Examination of Witnesses (Questions 391
- 399)
THURSDAY 20 JANUARY 2005
RT HON
JOHN HUTTON,
MP AND MR
JOHN BACON
Chairman: Can I welcome our witness this
afternoon who is John Hutton, who is the Minister of State at
the Department of Health. He is accompanied by John Bacon, who
is the Group Director of Health and Social Care Services Delivery
in the Department. We are very grateful to you for coming along.
The good news is that we are not the Health Select Committee!
The bad news is we do everything, that is to say we try to look
at some of these issues across government and across departments.
We have invited a number of ministers, starting with yourself,
to come and help us in thinking about these matters of—as
we call them—choice and voice as part of the public service
reform agenda. We are very grateful to have had a memorandum from
the Government on these matters and a particular one on health
issues relating to today's session. I am not sure, John, whether
you want to say anything by way of introduction?
Mr Hutton: No, I am very happy,
Chairman, to go straight into questions.
Q391 Chairman: Let me start us off
by wondering if there is not some kind of difference between the
approaches inside government on these matters. I ask this because
when I look at, for example, what the Prime Minister says about
choice—and I quote from the Government's paper to us—quoting
his speech in January 2003, he says: "Choice mechanisms enhance
equities by exerting pressure on low quality or incompetent providers.
Competitive pressures and incentives drive up quality, efficiency
and responsiveness in the public sector". Then, if I look
again in 2003 at the Treasury's paper on meeting the productivity
challenge it says: "It is important to ensure that choice
is not promoted at the expense of equity or efficiency, particularly
where there are market failures and capacity constraints."
I am not wanting to make a trivial point about are there differences
here between Number 10 and the Treasury but the substantive point
is, is it not the case that although the Prime Minister seems
to suggest it is an easy relationship between choice and equity
and efficiency, in fact what the Treasury says is "hang on
a minute, there can be real problems here in trade-offs with equity
and efficiency"? I would not mind hearing you say something
about that to start with.
Mr Hutton: I think that is the
$64,000 question, is it not, which goes right to the heart of
this whole debate about to what extent choice can lever up quality
and efficiency and equity at the same time. I think to be fair
it is also the case—I know this because I have read the
speeches, I am sure other colleagues have as well—the Chancellor
has made very clear his support for choice in public services
as well. I think the issue for us is this: unless you take the
right steps and do the right things if you are going down this
path, there is a danger that you can exacerbate inequities. You
might not improve efficiencies and the results and the gains that
you want do not materialise, of course that is so. That is why,
as we have been developing the proposals in the National Health
Service for greater and extended patient choice, we have been
very clear all along that choice is a means to an end, it is not
an end in itself. We do not want to develop and extend choice
in the National Health Service at the expense of equity or efficiency
or responsiveness or any of the other objectives that we are seeking
to do. We have done, for example, and we continue to do, a very
great deal of work with the NHS, both at Strategic Health Authority
level and with local NHS organisations, to make sure that one
of the key ingredients to make a success of these reforms—which
is access to the right information—tells people what they
need to know about different providers and so on and is available
to everyone. We recognise that some people might need more help
than others in making sense of that information and using it efficiently
and effectively. Certainly that was one of the lessons that we
learnt ourselves when we started to develop some of the choice
schemes, for example, around coronary heart disease which I think
have proved a huge success in reducing waiting times for heart
operations. Right at the core of that proposal around choice in
CHD was patient care advisers, people who have the time, experience
and knowledge to take patients through the various options which
are open to them, to explain things about the different providers
which are available to them so they can make informed and proper
choices. Of course there is a risk of those things happening.
What you have got to do if you are going to go down this road
is identify them and be clear about the values that you are determined
to hold on to as you go down this road. We are not going to compromise
on equity as we go down the choice road. I do not think there
is a simple trade-off between the two. Of course, you can sacrifice
one at the expense of the other unless you are careful, but we
are going to be careful and we are going to make sure that the
choices that some people in our society have always had, which
are based on personal wealth, in future become based on personal
health. The choices of the few literally become the choices now
available to the many. I think that is perfectly possible if you
set your horizons at the right place and you fly by the right
instruments. If you sacrifice instruments in the process or if
you do not fly by the instruments then I think you can have a
problem.
Q392 Chairman: Just on the point
you made about choice being simply a means, it is just a tool
that we can use for certain policy objectives and it is not an
end in itself. In fact, I am struck by the fact that the paper
that has come to us expressing the cross-government view on this
actually does say it is good in itself. Just to give you the quotation,
it says: "Choice emerges as both a means of introducing the
right incentives for improving services for users and as a desirable
outcome in and of itself", that is it is both intrinsically
and instrumentally valuable. You have a Government position which
says not only is it a useful tool but it is a good in its own
right. One of the things we have to think about is which of these
it is.
Mr Hutton: Maybe, Chairman, I
have not expressed myself clearly enough. Let me go back to the
beginning of this argument. We know from the work that we have
done in the National Health Service that choice makes a powerful
difference to the quality and responsiveness of NHS services,
and that is what we want to achieve and secure. Also, we believe
that choice is a good thing in itself, of course it is, because
I believe in a modern, democratic society choice is one of the
defining characteristics of modern citizenship. Choice should
not just be about who you elect to govern you but it should also
be extended to what choices of services you decide to use. If
I have expressed it to you bluntly, let me row back a little bit
from that. It is the case, I think, that choice is a good thing
as an aspect and future of citizenship, I am sure so, but I know
also that it will have a powerful, beneficial effect on improving
the responsiveness and quality of NHS services. That is my principal
responsibility here as a Minister in the Department of Health,
to find the right way of making sure that the NHS gives to the
public the services that it wants. I am aware, and I am sure colleagues
will be aware of the argument, that patients do not really want
choice, that it is just a myth, all they want is a good local
hospital. Of course there is some truth in that but I think the
view that you have to choose between the two is one of the fundamental
myths which has helped to confuse the argument here. I think you
can have both because there are bound to be plenty of reasons,
for example, where you do have a good local hospital but for perfectly
sensible reasons you might, as a patient, want to choose to go
somewhere else, for reasons of convenience. For example if you
are an older person and your family live a hundred miles away
you might prefer to have your operation, particularly if you are
going to be in hospital for a long period of time, closer to where
your family and loved ones are. I think we have to try and balance
the two things but I believe very strongly, from what I have seen
and what I have heard patients say to me who have been involved
in these schemes, that it has been hugely beneficial for the NHS
and it is certainly what patients want because the best way to
find out what patients want is to ask them, and that is precisely
what we have done. In opinion poll after opinion poll they have
confirmed they want choice. Yes, they want good local services
but they believe, also, that choice can help them deliver that.
Most importantly of all, when we have offered choice to patients,
very large numbers of them have exercised their right and have
exercised the opportunity to go somewhere else to have their treatment.
I am rowing back a little bit on my original answer.
Q393 Chairman: You are perfectly
entitled to row back a little bit. Let me get you to row back
a bit further on something else which is, just as a matter of
obvious fact is there not a trade-off between a choice based way
of delivering services and an attention to cost-effectiveness?
In a system where there is limited funding and, therefore, in
that sense limited supply, at some point there will be a trade-off,
will there not, between having a service driven by the notion
of choice and having a service driven by the notion of cost-effectiveness?
Mr Hutton: No, I do not think
so. I think if you look at—which I know you want to look
at later—the payment by results mechanism which we are proposing
to use as, if you like, the policy instrument to facilitate patient
choice, what payment by results and all prospective payment systems
do in health care systems is reward efficient providers, not reward
inefficient providers. I think choice and payment by results together,
and they are two parts of this very important reform, can help
promote efficiency in the use of capacity in a health care system.
Q394 Chairman: Can I give you an
example to make it less abstract. One of the things which I think
is valued by people in some health care systems—France,
Belgium, many ones cited—is that people can access specialists
directly. If you have a problem you go and see a specialist directly
and you get that under your insurance deal. If you want to develop
a serious choice based system, and given the fact that is a choice
many people would like to exercise, they do not want to go through
a gatekeeper for many things, they want to be able to go and see
someone who knows about the condition immediately, that will be
extremely expensive to do. In going down the choice route, we
have retained absolutely the GP gatekeeper model, have we not,
and set our face against a kind of choice that would be extremely
expensive to implement by people going directly to specialists?
Mr Hutton: I think the French
health care system is extremely expensive and has been running
at very significant deficits for a long time as a result of that.
We are not proposing to do what they do in France here in England.
You are quite right, we are not proposing to remove the important
gatekeeping role of GPs because quite clearly we have to manage
a finance budget. I think there is a way of extending very significant
extra choices to the system without sacrificing the obvious objective
of all governments, of whatever political persuasion, to maintain
the efficiency of the use of resources. I think in a sense it
comes down to this, does it not, we are talking about greater
choice but we are not talking about an absolute choice, unlimited
choice, because we all know in the real world that there are going
to be some limitations, some driven by the requirements of efficiency,
some driven by other considerations as well. For example, we are
not proposing that any patients, whatever their circumstances,
whatever the medical opinions might be, can demand any type of
service at all. Obviously the service has to be a medically justifiable
intervention and we added in, also, further requirements in relation
to efficiency that the intervention can be conducted at NHS tariff
prices because we save a public resource. I think the fact that
you have to engineer efficiency into the system does not mean
necessarily that you sacrifice all of the core components of a
system of greater choice.
Q395 Chairman: No. I want to put
on the record the fact that there is clearly a trade-off between
moving in choice directions and issues of cost-effectiveness.
The Treasury is quite right to flag that up as a consideration.
Mr Hutton: They are. I had interpreted
your remarks—I am sorry—as saying that choice based
systems must always be inefficient. I am trying to say the opposite,
I do not believe that to be the case.
Chairman: No, I am saying there are constraints
on choice insofar as we are concerned with issues of cost.
Q396 Mr Prentice: Maybe they can
be inefficient, and I just want to explore that because you talked
about dangers and risks in offering greater choice. GPs are the
gatekeepers and yet the National Audit Office told us yesterday
that about half of GPs know very little about the Government's
choice agenda and 61% feel very negative or a little negative
about it. Given that GPs have got this pivotal role, should the
Government not have done a bit more to explain to general practitioners
what its thinking is in trying to bring them round?
Mr Hutton: I am not sure whether
those figures that you have quoted relate to GP awareness of the
National Programme for IT or whether they relate to their opposition
to the principle of patient choice. The evidence that I have is
very different. There was a survey, for example, conducted by
the Dr Foster organisation in April 2003 which showed 71% of GPs
thought the NHS would benefit if GPs could offer patients a greater
degree of choice. Our own DoH research—which we are very
happy to provide to the Committee—showed 91% of GPs endorsed
offering patients the choice of time and date of appointment and
82% endorsed choice of hospital. I think we need to be clear and
it is very clear, also, Gordon, from the NAO report, the support
of the BMA and the Royal College of GPs for the principles of
patient choice.
Q397 Mr Prentice: I listened to the
Today programme this morning and there was widespread scepticism,
I think, amongst general practitioners, that GPs were spending
now 14 minutes per patient consultation as opposed to a previous
nine minutes. My central point is that the people who are going
to manage all this are not on board. The bit that I quoted earlier
goes on to say: "GPs' concerns include practice capacity,
workload, consultation lengths . . ." that is what I have
just been talking about ". . . and fears that existing health
inequalities will be exacerbated." Now that is pretty damning,
is it not, for general practitioners to tell the National Audit
Office this? The NAO canvassed opinions through a survey, I believe,
but that is pretty damning, is it not?
Mr Hutton: I think it would be
damning if it was true.
Q398 Mr Prentice: Okay.
Mr Hutton: It is not true. It
will not exacerbate health inequalities and, in fact, we know
the opposite to be the case from all the choice pilots that we
have done, and which we have provided evidence to the Committee
of.
Q399 Mr Prentice: How does it work
in practice? An ill person goes along to the general practitioner,
having listened to the Today programme and to Government
ministers like yourself talking about the choice agenda. In this—and
I do not say this flippantly—brave new world will the patient
be encouraged to ask the GP about the competence of the doctors
who are going to treat them in the hospital; the reputation of
the hospital or the department in the hospital that is going to
treat them; death rates? Will they be able to ask the GP that
kind of information because it seems to me that would stretch
the length of the consultation quite considerably?
Mr Hutton: There is a huge amount
of data available already which answers patients' enquiries about
exactly those issues. The idea that we have to prompt patients
to ask, for example, is the doctor you are recommending who is
going to treat me any good, we do not need to prompt them to ask
that, they ask that now. You would ask that question, I would
ask it, just about everyone wants to know if they are going to
be treated that they are going to be treated by a doctor who has
got some relevant experience. I think the difficulty for us, Gordon,
is that it is very easy to knock holes in the argument, it is
very easy to look at the immensely complicated operational task
in front of the NHS—and it is a big one—of converting
effectively a no choice system into a system which delivers more
effective choice and to say "it just cannot be done, it is
all too complicated so let us just stay with the system that we
have now where there is no choice, patients are told where to
go for their treatment". Now, given that health is the most
important service that any of us consume in our lives, I think
the idea that the public services can only offer patients one
choice, nothing else is permitted, frankly I think is a desperate
poverty of ambition around the public services. I am glad to say
it is for that reason that the Government has decided to embrace
choice and to find a way of reflecting that mechanism, of introducing
it into the NHS. I am very aware that GPs have concerns about
what this means in terms of the length of their consultations,
of course they are right to have those concerns, but the new GP
contract that we spent two years negotiating with the GPs themselves,
which they endorsed overwhelmingly, does actually remunerate GPs
for longer consultations now for the first time, and I think that
is a good thing. We know from some of the work around Choose and
Book, the electronic booking appointment system, some of the feelings
about the length of time it would take GPs to actually confirm
a transaction have been exaggerated. GPs are bound to be concerned
about that until they have actually got the system on their desk
and they can use it because they all work under enormous amounts
of pressure. What I would say about that in terms of the point
that you have specifically raised about length of consultations
and so on, is that we have always envisaged that most outpatient
appointments eventually will be booked through Choose and Book,
the IT system, but we have never said that all of those appointments
will be booked in that way. Even within Choose and Book, the National
Programme for the IT booking system, there will be opportunities
for patients to go home and think about what service they want
to access and to call in through the call centres and call booking
management services to make their appointment. The GP will generate
the initial inquiry and they can go away and book the appointment
at their own time and convenience as well. There are workarounds
around these perfectly legitimate concerns but none of them are
knockdown arguments against the principle or the value of choice
in the NHS.
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