Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 120 - 139)



  120. You also gave useful information on delayed discharges from hospitals and you said in your note the reason for delays in discharge are complex and it difficult to determine which delays are the responsibility of social services and which are outside that responsibility. It is often assumed that 50 per cent are due to a lack of social services. If you are finding it complex to analyse it, is this not a problem about the supposed charter system for discharges or social services?
  (Mr Denham) I do not think it is complex to analyse the reason for a particular delay, however it is not so easy on a national collection system to always get the details that underlie it. One of the incentives I suspect in a system like the one proposed is it will encourage people to think about what the real cause is. As you know, some of the delays are collected under a generic "other" heading.

  Julia Drown: By the time it gets together it becomes a problem.

  Mr Burns: On the question of delayed discharges, as you know your Report does refer to it, I am interested to know how is fining social service departments going to help reduce the problem?

  Chairman: That might be a question to put to the Secretary of State.

  Mr Burns: It might be but I thought as the civil servants are advising ministers they might have a view.


  121. I think it is more a political question perhaps.
  (Mr Denham) The simple answer is one about incentives and responsibilities in terms of responsibilities for all patients or users of services at a particular point.

Mr Burns

  122. That is not an incentive. Would it not be better to give extra money if they manage to reduce delayed discharge rather than penalise them by fining them if they do not?
  (Mr Denham) They are getting resources. I am sure the Secretary of State will give you the precise figures.

  123. The question is, are they going to use those resources on providing the services that would help to reduce the amount of delays because it comes back to the interests of individuals in hospital?
  (Mr Denham) Is it not in their interest to be in hospital where they could be looked at after at home or intermediate care or in other ways and the question is how do you incentivise the provision of services to make that change. I think that is what lies behind the proposals on reimbursement.


  124. Can I ask a question on activity and the way in which activity is recorded . I recently met with some of my colleagues in the local health service and we were discussing the issue between the secondary care sector and primary care and a point came out which concerned me that services delivered by primary care are not counted against local activity targets. Is that correct?

  (Ms Edwards) They have not been historically. We have started to do that for the first time this year as a planning process and we projected a baseline figure. We now have an economy starting baseline and we are beginning to collect information against that. It is fairly basic and crude at the moment and we are working on the definition. We are encouraging more to be done appropriately in primary care and we need to start collecting to make sure that we have a lot of activity that could otherwise be done in secondary care is not lost in statistics.

  125. Why historically has that never been picked up before? It does seem, in a sense, to reinforce the role of the hospital sector, it is more extensive, acute provisions when primary care could and does indeed undertake a significant number of interventions, surely that should be counted?
  (Mr Douglas) Historically the issue was it was not significant enough to be picked up. Our data collection has not moved sufficiently quickly alongside changes in the way that the service delivers. There is a recognition from us that our data collection has fallen behind the service changes that we have been encouraging.

  126. Right. What will be the term for equivalent treatment undertaken in primary care?
  (Ms Edwards) We are collecting it on number of patients, equivalent of an FCE at the moment. We are doing quite a bit of work with small groups to look at what the appropriate definition would be. We want something that is comparable otherwise we cannot compare ships.

  127. How soon do you anticipate that will come into practice?
  (Ms Edwards) I do not think we have made any decisions yet. This year we are collecting data for the first time, but we have not made any decisions really at this stage.

  128. This concern will be addressed fairly quickly?
  (Ms Edwards) Yes.

  Chairman: Thank you very much.

Dr Naysmith

  129. I found the section on inflation in the National Health Service very interesting. It is quite clear that the NHS pay prices which consistently rise faster than the general inflation rates does that not mean, Mr Douglas, that it is misleading to present future growth plans in terms of extra real terms cash?

  (Mr Douglas) We present them in two ways, in terms of cash and the real terms deflated by the GDP deflators. We use the GDP deflator as a well recognised and accepted way of presenting these. We have not got forward projection for NHS specific inflation so we could not present on that basis.

  130. Would it not be better to present those in terms of extra real terms volume, which you say you will be making some kind of estimate of? It is clear consistently over the last few years inflation has been different from base rate inflation.
  (Mr Douglas) The key issue is that I took the figure to be a cash uplift rather than a real term or volume uplift. We would have to make assumptions about what future pay levels will be. We have to make assumptions what about the level of incremental change in pay is going to be and we should not be making that sort of forecast.

  131. It would be bad human resources to do that kind of projection, nonetheless it is a bit misleading and it leads people into thinking you are going to get that volume increase for that money, which does not happen.
  (Mr Douglas) It depends how people use the figures. If you purely take the NHS inflation figure without any adjustments at all for efficiency, because you would expect to have that in the economy anyway, I think you could argue that that would be a misleading figure as well.

  132. I suppose it is back to statistics again.
  (Mr Douglas) Cash everyone understands, they know what cash is.

  Dr Naysmith: I am not sure that is true actually, not in the way it is used sometimes by statisticians.

Julia Drown

  133. On a specific within inflation, you gave the net ingredient cost in tab 3.6.2 to show over the last three years that the net ingredient cost per prescription item has gone up per head from £60 to £125, that is partly people having more prescriptions from 9 to 12 and also the cost per item going up from £7 to £11. Does that reflect an increased quality of drugs—supposedly some drugs are going down in price? The dramatic increase from £60 per head to more than £120 per head can that be justified? Are the pharmaceutical companies having too nice a time?

  (Mr McKeon) It reflects a changing product mix going towards more expensive and newer drugs. If you look at the generic prescribing it amounts to about 70 plus per cent. The bulk of the expenditure is on, if you look at the answer, statins, which have effectively doubled in cost from about £180 million to £420 million. It would be clear why it was going up with the same sort of trends being there on mental health and diabetes.

  134. You cannot be satisfied that it is likely to be reflected in the quality of care?
  (Mr McKeon) We are satisfied that the rising drugs bill is being reflected in the quality of care.

Mr Burns

  135. Do you think there is a danger here that people hear about sums of money flooding into NHS and pharmaceutical companies think hard about encouraging people to use their drugs and buy their drugs? Is that a danger? I have heard it said that that is a potential problem.

  (Mr McKeon) There are two points there. Firstly, there are quite strict rules on advertising and direct advertising to the consumer is not allowed. Also when disease awareness campaigns are seen no specific drugs are mentioned. If you look at where expenditure has been rising it has been in the last two or three years or so and it has been rising particularly in those areas where we have sought improvements in care through national service frameworks—CHD, mental health and so on.

  136. These tend to be brand names.
  (Mr McKeon) They tend to be branded products but not exclusively. For example, some of the anti-hypertensives are generic products and aspirin, for example, is a generic product and there have been significant increases in those areas as well but, yes, the tendency has been to use branded products.

John Austin

  137. We specifically asked about the amount of money spent on statins in relation to the NSF on coronary heart disease and those figures are quite clear and startling, but we do not have any data linking changes in the medicines bill to the introduction of the national service frameworks. How much of the £545 million growth in the community medicines bill and £123 million in the secondary sector medicines bill can be attributed directly to the implementation of national service frameworks?

  (Mr McKeon) We have figures which we did not show you which show fairly clearly that the main areas of growth have come in through, as I was indicating, lipid lowering drugs, the statins, which have gone up by 31 per cent and anti-hypertensives have gone up by 21 per cent as a direct result of the CHD national service framework, and diabetes drugs by another 22 per cent which is again directly linked to the diabetes national service framework and anti-depressives and antipsychotic and these are linked to the mental health national service framework. These have been the big drivers. I have not broken that down precisely in the £545 million but there is clear evidence that the increase in the rate of growth, which was eight or nine per cent a year and is now 11 or 12 per cent, has been factored in as being driven largely by the NSFs because that is where the significant growth areas have been.

  138. You mentioned the atypical anti-psychotics, if I could come on to NICE, I realise that the NICE guidelines only came out in June of this year so it may be too early to say whether that estimate is going to be realised, but of the £467 million (or £495 million depending on which paper I look at) identified by NICE, how much do you expect will be spent by the end of the current financial year?
  (Mr McKeon) We have not made an annual estimate of the level of expenditure on NICE products per se. The £495 million is NICE's estimate which, by and large, reflects full take-up in the light of their guidance, some of which they would expect to occur over a number of years and sometimes two or three years or longer as clinicians essentially pick up the guidance and use it to identify the at-risk population. So it is very difficult to make an annual estimate of what that will be. What we have done is look in the SR rounds at what the likely impact of NICE will be over that period, as it were, and make sure that there is enough money in the pot in order to fund that kind of level of growth. It is not all directly growth from NICE per se because the NHS would have picked up an element of this anyway because there has been spending on medical technology and new drugs, so the total extra cost of NICE per se is not £40 million over and above what it would have been otherwise.

  139. Can I ask you specifically about Alzheimer's because the figure quoted there is a long run and obviously that is going to hold up over time. Do you have evidence that suggests that NICE recommendations on drugs to treat Alzheimer's is being implemented?
  (Mr McKeon) Yes, I think there are two areas of evidence that we could look for and a third that we are now hopefully going to get our hands on. The two areas are principally in the evidence we gave to the Committee for their inquiry into NICE. On their chart you could see a kink reflecting when NICE guidance came along, there was a slight break in the line. We would look at GP prescribing as well to see how that is rolling out, but that does not tell the full story because you have to look at hospital data as well and we are now engaged in discussions with IMS to have access to their data on hospital prescribing which would enable us to get a better handle on what is happening with the anti-dementia drugs.

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