matter how relatively
unimportant a treatment may be we take the view that having been
referred by their general practitioner a consultant has decided
that somebody needs an operation they really as we approach the
end of the 20th century ought not to wait for more than 18 months
and we are determined that people will not wait for more than
18 months. The drive to get rid of the 18 month waiting list did
not just get rid of the 18-month waiters but it also reduced the
number of people who waited more than 12 months because in order
to stop people becoming 18-month waiters you have to deal with
people at 15, 16 and 17 months and it is part of a general drive.
The point Mr Walter makes on the question of the availability
of waiting time figures simply confirms the point I was making
to Mrs Wise that the information that is available is poor and
we want to improve it, but what we are determined to do and we
think it is necessary to do is to re-establish public confidence
in the National Health Service and also in any figures it produces
and so while all sorts of other people, quite rightly, are looking
at other ways of defining waiting and urgency of waiting and things
like that, we believe that we have got to crack the waiting lists
promise before anybody starts talking about assessing it in different
ways. In other words, we started this game saying it was won on
goals and we cannot say we would like you to judge us on corners
instead. We have got to crack the waiting list length before we
do anything else.
168. I would not like you to think I was suggesting
that you should not be tackling the targets you have set. My concern
is about the quality of the targets. I think that is partly because
my own health authority has the lowest waiting times in the country,
it is less than six months, but the point is that I am concerned
that we do not have any contemporary data on these times. I wondered
whether there is any intention of compiling that kind of data?
(Mr Dobson) We are looking at the data. For instance,
it is our intention to start publishing the waiting list figures
monthly because for instance we could have had the ridiculous
situation where the figures for the first quarter of this financial
year April, May and June, would be published at the end of August
more than half way through the next quarter. Those figures are
not produced for management purposes. They are produced for reasons
of short-term history and if the NHS is going to be properly managed
in future we need figures that management can make use of.
Chairman
169. Could I pick up one or two points on this
question. First of all, could I welcome David Amess who is making
his debut on this Committee. I am told it is going to be a silent
debut today but feel free to join in! When I first served on this
Committee prior to inadvisedly going on to the front bench some
years ago it was at the time of the introduction of the internal
market. I recall (and Mrs Wise was on the Committee at the time)
receiving quite clear evidence from people from local trusts in
front of us as a Committee that as a consequence of Government
pressure to address the issue of waiting lists and waiting times
they were quite clearly told to shift the priorities in relation
to people who were being treated and obviously clinical priorities
were being affected. I cannot say I have heard anecdotal evidence
that this is happening now as a consequence of the Government's
targets but certainly it is being thrown at us from the Opposition.
Do you have any evidence at all on this where people are being
treated for minor ailments at the cost of people with much more
series ailments as a means of reducing the figures?
(Mr Dobson) Only at fifteenth hand moderated by political
considerations and so on. Nobody has actually specified Mr Bloggs
in Scunthorpe to me. If anyone does I shall look into it. What
I should emphasise is the guidance issued to the NHS is that:
"Clinical priority must be the main determinant of when patients
are seen as out-patients or admitted as in-patients. The first
service priority of the NHS is to treat emergency cases quickly
and appropriately. For elective patients consistent principles
must be applied when planning out-patient clinics and in-patient
including day case admissions to ensure that patients with the
greatest need are seen first." That is the official advice
and if anyone is varying away from that advice, I have said it
in the House of Commons, I have said it on Radio 4 and invited
people to let me know if there is any evidence of this and to
the best of my knowledge I have yet to receive a specific case.
170. You have mentioned clinical priorities
being a key area. Can I put to you particularly in the context
of both the waiting list initiative the issue of the two-tier
question that was raised in my area some time ago as a direct
consequence of fundholding. The Government quite clearly is committed
to addressing two-tiering. It is a central commitment and efforts
are being made. I was quite surprised talking to a friend of mine
who is a GP fundholder—I have got friends in all directions—on
Sunday evening. I am not going to specify the area, it was not
my immediate area but it was within West Yorkshire. I was quite
surprised to hear him say that within the area that he operates
in they are readily using the private sector to access, for example,
barium meals and a range of other tests where they are referring
their NHS patients and paying for them. In the area in which he
operates there is still a significant number of fundholders so
obviously that ties in with the waiting list issue and the pressure
to get people seen. I am sure patients did not object to this.
It strikes me that we still have quite clear evidence, I have
no reason to believe he was telling me porky pies, I am sure he
was telling me the absolute truth, because he accepted the other
side of the story where people who were non-fundholder patients
did not get access to those tests which in many instances were
very important tests relating to possibly serious conditions.
(Mr Milburn) I think there are two responses, Chairman.
Firstly, GP fundholding does exist, it is a fact of life, it is
a legal entity. We want to succeed fundholding with new primary
care groups and hopefully legislation will allow us to do that
from 1 April next year. If you like the current financial year
we are in is something of an interim year between systems. We
have been very explicit with all commissioners whether they be
GP fundholders, health authorities, total purchasing pilots, multi-funds,
the lot. We have been extremely clear about this that in this
financial year we expect to see them using NHS resources and NHS
capacity in the first instance and if they want to use the private
sector to give good reasons for doing so. The reason for that
is extremely simple. It is a matter of principle, first of all,
that wherever possible we want to keep NHS resources within the
National Health Service. We want to make maximum use of those
resources for the benefit of the NHS and the benefit of patients.
Secondly, it is also a matter of principle about fairness, as
you rightly say. What we want to see in future, and these are
the reasons we are making the changes we are around primary care
groups and so on, is much fairer and greater access to services
than perhaps there has been in the past. The great irony is that
it has cut both ways with GP fundholding on the waiting times
issue, back to Mr Walter's concerns. We have evidence of course
that in some parts of the country patients of GP fundholders in
the past were getting faster access to treatments than patients
of non-fundholders. Conversely we have had situations where patients
of non-fundholders have been getting faster access to treatment
than the patients of GP fundholders. That cannot be right because
the principles of the National Health Service are extremely straightforward
and they are right and that is that patients should be treated
according to clinical need and clinical priority which is what
we have tried to enforce in this guidance that has gone out to
all parts of the NHS. It is the guidance we sent out last year
to all parts of the National Health Service to ensure there was
consistency in commissioning decisions.
Chairman: You have taken us on to PCGs and I
know Audrey Wise and John Austin wanted to raise some issues.
Audrey Wise
171. What work is the Department undertaking
on development of fair formulae for the allocation of resources
to primary care groups? How will the allocations be made?
(Mr Milburn) If I can take this first of all. There
are a number of issues. First of all, the allocation process will
be as now if you like that allocations will take place in the
first instance to health authorities and then health authorities
will be allocating to their constituent primary care groups. As
far as the first stage of that process is concerned as you know
we try to have as fair an allocation system as possible not just
based upon the size of the population that the health authority
is serving but also the needs of the population as well because
you may have a fairly small population in one health authority
cheek by jowl with a larger health authority population next door
but actually their needs are different because there are more
poor people or more elderly people or more people from an ethnic
minority background who might have specialist health needs and
so on. We try to allocate to health authorities on the basis of
fairness. We will be allocating similarly to PCGs on the basis
of fairness as well and there is a lot of detailed work going
on to make sure we get that right. The second crucial change there
will be here is that in future there will be a unified allocation
bringing together the currently distinct and disparate measures
for prescribing and referral which GPs hold. In future there will
be a single unified bundle and therefore a single unified allocation.
172. An advantage—I will not say one of
the advantages, I will say an advantage—of fundholding seems
to me to have been that it has allowed a rather broader concept
of prescribing than was previously and is often currently the
case.
(Mr Milburn) Absolutely right.
173. So that it moved away to some extent from
a drugs and surgery approach to taking in other kinds of therapy.
How will you ensure that the primary care group does not remove
from GPs who want it that kind of clinical freedom and clinical
innovation?
(Mr Dobson) Alan will give you a more detailed answer
but the object of the exercise is to spread that opportunity to
everyone not to take it away from people who have been using it.
Our broad objective has been to build on the good aspects, the
beneficial aspects of fundholding of which there are a number
while discarding the disadvantages of fundholding.
174. So you will not be expecting it to go down
to the lowest common denominator?
(Mr Milburn) No.
175. Suppose that most GPs in the area for example
will not refer to chiropractors but some do, the existence of
the primary care group will not bring pressure on those GPs to
revert to pain killers?
(Mr Milburn) What we want to do is spread the benefits
the patients have received from some services and from fundholding
to all patients. We have been extremely clear about that in the
commissioning decisions that primary care groups undertake. We
will expect the PCGs to look at the history of the commissioning
that their constituent elements have undertaken as GP fundholders,
there might be preceding multi-fund arrangements or, as in the
Chairman's area, TPP arrangements and we will expect wherever
possible where these services have been provided and have been
beneficial to patients for the benefits of those services to be
spread to all patients in the area. It is back to the Chairman's
issue about fairness. What we want to see is greater consistency.
But the other great advantage the PCGs will bring for the individual
general practitioner is the choice about what to do because at
the moment we have this rather absurd distinction between the
prescribing budgets and the referral budgets. We are going to
remove those barriers so, if you like, the GP can take a rather
more holistic view of the needs of individual patients. What that
might result in, to be absolutely clear about this, is more expenditure
from primary care in prescribing than there has been in the past
on drugs. It might mean there is more expenditure on referrals
to hospitals than there has been in the past but the point is
it is a decision taken purely on clinical ground needs rather
than having to keep within an artificially constrained budget
and that has got to be the right thing for patients. Sometimes
there is a view, we get a lot of advice from economists and others
that somehow we have got to bear down on the drugs budget, we
have got to bear down on drugs spending as if drugs spending is
somehow a bad thing. Ineffective drug prescribing is a bad thing
and we want to make sure that any drug prescribed is effective
on clinical and effective on cost grounds as well but the rather
naive assumption that some people make and offer advice to us
about that somehow an increasing drugs bill as a proportion of
in NHS expenditure is bad—it is not if it means patients
are able to avoid invasive, dangerous, risky procedures in hospitals.
If you think over the course of the last ten or 15 years what
has happened as far as the treatment of ulcers is concerned, people
used to have to go into hospital, take time off work, it was a
costly procedure, it was risky to have invasive surgery. Nowadays
by and large people take a drug, pop a pill. It is quicker, it
is better for the patient and it happens to be cheaper as well.
What we want to do is locate with GPs and community nurses, the
people who do the majority of the caring and treating of the majority
of the patients, the decisions about what is the most appropriate
decision for the individual patient and that is what the unified
budget arrangement will provide for the primary care group.
176. So your value for money exercises will
be not be based on tiny compartments but on a more unified examination.
This Committee's inquiry into the drugs budget a while ago confirmed
exactly what you are saying. That all sounds very good but what
will happen if the primary care group exceeds its total budget?
(Mr Milburn) Let's start with some first principles.
We expect that the primary care group keeps within its budget.
That is what we expect to see happen. Hospital doctors have to
keep within a budget. We expect the primary care groups to keep
within a budget as well. We accept and indeed the current arrangements
allow for overspending to take place because you cannot always
bank on events happening in a predictable fashion. There may be
a major flu epidemic in an area. It may result in more people
admitted to hospital or more drugs being given out. What we are
developing in every health authority area is an appropriate risk
management arrangement to deal with overspending on the budgets
that will be allocated to the PCGs. So the overspending will be
managed within the health authorities' overall budget and just
as now health authorities will be able broker cash between each
other. We all know that there have been problems with health authorities
in deficit which the Government inherited but some health authorities
have been in surplus and where that happens towards the end of
the financial year brokering takes place between health authorities
so that health authority A with a surplus pays some extra cash
to help health authority B which is struggling and health authority
B has to repay it over the next year or following years and we
would expect to see those brokerage arrangements continue to be
in place precisely to deal with the sort of eventualities you
describe.
177. Do you also expect primary care groups
will move funds between family health service and hospital and
community health service arrangements?
(Mr Milburn) That would be a matter for the individual
PCG operating of course within the confines of the accountability
arrangements that we are establishing. PCGs basically are going
to give frontline primary care professionals more leverage and
more influence than they have ever had within the National Health
Service. That is the simple truth of the matter. I think that
is the right thing to do because these are the people who know
the patients' needs best. The second thing that they are doing
is they are not operating as free standing entities floating around.
They will operate within the context of a locally devised health
improvement programme which they too have contributed to. In the
health plan for Wakefield or for Preston the primary care groups,
the trusts, the health authority concerned, the voluntary sector
and crucially the local authorities as well will be brought into
devising that health plan for the local area. That is going to
be important so all the players will be operating within the context
of one overall plan. We will have the local NHS working in one
direction rather than working in many directions competing against
each other. The final point on this which I think is important
(because I think again there has been a bit of crisis talk about
these primary care groups) to remember is that already something
around 19 per cent of family health services expenditure is cash
limited. It was cash limited by the previous Government. Fundholders
have cash limited budgets and no fundholders as far as I know
have complained about running out of drugs or not being able to
refer patients for care and treatment. Similarly the primary care
groups, and indeed I have given this guarantee—and the Secretary
of State has endorsed it as well—to the British Medical
Association representing GPs, that the primary care groups and
individual GPs will have a guarantee that they will not have to
turn patients away.
178. So you will be quite relaxed about movement
between FHS and HCSS headings? It is not going to be the labels
which are going to be the determinants?
(Mr Milburn) Yes, that is the crucial thing. There
will be a single pot of cash that the primary care groups will
be using for the maximum benefit of patients. They are not any
longer going to be confined within rather absurd artificial boundaries
and barriers because patient needs are different. Different people
have different needs and it is right that the individual GP who
has got to take that crucial decision about the needs of the individual
patient is able to do so on clinical grounds primarily and that
is what we will be affording the GP the opportunity to do through
the single unified budget system.
Mr Austin
179. I appreciate that you may not have the
answer at your fingertips but perhaps you could provide it. How
many GPs and what proportion of GPs in England are currently salaried
employees of the NHS?
(Mr Milburn) I do not have the exact number. It is
a small number but it is a growing number. The reason it is growing
is because the Government has been able to reach agreement with
the British Medical Association about introducing for the first
time in the history of the NHS a salaried GP option. It is an
option. I have been very struck in particular when I have met
younger doctors, younger trainee GPs who are coming through. Many
of them have said to me they want to go into partnership and want
to do so immediately. Some have said they do not want to do that,
it is a risk that they cannot afford at present but they do want
to work within the National Health Service so the salaried option
provides for them a career ladder if you like and the consequences
on the grounds has been extremely important. Just to give you
one instance of that. There is an estate in Sunderland, which
is an extremely deprived part of the North East, which has not
had a general practitioner for I cannot remember how many years—years
and years and years. Nobody has wanted to go and work there for
a variety of reasons. We now have a salaried GP providing family
health services to a community that desperately needs them. That
is precisely because of the agreement we have been able to reach.
I think that is hugely important particularly for the more deprived
parts of our community.
(Mr Dobson) On the question of deprived areas some
of the pressure for us to get on with facilitating salaried GPs
has been from hard-pressed doctors in deprived areas because they
were not able to get people to join them as partners and there
is too much to do and so it suited existing GPs. It certainly
suited the patients because it got an additional doctor or two
and it also suited, generally speaking, young would-be GPs who
were interested in it for the first time.
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