Examination of witnesses (Questions 20-39)
MS HAZEL
BLEARS, PROFESSOR
MIKE RICHARDS
AND DR
RUSSELL HAMILTON
MONDAY 15 JULY 2002
Dr Turner
20. Minister, in planning for financial year
2001-02 how were health authorities expected to define how much
of their allocation was new cancer money when they were given
no money information about it whatsoever as far as I can tell?
(Ms Blears) They were given guidance, in fact, about
their priorities for their planning. Mike will just talk about
that.
(Professor Richards) In addition to the detailed list
of planning there, the priorities and planning framework or priorities
and planning guidance, which goes out roughly speaking at Christmas
time in the year before—
21. This is it.
(Professor Richards) The short document there for
that year, to the best of my memory, actually made it clear that
£255 million was hypothecated and the word hypothecated was
specifically used that year whereas the word earmarked has been
used for the current financial year. The word earmarked, as we
have discussed in this Committee before, I think, is a stronger
word than the word hypothecated.
Chairman
22. Ring fencing beats it all, does it not.
(Ms Blears) Indeed.
Dr Turner
23. It was not only earmarked for 2002-03—we
are still only talking about £76 million out—but each
health authority was given a figure as to what their share of
the £76 million was. No health authority could possibly have
accurately worked out what its share of the £255 million
in the previous year was which is then running through and building
up.
(Professor Richards) They could not perhaps have had
the same level of detail, except to say that £255 million
spread between a population of £50 million, they could have
done a rough estimate and they could have been able to divide
one by the other and get it being £5 million per million
residents. What we saw then was that they had to complete their
service and financial frameworks and, broadly speaking, the service
and financial frameworks did suggest that money was going to get
through to cancer. We think in the end it has not which is why
we are now trying to find out retrospectively what actually reached
the cancer frontline but the service and financial frameworks
at the beginning of the year did give us confidence that the money
would get through.
24. Do you see our problem, Professor Richards
and Minister, because although the exposition book mentions things
which are not exactly headline as far as the public is concerned,
cost of living supplements hardly even match the profile of the
cancer plan and yet the cancer plan does not get a mention. It
seems very strange and it seems quite logical then that it was
not mentioned, whereas it was for this current financial year
and this financial year the money is getting through but it is
only a part of the money. So, on the face of it, unless I can
find evidence to the contrary because I know it is certainly not
true in my area, the £255 million has not got through, it
has not led to an increase in front line services. So the cancer
plan is going to end up being only about 50 per cent funded.
(Ms Blears) I think it is important to say to the
Committee that obviously we share the concerns about money getting
through to the front line and that is why we have set up a monitoring
mechanism for us to be able to drill down in each cancer network
and for them to report to us on what they actually got for their
money. I think I would want to couch that in terms of saying that
what we want the service to do is to deliver the cancer plan and
that means the targets, the increased operations, the increased
consultants, the extra workforce, the extra facilities. Therefore
if they are able to deliver the outcomes that we have set—very
important outcomes for patients and the public—then there
is always going to be a tension if we devolve money down to people
about delivering on that agenda. At the moment we are satisfied
that broadly speaking we are on track with the outcomes we have
set in the cancer plan. Therefore I would share your concerns
if we feel we are slipping behind with achieving the things the
public want us to do. I think we have to just bear in mind this
is not a process of an exact follow through of every single penny
through the system and seeing what it does because some of that
may be absorbed in infrastructure and properly so. I think we
have to be a bit flexible with it but I do understand your concerns.
Geraldine Smith
25. Surely you cannot have it both ways. If
there is £407 million almost for cancer for 2002-03 and you
have only earmarked £76 million then basically the health
authorities can surely spend the money on whatever they want.
What happens to the £331 million? Why do you not issue an
instruction to them that it has all got to be spent on cancer
if that is what you are promising to spend as part of the plan?
(Ms Blears) I understand the point you are making
but I think it does bring me back to what I have just said and
that is that if we insist on ring fencing every bit of our expenditure,
whether it is on cancer or anything else then we will have a very
centrally driven and centrally controlled system which says to
health organisations that all the money is in silos for expenditure
and if you spend anything outwith that then it is somehow against
the system. I think we have to balance that with wanting to devolve
the power to the health service to deliver on the outcomes. You
said what would happen to a health authority which did not do
it? If a PCT and a health community are not delivering on the
outcomes that we have set in the cancer plan that is their responsibility,
to deliver the increased services, the better palliative care
and all the facilities that we have set out in the plan and that
is what they have to deliver.
26. So are you saying that the £407 million
has not been promised for cancer care, that it can be spent in
other areas as long as they have suitable outcomes at the end
of the day? Is the £407 million for cancer or is it not?
(Ms Blears) Yes, it is. It is extra money to support
the outcomes in the cancer plan which is what we have said all
along.
27. Do the health authorities have to spend
that money on cancer?
(Ms Blears) Yes they do in their planning guidance
and in the priorities that they set but what we have done—because
we recognised there were concerns about the dilution of the funds
in the first year—we have said now that £76 million
of that will be earmarked which is quite a strong mechanism for
saying that we want to see this directed specifically to cancer
care. We have got, also, £76 million which is centrally allocated
which is an even stronger mechanism from the centre. So you have
£76 million centrally allocated on the networks, you have
got £76 million earmarked which has to be spent specifically
on the front line things which clinicians and nurses have identified
and then you have the base line budgets for the organisations
which includes the extra money for cancer care from last year,
this year and next year. So there are a range of levers here.
It is not simply that we would want to ring fence every bit of
cancer money because I do not believe that would deliver the best
outcomes for the patient. It is a matter of getting that balance
right, I think.
Dr Turner
28. Minister, we seem to be a long way from
a balance because so far over two years about £500 million
has gone in which has not come through in terms of extra oncologists
or facilities or whatever, to the best of my knowledge. This is
rather a large slice of money which would show, certainly my local
clinicians would be able to tell me and they cannot, which is
why they have raised the alarm. It is no fault of the health authority
because, to be fair to them—and I have criticised them often
enough in the past—they have passed on more than their allocation
of the £76 million.
(Professor Richards) I think we are all reasonably
confident that the additional £127 million this year is going
to go through.
29. That is not a problem.
(Professor Richards) The question is about the £255
million that was hypothecated last year.
30. From last year and this year.
(Professor Richards) Did that get through? We know,
also, that from last year the central funding got through, there
is no doubt about that. That is precisely why we are going back
to the individual networks and doing this bottom up exercise of
saying what did you actually get in terms of services so that
we can actually then put money against services to see what we
got for that money. Over the country as a whole we have got more
consultants and each six months we are monitoring that and the
number of consultants is going up in the areas that we have labelled
as cancer consultants. Equally, the number of radiographers is
not going up as fast as we would want it to go up but that is
because of recruitment problems but it is going up.
31. I am pretty certain even if there is some
getting through, in some places you will identify a huge gap.
What do you intend to do about that when you find it?
(Professor Richards) The first step is to find it,
identify it, see what it is, see how varied it is across the country
because as the Minister has said in some parts of the country
probably almost the full amount has got through and in other parts
it may well not have done. When we have got a clear picture then
we are in the position to make decisions which are sensible about
how to rectify the position.
32. So if you find you cannot account for £350
million of it, will you put in an extra £350 million earmarked
or ring fenced or whatever to make sure that the gaps are addressed
otherwise the plan falls down, does it not?
(Professor Richards) It cannot be that much anyway
because it is the £255 million that, as you say, we have
got to look into and some of that money has got through anyway.
I think we need to see exactly what the size of it is and what
the distribution of it is across the country in order to make
recommendations to Ministers on what we should do next.
Chairman
33. Do you think there are any lessons to be
learned? The mental health money is the next sum which is going
to be sent out. They will come back and say "We are not seeing
it either". What are the lessons to be learned?
(Ms Blears) I think there are lessons to be learned
and I think it is quite a complex situation because once you embark
upon shifting the balance of power, and actually saying to people
at the frontline "We want you to use your imagination and
innovation to come up with new ways of doing things".
34. Sounds like creative accountancy by another
word.
(Ms Blears) I would prefer to see it as creation and
innovation in the Health Service which is a very precious commodity
because if people are given the freedom to work in new ways and
to develop their skills and potential then quite often it results
in advances for patients and that is what is important. Therefore
giving people the room to innovate inevitably carries with it
the risk from the centre that you cannot dictate and dot every
"i" and cross every "t" and that is a tension
for Government. I think it is one that we should be continually
exploring and I am happy to do that with the help of this Committee
because I think as this whole programme unrolls where we get PCTs
spending 75 per cent of our whole Health Service budget there
are going to be tensions between the national standards that we
set and the local devolution. Those tensions are not all a bad
thing, some of them will actually create that innovation but equally
Members are absolutely right to call us back to the fact that
we have said extra money will go in to deliver this cancer plan
and therefore we have to track that as carefully as we can to
make sure we are delivering the improvements for patients.
Dr Turner
35. Can I just be sure, Minister, in the last
financial year, the £255 million was put into the general
allocations. Health authorities were not specifically told "You
have X million pounds which is your share of the £255 million
for the cancer plan"? Were they or were they not given that
information?
(Professor Richards) You are right, that is the difference
between the interpretation of the word hypothecation and the interpretation
of the word earmarking. That is why with earmarking you see laid
out for you exact figures being given to individual PCTs as to
what they should be spending. With hypothecated it was the overall
amount of money which was known and it was not given to them in
that level of detail.
Chairman
36. Why do you not just say "We are going
to give you £300 million more. Get on and do with it what
you like. You know best"?
(Ms Blears) Because there will be a need, increasingly
I think, to strike the balance and that is what this whole process
is about, striking the correct balance between, if you like, central
guidance and having a very rigid system which does not allow any
space for innovation and creativity at the frontline and actually
letting go completely and saying "Here is the money, as long
as you deliver this many operations . . . it is entirely a matter
for you". I think the balance lies somewhere between in terms
of setting the national standards which we are doing not just
in cancer but across the piece in the Health Service through the
NFs—for cancer, coronary heart disease, mental health, older
people and children—and saying the public have a right to
expect this standard of service but within that to say to local
organisations "You might be able to work with other people
to deliver some of that. It is not all down to you but here are
some resources to enable you to deliver on it". I think that
over the next few years there will continue to be a tension and,
dare I say it, not just in health but right across the public
service agenda about how you have national standards, local devolution,
skill mix and choice and all of those factors, will be a complex
equation for us. I do not think it is true any longer that A equals
B, I think it is a much more complex situation than that.
Dr Turner
37. Minister, earmarking does precisely that,
it is telling the health authority how much money it is getting.
It is not saying "You will spend it on this", in fact
the Departments words in here are: "you may wish to spend
more". So the flexibility is still there, the local decision
making element is still there and have you adopted the earmarking
process, which you are going through now, which seems to work
quite well because of the question marks over what happened to
the money in the first year?
(Ms Blears) Yes.
(Professor Richards) I think it is true to say that
possibly we have learned from our experience in the first year.
Chairman
38. This is confession time.
(Professor Richards) I am not sure I see that as a
confession.
Mr McWalter
39. I will ask first about my own general area
but I think it is of wider significance, it concerns the Mount
Vernon Cancer Network. A recent report suggested something like
£110 million needed to be spent just on building a new facility.
These figures look big until you start thinking about that. Then
what is your policy? First of all, is some of this money going
to say "Yes, one of these things we are going to do is we
are going to build a cancer centre"? The second thing is
until that is built in a way you cannot use some of this other
money very effectively, you have not got the theatres or the oncologists
or whatever, so does that mean within a cancer centre like that
you will lose out because it will not be able to take advantage
of some of this revenue funding because it has not got the right
infrastructure in place? Can they hold it back until future times
when they can cash it in? How does that system work? I am taking
up the reference to infrastructure that the Minister made which
I agree with very much but I cannot quite see how that gets factored
in then in the appropriate way.
(Professor Richards) The monies that have been allocated
for cancer do include a measure of capital spend related to specific
cancer facilities—CT scanners, MRI scanners and the new
accelerators—but they do not include money for major capital
developments such as the redevelopment of a whole cancer centre.
There are those that are going on anyway within the Health Service
and they are not included in these figures.
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