Examination of witnesses (Questions 180
- 197)
THURSDAY 17 FEBRUARY 2000
MS GISELA
STUART, MS
DENISE PLATT,
CBE and MR ANDREW
CASH
180. I would not deny that. As you know when
you came to Southend in December, the area I represent, we had
lots of elderly people and I seemed to spend all of my time writing
sympathy cards or becoming a professional mourner. There was so
many people who lost their lives. I just wondered if you really
felt that calling it an epidemic was helpful in terms of the way
these things are reported in the newspapers and then suddenly
everyone seemed to have this particular problem.
(Ms Stuart) As you mentioned newspapers, one thing
which I thought was not helpful over this winter was certain parts
of the media were determined that there would be a winter crisis
irrespective of what was happening out on the ground. If I may
be so bold as to single out the BBC and the Daily Mail
for pursing it. It was very interesting when we went to hospitals
and on the ground. I am sure every Member of Parliament did this,
we saw newspaper reports and if we went to our own hospitals and
said, "How is it for you?" Yes, they were really pushed,
it was tough, but nothing compared to the media portrayal of what
was happening out on the ground.
181. I am sure that is right. Obviously we are
all there to be shot down. I think that they were just testing
the fact that somehow, it was like your £1.9 billion earlier,
with these endless press releases there definitely was this impression
out there that since the 1st May 1997 we had entered the Promised
Land and everything was going to be different. I think that they
were probably challenging people's expectations. We were glad
when you came to open our unit and I can tell you every single
bed was occupied. I think it was challenging those expectations
and, perhaps, suggesting that in reality life was a little bit
more difficult than the reassurances that were being given.
(Ms Stuart) We all know as politicians that what goes
up must come down, what is praised in the press one day you know,
inevitably, it will get shot down. In the service we have extraordinary
dedication and I thought it was really unhelpful for not just
the doctors, but the nurses, the support staff, the catering staff.
They worked their socks off, they really did, they came in and
covered shifts and they covered their rotas and then they read
this in the press and it really did a disservice to them because
it did not recognise their commitment.
Dr Brand
182. Minister, I suppose I understand that you
do not want to call what happened during the winter a crisis in
the NHS but clearly you recognise that the NHS has been under
stress for a very long time and whether it is an acute crisis
or a chronic crisis you are certainly describing the strains that
the staff are under, which, I think, is one of the reasons why
the Audit Commission has picked up this business about infections.
In earlier answers when we were talking about critical care beds
you were concerned about the lack of capacity and also, like your
other ministerial colleagues, you are pleading for a long lead-in
time to train the necessary doctors and nurses. I have had contact
recently with someone who has worked in an intensive care unit
for ten years being employed as an E-grade nurse and he really
cannot afford to carry on doing that so he has now applied for
a job outside intensive care. I also know of an increasing number
of doctors who are retiring early, at the age of fifty, because
they cannot cope with the continuing stress of being in a service
that is, according to you, not in crisis, but certainly not a
pleasant place to work in. I also know when we had a branch of
Marks & Spencers opening on the Isle of Wight I think forty
nurses from the local hospital applied to work there because conditions
were better, pay was better. I know that was before the pay rise
but I do not think we have actually done enough for trained staff—very
expensive and high investments have been made in this—to
make sure we retain them or bring them back in spite of all of
the rhetoric.
(Ms Stuart) Can I say a couple of things? I think
everybody has accepted that the status quo of the NHS needs to
change. There is a recognition that it needs more funding. There
is also a recognition that it does need more capacity building.
Also, fundamentally, that brings in the people who want to work
in the service, that they feel valued and we use them to their
best and we change the way we do things. I know with the term
"modernisation" people always assume it is the same
as cuts but to change the way we do things. Can I just use an
example of what is happening to NHS Direct? I heard it earlier
referred to as an out-of-hours service. It is none of these things.
What it is, is a single phone number which through the trigging
process it makes sure that the next step of accessing the Health
Service is the appropriate one, so if the next step is the pharmacist
because it is a self-care one, that is fine. If as a result of
this you suddenly find there are more A&E admissions because
of chest pains, because we are identifying earlier cardiac problems,
then that is also the right thing to do. It is channelling people
at the right level and making sure they are seen at the right
level. Earlier reference was made to some out-patients and orthopaedics.
Manchester Hospital is doing a physiotherapy survey for us and
they have reduced their waiting list tremendously. It is using
people more appropriately. In terms of nurses, for example, that
is the biggest change, what is happening to them as a profession,
the creation of nurse consultants which is really pushing them
on one level. You are right but I do have to say that it is a
threefold process, if you look at funding, if you look at capacity
building and, even more importantly, the long-term sustainability
of more people and more money.
183. Minister, there is capacity and I really
get frustrated when ministers tell me that it is not a question
of money for the NHS, even if the money were there you could not
improve the Service. I think that is absolute nonsense. That certainly
does not help my constituent who has been working as an E-grade
doing a highly skilled, shortage job. If you want flexibility
in a system that is where you ought to be addressing it and I
am afraid we are not. Can I ask a specific question about NHS
Direct because I am getting very confused about NHS Direct? I
read the medical newspapers, I get letters from A&E consultants
and from GPs who tell me that it has created a fair degree of
chaos, irritation and has increased their inappropriate work load
considerably. We have also had reports of NHS Direct at times
of stress just going back to on answerphone message of saying,
"Please contact your doctor," one instance imitating
an answering machine, which I thought was particularly modernising
for a particular service. On the other hand we have ministers
saying this is the best thing that has ever happened to the NHS
and the whole structure of access to the NHS is going to be through
NHS Direct services or walk in
services. Are you not a little concerned that
we, as yet, have not had an evaluation of the effectiveness of
NHS Direct, whether it is actually raising people's expectations
unreasonably or whether it an agency for actually educating people
as to how to access and treat their health needs? When are we
going to see, for instance, an evaluation of the role of NHS Direct
within the Winter Pressures programme, because it has taken a
substantial amount of money, and when will we see a more general
assessment of NHS Direct, which I think is the Sheffield study?
(Ms Stuart) Can I put this into context, when NHS
Direct started we were extremely concerned that we should have
a system that is safe and a system that would not be overloaded.
We started with a number of pilots. It was very carefully rolled
out, so advertising for its services, for example, was kept very,
very local because the last thing we wanted to do was have a situation
where people had an expectation and the service was not yet available.
It is very important that to introduce something new along those
lines that you do evaluate it properly and roll it out so that
it is there to be safe.
184. You talk about pilots, I have not seen
any published assessment of the pilots before the programme was
rolled out extensively to cover 65 per cent of the country at
the moment and 100 per cent by the end of the year.
(Ms Stuart) We have continued internal assessments.
Sheffield had the first report, that was published last year,
and the second report, which is a much wider one, is being published
in late March or early April.
185. With all due respect, the first Sheffield
Report would not have been a report such that I would have committed
a roll-out of NHS Direct in one hundred per cent of the country.
(Ms Stuart) I can assure the Committee that we had
a continued assessment process of what was going out. The research
shows in terms of referral patterns that about one-third of the
patients are directed towards self-care. In the early stage something
like two-thirds of the patients did something different as a result
of having made the phone call. 98 per cent of patients are very
satisfied with it. Can I come back to what the purpose of this
is? There was a recent letter I read in one of the medical journals
where a Scottish doctor was deeply complaining and saying that
as far as he was concerned NHS Direct has made absolutely no difference
to the way he works. I sat there and I thought, yes, that is probably
because NHS Direct does not operate in Scotland. We need to take
quite a number of the comments with a pinch of salt. What its
real function is, and in that sense, I think, not only the Sheffield
report will show but once it is rolled out nationally and, also,
once people have used it. Can I ask you whether you have used
it? Have you rung it?
186. I talk to my wife if I have a medical problem.
It is difficult to get an appointment, though.
(Ms Stuart) People have the confidence as they are
going through a sequence of questions to take the right approach
and that can be, from the confidence, to say, "I need an
ambulance", to saying, "No, it is safe, I can wait until
tomorrow morning to see my GP." The experience so far is
that those who are using it find it very helpful and the pilot
which works with GP groups, again find them very useful.
187. The Cheshire comments, obviously they run
a system which does what NHS Direct does somewhere else and they
are going to be very pleased to have extra funding so they can
call it NHS Direct, which is basically what we have in our own
locality.
(Ms Stuart) NHS Directis not an out-of-hours service.
Dr Brand: No, it is an advisory service 24 hours
a day which, of course, in my professional life I have made sure
that my patients have available all of the time.
Mr Amess
188. Following on from that, there are other
alternative sources of information, health advice and treatment
advice, I am just wondering whether the Department is looking
in any way at the potential impact of health information and medical
treatment that is available on the Internet?
(Ms Stuart) We have launched NHS Direct which gives
health information. What we have done is we have used the experience
of NHS Direct and analysed the most common symptoms -—and
all of the other available wealth of information and advice that
is there.
(Ms Stuart) We know the Internet, one of today's wonderful
virtues, is a free for all in terms of what you can put on it,
hence our commitment to NHS-online, to make sure we as the NHS
have a source of information on health information. I hope people
will feel that because it does come from the NHS it is a tested
and a reliable source.
Mr Amess: I am aware of the impossibility of
regulating on the Internet. It is going to have an impact in all
sorts of ways to the way patients present and what they say to
their doctor when they do present.
Chairman: Yes.
Dr Stoate
189. I was fascinated by Mr Amess' party political
broadcast comment that you did not get flu epidemic during the
Tory Government. In fact there were three epidemics during the
Tory leadership and even I would not blame it on the Tories. It
is my belief the media were suffering from a lack of airplanes
falling out of the sky and had to fill it with something. I wanted
to raise the point about the NHS being a soft target. You said
yourself that a large bulk of people coming into hospitals were
over 65. If you look at Professor Maynard's work on over 65s being
a vulnerable group, if carers go down with flu not only is it
bad news for them it could be disastrous for the people they are
caring for and cause huge problems. If the Flu Campaign is going
to have an effect we need to widen the scope. I would like to
ask whether you are prepared to widen that scope to cover the
over 60s rather than the over 75s and to look at carers of any
age? Even if the person themselves may not benefit much there
is less risk of them passing that infection on to the person they
are looking after. I would like to know, firstly, what you are
going to do to increase the uptake? What are you prepared to do
to increase the scope of the availability of the flu vaccination?
(Ms Stuart) I did read that article and reading it
I thought purely intuitively it seemed to make sense that health
care workers should be vaccinated. First of all, it is a voluntary
choice as to whether they take it up or not. What we can do, and
have done, is to make the vaccine available on the ground. It
has been quite a campaign to increase that uptake. Of course compared
with the previous years there has been a tremendous increase in
the numbers who took it up. Looking ahead the Chief Medical Officer
is looking at that and two of the areas which we are really focusing
on is, would it be beneficial to bring it below the 75 age group—I
would have thought there would appear to be a lot of merit in
that—and also extending it to social care workers because,
as I say, they are working with vulnerable groups. In terms of
immunisation and the flu epidemic this winter we should also remember
it was not just Great Britain, in France they had to close down
hospital beds and whole hospitals were shut, also Italy and North
America, with its care system and with huge public campaigns of
immunisation again had problems. We need to improve the uptake
but it is not the whole answer.
190. We were not the only people in the world
to have such a grip on that but currently the only truly effective
method of reducing flu is the flu vaccination. It is not perfect
and there may be arguments about its effectiveness but it is currently
the only proven effective way of avoiding getting the flu. As
Professor Maynard has said, his work shows it would be cost effective
to bring it down to 65s because, in fact, the amount of hospital
beds saved, and morbidity saved would make it cost effective.
I would also like to ask you whether you are prepared to look
at making it a target for GP payments or giving GPs a vaccination
payment for including it in their public health programmes which,
in itself, would increase uptake I am quite sure, but also how
much you are prepared to advertise it to the public, to have a
properly managed flu vaccination campaign in future years which
would increase uptake significantly?
Dr Brand: Could we clarify the rules and regulations
as to whether a GP can give a flu jab to an NHS patient outside
the target areas and charge for it? It is important that carers
and NHS workers are given a flu jab but it is just as important
to allow industry itself to also encourage their workers.
Dr Stoate: The current regulations are that
a GP can give a flu vaccination privately but on the NHS we are
supposed to stick to the target groups. I am not sure how accurate
that is.
Dr Brand: I am very grateful to my learned colleague
but the only problem is that most of my colleagues do not. I have
had at least one dozen letters from people around the country
who said they wanted to have a flu jab, they had gone to their
GP, their GP said, "You are not in the target area, I cannot
give you a jab try a clinic down the road." That strikes
me as nonsense and it would be very helpful if that was clarified?
Chairman: Perhaps you could write to the Committee
on that?
Dr Stoate: That is a one point issue, whether
you are looking at giving GPs target payments or individual vaccination
payments in the same way that GPs receive money for other vaccinations.
Mr Burns
191. This is special pleading, you are a GP
and you want more money.
(Ms Stuart) As the Prime Minister would say, "I
will treat that as an early budget submission". The Joint
Committee on Vaccination Immunisation is reporting back to the
Chief Medical Officer on what is the proper way forward. First
we look at the evidence and then we take it forward. As I said
in answer to one of the very early questions, it is one of the
key areas we are looking at in terms of how we can improve the
winter planning for 2000 and 2001.
Mrs Gordon
192. Earlier the Trust seemed fairly sceptical
about the value of flu vaccination—Dr Stoate seems very
convinced—has the evidence of its benefits gone out to health
authorities and trusts, because they did not seem particularly
keen on increasing the uptake?
(Ms Stuart) There is variable evidence as to the young
age group, hence our referral back to the Joint Committee to get
more evidence back. I have seen some health authorities but what
happened everywhere is it was made available to the health authority
as part of their winter planning, so the availability was there.
193. A change of subject, could you confirm
whether the National Institute for Clinical Excellence will be
reconsidering its decision on Relenza. What is the current position
on that?
(Ms Stuart) The current position on that is that after
the rapid appraisal Relenza is now coming out of full appraisal
and it will be later this year when further evidence is likely
to be available, so it is subject to full appraisal. Early evidence
has been that it is not the panacea people thought, there is some
adverse evidence, some adverse inference.
Chairman
194. Mr Cash, I am conscious we have not involved
you, do you have anything you wish to add?
(Mr Cash) A couple of points, really, I think we were
better planned over the course of these months, given the special
circumstances of the ten days or the two four day bank holidays,
and the whole of the winter than we have been in previous years.
The key building block was the 1999 Winter Planning Groups, dividing
England into that, with the 150 Social Services Departments in
there. There were two sets of plans produced in June and again
at the end of September, these were assessed by the NHS regional
offices and the social care regions as well. There was a huge
amount of work, conferences, seminars and training programmes
that went on all of the way through and lots and lots of developmental
work. My own team visited forty of those ninety-nine places to
help in any way we could. My team was involved, clinicians, GPs,
directors of social services, and so on. I do think we learned
some very, very good lessons in tackling this and the whole system
approach, in self-care, primary care and hospital.
195. Are you seconded to the Planning Group?
(Mr Cash) Yes.
196. For how long?
(Mr Cash) Until the end of March.
197. Might you be reinvented in the autumn?
(Mr Cash) I am sure we will be reinvented, taking
account of some of the lessons we have learned.
Chairman: Thank you very much. On behalf of
the Committee can I thank you all for a most helpful session.
I am most grateful to you all.
|
