Examination of Witnesses (Questions 160-170)
MR JOHN
BACON, MR
RICHARD DOUGLAS,
MR GILES
DENHAM AND
MR ANDREW
FOSTER
16 OCTOBER 2003
Q160 Jim Dowd: I know from my own
Trust, in Lewisham, the one thing that threatened their potential
three stars was their performance on the four-hour timing. They
managed to keep it but it acted as a very positive incentive.
Mr Bacon: We really do think,
that target in particular, the emphasis on it through both star
ratings and the managerial process has meant that now we are delivering
a very significantly better service to patients and providing
our staff with a very significantly better environment, so we
make no apology for that target whatsoever.
Q161 Jim Dowd: Are there any other
areas where you are going to revise targets where they clash with
clinical advice?
Mr Bacon: What we have now is
an NHS planning round which is a three-year round. We are committed
to maintaining the progress towards the targets over this year
and next without changing them. However, then we are going to
think about what our approach should be into the next round, and
I think we are engaging very much more heavily with our clinical
colleagues in defining how those should progress. Indeed, the
professions are helping us to develop those. I am having currently
some very helpful dialogue with the Association of Day Surgery,
for instance, in looking at what international best practice is
on day surgery rates. Then the assumption will be that the Association
suggests to their colleagues what the best practice should be,
rather than us set a specific target. So we think this is a maturing
of the approach, but, again, we think the product of our admittedly
centrally-driven set of targets over the last three years has
been a very significant improvement in the areas with which the
patients were most dissatisfied. So I think the approach was absolutely
right for its time, I think it has delivered very significant
benefits very quickly. I think, once we have achieved those initial
targets then we can get into a different approach, with very much
more emphasis on patient experience, through clinical input. We
are not going to apologise, in any sense, for a heavily-driven
approach to those very important targets, at which we have been
successful.
Q162 Chairman: Can I come to Mr Denham's
area, last but by no means least, Mr Denham, that is social services,
we have touched briefly on social care but not in any detail.
I want to ask just one or two questions. One of the things that
is very apparent from the Annual Report is the extent to which
performance in personal social services does vary significantly,
and you give some very marked examples of differences in performance
between authorities. Looking at the latest star ratings, we see
an increase in three- and two-star councils, but also an increase
in those receiving no stars, so it would appear that the gap is
increasing. What do you feel are the reasons for this? When one
looks at the Health Service, perhaps the Acute Trusts and PCTs,
there seems to be far more effort made to address these differences.
Why is it that we are not appearing to make as much progress perhaps
within social services?
Mr Denham: I think it is quite
difficult to compare two sets of rating systems, because the social
services one takes in quite a lot of qualitative judgments by
the Inspectorate. It is difficult to say why individual councils
move their position, though I think we have been pretty active,
working with the Social Services Inspectorate as a department
and the councils themselves, where performance has slipped and
the judgment of the Social Services Inspectorate is that there
is not potential for improvement. Which is, of course, a factor
of their rating system, they do look at whether people are on
the way up already, or whether they are struggling with their
capacity to improve. In the four or five cases where councils
really have been felt not to have within themselves the capacity
to lift themselves out of the zero star range, we have commissioned,
with the councils' agreement, Performance Action Teams to work
with them to improve their performance, to produce plans to do
so, and, through SSI, the Inspectorate to be closely involved
in helping check how that improvement is going. So I think we
have been as active as we can, given the rather different management
relationship we have with local government, to tackle those authorities
where there have been problems which the Inspectorate judge are
not going to be capable of sorting themselves out with the local
management capacity.
Q163 Chairman: There have been some
quite profound changes within your Department, in relation to
the structure of personal social services management by the Department.
Will this have any bearing on the kinds of performance issues
that you pick up in the Annual Report, and your ability perhaps
to improve performance where clearly it is failing, in some parts
of the country?
Mr Denham: I do not think it should
impact adversely. One key point which was made in the Secretary
of State's speech to the social services conference yesterday
was, as I guess you know, the announcement of a National Directive
of Social Care within the Department. John, you were probably
going to say more about it.
Mr Bacon: Absolutely. I think
there are two things here. Of course, we are moving the inspection
itself into a new Commission, in the same way as we are for health
services, so the biggest single structural change in the Department
will be that the current SSI will move out, into the new Commission.
There is no reason at all why that should result in any diminution
of inspection, and indeed just the opposite.
Q164 Chairman: I was looking for
improving inspection?
Mr Bacon: That is why we are doing
it, so that would be a positive. What we are trying to do in the
Department now is ensure that we consider social care issues as
part of an holistic approach to care, so that the social care
czar, as we call it, the National Director, will take his, or
her, place with the other national directors and will be able
to work across the spectrum. Then we are embedding into both the
new Quality and Standards Directorate and in my own Delivery Directorate
social care expertise alongside the Health Service approach. This
approach now is to move away from the possibility of ghettoising
social care within the Department to one where it is fully integrated
and therefore works to develop a much more integrated service
at local level. On both counts we think the approach will improve
our approach to social care and should drive up standards.
Q165 Chairman: With the move of child
protection arrangements more towards DfES, what impact has that
had on the staff working centrally within your Department, particularly
where they may have been involved in the relationship between
health and child protection?
Mr Denham: Obviously, we have
retained within the Department of Health responsibility for children's
health services and the child protection aspects of that. At the
moment we are working through, with the Department for Education
and Skills, a series of agreements about how we are going to work
together. We have a temporary arrangement where, in fact, the
senior manager responsible for children's health and social care
has retained that responsibility, for the time being, so he is
reporting to me in the Health Department and to the Interim Director
General for Children and Families in the Department for Education.
We are aware of the need for the two departments to maintain that
very strong link, particularly around areas like child protection.
There will be others, I guess, disabled children, and, of course,
we are working still very much together on the development of
Childrens Trusts.
Q166 Chairman: Which would be the
lead department on Childrens Trusts, presumably it would be DfES?
Mr Denham: Because it involves
actually local government and health, it is at the moment a joint
unit and it is a joint initiative, with the two ministers responsible
being Mrs Hodge and Dr Ladyman.
Q167 Dr Taylor: Expenditure on prescribing.
We did ask for a breakdown between the generic and the proprietary
brands, and you gave us a very useful table, which shows that
in 1992-93 approximately 12% were generic, and by 2002 it had
gone up to 28%. Is that the maximum we can expect, because, obviously,
with some of the very expensive proprietary drugs, in their first
ten years, we cannot get away from those? Is 28% generic about
what we can expect, or are there still doctors prescribing proprietaries
when they should not be? Is that possible to answer?
Mr Bacon: I am sure the answer
to your question is, yes, there are doctors prescribing those.
Q168 Dr Taylor: How do we get at
them?
Mr Bacon: We have focused at local
level on prescribing advisers, who work closely with general practice
to ensure that they practise in the best possible way. There are
local committees which look at the prescribing practice, and,
again, through encouragement and advice on best practice, would
seek to raise that number. It is very difficult to say we will
ever eliminate the practice of prescribing in that way.
Q169 Dr Taylor: Are you able to name
and shame particular Trusts or areas where they do not do well?
Mr Bacon: Through our management
practices, we know which areas do well or not. I do not have that
information with me today, I am afraid, and we would be suggesting
to health authorities, and through them to our Primary Care Trusts,
if their prescribing practice looked out of line on the generic
versus branded products.
Dr Taylor: It is encouraging that it
is going up. Thank you very much.
Q170 Chairman: Gentlemen, can I thank
you for your attendance, once again. We are most grateful to you.
You have promised to come back to us with one or two points of
clarification. Mr Denham, I would be grateful, if it is possible
for a note on the new structure, as it relates to the PSS side
of our responsibilities, in advance of the Secretary of State
coming. Obviously, I was aware there had been announcements yesterday,
but if there is a chance of a brief note on that we would be very,
very grateful?
Mr Denham: Absolutely.
Mr Bacon: We shall do that. May
we thank you, as well, for the session.
Chairman: Many thanks, gentlemen.
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