|
UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 49-i House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE PUBLIC ADMINSTRATION SELECT COMMITTEE
CHOICE, VOICE AND PUBLIC SERVICES
Thursday 25 November 2004 DR TIM BROWN, MR ALAN WALTER and MR CHRIS WOOD PROFESSOR ALLYSON POLLOCK, MR JAMES JOHNSON, MR JOHN APPLEBY and MR NIALL DICKSON
Evidence heard in Public Questions 108 - 201
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Public Administration Select Committee on Thursday 25 November 2004 Members present Tony Wright, in the Chair Mrs Anne Campbell Mr David Heyes Mr Kelvin Hopkins Mr Gordon Prentice Brian White ________________
Memoranda submitted by Centre for Comparative Housing Research, Defend Council Housing and London Borough of Newham Examination of Witnesses
Witnesses: Dr Tim Brown, Centre for Comparative Housing Research, De Montford University, Mr Alan Walter, Defend Council Housing, Mr Chris Wood, Director, Housing and Customer Services Department, Newham Borough Council, examined. Q108 Chairman: Could I welcome our witnesses this morning who are Tim Brown, Alan Walter and Chris Wood. It is very kind of you to come and help us. This Committee is doing an inquiry into the Government's public service reform agenda and is particularly focusing now on issues of choice and voice and although we do not want to get into the details of policy areas, we want to get illustrations of how some of these things might work and you all bring considerable expertise in housing to us this morning. I do not know if any of you want to say a word by way of a very short introduction or shall we just continue with the questioning? Mr Walter: Could I make two very brief points? Q109 Chairman: Yes, of course. Mr Wood: I attended a public meeting in Tower Hamlets last week where there is a stock transfer ballot about to take place. We do not know when it is going to take place because it is under the control of the local authority. We ended up having a meeting in a church hall in an area where a significant minority of the attendants are Muslim and that is far from an ideal venue. We ended up there because the confirmed booking we had at the local primary school was cancelled at the last minute on the instigation of local authority members on the Board of Governors. I think that is an example of how we have got an outrageous situation where there is supposed to be choice but one side of this debate has unlimited resources, the names and addresses of electorates, they can employ professional consultants, translate material, they control local halls and determine when the ballot is held - maybe there is an analogy with what is going on in the Ukraine at the moment - and the other side has no resources and fits in campaigning around picking up the kids from school and their jobs and everything else. On any democratic criteria you apply that is not proper choice and it is not very balanced. The second thing is that there are plenty of authorities now where tenants who have been asked to exercise choice have done so and voted no and they are now being told to ballot again. The housing minister has gone to these areas and when he asked what will happen if tenants say no a second time, they said they will keep balloting them until they say yes and the money that is available if you give the right answer will not be available if it is the wrong answer. Those two principles sum up the fundamental contradiction. Q110 Chairman: Thank you for that. I am not quite sure it is quite like the Ukraine yet. Perhaps we could start more positively and concretely by turning to the choice‑based lettings system. One of the things the Committee is interested in is trying to find examples of choice models from different areas that have been designed to produce certain outcomes that are thought to be beneficial and choice‑based lettings is one of those that is often referred to. Could you just give us the essence of the scheme and tell us why the research seems to support the view that this is an advance over what happened before? Dr Brown: My name is Tim Brown. I am the Director of the Centre for Comparative Housing Research and I have been involved in both the development and evaluation of a number of choice‑based lettings systems. One of the key principles of choice‑based lettings is that it gives the customer or the applicant a relatively greater say in the allocations process. I think it has to be seen in relation to the traditional allocation systems that have dominated social housing provision where previously it has been very much based on housing officers taking the lead in the process and customers being passive and waiting for a letter or a phone call from the council or from the housing association to say, "We've got a property that we think is suitable for you." Often in high demand areas it is a limited offers policy, maybe you can only have two offers before you are suspended from the waiting list, and that does not give customers much choice in the process. Empowering customers to respond to adverts seems to be a very positive way forward and something that comes across from many of the Government pilot schemes and other schemes on choice‑based lettings where customers like the process of having greater relative choice. Q111 Chairman: Do you want to add anything, Chris? Mr Wood: I would be more enthusiastic than Tim about the positive attributes of choice‑based lettings. I think it has transformed the nature of my relationship with the people who are coming to the council asking for housing. It has given them control and greater power than can be exercised in their choice of housing. I strive to ensure the system is similar to that that we enjoy in the private market. We have an unlimited choice of housing. We can buy a house wherever we want. There are constraints on that and that is the affordability of it, but we do have choice. We can buy a large house in outer London or a small flat in inner London. Our applicants in choice‑based lettings schemes are afforded similar ranges of choice. There are variations between the schemes and the currency that is used to bid for the property. In the scheme that I administer waiting time is the currency and so the people who have the longest waiting time come to the top of the list and can choose any property that is available, but if they have a lesser waiting time they can choose a less popular property. They can sit and wait for the ideal three‑bedroom house with a garden and off‑street parking or whatever, but they recognise they may have to wait a long time for that. If they want to take a high-rise property of a similar size then the currency of waiting time is that they can move earlier. Q112 Mr Prentice: In the briefing material we have been given we are told that there are 91 bids per property, that is the average in Newham, but in the best areas there are 477 bids. How long do you have to be on the waiting list to be considered for a property in one of those popular areas? Mr Wood: You would have to be on the waiting list seconds to be considered. How realistic it would be that you would secure one of those properties ‑‑‑ Q113 Mr Prentice: You said it goes to the person who has been on the waiting list for the longest time. Mr Wood: That is right. Q114 Mr Prentice: How long would a person have had to have been on the waiting list to get a property in one of the popular areas of Newham where you have 477 bids? Mr Wood: In one of the popular areas then the waiting times can be eight or nine years, but for a similar sized property that same person could wait half or less that time. Q115 Mr Prentice: Do people who have their eyes focused on one of the popular areas in Newham think this is a great system that allows them to successfully bid for a property after eight or nine years on the waiting list? Mr Wood: I would make two points in response to that. You need to compare it with what went before and this is a hugely popular scheme compared to what went before. People feel much better about this scheme than what Tim described before, the kind of rationing system that we had previously. Q116 Brian White: People do not join the waiting lists because of that eight and nine year waiting time as they do not think it is worth it. Have you had people who previously would not have applied to go on to the waiting list now coming on to the waiting list and an increase in the number of people wanting council housing? Mr Wood: No, I do not think so. Dr Brown: I think certainly in high demand areas what is being changed is the process. Choice‑based lettings does not affect the supply. If it is a high demand housing market it is still going to be high demand. What a number of local authorities have done is to broaden out from choice‑based lettings to what I would call a housing options package by making information available about other ways of meeting housing needs, meeting their housing aspirations, promoting shared ownership, low cost owner occupation, the private rented sector and disabled facilities grants as a way of thinking about whether people really do need to move. There is always in a high demand area, whether it is east London or rural areas such as Harborough in Leicestershire, an imbalance in the housing market, but I think it is quite interesting that after two or three years some local authorities and their housing association partners are broadening it out to give people choice in social renting and making them aware of other products and services. Q117 Chairman: One of the issues that has arisen in our discussions about all of this is whether there is a conflict between choice and equity and I would be interested to know what you think of a scheme like this because someone could argue that the old system was basically, for all its defects, a needs driven system, ie you totted up the points that people got based upon the needs that they had and a property was allocated to them. That has the virtue of some sense of equity about it. Is equity a casualty of this, and do those people who are least able to operate this kind of system lose out? Dr Brown: One of the principles of choice‑based lettings is that it helps vulnerable people. A number of the schemes are trying to build equity into the scheme, not just by giving priority to vulnerable people through priority cards or bands rather than waiting time as the currency, but what we have found in choice‑based lettings is that it is about involving a wide range of advice and support agencies in working with vulnerable people, their advocates, health sectors, the social care sector, the Citizens' Advice Bureau, who are all partners in developing the scheme so that the schemes take account of people's needs. Can I give you an example to illustrate that? One of the issues in Harborough in Leicestershire, which is an agricultural area, was that many residents have got low literacy levels. Harborough talked to county council education departments and said they should not put the adverts in text format but use diagrams, signs, that sort of thing. There are all sorts of ways of ensuring that vulnerable groups are not missed out by the system. I am quite passionate about the fact that we have got to be sure that vulnerable groups do not lose out because of not being able to access the information, not having the support. Mr Wood: All the choice‑based lettings schemes that I am aware of hold back some properties for emergency applicants. I think in Newham it is around about 75 per cent of our properties we advertise through the scheme, but if there are life and limb situations then obviously there is an opportunity to move people urgently into properties and that protects the most vulnerable people in the most extreme circumstances. I would concur with everything Tim has said. Again you have got to compare it with what went before. I do not think people used to read our publications, I think they used to weigh it. There were just huge volumes to try and account for every conceivable circumstance that someone might find themselves in and make a judgment about whether that was relatively more needy than someone else. The system is very much more transparent and simple. The feedback I get from the users is that they much prefer that. The thing that most dissatisfied people about the old system in the research that we did was what we had called "leapfrog-ing" in that you could have 125 points and be top of the queue today and you would be told that you were top of the queue or second in the queue, but tomorrow if three people came in with 128 points you would suddenly become fourth or fifth in the queue. It was just counter‑intuitive for people how they could be a priority today and then tomorrow that priority could be reduced. Many of the new schemes are based on high‑tech solutions for delivering these schemes. Newham is one of the most ethically diverse places in the country. The concern about accessibility for people whose first language is not English has been a key concern for us, but we have been able to develop new methods and new solutions. We have automated telephones available in 11 and 12 different languages and we have talking heads on our website schemes so that if you want to receive instruction advice in the language of your choice that is available on the website. People use that and they have responded to it. Our tracking applications from different ethnic groups show that there is absolutely no lack of take-up from the different ethnic groups and we have solved the problem of language as a barrier. The area where I still have some concerns appears to be with older people where there is perhaps some technophobia, reluctance to engage with websites and touch screen kiosks and so on and so forth. People can be assisted through the process by staff in our centres if they wish. Dr Brown: Information communications technology does allow choice‑based lettings to do very cutting edge stuff, such as virtual viewings of property. My concern on that, wearing my information communications technology hat, is that only between ten and 20 per cent of applicants are likely to have access to the Internet at home and it is not going to be Broadband and if they are trying to download information with pictures, etcetera, it is very frustrating. I think we have got to be careful about the use of technology. It can be quite liberating but it could reinforce the digital divide. Mr Wood: I do not agree on that. Q118 Chairman: Tell us why not. Mr Wood: There is this notion of a digital divide and how that Internet banking is used by people in higher income groups and all these new facilities are for the more advantaged section of the population. Newham is one of the most deprived areas in the country and we have had absolutely no difficulty with people using the technology‑based system. We thought that automated telephones would be the primary channel by which people would access the service and the rate of take‑up through the Internet took us by surprise. These are very disadvantaged groups where Internet access in the home is only slightly less than the rest of the country, but now about 60 or 70 per cent of all our users are accessing it through the Internet either at home, in libraries, in our centres, we have touch screens in our public offices or Internet cafes and they are managing without any difficulty to use the technology and I think it just makes it very much more open and accessible and I am a great fan. Q119 Mrs Campbell: I was not going to follow up on ICT, I was going to take you back to the question of who manages the housing stock. The first question is really whether you think tenants should make the choice or councils should make the choice and why? Mr Walter: I think what is fundamental is that as far as we are aware there have been no instances in the country where that issue has been raised by the tenant. The debate about management and about who the landlord should be is one that is coming from the top down. What tenants are concerned about is the quality of the homes that they are living in. The issue of choice‑based lettings is outside of our remit. In metropolitan areas and the South East I think the major issue is how many homes there are and what the quality is like. I am not against choice‑based lettings but I think it is cosmetic and you have to ask why so much energy is going into something that is cosmetic rather than tackling the fundamentals of the problem. The satisfaction levels amongst council tenants about the principles of having decent, affordable and secure housing provided by the local authority are extremely high and universally across the country the criticism centres around the issue of investment predominantly, not the issues of who the landlord is and whether it is public or private. In that situation it seems to me it is completely false and dishonest for the Government to then try and make the issue of ownership and a change of landlord the central debate. As we have laid out, the justification they use for that, the arguments about separating housing strategy from housing management and the benefits of tenants' involvement, does not stand up to any examination whatsoever. Q120 Mrs Campbell: Do either of you want to add anything? Dr Brown: I would make the point that certainly in the first district‑wide scheme in Harborough what struck me very early on was that many of the applicants thought there was far more stock in Harborough than there actually was. I remember going to a tenants' forum meeting and they said, "Gosh, the issue in Harborough is not the allocations process, we much prefer the new system, choice‑based lettings, it is the fact that there is only 23 4‑bedroomed properties in Harborough." The fact that properties are advertised has made the issue much clearer to tenants. Q121 Mrs Campbell: I want to take you back to the choice of who manages the housing stock. Is there a real choice for tenants or for councils because if councils are to meet the Decent Homes Standard and the Decent Homes targets they cannot do it without extra funds? The Government have said that they will not make funds available directly to councils. Do councils have any real choice with it? Do they have any choice? This is why they are saying to tenants if they do not know they will have to come back to them and try again. Mr Walter: There are many councils that can. If Decent Homes is the driver ‑ and the ODPM Committee said it was a Trojan horse ‑ then there are many councils that can meet the Decent Homes standard using their existing resources and yet some of those councils, Sedgefield being one of them, are still trying to stop stock transfer by using the votes of council tenants. I do not think you can look at it simply on the basis of economics. There are councils that can bring homes up to the Decent Homes Standard, that is what the agenda is meant to be and yet they still want to get rid of their council homes to a private landlord. That does not make sense. In that situation there is a choice for council tenants to say something to the councils, but that choice only means anything if council tenants understand what those choices are and they have access to an argument that says the council can meet Decent Homes and you can remain council tenants. In lots of areas they never hear that case. Q122 Mrs Campbell: Can I just put to you the question that was put to the tenants of Cambridge City Council who have just had a ballot on the transfer of housing stock. They are able to meet the Decent Homes Standard without having to do any public borrowing, but they had set two standards. Apart from the Decent Homes Standard, they have a higher Cambridge standard and what they were asking tenants basically was do you want to go for the higher standard, the Cambridge standard, in which case it will mean housing stock transfer, or do you want to go for the lower standard. It seems to me that is offering choice, is it not? Mr Walter: As long as tenants are clear how the different elements fit together. There is a number of different issues. There is what extra work is involved in the higher standard, what the benefit is and how much extra money that will cost and what the timescales are if you either stock transfer or if the council keeps the stock. There are many councils that could meet the Decent Homes Standard and retain their stock using the existing resources but maybe not by 2010, maybe they could do it by 2011/2012. The way it is portrayed to tenants is that it is a black and white thing: either you stock transfer, in which case you will get gold taps, or there is going to be Armageddon. In terms of Decent Homes plus or whatever local authorities call it, it may be that the extra benefit could be achieved in 2012/2013. What tenants need to weigh up is those different elements, the amount of work, the amount of improvements they are going to get and the timescales and how much they stand to lose by whichever choice. In Grimsby, where the council by its own admissions can meet the Decent Homes Standard but it said it wanted to do more than that, the kind of work that was outside of its ability if it retained the stock were things like putting in extractor fans or repaving paths. If it had been explained to tenants that the fundamental improvements to their homes would be done but maybe some of the more peripheral work might take longer, that is a very different set of information on which to make choices than if you are told it is either/or and it is privatisation or disaster. Q123 Mrs Campbell: I understand that you clearly have some difficulty with the ways in which the choices are being presented to tenants and we could discuss that further. If a council is not able to reach the Decent Homes Standard except by extra funds which obviously are not going to be forthcoming, what choices do councils have if tenants reject the options that are put forward to them? Mr Walter: Government policy can be changed. The fundamental responsibility of a local authority is to represent the interests of its electorate, not to represent Government policy to tenants. For instance, in areas like Camden where the Government allocated £283 million of public money to the council but only if it set up an arm's-length management organisation is a reasonable thing to do where the council, tenants and the MPs have joined together to exert pressure on the Government. That seems to me a normal democratic process. In Birmingham where they voted two to one against stock transfer and the Government has said it would write off debt to the tune of £650 million, I think again MPs and tenants in Birmingham were right to say that if homes are sold then that money should be made available to the council to write off debts if they keep their stocks. Q124 Mrs Campbell: Basically you are arguing for choice, are you not? You are saying that the legislation should be changed so that tenants can have real choices. Mr Walter: I think there are two fundamental principles here. The choice depends on there being a fair and balanced debate, which there is not, and a ballot in every instance, which there is not. Secondly, all the choices should be available. We are not asking for the moon here, we are asking that the money that belongs to council housing is ring‑fenced and re‑invested back into council housing. That should be the parameters of a choice debate. Q125 Chairman: Are there cases where it is sensible for tenants to choose to move over? Mr Walter: I think that would be for individual tenants to decide. We have no problem whatsoever with tenants being given the opportunity and given more choices. All the evidence is that if that was done the vast majority of tenants would choose to remain with the council and get their improvements that way, but if tenants voted in those circumstance for a different landlord then that is democracy. As long as they have heard the debates then I am absolutely comfortable with that and it seems to me the Government should be as well. Mr Wood: I want to offer a contrary view. I think this is nonsense. This is my personal view. I am not articulating the policy of Newham Council in any way. I do not think tenants should collectively be given the choice of landlord. My belief is that these are the State's assets to provide housing for the current generation and for generations after. If the State chooses that it wants to re‑mortgage or re‑finance in order to bring this housing up to a standard and it has a responsibility to do that, then I think who owns the property, whether it is a housing association or the council, is not something that should be offered to the tenants by way of choice. The only choice that the tenants would have would be in the election where they would choose between one manifesto or another. No one has asked me to vote on the denationalisation or nationalisation of industry other than when I go to the ballot box. I do not see why council tenants are special or peculiar in some way and should be offered the chance to be balloted or to choose on the ownership of council housing. Q126 Mrs Campbell: Would you think they have a right to be consulted? Mr Wood: Yes. Q127 Mrs Campbell: And what method of consultation have you used in Newham? Mr Wood: I would defend their right to be consulted absolutely, definitely. In Newham we have had, we call it, a commission dominated by tenants with some independent people from housing associations and so on and so forth and they acted rather like a select committee, calling people to give evidence, housing associations, Defend Council Housing, and so on and so forth. We did more traditional things, public meetings, newsletters and so on, but we also commissioned a survey by MORI to do a methodologically sound representative sample, as it were, and the results of that were that people were saying that essentially they wanted decent homes and their preference, as expressed in the mechanism, was for the Arm's Length Management Organisation precisely for the reasons that you have given, because of the range of choices and options, PFI, arm's length management and stock transfer, so that was the range they were given and they chose what they felt to be the best of those three options. Q128 Chairman: Is there not, Alan, a logic in this position which says that given the fact that you are saying that all this choice is bogus anyway, would it not be much better just not to have it? Mr Walter: Well, I do not think the Government can pretend that it is committed to choice in public services and then either run a choice exercise that is fundamentally flawed and then when it gets into difficulty the professionals in the field basically say, "Well, it's better not to have it all because we can't guarantee we're going to win it", which is how this debate has been run. I think there is a fundamental difference between a commuter on a British Rail train and a council tenant and one of the fundamental differences is that actually we have a legal contract called a 'secure tenancy' and, particularly in today's times where the private market is running absolutely mad and is causing misery to millions of people, actually a secure tenancy is worth its weight in gold and I do not think that the Council or the Government should be able to take that away from us without us agreeing to it. There are comparisons with people at work. This is a legal agreement and it is up to the Government to uphold those agreements. Firstly, I think the Government should be consulting people about public services because they are our services and we have paid for them, but, secondly, in the specific case of council tenants, the secure tenancy is a legal contract and we have a right to defend it. Q129 Chairman: You say that the alternative that is being offered is privatisation, but it is surely not, is it? It is a different form of social initiative, is it not? Mr Walter: I think this thing about social ownership is an attempt to fudge. RSLs, registered social landlords, are private companies. Now, if you turn the clock back 20 odd years, I think Gerald Kaufman, at one of our conferences, explained that when he set up the Act which introduced housing associations, they were, by and large, and this is not paraphrasing his words, friendly, cuddly, locally based, community-orientated, specialist housing providers. That is not the case today. They are multi-million pound, increasingly national organisations dominated by the private sector and I think to call them "social" is meaningless. The Government keeps saying that they are not for profit. BUPA is not for profit, but if BUPA tried to take over your local hospital, most people would think that was privatisation and they would think that rightly. I think it is clear that we are talking about at the moment that we have a long tradition, a proud tradition, which I think has served millions of people well, of public housing provided by the municipality and there is a world of difference between that and what the Government is trying to do. There is also a world of difference in practical terms because, as we say to tenants when we get the opportunity, "If you get transferred to an RSL, you lose your secure tenancy, and this is not an academic issue, it means eviction rates by RSLs are significantly higher than by local authorities, your rents go up, and there is a loss of accountability because you can't hold them to account". These are concrete, practical issues and I think it absolutely justifies us in saying this is privatisation. Q130 Mr Heyes: Why would this be? You have used words that the Government is false and dishonest, that it is a charade, it is not real, but what is really underneath all of this driving it, do you think? Why would the Government behave in this way to present this as choice when really it is disguised as something else? What is that other thing and what is driving it? Mr Walter: Well, I think they present it as choice because they try and legitimise something. Why they are so intent on privatising council housing, I think, is a bigger question and I suspect it is because they believe that private is good and public is bad and what used to be, in many local authorities and for governments nationally, a public service that politicians were proud of, I think, because of the legacy of under-investment, has become an embarrassment that politicians would like to get shot of, but the facts are that the economic arguments do not stack up. The facts are that if all the money from tenants' rent, from capital receipts, the money they are spending on writing off debt and subsidising privatisation, if that was put into council housing, then council housing would be financially viable and Decent Homes could be met, so this is a political debate, not a financial one, and I think the Treasury has now accepted that. Q131 Mr Heyes: It is this parallel, the dogma, against what you say is a very logical and strong economic argument. It does not make sense, does it, that dogma can dominate in that way? Mr Walter: Well, I think if you look at what has happened with ALMOs, it really does expose the contradictions because the argument that ministers have put in the past has been that they need to lever in private money, but actually increasingly, because they have been losing ballots over stock transfer, they came up with the ALMO formula and now in many metropolitan areas that is the only one that they have any chance of getting through. ALMO expenditure is on balance sheets and it is no different from the councils borrowing direct, so it is clear that this is not about levering in public money. The Government has a commitment to trying to change the way that council housing is managed and the review that the ODPM is now conducting into the future of ALMOs, explicitly looking at selling them off, seems to us to vindicate our analysis that ALMO is two-stage privatisation and that is the Government's end game. Q132 Mr Heyes: Our inquiry is entitled, "Choice and Voice". What does all of this do for tenant voice? My thinking behind that question is that in my area where the stock transfer took place very early, it seems to me that tenant voice has been damaged by that because, remember, Chris Wood referred to the democratic process and the bottom line is that if you do not like the way the council is running the housing stock, you can have change, and the removal of that and, alongside it, the removal of the councillor advocacy role in dealing with individual cases or collective cases of problems, all of that has been taken way. To be frank, my view is that has damaged tenant voice and I am interested in your thoughts on that. Mr Walter: Personally, I happen to be the chair of a tenants' association on my estate and I think most tenants' associations know their ward councillors and most ward councillors know their tenants' associations and you know, when there is a problem, who to get hold of and, by and large, there is a relationship, regardless of political party, that works. I think, as you say, after stock transfer, and I think the same is becoming true of ALMOs, the politicians hold their hands up and say, "This has got nothing to do with us anymore. It is a separate organisation". It was interesting, I think, that the Health Secretary, John Reid, when he was asked about the deficit for the Bradford Foundation Hospital, where I think there are parallels, said, "This is a foundation hospital. It's not my responsibility anymore", so I think that experience is general. It is a way that local politicians can wash their hands of what has been a major part of their responsibility. What we would argue and what we would ask the Committee to do is, one, that there should be some proper research into actually what has happened with privatisation of council housing, what the experience has been, and that research should be made available to tenants who are having the question posed to them today in order to make the choice more real, and, two, there need to be some very clear guidelines on the obligation of local authorities when conducting these options of how they conduct it. It cannot be right, and maybe the parallel with the Ukraine is a bit overstretched, the idea that one side of the debate controls when the election is going to be held. The Leopold Estate in Tower Hamlets, we expected that the ballot would start this weekend, but we do not know, and the Council will determine it and they will use MORI or other professional firms to gauge not the right time democratically, but when they think is the optimum time for them to win their position. They can spend public money, unlimited amounts of public money, and they have access to the names and addresses of electors, whereas the opponents do not, even local MPs. David Drew in Stroud tried to get a list of council tenants who were being balloted over a stock transfer so that he, as their elected Member of Parliament, could communicate with them, and other MPs have tried to do the same thing and have been refused that. Where local councillors have asked for that information, they are democratically elected politicians, and when they have attempted to express a view in areas like Stroud and other areas, they have been threatened with the Standards Committee. Now, that is happening more and more as the Government becomes more and more desperate and it is clear that the strategy is advice coming down from the ODPM to the Housing Task Force, so I think for this Committee to say that choice means there have to be very clear guidelines as to how stock options and consultations are carried out and there has to be a ballot in all cases, not just using a MORI poll which one side can manipulate, but there has to be a proper formal vote and a clear period when two sides can debate and resources for both sides to debate and access to the electors and access to public halls and translation facilities, that would be a very helpful contribution. Also I think there needs to be some research. We do not have any full-time workers, so this is nonsense. One side has untold numbers of professionals and the other side is fitted in between taking annual leave on jobs, between taking the kids to school, caring for relatives and doing the shopping, so this is a nonsense in terms of any definition of choice, whether it is a British one, a Ukrainian one or somewhere in between. Q133 Chairman: Is Chris's argument not the one though which says that both this Government and the last one actually believe that councils should not run housing directly anymore and that is what their policy is? Would it not be just more honest just to implement that rather than go through this game about choice and balance because we know what it is all about? Mr Walter: I think some politicians have trouble being honest, so I think playing the choice game is a fig leaf. I think also this Government has a problem which is a legacy from the last Conservative Government which is that the Conservative Government, for whatever reasons, made the mistake, and I am sure everybody thinks it is a mistake, of giving tenants a vote with stock transfer, so, unlike other areas of public services where maybe majorities or minorities of users of those services are for or against privatisation, council tenants today on stock transfer, not on ALMOs and PFI, but on stock transfer do have a vote. I can well understand why politicians want to remove that right and where they are having trouble doing it, they want to use every other advantage that they have to try and circumvent democracy and rig the outcome, but it seems to me that what this Committee is considering is whether it is right that tenants have a choice. If it is right, then it seems to me that you have to make sure that choice is real and not just a paper one. Mr Wood: I just want to make two points, one on finance and then the issue about the voice. I think in Newham we cannot beat the Decent Homes Standard without one of these options, but I would go further than that. Even if we could, if we were awash with money that meant we could meet Decent Homes in Newham without pursuing one of the three options available, and I do not only want decent homes, but I want decent schools, I want a decent environment, decent hospitals and so on, I think that the Council could quite legitimately say, "Well, we could meet the Decent Homes, but actually we want to put our investment into schools" or some other service, "and there is a means here available to us, stock transfer, PFI, whatever it is, that is going to deal with our housing problem, so we can use the resources available to us to deal with some of these other problems". To me, that would be a legitimate choice to make and on the macrocosm I guess that is the choice that the Government is making about where it chooses to put its investment and I do not have a problem with that; it is an eminently sensible thing to be doing. On the question of voice, what has happened to the tenant voice, I absolutely agree with David Heyes and I think this has damaged the tenant voice. I think organisations like Defend Council Housing have become very dogmatic and they have become pernicious in some instances. We were talking before, and I do not know the particular example of Tower Hamlets that was quoted last night, but there are clear examples where Defend Council Housing have simply scared people and they have raised concerns that are not legitimately there, I do not think, and people have been frightened by some of the publicity and by some of the antagonistic nature of the debate and the dogma that has infiltrated the discussion and I think that has been damaging. Chairman: David's point was a rather different one, I thought, that the relationship between councillors and the people that they represent has been damaged. On the one hand, you are saying, unless I have got this wrong, that you are in favour of the policy, you are acknowledging this is a consequence and it is a problem, but I do not quite see how you have taken David's point on that. Once stock is transferred, people cannot go to their councillor and say, "I've got these problems about housing. What are you going to do about it?" because the councillor will say, "Not me, guv". Q134 Mr Heyes: And that is what housing managers, in my experience, now say to councillors and increasingly to MPs because MPs are mopping up the problems that used to go to councillors. "It's not your business, guv. We're an independent arm's length organisation. We're not going to be as responsive as we used to be when you had some power over us through the democratic process". Mr Wood: I do not accept that. My expectation is that housing associations, for example, operating in my borough have a responsibility to provide good-quality and decent services and, if they do not, then I want to know why not. I do get councillors coming to me and saying, "I have had a constituent in my surgery, and housing association X are not doing their job properly", and we sort it out. Q135 Mr Heyes: How do you sort it out? Mr Wood: It depends on the issue, but with associations, the basis of the relationship is that they want to be in the favour of the local authority and there is a partnership arrangement there. I write letters, I pick up the telephone, I talk to their managers, and housing associations are not driven by a desire to provide poor services. Generally speaking, they all want to provide good services and they are committed to the same ethics and principles that the Council have. Q136 Brian White: So you have no direct way of influencing them apart from the fact that your powers of persuasion are that good, like an MP talking to a housing association has the same powers available and they cannot force them to do anything, but only persuade them? Mr Wood: Yes, but how can a councillor force something to happen in the Council. If a councillor rings me up and says that there is a problem with a council tenancy, then I solve it, but I cannot do them special favours because they are councillors. Q137 Mr Heyes: The question about voice though, and councillors have an important role, in my view, of advocacy on behalf of that third, on your admission, of people who are not capable of using the Internet or using other modern methods and they need someone to speak for them or to support them and they have a very important role, but it seems to me that that has been stripped out and that is an element of reducing the amount of voice that tenants have. It might suit housing managers to make this argument because the people who really get the freedom and the choice and the voice in this new arrangement are the housing professionals, the housing managers, are they not? Mr Walter: And the pay rises! Mr Wood: Well, the housing professionals, I guess, yes, we are making recommendations and we are making judgments, but the motivation for that is, as I said before, we want decent homes. I am committed to people in the commercial housing sector having high-quality homes and high-quality services. Now, there is a financial paradox here and the most sensible way to resolve that is to pursue one of the options. My councillors are sitting in judgment on my recommendation and I have not thought it out of leftfield, but there has been a good deal of preparation, consideration and consultation and it is a reasoned judgment, so I do not see how in some way it turns housing professionals into Dr Strangelove. Dr Brown: I think it is very easy to have a debate around the Decent Homes Standard and a separate one about choice-based lettings, but I think that the two are linked. Choice-based lettings are leading to tenants and applicants saying that the services that local authorities run are improving no end. They then get told, because of a lack of a level playing field over the Decent Homes Standard, "Your options are these", and one of them often is not to remain with the council, yet you get some very perplexed tenants and applicants, saying, "Well, hang on a minute. You've introduced choice-based lettings and you have done other things to introduce choice in the service. Your services are improving and now you are asking us to move away from the council", and there are a lot of tenants out there who get very confused about the fact that services are improving. Certainly one example I can think of is a group of tenants who approached me who said, "Well, we don't want to go into a debate about whether we go down the ALMO route or stock transfer because the council has improved its services through things like choice-based lettings in a massive way over a period of time", so I think the issues are linked. The other point that I think comes out from choice-based lettings, and I think it is both a point that Chris and Alan have alluded to, is that applicants and tenants are not just concerned about the Decent Homes Standard, and I think there was the issue about what the standard is, but when they are making decisions about where they want to live, it is the quality of the area, it is the quality of the schools, the quality of the healthcare and what the public transport is like. We really need a decent neighbourhood standard as well and that is what comes over very strongly in talking to applicants about where they want to live, so I think the issue is of choice and it is not a series of separate debates, but the debates overlap. Q138 Mr Hopkins: Just taking up a few points which Chris made, I used to be vice chair of a housing committee 30 years ago and, in my experience, which may be old-fashioned, local authority councillors ultimately took decisions and officers gave advice, but took those decisions and implemented them. Therefore, if someone came to me with a problem and the council officer said, "I'm sorry, I'm not going to bother", I would say that the officer is in serious trouble because we are elected and the officer is supposed to do his job. Is there no difference, therefore, between that kind of relationship and a housing association where, at best, you can write them a rude letter? Mr Wood: I think there is a difference, there is obviously a difference, but I do not think that necessarily means that you cannot get good services from housing associations and you cannot resolve problems that tenants encounter. Levels of satisfaction with housing associations, generally speaking, are higher than levels of satisfaction with councils as landlords. Q139 Mr Hopkins: There is no suggestion that democracy and public services, we should forget about it, and really independent companies run everything because they can provide just as good a service, the tenants have public accountability through democratic elections and the Government should stay out of all these affairs? Mr Wood: Well, I think that is a debate for you guys and it is not for me. That is a political question and this Government, and the previous Government, as I said before, has set out its stall about public ownership and management of housing services. Now, I am working within the parameters which have been set by government policy. I have got to achieve Decent Homes by 2010 and I am being offered three options. I am consulting with my tenants and we are pursuing one that is going to deliver quality homes. Q140 Mr Hopkins: If I can shift over to allocations policies, we had choice because we built lots of houses and there was a very low level of points required for people and they could choose their estates and they could choose this type of house because there was plenty of supply. Is your system not a bit like the National Lottery for a lot of poor people with the chances of them putting their number in a hat and hoping they are going to be drawn out and get a nice house somewhere? Is it not going to make the fact that there is a desperate shortage of decent homes more palatable because people think they have a bit of a gambler's chance of getting one? Mr Wood: No. The comparison with the National Lottery, frankly, I do not think that is a goer. The point that Tim made before, you cannot disguise the fact that choice-based lettings does not increase the supply of housing. There is a shortage of housing and demand outstrips supply certainly in London and choice-based lettings has not done anything to produce more houses, and that is irrefutable, but given the situation that we have got, to my mind there is an enormous amount more dignity in a system of choice-based lettings than there was in the system which preceded it. Q141 Mr Hopkins: Well, there is plenty of dignity if there are plenty of houses and there is a real choice. If there is not a real choice because there are not enough houses, you are just playing a game with people surely? Mr Wood: But I think there is a real choice. Q142 Mr Hopkins: Would it not spice up this game, as I call it, by putting a few nice choice Docklands luxury properties in and tenants might get a chance of getting one of those as well? Mr Wood: Well, tenants do in Newham have a choice of properties. We have properties provided by housing associations in the docks, so they are advertised through the same choice-based scheme. Q143 Mr Hopkins: But people have said that there are literally hundreds of people applying for these better properties each week and only some can get them. Mr Wood: Absolutely. Q144 Mr Hopkins: So their chances are really minimal of getting one of those houses. Mr Wood: But that is a factor of supply and demand, not a factor of choice-based lettings. Q145 Mr Hopkins: Okay, I am coming to that. Does it not then take the onus off the local authority to provide those houses because they can say, "Well, you have not applied for one of these good houses. You've rejected one of the lesser properties and that's your problem. That's the real world you're living in"? Is it not the job of the local authority to provide housing for the great millions of people for whom owner/occupation is just not realistic and the only source of a decent home is for the Government and for society collectively to provide those homes through local authorities? Mr Wood: I would agree with everything you say, apart from through local authorities. I do not see why it needs to be through local authorities and evidently the last kind of 20 years has demonstrated that it does not need to be through local authorities because local authorities have not built new houses for years and years and years. Q146 Mr Hopkins: Well, we could have a national scheme, like the Northern Ireland Housing Corporation. That took it out of the hands of the local authorities because they could not be trusted not to do it on a discriminatory basis, so it could be provided nationally, but anyway, society collectively, it could be a national housing scheme or a local housing scheme. I happened to use local authorities because that is how we have done it traditionally in Britain, but society has got a job collectively to make sure that the least advantaged in society have decent homes and children have decent homes in which to grow up. Mr Wood: Absolutely. Q147 Mr Hopkins: The increasing marketisation of housing, does that not mean to say that we have winners and losers and we do not really worry about the losers too much? Mr Wood: It seems to me that you are just expressing in a number of different ways the difficulty that we confront because of the imbalance between supply and demand. I agree with you, that there is an imbalance between supply and demand, particularly in London, and that people have to wait unacceptably long times to access housing, the solution to which could be to build more houses, but that is a question for government. I guess if Mr Prescott were here, he would say he was addressing that question by investing in the growth areas, like the Thames Gateway. Q148 Mr Prentice: I will come on to John Prescott in a minute, but we are interested in responsiveness in public services and the key question, just reformulating what Tony said a few moments ago, is this: is there merit in separating housing strategy from housing management, just in a word? You are all housing professionals. Dr Brown: I believe that there is, but I think it is important that what can be learned from choice-based lettings, what is popular, what is not popular, needs to feed into strategy and investment decisions and it has to be a partnership between local authorities and housing associations. Some of the more enlightened choice-based letting schemes actually have tenants groups working as forums to discuss and to work on choice-based lettings to feed back, but I think there is a case for separating out strategy from management. It is not as though there has got to be a huge gap because they have got to learn from each other. Q149 Mr Prentice: I understand that and I am asking the question because that is what is driving government policy and I just want a snappy reply from you. Mr Wood: My view on this has changed. I thought it was simply dogma and I did not see the value of it, but my view is changing because the evidence seems to indicate that the arm's length management organisations are providing better services than their predecessors. Now, I manage a large, traditional, comprehensive housing department and we do repairs and benefits and the whole bit and I think we do it quite well, but I cannot refute the evidence which seems to be that the arm's length management organisations, where they are focusing exclusively on management, seem to be working. Q150 Mr Prentice: Okay, we know where you are coming from! Since we know where you are coming from, let me ask you this question. John Prescott told the Labour Party Conference just six weeks ago, "Public financing of housing doesn't treat local authorities on a level playing field. I'm going to set up an inquiry to look into it", and then the following day our colleague, Keith Hill, said, "We recognise yesterday's vote and we'll engage as a result of that and we're going to continue a review, continuing to negotiate and discuss with all the various interested parties". Then on the 29th October, just a few days ago, the Deputy Prime Minister said, "There is no fourth option. We're sticking with the three options that we've been talking about for the past hour and there's no need to create alternative options". You must have felt absolutely poleaxed by that.
Mr Walter: Can I start by saying - and it is not a form of flattery - I am not a housing professional, I am a tenant, and in terms of voice it is clear that housing professionals have all sorts of views on all sorts of issues. Actually, there is not the opportunity for a strong voice of tenants to come through. On the issue of separating housing strategy from management, I am not aware of any tenants who want that. Just to come back on Chris's point, I am always waiting for the evidence to support the benefits of separation. We have yet to hear any. The idea that the experience of ALMOs is evidence is laughable because the criteria for being an ALMO is precisely that you have already been assessed as being a good-performing authority. If you were good-performing with the council, then it is simply fair to expect, unless ALMOs made it worse, that you would continue to be good-performing. As the BFS committee made clear, there is absolutely no evidence to suggest that setting up the ALMO brings those benefits. In terms of being poleaxed by John Prescott, we were not poleaxed, but we are getting a bit tired of all this because the pendulum swings backwards and forwards. Q151 Mr Prentice: You were told one thing and a few weeks later you were told something else. Mr Walter: Yes, and I do think tenants are entitled to expect - remember we are talking about 6 million people who live in council homes around the country - when a senior politician like the Deputy Prime Minister makes a clear commitment that he will keep to it; and the idea that you can just ----- Q152 Mr Prentice: You want a fourth option, which is direct investment in council housing. That is what you tell us. Mr Walter: Right. For the record, can I say that my understanding - and I have talked to a number of participants who were in the private negotiations with John Prescott - is that he effectively, having talked to the Treasury, conceded that at least for good-performing councils there was no argument any longer in allowing them to have access to the ALMO pot of money. Q153 Mr Prentice: You hold to this view because you tell us in your submission that councils get £6 billion a year in rent, and £1.4 billion is clawed back by the Government, which just disappears into the Treasury coffers. You tell us that if that £1.4 billion were available to housing authorities to spend on doing up their council properties, then there would not be any need for all these other options that we hear about, because people would be living in decent houses and local authorities could afford to do them up. That is your position. Can I just ask about the costs of running choice-based letting schemes, because that is important, is it not? If you are translating into 12 languages and sending out leaflets to people's homes and this sort of thing, it must cost an arm and a leg. Mr Wood: It is cheaper. Q154 Mr Prentice: How do you manage that? Mr Wood: We save money because it is less labour-intensive. There is an initial set-up cost because of the technology, but in the longer run it is definitely more efficient. We have been able to reduce the number of staff administering the scheme and divert those resources into other areas, for example tackling anti-social behaviour, which has become an emerging priority for our tenants. Q155 Mr Prentice: What about voids? You often hear about council houses remaining empty for long periods when ----- Mr Wood: It is quicker. Q156 Mr Prentice: How long would a property be expected to stay empty for in, let us say, one of your worst areas? Mr Wood: The average performance in Newham now is about 25 days. Q157 Mr Prentice: What was it like under the old system? Mr Wood: Nearly double that. Q158 Mr Prentice: Down from 50 days to 25 days. Mr Wood: Yes. Dr Brown: That is a fairly common pattern across all of the 27 pilot schemes. I think what is interesting is what you do with the efficiency savings you make. I would argue that one of the things you do is put much more emphasis on the advice and support services. The way in which a number of the schemes provide better advice and support services for a vulnerable group is to use the savings from greater efficiencies in re-letting and voids into advice and support solutions. I would argue that if we moved to sub-regional schemes, which is what Chris is very keen on, and regional schemes, those savings can increase. Why do we need 354 back-office systems for choice-based lettings? You could have a regional system and really save quite a lot of efficiency, and push that back into front-line services. We have not really learnt all the lessons we can from choice-based lettings and efficiency. We could really do something about improving council services, I reckon, by greater efficiencies. Q159 Mr Prentice: A regional call centre. Dr Brown: Yes. Q160 Mr Prentice: Based in Harborough! Dr Brown: They are already running those in the Netherlands. They have eight regional systems. They started off with one in each municipality. They are learning the lessons from that, and actually you are seeing it in the types of services being run by Dutch housing associations and municipalities, through the efficiency savings. Q161 Mr Prentice: Are there any properties in Newham that you just cannot shift? Mr Wood: No. Q162 Chairman: This has been a fascinating session because it has tested both choice and voice - an example of choice being commended and an example of choice being commended and problems being identified with an example of voice. Do you think that out of this discussion there are any wider lessons or extensions of some of the things we have been talking about into other public service areas? What have we learnt from any of this about how we might extend choice in particular ways across the board; or whether there are issues about the voice that come out of this too? I know it is a large question to ask at the end, but very quickly. Dr Brown: I think it is really important that the links are made, only around choice-based lettings, with some of the choices that are happening, and I know you will be discussing very shortly, in the health service, things like tele-care services, and how very vulnerable people can access information in the home. What we do need to do with choice-based letting is get out of the silo, just saying it is choice-based lettings and housing, and actually widen it to the links with health and social care debates. People out there do not see it as just choice in lettings; once you start giving people choice, they want choice in lots of things, and they start asking questions - and why shouldn't they? Q163 Mr Prentice: I would like a bigger car! Mr Wood: There are three points for me. One of the lessons I am taking away from choice-based lettings is around e-government and the opportunities to automate many of the services, around people's ability to access schemes, and the ease with which they can do that. There is huge potential there, and we are starting to replicate it in other areas. The second one is that I am very positive about choice-based lettings, but I still think there is a long way to go. People do not have the choice to move from one part of London to another, and we need to create that choice. They have very limited choice to move from one part of the country to another, and we need to extend and break down some of those barriers. Choice-based mobility is the next phase. The final perhaps more philosophical point for me is that another lesson from the choice-based lettings experience is that creating these kinds of choices and handing over some of the control and the power to the consumer has reduced dependency. Some of the existing systems encourage a dependency. Previously, people accessed housing by demonstrating the extent of their misery and emphasising their disadvantage; and I think this turns that around and gives people more dignity but less dependency on the housing professional. Mr Walter: I disagree with Gordon - I do not want a bigger car, but I would not mind a holiday in the Caribbean! There are some issues, to go back to what Chris said earlier, where you have to make choices; but I do not think the analogy that maybe the Government should put money into hospitals or schools rather than housing is relevant to what we are talking about here in terms of housing. The Public Accounts Committee and the National Audit Office found that stock transfer was more expensive, and their argument that if you ring-fence the money for housing, then you could keep council houses, rather than have privatisation. The concrete debate we have had about stock options is not a debate about where Government should put big chunks of money; it is about the politics behind its policies. I suppose that comes under the second point. I am involved in my local community in the London Borough of Camden in all sorts of capacities, and my experience as a local community representative is that we get lots of things dressed up as choice, and endless consultations, and usually that is just a fig leaf for the council or any number of other agencies trying to drive a particular policy. Actually, there is very little choice and very little community involvement. The voice of the professionals is getting bigger and bigger, and the resources they put behind driving something. In the past you might have had the local council propose something, and you might have had the ward councillor, or even the leader of the council, coming to a public meeting and having to argue their case; and equally other people, and on a much more equal footing, would have been able to stand up at a public meeting and argue an alternative case. Now, they avoid public meetings like the plague, and instead you have lots of money being spent pushing a particular argument. Unless you are incredibly well organised and have lots of resources, then in real practical human terms there is no way of countering. Another interesting bit of research was that despite all the consultations that get carried out, at the end of them the view of the authority conducting that consultation often does not get through. It seems to me that in most cases the original document and the final document is very much the same. I think it is a game, which is an abuse of people. It has nothing to do with choice and does not give people a voice. Chairman: That is very good. One of the issues that comes out of the session, which we are all agreed on, is that if we have choice it has to be real. It does not have to be just a game that we play. That is something that the Committee is well aware of. We have had a very interesting session indeed. As someone who grew up just near Market Harborough, I never thought that it would be the centre of the universe for anything! I am delighted to know that it now is. The fact that we have had such an interesting and in some senses robust exchange of views has helped the Committee greatly. We are grateful to you all for coming along and giving us your time this morning. Thank you very much indeed. Memoranda submitted by Professor Allyson Pollock, King's Fund, British Medical Association Examination of Witnesses:
Witnesses: Professor Allyson Pollock, University College, London, Mr James Johnson, Chair, BMA Council, Mr John Appleby and Mr Niall Dickson, King's Fund, examined. Q164 Chairman: Thank you very much for coming. As you all know, the Committee is trying to grapple with some of the issues to do with the extension of choice, and also issues of what we call voice, larger collective choices; and we are trying to test some of the arguments out in different areas. Obviously, one of the major areas is health, which is why we have assembled you this morning. I do not know whether any of you would like to say anything briefly by way of introduction. You have given us some very interesting memoranda, which we have read, so we come reasonably informed. Mr Dickson: We are happy for you to ----- Q165 Chairman: Niall is speaking for everybody in saying "just kick off". As our starting text, can I take something from the King's Fund memorandum to the Committee. You say: "The key issue concerning choice in NHS therefore is not whether choice is indisputably a bad thing or a good thing, but more an empirical question of where choice, and what type of choices, can bring benefits where the cost of doing so is judged acceptable." Let us have a go at that to start with. Niall, do you want to help us and explain that to us? Mr Dickson: There is a danger that we look at choice as being something very simple, and on the face of it, it is; but when you start to look at it in detail, it is many layered and a lot more complex. I think we over-estimate at times our understanding of how people make choices and the fact that they make choices in different circumstances. There is something inherently good about the idea that people should be able to make choices in their lives, and it is inevitable in public services that there will be increasing choice. At the same time we have to be aware of the limitations on choice, the costs of choice, the circumstances in which choice will operate in different ways and different settings. Rather than simply repeating a mantra, we need to examine it and not be hostile; we should welcome the principle of it, but be aware of the limitations of simply embracing it in all circumstances or suggesting that it is going to be limitless, because it is not. Q166 Chairman: So we should look at cases and look at the design features of particular models: this is what a number of people have said to us already. Is it not the case, just so that we get a sense of where we come from, that the Health Service has not been terribly good at choice in the past? It has been the classic top-down model, has it not? When we start talking about giving people more choice it comes as a kind of revelation to us here, which it does not in other countries, where people are more familiar with the notion of choosing varieties of healthcare. There is a kind of culture shock, is there not, here? Mr Dickson: Yes, I agree. The Health Service has been quite slow to offer people choice. There has always been an element of choice within some aspects of Health Service delivery, but it has been largely a monopolistic service. Certainly, from 1948, when people were extremely grateful to be given anything for free, that has changed, and people are no longer quite as grateful and they are more discerning. There is a cultural issue for the Health Service about offering choice, not just between different providers but within particular treatments. This raises the whole question of the relationship between NHS professionals and patients, which is also undergoing change at the moment. Q167 Chairman: Can I bring Allyson in here. When I read your stuff - which I enjoyed very much, and I have read an article here - you do not like choice very much, and you strike me as being rather attached to this old model. You say, having a go at Woolworth's, "healthcare is not something we even want to make choices about", and you say it is all too technical anyway for people to do it. Is this not just out of synch with how people are now? They just want more choices about their lives, do they not, including big things like health? Professor Pollock: As Niall Dickson has rightly pointed out, it is a much more complex issue. The problem is that choice implies that there is going to be some sort of substitution, and, as Niall has indicated, very often you cannot substitute health services unlike manufactured goods of products. Healthcare choice is problematic because what you are really talking about is not a substitution of interventions of treatments, but you are asking patients to choose between providers. I think it is a myth that patients have no choice: until 1991 there was extraordinary choice in terms of providers. All patients were entitled to second or third opinions, and to go to the provider of choice. Indeed, the evidence shows that the impact of the internal market was to restrict choice because you brought in purchasers and providers and contracts were placed on the basis of where purchasers or commissioners decided to put patients. Indeed, what we will see is that the Government is now signalling - choice is simply a rhetorical device, and the Government is now implementing a full market, so we are going from a quasi or internal market to a full market. The choice is simply a device, and the key thing is to understand the new system of the market under which choice will be activated through price signals or price mechanisms. It is very important for the Committee to understand the new financial structures that have been put in place and the extent to which they will deliver the core objectives in the NHS. All the time when you are talking about choice, you need to return to the core values and objectives of the NHS. Will we still be able to deliver a universal healthcare system, planned on the basis of need and free at the point of delivery, and on the principles of equity in this market-based system? To what extent will choice be there for patients? Mr Johnson: From a political point of view there are two completely different elements of the choice agenda. The one that is always trotted out in a quick sound-bite is the choice of five hospitals to go to if you need an operation. Certainly, our evidence - and we have a patients group in the BMA - is that patients are very, very keen on choice, but they are not keen on that particular bit of it; they think that is irrelevant. The aspect of that from the political point of view, as Allyson has just said, is that with payment by results it forces competition - one provider against another - and in theory at least that will sharpen up its act, as competition does, and so on. The other element of choice - and this is what patients are interested in - is choice of treatment; people with chronic diseases who know a lot about their condition having some choice of where things are done and how things are done. They want choice in the community. We are seeing the different providers coming in the community to perform different services, which we have not traditionally done very well. We have two completely different things going on here from a political point of view, one of which patients really like and one of which they are fairly indifferent to. Q168 Chairman: We have to try and find some common ground in which we can have some discussion here. Does it really matter to patients in a direct sense, looking at Allyson again, how the Health Service is configured - payment by results, the different ways in which it is being organised now. Are those not things that in a sense should not concern patients? What patients want to know is, "can I get treatment in a timely way from a decent provider?" If it meets that test, in a sense does it matter how it is configured? Professor Pollock: There are two separate questions. It may not matter to patients how care is configured, but what you are asking about is whether the design of the system matters. The Treasury has made quite clear that the design of funding matters because progressive taxation is important because of its re-distribution; but if you are looking at whether it is healthcare or education, we all know that in order to deliver universal healthcare on the basis of equity, you have to build in re-distributive elements into the design of the system, which includes above all a mechanism for risk-pooling. The problem with market mechanisms is that they work against risk-pooling; they segment risk and cause disintegration and fragmentation. That decreases patients' access and choice and has a huge impact on equity. I have set this out in the paper for you to read. It is two different questions. It may not matter on the surface to patients where they go, though it will matter if they do not get the treatment they want, where they want it and how they want it. Your real question is about whether it matters as to who provides health services and how they are provided. All the evidence from across the world says that indeed it does matter. There is no universal healthcare system that delivers a universal healthcare service on the back of a marketplace or on the back of trans-national or international for-profit, or even not-for-profit, providers combined. Q169 Chairman: As I understand it - and I do not want to go too wide here - your argument seems to be that the way the Health Service is developing is bad; all these terrible things are happening to it, as you have just described. However, the contra experience from most people is that on the whole it seems to be getting better. The perspective that you are offering seems to be different from the perspective I see, from people who come to see me who are quite glad that they are waiting rather less than they were waiting before, that they are getting a bit more choice. Is there not a mismatch? Professor Pollock: In some areas, indeed, experiences for patients may be getting better, for example A&E waiting lists. However, you have to look at the system as a whole and whether it is working for patients. One of the things about a marketplace is the way it segments risk. We know that the mechanism of devolving risk to providers, where they now have the financial risk, means that because of their need to balance the books and make a surplus, they will have to carry those risks and reduce their liabilities in terms of patients and treatments. I suspect some of your patients may be having a very good experience, but if you went out - and Help the Aged will confirm this - and talked to older people, people with Alzheimer's or chronic illness and disease, and people at the health and social care interface, the experience is less than satisfactory. Indeed, the Ombudsman has recently highlighted the parlous state of these client groups. What we are talking about is not the people who can access elective care, and the quick and easy hi-tech solutions; we are talking about healthcare in the round, and you would have to look and examine the system as a whole. Q170 Chairman: Going back to the initial point about looking at particular examples and looking empirically at what we are talking about, what are the kinds of choices that seem to be working, and which therefore seem capable of some kind of extension? If we were seriously going to develop a choice menu for the Health Service, applying the King's Fund test what areas would we be looking at? Mr Appleby: In our written evidence we provided a table. One of the things that strikes all of us here is that current Government policy on choice in healthcare is very narrowly defined around choice of elective care, based on shorter waiting times. That really is it at the moment. Ministers have made various statements to try and enlarge that view of choice. At the moment, that is where policy is concentrated, and where all the effort is going. Clearly, if we are serious about choice, there is a whole range of different sorts of choices that you could imagine patients, and people before they even get into the healthcare system, may want to have the opportunity of taking. We tried to list some of these in a fairly ordered way, from somebody before they get into the healthcare system, and going through the patient care pathway. The last bit of choice is choice of provider, choice of hospitals, and so on. There are many other choices before then. We thought that was a useful way of thinking about the different types of choices there are. Then, as Allyson says, it does expose the fact that there are lots of choices within the NHS and always have been. We have had choice of GP. It may not work perfectly, so that everybody gets a straightforward choice of exactly the GP they want, but it works after a fashion. With maternity care, you can have choice about how you want your baby delivered and so on. You can look at different parts of the Health Service and different services, and pick out areas where people using the service are empowered to make decisions on their own and to choose things which in a sense best match their preferences for the services they want. Q171 Chairman: Given all that, do you think choice is a big idea or a little idea in relation to the Health Service? If you listen to John Reid, he thinks it is a big idea, does he not? You seem to think it is rather a little idea. Mr Appleby: In a way it is a big idea, but it is a very dispersed sort of idea. Jim may want to say something about this, but it draws in ideas about the relationship between clinicians and their patients quite strongly. It really draws in what we mean by medical training and what goes on there, and how doctors and nurses have a relationship with their patients so that they empower their patients to be able to make choices within the individual commitment decisions that those patients would face. As Allyson was saying, it also potentially includes choices within a market type framework, where you have a payments system which would penalise hospitals if patients did not choose them and so on. It has macro/micro levels to it, so in that sense it is quite a big idea. Mr Dickson: I know we separate out choice of provider on the one hand, and I think that, as Jim was saying, patients are not interested in that. I do not think we really know what patients will do when they are presented with more choice than currently between providers. I do not think we really understand how expectations and views and so on are changing. As more information becomes available, people's capacity to choose could be increased. It carries risks of segregation and different kinds of choices being made by different social groups, and one would need to put in mechanisms to counter that. I also think it is true that choosing between providers may encourage providers to offer more choice themselves, within the service that they are offering. One of the questions that the Health Service has to answer is this: if this is such a fabulous idea, offering people choice within a service, why has it not been done until now? There is a link between the two. I do not accept it is a full market that is proposed, and it is still a quasi market, but the difficulty is that it is a very powerful incentive. The dangers are that you get perverse consequences and people doing things that you do not want them to, rather than increasing cost and personalising the service that they are offering, as well as the possible benefits. Mr Johnson: The linkage of choice with payment by results is a very big idea, and an idea which, although at one end of the scale probably will provide a lot of benefits - we instinctively would not like having to go to one supermarket because there was only one supermarket chain. However, I do not think it has been thought through. If you have a private outfit and a National Health Service outfit competing for surgical patients, with the same tariff and same standard, and if those patients choose the private one because it has things that they like more - a better lunch, nicer decoration - who knows, but they choose it anyway - and the money goes there; then you are taking the money away from the NHS hospital. So far, so good - there is nothing wrong with that at all. However, the NHS hospital will be providing a whole lot of other services that probably no bit of the private sector wants to compete with at all - an A&E department for example, or psychiatric services, or some things that are not at all sexy and do not have any place in the market view of life. If you destabilise that NHS hospital because the money has gone to the private one for the surgical service, how do you protect those core services that only it can provide? I do not think we have worked that one through yet. I have talked to ministers about this and they say, "oh, well, there is further work to do on that and we have not quite got there yet"; but that is a very important question. You have to have the answers to all these questions before you can bring in payments by results, and the patients effectively deciding where the money goes. It is no use saying, "we will think about that later". Q172 Mrs Campbell: I want to come back to a rather narrow choice, which is the choice that patients may want to make about their own treatment. The recent research - and this is really directed to you Mr Johnson - has shown that Britain's doctors often fail to ask their patients their opinions about the type of treatment that they would like. It has obviously got to be informed by a doctor, but do you not think that choice there could be much more widely available than it is at the moment? Mr Johnson: Yes. I was quite surprised. That is the Angela Coulter research that you are referring to, is it not? Q173 Mrs Campbell: Yes. Mr Johnson: I do not really feel there is any intention to do that. If that is what the research shows, then presumably it happens; so you have to ask why. I suspect it is down to the fact that we are relatively under-doctored compared to a lot of countries, and we probably do not have the same time for consultations, either in general practice or in the hospital service, because to do what you have just described pre-eminently takes time. I do not have any particular defence for it, and I have no doubt at all that we should be spending a lot more time with patients, telling them the options and the pros and cons. Q174 Mrs Campbell: Is it time, or is it in fact skill? Mr Johnson: It may be both. I cannot believe the skills ----- Q175 Mrs Campbell: If I can just expand on the question, I think doctors are often used to being very much in control and want to take the decision and then just communicate that to the patient. That is a quicker way of doing it, obviously, but the skill of explaining to a patient what choices may be available, and explaining those in a clear way so that the choice does not necessarily override the clinical priority, is quite a different issue. It is a different way of presenting information. Do you think that doctors may need some training in order to do that? Mr Johnson: I would absolutely reject the suggestion that it is a kind of control idea, that we have them exactly where we want them by saying, "that is what you are going to have". Q176 Mrs Campbell: That is what it feels like sometimes. Mr Johnson: There may be often a case, in fairly straightforward and simple conditions, where there is only one treatment which is going to have any effect, and to try and give equal weight to a lot of other possible treatments that you know will not be effective seems to be a negation of what we are there for. I really do not believe that it is a way of controlling patients. That is now how we see it. Q177 Mrs Campbell: Can I be more specific then: some doctors think that alternative medicine is a waste of time, and that this choice should not be offered to patients. However, very often is it not true that some kinds of alternative medicines can sit alongside conventional medicine and offer patients real choice and make them feel better anyway, even if they do not have much medical effect? Do you think that is a choice that patients should be offered? Mr Johnson: In medicine we are very much encouraged to be evidence-based, and frankly, to set aside something that just makes you feel a bit better, like a gin and tonic or a holiday on the Costa Brava - you know, that is fine - there are lots of things that make you feel better; but we are really there to provide choice that is based on evidence. To give a choice by saying, "if you do this or that, it will probably make you better, and if you do any of the following there is not a shred of evidence to show it will do you the slightest good whatsoever apart from being nice" - again, that would be a complete negation of what we are there for, to attach equal weight to those options. Q178 Mrs Campbell: I would be interested to know what Allyson feels about this because she has talked about choice within systems, but I do not think you have talked about this particular element of choice, whether you think it is a good thing or not. Professor Pollock: The whole choice debate is a problem, as you are all highlighting, because it means so many different things. I have been talking about why the system is important. What you are talking about is largely the symptoms, but we need to understand the causes - so the feeling that patients perhaps do not get the choice of treatments, or doctors are talking down to them or exercising control may all be true; but these are symptoms and we need to understand that much more and get the evidence of the causes. Some of these will be system-related and some of them will be due to professional attitudes and all the rest of it; but we cannot come up with easy solutions. You have asked about alternative medicine. I work in a hospital which has homeopathics, so it is part of my remit. We, like Jim Johnson, are very keen on evidence-based medicine, and perhaps one of the questions is whether we are doing enough research into the evidence behind alternative medicines in order to give patients more choices. One of the big concerns in research, which is one of my areas, is that increasingly because of the pharmaceutical and commercial interests - and these are interests that are being driven by the Government and the Department of Trade and Industry - we are getting a crowding out of some of the other more valuable types of research, whether it be rehabilitation or speech therapy or alternative medicines, because they are not seen as profitable areas for research to follow. This is not an issue perhaps for the Committee, but it is certainly an issue in terms of the fact that one of the great things about the NHS has been its pioneering spirit and innovation. Indeed, if you look at geriatric services and day-case geriatric provision, these were pioneered in the UK, and they have been exported widely abroad. The tragedy is, companies like United Health Group and EvercCare are coming back into the UK to sell us the very same services that we have pioneered since the 1960s. This is another issue where we are forgetting this extraordinary tradition in the NHS that risk-pooling gave us, this extraordinary entrepreneurial spirit which allowed us to develop new treatments and methods. One of the problems with a market-dominated system is that increasingly you have commercial imperatives dominating, so that treatments that may be open to research that are not going to be valuable in commercial terms simply get crowded out. That is an increasing frustration for doctors and patients alike. Mr Appleby: There is a big issue here about information and choice, at a whole set of different levels. In a sense, Jim raised information about the evidence base for what works and what does not in healthcare; but the trouble is that that evidence is not that clear-cut. It is not a case of "this works and this does not for all people at all times". It is often a bit blurred. We have a National Institute of Clinical Excellence, which looks at the clinical and cost-effectiveness of healthcare. You only have to look at its technical reports to see how difficult it is sometimes to tease out what works and what does not work for which groups of patients. One of the issues that we raise in our evidence is that there will be patients who would want to choose treatments which may be alternative treatments or treatments evaluated by NICE but which NICE has said on average in general are not worth the NHS providing. But some patients may believe that they could benefit, and they may be right for them individually, but we just do not know. It is a difficult issue. This is where we could get into what is the cost of choice. It could easily push up cost if we wanted to extend choice and draw the boundary further on. There is another issue about information: a lot of the information that we would perhaps as consumers or patients, or even primary care trusts, in terms of their commissioning, would want to know, which we simply do not have in the Health Service, is to do with the health of patients. The NHS does not monitor on a regular basis the health status of the people who use its services; it simply does not happen. We do not have that information. There are some experiments that the Department of Health is starting now to look at, but even without choice the sort of information we would want to get our hands on so that we could make assessments not just at a hospital but at a clinical team level and a treatment level, is information that is fundamental: does this intervention do you any good; does it do you any good if you are a 60-old with a certain co-morbidity? The crude fact is that we do not have that information on a routine basis. Professor Pollock: That links back to your question on access and whether things are getting better for patients. As the Government is currently pushing more work into the community and primary care sector, it does not have the data sets to monitor it. Recently, John Reid has said that we collect too much information, and currently information systems are under a huge set. They have already failed to implement the community minimum data set. We will never be able to answer your question as to whether things are getting better, or on the equity issue, while information systems are being ripped out and dismantled as they are now. Mr Dickson: Going back to your question on alternatives, Allyson mentioned the pioneering spirit of the NHS. I think it has been anything but pioneering in that area, and very large numbers of people have in a sense voted with their feet. I think we have to have a more open-minded view. I do agree that it is partly about how you research things, and finding new ways rather than simply relying on double-blind trials and the rest of it as ways of measuring whether or not things are effective. That is one aspect of choice, and I think it will come in. I think that the NHS should adapt and offer more than it currently does. Q179 Mr Prentice: I will just put reconfiguring the NHS to one side for the moment, but I want to come back to that. Picking up on the point John Appleby made, who is driving this demand for greater choice? Is it patient groups? Are people logging on to the Internet, and saying, "hang on a minute; if I spend a couple of days on the Internet, I can end up with more knowledge than my general practitioner for God's sake". Who is demanding this increased choice? Mr Appleby: In policy terms it is fairly straightforward; it was the Government, the Department of Health, which really in a sense constructed a policy around choice, which has its roots in reducing times. If you look at the pilots that have been conducted on choice, particularly in London, their main objective was in a sense to bus patients around from longer lists to shorter waiting lists. That is essentially what happened by offering patients on long lists the choice of quicker treatment in a hospital with a shorter list. Q180 Chairman: That is a good thing, is it not? Mr 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 the 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, in a sense; that they do look at the Internet. Q181 Mr Prentice: They do. Mr 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. Mr 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 Mr 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. Mr Appleby: I think they are, yes. Q185 Mr Prentice: That is a good thing. Mr 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 there are some benefits potentially. 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? Mr 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 per cent; and at the moment administration soaks up about 11 per cent. 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 per cent. 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. Mr 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 trans-national 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 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. Mr Appleby: I think the key word there is "may", I have to say. There are elements 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 - you know, that is just what happens 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 build 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. Q200 Mr Prentice: As a health professional, you tell me that over the years the BMA has been putting pressure on the government of the day to open new medical schools, to have new doctors in training, but it has not happened. Mr Johnson: I think it is quite scandalous that 55 years into the National Health Service we, as the fourth largest economy in the world, are still taking doctors and nurses from developing countries, as are the USA, Canada, Australia and New Zealand. We ought to be self-sufficient by now: I have no doubt about that whatsoever; it is a scandal. Q201 Mr Prentice: A disgrace? Mr Johnson: Yes. Chairman: On that note, I apologise that we have only scratched the surface of these big issues. You have in your memoranda helped us greatly in the conversation we have had today. Thank you for helping us to think both about the choice and the voice side of it. It is our job to try and bring these things together in some way. Thank you very much indeed for your time this morning.
|