Examination of Witnesses (Questions 120
- 139)
THURSDAY 2 NOVEMBER 2000
MR COLIN
REEVES CBE, MR
BILL MCCARTHY,
MR DAVID
WALDEN, MR
HUGH TAYLOR
CB AND MR
PETER COATES
Mrs Gordon
120. I was just going to ask, what is going
to be the sort of complaints procedures for an NHS patient being
treated in a private sector hospital?
(Mr Taylor) My understanding is that the complaints
procedure would be the same as if they were in an NHS hospital,
in effect.
John Austin
121. It is partly this question, and partly
going back to our earlier discussion about long-term care. How
is the Department going to ensure that money which is going into
nursing homes in the private sector is actually spent on nursing
care?
(Mr Walden) I think this is probably one for me. Through
the regulatory activities of the National Care Standards Commission,
which will be operating the national minimum standards that we
are currently consulting on, for care homes, and will be consulting
on and publishing for a variety of other regulated care services
in due course.
122. And will the Department actually be laying
down explicit standards on levels of staffing, training, qualifications,
in terms of the quality of care that is going to be provided?
(Mr Walden) The national minimum standards cover a
very wide range of factors that link to quality of care; staffing,
obviously, is one, the physical environment is another, complaints
a third. So it will be covering the sorts of area you indicate.
123. And training and qualifications of staff?
(Mr Walden) I am not sure precisely how the training
component will be formulated, but certainly the numbers and input
of staff is a key factor in any assessment of the quality of care
being provided.
124. Because, of course, the Independent Care
Homes Association say, if you try to do that you will put them
out of business; I do not believe them?
(Mr Walden) There has been a consultation on the `Fit
for the Future' standards, as you will know, for care homes for
older people, and obviously a range of views have been expressed
about that, not only about staffing levels, and so on, but also
about physical conditions and room sizes, and so on, and the Government
has made some announcements about some of those, particularly
around room sizes, but has not yet published the final version
of those standards, which it plans to do fairly shortly.
125. And will the standards be legally enforceable?
(Mr Walden) Yes. The National Care Standards Commission
will inspect and regulate against those standards, and anybody
who does not come up to those standards will not be registered
or allowed to continue operating.
126. And you will be able to guarantee that
any money which is spent from the NHS budget on paying for nursing
care in the private sector will go on nursing care?
(Mr Walden) It is certainly our intention to ensure
that that happens.
Dr Brand
127. If we can go back, in relation to a point
Mr Austin made. Staff in the private sector obviously have a choice
whether they work in the private sector or not, and they have
got to accept the conditions that go with it; patients do not
necessarily have a choice. Are you going to have a sort of rule
that NHS patients in private sector facilities are going to be
treated exactly the same as other patients in that facility? And
I am a bit worried about things like charges for extras; and I
know that some private establishments are very clever at knocking
up the bill for things that nowadays people consider to be the
norm. And are you going to make sure that we are going to have
a ban on charges that would not normally be levied within the
NHS; and if there are charges levied within the NHS the private
sector will not make them more expensive, I am thinking about
telephones and televisions, and that sort of thing?
(Mr McCarthy) I think the intention is that NHS patients,
wherever they are treated, will receive NHS care to similar specifications
that they would have in the local NHS facilities. It may be that
some private sector facilities might offer other things; and I
expect in those circumstances the patients will be able to exercise
some choice. But there is absolutely no intention that an NHS
patient should be somehow forced to pay charges that they would
not expect to do in the NHS care.
Mrs Gordon: So you will have a two-tier system
within the hospital, basically; you will have NHS patients up
one end and private patients the other end. You are going to have
a two-tier system.
Dr Brand
128. It is not within the concordat, clearly.
(Mr Walden) It is certainly not clear.
Dr Brand: We had better ask the Secretary of
State, I think.
Chairman
129. What would you do if you had a patient
who, on principle, refused to be placed in a private hospital,
a National Health Service patient who felt so strongly that they
did not wish to be treated in a private hospital that they refused
to be; how would you deal with that? Would they have the right
to say "I'm sorry, I don't want to go, under this concordat,
to the local private hospital"?
(Mr McCarthy) I think the concordat sets out the fairly
high-level framework for encouraging partnerships, where that
is in the interests of patients in the NHS locally.
130. What would happen if the patient said "I'm
not going," and needed some surgery?
(Mr McCarthy) I do not think the concordat, in itself,
changes the current position. It is entirely possible for patients
who are on an NHS list to be offered care in a private setting,
and I know of cases where patients have declined that offer, because
they prefer to wait for the NHS; and there is nothing in the concordat
which changes that position.
Dr Brand
131. NICE, let us be nice about NICE. Recent
figures suggest that the rise in drug spending is going up quite
dramatically, more so than the rest of the European average. What
is the Government's prediction of what will happen to that rise?
(Mr Reeves) In terms of overall prescribing?
132. It is about 11.5 per cent now, which is
going up 5 per cent above inflation; do you anticipate this continuing?
(Mr Reeves) I am not sure I entirely agree with the
figure of 11 per cent, I think the average growth over the last
five years has been 8 per cent.
133. No, the last year, it was 11.5?
(Mr Reeves) And we still believe, our line to the
services, that we believe, in terms of this year, the figure will
still be 8 per cent. And that is partly, I think, a reflection
of the fact that, the previous year, the 1999-2000 budget is actually
artificially low both in price and volume terms. And, secondly,
some of this cash we used to claw back from the pharmacists has
also been reducing as well. So there is an issue, I understand
entirely. Though I would say perhaps one or two things. Firstly,
that in a way we are not so much focusing, cost reductions are
important but I am thinking the Government is more interested
at the moment in terms of cost-effectiveness. I will give you
one or two examples. Obviously, the introduction of NICE, the
work around implementing Prodigy, which was one-third of the 9,000
GPs, the National Prescribing Centre, the whole increasing number
of nurse prescribing people, 33,000 I believe it is talked about
in terms of the Plan. So I think, yes, we are concerned, obviously,
in terms of what the overall cost is and will be in terms of prescribing
in the future, but we do believe the focus will be much more in
terms of cost-effectiveness; that is the first point. I suppose
the second point is we are doing two things, one in terms of generics,
whereby we did put some money in last year to help the generic
problem, which we do believe is predominantly a one-off issue,
in terms of supply, last year we had problems with one or two
firms, as you know, one or two firms relocated abroad.
134. I hope you have closed the loophole that
they were using to boost their profits?
(Mr Reeves) Yes. We are working currently to move
towards an approach whereby we could be thinking, and only thinking
at this stage, in terms of setting maximum prices based on the
prices in play in April 1999, so that is one possibility as well,
although we think the loop has cut itself off because it was predominantly
a supply problem. I suppose the other thing we are doing is the
pharmaceutical price regulation screen, and the fact now we have
agreed a 4.5 per cent cut from October 1999, agreed that with
the ABPI, and also there is going to be a price freeze now until
2000-01, January 2001 being the precise date. I think one of the
big issues around that as well is not just the price reduction
but also the number of unauthorised price increases, which used
to occur in the past, have reduced quite dramatically, I think
we have had three this year, since the PPRS Agreement, compared
with an annual figure of round about 20, 25. And, again, I think,
the PPRS will save altogether, in a full year, about £150
million. So, although there are concerns about the overall growth
in terms of prescribing, in terms of the figures you quoted, although,
as I say, I think we still believe it is 8 per cent rather than
11 per cent, but if you think about cost-effectiveness and the
focus on that, if you think what we are doing in terms of generics,
if thirdly you think what we are doing in terms of the PPRS and
branded drugs, I do feel, in actual fact, the way forward is quite
clear for the NHS in terms of this.
135. So NICE is not specifically charged to
meet a particular target on drug expenditure?
(Mr Reeves) No. We have taken account of what the
implications of NICE's advice might be, and part of the allocation
of the £600 million that went out in March of this year,
one element of which was to respond to the potential implications
of NICE. There are also estimates made in the spending review,
in terms, again, of what the implications of NICE might be, and
we have a loose working model in terms of how we would make those
calculations.
136. So when NICE sort of suggests that some
things should be made available, like some of the more expensive
cancer treatments, you will automatically adjust health authorities'
and trusts' budgets to take account of that?
(Mr Reeves) What we have always done in the past,
as you know, is when we give general allocations to health bodies,
in certain cases we earmark, and then in most cases we indicate
that there are various conditions and pressures on the service,
and these are the sorts of pressures that need to be taken into
account, without putting a definitive number against each of those
conditions.
137. But most trusts can reasonably anticipate
where their pressures are going to be, and what they cannot anticipate
is a decision that NICE might make, making a drug available, and
we all want to get rid of postcode prescribing, but unless people
have got equal resources you are going to continue having postcode
prescribing. So should there not be a mechanism actually to match
the funding with NICE decisions?
(Mr Reeves) Yes, certainly. Let me make two points.
Firstly, NICE is intended as an independent body, it is set up
so that the Government does not have to try to second-guess NICE's
judgements, neither approve nor overrule it; so that is the first
point to be made. Having said that though, there are two or three
areas where I would say that Ministers would be interested in,
obviously, taking forward the recommendations of NICE, and that
is, on occasion, when there will be issues concerning affordability
and priorities, and I think Ministers would want to say, in conjunction
with NICE, in terms of what the implications of some of NICE's
decisions are. Now what we will try to do to link the two together
is ensure that, firstly, through what we have already done this
financial year in terms of the allocation of an additional £600
million, and, secondly, in terms of what we are going to be doing
over the three subsequent years, in terms of what is a massive
sum of money, we are making it very clear that there are implications
of what NICE is undertaking and these need to be taken account
of by health bodies. And, obviously, when NICE comes up with a
recommendation we will try to give as much indication of what
we think the financial implications are; but, at this point in
time, I cannot second-guess even the topics that NICE are going
to be discussing and focusing on over the next few years anyway.
138. But should not there be a mechanism where—at
the moment, NICE is grossly underperforming in the number of things
they are looking at, I think they were charged to do, what, 30
a year and they have done ten, or something, I cannot remember
the exact figures, but it is actually quite a small number. And
I would have thought you could work out what the implications
might be of a decision to allow wider access to a particular jug
within the NHS?
(Mr Reeves) I would think, in the fullness of time,
as this institution develops, that might well be the situation.
Part of the reason why it has not done the number of reviews you
suggest is because it is a new, embryonic organisation, it is
still developing, expanding, and we want to give it time and space
now to try to develop properly. And what we are trying to do is
probably match, we think, the number of recommendations that NICE
are likely to be making over a period of time with the funding
availability; and, as I say, we are in a good position, because
from now for the next three years we have, in relative terms,
a good quantum of money to respond to a number of issues, one
of which is this.
139. Yet, beta-interferon, because that probably
would have been the one decision that would have made a dramatic
financial impact on all trusts, the decision was not to make it
available, except, very illogically, for people already taking
it. Now either it is a useful drug or it is not a useful drug.
Why are we exposing people to beta-interferon, which actually
has got nasty side-effects, if NICE thinks it is useless for the
rest of the population? I do not see any logic in that, other
than a financial one.
(Mr Reeves) I am not sure, in all fairness, NICE said
it was useless. I think they concluded that it was not necessarily
as cost-effective as possibly some other drugs, and, at the moment,
obviously,—
|
