Examination of Witnesses (Questions 40-59)
4 MARCH 2004
LORD WARNER,
MR MILES
AYLING, MRS
ANNE RAINSBERRY
AND DR
CHARLES DOBSON
Q40 Dr Taylor: You have already said
lots of the staff of CHI are transferring. A very useful local
function that has happened in conjunction with CHI is the use
of local auditors who are there on the ground. CHAI is obviously
taking over the audit function. Is it still going to use local
auditors or are they going to be squeezed out of its function?
Lord Warner: It will have a memorandum
of understanding with the Audit Commission for the auditors
to do whatever . . . I have not seen the memorandum of understanding
but it reflects the work that the Commission for Health Audit
and Inspection are expecting Audit Commission auditors to
do on their behalf
Dr Taylor: Thank you.
Q41 John Austin: You have said that
a large proportion of the staff of the old CHI will transfer to
the new CHAI. I think we would welcome that because one of the
strengths that has been identified of the old CHI was the credibility
within the NHS of the staff (who had a great deal of experience
of the NHS) and, indeed, the chief executive. My understanding
is that, although the staff will transfer, none of the directors
of the board of the new CHAI has any experience of the NHS.
Lord Warner: I am not sure. I
do know a little about the background and experience of the new
chief executive of the Commission for Health Audit and Inspection
and she does have a background in regulation. I would not myself
take the view that because everybody is not from an NHS background
that they are unable to do that particular job. There is a lot
of continuity, as you have acknowledged, below the board level,
if you like. It was the job of the new Commission to make their
senior appointments and appoint the best people for the job. If
I may strike a personal note: I do not think it follows that if
you have not had a background in a particular field that you cannot
do a job at a very top and strategic level. As someone who had
never been in a social services department before he was a director
of social services, I would like to claim I did have some passing
competence in actually managing the organisation.
Chairman: Shall we vote on that one!
Q42 John Austin: As a social worker,
may I say it is perfectly possible for a director of social services
to be an effective director of social services without being a
social worker. Do you think it would not have been useful to have
had some experience of the NHS on the board of directors?
Lord Warner: One cannot, in a
sense, hire a dog and bark oneself. One has actually appointed
an independent watchdog. If ministers and the Department had gone
interfering in those appointments, there would have been a lot
of, I think, correct criticism of them for doing that. There would
have been a lot of doubts about their level of independence. The
Commission was appointed on a basis of fair and open competition.
Appointments were supervised by the NHS Appointments Commission.
One does have to trust them. They are people of judgment, one
does have to trust them to appoint the cadre of senior management
that they think is appropriate to do the function that they have
to carry out.
Q43 Mr Jones: In Derek Wanless' latest
English report he is very critical of public health initiatives
being announced and taken up with little or no evidential basis
that they would actually work and no effective follow-up to judge
whether they are working or whether they are cost-effective. He
made similar pronouncements over public health initiatives in
Wales as well in an earlier report, so it is a consistent view.
Do you share his criticism or his worry?
Lord Warner: Certainly, so far
as the Government is concerned, the Government set up the Wanless
report so we do welcome the report and the report itself comes
happily to coincide with the consultation on public health which
the Secretary of State has launched which will lead, after that
process of consultation, to a White Paper. I think many of us
would accept that perhaps public health does not have the attention
always that it requires. I do not think there is any secret about
that. The issues around in public health have been around a long
time. I think there has been a growing public and political awareness
that these issues need to be grappled with more vigorously. I
think Derek Wanless has performed a great public service in drawing
those to our attention. Probably you can point to some shortcomings
over time across successive governments in whether we have evaluated
all these as well as we might have done; but you can also point
to areas where there is a good evidential base that a pound or
a dollar spent on, for example, advertising to deter smoking does
have a result. There is good evidence from California, for example,
in that particular area.
Q44 Mr Jones: That is an interesting
example. Would you also then think that if a pound advertising
smoking has a good result, then a pound not advertising bad food
to children would also have a good result?
Lord Warner: Public health is,
I am pleased to say, not my responsibility. I was merely illustrating—
Q45 Mr Jones: It was an interesting
illustration and I was following up the argument.
Lord Warner: I was illustrating
a very narrow point—a very narrow point—about the
fact that in some of these programmes there was data on effectiveness.
I was not making a judgment about what is the best way to help
people to quit smoking or to stop eating "undesirable"
foods. I think we do need to get smarter about measuring
the effectiveness of these programmes. I do not think anybody
in government is arguing that these are perfect solutions; on
the other hand, we can point to some evidence (for example,
in quitters programmes) where we do know that, give or take, it
has cost about £200 to get people to quit after four weeks
on quit programmes. That is a fairly low cost to get people to
quit smoking.
I would not want you to think it was an evidence-free
zone. It is not an evidence-free zone.
Q46 Mr Jones: I take it from that
answer you agree that we should measure it.
Lord Warner: We do need to measure
and we need to measure more effectively.
Q47 Mr Jones: Do you think therefore
that there should be a role for CHI in auditing the public health
role of strategic health authorities and primary care trusts?
Lord Warner: It will be for CHI,
as I have indicated earlier. There is a domain called public health
in the new NHS standards and it will be for CHI to create criteria
for measuring performance across the NHS in their work in that
area. It is quite clear that they will be into that area. Precisely
what their forms of measurement will be I do not know and I suspect
at the moment they do not know.
Q48 Dr Naysmith: Can I turn to a
different area which I understand is part of your responsibility,
the National Institute for Clinical Excellence? You will be aware
that this committee looked at NICE, which had been going for about
three years then, in 2002, and I am glad to say that most
of our recommendations were agreed to be fairly wise and approved
of by many people, and also many of them have been implemented
by the government. One of them was that the government should
take steps to ensure the systematic monitoring of the implementation
of NICE guidance. With NICE having been in existence now for nearly
five years, is there any evidence that this guidance is being
implemented within the NHS and do you monitor it carefully?
Lord Warner: What we have done
is for the most part give a very clear instruction that where
there is a technology appraisal the expectation is that it is
implemented within three months. That is not the same as the clinical
guidelines which tend to be rather more far-reaching recommendations
with implications for patterns of service provision, but there
have also been technology appraisals where NICE themselves have
indicated that it is not going to be possible to meet that
three-month implementation, usually for issues around whether
staff with the necessary skills and competences are available
across the whole country to do that or whether there is technical
support to enable a particular technology to be implemented quickly.
There has always been a proportion of the NICE recommendations
which on NICE's own recommendation could not be implemented in
that time.
Q49 Dr Naysmith: With respect, minister,
that was not my question.
Lord Warner: No. I am just getting
that out of the way. In terms of the monitoring of the others,
we do know that there have been concerns about full implementation
and some work has been commissioned from the University of York
looking at the implementation, which is being undertaken by Professor
Trevor Sheldon and which will probably be available within the
next few months.
Q50 Dr Naysmith: Is this commissioned
by the Department of Health?
Lord Warner: This was commissioned
by the department and there has been some work which was also
commissioned by the Secretary of State asking Mike Richards, the
cancer czar, if you like, to look at NICE recommendations on cancer
drug treatments. That was in response to some concerns that these
were not being implemented as quickly as everyone would like.
I think Mike Richards is finishing his work, if my memory is right,
in the next two or three months, so that will also be an issue.
What we do know is that we get a flow of letters from people saying
that a particular drug is not available in their area. We have
increasingly worked with the new strategic health authorities
to look into those particular cases and take action with the PCT
to make changes. The responsibility is with the PCTs. We are using
increasingly the strategic health authorities to oversee their
performance in the area of implementing NICE recommendations.
Q51 Dr Naysmith: Strategic health
authorities are not very big organisations. They are intended
to be fairly small and strategic. I would have thought that most
of them (the one I know best and I expect the rest are the same)
do not really have the resources for doing that sort of thing.
Lord Warner: They do have a responsibility
for performance management for the bodies in their area and it
is an issue. It is not so much whether there is one case but if
there is a repeated concern that particular PCTs are not implementing
NICE guidance then I think it is their responsibility to pursue
those issues with the particular PCT. We have found, certainly
in some of the ministerial correspondence that I have dealt with,
that sometimes there has been a communication problem between
the PCT and a particular doctor and actually just involving the
PCT has put things right.
Q52 Dr Naysmith: Is there a possibility
that implementation of NICE guidance might form part of the new
CHAI responsibilities? Is that talked about?
Lord Warner: The implementation
of NICE guidance is part of the national standard and we do know
that the Commission for Health Audit and Inspection will themselves
be wanting to find a methodology for assessing the effectiveness
of that. Certainly it is part of their remit though I do not think
we know at this point in time precisely how they are going to
do that.
Q53 Dr Naysmith: It sounds a little
bit hit and miss at the moment, depending on complaints coming
in and that sort of thing, but this could well form a proper way
of monitoring and assessing the implementation of the guidance
monitored by new CHAI.
Lord Warner: I think we are trying
to come at this from different angles. We are using the SHAs in
the short term. We are using known complaints for taking things
up directly with the PCTs. We are using areas where there have
been concerns like the Mike Richards study and we are using the
York study. Belt and braces and all sorts of other things we are
trying to use. In the period when the new Commission comes into
operation we are looking to them to structure on a more systematic
basis the inspection arrangements but we are not just waiting
for that; we are trying to take other measures as well.
Q54 Dr Naysmith: One of the other
of our recommendations involved the principle of transparency,
particularly in basing the guidance on unpublished industry data,
and you will recall that the World Health Organisation, the European
branch, carried out (as we also recommended) a look at all NICE's
functions and they came out in support of our recommendations
along those lines. Have you been able to reconcile the inherent
contradiction that the World Health Organisation talked about
in NICE trying to be a transparent organisation and this inability
to publish quite a lot of data that it based its guidance on?
Lord Warner: They are on the slight
horns of a dilemma because in order to be as effective as possible
they are getting data which is commercial in confidence. That
is another of the issues. There have, and I can write to you about
this because my memory is a bit dim on it, certainly been some
cases where they have written to the pharmaceutical company and
persuaded them that this information should be put into the public
arena and they are certainly conscious of the need in terms of
public confidence to pursue that as far as possible. They have
a difficult judgment to make which is that either you accept some
of this evidence and information on a commercial in confidence
basis or you cannot get at it at all, so there is a complex public
policy benefit issue to be weighed up there. My understanding
is that the WHO recognised that that was an intrinsic dilemma
but I am pretty sure there have been some examples where they
have persuaded the pharmaceutical company to put this information
in the public arena and I will write to the committee about that.
Q55 Dr Naysmith: It is true the World
Health Organisation did recognise there was a dilemma but they
did say that NICE must reconcile this contradiction somehow.
Lord Warner: They are trying to
reconcile it, I think, by trying to persuade people to put the
information in the public arena. What I have not got is precise
data about how successful they have been with what proportion
of companies.
Q56 Dr Taylor: Minister, I remember
your predecessor sitting in exactly that seat when we were doing
the NICE inquiry and saying absolutely categorically that in those
days health authorities and trusts had enough money to meet NICE
guidelines. This was at a time when my own PCT was absolutely
desperate and could make no advances at all. Recently the Secretary
of State has announced that PCTs need only fund one cycle of IVF
treatment, which is less than the three cycles that NICE recommend.
Does this mean that the department recognise that there is not
enough money to fund NICE guidelines just as they stand?
Lord Warner: The short answer
is no. On the particular IVF guidance NICE themselves recognise
that the NHS could not implement that overnight and it is not
just a straightforward issue of money anyway. We are talking about
something which is a little more complicated than that. What
the Secretary of State was announcing on that guidance was a commitment
to try to ensure that one cycle was available across the whole
country. That may not be the answer you want but what I would
say to you is that one cycle everywhere is better than no cycles
in some places and does bring a lot of support to a lot of people.
We have gone along with the NICE recognition that you cannot do
this immediately. On the money side I think we would say that
financial resources are not an impediment to implementing NICE
recommendations and technology appraisals because we are going
through a period where in real terms NHS funding is going up by
7-7.5% a year over a five year period so there is consistency
of commitment to that money. It is not just going up one year
and then zinging down again. It is going up over a five year period
and 75% of that money is in the hands of the PCTs. It is quite
difficult to run the argument, if you look at the scale of the
NICE recommendations in relation to the total budgets that are
available to PCTS, that they have not got the cash.
Q57 John Austin: It does raise an
issue in relation to the impact on budgets because in the review
by WHO they specifically made the point that although budget impact
is not a consideration in making recommendations by NICE it is
important to develop that budget impact modelling and they feel
that that could most effectively be done by NICE and would assist
the local trusts in analysing the implementation costs themselves.
Do you not think this is an area where NICE should have some responsibility?
Lord Warner: I cannot remember
the precise timing of the WHO report but certainly when they were
they were looking at this before we had really got into this period
of this very large and continuing increase in budgets, and I think
before it was clear that 75% of those budgets were going to be
in the hands of the PCTs. I am not sure that all that information
was available to the WHO when they did their study. I will certainly
look into that, but I am not sure how well-founded some of that
judgment was given the subsequent decisions that have been taken.
Q58 John Austin: They also said that
the advantages of doing so include not only the provision of useful
advice to the trusts but also the avoidance of duplication of
effort by the trusts in making their budget analyses.
Lord Warner: Of all parts of the
public service it seems to me that NICE are one of the most open
that there are. They put on their websites well in advance the
work that they are doing and the likely dates of publication,
so it is not terribly difficult for any NHS organisation when
budgeting to try to anticipate some of the work that is available.
I think we could overlook that because they can tell. They can
go to the website and they can tell what proposals are likely
to be coming out in the next year and the year after that.
You can factor some of those considerations into your budgetary
systems.
Q59 Mr Burns: On the very narrow
point I just want to pick up the minister's comments about PCTs
and their money. Surely you have seen the evidence that we as
Members of Parliament have seen so far in certain parts of the
country of the financial pressures on a number of PCTs who have
got deficits. For example, my own PCT today is announcing how
it is going to make cuts in service to make up the two million
pound deficit this year. You seem to suggest that PCTs had all
the money that they needed with which they could fund whatever
they wanted and so the IVF decision was not taken on financial
grounds, and I just question the reality on the ground of what
is happening with the funding of PCTs at the moment.
Lord Warner: I was not saying
that there is no PCT in this country that does not feel under
some financial pressures. What I was saying—
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