Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 120 - 139)



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.


  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,—

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