Examination of Witnesses (Questions 280
- 296)
Thursday 30 October 2003
DR JOHN
REID MP, SIR
NIGEL CRISP
AND MR
RICHARD DOUGLAS
Q280 Chairman: Can I just say that
I am concerned that there may be a division in the near future
and as this is a particularly important item on which we need
a maximum vote I am anxious to ensure that we allow members to
go and vote.
Dr Reid: I am willing to talk
through this vote, Chairman. There is no reason why we should
rush away.
Chairman: I do not think it is reasonable
to bring the Committee back after the vote, so what I propose
to do is bring in two colleagues who have not had the chance to
ask any questions.
Q281 Mr Amess: I have a quick question
on A&E waiting time targets. They have been in place for three
years. It is only recently that action has been taken to address
the issue of what to do about patients who have a genuine clinical
need to remain in A&E for more than four hours. This could
be taken to suggest that there was insufficient input from NHS
clinicians or managers in the development of the target. I wonder
how the department consult with the NHS on the appropriateness
of the targets.
Dr Reid: The fact that it is only
recently that we have sat down with clinicians and discussed what
might happen in those cases where people may clinically need to
stay more than four hours is not an indication that we in any
way either disregarded the clinical questions involved here or
were not willing to consult clinicians. It is simply this, Mr
Amess, that as long as we were beneath 90% of people as a target
being seen, diagnosed and treated on the NHS, in other words,
as long as we had a 10% leeway, we knew that there were not anywhere
near 10% who, on clinical grounds, would have to stay more than
four hours but, as we approached 95% performance on target and
then got to 100%, we effectively were going to be saying, "Even
if there is only 2% who need this you have not got the leeway
to do it". Do you follow me?
Q282 Mr Amess: Yes.
Dr Reid: I said that as soon as
we hit the 90 and it was consistent, because we hit the 90 at
the end of March, then we dipped down and have come back for several
months now to around the 90%, we were going to be trying to get
100% of patients seen, diagnosed and treated, either sent home
or in the ward, within four hours, at that stage, when we are
starting to say, "Now we are going for 100% target",
we have to say, "Yes, but if we go for that there might be
people who the clinicians feel ought not to be sent home within
four hours but kept longer than four, so now is the time to sit
down with them and discuss exactly what are the grounds on which
you might ask for a patient to stay more than four hours".
My estimate is that it will probably be a maximum of 2% of patients.
If somebody is hitting 98% they are doing as well. Does that answer
your question?
Q283 Mr Amess: It does. Very, very
quickly, I wonder what is being done to reduce the waiting times
from when a patient is admitted to A&E to being placed in
a bed in a ward? What I particularly was drawn by was your colleague,
Stephen Ladyman, gave me in a Commons' written answer something
which seemed to me to be pretty well hit and miss. For example,
in one quarter of 2003-04 only 24% of patients admitted were placed
in a ward within two hours, yet in one quarter of 2002-03, 57%
of patients admitted were placed in a ward within two hours. That
just seemed unsatisfactory really.
Dr Reid: I am not sure that you
are reading the right thing into the figures, if you follow me.
I will have to look at those figures and perhaps write to you.
What it may be indicating is in a particular area at a particular
time, or even nationally, that 24% were seen, diagnosed and judged
as being people who ought to be admitted to wards rather than
treated there or sent home after treatment and in another quarter
double that amount were admitted. It could be that but I would
really need to see the figures and write to you on them, if you
would permit me to do that.
Q284 Mr Amess: Just two more very
quickly because I would feel guilty if I did not put this to you.
The RNIB have been lobbying on the particular issue—Paul
is not here now but he was talking about the National Institute
for Clinical Excellence—of people who have wet age related
macular degeneration. 7,500 people are affected by this and the
National Institute for Clinical Excellence examination into the
case for photo dynamic therapy is the second longest inquiry that
there has been and at the end of it all rather than agreeing to
the three month period it has turned out to be a nine month period
and there are any number of reasons given for that case. Without
being dramatic it means that in that time probably 2,500 people
will go blind as a result. All I am asking you, Secretary of State,
because it involves complications with how the PCTs are administered,
and already Cheltenham and Gloucester, for instance, have decided
to stop paying for photo dynamic therapy following the extension
from three months to nine months, is I just wonder, if you have
got time, if you would look at it and perhaps write to me. The
final thing, and I put this to your predecessors before, is when
a relative has someone who is being treated by the National Health
Service and the outcome is not exactly what they would hope for,
the person dies, the Government has tried a number of approaches
to dealing with the dissatisfaction of the relatives and I suppose
at the end of the day someone has to say, "No, we have tried
everything, we cannot go any further", but I have got here,
for instance, one file where the lady is dead and it has been
going on for three years. Now, here I am, a Member of Parliament
trying to help constituents, and I told them I was going to tell
you this, Barking, Havering and Redbridge Trust, and what has
gone on with this is a complete and utter fiasco. To tell you
how insulting it is, the latest letter that I have got, which
is replying to one of 15 April, has the chairman as a particular
person, the chief executive as a particular person, but they have
both gone and they could not even be bothered to cross out who
they were. This is a case where the individual was given electric
shock treatment without permission, she had mental health problems,
it is a catalogue of disasters and still three months later I
cannot get this resolved. Again, I do not expect you to know about
it now but if I could write to you about this particular issue
just to give more confidence to people who are raising these concerns
who are not happy with the National Health Service.
Dr Reid: Certainly. Without prejudging
it, by all means write to me, Mr Amess.
Q285 Mr Amess: Thank you.
Dr Reid: I would say two things.
First of all, what we are trying to do in terms of treatment,
of operations, of access to GPs , all of these things that some
people regard as political targets are not, they are a means to
an end and the end is a better service for people inside the NHS.
If we are getting examples of this, without prejudging it, by
all means let me look at them. All I would say is let us always
remember that the people who work in the National Health Service
treat something like one million people every 36 hours. The bad
stories, and mistakes are made, irritate us and get in the press;
the good stories, the lives that are saved and distress that is
minimised and pain that is relieved, very rarely get in the public
domain. Sometimes, when looking at these things, we would do well
to remind people of the good that is done.
Siobhain McDonagh: Secretary of State,
I would like to ask some questions about how—
Q286 Chairman: We will not keep you
much longer.
Dr Reid: That is all right. Never
underestimate the endurance of a quiet man!
Q287 Siobhain McDonagh: Have you
been working out how to fit that phrase in all afternoon? I want
to look at improved outcomes in the NHS Plan. How do you plan
to demonstrate the "improved quality and outcomes in priority
areas" promised in Delivering the NHS Plan?
Dr Reid: At the end of the day
there is only one way to do that and that is, firstly, to deliver
a better service, and that is by reducing the number of deaths
in cancer, in coronary heart disease, in reducing the time that
people have to wait in accident and emergency, the time they have
to wait for an operation, in speeding up the access that people
have to doctors and so on. In my view, although it is not something
that would statistically throw itself out as an evaluated process
of value for money, it is what makes the difference to the public.
They are not going to believe a politician, even those as eminent
as on this Select Committee, but they are going to believe the
experience of their own eyes. The interesting thing about all
the opinion polls now is they show when you ask people who have
recently been in the National Health Service, or had experience
of it, what they think of the National Health Service, their response
is 10 to 15% more positive than if you ask people who have not
recently had any experience of it and who are getting their views
through the press. There are improvements under way and I think
that delivering on the ground is the most important thing. There
are two other things, and both will be of interest to this Committee.
The first thing is the much maligned targets, because they do
not only give us an objective to drive towards but, when we say
we want to have nobody waiting now more than 12 months for an
operation and we reduce that from the 30,000-odd that were waiting
when we came in to 30 last month, it gives a standard to measure
us by. You can either say "that has been a great success",
which I would hope you would, or you might say, if you were penny-pinching,
"there are still 30 there, so it has been a failure".
At least outcomes can be judged according to the targets that
we put out. The third thing that we are doing now is developing
the programme budgeting which means that I am overseeing a new
system which tries to more clearly identify the amount of money
that goes into a given treatment in a given area, whether it is
cancer or any other area as a whole, not just in the much concentrated
upon hospital sector but also primary care, public health, coronary
care and so on, so that we identify what goes in and then we can
measure it, others can measure it for us, as they will, against
the amount of money we put in. So you can judge investment versus
outcome. Those three things are how we will be judged. I am content
to be judged on that. I could give you a litany of the good sides
and many of them, no doubt, have been paraded before you by others,
but they are getting better in so many other areas. The other
day when we got the headlines about the cancer drug, to which
people were asking for access, it actually camouflaged the story
on the same day which was the appraisal this year of cancer deaths.
There has been a 10.3% reduction in cancer deaths in this country
in the past two or three years. We are half way towards the target
of a 20% reduction. There has been a 19% reduction in coronary
heart disease deaths. It is quite incredible. We have gone from
something like third bottom of the international league on these
things to fifth top. We have got 55,000 more nurses, we have got
5,500 more doctors, roughly, more consultants, and yet in each
area I am the first to admit that I still want another 25,000
nurses. We may or may not just hit the 100% target for consultants
of 7,500. We probably will hit the GP targets. At least they are
out there now, people know what it is they can judge us by according
to experience and according to what we publicly said we wanted
to do. You, on behalf of Parliament and on behalf of the country,
can hold me to account for those outcomes. That is a more uncomfortable
way of doing things, Chairman, but at the end of the day I think
it will be a more viable way because people are entitled, not
only according to their experience but according to transparency,
to say "You have done well. You have done perfectly"
or "You have not done so well".
Q288 Siobhain McDonagh: Thank you.
In June the Audit Commission recommended that you should provide
guidelines on how trusts should demonstrate and record that new
money has been spent to boost the services it was intended for.
Dr Reid: Yes.
Q289 Siobhain McDonagh: Have you
any plans for this?
Dr Reid: Basically that is what
we are working on by what I call the programme budgeting. Some
people think this is merely an internal matter of management flows
and so on, but actually it is quite important. We are doing two
things with financial transactions inside the National Health
Service. The first is we are trying to get an holistic picture
of the investment we make in a particular area so that judgments
can be made contrasting the outcomes with the inputs and then
you can either criticise us or praise us or say "this seems
reasonable" or whatever. That is quite controversial and
certainly novel. The second thing we are doing is the money inside
the service is following the patient preference. This is a controversial
and radical area. I would want to insist that that is entirely
different from what the previous government did where there were
cash transactions involved with the patient, as it were, but what
it does for the first time in the National Health Service is it
takes that element of the market transaction, because when you
buy something there is a cash transaction but there is also a
choice you make between that provider, this provider and the other
provider, so you exhibit preference, it is an attempt to take
that further and give it to the patient while retaining the founding
principles of the National Health Service that there will be no
need for you to find cash. Both of those things are transparent,
both of them are radical and both of them, I think, assist towards
particularly the programme budgeting towards what the Audit Commission
is looking for.
Q290 Chairman: I am conscious that
we have had you here for two and a half hours and there is likely
to be a division, as I mentioned, if colleagues can try and keep
their questions brief.
Dr Reid: And I will try and keep
my answers short.
Q291 Dr Taylor: We were rather worried
a fortnight ago when we asked your officials about hospital doctor
vacancies when they implied that the figures that were collected
were, for various reasons, pretty underestimated. Does that affect
your targets for consultants and does it give you extra worry
about the European Working Time Directive?
Dr Reid: Can I deal with the two
questions separately and as briefly as I can. On targets, on doctors,
GPs, I cannot swear to you absolutely, we are here as politicians
saying "yes, we are going to get them", but I can give
you my judgment and that is I think we will get the GPs target.
On nurses I think we will get it, indeed we have already got it.
On consultants, my degree of certainty about hitting the target
goes up according to where I tell you we will hit. I am pretty
certainly we will get 80-85% of our target. I am less certain,
although I think we have a good chance, of getting 100% of our
target. On consultants we said we want 7,500 new consultants and
we have got over 5,000 already. We could well get the 7,500 or,
on the other hand, we could strike somewhere between 6,500/7,000.
I suppose what I am saying to you is on nurses and doctors and
consultants I am pretty certain we will hit our targets or if
we miss them it will not be that far off and, in any case, they
will be hugely in advance of where we were because, quite frankly,
if we are looking for 5,000 doctors and we get 4,800 we are a
bit better off than we were in the first instance but you would
be entitled to say "but you did not quite hit it, did you?"
It is like the reduction of 20,000-odd or 30,000 people waiting
more than a year to 30 now.
Q292 Dr Taylor: The European Working
Time Directive is going to hit very soon before we can realistically
expect to have the extra doctors around.
Dr Reid: It was not expected.
It arises not of the intention of the regulation itself but of
a legal interpretation. We thought that the first judgment might
be qualified by a second one, the Jaeger judgment in Germany,
but unfortunately no such luck. I can tell you we are working
furiously paddling beneath the water to try to make sure by 1
August next year we will be able to cope with some difficulty,
no question about it, without any closures or whatever of accident
and emergency, while at the same time we are trying to speak to
some of our European colleagues who will be equally badly hit.
The number of doctors that will be required in Germany and France
I think is just dawning on them and it is actually greater in
many cases than for us. We are trying to see if we can get—It
is not the Working Time Directive that is the problem, we can
handle the Working Time Directive, it is the legal decision which
has said the time you spend sleeping on call will be regarded
as working time, that is what causes the problem. We think we
can cope with it but not without great difficulty. Yes, it does
throw an additional burden on us in terms of the need for doctors
but it would be much better, to be quite honest with you, if the
original intent of the regulations, which I am sure did not include
interpreting sleeping time as working time if you were not disturbed,
was reinforced.
Q293 John Austin: Finally, good access
to secondary care and hospital treatment depends upon good access
to primary care and in a primary care led NHS we are looking to
see more care and treatment delivered in a primary setting, yet
the figures show that hospital spending rose 9.7% and spending
on inpatient admissions by 9.3% while spending on GMS primary
care services only rose by 1.1%. How can you account for a nine
times growth in secondary care compared with primary care? What
is going to be done to redress this?
Dr Reid: It has been such a convivial
two and a half, three hours, exchanging of views that this is
the first time I have to say we do not recognise the figures that
are being used here. We have tried every way to find out what
this 9% and the 1% is. Let me tell you the figures.
Q294 John Austin: It is table 3.1.3
of your response.
Dr Reid: We think perhaps it is
2.1.2 that is being referred to and the figures have been wrongly
interpreted. I have spent some time trying to figure out what
it was and I merely throw this in to let you know that in deference
to the Committee we do prepare for this.
Q295 Chairman: The division, you
are saved by the bell.
Dr Reid: We do not recognise the
figures.
Q296 John Austin: Let me say how
comforting it is that when you do not know the answer to the question
you say you do not whereas previous Secretaries of State gave
lengthy answers.
Dr Reid: Or read out what was
in front of them. I think this is a terrible accolade towards
my honesty, I have never been accused of this before, Chairman.
I will finish off very quickly by saying what we think the figure
is, that the increase in primary care spend for 2001-02, the years
we are talking about, was 7.3 in cash terms, or 4.7 in real terms,
and that compares with 7.7 in cash terms or 5.1 in real terms
of hospital spend. In other words, there was a differential towards
hospitals but not nearly as big as the question implies. We can
write to you on that if you like.
Chairman: Perhaps you can clarify that.
Secretary of State, gentlemen, we are grateful to you for an excellent
session and we look forward to seeing you in the future. Thank
you.
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