Examination of Witnesses (Questions 20-39)
ALAN MILBURN
MP, JACQUI SMITH
MP, MR RICHARD
DOUGLAS, MR
GILES DENHAM
AND MR
NEIL MCKAY
WEDNESDAY 17 OCTOBER 2001
Jim Dowd
20. I take your point about the broader nature
of public health. If I can look at one of the initiatives this
Government has taken since 1997, and that is Health Action Zones.
We have one in my area—Lambeth, Southwark, Lewisham—a
Health Action Zone, the whole programme could have been designed
with that kind of area in mind, pockets of deprivation in towns
and cities, in one of your earlier answers this fits archetypally
into the area.
(Mr Milburn) Yes.
21. I have a good relationship with them. They
are doing a lot of work. They are looking at very original and
imaginative ways of approaching the age old problem. There is
a lot of money being allocated to the 26 which now exist. How
are you going to ensure that they are actually meeting the objectives
rather than just doing good work and the acid test of that will
be in reduced numbers with coronary heart care and cancer cases
etc in some of the inner urban areas, which are not only the most
deprived but have some of the most deeply entrenched and worsening
public health problems?
(Mr Milburn) I think the answer to that is the same
as the answer to how we ensure that PCTs carry out their public
health function, which is that we monitor them. We have an accountable
system in this country which is a real strength actually, I think,
for the health of the population and we have a means of doing
that now. We have got a performance assessment framework which
covers a number of areas of activity, whether it is Health Action
Zones, PCTs, NHS trusts, Uncle Tom Cobbley and all have got to
account against. There was a time, I will be frank with you, when
for the first couple of years, we were not monitoring the Health
Action Zones as actively as we should have done. I changed that
I think last year partially because I was concerned that some
of the initiatives that they were undertaking, although they were
good things in their own right were not focussing on what we know
really makes a difference because if we can bear down on smoking,
if we can improve diet and exercise, if we can ensure that in
primary care people are taking sensible, pretty straight forward
steps to monitor health incidents then we can make a big difference.
That was not happening everywhere, I cannot remember whether it
was happening in your area or not, I hope it was. We changed the
regime so there is actually much tighter monitoring of the Health
Action Zones now. What I want them to do is to spend the majority
of the resources that they get, which are quite considerable,
on precisely the areas that we know will make the greatest difference
on dealing with coronary heart disease, on improving cancer outcomes,
on dealing with the things that I have been discussing with Dr
Taylor. I think that in all of these cases I want to assure the
Committee that what we have is a means of the local health service
being able to account for its performance, not just on the narrow
issues of acute elective activity or recruitment and retention
rates but on the broader public health measures too. With one
caveat, you have made the important point and it is absolutely
right, we should be bold about this and very straight forward
with the public. To get where we need to get to in terms of improving
cancer outcome rates or heart disease outcome rates is not going
to be achieved in one year or two or a Parliament, it is going
to be achieved over a period of time. That is why all of the frameworks
that we publish and all of the plans that we have published are
deliberately long term and I think unashamedly so too. What we
have got to be able to do if we have got long term plans in place
is to be able to demonstrate year by year improvement. Now in
some of these things, to be frank with the Committee, it is pretty
hard. You saw that very, very recently, I think, there was reference
in the newspapers to improved cancer outcome rates but those figures
referred to several years ago because we are always behind the
mark in terms of measurement. We need to improve that and we have
got some things in train that will allow us to do that. That aside,
what we should do with every part of the NHS is make sure that
the appropriate monitoring is in place so that we, as decision
makers, but more importantly members of the public can actually
see where their money is going and what results they are getting.
Mr Amess
22. I have been listening very carefully to
your hopes and aspirations for the Health Service but how can
this Committee take your utterances seriously when we consider
everything that you and your fellow ministers have said about
waiting list targets for the last four years? I am not going to
embarrass you by reading out the responses that you have given
to Committee Members.
(Mr Milburn) Generous to a fault as always, Mr Amess.
Generous to a fault, well known for it.
23. Defending staunchly why these targets were
so marvellous and how it was sensible to put extra money in, etc.
Then breathtakingly in June after four years defending this rotten
policy you said "There will be no waiting list target but
there will be a concerted drive to reduce waiting times"
and yet when Her Majesty's Opposition had tried to persuade you
of that position you did not want to know. How is it that you
suddenly changed your view on that very important issue after
four years?
(Mr Milburn) I do not think Her Majesty's Opposition
liked the change either because you do not like either the waiting
list or the waiting times target. However, let me explain what
we have to do here because this is very, very important. When
we came into office in 1997 the major public concern was about
the length of the waiting list because it had been rising and,
in fact, I think during the course of the previous administration
had risen by about 400,000 from around 700,000 to well over one
million. Of course there were public concerns about that and it
is right that we deal with public concerns because in the end
the NHS, just like any accountable organisation, has to command
public confidence. We succeeded in doing what we said we would
do, which is to get the waiting list down. We managed to do precisely
that, we got the waiting list down by over 100,000. These things
do not stand still, we go on from year to year trying to make
improvements. Because we have managed to achieve what we set out
to achieve on waiting lists, compare and contrast 400,000 rise
against 100,000 fall, we can move on to our next ambition and
our next ambition is to get the waiting times for treatment down.
Let me just finish the point. It is very, very important for people.
People do not like waiting 18 months for an operation, whether
it be a heart operation or a cataract operation, and rightly so.
Actually, I think that we are making good progress on this. I
wish we could go faster but the capacity constraints are such,
the shortage of doctors, the shortage of nurses, and until very
recently the shortage of beds which had been falling for 30 years
and are now rising again in hospitals, mean that we have got to
take this thing stage by stage. What I can say is from a position
where we had a maximum 18 month waiting list, by March next year
we will have a maximum 15 month waiting list. In fact, I expect
very many NHS trusts to do even better than that. Some NHS trusts
are already achieving six months. My own trust in Darlington has
long achieved a maximum waiting of 12 months. Within that we will
make even faster progress still particularly for coronary heart
disease and for cancer, the clinical conditions that affect most
people most severely. That is the simple reason for it. You are
speaking for the Opposition here today obviously but I just hope
that what people have been clamouring for they are now happy with
which is, I think, a step in the right direction.
24. My colleague is bursting to come in but
I just want to pursue this point. What you have said is absolutely
incredible. Is not the truth of the matter that after four years
the general public more than twigged that it was minor operations
that were being carried out before more difficult ones in order
to get these wretched lists down and it was the friends and relatives
of people who had serious operations needing to be carried out
and it was through public pressure that you dropped this ridiculous
policy? The whole point of this Committee is we are talking about
expenditure on the Health Service. Are you actually telling this
Committee that you are not admitting that this policy that you
pursued for four years was wrong? Are you also expecting us to
believe that the extra money that you deliberately put in to pay
these consultants—I have had so many conversations with
them about what was going on—was not in order to get the
smaller operations carried out quickly so that these figures would
look good? You are seriously expecting this Committee to believe
that, are you?
(Mr Milburn) Yes, I am. In fact, you can see from
the figures, and again I would be quite happy to share the figures
with you in due course, when you have a look, for example, the
big expansion that has taken place in heart operations. A heart
operation is a major operation, heart disease is a serious clinical
condition.
25. Yes.
(Mr Milburn) And there have been big increases in
the number of heart operations. So the charge that somehow or
other the only operations that were being done were toenail clipping
rather than heart operations just simply does not stack up. I
think the other important point to bear in mind is this: there
is a direct correlation between the number of people on the waiting
list and how long individuals wait in terms of waiting time. If
I go to the supermarket, when I have bought my goods by and large
I do not go and join the longest queue, I try to join the shortest
queue because I am going to get through the till most quickly.
What our modelling suggests very, very strongly, and I think you
can see some of this already in terms of the impact of the inpatient
waiting list on waiting times, is whether you reduce inpatient
waiting lists or your focus is on reducing inpatient waiting times
the two come down together. That is what we have got to achieve.
I think the most important thing from the patient's point of view,
from the point of view of the individual patient, is to know that
the National Health Service is moving in the right direction,
that if you have got a serious condition or any form of condition
that the National Health Service is going to be there for you
and it can deal with you in a timely fashion. If you ask me right
now whether people wait too long for a hospital operation, of
course the answer to that is yes, it must be yes. What we have
got is a determined effort to get them going down. As you can
see from the big reductions that have taken place in the number
of people waiting over 12 months already from the peak just a
few years ago this can be done and it is being done in certain
NHS trusts. The big question that should concern all of us is
this: if some NHS trusts, if some hospitals, can manage to achieve
a maximum waiting time of 12 months, let alone six months, then
why on earth can every NHS trust not achieve that?
26. I find it more and more incredible but on
that specific point, if you turn to Table 4 16.9 you will see
that the total number of people being removed from the waiting
lists for ordinary and day care has actually been falling since
March 2000. Moreover, there is a pattern of falling for admissions
since March 1999. That is in that table. How did you work out
the new waiting time targets?
(Mr Milburn) We modelled it. I think it would be reasonable
to share with the Committee some of the modelling that we did.
We modelled it and I think that is perfectly fine, you can see
that for yourselves.
27. And you took into account falling nursing
home beds?
(Mr Milburn) And we took into account a range of factors.
We took into account not just the extra investment that was going
in. Remember the investment that is going in is now at twice the
rate of the past, which allows us to go at least twice as fast.
We also took into account some of the changes that need to take
place in how care is delivered. Let me just finish this point
because I think this is really important. I do not believe that
in the end the way that you will get the big reductions in waiting
times that patients nowadays expect to see out there is simply
by cranking the machine even harder, it is not achievable by that.
28. Just one or two very, very quick points.
Just for the record then, you are confident that you will achieve
these waiting time targets?
(Mr Milburn) Absolutely, yes.
29. The final point is when you came before
the Committee in November 2000 we had an exchange over naming
and shaming Southend Hospital. This was all about the consultants
and on this particular proposition of targets. One colleague is
going to talk about the hotel star rating. How do you justify
that you announced hotel star rating for hospitals when Parliament
was not sitting and given we had an exchange last November you
actually had the audacity to give Southend Hospital, which serves
four constituencies, a one star hotel rating. So in our exchange
in November, which is on the record, you said you were going to
do a great deal to help, we were going to boost staff with all
sorts of initiatives, a Government Minister came down, and now
you have given our hospital a one star rating. Who was the idiot,
absolute idiot, who thought up hotel star rating and could not
see the terrible effect it has had on staff morale in my own local
hospital? An absolute disaster.
(Mr Milburn) I gather that you are not very happy
with the policy.
30. I am not, no, and even the doctors, nurses
and consultants are outraged.
(Mr Milburn) Even I, with respect, Dr Taylor, as a
politician got that message.
31. It is a disgrace.
(Mr Milburn) I know you think it is a disgrace and
I am extremely sorry for that. The reason why it got a one star
rating is that is what it deserved according to the figures that
were measured. If you do not know this as a Member of the Health
Select Committee you should. The truth about the National Health
Service is this: there is excellent performance, there is indifferent
performance and I am afraid in some parts of the NHS, to be blunt,
there is bad performance. Every patient knows that, every doctor
knows it, every nurse and every manager knows it; every politician
should know it too.
Sandra Gidley
32. Fun though it may be to attack the record
I am more interested in looking forward to what may or may not
happen. One of the side effects, if you like, of the 18 month
target is that people are now waiting an extraordinary amount
of time before they can see a consultant, particularly in the
orthopaedic fields. It is locally 52 weeks if you want to see
a specific consultant and I was recently quoted somebody who had
to wait 92 weeks to see a consultant in the NHS. What is being
done to address this problem centrally? I know there are some
local initiatives that are working quite hard on this. Will the
change to the 15 months actually worsen this problem? The other
aspect of the problem which I would quite like to explore is the
fact that local GPS are in fact very hampered, they are very restricted
in where they can send the patients. It is a fact that if 40 miles
down the road there is a hospital with a three month waiting list
GPS cannot send patients there. When budgets are devolved to PCTs
will there actually be a greater freedom for GPS to spend the
money where they want and without excuses such as destabilising
the local health economy?
(Mr Milburn) I think that is one of the very real
benefits that we will see. In most parts of the country, it is
not true in every part of the country, there tends to be a monopoly
health provider. In Darlington there is one hospital. The next
hospital is in Bishop Auckland, it is ten or 15 miles away, Durham
is the next one, 20 or 30 miles away. By and large people would
choose and GPS would choose, quite rightly, to use their own local
hospital for perfectly good reasons. If you go to any hospital
nowadays one of the most noticeable things you will see is that
there are a lot of very, very elderly ladies in the wards, old
people who tend not to be mobile and want to be as close to home
as possible. The local hospital will remain a very important focus
and it will be a matter for the primary care trust rather than
anybody else to decide who on earth they should contract with.
My own view is that I think we do need to see more choice being
made available to patients and to GPS. I think we can get there.
Over time I think we can get to a position where as we get improved
information technology in the GPS' surgery, in three or four years'
time we will be in a position where you as a patient, and your
family doctor, will be able to sit down together and decide not
just on when the hospital appointment should be at your convenience
rather than at the system's convenience but also the location
of the hospital appointment. Frankly, if there is a shorter waiting
time in a hospital that is ten or 15 miles away rather than the
one around the corner, and that is where you as the patient want
to go and it is where your GP wants to send you then we have got
to be able to facilitate that. That seems to me to be eminently
sensible, precisely bearing in mind the point I made earlier that
there is good, bad and indifferent performance. Indeed, in neighbouring
hospitals, as you well know, you can get quite short waiting times
and quite high waiting times, sometimes for pretty inexplicable
reasons. The patient, nor the family doctor, should not be the
person who suffers the consequence of that. That is the first
point referring to your latter point. On your first point you
raised, which was about long outpatient waiting times, you are
quite right, the outpatient waiting times, just like inpatient
waiting times, are too long. We have got a lot of people who wait
over 26 weeks for an outpatient appointment at the moment, even
more who wait over 13 weeks. I hope you will take some comfort
from the fact that over the course of the last couple of years
in particular there have been very, very large sharp reductions
in the number of people waiting for an outpatient appointment
and we have set further targets to ensure that not just do we
get to a 15 month inpatient waiting time maximum but we also get
to a 26 week outpatient waiting time. We aim to do that by March
next year and then we will go further still in the years that
follow. Over the course of the next few years we want to get down
to our maximum outpatient waiting time of three months and we
want to get down to a maximum inpatient waiting time of six months.
I think if we can get there stage by stage what people will begin
to see is that these things which have only been possible in some
hospitals thus far are possible across the whole National Health
Service.
33. This is a problem because there is no mechanism
that I can see in the health service for spreading this best practice.
I am also very interested in why one trust delivers and the neighbouring
trust does not. There does not seem to be much interchange between
the two to expedite that.
(Mr Milburn) That is an accusation that you could
have fairly levelled in the past, I hope it is not an accusation
that you can level now. We have a whole apparatus for spreading
good practice, as it is called, including a new Modernisation
Agency whose sole job is to do precisely that. Its whole raison
d'etre is to learn from the things that are going right in
pockets within the National Health Service and spread their benefits
elsewhere in the NHS whether it is a question of how long people
wait on trolleys in an A&E department or how long people wait
in this city, for example, to get a GP's appointment. You know
people wait weeks on end and in some surgeries they wait 48 hours.
I think there are profound questions to ask about why is it possible
that between a third and a half of GPS already can deliver a maximum
waiting time for their patients of 48 hours while other GPS say
that is absolutely impossible. It is not impossible because it
is already being done. What we have got to have is both the means
to spread best practice first of all through the Modernisation
Agency and other devices but, secondly, I think we have got to
have the incentives in place so that people who have already improved
get a reward and people who need to improve see that there is
some reward around the corner if they actually get on and improve.
That is what we are trying to introduce. Some people do not like
it but the NHS is an unusual organisation in that our tendency
rather than rewarding the good tends to be to bail out the bad.
I think that is a perverse incentive and we have got to change
it and we have got to have the courage to do that. Sometimes that
will be in the face of people who actually work in the NHS who
do not like it but I am afraid that is what needs to happen if
we are going to make sure that we do not have short waiting times
in some places but we get them everywhere.
Chairman
34. I am anxious to bring in the Minister of
State on the area you are responsible for of the community care
side. Before you have a breather, Secretary of State, can I just
throw one final point at you. We set off talking about public
health and rapidly got into waiting lists and waiting times but
how can we make public health more politically sexy and does Government
have a role in this respect?
(Mr Milburn) I will tell you what is interesting.
Every time we do a story about cancer and what we are trying to
do it always gets into the newspapers but every time we do a story
about coronary heart disease it never gets into the newspapers.
I do not know what the answer to that is but maybe the answer
lies on the table to my right rather than to me. Frankly, I think
part of the reason is that with coronary heart disease it tends
to be a much more working class disease. You know that yourself
from your own area. Unskilled men run three times the risk. Just
because it adversely affects disproportionately one part of the
population should not mean that it is not a concern for the whole
of the population, because it is, and we have just got to keep
ensuring that there are both the focus and the resources there
to really make a difference. In terms of so-called sexy initiatives,
part of it is through advertising and so on and so forth. The
anti-tobacco advertising campaign that the Department is running
is pretty effective and winning awards and so on and so forth.
It is important to get these messages out to people.
Dr Taylo
35. Can I make one very quick point on that,
to make it more sexy, more attractive. The public health doctor
is becoming more and more a civil servant and this has been raised
to me by both public health doctors and citizens. He used to be
independent, the voice of the people. If you could make a new
breed of public health doctor who really was the voice of the
people, that would increase the attraction tremendously.
(Mr Milburn) I hope you are not alluding to the fact
that civil servants are not sexy. The top table indicates it all
too well. No, I think you are probably right.
Chairman: We had better move on from that, Minister.
Dr Taylor
36. We are going on to community and residential
care, if we may. Obviously it is very good that the Government
is committed to increase spending on intermediate care beds. We
are very concerned that nursing home beds are being lost at quite
a rate because of the increased costs, the increased care standards,
which obviously they do not object to and they approve of but
they are finding it very hard to keep up with those. I got a letter
just a day or two ago from the Registered Care Homes Association
of Hereford and Worcester, quoting "A growing number of homes
are in dire financial trouble, especially those who are unable
to attract a sufficient number of self-funding residents who in
fact subsidise others". So this local group for these two
counties is about to put up the fees per patient by £50 per
week. What bothers us is however can you accommodate this tremendous
increase in costs in nursing home care and still have money to
make the planned increase in intermediate care?
(Jacqui Smith) The first thing, of course, is I have
had that letter as well. There is concern. We are concerned about
the capacity within both nursing and residential care homes and
that, of course, was part of the thinking behind the announcement
last week of the £300 million. It seems to me there are a
variety of things that we need to do. Firstly, I think we need
to recognise, and care home owners and local social and health
care economies recognise this and all of us think it is a good
thing, that we are in a situation where we need our services to
change. So we do not need to maintain necessarily exactly the
level of capacity we have previously because older people have
said to us as a Government, and they will undoubtedly have said
to us as individual MPS, that what they increasingly want are
the sorts of services that enable them to stay in their own homes
that prevent them from having to go into hospital in the first
place but help to promote their independence and rehabilitate
them if they have been in hospital and they come out. So there
is a challenge in the system which is about managing the capacity
whilst we also reconfigure and develop new services. That was
what last week's announcement was about and that is what I know
a lot of work at local and social health care levels is also about.
How can we maintain that capacity and how can we develop new services?
One of the important ways that we need to do that is by making
sure that the sort of commissioning that happens locally is better
than it has been. There have been authorities where quite frankly
I do not think they have involved their independent and voluntary
sector partners and their care home providers in the planning
of their capacity in the way in which they should have done. That
was the reason why John Hutton, my predecessor, firstly brought
together the Strategic Commissioning Group at a national level,
the results of which were the agreement that we published last
week alongside the announcement of the extra money as a guide
to the sort of practice that ought to be happening at a local
level to ensure that commissioning is better. Involved in that
as well, of course, will be much better planning into the future
of what sort of capacity of services we need so that care home
owners precisely like those who have written to both of us from
Hereford and Worcester have a bit more certainty into the future
about what sort of services are going to be commissioned and,
therefore, how they can contribute to ensuring that those services
are there for people.
Chairman
37. Can I offer a slightly dissenting voice
in this. There was an assumption in your answer that a contraction
in institutional care policies may be a bad thing but there are
certainly one or two of us here who think it may well be a good
thing. I would put to you the concern that one of the difficulties
we have in this whole area is that this area of service has for
far too long been provider led by the interests of care home providers.
This Committee has been on a plane for an hour and a half to Denmark
and we have seen a country that has no care, no old people's homes,
they have moved away from that. Is that not an objective that
we should set and not be ashamed of that, that we actually reduce
the number of places?
(Jacqui Smith) I am sorry if I gave the impression
that I necessarily thought it was a bad thing. I think there are
two challenges. I said that I think it is important that we change
the system because older people want precisely those sorts of
non-institutionalised methods of support but we do need to maintain
capacity at the same time, which is why, for example, alongside
a declining number of nursing and residential care places it is
encouraging that, for example, there are 30,000 more intensive
home care packages being offered to families since 1997. A symbol
of the shift of service that is happening that most of us would
accept is right, a shift out of institutionalised care and into
the sort of care that promotes more independence. Whilst we are
reconfiguring the system we do have concerns about ensuring that
we maintain that capacity, that change happens in a managed way,
that it happens in a way that brings together partners at a local
level to commission more effectively than I think they have done
in the past.
38. The next thing is to confirm that this really
is new money, so often money that is announced by ministers when
we really look into it is actually included in the allocation
that the health authority has already had. Is this genuinely new
money over and above the allocation that social service departments
have?
(Jacqui Smith) Yes. This is not money that local authorities
believe they were getting, it is not money that has been allocated
to social services, it is in addition to the investment that was
going to be made. The £700,000 in Worcestershire, for example,
will make a significant difference.
39. Have you calculated how mean extra beds
it would fund?
(Jacqui Smith) It would fund, for example, 7,000 extra
nursing home beds, however I do not think that is what it should
be funding, I think it should be funding partly some extra beds,
where those are necessary. I think in some areas it should be
contributing to higher fees for some of the services that are
available in order to make sure the supply is there in the future.
I think it should be contributing to a better intermediate care
provision. I think it should be contributing precisely to the
sort of intensive home care packages to the measures to promote
independence that are going to be important if we are going to
reconfigure the system. We have some strong targets about what
we want to achieve with the money but that is not about a given
number of beds, it is about how the system is able to change,
be managed more effectively so that it delivers the sort of care
for people in the right place and at the right time.
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