Examination of Witnesses (Questions 420
- 439)
THURSDAY 20 JANUARY 2005
RT HON
JOHN HUTTON,
MP AND MR
JOHN BACON
Q420 Chairman: These groups will
produce their lists of the top six centres for this condition
and when they go to their GP they will pull this thing off from
the Internet and say, "Look, these are the places I want
to go to for my condition" and the GP will say, "Unfortunately
everyone is saying that. It shows on my screen they have got these
terribly long waiting lists so you will not be able to go unless
you want to wait a long time for it".
Mr Hutton: This is fundamental
to the whole argument, is it not? When we say that we want choice,
of course we want choice, but not every sick child can be treated
at Great Ormond Street Hospital for Sick Children because we know
it has a finite capacity. There are other ways to solve that particular
problem. For example, Great Ormond Street are looking at, as it
were, branding or franchising their product in other parts of
the NHS to run local Great Ormond Street Hospitals for Sick Children.
There are ways round that. You are quite right, by definition
not everyone can be crammed into the same building at the same
time, so the choice menu will have to be predicated on a number
of assumptions, will it not? One is about capacity and availability
and that if you really want to insist on a particular provider
you will have to wait and there might be other perfectly good
providers who can provide the service with a shorter waiting time
that patients might decide to use. There will be a variety of
sources of information and some of it will come from organised
patient groups, as it does now. You can talk to any number of
groups and they do exactly that now and will continue to do that.
That is a good thing, patients should have the power to drive
improvements in patient quality. Patients will rely on a variety
of other forms of information, some of it will come from GPs,
some of it will come from other patients who have experienced
or been to that hospital, and the reputation of the hospital is
very important, the speed of access and their clinical quality.
If you guys have not ever been on the NHS Net have a look at it,
a lot of that information is available now. It is not some sort
of futuristic scenario we are talking about, it is used now. I
am sure that the Department will provide for the Committee some
information about how many patients actually access that information
on a daily basis now. I think you would be quite surprised.
Q421 Chairman: To get back to where
we started, and you hear this said often, what a patient wants
is not to have to wait very long to get their condition sorted.
They want a guarantee that the hospital they are sent to can do
the business properly. They might say that is an obligation on
the state to make sure those conditions are met and, indeed, the
Government is going a long way to make sure that these conditions
are being met. To go further and to say, "Ah well, you have
now got to start shopping around amongst the different providers
and we are going to give you this little list", the question
is, is it what they want? That is the first thing. The second
thing is would they ever be in a position to have the kind of
information sources that would enable them to do if? If I could
just finish this by mentioning the NAO report that came out yesterday
which was critical in a number of respects, and we may come back
to some of them. On the information point it talks about the imperfect
state of information sustaining the choice agenda at the moment
and it says: "Informed by the experience of choice pilots
and Dr Foster's research, the Department's view is that it would
prefer to roll choice out with the existing limited set of information".
The NAO says: "While this is reasonable, it does fall some
way short of patients' expressed preferences as noted in Building
on the Best for information on outcomes and quality to make
choices". The choice scheme that is coming in now is not
yet underpinned by the kind of clinical outcome information that
a genuine choice making system would need, is it?
Mr Hutton: John will want to come
in on this but let me just say one or two things. That is right,
there is more information that needs to be made available to the
public. Gordon is right as well, I think some of the data that
patients need and want to have access to is not available currently
in the format that you have just described. I would just say this
to the Committee: this is an area where we have to be extremely
careful in how information is presented because there is a real
danger that a completely unfair and inaccurate presentation can
be made. When we are talking about the outcomes of individual
surgeons, for example, we need to distinguish between the fact
that some surgeons deliberately will take on more complicated
cases and, therefore, by definition the success rate may be not
as high as a surgeon who does not take on that particular case
mix. We have to find an effective way of communicating that, the
fact that some doctors do particularly complicated and dangerous
procedures, without making it look like that doctor is a dangerous
doctor because that would be totally unfair. We are working very,
very hard, the officials and also the medical organisations, to
find the right way that we can present that information in a sensible
and meaningful way. I am hoping in the next couple of years we
will be able to do that but currently I think there is a very
significant volume of information out there on which patients
can make perfectly sensible and informed choices. John might want
to add to that.
Mr Bacon: Just to add to a point
you were making, Chairman. We have developed, and are continuing
to develop, quality and standards frameworks that are the minimum
quality that must be offered in any hospital that offers NHS treatment,
be that NHS or private sector. So there is a guarantee in that
that you can expect that level of quality and standards if you
are going to an NHS kite-marked institution, as it were. Those
quality and standards are subject to inspection by the Health
Care Commission, so there is an independent inspection service
which will ensure that those hospitals are reaching that level
of quality and standards and their reports will be public and
will be available to the public in informing their choice. There
is a mechanism in place to ensure that that level is both agreed
at the outset and is maintained.
Q422 Chairman: So if I say to my
GP, "Who is the best doctor?", then what happens?
Mr Hutton: Who is the best doctor
locally?
Chairman: If he says, "You have
got this condition, I am very sorry"—
Mr Prentice: It is a big complaint.
Q423 Chairman: "I can give you
four or five choices where you might go" and I am taken aback
by the news I have got this condition, so I say "Who is the
best doctor then?", then what happens?
Mr Hutton: If you were to ask
your GP now, if he said, "Mr Wright, you need to go into
hospital. You have got a rash and we need to look at it",
he would know from his experience of that hospital which consultant
he would prefer you to be seen by. That is true now but obviously
in the menu of four or five providers, that GP's experience of
those particular providers may be less strong. In that case, the
GP, rather like you, will have to rely on the information that
is currently available to make those choices. In a sense, the
idea that this is going to be a unique set of problems when we
extend choice across the NHS is a misreading of the current situation.
There are reputations known within local economies between hospitals
and GPs about which would be the best consultant to see for a
particular complaint. That is the case now and that will certainly
continue within the local knowledge networks that exist in local
NHS organisations and that is regularly exchanged with patients.
In relation to the wider choices that patients eventually will
be able to activate, it is true, as I said earlier, that we need
to continue to make sure that the widest possible range of information
is available to support patient choices because immediately you
widen the network of choices then by definition you are going
to start standing outside those local knowledge frameworks, those
reputational relationships that have been established locally
over many, many years and GPs and patients will have to rely on
a wider spread of information and data to support the patient
choice. As I said, we are working to support meaningful presentation
of that data but, as I hope the Committee will be reasonable in
accepting, it is important that we get that right for the consequences
of getting it wrong are very obvious: reputations could be damaged;
we could misrepresent data and unfairly and improperly influence
the choices that patients are making. It is a complicated area.
There is a lot of work that we are doing with the medical organisations
to try to get it right. I think it is true that the cardiothoracic
surgeons, for example, have been working with the Department for
some time in exactly this area to try to find the right way to
present the data in a meaningful way for patients. I am sure there
is a way to do that and we remain committed to finding that way.
Q424 Mr Liddell-Grainger: I am intrigued
by delivering of patient's choice when a GP is referring. The
NAO report says: "The Department believes that choice is
affordable. Additional annual infrastructure . . . costs are estimated
to be £122 million—or 1.4% of the current total expenditure"
and then it goes on to say ". . . it should lead to increased
efficiencies in primary and secondary care services worth an estimated
£71 million, off-setting some of these costs". How do
you cost choice?
Mr Hutton: That is definitely
John's territory, I think.
Mr Bacon: I think that the numbers
referred to by the NAO relate to the infrastructure costs of establishing
the mechanisms to enable patients to exercise choice.
Q425 Mr Liddell-Grainger: Why £122
million? Why not £100 million or £130 million? Why is
it £122 million?
Mr Bacon: £122 million is
the NAO's view based on the information we have given them of
the infrastructure costs of establishing the process. It is just
a factual number how much it will cost.
Q426 Mr Liddell-Grainger: They are
your figures and they are a factual number. Give us the facts.
How do you come to the fact that is the figure?
Mr Bacon: That is the addition
of the direct infrastructure costs of setting up the process and
the training and development that goes with it.
Q427 Mr Liddell-Grainger: So choice
is costing us £122 million?
Mr Bacon: The costs of establishing
the mechanisms to enable patients to exercise choice is costing
us £122 million.
Q428 Mr Liddell-Grainger: We are
not talking about e-booking in this, are we? Is e-booking included
in the £122 million?
Mr Bacon: I think it is, yes.
Q429 Mr Liddell-Grainger: I will
come back to that in a minute. How do you have an estimated worth
of £71 million off-setting some of these costs? What have
you off-set?
Mr Bacon: Again, the off-setting
costs, as I understand it from the brief opportunity I have had
to read the NAO report, are the savings you make from missed appointments,
et cetera, that cost the NHS considerable amounts of money. We
know from the evidence that we have already that the ability to
book a defined date at the time at which you exercise the choice
will reduce the number of missed appointments, et cetera, and
that will produce a saving and the NAO's estimate is that is £71
million.
Q430 Mr Liddell-Grainger: I think
you are about to be passed something. For making up the difference
on missed appointments, et cetera, you off-set the cost of £71
million, so you are saving on just efficiencies £71 million
but it is costing us £122 million.
Mr Bacon: Yes.
Q431 Mr Liddell-Grainger: Not a great
return, is it?
Mr Bacon: You are not building
in any of the benefit of the patient's ability to choose.
Q432 Mr Liddell-Grainger: The figures
are in here. They are your figures, you provided the information.
Mr Bacon: I am not disputing the
figures, I have agreed those.
Q433 Mr Liddell-Grainger: I know
that. I am trying to get to the bottom of why you come to these
figures because there does not seem to be an awful lot of added
value in choice. I am not talking about patient care wise, I am
talking monetary wise.
Mr Bacon: The £122 million
is set out in detail in the document, so that is where the numbers
come from. As the document said, the off-setting costs are the
savings that I have mentioned.
Mr Hutton: We need to keep one
other thing in mind here. If we are talking about £50 million,
we are talking about £50 million out of a budget this year
of about £70 billion rising to £92 billion by 2008.
In overall terms £50 million is £50 million, of course,
but, with respect, I would say that we have got to look at the
wider picture here. It is not possible to introduce different
systems into the NHS that are necessary to sustain choice, and
we have spent the last hour talking about some of them, on the
understanding that it can be done for nothing. Obviously there
is going to be a cost in relation to this and we work very hard
to try to minimise those infrastructure costs because we can only
spend the same pound once, we do not have a chance to spend it
on patient care or anything else. The collective decision, the
judgment that all of us have to make, is whether we take the view,
which I understand you do, that patient choice is a good thing
in the NHS and, therefore, we need to make the investment to make
it happen. The wider benefits for the National Health Service,
for all us as taxpayers, are very significant. I think choice,
together with payment by results, will support good performance,
it will certainly throw a spotlight on poor performance and I
think drive inappropriate costs out of the system and fundamentally
make sure that we try to get the one really difficult equation
right here, which is to match capacity in the system to where
people want it to be. So we minimise excess capacity standing
empty and make sure that we can optimise sufficiently and use
the capacity in the service. We do not always do that now and
certainly we do not do it under the present commissioning of the
block contracting produces that we use in the NHS. I believe that
payment by results and choice, and the evidence from all of the
pilots supports this, is a more efficient way of targeting resource
to need and to making more efficient use of capacity. If it costs
us £50 million to introduce this system, in the overall sweep
of things that is not a disproportionate cost and it has to be
set aside against the wider benefits that this policy will produce.
Q434 Mr Liddell-Grainger: One of
the whole ideas of choice is to make the NHS more efficient, to
streamline it and to bring in more capacity, to create more friendly
end-usership. What I am trying to get to the bottom of is, you
have tried to quantify a figure—and I do not know if the
figure is right and I am not entirely sure we are at the bottom
of the figure—but there is a cost to all of this. If you
are saying—and both Gordon and Tony put it very eloquently—if
a department shuts, you will have presumably redundant doctors
and nurses, you are going to shift them on to another hospital
to try and take up more capacity there, there must be a cost to
all of this. You have given a very eloquent political answer,
which is very nice, and John gave a very eloquent Department answer,
but we are not getting down to the bottom of what the cost is.
I come on to the e-booking system. There has been quite a bit
of information in the press about this, where it was supposed
to have a capacity of X and it actually hit Y, which was quite
a big discrepancy. You have put an enormous amount of money into
this, many billions I think ultimately, is it actually going
to work? Government and computers do not always hit it off, and
I am not blaming your Department, I think this is true of every
department. Is it actually going to work?
Mr Hutton: It is going to work.
Q435 Mr Liddell-Grainger: When?
Mr Hutton: Well, it is working
now. I had the very good fortune to be in Barnsley yesterday to
meet the GP who has made I think 63 of these appointments.
Q436 Mr Liddell-Grainger: He has
got a statistic!
Mr Hutton: I think there has been
a fair amount of rather predictable use of that figure to attack
the national programme of IT. There is only one story that anyone
ever wants to write about IT programmes, and that is "Another
IT screw-up", it is the easiest story in the world to write.
I would just say a couple of things about that. In relation to
the 63 appointments, it is true two years ago we thought we would
do 200,000 by now because what we planned to do was to test the
scheme in a fairly large number of practices to see what happened.
We decided last summer we would not do that but test it in a small
number of practices with a smaller number of specialties to make
sure we got the gremlins out of the system rather than inflict
this on hundreds of practices. That is what we have done, that
is what we have tried to do, and that is why the figure of 63
does not look terribly clever in comparison with the earlier figure
of 200,000, and everyone can make fun of that and they did. That
is life. The system works, is my answer to you. The e-booking
system works and we know because we have tested it. The other
issue I would say about this is, people have confused a lot of
issues and they have assumed because we have made 63 appointments,
rather than the 200,000 planned two years ago, you therefore cannot
deliver choice in the NHS because the system sucks. Well, the
system works, as I said, and there are other ways—as, to
be fair to the NAO, they acknowledged in their report—you
can work around that issue and make sure you deliver choice in
the system. We, for example, have said to the NHS recently, and
John will have more information about this because he is overseeing
this, that it is possible to complete choice at the point of referral
through telephone booking services, what we call indirect booking
services, where a GP alerts the hospital the patient wants an
appointment, the hospital will contact the patient directly and
negotiate the booking with them, probably over the phone but maybe
in other ways as well. There are delays in using the booking system,
I am not going to pretend otherwise, some of them are to do with
technological complications, some are to do with getting the NHS
geared up to accept the new software into their own patient administrative
systems. Maybe a few months will help. I believe very strongly
that that will not compromise the delivery of our choice objectives
by the end of this year. Patients will still be offered the choice
of four or five providers. I think the large majority of those
appointments, maybe up to 70%, will be booked through the new
IT system but the remainder will be booked through these work-around
devices—indirect booking, call management services as well—so
we can still deliver the choice policy but we might have to do
it in a different way from the way we thought two years ago.
Q437 Mr Liddell-Grainger: You answered
the question to an extent, but I was talking to a doctor who happens
to be a personal friend of mine and he is very concerned about
centralised booking because he lives in a rural area, his choices
as to which hospitals he can go to are limited by virtue of geography,
and his concern is that if he comes up with the best alternative—in
his case it is Somerset—and says, "You are going to
go to Exeter", that is a hell of a long way, it is one and
a half hours away. That is the concern they have. Again, it is
the delivery—and you are talking about primary care—and
if they have not got the choice to refer, or it is an impractical
referral through the e-booking system, they may have a problem
simply because of the vagaries of technology.
Mr Hutton: I do not think technology
will make the booking of that appointment impossible or more difficult,
in fact frankly it will make it much easier, but I do accept the
wider point you are making, that in some parts of rural England,
for example, patients will not have the same access as patients
in London and the South East, or Greater Manchester or Birmingham,
or even Lancashire, to a range of different providers.
Q438 Mr Liddell-Grainger: Pendle
is rural.
Mr Hutton: Yes, and Gordon will
be able to correct me, but I would be surprised if there were
not a range of providers within an hour's travelling distance
of Pendle which patients could consider going to. That is the
important point, these will be the choices on offer, you choose;
any travel, any movement, you make is your choice, it has not
been forced upon you. You cite the example of one of your constituents
being forced to go to Exeter, there will be a range of different
providers they can choose from. If they want to go to Exeter,
they can go.
Q439 Mr Liddell-Grainger: Let us
look at one of your scenarios. Tony has quite rightly pointed
out that if something goes wrong with a department and the department
has to close because it is just not going to work, that department
has to move, in my case, to Bristol, Exeter, and you then have
no choice, you have to go there. I am not saying that is going
to happen but you do not know that and I do not know that, but
that is the ultimate choice which is no choice.
Mr Hutton: Let us start at the
beginning with this. I think the scenario where the service suddenly
gets pulled away and people get no choice, is not going to happen.
Moving on gradually to payment by results means that we give poorly
performing organisations a chance to get their act together, and
that might mean different clinical leadership or different management
of the organisation. If we know that is not having the positive
or desired effect on that organisation, it would be perfectly
possible for a primary care trust to commission an alternative
provider to run that service. What we are seeing, for example,
from the independent sector providers is innovation in terms of
how we deal with these problems and providing capacity in rural
parts of the England. For example, I think in Mr Prentice's constituency
and certainly in mine we have mobile cataract surgery units which
are travelling the country and which have done about 10,000 operations,
and we can take a provider to a particular location and overcome
precisely the point you have just described about the fixed, established
provider having difficulty with the service which no one wants
to go to and, as a result, its income has been drastically reduced
and they might have to take the steps you have described. There
are work-rounds in all the examples you have given, where we can
continue to provide choice for National Health Service patients,
and that is the job of primary care trusts, and increasingly will
be, to make sure patients have access to those choices. They will
start to move away from the traditional role and start to be commissioners,
they will decide for us what service we are going to have and
buy it and commit on a block basis on those contracts. The job
of the PCTs in the future will be overseeing choice.
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