Examination of Witnesses (Questions 80
- 99)
THURSDAY 2 NOVEMBER 2000
MR COLIN
REEVES CBE, MR
BILL MCCARTHY,
MR DAVID
WALDEN, MR
HUGH TAYLOR
CB AND MR
PETER COATES
Chairman
80. You know as well as I do, the equivalent
of many of our personal social services are included in the calculations
of certain other European countries within their proportion of
GDP; it does not make sense at all, really?
(Mr Reeves) Yes; to come back to Mr Burns's original
point, was it not, in terms of definitions, and while the definitions
are as they are personal social services does not come into the
calculation. I am sure, in certain countries, and The Netherlands,
I am sure, is one of them, they have an unfair advantage, in terms
of that percentage calculation. So you are absolutely right. I
think this is what we need to do, I think we do need to make sure
that we have commonality of definition from all European countries.
Mr Burns
81. I was just wondering, because, obviously,
the RPI is a very different figure, and invariably lower figure,
than the health inflation figure; so spending on the health service,
6 per cent in real terms above the RPI, is great, but the impact
is slightly reduced if the RPI is running at 1.5 per cent a year
but the health inflation figure is 5 per cent a year, or whatever.
Could you explain, please, in your document, responses to the
written questionnaire from this Committee, and just to help you,
page 42, why, under headings E and F of the main block, there
are no figures, in a particular year, from 1999-2000 right up
to 2003-04, which would show us what you think health inflation
is going to be, which will give us an idea of how we can think
about the 6 per cent real terms increase in health spending?
(Mr McCarthy) I think they are probably—Mr Reeves
will find the precise references, I will give two brief responses
while he does so, Mr Burns. I think, first of all, it is worth
noting the distinction between the NHS inflation, which essentially
is an index of input prices, so we look at the pay increases and
we look at the price increases, so it is an input price measure.
The RPI and GDP deflator are really factory gate prices, so they
are, if you like, output measures, the prices after the process
of manufacture. The difference, pretty well, is that, in looking
at our input prices, there is no account made there for improvement
in efficiency, or improvements in process, which would mean that
the effective price, if you like, of the provision that we are
providing in the NHS does not go up by the same rate as the inputs.
It is exactly the same as in the manufacturing business; if you
looked at the costs of their raw materials and if you looked at
the costs of their wages, you would tend to find those input price
measures are higher than the factory gate price, because they
are achieving efficiency gains year by year. So what I am saying
is it is not an exact comparison, you are looking at two slightly
different things, and you would have to take account of improvements
in efficiency to try to make them more comparable. Your second
question, why do we not have figures for the future, is that we
do not guess, certainly not, for these documents, of what—
82. Because, presumably, most figures in there,
or some figures in there, are estimates?
(Mr McCarthy) Many are estimates, but what we do not
do is try to second-guess what the pay awards, for example, are
going to be over the next three years, which probably would not
be a sensible thing for government to do.
83. Can I ask you another question then. Is
this unique?
(Mr Reeves) What Mr McCarthy was saying was extremely
helpful indeed.
(Mr McCarthy) It gave you a chance to find the page,
I think, Mr Reeves.
(Mr Reeves) We do not have numbers at the bottom of
the page, actually, which is the hard thing. But on Table 4.4.4
we have the three columns, the first one that shows the overall
cash change—
John Austin
84. It is page 113.
(Mr Reeves) We do not have page numbers, but it is
Table 4.4.4, where I think Mr Burns is referring to.
Mr Burns
85. I was on page 42, actually, which is Table
2.1.1.
(Mr Reeves) Can I use 4.4.4, it is exactly the same.
86. If it is exactly the same.
(Mr Reeves) It is a cross-reference, really. But I
think the point we are making is that if you look at it over a
long period of time, and the period in Table 4.4.4 talks about,
I think, 1992-93 up to 1998-99, there has been a large increase
in cash expenditure, the figure is round about 30 per cent, but
then if you bring in what we call inflation factors to cover the
broader macroeconomic position, which is the GDP deflator, that
30 per cent cash increase falls to 12 per cent, so it is a lot
less. And when you bring in NHS inflation it drops to 10 per cent,
which means that the NHS inflation over that period of time has
actually been greater than our proxy in terms of what it has been
in terms of macroeconomic inflation across the economy. As Mr
McCarthy mentioned, in a way it is a combination of two things;
one is pay and one is non-pay, or prices. We would expect the
pay to be probably high in the NHS because review bodies have
tended to be higher than other areas of pay award, and on the
prices though, if anything, because we have been quite efficient
in terms of procurement, the non-pay prices element, which is
determined by what we call the Health Services Cost Index, in
actual fact, has actually proved to be more efficient, and therefore,
in terms of prices, lower than the GDP deflator. So, in answer
to your question overall, yes, inflation has been higher over
this period than the macroeconomic position, which is mainly because
of the pay as opposed to the non-pay element of the calculation.
John Austin
87. Can I ask just a quick question on that.
Since this was published in August 2000, after the pay settlements,
if I refer you to the previous page, on Table 4.4.2, why do you
not have the inflation figures for staff for 1999-2000?
(Mr Reeves) In terms of the estimated outturn, because
at this stage we actually do not have the final figures, at this
stage it is, as it says, an estimated outturn, as opposed to an
actual outturn, and it does take some time to produce these figures.
All we have done at the moment is to give you what we can realistically
give you, through the medium of the annual accounts, the position
up to and including 1998-99. But these figures will come through
in the future, it is just the timing.
88. After your planning assumptions have been
made?
(Mr Reeves) Both, is it not, because the Table actually
then goes on to look at the planning assumptions from 2000-01
thereafter as well.
Dr Brand
89. Over the last few months we have been concentrating
very much on waiting lists as a performance indicator for the
NHS, or a performance indicator for the Secretary of State for
the NHS. Is that going to continue to be the main thing you are
going to concentrate on?
(Mr McCarthy) I will take this one, Chairman. Certainly,
the current year, we are working on continuing to reduce waiting
lists, both for in-patients and day cases, and, as you will know,
we are trying to reduce the numbers of out-patients who are waiting
more than 13 weeks. So the current position today is absolutely
that, that we are continuing the drive on waiting lists.
90. Hang on, you said reducing out-patient waiting
time to 13 weeks?
(Mr McCarthy) Yes.
91. Now, clearly, if that is your objective,
one of the things you have got to tackle is the number of people
on the list, but there are other ways of tackling that?
(Mr McCarthy) That is certainly our intention.
92. So is the emphasis now going to shift to
something a bit more meaningful, like waiting times rather than
waiting lists?
(Mr McCarthy) I shall leave you to make your judgements
on what is more meaningful, but the NHS Plan does set out, I think,
quite a clear direction for the future of access targets. It is
a move towards maximum waiting times, so, you are right, it is
a move forward and it does not keep future targets onto waiting
list numbers. We are looking, by 2005, to get rid of all over
six-month waiters for in-patients and day cases, and all over
three-month waiters for out-patient appointments. What we are
also doing, and I think this is quite important, is trying to
bring in booking systems, so that the access targets and objectives
are not just about chasing numbers, they are about providing services
in a more responsive, convenient way to patients.
93. So it is not absolute numbers on the waiting
lists, it is how you manage the waiting lists to achieve waiting
times for targeted groups?
(Mr McCarthy) Precisely; a better managed way.
94. That is a lot more intelligent than what
we have had in the past, I think. There is a certain target set
in the NHS Plan. One is "ensure a maximum two-week wait for
an out-patient appointment for all those with suspected cancer";
is that all cancers?
(Mr McCarthy) That is all cancers, and there is a
programme now to move forward; we have already achieved very great
success for breast cancer, over 96 per cent—
95. I think, breast cancer, no-one would argue,
but would it surprise you to know that currently we do not have
a consultant dermatologist, and, therefore, anything other than
suspected melanomas, you wait 18 months, two years? Now that,
in itself, is probably not a disaster, but if it is a cancer?
(Mr McCarthy) I do understand that, and I think there
is no question that some of these targets, as we were talking
about earlier, are ambitious, and they do need not just the more
money that is going into services and the staff that will follow,
but what they also need is to think about the ways and the processes
for providing care to patients. But, certainly on the breast cancer
example, what people have found, around the country, is that you
can make a real difference simply by looking properly at the processes
and thinking about the patients and the patients' needs. And it
is that more intelligent approach to pressing forward we are looking
for.
96. I have no argument with the way that breast
cancer should be treated. Unfortunately, I think, some of the
other targets actually make it more difficult to meet the really
important targets in cancer care, but that is probably a clinical
argument, rather than an administrative one, but it is unfortunate
that the politics sort of got more important than the clinical
need. How are you actually going to increase the capacity, because
there is no doubt that we will need increased capacity to meet
those targets?
(Mr McCarthy) Yes, we will. I think there are probably
two sides to this, and I might hand over to Mr Taylor to talk
about the staffing in a minute. But we have been looking very
hard at the bed numbers, put simply, more precisely we have been
looking at the occupancy rates, which would enable us to provide
services which not only allow the extra volumes to move through
our hospitals, which would bring those waiting times down, but
also should make a significant difference to cancellations, for
example. I think it has been demonstrated, if you run the system
too hot, whatever your intentions, your objectives, you are at
risk of cancelling operations when the occupancy levels just get
too high. So the work and the analysis I was talking about earlier,
which was underpinning the Plan, was looking at how we can achieve
better occupancy levels; some of that is about extra beds, and
we have got our views in the NHS Plan of the extra beds in the
acute sector in G&A that would be needed, about 2,000 extra
over the period. I think just as important is not to assume that
all of this has to be achieved by expanding the acute sector,
and I think that is something this Committee has been interested
in, in the past. We do need to move into better facilities in
the community. In the Trust I am in now, I know that we have problems
moving people out, I also know the worst place for elderly people
to be waiting to move into the community is probably acute wards.
So we have got commitments also in the Plan to expand the number
of beds in the intermediate care sector. And, picking up on what
Mr Walden was talking about earlier, we will develop new and better
arrangements for working in partnership with social care to ensure
that people can move through the system quicker. So it is not
just extra beds, it is about using the beds better and about moving
through.
Dr Brand: That will, of course, have a great
impact on members of the primary care team, notably GPs, if I
can declare an interest. Earlier, we talked about the targets
for seeing GPs, and do we know what the current wait for a GP
appointment is, or a nurse appointment in primary care; do you
distinguish between booked and emergency appointments, and what
is the variation across the country? I do not need to have the
answers today, but it would be very helpful to the Committee,
because I actually think 48 hours is a ridiculously non-ambitious
target; unless you are talking about a booked appointment with
a GP of your choice then it is an impossible target. So it would
be helpful to have some feedback on that.
Chairman: Peter, by the time we have finished
our public health inquiry you will be visiting your patients,
at least, any patient, once a week, as you well know. I should
be careful what you are saying.
Dr Brand: Absolutely. As my wife does, of course.
John Austin: And every infant once a day.
Dr Brand
97. Can I pick up a slightly different point
we made last year, which is the time from referral to provision
of treatment. There seems to be a hidden waiting time that you
were going to look at for us, to see whether one could make an
estimation of the time people were waiting for investigations,
for instance, MRI scans, a very long waiting time, and it seems
to be used, in my experience, by orthopaedic surgeons, for instance,
as a useful oubliette to stick people for a little while,
for 18 months, waiting for a scan before they actually then commit
themselves to treatment, and that time does not appear to be measured.
Have you done any work on that?
(Mr McCarthy) I am afraid I do not have any figures
on that, that is not one of the collections that we have, so I
do not have information on that. What I can tell you is the move
in the NHS Plan towards booking will cover the whole pathway of
care, that is the principle of booking. So I do believe that in
future it will not be possible any longer for; a gap in the system,
which you pointed out last year, to remain, we will be looking
for patients to be booked on to their next clinic each time that
they attend.
Mrs Gordon
98. On waiting lists, no doubt they have come
down, but I should think that some trusts have done it better
than others, some doctors have done it, some consultants have
managed it better than others, and I just wondered whether you
had made an analysis of what has worked, basically, and whether
you are sharing that with all the trusts?
(Mr McCarthy) Yes, we are. To date, we have already
put out what is called the Waiting List Handbook, and it is based
on the existing targets that the Government has had for the period
to date. That has been produced by the National Patient Access
Team, who are our expert group, who work with trusts who have
had problems in trying to put those systems right, but also have
groups of the very best in the country who have achieved really
magnificent results. That Handbook has been sent to every trust
in the country, and it is about effective management of the processes
around access and waiting. Further to that, the NPAT again, the
expert group, send out and have web sites which give examples
of best practice and give contacts, which all trusts can have
access to, of places where particular problems have been overcome.
They run learning sets with trust management and clinicians who
have had difficulties, particular problems. As we move into the
new objectives, the new targets, we are going to be emphasising
that approach, and I think that was set out in the NHS Plan as
the way we wish to manage change in the NHS in the future. It
is about spreading best practice but in very practical ways. I
think the perception we had, when we were talking to members of
the Modernisation Action Teams, is that sending out yet more paper
to chief executives or directors was only effective up to a point,
and that what we really needed to do was get together teams of
practitioners who are achieving success, put them in partnership
with people having problems, in their local areas, and work together
to achieve changes which we think will be very positive. We do
think that is necessary, it is not just like icing on the cake
to achieve the sort of quite ambitious changes that we have set
out, and I think that has got to be an absolutely integral part
of the way we manage change.
Mr Burns
99. On waiting lists, just very briefly, on
in-patient lists, if you personally needed to have a cataract
operation in each of your eyes, and for clinical reasons alone
there had to be a three-month gap between the two operations,
how many operations do you think you would be getting?
(Mr McCarthy) I would be getting two operations in
an episode of care, I expect.
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