Examination of Witnesses (Questions 380
- 399)
WEDNESDAY 26 MAY 2004
MISS MELANIE
JOHNSON MP AND
DR STEPHEN
LADYMAN MP
Q380 Dr Naysmith: We are finding
a lot more patients say they would prefer to die at home than
die in a hospice or in a hospital.
Miss Johnson: Yes. The point I
am just making is that those patients were in the community for
a long time in any case so they effectively were on their GPs'
lists. They are their patients and they would have been actively
involved with their care up to a point. It just would not necessarily
have been the closing stages of their life and their actual death.
We need to recognise the fact that it still is something which
will not impact on GPs. It is not so common as something like
asthma. We have to accept that if you are trying to get GPs trained
on things there are other things which people may well think they
see an awful lot more people with, various conditions and issues,
than they do with people who are in need of palliative care. I
am not saying that does not make it important. I think it makes
it extraordinarily important because of the nature of that time
in someone's life and because of the importance of that care,
but what we have to recognise is that there may be other professionals
with whom the skilling up is going to be a lot easier and the
dialogue needs to take place with the royal colleges about doctors.
Q381 Dr Naysmith: When we were in
Scotland, we saw this young consultant in palliative care who
saw it as part of her mission to go into acute hospitals with
her palliative care teams and try to encourage them to feel less
frightened of dealing with these kinds of situations. She very
clearly told us that people were anxious to get help in doing
it, once they saw a demonstration of how well it could be done
and people were really very keen to get involved and much happier
to do so. There really is a role for this kind of training and
this kind of assistance if we could provide it, not necessarily
through the colleges but if we can put a bit of pressure on and
resources in to get people who know how to do it, to teach others
in a sort of apprenticeship way, it would really make a big difference.
Miss Johnson: Sometimes these
things are more informal than the collaborative arrangements we
have but a lot of the collaboratives that we have are based on
just those sorts of ideas. I certainly think that we need to use
people within the services to skill each other up in areas where
their work interfaces.
Q382 Dr Taylor: You have talked about
the increases in consultants in palliative care that are planned.
In the evidence, it has been pointed out to us that there are
at least 100 posts in consultants in palliative medicine that
cannot be filled at the moment. Is not the desperate fact that
there are too few consultants around to do the training which
brings one down to the absolutely crucial importance of the apprenticeship?
I never had any formal training in this obviously because it was
a bit of time ago, but working for consultants you very quickly
worked out who was good at it and who was bad at it. With the
junior doctor training as it is at the moment, getting harder
and harder, there is less and less opportunity for skills to rub
off onto the juniors who are working with the people who are good
at this. Does this concern you? Can you see any way round this,
because more and more generalists are going to have to do the
bulk of palliative care but if they cannot be trained by specialists
because there are not enough of them it has to rub off on them
from people who are good at it. They are not getting the time
for it to rub off.
Miss Johnson: We are working with
the National Partnership Group about the scale of workforce needs,
both nursing and doctors, on the palliative care side of things.
One of the main issues is around nurses, to be honest, because
that is one of the main areas where growth is going to be needed.
We are discussing with them the scope of the workforce that is
needed in the voluntary sector in the near future. We are working
on the issues about what is needed. I think there are two things
here: what is needed and then supplying it. We have some idea
about what is needed. We have some workforce plans, as I have
already mentioned, on consultants, but we also need to be clear
about what the actual needs are and what the skills mix ought
to be and what the routes are. People have different views about
what the routes are that people ought to go through to get to
the point of working in these, talking to people who are involved
with this sector. Many people have come through different and
diverse routes and I do not know that that is necessarily a bad
thing because they bring a different range of backgrounds to it.
The important thing is that, if they are interested in working
in this area, they get the opportunity for training and that is
why we have put the extra money into training and why we will
obviously have to continue to look to make sure that we are training
the workforce that we need for the future with the right skills.
The £50 million that we have put out as part of the £119
million has also included money that will help on this workforce
provision side of things, as indeed the money specifically related
to training people is specifically related to increasing the range
of skills available in the existing workforce.
Q383 Mr Bradley: For your purposes
in the Department, what do you envisage will be the cost of providing
the services recommended by the NICE guidelines?
Miss Johnson: I am not sure whether
it is a single set of NICE guidelines, if you are talking about
NICE guidelines on palliative care?
Q384 Mr Bradley: Yes, sure.
Miss Johnson: Where appropriate,
NICE do costings of things and they will produce costings as part
of their analysis.
Q385 Mr Bradley: From the Department's
planning point of view, how much money do you think you will have
to allocate to provide the services?
Miss Johnson: I do not have a
figure for that. I am not sure that we have a figure for that
at the present time.
Q386 Mr Bradley: I think you are
just about to get one.
Miss Johnson: No, I am not about
to get a figure because I know there is not one in what I have
been supplied with. We are assuming that funding for implementing
the NICE guidance documents is allocated as part of the total
baseline to PCTs, so we are not expecting to produce some extra
money out of that. We will be monitoring the implementation of
it in the same way that we monitor the implementation of all other
work that goes on in terms of performance management mechanisms
and so forth. We do not have a costing figure that I am aware
of as part of this.
Q387 Mr Bradley: Is it envisaged
that all the voluntary sector current provision, say for hospices,
will be funded through the public purse and be transferred to
direct funding?
Miss Johnson: I do not think that
is the intention, no. Currently, the level of funding put in by
the government to the hospice sector is something like 35%.
Q388 Mr Bradley: How would the national
tariff work in terms of commissioning services from those hospices
if it is not intended to fund that provision fully?
Dr Ladyman: From children's point
of view, services that are commissioned for children will be paid
for by PCTs.
Q389 Mr Bradley: If all the services
from a hospice are commissioned by PCTs or, with children, a collective
of PCTs, that ultimately could lead to fully funding from the
public purse?
Dr Ladyman: That would depend
upon the negotiated relationship between the PCT and the hospice.
There may have been an agreement whereby the hospice continues
to provide some of its funding on a voluntary basis and the price
for the commissioned services will not therefore reflect the total
package of costs, but that would be a local decision.
Miss Johnson: That is what I am
saying also. In terms of the detail of it, as I said earlier in
talking about payment by results, we are not in a position yet
to decide exactly what the basis for funding for hospices is,
but as I indicated earlier on we think it needs to reflect the
difference that hospices are from other forms of provision. It
may be more akin to some other specialist provision where again
we are thinking about the way in which that ought to be reflected
in terms of the tariff arrangements. Maybe there should be different
arrangements for short stays and long stays, for example, and
also in terms of whether we ought to have an episode based approach
that would be supplemented for long stays is one option on it.
There are a number of things under consideration and it would
be a little time before we get the answer out of the machine,
as it were. Everybody is engaged in the discussion on this and
we are making sure that all the interested parties have an input.
Q390 Mr Bradley: In terms of the
current situation and the extra £50 million that was put
into palliative care and the establishment of the National Partnership
Groups, what monitoring is going on currently to ensure that money
is being spent by PCTs for palliative care? What arrangements
are in place in the Department to look at the development of those
palliative groups against the money that is currently allocated
for those purposes?
Miss Johnson: We have been quite
careful with the money that has gone out. In some cases, it has
been bid for, for specific things. We have been very careful and
demanding about the quality of those bids so the money is going
in the right area. On the £50 million expenditure, we have
had returns back as a result of inquiries that we have made from
25 out of the 32 networks and many of those are in quite a lot
of detail. We are currently looking at the analysis of those returns
and officials are going to report to the National Partnership
Group and to me when the analysis is complete. I would be very
pleased to let the Committee know the results of that analysis.
We know there were problems in a couple of areas, but beyond that
we are not aware of difficulties at this stage. I think those
couple of areas you are aware of too and those problems have been
addressed directly with those areas.
Q391 John Austin: I did not want
to raise the specific issues of Greenwich and Swindon because
Professor Richards has sent us a detailed letter and I know that
there is a stakeholders' meeting to take place, but it follows
on from Keith Bradley's question. Are you satisfied that in the
future it will not be possible for PCTs to use money which is
intended for additional money for palliative care to be diverted
to respond to other cost pressures?
Miss Johnson: We need to make
sure that, if we are sending out money centrally with a particular
tag attached to it, it does reach its destination. With cancer
funding, when we have done the audit and checked out a year or
so ago that it was reaching cancer services, we found it was.
The vast majority of it had gone in the right way. We will be
concerned to make sure that any money that we send out nationally
on a centralised basis with a particular tag for services attached
to it does end up with those services, so we will be making every
step to both check up that it has arrived, take steps if it has
not but, most of all, to make sure in the first place that it
is fairly tight and clear about what it is going to and that people
will be monitored on how they are spending it, because I think
that makes sure that we do not have the problem in the first place
in as many cases as possible. It is impossible to give you a guarantee
that it will never, ever go astray in any single case around the
country, but we certainly do our best to make sure it does reach
the services we want it to.
Q392 Mr Burstow: I have two questions
arising from the answers given to Keith Bradley. One is on tariffs.
You mentioned earlier that tariffs will apply from 2008.
Miss Johnson: By 2008.
Q393 Mr Burstow: Could you talk us
through the role of the Commissioner PCT and what it will be once
patient choice and tariffs are fully operational, given that in
those circumstances the patient's wish as to where they wish to
be treated and presumably receive their palliative care, whether
it is at home, in a hospice or wherever else, is a matter for
them in consultation with whoever makes the referral? How will
commissioners, who no longer have control of the money because
the money is with the patient, be able to exercise a commissioning
function? How is that going to work? How will services be changed
other than by the way in which patients make choices about where
they want to go and have a service?
Miss Johnson: Obviously, the more
minority something is the more the individual choices are likely
to make an impact on it, so the smaller services are more likely
to be strongly influenced by patient choice because they are also
likely to be more specialised and there are likely to be more
different choices made, as it were, perhaps than there will be
about, say, where people have a standard operation of some kind
or another, for the sake of argument. That is far more likely
to be done in general at a local hospital unless of course the
hospital is not able to provide a reasonably quick service, in
which case it will be open to the patient to go somewhere else.
That is one of the advantages of the system. The role of the PCTs
is to look at the health needs of their area and to make sure
that local health services are configures in such a way as to
be able to provide for the health needs of the local population.
In an ideal situation, the PCT gets that entirely right, the providers
get it entirely right and people go as close to home as they can
or indeed are at home, if that is appropriate, depending on what
the service is, and the money follows the patient. There is going
to be some considerable skill needed from the PCTs to make sure
that they do develop their assessments of local needs and providers
are responsive to what people want, to make sure that that actually
happens. The whole point of the system is not to fit the patient
into the system but to make sure that the system fits the patient.
Nobody as a patient—we are all patients from time to time—can
do anything other than think that that is the right way round.
We need a health care service that is patient centred.
Q394 Mr Burstow: This is probably
an area for further exploration on a future occasion. Can I come
back to costings and this issue that was raised just now? In the
report by Derek Wanless published earlier this year he records
the fact that the Department has costed national service frameworks
and you made reference earlier on to wanting to ensure that there
would be modules within the NSFs that deal with palliative care.
Would it therefore be right to conclude that you have already
undertaken costings for the implementation of those NSFs that
already refer to palliative care and, if so, could you give us
some indication as to what the costings were?
Miss Johnson: I do not have those
costings, if you are about to ask me about them. I do not know
whether Stephen wants to comment.
Dr Ladyman: I do not have any
figures for you and I would not be in a position to give you any
cost estimates for the National Service Framework for Children
anyway until we publish them. Certainly, we do an assessment as
to what we think the cost pressures will be of a national service
framework before we publish it. You have to remember as well that
most of the national service frameworks are ten year programmes.
Some of them are five year programmes. The National Service Framework
for Children will be a ten year programme and we will not be giving
PCTs dated milestones by which time they have to do any particular
step. It would not be possible, for example, to give you a figure
that says the National Service Framework for Children palliative
care will cost £X million next year. What we will be in a
position to give when we publish it is an estimate of what we
think the underlying cost pressures as a result of meeting it
will be over the ten year time frame.
Q395 Mr Burstow: Historically, when
the NSFs have been published, those assessments have not been
published alongside them.
Dr Ladyman: They have not, so
far as I am aware, no. You are right.
Q396 Mr Burstow: In future they will
be?
Dr Ladyman: There are only two
more NSFs in preparation at the moment.
Q397 Mr Burstow: I thought that was
what you said. I was just trying to clarify it.
Miss Johnson: Clearly with some
things like the cancer plan, which I know is not formally an NSF
but has the same force as an NSF effectively, there was money
attached to that plan, invested accordingly, and £570 million—
Q398 Mr Burstow: This Committee and
other Members in the House are always interested to know how much
the money that was allocated matches up to the Department's own
as of the costs of implementation. Therefore, having that assessment
published would enable us to more clearly see whether there is
a gap.
Dr Ladyman: That assessment would
only make sense if we gave a time line. Were we to give a time
line for implementing the national service frameworks, I suspect
that you would be the first to stand up and say that we are trying
to manage the National Health Service from the centre.
Q399 Mr Burstow: Because there are
no longer any time lines, does that mean you are not making assessments
of costs in the future?
Dr Ladyman: No. I am saying that
we are making an assessment of the cost pressures that it will
introduce. Clearly, something that is emerging in a national service
framework is something that lots of people would like us to do
but it is unaffordable within the time frame of the national service
framework and it will not be published in the national service
framework. We need to do an assessment of the cost pressures the
NSFs produce in order to make sure that anything we are putting
in it is affordable out in the field.
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