Examination of Witnesses (Questions 20-39)
4 MARCH 2004
LORD WARNER,
MR MILES
AYLING, MRS
ANNE RAINSBERRY
AND DR
CHARLES DOBSON
Q20 Mr Burns: Right.
Lord Warner: I have been around
long enough to know that sometimes there is another side to the
story, and I am offering to go back, make an inquiry into what
the conventions are on statistics being collected by age groups—I
will consult my colleague on what he said and why he said it—and
I will give a full reply to the Committee.
Q21 Mr Burns: Thank you.
Lord Warner: I can do no more
than that.
Mr Burns: Thank you.
Q22 Mr Bradley: Good morning, Minister.
Could I return now to the questions around star ratings and the
new architecture that you have described that will be coming forward.
A lot of time and effort obviously went into developing the star
rating system, and other policy areas have been and are currently
dependent on star rating assessment, particularly the selection
of, for example, Foundation Hospitals. Are you therefore satisfied
that the current star rating system is robust enough to ensure
that the selection of those hospitals is correct? Secondly, if
you are then extending or changing the architecture on which you
are making assessments of hospitals, how will that impact on future
discussions about selection and policy determination for, again,
particularly Foundation Hospitals. How will the new landscape
develop? Are you happy with the level of satisfaction for selection
processes currently?
Lord Warner: There are several
strands to that, if I may take them slightly separately. The first
strand is: Is this a perfect system? The answer is: We have never
said it is a perfect system. It has been an evolving system. It
has got better over time but one would be a rash minister who
said, "That is the end of the story. This is the most perfect
and wonderful rating system." We are not saying that. Indeed,
the decisions, as I said earlier, so far on most of the indicators
in that rating system have been devised and modified by the Commission
for Health Improvement. They will hand that baton over to CHAI
on 1 April, so the indicators for the following year (that is,
for 2004-05) will be a responsibility of CHAI. As I think the
Chairman was indicating earlier, Sir Ian Kennedy and CHAI have
indicated that they would want to revisit at a later stage the
devising of, in effect, a new rating system with criteria which
were related to the new standards which are out for consultation.
It would be surprising, I think, in the light of the new architecture
of standards, the remarks of Sir Ian Kennedy, if we did not see
some changes in the rating system over time. I am continuing to
use the terms "performance rating" and "rating
system" rather than star ratings. We do not have hang-ups
about star ratings. The phrase that I recall Sir Ian Kennedy saying
is that he would like to see this rating system "more nuanced"
and I think he means trying to make something a little more subtle
in the way that it actually measurers performance and quality.
That is what I think he is looking for. Getting back to whether
the system of approvals for Foundation Trust is dependent on that
system, the performance rating system in selecting candidates
for Foundation Trust status, has been used as a preliminary sift.
It has not been the final decision maker. That is a decision for
the independent Regulator. The rating system has enabled the Secretary
of State to put to the regulator a group of hospitals who appear
to be performing well and have the qualities for Foundation Trust
status, but the decision on whether they achieve Foundation Trust
status is for the independent Regulator, who carried out a lot
more detailed work and is in the process of doing that detailed
work with the first lot of candidates, so one should not overestimate
the influence of the rating system on the final achievement of
Foundation Trust status. The Secretary of State also said when
the Health and Social Care Bill was going through Parliament that
there would be a review of governance arrangements, et cetera,
in relation to Foundation Trusts after the first waves had been
approved, so there would be a kind of hold on . . . That process
will also take place. I hope that clarifies the way things will
unfold.
Q23 Mr Bradley: The timetable for
that review and at the same time the development of a new system
of assessment, what sort of timeframe are you envisaging before
any further wave of proposals on Foundation Hospitals can come
forward?
Lord Warner: In terms of the rating
system, the kind of timescales that we envisage and I think Sir
Ian Kennedy envisages is that essentially you would be tweaking
the current rating system until we got to 2005-06. By that time,
we should have in place the agreed standards, which will be, we
would hope, agreed and published later this year. Sir Ian and
his team at CHAI would have actually worked out a new rating system
and would have been able to give information on that to the NHS
in good time for them to understand how things were going to work
and would have put the new indicators in the public arena so that
everybody in the NHS knew what they were going to be assessed
against in terms of indicators. We would see that 2005-06 is the
period when that comes into operation. I would need to go back
and make further inquiries, I would not want to guess at a precise
time, in terms of Foundation Trusts, because the time for a review
is a bit uncertain at the moment, how long it will take to do
that and re-gear the system for the next phase of Foundation Trust
status. I can look into that and write to the Committee.
Mr Bradley: If you would, please.
Q24 Dr Taylor: Minister, I am sure
you are aware of the Royal Statistical Society's criticisms of
the star ratings. Have you had a chance to meet them and discuss
this? How are you going to make sure their advice, which I think
is entirely valid, is going to be taken on by CHAI, in their new
work?
Lord Warner: We do respect the
views of the Royal Statistical Society. I think we took a slightly
different view from them on some of the detail. I understand where
they are coming from but we have also always said—and indeed
this has been the reality—that the system is being refined
and has changed from time to time. The indicators have changed.
Some indicators have been dropped by the Commission for Health
Improvement—when they realised there were statistical difficulties
about collecting the data or relying on the data. So there have
been changes made, but it is not our job to reconstruct the new
system and I will certainly make sure that the Commission for
Health Audit and Inspection are aware of the Royal Statistical
Society's views and I am sure they will take those into account
in devising the new arrangements.
Q25 Mr Jones: Thank you. I understand
that CHAI do have representatives talking to them from the RSS
and that would be essential to be continued.
Lord Warner: Sure.
Q26 Mr Burns: You probably remember
before Christmas that there was a considerable amount of speculation
about what might have happened in July 2002 over the 3-star ratings
for certain hospitals, including a hospital in Durham that served
Sedgefield, and Darlington. There were concerns, following a telephone
conversation seeking out information for the Secretary of State
at the time, that that hospital, instead of getting a 2-star rating,
which was anticipated, the decision was reversed and it still
kept its 3-star rating and the extra million pound bonus that
those hospitals get. Whatever the rights and wrongs of that case
were or are, would you expect under the new regime that the Secretary
of State would still keep a close watch on the production of star
ratings when they are produced exclusively by CHAI?
Lord Warner: "Keep a close
watch," I am not sure what that means. If you are meaning
by that, dabbling in the production of them, the answer is no.
If you mean would we take cognisance of the results of those performance
ratings, the answer is yes. If there were NHS substantial criticisms
of the rating system itself, clearly any Secretary of State for
Health would have to listen to those criticisms and would have
to understand whether they were valid or not. That is not to say
that he or she would rush in and try to change the system but,
if there were a lot of concerns, one would expect CHAI to be able
to explain why the concerns were valid or invalid, but it would
be their job to assess those concerns.
Q27 Mr Burns: To help you out, I
was not suggesting, when I used the phrase "keep a close
watch," that the Secretary of State's office or those acting
on his behalf would be seeking to use undue or unfair or inappropriate
influence to get any changes to any decisions being taken. But,
is there not, as the problem before Christmas illustrated, a slight
problem, in that if people keep a close watch in a perfectly proper
way, with that sort of independent organisation coming up with
fairly important decisions, that it might be misconstrued by people?—not
the Secretary of State or those acting on his behalf, but those
at the receiving end, who may want to please a Secretary of State
or think they are doing the right thing in helping a Secretary
of State when in fact he needs that sort of help like a hole in
the head?
Lord Warner: I am always touched
by this thought that there are large numbers of people out there
waiting and wanting to help and make the Secretary of State feel—
Q28 Mr Burns: Hang on, you know the
culture of life. If the Secretary of State, frankly, rings up
somebody who has no dealings with the Secretary of State's office,
they may, inappropriately and for all the wrong reasons, think
they are being helpful if they are providing an answer to something
that they know a Secretary of State or anyone else would welcome.
It is part of the culture, whether it is politics, business or
any other walk of life in some cases.
Lord Warner: I think we could
speculate endlessly about this, but let me just say a couple of
things. I think the issues that related to the past experience,
it is very clear—and it was made very clear I think early
on—that in the very early days of the CHI system there
was discussion between the Department of Health and the Commission
for Health Improvement, quite legitimate discussion, about the
statistical validity of some of the indicators, whether there
were good robust systems for collecting information. We were setting
up a totally new system: it would have been a strange world if
there had not been those discussions. The world has moved on,
as I think the debate on 7 January demonstrated and the follow-up
letters that the Permanent Secretary sent to Dr Liam Fox and Tim
Yeo. I think the world has moved on. Where we are at now is that
there is a new body coming into operation on 1 April which will
have responsibility for those indicators and for the measurement
of those indicators. Clearly they have to establish with the NHS
a reliable system of providing information for those indicators
and they have to validate that information and they have to have
a relationship with the NHS which enables them to make sure that
they have confidence in the data that is coming from the NHS for
those performance ratings. But that will be their job. It will
not be the Department of Health; it will not be the Secretary
of State. They will have no role in that whatsoever and that information
will be published by the Commission for Health Audit and Inspection
and that will be the information that is put in the public arena
and that will be their business.
Mr Burns: Thank you very much.
Q29 Mr Burstow: Could I take that
another step and explore a little the relationship between the
star rating system, other patient information that the new Commission
will be publishing as part of its work and the role our of the
Government's policies around patient choice, because clearly access
to understandable and readily comprehensive information, whether
star ratings or otherwise, is a key aspect to enabling patients
to make those choices about where they want treatment to be provided
and so on. Could you therefore say a little bit about what research
has been conducted, either within the Department or by the Commission,
the current Commission or the new Commission, to develop its thinking
about how it can ensure the information it is publishing is readily
accessible, particularly with hard-to-reach groups, people with
English as a second language and so on.
Lord Warner: The Commission for
Health Improvement, as I recall, had certainly put up all their
information on their website, which can also be accessed through
the Department of Health website. There is a link there. My clear
understanding from talking to Sir Ian Kennedy and his colleagues
is that that kind of practice will be continued. Certainly there
are always printed versions of these documents available at the
local level—they are distributed to health authorities.
There is always, I think, a difficult issue about whether patient
groups, particularly hard-to-reach patient interests, can get
access to that information. One of the purposes, however, of the
new patient forums at the local level is to ensure that patients
and communities in those smaller local areas can access the information
that enables them to make sensible choices. It is not just, to
put it crudely, for the well-informed middle classes to have access
to that information to make those choices. In terms of how that
will be done, I think we do rely quite a lot on the local agencies
to, in effect, access this data. It is very difficult to envisage
small community groups having a direct relationship with the Commission
for Health Audit and Inspection. That is a very difficult thing
to pull off, so we are going to be dependent, I think, in terms
of the community groups in which I think you are interested, and
we are going to rely very much on the patient forum focus at the
local level to help brigade some of that information in a way
which is helpful for people in those communities.
Q30 Mr Burstow: Clearly those sorts
of steps are ways in which access can be secured. It is then a
question of the information itself and whether it is worth accessing
in terms of its relevancy to patients making choices about where
they would wish to have treatment provided. Are you aware of work
being done to ensure that the information which is being put out
there—and it is on the web, which obviously has access issues
for those who do not have access to the IT—is being put
together in ways which represents the very best standards of plain
English, represent the very best standards of material which is
relevant and understandable to the layperson?
Lord Warner: I would not want
to claim that if you went and looked at, for example, the last
set of publications from CHI on performance ratings, that everyone
who picked that up would immediately understand the full significance
of it. It would be a rash person who would say they would. But
I think we are really talking about how you construct intermediaries
between that data and a lot of patient groups, communities, so
that it becomes translatable. I think the data is as reliable
as it is possible to make it. The evidence suggests that one or
two of the indicators and the measurements of them were not as
reliable as CHI wanted, and they were dropped because the data
was not reliable enough. There will always be, I think, issues
around ensuring that data is reliable, in terms of it is the same
data in different parts of the country coming in from different
parts of the NHS. That will be a continuing problem, to make sure
that is valid. But I think you are asking about how we make some
of this translatable, and that is going to be down to patient
groups and, indeed, sometimes independent bodies, like Dr Foster,
who have done a lot of work in actually trying to present information
in an attractive and useable form. To try to give you a specific
area, if we go into the area of where there are long waiting times,
as we move to the point where patients will be given a choice
of hospitals from which to choose where they may be able to get
a treatment quicker, that information is likely to be processed
through their GP. The GP will be an interpreter of that information
when he has a discussion with a particular patient about a particular
waiting time for a particular condition, so there will be interpreters
of that information.
Q31 Mr Burstow: Just to end on this
little bit, would it be possible for you perhaps to come back
to us with any further information about the work that is in train
with the Commission to work through how its outputs do impact
upon the patient choice initiative, to make sure that they are
properly dovetailing. It would be very useful to know a little
more about that.
Lord Warner: Yes, I am happy to
do that.
Q32 Mr Burstow: In the report Securing
Good Health for the Population which Mr Wanless published
last week he makes reference to the National Service Frameworks
that have been published over the last few years and says that
the NSFs were costed but this information has not been published.
I am wondering, given that the new Commission for Healthcare Audit
and Inspection has a remit for seeing how NSFs are being implemented
on the ground, whether or not the information that is part and
parcel of the costing of NSFs is all being made available on request
from the Commission in order that the Commission can properly
undertake its functions, both in terms of looking at quality of
delivery and also the financial aspects of the implementation
of NSFs.
Lord Warner: I am afraid I have
not had time to read the whole of Wanless so I am a bit unsighted
on some of the detail of that. On the basic point, the answer
is almost certainly we would, because, if CHAI ask us for information
which we have, we would provide that information in as helpful
a way as we can.
Q33 Mr Burstow: If that information
is provided to CHAI, would it then be possible to have it placed
in the public domain?
Lord Warner: I think I do not
want to be put in the position, because I think it will go against
the spirit of CHAI, of being seen to be saying, "We will
provide something to CHAI and we will instruct them to put it
in the public arena." If they ask for information from the
Department, they will almost certainly, I suspect, want to process
that information and present it in the public arena in a way which
they think is appropriate and helpful. I do not want to be put
in the position where we are seen to be pre-empting their consideration
of the information, the linking of it to other information. I
am not trying to be secretive about it; I am just trying to be
cautious about not appearing to be saying, "We will give
instructions about the use of that information to the watchdog,"
because I do not think we will. But I think we would be, in effect,
responding to a request from them for information and we would
have to rely on them to use it for the purpose that they want
to use it for and put that in the public domain.
Q34 Mr Burstow: But those instructions
could be positive or negative in terms of saying do something
or not do something.
Lord Warner: I do not think they
would be negative.
Q35 Mr Burstow: So you are not saying
not to.
Lord Warner: We are not saying
not to. We are more likely to say, "You must use this to
carry out your functions in the way you think it is necessary
to carry out your functions."
Q36 Mr Burstow: Just a very quick
closing question: There is a view perhaps in some quarters that
the work that has been done by CHI had been well developed over
the last four years, that there was a pattern of progress of work
emerging, and that now there is to be, in a way, a discontinuity
in the way that the new CHAI takes on some aspects of the old
work. What is, if you like, the justification from your point
of view for this change? Would it not have been more sensible
to have carried on and tried to continue to develop its role?
Lord Warner: I think we are back
to some of the remarks I was making at the beginning to the Chairman.
We were constructing a new architecture in terms of the standards
(that is the overarching architecture), we were trying to pull
together a range of regulatory and inspectorial functions. I mean,
one of the other complaints is that the public sector generally
and the NHS in particular is awash with inspectors and regulators,
so new CHAI does not just take over from the old Commission for
Health Improvement but it takes over functions from the Audit
Commission and it takes over functions from the National Care
Standards Commission. It is actually merging some of those functions,
so that it has a wider set of functions than the old Commission
for Health Improvement. I think to deal with the problem of discontinuity,
Sir Ian Kennedy and his team have agreed that they will not dramatically
change overnight the performance rating system. There is a gradual
transition over about two years. The next lot of performance indicators
will be their responsibility to produce but they have said that
the next lot will be an evolution from the current year's and
it will not be until, as I said earlier, 2005-06 that we will
see perhaps a more radical revamping of the performance rating
system. So there will be some gradualness to this so that the
NHS can itself get used to this changing process.
Q37 Dr Taylor: I personally think
there were some very real defects in CHI and I would like to know
very much what lessons the Government has learned from CHI, what
defects they have found, if any, what advice they are passing
on to CHAI, learning from these lessons.
Lord Warner: I do not think it
has been necessary for us to pass on lots of lessons. We have
made sure that in the transition from one body to the other there
were good communications between those bodies about their experience.
Although the senior management of the old Commission will not
be transferring to the new CHAI, there is no loss of collective
memory because a huge proportion of the staff of the old Commission
for Health Improvements is being transferred to the new organisation.
They suddenly will not have collective amnesia when they move
into the old organisation; they will bring that experience to
bear on the new work. I think, to be fair to the Commission for
Health Improvement, they have been quite willing to be self-critical
and to modify what they saw as shortcomings in their work. In
my short time in the Department and my dealings with them, I have
not seen anything to suggest that they were unwilling to be critical
about some of the shortcomings in the system where these were
pointed out to them and there was good evidence for that.
Q38 Dr Taylor: I think the main shortcoming
and the main defect is that they were limited by their very sort
of rules. Their reviews were purely and simply clinical governance
reviews and that is all. How is CHAI going to base it differently
from that?
Lord Warner: They had a balanced
score card around some other things as well. I am conscious that
I may be repeating myself, but you need to go back to this architecture
of standards which has seven domains in it. There is a very wide
range of things with which health bodies are expected to conform
and the criteria that CHAI will be developing will cover all those
domains. For example, there is a domain on safety; one on governance;
one on clinical cost-effectiveness; patient focus; accessible
and responsive care; public health; care environment amenities.
This is a pretty broad picture of the way the health service is
performing and there will be an indicator system by the new Commission
for Health Audit and Inspection that actually measures performance
and quality of performance in those areas.
Q39 Dr Taylor: I was going to avoid
mentioning this score card approach because it is something that
has completely puzzled most of us, and the Royal Statistical Society,
at a meeting on Tuesday, were not particularly keen on that. But
I am going to be absolutely frank, I am really rather disappointed
because to me this striking huge improvement that CHAI has over
CHI is that no longer is it just reviewing clinical governance;
it now has the power to inspect management, provision and quality
of health care and taking into account the national standards
and priorities. So really I think this is a huge, huge improvement
for it. Could I just go on to ask about some of its new activities.
It has responsibility for the independent scrutiny of complaints.
How are complaints going to be screened before they get to CHAI?
With the complaints procedure as it goes at the moment, the complaints
convenor in any trust is in fact an employee of that trust and
has a complete stoppage on letting complaints get further. Is
that going to be addressed?
Lord Warner: I am pleased to say
that I do not have responsibility for the complaints procedure
but I do know that CHAI are expecting to start the new complaints
procedure in June this year. I am happy to deal with that particular
detailed point by correspondence and write back to you about how
that particular problem is going to work, but I am not briefed
to give you a detailed exposition on the complaints procedure.
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