Examination of Witnesses (Questions 180
- 199)
THURSDAY 25 NOVEMBER 2004
PROFESSOR ALLYSON
POLLOCK, MR
JAMES JOHNSON,
PROFESSOR JOHN
APPLEBY AND
MR NIALL
DICKSON
Q180 Chairman: That is a good thing,
is it not?
Professor Appleby: Yes, I am not
being judgmental about that; I am just saying that that is the
origin of the London Patients' Choice Project. It is couched in
terms of patient choice; but in a way you could look at that experiment
as an almost military style capacity planning exercise to make
sure the beds are here, the patients are over there—"how
do we get these patients into those beds?" That is what the
exercise was really about. In one sense choice of policy is being
driven by the Department of Health, and the objective is to reduce
waiting times; and there seems to be some evidence that that is
what has happened. On the other hand, there is the rhetoric that
patients are more consumer-ish, that they do look at the Internet
and so on.
Q181 Mr Prentice: They do.
Professor Appleby: Of course,
yes, and they do inform themselves.
Q182 Mr Prentice: People with a particular
condition band together, form a patients' group, put pressure
on MPs, on their PCTs, on their trusts and on the GPs.
Professor Appleby: Yes, I would
agree. There is a pressure there. It is coming from patients,
and always has done actually at different levels. As I say, in
terms of the particular thing that is going on now within the
NHS, the Department of Health—
Q183 Mr Prentice: I do not disagree
with you, but you would think that if patients were becoming empowered
through the Internet and so on, they would be demanding more of
the Health Service now than they ever did before. Allyson told
us right at the beginning, and I hope I did not get it wrong,
that under the old system people could get two or three opinions
Professor Appleby: You still can.
Professor Pollock: And they could
go wherever they wanted.
Q184 Mr Prentice: People now must
be demanding even more from the Health Service, all the way along.
Professor Appleby: I think they
are, yes.
Q185 Mr Prentice: That is a good
thing.
Professor Appleby: Yes. One of
the things we are talking about with choice is the mechanism by
which patients get their preferences for healthcare met. There
are market type mechanisms where you put more pressure on doctors
and providers of healthcare to do the things that patients want
them to do. We are arguing where this line, this pressure, gets
drawn, where some perverse things may happen if too much pressure
is put on a hospital. If it is losing patients and cannot respond
quick enough, what will happen to it? There is a lot of risk in
this, admittedly, but potentially there are some benefits too.
Q186 Mr Prentice: You will be familiar
with the website that has been constructed by the Department of
Health with the help of the MS Society and so on, which allows
people with MS to decide which of the various treatment options
may be right for them. I used to be chair of the All-Party MS
Group, so you know where I am coming from. These interferons cost
a fortune, £7,000-£9,000 a year; and yet patients are
being empowered to make a decision on which treatment is best
for them. Is that a model that could apply to other conditions;
or is it unique—because we know so little about how to treat
MS successfully?
Professor Appleby: I do not know
the details of the website and I am not medically qualified, but
I would have thought that that could easily be a model. I do not
see why it should not be at least part of a model for providing
patients, especially people with chronic disease, with more information
about their condition, and what is available.
Mr Johnson: As is the Government's
Expert Patients' Programme. People with long-term conditions tend
to know a lot about it, not unnaturally really because they will
have it for the whole of their lives and have to learn to cope
with it. It is a group that is uniquely placed to exercise choice,
and really wants to exercise it.
Mr Dickson: We are on a journey.
If you look back 20 or 30 years, patients, even patients with
long-term conditions were told very little, and it was not thought
suitable that they should be part of the professional decision-making
process. That has changed, and is changing. A lot of what we are
talking about here is capturing something that will change even
more. I can give an example of a young man who had a collapsed
lung. He had had it before and it had been re-inflated. He walks
into an A&E department when his other lung had collapsed,
and he tells the doctors what is wrong with him. He tells them
what they ought to be doing and the protocols involved, because
he knows it all. Of course, for them it is something that they
do not come across every day. It is an extreme example, but even
an educated young man, I suggest, a mere 30 years ago would not
have engaged in that way and would not have had access to the
information. He would not have known how to use the information
and would have simply gone in and said "do something to me".
There are profound changes happening in the way that people will
interact with the healthcare system, and we need to be aware of
that. In a sense, groups like the MS group are at the leading
edge. There will be different responses depending on whether it
is episodic care or long-term care; but something is changing.
Q187 Mr Prentice: The decline of
deference, I think.
Mr Dickson: Indeed.
Q188 Mr Prentice: Professor Pollock
talked about the reconfiguration of the Health Service and the
foundation trusts that are being set up. I was staggered to read
in your evidence, and want to check that this is correct, that
the administration costs in foundation trust hospitals could be
approaching US levels of 24%; and at the moment administration
soaks up about 11%. Is that right?
Professor Pollock: We know that
administration costs were very low in the NHS prior to 1991, purely
because you had great risk-pooling and integration. It was a very
coherent, accountable and transparent system. We know that after
the introduction of the internal market, administration costs,
on rough estimates, doubled. We also know that the Government
is moving very quickly to a US style healthcare system, with all
the problems that has. That means that you have billing and invoicing—these
new financial flow systems are very, very expensive to administer—the
HRGs. You are going to have bidding and invoicing and transaction
costs; you will have marketing and joint ventures. All of these
things are things that the trusts are currently considering. We
know in the US that USHMOs, both not-for-profit and for-profit,
can have transaction costs of anything from 24-35%. I am not saying
what they are now; I am saying that transaction costs will definitely
increase quite considerably.
Q189 Chairman: Can I ask King's Fund:
are we going in the direction of a US healthcare system?
Mr Dickson: No.
Professor Appleby: No.
Q190 Chairman: I think we should
just register a disagreement there and not go further. It would
take us into interesting and fascinating territory.
Professor Pollock: I talked about
system delivery of HMOs. The Government is committed to a publicly
funded NHS. The question is, if more money is trickling out to
these transaction costs, to private finance, to the profits of
the transnational corporations that are moving in, then something
has to give. You may have a universal healthcare system that is
greatly reduced in quantity and quality.
Q191 Brian White: In previous evidence
sessions one of the things that was said was that the voice of
professionals, when choice becomes the issue, is greatly enhanced,
and the voice—in that case the tenants but in this case
it would be the Health Service users—is reduced. Do you
think that is a fair criticism?
Mr Dickson: There is a danger
that if you are presenting complex choices, in a sense the asymmetry
between the professional and the patient can be greater. As I
said before, I think attitudes are changing, and the way in which
technology is developing and the way that information can be put
across can help. If we put into the system means by which translators,
people who are advocates for patients or who are navigators, can
overcome it, you would have to be aware of that asymmetry and
the fact that professionals do have a great deal of power. Simply
to say that there is choice in the system and that patients are
able to find their way around would be deluding ourselves.
Q192 Brian White: So setting the
question of choice has to recognise that asymmetry, is what you
are saying.
Mr Dickson: Yes.
Mr Johnson: There is always going
to be a knowledge imbalance. That is why people go to see a professional.
That is why any of us use professionals, because they know more
about it than we do. If you believe the best treatment for this
condition is the following, but there are others, it is quite
difficult to construct a conversation in which that does not
come through. It might be completely unconsciously, but nonetheless
that is where you are trying to steer people.
Q193 Mr Hopkins: I find myself very
persuaded by Allyson Pollock's analysis of what is going on here.
To crystallise it, you said that the choice is simply a rhetorical
device, which makes me wonder whether we are completely on the
wrong track with our inquiry. If it is just that choice is a disguise
for a sinister move towards full marketisation of the NHS, should
we not just abandon our inquiry and look into what really is going
on? I would be interested to hear what the other members of the
panel say about this. Should we forget about it; and the whole
thing is a trick?
Professor Pollock: I agree. The
terms of reference for the inquiry as cast are inappropriate.
The most serious thing that is happening at the moment is the
major change to the NHS that is taking place, which may well have
catastrophic effects on the whole of the population and the public
health function. We are in a very, very serious period, and you
as the MPs will have to take this on board. You are the people
that we are asking to champion the NHS.
Q194 Mr Heyes: This is just a diversion.
Professor Appleby: I think the
key word in what Allyson has just said is "may". There
are aspects of choice where clearly there is a big rhetorical
element. If you read ministerial speeches on choice within healthcare
it does look like a cure-all for everything, from athlete's foot
through to schizophrenia, and "we will all be much happier
after we have it" sort of thing. I take that as—well,
when you have a policy to sell: you oversell it and you rubbish
the current system.
Q195 Chairman: We are talking in
big generalities, but is it not just the case that we are trying
to turn public services on their head and to make them less looking
towards the people who provide them and more towards the people
who use them? The great National Health Service, which we love
to bits, has been the great producer-driven organisation; it has
been completely inattentive to the people who use it; people just
sit at home, waiting to be told if and when they are going to
be treated, by whom, in what way, in what place. It comes as a
kind of shock to have people say, "we are going to give you
a bit more say in all this". Is it not interesting that it
is very difficult to get a common dialogue going about this, because
in a sense, Allyson, you do not want to talk about whether choice
could be made more of a reality in terms of how we provide services
to patients; you think it is just a cover for all kinds of other
things going on? The Government, despite what may or may not be
good about the way in which it is organising it, is trying to
turn the system round to make it face far more to the user. We
are having a kind of non-conversation about this, are we not?
Professor Pollock: Well, if you
were really serious you would be looking at the issues of accountability
and democratisation. One of the problems of the NHS since its
inception, which is why you are hearing many of these symptoms,
is that it was never truly democratised or made accountable at
all levels to local people. There was a great deal of lip service,
and there were some attempts through community health councils,
et cetera, but that is the real issue around choice,
the democratisation and accountability. If I were to ask you to
describe the new system of the NHS, any one of you in this room,
and the new systems of patient accountability and public accountability,
I bet none of you could give me a coherent response. That is a
travesty. The old system had its weaknesses in terms of accountability
and democracy; but that could have been built on and improved,
and should have been. That is what this inquiry should be about,
not choice—it should be about accountability and democracy,
at all sorts of levels, and unpacking that.
Mr Dickson: I agree with Allyson
that the current systems of accountability are a shambles, and
they are a disgrace; they are certainly not transparent, and a
lot of them simply do not work. However, I do not think there
is a choice that one has to make between giving patients more
choice within the system, and having voice, that is to say democratic
accountability at different levels within the system. Even in
a more market-orientated system, there will of course be regulation
but there also must be planning. It is not something that is going
to happen just by patient choice, and there are choices that have
to be made about the re-distribution of resources, the reconfiguration
of services. We need to think through how to make them much more
accountable than they have been, frankly, since the service was
started.
Q196 Chairman: You have seamlessly
brought our themes together. We are almost done, but let me ask
this as a closing question. When I was in hospital recently, I
would have killed to get a private room, to be able to choose
to have a bit of privacy. Being in a ward with a cacophony of
television sets, with people making all kinds of funny noises,
and lots of things going on, you sit there and you have nothing
else to think about. You think, "Am I having an unworthy
thought, that I would like to choose privacy? I would even be
prepared to pay a large sum of money to get some privacy."
Would that cut across equity, and therefore I should not have
this unworthy thought? Surely, we have to have a health service
which is just much more responsive to what we want in our ordinary
lives, including things like that?
Mr Johnson: Exactly, and this
is really what the Government have hit on. Whether it is right
or wrong in any moral sense is irrelevant; it is what the public
want. Even if you can demonstrate to them that when you offered
them choice they nearly always chose what you would have just
given them without choice in the first place. They still say,
"but we would really like to have been given the choice".
You cannot get away from that: it is a vote-winner and that is
why it will be pursued.
Professor Pollock: Again, it is
coming back to symptoms. You had a nightmarish experience; you
talked about the television sets and the noise: perhaps you should
have asked what was going on in these wards and why they are not
quiet, tranquil places. Perhaps one of your inquiries might be
into the built environment. What is the effect of a television
set on each bedside, both in terms of charging but also in terms
of noise levels, and the disappearance of the day room because
of the space constraints. What you are describing is very valid,
and patients' experience in terms of the symptoms, but it needs
a much more detailed analysis to look at the causes and then to
arrive at the solutions.
Q197 Chairman: So it was an unworthy
thought really, was it not?
Professor Pollock: It was not
an unworthy thought, no.
Q198 Mr Prentice: Mr Johnson, you
told us earlier that Britain was under-doctored, and talked about
this whole capacity thing. What pressure has the BMA put on the
Government over the years to expand the number of home-grown doctors?
Mr Johnson: The numbers have expanded
enormously. We have shifted, over the last 20 years, from being
a bit sceptical about this to being absolutely for it. One of
the problems is that a lot of European legislation that limits
hours and so on has mopped up—we reckon, for example, that
the Working Time Directive will probably mop up the equivalent
of 6-8,000 doctors; so you will get 8,000 doctors to have to pay
for but not one extra bit of patient care. Then you still need
more again.
Q199 Mr Prentice: It just seems wrong
to me that we should be plundering other countries for doctors
and nurses.
Mr Johnson: Absolutely right,
yes.
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