Examination of Witnesses (Questions 140
- 159)
MONDAY 21 OCTOBER 2002
MR RICHARD
DOUGLAS, MR
ANDY MCKEON,
MR GILES
DENHAM, MS
MARGARET EDWARDS
AND MR
ANDREW FOSTER
Dr Taylor
140. You have said that the national service
frameworks are big drivers in increasing the spending in that
particular subject. What do I say to consultants in non-NSF specialties
who feel very hard done by because they have not got the push
behind their funding? How do I answer them?
(Mr McKeon) You answer by saying the
Government has made some choices in terms of priorities in terms
of the NSFs which now cover CHD, cancer, older people, mental
health, and coming along are renal disease, children and longer-term
conditions.
141. So other ones —
(Mr McKeon)—other ones are in train. The next
three are going to be renal disease, children and longer-term
conditions and diabetes, I forgot to mention that, so there is
a pretty wide coverage.
142. One more question about NICE. During the
NICE inquiry I think it was Lord Hunt who told us categorically
that health authorities had been given enough money to fund the
NICE recommendations. Were they given the £225 million in
the last year? Are they going to be given the £467 million?
Are they going to be given enough to fund these changes?
(Mr McKeon) We are satisfied that over the period
of the SR round that we factored in sufficient to cover the cost
of the NICE recommendations. It clearly has to be a bit of a guess
because we do not know exactly what the recommendations are going
to be, but we have factored in enough for that estimate and indeed
for other pressures on prescribing and so on.
143. Do they have a chance to come back to you
and say they do not agree?
(Mr McKeon) They always have a chance to come back
to us, and they frequently do.
Mr Burns
144. And say they do not agree?
(Mr McKeon) It is very rare in my experience
in the Health Service for people to say to us, "Yes, you
have given us all the money we need."
145. So in fact the answer to the question is
no because almost certainly NICE will come back most of the time
and say they have not got enough and you will say for a variety
of reasons they have and possibly the funding will not be to the
level that NICE thinks it should be.
(Mr McKeon) No, so far on the basis of NICE recommendations
we think our estimates have actually been reasonable in the light
of their recommendations.
146. That is what you think?
(Mr McKeon) That is on the basis of what they have
told us they are estimating.
Mr Burns: Have they come back to you?
Chairman: Mr McKeon, you are saved by the bell.
We will adjourn for ten minutes for a division.
The Committee suspended from 5.54 pm to 6.05
pm for a division in the House.
Chairman: Can we recommence. I think, Doug,
we were over to you for a question.
Dr Naysmith
147. We were talking about increases in expenditure
not necessarily being parallelled completely by increases in activity.
That could lead us to conclusions from Table 2.2.5 that the productivity
of hospital and community health services has fallen overall since
1996/97. Is that a fair conclusion to draw from those figures?
(Mr Douglas) I do not think it is a fair
conclusion to be drawn from the figures. It is what the cost weighted
activity index will tell you. I think most people would accept
that this index is becoming an increasingly flawed way of trying
to measure what is really happening with NHS efficiency. When
the Chairman discussed with Margaret earlier on some of the issues
about not counting activity, increasingly as we shift out of traditional
settings we are going to miss a large amount of the activity within
that index. As Andy discussed as well when we were talking about
NICE and the national service frameworks, we have made an increasing
investment in quality that is not picked up in any of these activity
figures. What we have really got to do is fundamentally look again
at how we measure NHS productivity so we have work in hand on
that now.
148. What is the effect on efficiency targets
that are set every year for the NHS trusts? What, if any, effect
has that had and is it using an inadequate tool to beat some trusts
with?
(Mr Douglas) For the next round of allocations during
the spending review we had long discussions with Treasury about
this whole approach to efficiency measurement. We have reached
an agreement with them that whilst we will retain within the settlement
a two per cent efficiency target each year, that will be broken
down in two ways. Firstly, we will have to demonstrate quality
of improvement, not just unit cost improvement. Basically we have
split the two per cent between one per cent quality and one per
cent unit cost, but within the unit costs come up with a more
sophisticated measure that takes into account the spending quality
areas and takes into account the shifts in settings of care as
well, so we will have a more sensitive measure for next year.
149. How does this map up with the targets set
up under the National Health Service Plan?
(Mr Douglas) Which targets?
150. The efficiency targets.
(Mr Douglas) We will still have a two per cent annual
efficiency target but it will be measured in a more appropriate
way.
151. When do we get to hear about these methodological
changes?
(Mr Douglas) The measures we have proposed with the
Treasury are out for peer review with academics and HS managers
at the moment so I would have to check with my colleagues, but
we have got to be in a position to tell the NHS at the same time
as they are planning, which has got to be by November/December
this year.
152. So quality is going to be an important
factor?
(Mr Douglas) We will take into account quality. There
is a very, very clear agreement with the Treasury that there is
a one per cent quality element and a one per cent cost efficiency
element we can measure.
153. Can you give examples of what that will
mean?
(Mr Douglas) Part of that is to try to link the input
far more clearly to the outcomes. What we tend to do at the moment
is try and link the inputs we have got to the activity levels.
What we have got to look at is what are the outcomes as a result
of that rather than just the activity levels, so that is the way
we will try and do it.
154. Is there any kind of example you could
give to me of what we are talking about, what sort of quality?
(Mr Douglas) I have not got the details with me here,
I am afraid, but I could come back with some of the examples linked
to that of the ones that are proposed at the moment.
155. I interrupted.
(Mr Douglas) I have forgotten what I was trying to
say.
156. I will give you time to think about your
answer by asking another question. This issue of qualitative care
you talked about, obviously the Department has on the issue of
fallen productivity frequently pointed to the measurement of the
increase of quality of care. One of the issues we pick up in the
survey response is that two of the major indicators of quality,
waiting times and readmission rates, have not improved in recent
years. What concrete evidence do we have that these quality improvements
are taking place? You say it is going to be measured. I am not
clear. Looking at the figures we have the measurements so far
indicate what you are saying is happening, it may well be happening,
is indeed happening?
(Mr Douglas) This is one of the problems we have.
The weighted figures are improving, they are one of our quality
measures. What we have to do is to break down some of the National
Service Frameworks and say what we are looking at from National
Service Frameworks and they measure more precisely the impact
of those and the amount of investment that has gone into them.
Frankly we have not done that up until now.
157. It will reach areas of National Service
Framework breakdown into evaluating those requirements at a local
level presumably?
(Mr Douglas) Whether we break it down into every element
of the NSF we have to work through the appropriate methodology
at a national and local level. In most of these areas there is
already local measurement and what we are not doing is bringing
those together in our aggregate measures in any way.
(Mr McKeon) I can comment on the readmission rates.
I am not sure you can tell too much from the figures presented
from the reasons given in the answer to your written question,
I think there are two or three reasons for that. Firstly, because
these are clinical indicators we need to look at the confidence
intervals that are there, which information has been provided,
and once you have done that there is possibly a small increase
into the readmission rate. That could also be accounted for by
improving quality of data. If you are picking up more episodes
and making better linkage between those episodes it is clear that
readmission rates are likely to be rising purely as an artefact
of the data, so there have not been significant changes in readmission
rates. If you look at other figures, such as 30 days after surgery,
there has been an improvement. That is probably equally a case
for caution in terms of analysing the figures. There are some
improvements that we could chart, particularly going back to prescribing—I
do not know whether the Committee is familiar with the work of
John Alton's collaborative on primary care, but that shows quite
clearly in the PCTs, which have been with his collaborative, there
has been a fourfold decrease in the death rate from heart disease
compared with those who are not in the collaborative. That is
largely because of the prescribing that has gone on, improvements
in prescribing statin betablockers, and so on. There is a very
definite improvement in quality. I do not think one measure is
good enough. There are a number of steps we are taking to do that,
through the planning framework, and so on, and through the introduction
of systematic audit and CHD in cancer care, which is a specific
requirement over the next three years, which should give data
on outcomes and on clinical quality.
158. If we look at average total waiting times
what would that be in terms of trends? I am conscious neither
the current government or the previous government measured the
total waiting times for initial referral to specialists to the
point of treatment. If we look over a period of time what would
the trend show in relation to whether it is improving or not?
I am advised it has more or less unchanged during the period of
the current government.
(Mr McKeon) We do not measure it.
159. Why do we not measure it?
(Mr McKeon) We have never had the ability or the data
to do that. It is something we ought to move towards in measuring
from the point of time of referral to the completion of the procedural
operation.
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