|
UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 397-i House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE HEALTH COMMITTEE
The Responsibilities of the Lord Warner
Thursday 4 March 2004 RT HON LORD WARNER, MR MILES AYLING, MRS ANNE RAINSBERRY and Evidence heard in Public Questions 1 - 94
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Health Committee on Thursday 4 March 2004 Members present Mr David Hinchliffe, in the Chair John Austin Mr David Amess Mr Keith Bradley Mr Simon Burns Mr Paul Burstow Jim Dowd Mr Jon Owen Jones Dr Doug Naysmith Dr Richard Taylor ________________ Witnesses: Lord Warner, a Member of the House of Lords, Parliamentary Under-Secretary of State for Health [Lords], Mr Miles Ayling, Deputy Head, Planning and Programmes Unit, Mrs Anne Rainsberry, Change Management Head, and Dr Charles Dobson, Special Projects Adviser, Clinical and Cost-Effectiveness Group, Department of Health, were examined. 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. 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 2004/5) 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 Government 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 2005/6. 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 2005/6 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, 2005/6 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 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 meting 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. 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 has 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 about 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 CHI 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 CHI. 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 7.0-7.5 per cent 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 per cent 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 per cent 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 ----- Q60 Mr Burns: It sounded like that. Lord Warner: Possibly I was giving a complicated answer which may have made you think that, but I was giving ----- Q61 Mr Burns: It seemed very clear. Lord Warner: I thought I was being very clear. Q62 Mr Burns: You said that PCTs had money so that there was not a problem with consideration of the finances in taking the decisions on IVF, for example. Lord Warner: Would you like me to have another go? Q63 Mr Burns: Go on then. Lord Warner: What I was saying was that we are in the middle of a five-year period when NHS budgets are going up by 7.0-7.5 per cent in real terms. Those are very substantial increases. We are agreed on that. Q64 Mr Burns: We got that. Lord Warner: Seventy five per cent of that money is at the disposal of PCTs, so not at the disposal of the Secretary of State, not at the disposal of the SHAs. It is in the hands of the PCTs. NICE guidance itself has variable impact in different parts of the country to do with what the demographics of that particular part of the country are, almost by definition, because some people have got more elderly people, others have less, some people have got more younger people where women would be at the age for possible fertility treatment and others have less, so there are variations in the socio-demographic profile of the PCTs. The system works on the basis that they make the judgment in the light of their local priorities and their populations on how they spend their money. Those are the rules of the game. In that context what I was saying as a general point was that if you put that amount of money into the system, 7.0-7.5 per cent real terms increase over five years, and you look at the total cost of the NICE recommendations, there is no reason for thinking as a general proposition that money is a factor because there is enough money in the system to implement those NICE guidelines. That is the position of the Secretary of State and it is the position of me and it is the position of the government on this issue. I am not saying that within particular areas there may not be some difficult judgments to be made about the priorities on which they spend their money. Mr Burns: I think you are absolutely right on that, but that is not what you said the first time round. Q65 Mr Burstow: Taking it on a step further from that answer, the implication of what you were saying to Dr Taylor earlier on was that there are capacity bottlenecks within the system that make it impossible for three cycles of IVF to be introduced on the timescale that would normally be applied to the introduction of such guidance. Can you identify what those bottlenecks are, how widespread they are and how soon they will be overcome? Lord Warner: I have not got the details of the NICE report with me but my memory of it was that NICE themselves recognised that there were implementation issues so that, even if you wished it, you could not simply overnight introduce three cycles, not least because in many parts of the country there are already waiting lists for people wanting to access IVF. Those waiting lists would not simply disappear overnight just because NICE had produced their guidance, so there is a people capacity issue about their capacity to do that. There are also, which I think may influence people's judgment about what the costs are, differences of view probably about whether, if there was NICE guidance for three, you would not actually increase demand as well. There is some evidence base, I think, to suggest that all the while that there is not any NICE guidance there is probably some unmet demand in the system, so even if you just announce that one is going to be available everywhere on the NHS, you are probably putting up demand, so you would be facing NHS providers with a growing demand and existing waiting lists. In those circumstances you cannot magically increase the number of staff that quickly to meet those two pressures. That is the thinking behind this. Q66 Mr Burstow: That is useful, and if it is possible for you to amplify that a little further in writing it would be very helpful to identify further the rationale. Can you say a little bit as to why that process and the advice that ministers received that led to the decision by the Secretary of State to say that it should be limited to one cycle and whether or not a view was taken as to at what point in time it would be reasonable to say that the NHS should be delivering three cycles, because that has not been said yet and yet that means there are many people in the country who feel to some extent that they see themselves not able to get access to the treatment they want and certainly not access to the treatment that NICE said they should have? Lord Warner: I do not think we can anticipate that, mainly for the reasons that I have just given. What we are doing is encouraging all PCTs to make one cycle available throughout the NHS and we need to wait and see how they get on with that and see how things work. There are the resource constraints that I have mentioned. It is worth bearing in mind that even on one cycle the success rate is estimated to be that about 25 per cent of the women get pregnant, so that in itself will bring quite a lot of success in quite a lot of cases. Q67 Mr Burstow: Would you be concerned if some PCTs who offered more than one cycle already levelled down to the recommendation by the Secretary of State and only had one cycle? Lord Warner: We are back to the earlier discussion about PCTs making judgments about their priorities in their local areas. What we cannot do is have it both ways. You are either running a devolved NHS with a lot of local people making their decisions which, if I may say so, I understood your party to be in favour of, or you say, "We are going to try and control everything from Richmond House". Q68 Dr Taylor: I think we will move on from IVF, but just a quick comment on the money side. I do understand and welcome the vast extra investment. It is the distribution that is so difficult because I am sure many of us see our own counties in really quite massive deficit and it is hard to know where the extra money is, but I take that. Moving on, one of the other things that our report on NICE recommended was a change in the appeals process because we were rather concerned that the Chair of the Institute was the Chair of the Appeals Committee. He made it quite clear that because he was not taking active part in the actual inquiries he was therefore distant from them, but the government recommendation was that a change should be made. I wonder if that change has been made? Lord Warner: I am going to ask Dr Charles Dobson to speak on this. Dr Dobson: NICE have always been very clear that they see the appeals process as an integral part of the whole appraisal process. It is as it were part of the remedies available to interested parties who are not happy with the initial judgments. They have also consistently taken the line that it would be quite wrong for the appeals process to be too separate from NICE because that would in effect create two separate sources of advice to the NHS, NICE itself and the supposedly independent appeals process, so they have always very clearly taken the view that the appeals process should be an integral part of their operations. They do understand the argument about the need for individuals not to have a conflict of interest and therefore they have always said that if one of the non-executive directors is involved at an earlier stage in the appraisal process itself they should not also chair the appeals panel. They have reiterated that and that was included in the government response to your report. They still think it is a perfectly proper role for a non-executive director of NICE to chair an appeals panel in the sense that they are the guarantor on behalf of the public of the independence and the fair dealings of NICE. Q69 Dr Taylor: So that change has now been made and a non-executive takes the chair? Dr Dobson: The Chairman is a non-executive director. As I understand it they now have two distinct processes. If an appeal is lodged the Standing Appeals Committee first of all judges whether the appeal has merit prima facie and whether it should go to an appeals panel, and they have decided that the chair of the Standing Appeals Committee will be a non-executive but not the Chairman of NICE. If a particular appeal is accepted as having prima facie validity and goes to an appeals panel, the appeals panel could still be chaired by the Chairman of NICE if he had not had any previous involvement. That is my understanding of it. Q70 Dr Taylor: Going back for a moment to the WHO review, it was actually very recent. It was June/July 2003. The BMJ did a leader on the report back in November and by and large they welcomed the report. They said the report was good but it was incomplete. One of the things they pointed out that was lacking was that it did not answer the question. "What impact does guidance from NICE have in practice on allocation of resources and health outcomes at local levels?". I wonder if you have any idea if there is yet any evidence that NICE guidance is having an impact on clinical outcomes? Lord Warner: I am not aware of any but on the other hand we are talking about a pretty short period of time from the first lot of technology appraisals and we are talking about relatively small numbers. I will certainly go back and check whether there is any evidence and I will talk to NICE to see whether there is any evidence and come back to the committee. Q71 Dr Taylor: One minor measure would be if there was a reduction in letters of complaint about postcode rationing. Is that anything one could look into? Lord Warner: I am certainly happy to have a look into whether our correspondence mountain has changed in the little bit around NICE implementation. I will certainly look into that. It is a pretty unreliable measure. Q72 Dr Taylor: It would at least be interesting. Lord Warner: I will see what we can do. In the absence of the Chairman, John Austin was called to the chair Q73 Jim Dowd: I want to speak in particular about pharmaceutical issues. I was struck by Richard's use of the phrase just now "postcode lottery" which is bandied around in an almost self-evident fashion as if it is a bad thing, but it relates to something you said earlier. How do we reconcile the power to determine priorities locally with an expectation that anybody anywhere in the country must have the same range of treatments available to them? Lord Warner: The straight answer is, with the greatest difficulty. What we know with absolute confidence is that where we tried to run the NHS in a much more centralised manner we certainly did not achieve standardisation across the whole country. We know that the evidence is that there were differences of approach, different response times to particular treatments, variability in access to treatments. All those things we know from trying to run it in a very centralised manner. We also know that we alienated quite a lot of people by trying to do it that way, so we are moving to a situation in which the decision-making is much more locally based. Where I think that takes you in terms of the postcode lottery and variability in treatment responses is that you rely on local mechanisms and you rely on PCTs and providers to develop their relationships with communities and patients' forums as to how well they are doing in responding to those community needs. You have shifted the responsibility down to the local level; that is the reality. At the same time one is giving some broad strategic guidance from the centre and the example of "Please implement NICE technology appraisals within three months" is an example of that, except where NICE themselves say, "There are good and sound reasons why it is not possible to do that", not for financial reasons but for other reasons. That is why I think it is probably right that NICE keep out of the area of giving advice on resource issues because they are meant to be above that battle. They are meant to be looking at the merits of particular treatments in terms of cost effectiveness and not skewing their advice in relation to the particular availability of resources in particular areas. Q74 Jim Dowd: But has it not also generated an expectation that apart from deciding what the efficacy or otherwise of a particular procedure or therapy is, once it decides that this can be provided there is an expectation that everybody can have that? Lord Warner: I think we probably have fed some public expectations there, but on the other hand it would be fair to say that a bit of aspiration setting is the way you drive up performance and practice in public services probably. The journey can be a bit uncomfortable along the way. Q75 Jim Dowd: To turn to the pharmaceutical industry issues, the King's Fund, which of course is a research establishment, not a research provider, presented a report late last year - and I am not sure if you have had a chance to look at it yet - on the relationship between the National Health Service and the pharmaceutical companies and argued that for too long the relationship has been uneven in so far as the pharmaceutical companies themselves have driven the pace of development and the Health Service has acted as a passive purchaser of their products. How do you respond to that? Lord Warner: One of the things which has struck me in my eight months or so in the job is that one is actually trying to do two things. One is trying to maintain a very successful research based pharmaceutical industry in this country which is second only to the US. I spend quite a lot of my time going to EU meetings, more time than I would care even to reflect upon, but one of the striking things is how well we have done in maintaining that industry in this country compared with one or two places in Europe. We have to hang on to that because they are a very big driver of commercial R&D jobs. That is that bit. Q76 Jim Dowd: Is that because we let them dictate the pace? Lord Warner: I think we do not let them dictate the pace unreasonably. You can argue that we could do better in some particular areas, and I will come on to one of the areas where we are keen to drive the agenda more strongly. I do not think the King's Fund arguments are totally fair. They make some arguments, as I understand it, about elderly people having been neglected. If you just look at the NICE recommendations I think there has been a good improvement in the quality and the needs of elderly people being met through research based drugs industries in areas like dementia drugs. Children's needs are a slightly different situation but we do know that there is general concern about whether there should be a more bespoke range of drugs for children rather than modifying ad hoc drugs and that is a concern across Europe and there is an initiative going on in Europe and we are looking at the moment at not only tying into that European initiative, where we are one of the drivers of it, but at the same time seeing whether within the framework of European legislation we can take some initiatives to incentivise the pharmaceutical industry to move more rapidly along the path of bespoke paediatric drugs. There are some levers which we are exploring. We have just opened negotiations on the PPRS and that, in terms of research incentives, may be an area we can use. We could look at some of the regulatory fee systems to see whether we could give incentives for particular types of drugs. We are trying to respond to some of the spirit of the King's Fund report and try to identify areas, in particular this children's area, where we could be, if you like, a more active driver of the agenda. Q77 Jim Dowd: I was going to come on to the vulnerable groups they identified as not being best served by the current arrangements. You mentioned children and older people. The other group identified was women as not getting a fair deal. Do you have any response to that? Lord Warner: I do not have a response on women. It is a bit hard to make the case outside the children's area. Certainly for older people I do not think you could easily make the case because a high proportion of drugs on the market or in development have been developed particularly for that age group. I will go away and look at what the evidence base is on women and come back to you on that. Q78 Jim Dowd: They suggest for dealing with these perceived inequities, although I take your point that you do not think the case is as monochromatic as they make out, the establishment of a Health Research and Development Task Force. Do you have anything to encourage them in that direction? Lord Warner: As someone who is trying to review and rationalise arm's length bodies, probably setting up another arm's length body to go into this area is something I would be a bit circumspect about. I am not sure that we do need a task group. There are plenty of resources available for us to draw upon in reviewing this particular area. We have a lot of evidence from NICE on their work on drugs. We have the MRHA. We have a lot of professional advice available to us. I think this is a question of us looking at the evidence where I think it is not good. Their arguments are not good on the elderly. I will look again at the issue of women. We recognise there are problems on children but I think you are going to have to find solutions which are bespoke to particular kinds of groups if there is a problem. That would be my take on the issue. Q79 Jim Dowd: Finally, the steep rise in the cost of some generic drugs in recent years: what is the department doing to get better value for money for the NHS? Lord Warner: You may know, and I will send you the details if the committee does not know, that we did take some action just before Christmas on four drugs which have produced an annual saving of about £200 million. We recognise that there are some issues around generics. We are on that particular case. I cannot at this point give you further and better particulars but we are looking very carefully at the whole generics area. We are moving into an era when quite a lot of drugs will come off patent so this will be an important issue over the next few years. We are considering what action we might take but if you look at what we did before Christmas you can see that we are collecting the data and looking at that particular issue. Q80 Jim Dowd: So you are considering it at the moment? Lord Warner: We did take action. I do not at this particular time want to give a timetable. There are some relationships between this and the negotiation of a new community pharmacy contract because at the moment part of their income is derived largely from profits of generics, so there is a complex issue here to be dealt with. Certainly the last thing we want to do is damage the network of community pharmacists. Q81 John Austin: Could I just ask on the rise in the number of generics that Jim Dowd referred to, is that rise because of the manufacturer's price or is it a rise due to the mechanism by which the NHS purchases those drugs? Lord Warner: I do not think there is a single answer. There is certainly a pricing issue. It is complicated because there are some drugs which are coming in through parallel trade which are quite low. There are some drugs which do not come in that way. There are different purchasing arrangements between community pharmacists and hospitals. As a generalisation I think you will find that bulk purchasing in hospitals drives down the price more than the individual purchasing in the community pharmacy world. There are different sets of arguments in different parts of the NHS and in relation to different types of drug. John Austin: You mentioned earlier that you were responsible for the arm's length bodies. Q82 Mr Jones: When is your review likely to be completed, Minister? Lord Warner: Our aim, and I emphasise "aim", is to produce the report before the summer recess. Q83 Mr Jones: Do you foresee any mergers of these bodies in the review? Lord Warner: We have communicated with each of the bodies. We are still at the stage of getting more information from them about their work, their costs, their functions. What is already clear is that there is in some areas, and it would be wrong of me to go into too much detail at this stage; it would not be fair to the bodies concerned, some overlap of functions. There is also a big general issue which you may have picked up on in terms of the government's work through Sir Peter Gershon on back office services. It is a phenomenon of the arm's length bodies that they have all set up their own finance departments, their own human resources departments, their own IT systems, their own estates management functions. Those back office functions, which are essential but they do not relate to what you might call the front line services, are certainly an area where we are looking pretty critically in this review to see whether you can streamline them and make savings. Even if you did not have mergers per se you would be joining organisations together in some way in the provision of those back office services. Whether that would be a full scale merger or not will vary from place to place. Q84 Mr Jones: The committee recently were in Scandinavia and spent some considerable time being briefed by officials of public health organisations within various countries. It was remarked on in Finland that virtually all European countries have a public health function which is separate from their departments of health but they have this health education perspective and role to play. We do not have any such body and I know I quoted Derek Wanless earlier but I quote him again. He argues that without a health education authority no one organisation has clearly assigned responsibility for the health educational role. He sees this as a problem. Do you see it as a problem and do you have any plans to rectify it? Lord Warner: There is a body - you can argue that it is not strong enough, not resourced enough, etc - called the Health Development Agency which did succeed the old Health Education Council, so there is a body which exists in this area. One of the issues now for the government, both in considering the Wanless report and in taking forward this consultation on public health before it gets to the White Paper and as part of the arm's length body review, is whether this body needs to be strengthened, changed, adapted, whether there is a case for a different format in terms of a public health arm's length body. I cannot go any further than that this morning. This is territory which is not my responsibility but also we are at the beginning of a public health consultation and policy formulation. Q85 Mr Jones: Can I remark on what would appear to me, from many conversations that we have had, that the public health agenda is in a different culture from the curing people of being ill agenda and that the clinician viewpoint (or even the social services viewpoint) is about dealing with a problem that currently exists whereas the public health agenda is dealing with something that is foreseen and trying to stop it existing, so it may well be appropriate that you do not try and carry out that public health function within a department which is largely about looking after people who are already ill. Lord Warner: There are two strands to this, are there not? There is the provision of the service and there is the surveillance and strategic policy formulation. The Health Development Agency is clearly not a service delivery agent. Much of the public health delivery is down at the local level through directors of public health. Q86 John Austin: Nor does it have health promotion as part of its functions. Lord Warner: No, but there are some educational functions around that which it took over, as I recall, from the --- I will clarify this and write to the committee but I think you will find that it does have some educational functions. The point I am trying to make is that there are down at the local level directors of public health on the ground, there now at the PCT level, and you may argue that they are not resourced adequately but there is a potential local delivery mechanism. Q87 Mr Jones: It is not so much the local delivery mechanism that concerns me. Lord Warner: No; we were talking about the strategic position. Q88 Mr Jones: It was particularly our experience in Finland, which is a country which is a leader in this field. As well as the local delivery system it is clear that it is a national strategy worked out by a national body with a high profile which has driven successfully some of their policies. We do not have such an organisation. Perhaps we should. Lord Warner: What I was trying to say in my earlier answer was that this is an issue to be dealt with as part of the consultation and leading up to a White Paper on public health and in the light of consideration of Derek Wanless's review. All I was trying to say was that there was a body in existence; I was not claiming it met all the needs that you are suggesting, and that there were local delivery mechanisms. It is now for the government to consider this issue in the light of the Wanless proposals. Q89 John Austin: Some of us have a suspicion that the Health Education Agency was wound up because the government of the day did not like what it was saying. Lord Warner: I was otherwise gainfully employed at the time. Q90 Mr Burstow: You also have within your brief research and development. I wondered if you could say what work is currently being done to ensure that the department has a robust standardised and systematic approach to the commission research. If you cannot outline what it is today would you perhaps send us some more details on what that systematic and standardised process actually is? Lord Warner: I am happy to write and elaborate on some of those issues. Of course, a lot of the research which impinges on health is done by the Medical Research Council which is not the responsibility of the Department of Health. We have in this country a complex research system in relation to health. We have the Medical Research Council in one position. We have, unusually in Europe, a very powerful, strong and not-for-profit research sector with bodies like Cancer UK, and we have the government machinery in the Department of Health as well, so one is spending time in the Department of Health ensuring that one is not duplicating these other strands of activity and the department's Director of Research and Development, Sir John Patterson, and his team work on that particular basis. It might be helpful to the committee if I sent a short paper to you showing how that particular system works because it is not a simple system and a lot of the money in that programme is devolved down and has been historically down at the local level to ensure that there is also a robust and strong local research capability as well to carry forward research in particular trusts. Q91 Mr Burstow: That would be very helpful. The reason I asked the question primarily is because of some briefing I had last week regarding the issue of diabetes and the need to develop practical methods for early detection of diabetes and susceptibility to diabetes that the National Screening Committee has said needs to happen. My understanding is that there has been no scoping study done in advance of individual pieces of research being commissioned which could result in research coming up with information or results that are irrelevant to the primary need because of the absence of scoping in the first place. That is why I am a little bit anxious as to whether there is a systematic process in place to see whether scoping is always done before research monies are spent. Lord Warner: I would need notice of the question, but I have taken notice of the question and I will respond to it. Q92 Dr Taylor: As Minister in charge of research are you aware of the very real distress among the research community about the Human Tissue Bill as it stands at the moment? Lord Warner: I am only too well aware of that and if you are in the House of Lords there are a very large number of eminent scientists and doctors who never miss an opportunity to express their concerns to you. We are considering those concerns and, if only for the purposes of self-preservation, I hope we will be able to resolve them before I take the Bill through the House of Lords. John Austin: Minister, you have offered to write to us on a number of points. I am sure our Clerk can clarify with your officials the areas that we have sought information about. Q93 Mr Amess: Chairman, could I ask a very quick question? We obviously understand that the government has no plans at present to change the law on euthanasia but what is the government's position in terms of Lord Jopling's Bill? Lord Warner: I am not the minister responsible for dealing with this, although I will have to deal with it in the House of Lords. I do not have policy responsibility in this area. It is Rosie Winterton's responsibility. I would suggest that if you wish to pursue this question you might correspond with or see Rosie. Q94 John Austin: Could I express our thanks to you, Minister, on your first appearance before us. I hope it was relatively painless. Lord Warner: I enjoyed it very much. |