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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 398 - i House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE HEALTH COMMITTEE
THE USE OF NEW MEDICAL TECHNOLOGIES WITHIN THE NHS
Thursday 3 March 2005 PROFESSOR CARL MAY, MR BALJIT DHEANSA, MR JOHN WILKINSON, PROFESSOR SIR JAMES UNDERWOOD and MR TONY RICE DR FELICITY HARVEY, PROFESSOR TOM WALLEY, PROFESSOR IAN PHILP and SIR CHRISTOPHER O'DONNELL Evidence heard in Public Questions 1 - 109
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Health Committee on Thursday 3 March 2005 Members present Mr David Hinchliffe, in the Chair Mr David Amess John Austin Mr Simon Burns Jim Dowd Dr Doug Naysmith Dr Richard Taylor ________________ Memoranda submitted by Carl May, Queen Victoria Hospital NHS Foundation Trust, Association of British Healthcare Industries, Royal College of Pathologists and Tunstall Group Ltd
Examination of Witnesses
Witnesses: Professor Carl May, Centre for Health Services Research, University of Newcastle upon Tyne, Mr Baljit Dheansa, Consultant Burns and Plastic Surgeon, Queen Victoria Hospital NHS Foundation Trust, Mr John Wilkinson, Director General, Association of British Healthcare Industries, Professor Sir James Underwood, President, Royal College of Pathologists and Mr Tony Rice, Chief Executive, Tunstall Group Ltd., examined. Q1 Chairman: Can I apologise for the slight delay and can I congratulate those of our witnesses who have managed to make it through the snow, from wherever you have to come, as some of you have had to travel some distance, and we appreciate it. We have one witness who is stuck on a train and who hopes to be here as soon as possible, but we felt it important to make a start. Can I thank you for your cooperation with this short one session inquiry; we are most grateful to you. As you appreciate, we have two short sessions this morning, so I hope our questions will be reasonably concise and I would appeal for reasonably concise answers. I think in some respects, because the area that we are looking at is so wide ranging, that perhaps we are looking at common things which we can pull out of the two sessions that might be helpful in any report that we produce. Can I begin by asking you each to briefly introduce yourselves to the Committee, starting with you, Professor May? Professor May: My name is Carl May; I am Professor of Medical Sociology at the University of Newcastle. Over a period of several years now we have undertaken different kinds of evaluation work on telemedicine, telehealthcare and telecare systems, which we have enjoyed greatly and which we hope have made a contribution to debates about policy and practice in this field. Mr Rice: I am Tony Rice, Chief Executive of Tunstall. We are the leading company in the UK on telecare, with one and a half million systems installed in the homes of the elderly, those with chronic conditions, and who are frail and at risk. Professor Underwood: James Underwood, President of the Royal College of Pathologists. Our responsibilities are for professional training and standards in pathology. Mr Wilkinson: I am John Wilkinson. I am Director General of the Association of British Healthcare Industries. We represent businesses producing and distributing everything from sticking plasters to MRI scanners. We represent in excess of 500 companies, and we acted as the Secretariat for the Healthcare Industries Taskforce. Q2 Chairman: Does your remit include companies of the kind that Mr Rice has, the telecare section as well, or are you primarily on the medical side? Mr Wilkinson: Not specifically. We have a broad reach. There are companies in our remit that cover specific telecare, but we have a broad reach. Mr Dheansa: My name is Baljit Dheansa, I am a burns and plastic surgeon based at the Queen Victoria Hospital Foundation Trust, which is a Trust that has a significant input in the practical use of telemedicine for the management of burns and plastics format. It is currently going under review for its critical care burns service and the telemedicine that we use is an essential part of that. Q3 Chairman: Thank you very much. Can I ask a broad opening question about where we fair in terms of telemedicine and telecare in international terms? One of the advantages of being on this Committee is that we get the chance to look at other healthcare systems in various parts of the world, and I have always been very struck by other countries making much greater use of new technologies compared to ourselves. I was conscious of the Wanless Report's comments some time ago about the way we have been historically slow to adapt to these new technologies and we have had figures presented to us showing that we are more or less at the bottom of the European league on percentage of healthcare spent on medical technologies. Why is this when we have some brilliant ideas - some of the people I meet, some good companies are in the forefront of world technology advancing ideas - that we as a country are so slow to take advantage of these innovations? I do not know who wishes to start on that? Mr Wilkinson. Mr Wilkinson: Could I perhaps introduce a perspective from the Healthcare Industries Taskforce, which we were heavily involved in last year, which was really addressing these issues and trying to work our way through with the Government and a number of stakeholders in the sector as to why things were not happening? I think one of the key elements is the propensity for budgets to be held in silos in the UK, and it is quite difficult to demonstrate value across silos and treatment pathways, if you like. Let me give you an example. Insulin pumps are a technology which has been well adopted in other countries - 40,000 people use them in Germany and less than 2000 use them in the UK. Why is this important? Type 1 diabetics, if not managed effectively, suffer substantially later in life and cause huge costs to be brought on to the system. An investment up front in managing diabetes effectively can downstream, bringing huge benefits in avoiding blindness, amputation, ulceration and all sorts of unpleasant consequences. So I think there is a silo issue. I think also there is an issue relating to the engagement of the involvement of clinicians in the procurement process and particularly the evaluation of technologies and translation of those through every day use. Again, the Healthcare Industries Taskforce has been working very hard to try to work on the mechanisms which can join these bits up and pull technology through the system. Q4 Chairman: I am assuming that if we were, for example, to make a recommendation suggesting the integration of our health and social care systems that might be helpful in advancing the cause of telehealth and telecare. Mr Wilkinson: I think increasingly the location of treatment and management of patients is becoming less hospital-centric. Q5 Chairman: So a more integrated system would be helpful? Mr Wilkinson: It is integrating the passage of the patient from first presentation at the GP through to management in the community afterwards, potentially after a surgical intervention, is clearly the way the world is going. So I think integrating those activities clearly has value. Q6 Dr Naysmith: Can I just come in on that? You still have not answered the question the Chairman asked you. Let us say there were 40,000 using these insulin pumps in Germany and less than 2000 here. Mr Wilkinson: As I say, there are a number of issues. There are clinical practice issues and how do we get best practice consistently applied across the country? I believe that there are issues in terms of funding reaching the front line, so certain PCTs are happy to fund this sort of activity whereas a neighbouring one may not be. So there are many issues. Q7 Dr Naysmith: Nobody is saying it is a waste of money, are they? Mr Wilkinson: I do not think so. I think the challenge is recognising the value effectively and translating that across the system so that people can make wide decisions. People are hard pressed to manage their individual budgets. Q8 Chairman: I know that Mr Rice and Professor May may want to come in on that general point, but can I throw in another question arising from your answer? One of the things that struck me in looking at how we can advance this whole area within the health service is the way in which increasingly both the current Government and the previous Government have moved in the direction of devolving decision making and devolving budgets, so perhaps in a sense reinforcing the silo concerns that you have pointed to. Is that a factor in some of the concerns you have about the inability to move things forward? Mr Rice, do you want to come in? Mr Rice: Yes. The answer is absolutely, unequivocally yes. The role of telecare is to effectively keep people where they want to be, in their own homes, and remove the routine load from the acute sector, the hospital sector essentially, and bearing in mind that the routine load is largely centred around the elderly who are the people who mostly have the chronic conditions, although obviously Type 2 diabetes is a much younger condition. Everyone contracts MRSA but the elderly are the ones who tend to die, they are the more frail and vulnerable and therefore we want to keep them away from hospital. So telecare fulfils that role. Telecare of course is preventative and it is funded by social services and acute care is funded by the Department of Health and therefore the removal of people from the acute sector, which saves the Department of Health money, imposes an additional cost burden on social services, and until we find a way to pool those budgets - and there are initiatives underway to do that - then I think the budgets and responsibilities being divided will continue to mean that we are sub-optimal in our utilisation of new technologies. Q9 Chairman: Professor May? Professor May: It seems to me that one of the errors we fall into is viewing the National Health Service as a unitary organisation, when it is actually a federation of several hundred NHS Trusts, each of which have often incompatible and inconsistent procurement policies and which have different political interests. This places a huge obstacle to industry in negotiating its way through the procurement pathway. So relatively small companies and quite large ones find it very, very hard to engage with the National Health Service because it is not a National Health Service, it is many different health services. There is a second problem, which is something that we have noted many times in our own studies, which is the incompatibility of two key policy streams: the modernisation stream which seeks to use technological innovations to move services forward very rapidly and to develop their patient centre services, services which have a degree of local participation and which cross organisational boundaries, and the policy stream that demands evidence-based practice because the production of evidence always takes a very long time if it is going to be formed in a way that will satisfy the demands of clinicians and budget holders. Those three things come together to make it very hard for the private sector to negotiate with the NHS. Q10 Chairman: The areas that you are concerned with really look at the relationship between primary care, secondary care and obviously social care. How satisfied are you currently in local discussions - and my area is a good example, we have a major PFI capital scheme for a new hospital in Wakefield, and that scheme has been called a "whole district" scheme because it has looked at not just one hospital but three hospitals and also links with primary care - that evaluation of schemes of that nature and moving schemes of that nature forward are taking account of where we are now on the areas that you are concerned with, and certainly where we will be in ten, 20 years' time when these facilities will be up and running and serving people? The frustration I have had with my own scheme is there has not been sufficient vision, particularly about the relationship between primary and secondary sectors, as to what telemedicine can achieve in terms of reducing the current reliance upon your acute hospital sector? Professor Underwood, would you like to take that? Professor Underwood: I cannot understand that but can I throw in another factor, which is geography and population density? In my own field of pathology, telepathology - that is the transmission of diagnostic images of human tissue - is quite established in Scandinavia. That is because the population is so sparsely distributed and there are many hospitals that do not have on site pathology services. If a patient has a breast lump which necessitates intra-operative diagnosis by what we call frozen section, in this country that is dealt with by the pathologist on site in the hospital because we have a dense population and every hospital in this country has on site pathology services. But in Scandinavia that is not the case and in Scandinavia the image is transmitted from a small hospital with no pathology service to a large hospital with an expert pathology service where the diagnosis is made. So there is the necessity factor, which is driving the implementation of telepathology in some countries. That is less of a pressure here because although we do not have enough pathologists we have more pathologists, more widely distributed than in Scandinavia. Chairman: That is very interesting because I was actually in Tromso, in the north of Norway, where there is a centre of the work in Norway doing exactly what you are describing, and I thought at the time, Richard, that with what they are doing there you do not need Kidderminster Hospital, so over to you for your questions! Q11 Dr Taylor: Thanks, Chair! Chair, can I declare two interests first? I have to declare a personal interest because my wife is a quite severe insulin dependent diabetic who ought to be on a pump, and I shall be campaigning for insulin pumps. Secondly, I do have a very few shares in Smith & Nephew. I want to follow up with Professor Underwood. Going down to basic telemedicine as far as laboratory data is concerned, the electronic transfer of data is fairly well developed when you talk about just pathology results. Is that universal across the country? Professor Underwood: It is quite well established. I know you do not want to talk about the National Programme for Information Technology, but our concern is the interface between our laboratory information systems and NPFIT. We do have concerns about the lack of seamlessness at the interface between our laboratory systems and the National Programme. Q12 Dr Taylor: So there are very real concerns on that? Professor Underwood: Yes. Q13 Dr Taylor: We will be raising that with the Department's representative in the second part. In the broadest terms, what do you think are the advantages to patients and to professionals of telehealthcare in the broadest terms? Professor Underwood: I think in this country the place of telepathology - that is what I have been describing in Norway - is in seeking expert opinion on particular features of a case, particular aspects of a case. Not the overall diagnosis, because I think in my field of histopathology the overall diagnosis is best made when you can see the specimen that has been removed from the patient, you can talk to the surgeon who has removed that specimen, you can look at the X-rays and you can have access to all sorts of additional clinical information that contributes to the diagnosis. I do not think in this country we are confident that telepathology, the interpretation of the image on a screen from a hospital 100 miles away, is necessarily the best way to make the diagnosis, but it is a good way to seek an expert opinion on a specific feature or aspect of the case. Q14 Dr Taylor: If the expert is not with you on the same site? Professor Underwood: Yes. Q15 Dr Taylor: So it is a form of video conferencing? Professor Underwood: It is, yes. Q16 Dr Taylor: And that is in wide use? Professor Underwood: No, it is not. There is a lot of enthusiasm for it in the profession but it is not widely used. Q17 Dr Taylor: I think you were quoted yesterday talking about imaging in some way taking the place of post mortems? Professor Underwood: I was mentioned in the Press yesterday as a result of a briefing, yes. Q18 Dr Taylor: Is that a realistic hope because the post mortem rate, as we have discovered on a different inquiry, is dropping alarmingly. Professor Underwood: It is, yes. Q19 Dr Taylor: Is this a realistic way forward? Professor Underwood: I think we could do more to make the post mortem examination more informative by capturing digital images taken at autopsy and showing them the same day or the following day to the surgeon or physician who has requested the examination. The problem with post mortems at the moment as you, as a doctor, will know is that often a long interval elapses between doing the post mortem and the issuing of the report of the examination, by which time the surgeon or physician has seen hundreds of other cases and they have lost, in a sense, interest in that case. Q20 Dr Taylor: It is particularly with examination of the brain where that has to be fixed for weeks and weeks? Professor Underwood: Yes. Q21 Dr Taylor: So could that speed up examination of the brain? Professor Underwood: No, not of the brain but it could make the post mortem examination more informative and therefore motivate physicians and surgeons to request them more often. Q22 Chairman: Professor May wants to come in. Professor May: I think one of the things that we need to remember is that incorporating these new technologies into clinical practice actually requires that the hospital departments re-engineer their business processes. For example, in some work that we did on a telepsychiatry service we found that the pressure on consultants to be in a particular place at a particular time to see a patient on a video link created real problems in the distribution and organisation of other work. So a problem for NHS departments that want to use these systems is thinking about how to integrate the hidden work of delivering healthcare, the things that none of us think of in terms of professional practice because we see a doctor at work on a patient and we neglect the work that goes on to deliver that service in a flexible way. Some of these systems can be quite inflexible for clinical users and that has led to some resistance. One further point to make of course - and I know also that you do not want to discuss the National Programme - is that for many IT professionals in the NHS a real problem with these systems (and there are many of them) is concern about whether they will be compatible, whether they can be compatible with the new information spine and the work that different contractors are doing on NPFIT clusters, Mr Dheansa: At the Queen Victoria Hospital we have successfully introduced a telemedicine system which is a store and forward system, which looks at plastics trauma patients and burns patients, and it has been successfully introduced and it has been incorporated into the daily use of the hospital because it has changed the way that we manage patients, to avoid the unnecessary transfer of patients, to safely triage patients at a distance and to plan their appropriate surgery without unnecessary visits to our hospital. Because it is a regional trauma centre it covers a population of four million people, and patients may have to travel up to 80 miles to see a plastic surgeon. With the use of telemedicine pictures one can make much more appropriate decisions, thus avoiding late night transfers, which can sometimes be unsafe and also make appropriate operative decisions, such that a patient can come directly to theatre rather than making a visit and then having to wait unnecessarily. Q23 Chairman: Just before you carry on, I was very interested in what you have done because I have a burns unit, as you know, in my part of the world. In 1999 what actually kicked off the idea of introducing this approach? What were the factors that resulted in huge interest? Mr Dheansa: It basically stemmed from patient safety. We had a patient who was referred to us, we were informed that they had a very large burn, they needed to have immediate transfer to enable their safe management, intravenous fluids and what have you. On the information we were given from the referring hospital we felt that the only way to get them to us quickly was to use a helicopter. Helicopters are very useful in transferring patients quickly but they are also very, very cold and relatively unstable. If a patient becomes very unwell in a helicopter transfer then it is much more difficult to manage them. This patient came over, we assessed them and they did not have a burn; they went home in a taxi that day. Q24 Chairman: In other words, if you could have seen them it would have avoided all the expense. Mr Dheansa: That is right. To some extent the cost to us was not significant but the cost to the NHS as a whole was massive. Q25 Dr Naysmith: If I could just come in here, Richard? It is a question I was going to ask Mr Dheansa later on but this is a very good point to ask him. One of the criticisms often made is that it is quite hard to produce links between primary care and secondary care and between specialists and non-specialists. You seem to have solved that problem at the Queen Victoria; you have very good relationships with everybody you need to have a relationship with. Why have you managed that and are there lessons that other people can learn later on? Mr Dheansa: The first thing was identifying the problem and the problem was that patients were travelling long distances and sometimes unnecessarily. We then found the means to avoid those unnecessary trips, and at the same time we had an increasing number of referrals and we were filling up to capacity, so we needed a safe way of triaging and changing our practice to enable a vast number of patients to come through, and explaining this to our colleagues in the Accident & Emergency Departments and then providing a clinical champion. So we provided support in the form of a clinical champion and also identified the clinical champion within those Accident & Emergency Departments. Providing that support enabled doctors in those units to see the benefits of those cases where telemedicine was useful, and in fact it has become so useful now that patients' photos are sent to us before they actually get on the phone, to make it even easier for us. It is the constant support so at that A & E Departments do not have to worry about having to maintain the system because we will provide that support and, equally, legitimising its benefits. The doctors and the nursing staff can actually see the benefits of doing that because it means that their referrals are quicker and easier and it means that patients are happier because they do not feel unhappy about travelling long distances when they do not need to. Q26 Dr Naysmith: Forgive me, Richard, this will be the last one. Is that because you have a very specialised area of medicine that you are involved with in burns surgery, and that sort of thing, or could it work with other things too? Mr Dheansa: It works in two ways. For instance, in burns critical care, where we have a very large burn, someone has had smoke inhalation, where they have potentially life threatening conditions, it is a situation that A & E doctors do not come across very often and it is something with which they need as much help as possible. So it means that I can start managing the patient right from the beginning. I can say, "This patient may well be safe for transfer with the clinical information you provided over the telephone and the photographic evidence I have before me." So in situations where doctors feel out of their depth and rarely treat a situation it is very, very useful. Equally, there are situations where there are benefits to be had from much more common injuries, so finger injuries where some specialised treatment may be necessary in certain situations but not in others. Equally, it is also useful within the hospital because it means that consultants who are, for instance, in an operating theatre can also help manage patients in the rest of the hospital whilst still in theatre. A good example would be that I was operating on a large burn the other day, I had a patient who had a wound break down in dressing clinic and I also had an outside burns referral, all of which needed expert opinion, which the junior doctor wished me to be involved in, and I was able to do all three to some extent without leaving theatre, without compromising any of their care. These sorts of things are quite useful, not just outside of hospitals but within. So transferring pictures of wound breakdowns for general surgeons, for instance, or for orthopaedic surgeons and X-rays. Dr Naysmith: Thank you very much. Q27 Dr Taylor: I think your speciality is one that lends itself ideally to this sort of work. In your memorandum, Professor Underwood, you said that there was often a reluctance to use the new technologies; that it was more difficult to look at a section on a video screen rather than down the microscope. Professor Underwood: Yes. Q28 Dr Taylor: How can you overcome that reluctance? Professor Underwood: Through training. We train with microscopes and I daresay that in 50 years' time histopathologists like me will be using flat screens on which the images will be projected, perhaps the histology slides will be digitalised and therefore transmissible more widely. The other thing is, that in seeking second opinions it is much easier in this country to put the histology slides into a padded envelope with a referral letter and send them by post and to get a full and reliable expert opinion than to get a partial opinion more quickly by telepathology. Often the opinion that we are asked for does not have to be given so quickly that it needs telepathology. It is not like burns, which is a very acute situation. We are dealing with cancer diagnoses, which, apart from the intra-operative situation, do not necessarily have to be made within a few hours - often a day or two to get a very reliable interpretation is better for the patient. Q29 Dr Taylor: To someone who was not used to looking down a microscope it would appear to me to be far easier to look at a huge screen with everything magnified even more times than just peering down a microscope. Professor Underwood: Yes, I suppose it is like the difference between driving a car and flying a plane. I can drive a car but I would find it impossible to fly a plane, but pilots have no problem with that because they have been trained to do it. If we are confident that in ten or 20 years' time colleagues of mine will be diagnosing off flat screens then we had better start training them to do that now. The other thing is that the technology has improved considerably over the last decade or so, but the resolution that one can achieve with digital microscopy is far superior now to what it was even five years ago. So it makes it more realistic and feasible to consider diagnosis off screen. Q30 Dr Taylor: So it is a question of training, practice and usage? Professor Underwood: Yes, and developments in technology that make it feasible. Q31 Dr Taylor: I want to move on to regulation because POCT - Point of Care Testing --- Professor Underwood: Or Near Patient Testing, it is often called. Q32 Dr Taylor: You are suggesting either a single regulatory framework must be applied to all diagnostic tests, whether Point of Care Testing or laboratory based, or that somehow laboratories have to somehow take the responsibility for controlling the point of Point of Contact Testing. Professor Underwood: Yes. Q33 Dr Taylor: What do you want us to recommend on those lines? Professor Underwood: It is important to bear in mind that Point of Care Testing includes a wide spectrum of patient testing. Your wife is a diabetic, so is mine; so our wives do blood glucose tests frequently, and that is Point of Care testing - the patients test themselves. We do not envisage that that test ought to be regulated by a local pathology service and quality assured and that sort of thing. But where in a hospital testing is being done at the bedside or in the operating theatre, we believe it should be done to the same quality assurance standards as the same test done in the laboratory. It is perhaps even more important it should be quality assured to the same standard because if it is being done at the bedside the clinical action that is likely to result is going to be very immediate, so we need to make sure that that action is based on the most reliable result. Q34 Dr Taylor: What about chemists' cholesterol levels? Professor Underwood: I have concerns about that, from the pre-analytical, analytical and post-analytical aspects. On the pre-analytical aspect I went into Boots recently and I found a leaflet that said on it that three out of four adults over the age of 45 have high cholesterol. What does the ordinary man in the street conclude from that, that only 25 per cent of people have a normal cholesterol? I think that is grossly misleading information that is given to patients, motivating them to have a test, which is 75 per cent likely to show that they have, by Boots' standards, a high cholesterol, which then results in over the counter sale provision of superstatin. So I am concerned about the probity aspects of that and the quality assurance aspects. Q35 Dr Taylor: So it is a very good way of increasing sales? Professor Underwood: I am not unhappy for you to say that. Then there is the test itself and its quality assurance. If the patient has a high result it could be because they genuinely have a high cholesterol or because there is a problem with the test itself. In hospital based testing we know whether it is a genuinely high cholesterol or a wrong result because we quality assure the method. I do not now if Boots and other high street chemists do that. Dr Taylor: Thank you; that is very clear. Q36 Chairman: Could I ask one more question before I bring in Doug? Going back to Dr Dheansa, one concern that I have had raised with me about down the line consultations - and frankly this is nothing new, I can recall 35 years ago when I was training in social work I was going into hospitals where we were doing sessions where a consultant psychiatrist interviewed a psychiatric patient in front of a camera and a roomful of people saw the outcome, and we discussed the diagnosis and all this sort of stuff, so this has been going on for a long time - is that where you have people going down the line, maybe in primary care, and someone like you in a tertiary hospital or wherever, looking at that patient, there is some anxiety on behalf of the patient about who is seeing them down a camera, particularly if they are showing their more private parts, shall we say. Is that an issue that you have addressed and how do you deal with those anxieties? Mr Dheansa: It was actually integral to our development of the whole system because we have certain regulations, Data Protection Act, Human Rights issues and what have you, which we pull together with the general act of patient dignity and privacy that we all need to address, and we have developed quite a comprehensive photographic and video recording policy, which includes getting the patient's consent but explaining to the patient where those images are going to be used. Q37 Chairman: I a appreciate that this is quite a complex area and if it is possible for you to give us some follow-up information on exactly what is given to patients, that would be very, very helpful. Mr Dheansa: If you would like I can actually forward the policy we have developed. Chairman: That would be very helpful; I am most grateful. Q38 Dr Naysmith: I want to follow up with Mr Dheansa an aspect of the fact that you are giving advice fairly widely to people who ask for it, and you have good links with other Trusts, and so on, partly because of the success of what you have done at the Queen Victoria. But do you suffer a financial disadvantage in any way because you are offering this service? How is it paid for? Mr Dheansa: To some extent we have had a financial disadvantage. We have been very cost efficient in developing this system. To date, since 1999, we have spent £85,000 on developing a system that has transformed our management of 3000 patients a year, and we have not been reimbursed for that cost. The advantages that it gains to the Trust in terms of efficiency and appropriate theatre and bed utilisation is such that we can treat more patients; and also to the NHS in general in terms of avoiding inappropriate transfers, and more importantly to the patients. So although there are cost benefits the hospital itself has not realised those cost benefits except by more efficient usage of the facilities that they have already. Q39 Dr Naysmith: Is this then an inbuilt disadvantage or disincentive to do things because spending money on developing new systems means that you actually spend the money and you do not get any reimbursement for it? So some Trusts are making use of your facilities and not paying for them. Mr Dheansa: There is and certainly that is an issue in terms of payment by results issues, in terms of commissioning for patient care. To some extent we feel that it is important that those costs are reimbursed because on a wider scale it would be cost inefficient and even in the States, where telemedicine is utilised on a wider scale, those costs are not reimbursed and it is detrimental. Q40 Dr Naysmith: Have you anything to offer in this area on how it might be done because I know that usually when I speak to clinicians about this sort of thing they say they do not want bits of paper flying around the system and charging each other. Although it is coming in in in some centres. Mr Dheansa: I think it may well be in the form of recognition. So, for instance, with payment by results, where care at a particular facility is paid for, I think when one is actually organising tariffs for patients one ought to introduce a cost within that for telemedicine and telecare because it is the simplest and most efficient way of doing things. Dr Naysmith: Thank you. Q41 John Austin: I think everybody can point to the long-term potential benefits of various new technologies, but it is quantifying the risks and balancing the risks and I think that Professor May was talking about some of the problems about lack of a central sponsorship or procurement, and I think Professor Underwood was talking about the lack of compatibility with other systems. We have also had some evidence that sometimes there is a problem with patient compliance as well, even in some of the well and heavily managed trials. How do you balance the benefits of the risks, are they clearly understood and how they are managed, particularly when we are talking about a proliferation of potential commissioners and purchasers of these services? Mr Rice: Just an observation, which is that it is very easy to go for a number of high technology solutions that are incompatible. It is really important, certainly in the teletechnology field, that the solutions are relatively simple, the clinician still has complete control of the process and where more complex solutions are needed then they are delivered in an institutional setting where the quality of the assessment, for example, can be higher. I always have a concern about non-compatible systems. One of the interesting things about telecare is that we already have an installed base of telecare systems and monitoring systems which can be used for simple monitoring. That really just removes, if you like, the bread and butter workload from the clinicians so that they are free to do the more higher quality work in an institutional setting or, indeed, by using teletechnology if they want. I do think that with the National Programme for IT and the desktop applications that are overlaid on that in terms of teletechnologies that it is very important that they are compatible, they are simple and they work in a mass market, because the savings are immense and the qualitative savings are huge. To give you a very quick example, the example we always use for telecare, which is similar to my colleague at the end, is pregnant women in the outer isles. We install vital signs monitors there because at present - or until two years ago - they had to fly to Glasgow for assessment, stay overnight after assessment and fly home, and arrange childcare if they could not arrange childcare on North Uist, or whatever. Now we have vital signs monitors where they can be assessed and a nurse in Glasgow looks at it and says, in 99 per cent of the cases, "Fine, same time next month," and in one per cent of the cases, "You need to come over here." But actually that is not the mass market, the mass market is Mrs Smith, aged 82, who has a routine visit to her local hospital or her clinic, and for her it is much more arduous to get from the south of Leeds to the north of Leeds by public transport for a monthly assessment when she could go to a local health centre or indeed the common room of her sheltered housing development to have an assessment. So I think there is a simple market and there is a complicated market; the complicated market I am happy to leave to my clinical colleagues, who know a lot more about it. Q42 John Austin: I think Professor May wants to come in. Professor May: I was going to echo that point, which is that it is very important to separate the different kinds of service. Telemedicine is usually a very specialised clinical service and telecare is a much more general field. It is worth contrasting the failure of the NHS to invest in telecare systems with the massive investment in teletriage which you have with NHS Direct and NHS 24 in Scotland. Those have been very successful; they were rigorously piloted; good quality data was collected about successes and failures and, lo, we now have the National Teletriage Service which will provide advice and referral and will call you an ambulance if it transpires that you need one. The failure of the NHS to engage with telecare systems comes back to the problem where the benefit lies. The benefit for telecare lies largely, as Mr Rice has said, in the field of social services because it manages often elderly, often disadvantaged, often very vulnerable people remotely. It has very clear parameters for calling in specialised or expert help and that means it can be very cost effective. The cost effectiveness of telemedicine systems is sometimes in doubt and that cost effectiveness is in doubt largely because of the poor quality of most of the economic evaluations that have been done. The truth is that we do not know whether these systems are cost effective - not that we say that they are not cost effective - and that is because the economics of the National Health Service are really some of the most extraordinarily byzantine things in the history of humanity. Q43 Chairman: Can I pick you up on that point? What you are saying is that the kind of stuff that the telecare aspects of this inquiry are more beneficial to financially is social services. My recollection of the last time I visited Tunstall Telecare, Mr Rice's company, was probably last year some time - and I cannot remember whether you were actually there, Mr Rice - and you gave somebody from the Treasury and myself a presentation on the cost implications for the NHS of avoiding elderly people falling in their own homes, and in particular fracturing their hips which, as we all know, is a common problem that leads to other difficulties and is hugely costly for the NHS, and we had a presentation which enabled us to understand a series of quite simple mechanisms that can be fitted into a person's home that enables elderly people to be less susceptible to falls of the kind that result in broken hips. Basic, simple straightforward things like when you get out of bed to go to the loo during the night, when your foot hits the mat the light goes on and you can actually see where you are going. Simple, straightforward, commonsense things like that. The figures that his company gave us showed a direct impact upon NHS costs of saving the person having that serious accident. So I think I would disagree with you - unless I have misunderstood what you are saying - that I think there can be huge cost savings for the NHS in telecare. Professor May: I cannot comment on that particular case but what I can say is that the published evidence about cost effectiveness is often of methodologically very poor quality. Individual companies can produce service specific evaluations, as can individual NHS Trusts. To go back to what you were saying, there are some even more simple ways of stopping elderly people breaking their hips, using hip pads and using cushioned underlay - Duralay make a cushioned underlay for carpets - that will negate some of those problems. Q44 Chairman: The point I was concerned about was that the outcome of that meeting with Mr Rice's company, with this Treasury person, who was involved by the way, and I took to see, and what I thought was interesting stuff was that in the budget statement last year we got some additional resourcing for investing in telecare, which in a sense will save huge amounts of money in the NHS, and it is commonsense, and it frustrates all of us that we cannot see these connections more often. There are all sorts of hands going up. Mr Wilkinson. Mr Wilkinson: The point I was going to make is actually telecare, investments in IT, investments in all manner of technologies only work if they are integrated into a system of care and you re-engineer, as my colleague said, the whole way that you manage patients. I think most of these technologies are enablers of significant changes. We have had lengthy discussions about telemedicine. Implantable devices, a lot of them are very active, produce information; pacemakers produce information about the status of the patient. That, while the patient is walking around, can be transmitted back to a computer which can analyse what is going on and flag up problems. That is, one, very good for the patient; but, two, it potentially eliminates regular checkups because you can actually pick up the patient's call when the need is there. This principle applies to most of the technologies. They have to be applied across the system and that is about evaluation methodologies, getting the value appreciated across the system and re-engineering the patient pathway and the way the patient is cared for. That is where the real value is. Q45 John Austin: I wanted to go on to the evidence that we had from the Medical Technology Group, and I understand that Ms Lobban is stranded somewhere, but perhaps Mr Wilkinson might be able to answer the point, because in their submission they were talking about slippage between the national guidelines being issued by NICE and the introduction of the new medical technologies, and really saying that what happens on the ground, particularly with PCTs, that if there was something within the National Service Framework there was more likelihood of implementation, whereas there was a real slippage if there was not. Mr Wilkinson: It is a shame that Trudie is not here because she could speak very clearly from a patient's perspective, but I will attempt to cover the issues. Q46 Chairman: We understand that she is stuck in Oxford, so she has made every effort to get here. Mr Wilkinson: The issue she is talking about is very much about that there are centres in the UK which take, adopt and use new technology as fast as anybody in the world. The challenge we face is getting that translated and being available for patients broadly across the country, particularly in relation to NICE recommendations. We have seen some recent work done on the implementation of NICE recommendations and concerns that these technologies just do not get out and do not get propagated and are not available to large portions of the population. So this is real postcode, not prescribing but availability of technologies. I think I have already alluded to that in the context of diabetic pumps. You can look at many technologies; if you are in the right place at the right time you can get access to these things and if you are not then you cannot. Clearly there are a number of mechanisms that drive towards that. NICE is one. Just creating the atmosphere in the environment for innovation and encouraging doctors and systems to become informed and pull innovation in the ways that patients are treated would be an encouraging move forward. The Department has just announced the establishment of an Institute for Learning Skills and Innovation and if that works well - and we hope it does - that will be crucial to supporting this process of getting good practice, good ideas out, and that means that patients get access to the good stuff that is available in parts of the country. Q47 John Austin: Much of the examples that have been given have been about technologies which are used outside of a clinical setting, possibly in the patient's home, involving very much the patient or the carer of the patient. Does this prevent new risks and what are the implications for patients, and also what use is being made of user groups in terms of learning about new technologies and designing them so that they are patient friendly? Mr Wilkinson: If you transfer the focus of care from a highly controlled environment into a less controlled environment, if you like into a domestic environment, then you need to build new quality systems to manage that, particularly if patients are involved, and then patients are intimately apprised of the challenges of managing their situation and need to be full stakeholders. Medicine is not being done to people the way it was 25 years ago. People are increasingly being engaged in their care and I think engaging patients, patient groups to help set up the systems which effectively manage the use of these technologies in these new environments is crucial to their success. Q48 Dr Naysmith: If we can return to the discussion that was going on about on about five minutes ago about the economic benefits of some of these new technologies and looking in a wider sense, not just about telemedicine, although it is included here, there is a feeling - and it was in the MTG memorandum and I am sure you have read it, Mr Wilkinson - it talked about the traditional approaches to measuring the benefits often fail to address quality of life and productivity dimensions in the way new techniques are assessed. I suppose it draws to mind the old joke about the surgeon - I apologise, Mr Dheansa - saying, "The operation was a success but unfortunately the patient died," and just evaluating things from the purely medical and clinical may not reveal all the benefits to patients. Is there something in that? Mr Wilkinson: Perhaps I can give you a couple of examples which might illustrate the situation. Potentially fatal cardiac arrhythmias, i.e. random stopping of the heart in young children, is sadly not as rare an event as many of us might like to think. Can you imagine the situation where you, as a parent, have a child who is susceptible to this complaint, it has been identified and you have been present when your child has dropped to the floor lifeless, you have administered CPR or whatever and brought your child back to life. The stress of living with that sort of tension for the child, for the family, for anybody engaged with that child, the teachers, is enormous; it does not bear thinking about. I have fortunately never had to experience it. The technology is available to implant a device which monitors the heartbeat and when it starts behaving badly it effectively gives it a jolt and gets the thing going, so that the fear of going to bed one night and kissing your child goodnight and waking up the next morning and finding him a lifeless corpse is eliminated; it is very profound. Another example, if I could quickly burden you, I met a patient who had severe Parkinson's Disease, shuddering severe Parkinson's Disease, of the sort in which the physical manifestations are profound but the psychological effect is even more profound and you become a social leper effectively and really do not want to present yourself to the world. One of our member companies has a technology which allows you to implant electrodes in the brain and provide minute electrical stimuli, and you can walk up to this chap who is standing at a bar with a pint in his hand, rock solid, shake his hand and have a conversation and you would not be able to distinguish him from any of us sitting in this room. It has profound impact on that person's life; he has a productive job, he is engaged in normal life. I think those sort of criteria are often lost and they have, I suspect, profound economic consequences as well as social consequences. Q49 Dr Naysmith: Why do you think that is? Is it - because I was suggesting that these things are looked at in the purely medical and clinical effects - that not enough attention is paid to what it allows patients to do? Is that a factor in it? Mr Wilkinson: I think often technologies are looked at as very technical solutions by technical people to specific problems and I think further engagement with patients and understanding the real impacts of these technologies on their lives can only be good. Q50 Jim Dowd: I wanted to press that a bit further with Mr Wilkinson. I accept the point he is making, but what kind of formula, what kind of uniform calculation could be made of such abstract notions about quality of life and impact? Mr Wilkinson: There are many models for life adjusted quality of life. It is all very esoteric and rather complex, I am afraid, to most lay people including myself in that context. I think there is scope to work on methodologies to evaluate these impacts. Certainly the economic impacts are profound. The difference between somebody getting work and earning the average wage and paying taxes like the rest of us, rather than being a burden on society, is a very simple number to calculate. I think some of the quality of life issues are much more difficult, but there is scope for methodological research in that area. Q51 Jim Dowd: But you run up against the practicality of public spending, which it is that it is better under the system we operate to spend a pound from now until infinity than to spend £5 now once off. Mr Wilkinson: I think that is where the evaluation methods need work and it needs to engage patients, clinicians, economists who can capture some of those things, so that we get a mechanism for making decisions with the annual budgetary cycle or even the five-year political cycle because some of these technologies have profound benefits long-term. We have to find methodologies that achieve that and some of the stepping-stones are in place to do that. The effectiveness of NICE is clearly one, the HITF report alludes to the Device Evaluation Service, a lighter on its feet mechanism for looking at the value that various technologies can produce. I do not think there is a perfect answer but I think there is scope for much more rounded input from a variety of stakeholders in the process. Q52 Dr Taylor: We have talked quite a bit about cost effectiveness. You have just mentioned, Mr Wilkinson, Payment by Results. I am very bothered when in your submission you say that the present tariffs' arrangement is not clear "and some procedure payments appear to be so inadequate they would fail to cover the cost of the technology alone" and you have given us a table of uncoded activity and the huge payment shortfalls. Could you expand on this a little bit? Mr Wilkinson: I think, broadly speaking, the industry is supportive of Payment by Results. Because if the quality agenda attached to Payment by Results and the flexibility agenda which allows flexibility in the way that patients are cared for and treated come to fruition, I think that would be very good for all concerned - and, most importantly, patients. We do have some concerns, however, in terms of implementation and the capacity of the system at the moment to generate accurate, reliable tariffs. There is also a concern that if this massive process of generating large numbers of tariffs is slow then new technologies will not be reflected in the tariffs, or they will be reflected very late, so we have made some very specific proposals regarding mechanisms to try to circumvent some of these less than ideal outcomes in the process. As an industry, many of my members have experienced payment-by-result type schemes coming in in other countries, so we have seen a lot of the problems. I think we are very heartened by the fact that the Department of Health is keen to engage us in helping to resolve some of those problems. Q53 Dr Taylor: Will it be possible to have tariffs for virtually everything, including the implantable defibrillators that you mentioned? Mr Wilkinson: The view is that tariffs are targeted to be aggregates of a number of procedures. In some cases, there is no aggregating. There is a need for very specific tariffs for technologies which do not fit comfortably into the buckets which might have been created in the system. The key thing is to have a system which is light on its feet, which engages very much with clinicians, industry and other stakeholders, and is not just an accounting exercise, because there are profound impacts of getting this wrong. If we get that sort of engagement, we may get the system to work rather more rapidly and effectively than we have seen in other countries. Q54 Jim Dowd: If I could go back to the theme I was exploring earlier, triggered by Dr Taylor's mention of the implantable defibrillator. In an earlier inquiry we were told that this cost about £30,000 for unit and the procedure. The difficulty we were faced with was evaluating the benefit of that for one individual - for whom it is crucial: literally a matter of life and death - when you can employ a nurse for £30,000 a year. How do you evaluate the contribution he or she could make to a number of people over the course of that year compared to the benefits for one person? Mr Wilkinson: If I were to use an industry analogy: companies that do not invest in technology and look at new ways of doing things, get drowned with trying to do the same thing over and over again more effectively more often. I think there is a balance between human resource needs in delivering healthcare and using technology effectively to minimise the increase in human resource. I wish I could give you a clear answer, but clearly every individual treatment and situation has a different set of dynamics to it. Chairman: I am very conscious that this has been an extremely short session and I think all of us would like to have pursued the various avenues we have touched on at much greater length. I apologise that it has been brief, but it has been very valuable from our point of view. It may be that you would wish to follow up with further written comment on issues that we have touched on and we would be very pleased to hear from you. Could I place on record our thanks to all of you for coming along today. Memorandum submitted by the Department of Health Examination of Witnesses
Witnesses: Professor Ian Philp, National Director for Older People's Services, Dr Felicity Harvey, Head of the Medicines, Pharmacy and Industry Group, Professor Tom Walley, Director of the Health Technology Assessment Programme, Department of Pharmacology and Therapeutics, University of Liverpool, Department of Health, and Sir Christopher O'Donnell, Co-Chairman, Healthcare Industries Task Force (HITF), examined. Q55 Chairman: May I welcome our second group of witnesses. We have an empty chair at the present time. We understand that Professor Philp is stuck in a traffic jam with a minister - we are not sure which minister he is lucky enough to be stuck with - but he hopes to be here within the next quarter of an hour or 20 minutes. We will make a start because we hope to complete this session in round about an hour. Could I ask our witnesses to introduce themselves to the Committee briefly. Dr Harvey: I am Dr Felicity Harvey and I am Head of the Medicines, Pharmacy and Industry Group within the Department of Health. Within my remit I cover the sponsorship of the devices industry; indeed, it was my part of the Department that was working very closely with industry in the Healthcare Industries Task Force work over the past year. Professor Walley: I am Tom Walley. I am Director of the Health Technology Assessment Programme on behalf of the Department of Health. I am also Professor of Clinical Pharmacology at the University of Liverpool and a Consultant Physician at the Royal Liverpool University Hospital. Sir Christopher O'Donnell: I am Chris O'Donnell. I am the Chief Executive of Smith & Nephew, which is the largest producer of medical devices and technology based in the UK, one of the ten largest companies in the world, and we contribute particularly to healthcare technology research and innovation as a key part of our activities. Q56 Chairman: Could I begin by referring to some of the evidence that came out in the earlier session. I am not sure whether you were present and heard the evidence but one of the points that was raised related to the difficulties of services being organised and viewed in silos. One of the issues that particularly concerns me - and you probably heard the example I gave of the effect on the National Health Service of telecare solutions preventing a broken hip - is that the budgetary crossover is not there, so the investment, possibly by social services or, indeed, the individual into those telecare solutions in their own home, does not in a sense relate to the savings that are made in the health service. I wonder, Dr Harvey, how you would respond to that concern, in particular the concern that increasingly the service is devolving decision-making to a local level. Is there any strategy you might favour nationally? It is, in many respects, down to those local people to drive it forward, and it would appear in many instances that they are not driving it forward. Dr Harvey: Chairman, quite an element of this Professor Philp would be in a very good position to speak to when he arrives. He, as you know, has the brief for older people's care, both from the health and social care perspective. In terms of what we were talking about in terms of silo budgeting, from the primary care trust perspective, as you are aware, they now have budgets - they have about 80 per cent of the NHS budget now. That allows them to develop services, working closely with social care across the health/social care interface, and through the Payment by Results mechanism that we have, which was referred to earlier, with the intention through that to unbundle what we have as the groupings of services within the HRGs that lead to the tariff, this will allow primary care trusts, working with their local authorities, to look more carefully at how they deliver services locally. It is down to local decision as to how they do that but, as you are aware, there is quite a lot of movement now from care that would have been delivered within a secondary or tertiary care setting to looking at delivering that in different ways in a primary care and a primary care/local authority/NHS way. I think there are now more mechanisms, particularly as Payment by Results develops. Also, I think one needs to remember that primary care trusts, although in the past they have had annual budgets, have now for the first time been given a three-yearly budget. Some of the concerns that have been raised have been around short-termism, and therefore primary care thinking about just one year. Now we are looking to a longer horizon, to say that primary care trusts, working with their local authorities, should be looking over a longer period of time. Therefore some of these benefits, around the sorts of treatments that they might deliver that would have efficiency/cost-saving benefits or whatever, and, most importantly, benefit patients more, are now far more within the capability of PCTs to deliver in terms of this new mechanism that we have in place. Q57 Chairman: Why do you feel we are so behind other similar European countries in introducing telehealth and telecare within the UK? I mentioned in the first session that it always strikes me very strongly when we go to other European countries and elsewhere in the world that we frequently see they have made these quite remarkable advances but often using British technology that we do not see in use in our own country. Dr Harvey: I think there are two issues. One relates to where we got to in the Healthcare Industry Task Force about how we get innovation into the NHS, but the other is possibly a more practical immediate one, and that is that, in terms of telemedicine - telemedicine requires the possibility of transferring data, transferring digital images, etcetera - it needs quite a lot of capability within the system. The national programme for IT is actually rolling out a broadband based network and service between primary, secondary and tertiary care. This, if you like, gives a platform to allow the telemedicine aspect, which is very much around the clinician and interfaces between the clinician with the patient. If you look at the telecare element, and even telemonitoring, where, as one of the witnesses was suggesting, you could send data down the telephone line - you do not require broadband for that, you can just do that through an ordinary telephone line - there is therefore the possibility for doing telecare - and we have already heard there are some examples of that, although possibly not as many as we would like to see in the future - and also there is a possibility for telemonitoring, of patients transferring data into hospitals. I think the national programme for information technology allows us the platform to develop that further in the telemedicine context. In terms of the telecare context, Professor Philp will be able to say a bit more about what is happening in terms of strategies to move that forward, but I think it is very much supported by the Healthcare Industries Task Force recommendations which are very much around: How do we get new innovation into the National Health Service? We very much accept the fact that the NHS has not been very good at getting new technology in. I think there were quite a lot of environmental issues, particularly working towards the target within the National Health Service Improvement Plan around a maximum of an 18-week wait for treatment from referral. To deliver that - which means diagnostic services have to fall before that 18-week maximum - we have to move to far more innovative methodologies for both diagnosis and treatment mechanisms. I think that gives us the sort of impetus, along with the mechanisms that we have been trying to set up through HITF - the implementation of which Sir Christopher O'Donnell as well as Lord Warner will be overseeing - to catch up with those other countries, whose innovation and entrepreneurial culture is possibly indicated more in terms of how they deliver services now. Q58 Dr Naysmith: Are you implying that a lack of "good enough" IT systems in this country up until now has been one of the factors inhibiting the growth of telemedicine? Dr Harvey: In terms of telemedicine, the fact that you do need more of a broadband based basis - and I am not the expert on this, but we would be delighted to give you further details - does actually mean that for things like, for example, the Picture Archiving Communications which are now being introduced and will be introduced by 2008 (for example, for diagnostic radiology and scans), unless you have a networked facility ----- Q59 Dr Naysmith: Yes, I understand that, but are you saying that it is because of a lack of the ability to transmit images of sufficient quality that that is inhibiting that? Then the question is: Why did they manage it in the Scandinavian countries ten years ago? Dr Harvey: I think it may be the lack of a national capability for doing it. There are various pockets within the country where they can, they have, and they are doing it, but in terms of a national capability to do that, the national programme for IT gives us the platform from which to think about that nationally, rather than just local investment in local particular areas where they have decided in the past that for them it would be of benefit. Chairman: Could I go along that tack. I am interested in you calling it a platform because that implies it is just a start and you can jump off it into all sorts of directions. Chairman: Or fall off it! Q60 Dr Taylor: Or fall off it, yes. We have had a letter from the Association of Healthcare Technology Providers for Imaging, Radiotherapy and Care - who are not among our witnesses - who are very concerned that, by looking at the new technology, we are in some way disregarding the advances in the routine services, like routine x-rays. They say - which is rather the opposite to what you have said: "Within the current remit of the national programme for IT, there is no provision for direct digital acquisition of x-ray images despite the fact that the roll-out of IT infrastructure relies heavily upon hospitals being able to acquire images digitally." Do they have that wrong? Did I understand you to say that the Picture Archiving Communication System is going to be in everywhere by 2008? Dr Harvey: It is actually being rolled out across the NHS starting this year and it is due to be rolled out. We should have 80 per cent coverage using the PAC System by 2006, with full coverage by 2007 in fact. Q61 Dr Taylor: Eighty per cent by 2006? Dr Harvey: Eighty per cent PACS coverage is intended by the end of 2006, with full by 2007. That is, I think, fairly recently announced. Q62 Dr Taylor: That is very, very reassuring. Can we hold you to that? Dr Harvey: We would be very happy to provide more details through the national programme on that. Dr Taylor: It would be very helpful if we could have that. Q63 Chairman: The information you have given us is in contrast to some other information we have received. We would perhaps welcome you writing to us on this, if that is convenient. Dr Harvey: As you say. Q64 Dr Naysmith: I would like to ask Sir Christopher a question relating to the Device Evaluation Service. It is said by the Department to be a cornerstone of the task force report. Do you think the Department will be ensuring, therefore, that it will be closely linked to procurement? How will this advice tie in with the National Service Frameworks and the new NHS Payment by Results? Are you confident that it is going to work is basically the question. Sir Christopher O'Donnell: I think there is a very good chance it is going to work. A lot of effort is going into it between industry and government. A fair amount of the discussion has gone on about: "Why have we not in the UK adopted as much innovation in terms of technology as other comparable European countries in particular?" Historically, to be blunt, there are three factors. One is absolute level of spend, which has been lower. The second is the silo budgeting issue. The third is the issue of multiple acceptance points. Professor May pointed out that the NHS is in fact a confederation. Particularly for smaller companies, if every one of the trusts who are thinking about using something decides it wants to do an evaluation, it (a) slows things down and (b) is a diabolical use of overall resources. We see, in terms of the adoption of innovation, really three key poles to this. One is to have a focused Device Evaluation Service - and that is at the point where there is a device; in other words, if a company brings something that is a product in production, appropriately signed off in terms of the quality assurance standards related to the EU Directive and so on, that device can then be evaluated - and evaluated once, not evaluated 246 times or whatever the number happens to be at the available centres. In order to do that and fund it effectively, the proposal is made to move the Device Evaluation Service from being managed by the regulator, which is the MHRA, to the Procurement Advisory Service (PASA), and to make it an integral part of that service, so that it gives the service the ability actually not just to make unit-cost based decisions but to look at how value and innovation can be brought to bear. That is not an easy task but the work of doing that is underway. It is my understanding that the transfer of the resource will take place effectively from 1 April, with the administrative follow-up to make that happen constitutionally taking place later. So I think that is going to happen. I think it will be very effective. The second issue is to get cultural change and to work out how this mechanism should work on a once-only basis, and that relates to evaluation methodologies and toolkits, so that people have a broad acceptance of what is going to be done, so that it does not get repetitively done in a wide variety of locations, as unfortunately is the case at this point in time. Q65 Dr Naysmith: How is it going to be tied in with NICE and NICE evaluations? Sir Christopher O'Donnell: NICE concentrates, in relation to medical technology as opposed to pharmaceuticals, in terms of interventions, typically surgical or medical interventions, and makes recommendations related to those. For example, is it sensible to do hernias by endoscopic means? It does not really talk about the technology related to endoscopy and how you process the digital images. Q66 Dr Naysmith: But presumably they have to be aware, when they are doing their evaluations, of what may be in the pipeline and coming along. Sir Christopher O'Donnell: NICE have a fairly effective way, and there is a horizon-scanning facility which inputs to both, but they do come out with a fairly regular consultation document saying, "We are going to look at this. Does anybody want to make a submission?" Q67 Dr Naysmith: That is what I am really getting at. You can feed into that. Sir Christopher O'Donnell: Actually NICE is a reasonably good model. It is relatively light on its feet. It does not spend - and I am talking in the interventional area - enormous amounts of time assessing things, so it does make concrete recommendations. That is the sort of model we would like to see the evaluation centre impose. Q68 Dr Naysmith: Finally, on this bit, how do you tie in with the National Service Frameworks and when they are being produced? Sir Christopher O'Donnell: That is something that probably Dr Harvey would be better able to relate to, but the intention is that it would tie in because of the positioning of PASA within the Health Service framework, and they would be looking at how those are integrated. Q69 Chairman: Do you want to answer that point on NSFs, Dr Harvey? Dr Harvey: I think in terms of the mechanisms for joining up, we do need very much to make sure that NHS PASA and the Device Evaluation Service are very tightly joined up in terms of the intelligence they get. That also needs to include NICE. Certainly NICE do carry out the interventional procedures. If there is a particularly disruptive technology which is changing delivery of care, they will actually do an appraisal of that as well. That also, I think, needs to link into the new innovation centre. The new innovation centre which will sit within the NHS Institute, which, as you are aware, pulls together the skill sets from the modernisation agency, the NHS University and this new innovation centre, is really almost at the forefront of trying to pull all that information together, with horizon scanning as well, to make sure that the right information is informing the Device Evaluation Service, is informing NHS PASA, and, indeed, the collaborative procurement hubs that will work very closely with PASA. In terms of a linkage with industry on the National Service Frameworks, it is really the National Service Frameworks and what is happening in terms of innovation. That will be initially certainly through the strategic group that we will have overseeing HITF, but actually each of the strands of HITF has very close working between government and industry, so that we ensure that in designing the new mechanisms that we have it actually answers the problems and possibly some of the disjunctures that there are the moment to make sure the right bits talk to the right bits and we have an integrated, strategic approach. Q70 Chairman: Could I move on to Sir Christopher. You analysed why we are behind other countries and gave a series of three key points. One was general underfunding, you implied - and, as I am sure you will accept, a lot of additional money has gone into the NHS now. Sir Christopher O'Donnell: Indeed. Q71 Chairman: Which should make a difference. Sir Christopher O'Donnell: Sure. Q72 Chairman: Although, I have to say, if people are short of money I would have thought that was an argument to look at some of the technologies that could save more money. I wondered, in relation to the improvement mechanisms for telehealth/telecare technologies and the new advances that we have talked about this morning, looking at the silos and the dilemma between a national recognition of what can be achieved by some of these new technologies and the decisions to use them being taken by a large number of local bodies such as PCTs, is there a mechanism, if we have a clear assessment of advantages that could be gained by the use of these technologies, whereby you could include an assumption in terms of your national budgeting that: "We are assuming you will be using this technology and therefore we can reduce your money by such and such because you are going to be using it." Do you follow the point? You could incentivise. You have your PCT allocations of budgets two weeks previously and you could incentivise the use of these approaches by centrally budgetary mechanisms. Is that a possibility that you would think is reasonable? Would it be helpful? Sir Christopher O'Donnell: You are stretching me out into two areas which I know nothing about: one is telemedicine and the second is NHS budgeting. Q73 Chairman: You gave us three reasons why and that is why I came back to you in particular. I know you are not in the Department, I appreciate that, but I would be interested in what you feel could be a way of moving this forward at a local level. Sir Christopher O'Donnell: I think the issue is that you say: What is the central role of the National Health Service? Given the fact that the budgeting is a distributed process and that decisions are taken at local level against national targets, the frameworks of the national targets, I think the issue and the thought behind the Device Evaluation Route was to try to get a fairly clear idea of what the benefits actually are and what the best way of achieving them is. and then to disseminate that information and have intelligent purchasing. It may be purchasing of a device or a piece of capital equipment or it may be buying into a system, but I think that is more likely to be a successful route, looking from the outside in. Certainly, the way of going forward, the National Health Institute to which Dr Harvey referred, it is really going to be important that that actually looks at the adoption of innovation as one of its major driving forces. Telecare/telemedicine may be a very good example for it to pick up on and determine exactly what the best methodologies are, what is likely to work best, and certainly that is in a very good position to disseminate information and best practice. Q74 Dr Taylor: I really wanted to go on to training. With the arm's length body review, we had the abolition of the NHS University and the modernisation agency, now called NILSI (NHS Institution of Learning, Skills and Innovation). How is this really going to take on the huge new training programmes that are going to be necessary for the use of the new medical technologies? What sort of staff are going to be trained? Is it in medical schools, nursing schools? There are very few schools for medical technologists. How are you going to face that. Dr Harvey: Firstly, in terms of the Institute itself, it will indeed have a strategic oversight for training and development of staff. But I think one of the issues through the Healthcare Industries Task Force that we recognised was that the whole area of training and development we had not had sufficient time through the course of the task force to really get to the bottom of. We were very clear that it was absolutely fundamental in terms of getting innovation into the NHS. In fact, through the HITF implementation, we have a workstream devoted to training and development which from the Government side will be headed from Sir Ara Darzi and there will be a co-Chair from the industry perspective. Because we also have the Institute, which has the innovation bit as well as the modernisation skill sets in it, we will be working with them along with the MHRA and others to see how we move the system from what we have at the moment to something that is better in dealing with the skill sets required. We do already have the MHRA taking forward some work, looking at the development of a medical device driving licence, looking at modules of training that people need for individual devices, and they are about to pilot that with the Royal College of Surgeons. Industry obviously has a big role in this because industry already provides a huge amount of training for clinicians around the use of devices and that is clearly very important. There are issues that concern us, though, about the devices you have in hospitals where people may have been trained or they may have been trained on a different one, and how we ensure, from a patient safety perspective, that everyone has been trained on all of the devices - be they external devices, or, indeed, surgically trained if they are dealing with internal devices. We need to work with the Royal Colleges, with Skills for Health, with the Institute, to pull together all of those strands to have a coherent strategic way forward. Because, as you say, at the moment there is a lot of training and happening in a lot of different places, and we really need to see how that all fits together and whether, indeed, it is coherent or whether there is more that we need to do. I think the MHRA have also developed a multimedia device educational programme as well. We do understand that this is a very important area in which we need to do more. One of the other recommendations that came out of HITF, in terms of procurement and in terms of making sure that we have, as Sir Christopher said, intelligent procurement, is that we need to ensure that in procurement for the future we include a training aspect. That may not necessarily have been what happened in the past. Basically, if we move to intelligent procurement, which means that the specifications that get used, either by NHS PASA or, indeed, by the collaborative procurement hubs, it means we have to have enough information in the specification so that the specification is properly defining what is required, and also it is something that does not dampen down innovation but facilitates more innovation in terms of the way people might meet that spec. Q75 Dr Taylor: So, despite the fragmentation of the NHS into trusts, procurement for relatively uncommonly used bits of medical technology could be standardised across the country? Dr Harvey: Indeed - one of the recommendations through HITF, as Sir Christopher and others have said. At the moment in terms of buying something for a primary care trust to use, there are lots and lots different mechanisms for doing that - and I think somebody said you may have to go and see 300 or 400 different people. In terms of having a Device Evaluation Service that comes out with a national standard product that can be used by anyone who purchases, we are moving more to a situation where you will have a reformed national PASA, intelligently procuring, you will then have the development of collaborative procurement hubs, which will be lots of trusts coming together with much more clinical input than has hitherto been the case, and we think that will then move us to a position where the vast majority of purchasing for the NHS takes place either through the collaborative procurement hubs or, indeed, through NHS PASA, all being supported by the information from the Device Evaluation Service, from NICE, with information going to them from the National Innovation Centre within the NHS Institute. Dr Taylor: I am sorry, what is a collaborative procurement hub? How wide does that stretch? Chairman: Do you mean you do not know, Richard? Jim Dowd: Keep up to speed! Q76 Dr Taylor: Is it a strategic health authority? Dr Harvey: It could be bigger than that but it could be a strategic health authority. We have at the moment three pilots, one running in Greater Manchester SHA, one in West Mid-South SHA, and one in Shropshire and Staffordshire SHA. There is not any definition as to how many of these there will be. They are developing. At the moment we have supply management confederations up until this point, but we see the movement through to these collaborative procurement hubs being very important in terms of purchasing for the future. Q77 Dr Taylor: A really basic piece of equipment throughout the hospital service are defibrillators. These are as old as the hills, but is there yet any standardisation? I remember going somewhere where each ward had a different one, so a cardiac arrest team had to know how to drive each one of them. Is there any standardisation in that sort of thing - standardisation yet across not only collaborative procurement hubs but the whole National Health Service? Dr Harvey: To be honest, I do not know the answer to that because it is not an area of which I have detailed knowledge. I know that in terms of where we are aiming to go in the future, with the HITF recommendations and their implementation - and we have to remember NHS PASA is in transition to the new NHS PASA now, so these figures are being set up very shortly - the intention is that with a lot of clinical input into each of these collaborative hubs, they will then know what it is that they should be procuring for the clinicians within their patch. That patch might be very large but the clinician is still going to be very important in that, along with the advice they will get from the Device Evaluation Service, if there has been a NICE review, either a guideline or an appraisal. Q78 Dr Taylor: There is a fearful paradox, because, although we want national standardisation, that completely removes competition among commercial firms that produce things and obviously raises tremendous implications for different firms that are making different things. Sir Christopher O'Donnell: If I may comment, I do not think we are specifically looking at national standardisation. We are looking for a clear case for the benefits and obviously the costs of any particular device, but for devices like defibrillators, infusion pumps, and things where a wide number of people come into contact, broadly it is best practice to have one or at most two per facility - hospital or whatever - and then to make decisions after whatever time to replace the whole lot. Because what tends to happen is that something comes out that is better, so you get ten of those, then something else comes out and you get 20 of those, and you end up with a creeping mix of equipment. In terms of the training and development needs that were specifically identified in the task force, they particularly relate to (a) the need for making sure that safe practice is followed and (b) taking advantage of the benefit of equipment. For example, if you do install an MRI imaging suite, then you need to have staff who are able to use it for its full benefit, and it is pretty obvious that there are cases around the country where actually that has not happened - so I am reliably informed - and therefore the considerable installation and maintenance costs are not being fully utilised. So an integrated plan needs to be undertaken in this area. It is quite a task and it is on the agenda of the NHS Institute of Learning, Skills and Innovation. Q79 Dr Taylor: Yes. We have already heard about other reasons why MRI scanners are not being used. Could I turn to Professor Walley for a moment. With the Health Technology Assessment Programme, did you look at training for the various bits of equipment under that? Professor Walley: We look at technologies in a very broad sense, which includes not just the individual technology but also how to influence the pathway of patient care. So issues such as training and patient outcomes are key to what we do. Yes, we do look at training issues, and they are usually particularly in consideration of the cost-effectiveness of the therapy - because there is a training cost to be put in there and a question of how that training is renewed and as to the advice that has to be renewed in the future. So, yes, we do address this. On the specific point you raise about defibrillators, this has been a hospital-by-hospital issue, as you are aware. My hospital is finally down to two different devices. Dr Taylor: Down to two! Thank you. Q80 Dr Naysmith: I have one or two other questions associated with the Device Evaluation Service and the task force before we move on to Professor Philp, now that he has arrived, and a different area. I was going to ask how the Device Evaluation Service is going to decide on its priorities, and, crudely, which it was going to look at first, and I was going to ask Sir Christopher O'Donnell - but maybe, since Professor Walley has not had an awful lot to say, I could ask how he thinks it should decide on its priorities and then I will ask Sir Christopher if that is what they are planning to do. Professor Walley: I think it is important that the evaluation of the device is proportional to that device. Some devices might be regarded as disruptive technologies that will cause a major shift in how we manage patients in the NHS - and they clearly are the major priority for very detailed evaluation. Other devices might be regarded as an incremental advance: in other words, we are already doing this and this new device may be a slight advantage over the old devices. I am not quite sure what the structure of the DES is going to be. It is going to take time to build up its skills and its abilities; particularly in areas such as health economics, to undertake studies of the long-term cost-effectiveness of devices. My own programme particularly looks at the much more disruptive devices - as, indeed, NICE does - and, depending on the level of evidence available to evaluate that device, we may either commission work on behalf of NICE to review the existing evidence around a device or build a UK-specific economic model around that technology and then NICE might issue guidance on it. Q81 Dr Naysmith: What is an example of a disruptive technology? Professor Walley: We have had an example already: for instance, insulin pumps. There is a treatment that has not been available up to now which has a potential benefit for selected patients but it is a completely new way of managing patients. On the other hand, there may be other disruptive technologies where there is currently inadequate evidence available to judge what the benefit for devices is. In that situation, my programme might undertake a full, randomised-control clinical trial. We have heard already from Professor May this morning that there is a conflict here between the time it takes to develop evidence around a new technology like that and perhaps the urge to modernisation. If I might give you an example: one of the trials we are funding at the moment is an evaluation of a graft into the aorta (the major blood vessel through the abdomen) to replace an aneurism (a swelling of the aorta which can rupture and cause sudden death). Up to now this has been undertaken by open surgery. We have a new device available which can be inserted by radiologists working through the patient's artery without a need for a laparotomy - so it is a much simpler technology to put in place - but it may have a downside. The downside is that the major operation is a once-for-a-lifetime procedure; we are not entirely clear that the radiological procedure is actually going to last as long. So there is a device that will totally alter the pattern of care. We cannot evaluate it simply in a small study lasting six months, we need a study that is going to go on for several years, so we have been funding that study. One of the advantages we have had in funding that study is that the access to that technology has only been available through the trial. As a result, we have captured everybody in the country who has had this technology performed and we can follow these patients - obviously with their consent - so we will know ultimately what the benefit of this is and whether we should allow this technology to filter into the NHS more widely. Q82 Dr Naysmith: Roughly how many people does that involve? Professor Walley: In the trial so far? Q83 Dr Naysmith: The ones you have been able to contact. Professor Walley: We have randomised over 600 patients into each arm; so 600 patients with surgery, 600 patients with the new device. We have 30-day results which show a benefit for the new device but we need to see the follow up over the next five years. Q84 Dr Naysmith: Will it take you five years to reach a decision? Dr Harvey: I think a decision has to be incremental. There may be a process whereby we may allow it in to a limited degree after one year, but the final decision may need to be taken at five years, because, for instance, although I mentioned that the old technology is a once-for-life procedure, the early evidence is that the new technology requires a new procedure in one per cent of the patients every year. If the patient has a life expectancy of 20 years, this new technology might not be very smart. On the other hand, if we can reduce that rate, it will be very valuable. It is another interesting example of how we evaluate individual devices, because it takes a long time to do a trial like this to recruit the patients and follow them up. These devices are changing all the time. In setting up this trial, we did not specify that a single device had to be used; we specified that there are standards to which any device used must reach. We would hope that over time we will be able to track sufficient numbers of patients on each of the devices that at the end of the day we will be able to compare the different technologies. It is what we call a tracker study, where we are not looking at a static technology. We may observe, for instance, that later results are better than earlier results. With sufficient numbers of patients in the study we should be able to detect that. Q85 Dr Naysmith: I was going to ask Sir Christopher if that is the way they have gone. Sir Christopher O'Donnell: If you want me to follow up on that, let me just stick with the insulin pump example, because it is probably a good one as to who is going to do what. If the issue is: Should the NHS be more widely using insulin pumps as a method of treatment? then that is a health technology assessment issue, it is not a Device Evaluation Centre issue. The Device Evaluation Centre, as we would see it in the task force, would say, "Okay, there are six insulin pumps on the market," and produce a matrix of "Here are their characteristics, this is what you get," effectively producing a Which Guide to these. For example if it was an elderly patient who needed larger buttons, for the sake of argument, then this device might be preferable. If it was somebody who was very, very active, weight might be very important. That will actually evaluate the device. Q86 Dr Naysmith: That is the role of the Device Evaluation Service. Sir Christopher O'Donnell: Yes. Q87 Dr Naysmith: Not the bigger question of whether it should be adopted. Sir Christopher O'Donnell: Not the bigger question, which is somewhere with health technology assessment, typically, and also things like some aspects of innovative service delivery will fall within, I think, the National Health Institute. It is pretty evident which patients will benefit from insulin pump treatment, the problem is - just to give you an example of silo budgeting - the diabetic department in the hospital has small budgets and low political clout. We, as a company, are not involved in insulin pumps; we do have bio-engineering products that are suitable in this area. We have not introduced them into the UK because they will not get funded. Dr Harvey: I think the other incredibly important aspect here is the aspect of patient choice. Because, with Payment by Results and trying to unbundle the sort of different services that are delivered to the primary care trust, which is the GP referring through to secondary care, or maybe not secondary care but maybe a specialist practitioner in primary care, there is the element of patient choice in terms of how they are treated and, I think, as we see that coming more to the fore, this will also have an impact in terms of the types of treatment that people have. That means they have to be properly informed about the different sorts of treatments and there is also an aspect - one of the outputs from the Healthcare Industry Task Force again - about communication with patients and patient information, because patients cannot make informed choices unless they actually have that information. I think, therefore, whereas one might have been concerned more up to now in terms of budgets within NHS trusts, it now comes back more, with Payment by Results, to the treatment that an individual patient with their GP and then their clinician would choose, which then is reimbursed through Payment by Results. Q88 Chairman: Could I turn to telecare and particularly the care of older people. I presumed Professor Philp was stuck in a snowdrift in God's own county but I gather you were stuck in a traffic jam. We are pleased to see you here. I wanted to reflect on a question that arose from the earlier part of this morning's session, which was how we get away from this silo mentality, with health and social care separated in budgetary terms and in organisational terms. Looking at the advantages of telecare for the health service, we had the example discussed of technology that exists to quite radically transform the house of an old person or flat to avoid them having falls or problems that would result in some fairly intensive care within the NHS. As that care within the home is a social service responsibility, it is organisationally separate, and separate in terms of budgetary considerations from the NHS. How do you make those two click together in a way that they are not doing at the moment? Because it is such an obvious commonsense thing to do to save funding in the NHS. Professor Philp: Yes. Thank you, Chairman. First may I record my apology for my delayed arrival. In fact I was returning from a visit to Hertfordshire with Dr Ladyman, Parliamentary Secretary for Community, where we were announcing £60 million going to councils to help keep older people at home in order to reduce pressure on acute hospital beds - the very point you are making. Q89 Chairman: That is a pretty good excuse, anyway! Professor Philp: Thank you. The issue as it stands in terms of the interface between the NHS and social care in policy and practice is that we are dealing with two centres that are interdependent on each other for their mutual success. The overall thrust of policy for older people has been to invest in community services, usually led by councils and social services departments but with clear agreements with the NHS about both the NHS contribution and the outcome impact on not only the wellbeing, independence and health of older people but greater, more efficient use of health services. That is the overall policy direction, accepting that there are separations in these two big sectors that need to come together to deliver the care that older people, in particular, but many of our client groups need in that joint approach. In relation to telecare, we have also announced an £80 million budget to councils to invest in telecare, again with the explicit objective of both keeping older people in their own homes and reducing pressure on acute hospital services. Q90 Dr Naysmith: That was in the last budgetary announcement. Professor Philp: Yes. Q91 Dr Naysmith: Which arose from a Treasury visit to a company where they could see the advantages. We are wondering how we can drive that concept much more radically, because that was just the start, and surely they can save huge amounts of money by that little bit of investment in telecare impacting on the NHS in a massive way. Professor Philp: Small investments can make a huge difference. Q92 Chairman: Absolutely. Professor Philp: For example, £2 will pay for a temperature sensor in an older person's bedroom or living room, and, if connected to a warden scheme and if targeted on vulnerable people, we could detect temperature drops, say, below 16◦C, at which point a vulnerable older person is at risk of death due to low temperature. There is a clear correlation. So small investments tied to good organisational practice, in terms of linking the system together can make a huge difference. We know that. The trick, as you rightly say, is: How do we translate that knowledge that we have through our systems into effective practice and deployment of good telecare? The main vehicle that the Government is using to support that is the policy collaborative on telecare, which has engaged a large number of stakeholders from industry, from the advocacy sector, from the statutory sector and academia, in order to get a shared understanding of what would make the biggest impact through the investment in telecare. To secure effective deployment of telecare within local communities, there needs to be local ownership as well as national ownership of the agenda and to support that the telecare policy collaborative will be publishing this summer a shared vision of what makes a difference. That is a shared vision of all the stakeholder groups. Then we will be encouraging councils to work with PCTs to that shared vision, owning it, and using the money that government has made available to councils in order to deliver better investment in telecare. Q93 Chairman: We have been looking at new technology, particularly from a care perspective, and one of the concerns that is expressed by some people is that we are losing the personal touch. People increasingly are being monitored technologically rather than by somebody coming along and saying hello at their door. How do you balance out those concerns in looking at the interests of older people? Professor Philp: From the older person's point of view, the human factor is the most important. The visit that we made this morning was a handyperson scheme, where the council are working through the Anchor Trust Organisation locally to provide handyperson support to vulnerable older people with simple things, like fixing electric points or if there was a problem in changing a light bulb - not undercutting the local market in terms of major plumbing jobs and so on, but these low-level things. It is that sort of way, in which a care assistant or a handyperson or whoever is in contact with the older person has the knowledge and skill to support the older person in making best use of technologies, some of which can be quite mundane - as I say, temperature sensors - and some which can be much more complicated - extensive home monitoring schemes, for example, for somebody with advanced dementia who wants to stay and their family wants them to stay in their own home; a telecare system of alerts when a door opens, to make people aware that a person might be walking outside; or having reminders and prompts in the house. We can use telecare at a low level or a very high level but it does depend on the level of dependency and need of the individual, and not to intrude beyond what would be acceptable for them enjoying an independent quality of life and a degree of autonomy. Q94 Chairman: You described some changes in terms of investment in telecare, which is very welcome. In the dialogue that your Department will have with the Treasury, have you raised with them at all the possibility of somehow through the tax system incentivising older people who may wish themselves to take steps to raise their own telecare in advance of needing it in their own home environment? It strikes me that we have not really helped people to think through. We talk about saving for old age, we talk about the pensions' issue, but equally important is where people will be when they reach the stage of limited ability and of requiring care and support. Some people may take steps to spend their own money on making arrangements for their home to be suitable for their care and supervision when they reach that stage. Have you had any dialogue with the Treasury about how in fiscal terms we might encourage that sort of step being taken by older people? I would argue that society ought to help people with that kind of provision. But, realistically, that may well not happen. Professor Philp: You are absolutely right to point out the interconnectedness of the work of many government departments if we are looking to improve the independence, wellbeing and quality of life of vulnerable people. In the context of cross-government work in relation to older people, there have been extensive discussions which have been led by the Department of Work and Pensions, with the Treasury, with the Department of Health - in fact with every government department - and there is a cabinet committee on which the Secretary of State for Health, a PSA in Health, the Secretary of State for Pensions and the Pensions Minister will sit, as well as there being representatives of every government department, and that committee is considering the interconnectedness of the whole range of government policies for the older population. So discussions are taking place and I hope there will be something coming out in the near future that reflects these discussions. But I do not think I am in a position to talk about the detail of the interaction between the Treasury and DH on the issues that you describe. Chairman: May I apologise, but I have to leave. I have to speak at Leeds University at four o'clock and I am slightly concerned about the travel arrangements today. Dr Naysmith will take over the chair. In the absence of the Chairman, Dr Naysmith was called to the Chair Q95 Dr Naysmith: Professor Philp, the British Geriatrics Society put in a submission in which they argued for "soft technologies" in the care of older people. In particular they asked that new levels of service provision around intermediate care and chronic disease management should be provided, and that intermediate care and chronic disease management should be provided and would require proper needs assessment methodologies as well. Do you agree with them? Professor Philp: Yes. A lot of the detail of our thinking in this area is likely to be described in the forthcoming Green Paper Vision for Adult Social Care, and I think it would be reasonable of me to say that PSA has already spoken publicly about the direction of travel in this area and the importance of investing in telecare in combination with the development of services in intermediate care and in long-term conditions management, and to integrate these different parts of service improvement. Q96 Dr Naysmith: One of the things which has been drawn to our attention as well is the fact that there will be an increasing burden of responsibility on informal carers when the telecare system is used for caring for older people. Has the Department considered that? Professor Philp: Yes, again the Department is not only trying to provide more support for informal carers to recognise the critical role that they play in the care of older people and other groups, but is also recognising that the carer prospective and the carers having power and ownership (and not just respite, if you know what I mean) are genuinely empowered to help find solutions that meet their needs as well as the person's that they care for. Also in that context the need to link the assessment of the older person's needs with an assessment of the carer's needs. Q97 Dr Naysmith: That is the point, in a way, that we are getting at. It is a new thing for carers to have to do ‑ to act as an intermediary between the Health Service and the person they are caring for. They have got to be absolutely clear that the information is provided to enable them to do this properly and feel comfortable in doing this. Professor Philp: Absolutely. This is about the social contract between the state, the citizen and the support for the partnership that carers have for their loved ones. If I could go back to what was quite critical in forming my thinking about this. As we were developing the National Service Framework for Older People's Services, two principles came into conflict. One principle was the autonomy of the older person and the concern that professionals sometimes talk over the older person to the family and make decisions when the older person is not fully engaged and involved and is rather patronised and infantilised as a result of that. There were concerns about that. On the other hand, there was the principle about the partnership with carers and fully involving carers in the decision-making process. We got our advisory structures representing older people and carers, including many older people and carers, to debate these issues. It surprised me that unanimously all the advice from older people and carers was that older people saw their family carer as their main guardian and protector within the care system and they wanted as far as possible ‑ except when there were extreme cases of the career not providing love and support or concern - that the carer would always be involved in the decision‑making process and that the carers' needs would be respected. We are trying to reflect that perspective in giving a very strong emphasis on obtaining the carers' viewpoint and offering carers choice to engage and support as much as much as they wish to do but also giving them choice and support to withdraw and help to withdraw when it becomes inappropriate for them to be involved in care that they do not feel able or competent so to do. Q98 Dr Naysmith: It will be a fairly complicated relationship in some instances, I suspect? Professor Philp: It is human nature, is it not? It is complicated and I think we should avoid simplistic solutions. Q99 Dr Taylor: We have talked about cost effectiveness quite a bit so I have only got a couple of questions. Professor Walley, you talked about access to this particular aortic graft being available only through clinical trials. I think we can understand the importance of that but we do get people coming to us to complain about having to wait for a clinical trial before they can get a treatment or a technology and from some of the firms that this is one way that in the UK we are slower at adopting things than elsewhere. What are the answers to these sorts of questions? Professor Walley: I do not think there is an easy answer to this. I think clinicians are going to demand evidence of the benefit of the new technology before they wish to unleash it on their patients and likewise patients are entitled to have that evidence before they undergo a new technology. Sometimes I have to say this argument that we need further evidence before accepting technology is used as a barrier to the introduction of new technology. I think that is inappropriate. If for instance the technology is not a disruptive one that is going to alter fundamentally patterns of care and is a matter of device evaluation, as Christopher has outlined, then I do not think that is a reasonable argument as to why that technology could not be adopted. Q100 Dr Taylor: The Chairman did mention incentives for people themselves. Would there be any opportunities for financial incentives for trusts to take on new technologies? Professor Walley: Within trials, if I can answer in this specific case of the aortic graft, we have had to incentivise trusts to take part in the trial. We have had to fund them specifically for the service costs required in taking part in this trial because it would be quite expensive otherwise and we would have had no up‑take whatsoever. For many important trials we do have to provide some kind of support for trusts, PCTs or hospitals to allow them to participate in the research. Q101 Dr Taylor: Where does that support come from? Professor Walley: It comes from the NHS R&D support fund. Q102 Dr Taylor: Not from the firm that is making the technology? Professor Walley: No, not usually because we are not in the business of evaluating a single device. We are looking at a technology which could involve several different devices. We are not making a market for one company. Having said that, we would often encourage investigators to seek some kind of support from a company providing it was done in such a manner that it would not influence the outcome of the study. I cannot think of an example for a device but there are certain examples in drug trials where the drug has been supplied by the company at no cost to the NHS but the service and research costs related to that trial are supplied by the NHS. Sir Christopher O'Donnell: It is very frequently the case if you are introducing a new device ‑ even a simple device like a compression bandaging for leg ulcers ‑ if you want to do this and demonstrate your product is better then you have to fund the cost typically of the research associate, nurse, fellow (depending on what level) to actually do the work associated with the trial. It has to be done in the right way and in the right framework. Dr Harvey: I think there is also, in addition to the incentives that colleagues have spoken of, an incentive in terms of as we move to a position where we are trying to get a maximum 18‑week wait for treatment (which means diagnosis has to happen before that time) there is more of an incentive for NHS trusts to develop services that people will choose because of the patient choice agenda where they do bring technologies in that allow them, for example, to do day case surgery or even interventions in a clinic so you do not have to be an in‑patient at all. Those are the sorts of interventions with payment by results, whereas before with block contracts there was no benefit to a trust in actually being able to carry out a lot of interventions. Through payment by results there is because you are being reimbursed for each event with a patient, so with the patient choice agenda and with more technologies that allow more rapid, high‑quality interventions for patients and with payment by results, you do then get some incentives coming into the system that possibly we have not had in the same way of late. Dr Taylor: Thank you very much. Q103 Jim Dowd: This is principally I think for Sir Christopher and the officials. I want to look at a few questions on whether we can approach this in a more strategic and co‑ordinated fashion. Many submissions we have received have highlighted the lack of co-ordination of the many bodies involved in developing health care technologies and thee fact that it was completely ad hoc. It has even been suggested there should be one body, perhaps even a special health authority, charged with co‑ordinating across the whole e‑health field. What is your response to that? Sir Christopher O'Donnell: I think it is difficult to do because technology arises from such a wide variety of sources that it may be sensible to have some kind of evaluation or technology assessment groups, of which those do exist, but in terms of looking at where it comes from, there are some very good ideas originally within the National Health Service but there are an awful lot more that come from outside. It is a case of trying to work out through horizon scanning and technology assessment as to which of those are worth taking forward. Does that answer the question? Q104 Jim Dowd: Yes I think the answer is no, if that is what you mean. Within the task force you recommend the Innovation Centre. Would that not fall into that category? Sir Christopher O'Donnell: The Innovation Centre is not going to originate the innovations; it is going to look for providing frameworks or pathways for taking them through, depending on what the level of the innovation is, and essentially almost, as a "go to" point in terms of expertise, whether it is somebody in the NHS who has come up with a very good idea and does not know what to do about it because they are not in the business of developing them or whether it is somebody in industry, particularly from the small and medium-sized enterprises to go to the centre and say, "I have got this great idea. It is not quite a product (and if it is a product it needs to go to the Device Evaluation Centre) but this is what we think it could do. Can you help me find the right people to work with and the right centres to trial it?" It would be a "go to" mechanism both for inside and outside the Health Service and also then to act as a facilitator to drive innovation forward, which is a secondary role which is very important but which is going to require a combination of leadership skills, training and development, and looking for ways of minimising any disincentives and providing some incentives to the system. We heard the plastic surgeons say that they had to find £85,000 which they have never been formally funded for to put their telemedicine system into place, which is great but it really ought not to be happening that way round. The idea of the Innovation Centre would be to facilitate exactly that kind of development. Dr Harvey: As a result of that function, one would hope that the Innovation Centre will actually get a lot of intelligence from what is happening out in the market‑place, what the developments are out in the market‑place that they can then feed into the Device Evaluation Service and indeed NICE, the HTA programme, et cetera. As Sir Christopher says, they will get a lot of information and as a result of that we would hope that our horizon scanning is better. The other thing that we need to flag is that as we were going through the HITF process, one thing that we recognised is (and we have had horizon scanning for a while ‑ horizon scanning for NICE ‑ so we know what the big issues are that coming over the horizon that should be going into the appraisal process) that may be very good for pharmaceuticals but when you look at the device sector it is probably not as good at picking up all of the innovations that are coming up as it would be helpful for it to be, and therefore one of the other issues that we need to follow up in implementation of HITF is how we improve the horizon scanning so that we have more of a large view of the innovations that are likely to come over the horizon that could be either disruptive and therefore very important in terms of different ways of providing services or indeed important developments on things that we already have. I think the Innovation Centre will have a role in terms of its intelligence and we need to try and build in a better horizon-scanning process that can feed into NICE and indeed the Device Evaluation Service. Q105 Jim Dowd: Thank you. Many telemedicine and telecare initiatives are developed through a combination of local enthusiasts and supportive environments in local authorities or health authorities but that has led to an ad hoc development and uneven pace of development. Is there any way we can approach this more strategically and have a more consistent approach in developing new initiatives? Sir Christopher O'Donnell: Are you talking about telemedicine or more generally? Q106 Jim Dowd: Telemedicine. Sir Christopher O'Donnell: I will pass that down the table because I do not know. Dr Harvey: I think in a way ‑‑‑ Q107 Jim Dowd: I think the answer is no so let's save time! Dr Harvey: I think where we are saying the Institute will have a role in terms of technology is if you think of a new type of pacemaker, we would also expect them to be able to pick up new technologies in terms of telemedicine as well so we would hope that it will be able to scan the breadth of new devices, et cetera, that will come up that could have an impact. We do not just mean a surgical device or whatever. It will be very important in terms of informing the NHS of the sorts of things it may wish to invest in. I think it does cover the telemedicine aspect as well and the platform is there on the telemedicine as against the telecare side through the national programme for IT and we would expect that to build over time. Q108 Jim Dowd: Finally, because you have answered one of the points I was going to make, what about the criticism about the lack of co‑ordination between the UK health technology industry and the Department of Health? Does it exist? If so, what is the effect of it? Sir Christopher O'Donnell: I think the whole idea behind HITF, which started in discussions in 2002 really, was that over a relatively long period of time the medical technology industry in the UK has grown but it did not have an interface with Government in the same way the pharmaceutical industry has, and I think both industry and certainly Government see this as being a step to say, "Look, there are some needs here, there are some mutual benefits. Let us try and find some practical ways of making this happen." Now I think we have identified some practical ways of going about it and made a commitment on an on‑going basis over the next two years to follow up on that in terms of the things that we have talked about today. There is a high level of commitment from both the Government and the industry to do so and that meeting programme will commence shortly. Q109 Dr Naysmith: Professor Philp wanted to say something on the previous question. Could I take the opportunity of saying this will be the last chance that any of you have got so if there is anything that you came bursting to the Committee to say this morning and you have not had a chance to say it yet, now is your chance. Professor Philp first. Professor Philp: I wanted to add a supplementary to your question about the strategic, as I see it, adoption of high‑impact technology changes because I have been involved in some of the latest discussions about the new Institute for Learning Skills and Innovation. It is very clear that one of its purposes is to be strategic and to use horizon-scanning techniques to identify where there would be high impact on the NHS and our care system through adoption of new technology which is emerging from whatever source and that part of the process of that is for national clinical directors such as myself to advise on the one or two things that might be happening in our area where there really would be a difference if we could accelerate the pace of movement from invention to adoption within the service and then how we would stimulate that through market mechanisms or whatever. I think there is a mechanism through the Institute to be more strategic in the way that we pick up on new technologies and the potential impact they could have on health. Dr Naysmith: If there are no takers on my offer, then can I thank you all very much indeed for coming. This is a relatively short inquiry but it has raised a lot of interesting questions. Jim Dowd: And I hope all your horizon scanning and blue skies thinking does not damage your eyesight!
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