Examination of Witnesses (Questions 80 - 99)
WEDNESDAY 20 MAY 1998
MR ALAN
LANGLANDS, DR
SUE ATKINSON,
and MRS JULIETTA
PATNICK
80. That is the skill of managing and diagnosing
local needs and so on. The question is why are they not setting
targets year on year?
(Mr Langlands) We build on the success
and we make incremental programmes each year. That has been the
approach we have adopted. That has been the successful approach
that has got the vast majority, the 87 of the 100, over the 80
and up to the 85 limit.
81. We have had discussions in this Committee
in other areas about examinations where people have talked about
targets without setting deadlines beside them and the targets
frankly become meaningless.
(Mr Langlands) We can give you precise
targets for 12 months ahead, we cannot give you targets beyond
that.
82. I do not understand why you cannot.
I understand you are telling me historically people have moved
forward. I cannot understand why, on that basis, using evidence
from others, you cannot set challenging targets, targets that
are demanding targets, for achieving something which will have
so much significance and consequence for women's lives. I do not
understand why you cannot give me an answer as to why, year on
year, you cannot set targets and then go and meet them?
(Mr Langlands) We do set challenging
targets. The aim each year is to build on the success of the previous
year. That has been the tried and tested way of achieving progress.
83. I will leave it there on that one. I
want to move into a specific area which has been picked up again
before now, the question of women from minority ethnic backgrounds.
The data in this report is fairly light. It refers to a 1994 report
that suggests there is underscreening of that particular group
and there has been evidence given on various initiatives being
taken in local authorities. Do you have a detailed break down
of the kind of coverage for different minority ethnic groups?
(Mr Langlands) In each of the health
authorities and in the relationship between the regions and each
of the health authorities, especially in those places striving
to hit the 80 per cent, that information will be known for each
of the groups. I was looking at the Redbridge and Waltham Forest
figures the other night and for the Turkish community, for the
Somali community, for the Muslim community, very precise and targeted
interventions are in place to try to make progress in these areas.
84. Do you think it would be useful for
the Executive to pull together a national picture of the different
minority ethnic communities' experiences and percentages of coverage
and uptake in order that nationally we might see an improvement
across the board for women from these different minority ethnic
groups?
(Mr Langlands) We will be able to
do that on the basis of the work being undertaken by the regional
directors, yes. [5]
85. So in your answer yes, can we look forward
to seeing a profile—I cannot think of another word for it—of current
coverage of those groups nationally across the country and targets
set for improving them?
(Mr Langlands) I think we can certainly
build that profile. It will not necessarily be the case that we
will be making the same pace in different communities in different
parts of the country but the aim is always in these situations
to level up, yes.
86. I have to say that worries me. If I
am a Somali woman living in one part of the country and in another
part of the country I feel my needs are not going to be met equally
I am going to be anxious, or for whatever, Pakistani women, Bangladeshi
women. Why should a woman from a minority ethnic group in one
part of the country not have the same access, opportunity, coverage
as another?
(Mr Langlands) The objective is
to level up and to reduce the inequalities. These are explicit
Govern ment objectives, not just in this area but across the board.
We are starting from a different base line position in each place.
87. We can produce a base line position
for each of these minority ethnic groups, can we?
(Mr Langlands) In each health authority—
88. I know that.
(Mr Langlands) I cannot do it at
this precise moment.
89. Would it be valuable to you? Could we
then look at how different women in different minority ethnic
groups are being treated by different health authorities? If we
had a national picture we could do base line comparisons and set
targets for health authorities for treating women from different
min ority ethnic groups.
(Mr Langlands) I think there is
already a lot of experience of that. Indeed, we employ people
from many of these groups as link workers to help us on that programme.
I do think it would be helpful, against the background of wanting
to tackle some of these inequalities, to have a national picture.
We can only build that over time based on the local data.
90. I would like to suggest to you that
I think it is a matter of priority and urgency that this happens.
I do not see why, if variations between population groups is one
of the core reasons, we are not getting the kind of coverage we
want and then a targeted approach like that, a national picture
and then offsetting targets for each health authority is the right
way forward. I say this because in my health authority, Northamptonshire,
there is a specific project that has been developed to achieve
racial equality in the uptake of health services involving interpretation,
involving translation services, involv ing actively women from
those communities, talking with workers. There is a whole lot
going on. If it can be done in Northamptonshire it can be done
elsewhere.
(Mr Langlands) These are precisely
our objectives. You will find schemes like this all over the country.
91. It is not just about disseminating good
practice but disseminating targets. I believe that our people
deserve to know that their providers are being set challenging
targets locally and nationally. With that I think people would
have more confidence that this lucky dip good practice is actually
going to be more consistent and they will have greater access.
I just put my comment on what is going on.
(Mr Langlands) I agree with that.
92. Just one final point on that. On page
45 there is mention in paragraph 3.3 of the idea of target payments.
I do not want to go into the whole area of levers and carrots
and sticks to get GPs to change, but here it appears that general
practices have said that the target payment scheme would be more
effective if it could take into account the general practice's
population profile, such as ethnicity, deprivation and mobility.
Are you considering doing that?
(Mr Langlands) Yes. We are not just
considering doing it in relation to this area. I think one of
the most significant areas of inequality in this country is in
relation to access to general practice and we have a very significant
study going on which will inform the next round of resource allocation,
if you like, from this autumn onwards in which we hope to right
some of these differences by taking a much clearer account of
population need, the historical development of services, age and
population mix.
93. Can I move on to costs which have been
touched on before. Appendix 7, page 108, contains some quite remarkable
figures of variations between laboratories and clearly there is
no explanation in appendix 7 from the Comptroller & Auditor
General to explain these variations. I would like one bit of reassurance.
There is no linkage between these high and low costs and between
high and low coverage and response in different areas?
(Mr Langlands) No. These figures
are failures of the costing methodology rather than anything else.
As I said earlier, there are significant problems in grinding
down to costs at that level of detail.
94. I just want to be reassured. You say
yes but I want to make sure I have heard that right: if x health
authority is finding the cost of having a service provided to
it, cervical screening of some kind, higher or lower, that is
not a blockage, it is not a reason for why they may not be doing
things that they should be doing?
(Mr Langlands) No. There are some
legitimate differences in terms of case mix, in terms of populations
that use the laboratory services at university hospitals that
tend to be better geared up for a whole variety of other reasons.
The main differences that you see on these charts are to do with
the costing methodology rather than the realities of life.
95. So the variation in cost does not explain
any variation between uptake of screening, coverage or anything
of that kind between populations in health authorities?
(Mr Langlands) Let me be clear.
I do not believe that there are financial barriers to upping coverage
and improving the service in these places that are less well developed.
I really do not think this is a financial problem, it is a good
practice problem.
96. If we were to try to get more equality,
less variation, indeed become more cost-effective as a goal, that
would not have a negative effect on achieving the purpose or the
outcomes of the system?
(Mr Langlands) It would not have
a negative effect, no.
97. Right. So are you taking steps to improve
cost-effectiveness?
(Mr Langlands) Yes. We are doing
so in this area right across the board. As I said earlier, in
the absence of the dynamic that has until now existed, or in recent
years has existed, between health authorities and trusts and GP
fund holders, we will be managing much more through comparisons
and reference pricing and benchmarking. That has been the clear
policy of the Government for the past year and that is what we
are pursuing across the board in the NHS.
98. My last question is a different topic
about smear reporting on page 64. It reads in paragraph 4.22 that
only a quarter of health authorities are giving you any data about
smear reporting. Is that correct? 27 per cent of health authorities
are giving you any figures. Why are they not co-operating with
you? Why are they not providing you with the data that you require?
I am on paragraph 4.22, page 64, line four.
(Mr Langlands) I certainly do not
dispute the figures, the point is these new disciplines are recent.
These are precisely the sorts of areas that we are looking at.
99. It is because it is recent that they
are not co-operating with you?
(Mr Langlands) It always takes time
to build up. There is information collected on a fairly routine
basis from the laboratories but imposing and ensuring there is
discipline in health authorities is an important objective for
us. [6]
5 Note by Witness: The witness has subsequently informed
the Committee that monitoring of screening coverage and uptake
by different ethnic minority communities is not possible because
the population database used for the call and recall programme
does not include data on ethnicity. The NHS Cervical Screening
Programme is looking into the possibility of other research-based
methods of obtaining this information. The witness has provided
a separate note on reducing inequalities in screening coverage. Back
6
Note by Witness: The witness has pointed out that information
is collated centrally, on an annual basis, on the time taken by
laboratories to report on smears. The information collected by
the NAO related to the timescale in which women were notified
of their results. Health authorities often delegate this tasks
to general practices and may not collect data from them. Back
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