Examination of Witnesses (Questions 1-19)
4 MARCH 2004
LORD WARNER,
MR MILES
AYLING, MRS
ANNE RAINSBERRY
AND DR
CHARLES DOBSON
Q1 Chairman: May I welcome you to
this meeting of the Committee. May I particularly welcome you,
Minister, on your first visit to our Committee. We wish you well
in your relatively new role and we are most grateful to you for
your cooperation. Could I ask you to briefly introduce yourself
and your colleagues to the Committee.
Lord Warner: I am Norman Warner,
I am the Health Minister who covers all health matters in the
Lords and I have a portfolio which is around performance management,
pharmaceuticals, regulation and pricing, and a number of issues
like NICE, cleaning, food and issues of that kind around support
services within hospitals. On my far left is Anne Rainsberry,
who deals with issues around the Department of Health Change Management
Programme and other issues. Dr Charles Dobson is in the pharmaceutical
area and Mr Miles Ayling I suppose we might even describe as one
of our bureaucracy busters if one wanted to put it in common parlance.
Q2 Chairman: Thank you very much.
We would like to begin by looking at the whole issue of quality
management and assurance, the role of CHAI, the new organisation,
and, in particular, the issue of star ratings in the current system.
One of the concerns the Committee have is quite what the Government's
view is on the future of star ratings. We appreciate we have detail
of the proposed changes but we noted that the Secretary of State
said on 9 February that "star ratings will continue"
despite some reports in the media to the contrary. Sir Ian Kennedy
said on 27 January that ratings were more likely to consider "relative
performance" than take a "one, two, three, fail/succeed"
approach, and then on 29 January he told the PAC in this House
that he would like to say to government, "Let's move away
from stars". We wonder where we are at on this issue, because
there appears to be some difference between what Sir Ian is saying
and what government ministers have been saying.
Lord Warner: We have to go back,
I think, to the new legislation, the Health and Social Care Act
last year, where, within that, it does require CHAI to conduct
a review of the provision of health care by and for each NHS body
and to award what are there described as performance ratings.
I think we should not necessarily get hooked on this term star
ratings; I think the important term to hang on to is performance
ratings, which is the phrasing that is actually used in the legislation.
That is the legislative framework. The context in which those
performance ratings will be done will again be a new one, framed
by the legislation, which enables the Secretary of State to issue
standards across the NHS. The standards are, if you like, the
overarching architecture which try—and we no doubt will
get on to this in a little more detail—to set a framework
for quality assurance in the NHS. They have been framed in a broad
way rather than in a detailed way and it will be the job of CHAI,
as the new independent inspectorate, to construct what are in
the terms of the legislation called criteria and some method of
measuring those criteria in terms of conformity with the standards.
That will lead into a performance ratings system. That is the
sort of new architecture which that legislation provides for.
The responsibility for the standards is the Secretary of State;
the responsibility for devising the criteria and, indeed, some
of the indicators, if you like, which would measure those criteria
will be a matter for CHAI, although the Government still reserves
the right in certain key areas to have some targets. But the basic
architecture on quality assurance is as I have described.
Q3 Chairman: I know my colleagues
will want to raise the issue of the evaluation of Department of
Health measures within the quality assurance system. You have
a not dissimilar background from my own and are aware that other
key services can play a very important part in the performance
of the individual NHS trust. I think there is much evidence to
suggest that the Government do not make as much as they perhaps
might of the fact that we have seen some very significant improvements
in quality of health care over recent years because of the measures
that have been taken, but, in evaluating quality and performance,
one of my worries has been that we have taken much too narrow
a view of the performance of individual trusts without taking
account of the factors outside the immediate responsibility of
that trust that have a bearing on their experience locally. I
appreciate that the new organisation is looking more at that issue
but what kind of reassurance can you give us that when evaluating
the performance of, say, an acute trust, the kind of health environment
in which it is working is taken into account? With a background
of chronic disease in an area, say, like mine, where we have high
levels of chronic disease, and, say, an area like Simon's, in
Essex, what assurances do we have that those factors will be taken
into account, and, in particular, the performance of primary care
and, for example, local authority social services, which do, as
you know, have a bearing on evaluating the work of the acute trust?
Lord Warner: Where I would, so
to speak, direct your Committee's attention is to the seventh
Domain, if I may put it that way—which is its title—in
the new draft standards. That domain is about public health, but
I will just read you one very short bit of it, just, I hope, to
reassure you. It says, "Health care organisations should
promote, protect and improve the health of the community served
and narrow health inequalities by . . ."—amongst other
things, there are three of them—"cooperating with each
other and with local authorities and other organisations."
I will not read the whole lot out, but if I direct you to them—
Q4 Chairman: We have copies of that
document.
Lord Warner: That I think illustrates
that in framing these standards we were well seized of the need
to have a new architecture for standards which really deals with
the issues about which you are concerned—and rightly concerned—and
it will now be for CHAI (reference to my earlier answer) to construct
some criteria for measuring whether or not that is actually happening
and what the performance is. So it is moving acute trust, if you
like, in your own terms, away from a narrow view of their role
into a wider and more cooperative relationship across the NHS
and social care boundaries.
Q5 Chairman: If, in looking at the
seventh Domain—and I think we all appreciate the fact that
this just take us into a different area—CHAI were to say
to the Government that the actual structures that are currently
involved in providing a service do not encourage an integrated
provision, and came up with some argument along the lines, as
this Committee has come up with in two separate parliaments, that
there ought to be an integrated health and social care system,
would you be willing to look seriously at that? Certainly I have
talked to people evaluating services in different parts of the
country who have been quite critical of the way in which, despite
all the Health Act's flexibilities and all the encouragement to
work together, we are still narrowly focused down an individual
route of our own agencies and do not think in a holistic sense
along the lines that that Domain would imply we should.
Lord Warner: I cannot but agree
with you over some of these concerns. Having spent much of my
working life in local authorities, actually making stirring speeches
on some of these subjects many years ago, I can well understand
where you are coming from. This new structure of standards suggests
we are trying to address that issue. The first thing for CHAI
to do is to produce criteria and indicators for measuring performance
in this area and seeing how well the system is actually working.
That will give us all, I think, a better picture in this area
about where the problems are, where the gaps in performance are,
where the successes are—because there will be some successes—and,
despite what are perceived as organisational barriers, there are
parts of the country where very good working relationships work
and people get effectively almost a seamless service between health
and social care. So it would be wrong to give that appearance.
Of course, the Government is not going to set up CHAI as an independent
watchdog and then not listen to what they have to say; on the
other hand, I do not want the message, so to speak, to go out
from this room that we are contemplating yet another reorganisation
of the NHS. I am not sure that would be well received anywhere
in the country if that rumour got around. We do not have a secret
plan to conduct a further organisation, but of course we would
look at the evidence and we would listen to what CHAI had to say.
Q6 Mr Burns: Minister, one of the
ways this Government has monitored performance of the NHS has
been through targets, as has already been discussed, and the Government
has then published figures at regular intervals, like inpatient
waiting lists, outpatient waiting lists, information on hip joint
replacements, et cetera, to show what is going on in the NHS.
I am sure you would agree with me that is one way of monitoring
the performance of the NHS. Would I be correct?
Lord Warner: You would.
Q7 Mr Burns: Thank you. Obviously,
in a number of specialities it is not simply the numerical figures
that are published but it is also broken down usually within the
NHS by age groups, so that one can see, for example, emergency
readmission figures published for the over-75s which is quite
relevant to show what is happening in that sector of health care.
Would you agree with that?
Lord Warner: Yes.
Q8 Mr Burns: Then can you explain
to me, does the Government publish now figures on emergency readmissions
for over-75s?
Lord Warner: I cannot recall the
exact position on that, but I can certainly make some inquiries
as to where we are on that. I can see you have led me along a
path where you would wish me to say—
Q9 Mr Burns: Well, I have not finished
yet.
Lord Warner: No, no. Well, carry
on leading me along the path, but I am not sure where this line
of questioning is going.
Q10 Mr Burns: Let me help with where
it is going. It is just that my brief tells me that you are the
Minister in the Department of Health who has a portfolio which
covers the following issues . . . one being CHI and the NHS performance
ratings.
Lord Warner: Yes.
Q11 Mr Burns: Performance ratings
and the performance of the NHS are under this Government monitored
in a variety of forms but one of them is through targets and through
the publication of statistics of what is happening. One of the
figures which was particularly useful was the over-75-year-olds'
readmission list. I will help you with that because one of your
junior colleagues in your department came to this Committee about
eight weeks ago and said that the Government was no longer going
to publish those. If one were cynical—which I am not—one
would suspect that it might highlight the failings of the delayed
discharge fines legislation, because one would anticipate them
to go up. But I was perplexed because the Minister told us he
had done it because it was age discriminatory. Do you think it
is age discriminatory?
Lord Warner: Contrary to popular
belief, I do not have responsibility across all the client groups.
I have responsibility in the area of performance ratings. The
actual work on indicators, as you possibly know, has been done
by the independent Commission on Health Improvement and in future
will be done by the Commission on Health Audit and Inspection.
They set out the detailed indicators, and, if we are talking about
a particular indicator here, those decisions on those indicators—apart
from targets, which I do not think you are talking about—have
been done independently by CHI. They have varied those indicators
over time. So it is not a Government decision, if it is one of
the indicators we are talking about, to publish or not to publish;
it is actually CHI's decision.
Q12 Mr Burns: No, it is the collection
of statistics which helps to build up a picture of performance.
The Minister told us that the Government has decided they will
no longer be publishing them because it was age discriminatory.
Lord Warner: So it is a Government
statistic.
Q13 Mr Burns: Yes, it is. Absolutely.
Lord Warner: I will certainly
go back and look into . . . There is a wide variety of returns.
Q14 Mr Burns: I understand that.
Lord Warner: I will certainly
look into that particular return and I am happy to write to you
about that particular circumstance.
Q15 Mr Burns: But the answer is,
as the Minister told us, that they were stopped because they are
age discriminatory. I assume, as a Minister in the same department,
that you would agree with that. You would do nothing else.
Lord Warner: I have no idea what
the answer to that is. There is no particular reason why I should.
Q16 Mr Burns: No, I am sorry; I was
making a statement, not a question. Given that you are bound by
collective responsibility and you are a Minister in the same department,
I would assume that if a Minister comes to us and says, "We
have stopped publishing figures because it is age discriminatory,"
you would agree with it, because I would be astounded if you told
me that you do not.
Lord Warner: No, I am sure that
if my colleagues have come along here and said something, it was
a wise and sensible thing for them to say.
Q17 Mr Burns: Great. I am glad you
have said that because now you can help me on one final question.
What your colleague said was wise and sensible—and nobody,
interestingly, around this table has challenged my understanding
of what the Minister told us when he said that they were stopping
publishing those figures for 75-year olds because they were age
discriminatory, so let's take that as factually correct. If that
is the case—and it is—could you then explain why another
of your junior ministers tells me since that exchange in this
Committee that the Department of Health continues to keep NHS
statistics, by age band, and for the over-60s and the over-75s,
for smoking cessation, patient data, genito-urinary medicine services?
Why is it not age discriminatory in those areas but it is in emergency
readmission figures?
Lord Warner: I think we are on
a rather narrow—
Q18 Mr Burns: We are, but I am asking
the question.
Lord Warner: I understand we are
on a rather narrow point, and, if I am absolutely straightforward,
I cannot answer that particular question. I certainly did not
come armed with that level of detail. All I can offer to do is
to look into this. I will consult the Office of National Statistics.
There are statistical conventions around a lot of these issues.
I will find out what the position is and I will write to the Committee.
Q19 Mr Burns: I am very grateful.
Can I then ask you a question of logic: if it is age discriminatory
to publish figures for the over-75s in emergency re-admissions,
then would you agree just on the logic of it that it is illogical
to continue then to publish figures by the different groups in
other areas of health service activity. That is just a broad question.
Lord Warner: I can see that you
have constructed a persuasive case that there are inconsistencies
in the argument.
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