Examination of Witnesses (Questions 40-59)
RT HON
PATRICIA HEWITT
MP AND SIR
NIGEL CRISP
27 OCTOBER 2005
Q40 John Austin: I think we will
go into this when we come into the inquiry further on local decision-making,
but given the hassle that you had, and I think you have to accept
you had a bit of a hassle over the PCT document, I would like
to ask a brief question about the timing. Was it really sensible
for Sir Nigel's letter to be sent to PCTs two or three days after
Parliament had risen, given only until October, before Parliament
returned, an opportunity to come forward with complete proposals
for restructuring, for implementation the following year certainly
at a time not only when members of Parliament were not aware until
the middle of August but also when key personnel within the PCTs
who would be responsible for providing a response would have been
more likely to have been absent because of the summer recess?
Ms Hewitt: I completely understand
and accept your frustration on that point. We wanted to have it
ready earlier—we wanted to get out before the summer break—not
least so that parliamentary colleagues could have been properly
involved. It simply was not ready in time and that was just, I
am afraid, one of those things that does sometimes happen, particularly
after an election and a reshuffle when where there has been a
change of people. It is very frustrating, but what I did not want
to happen was a lengthy, drawn out process on this issue of possible
boundary changes or mergers, and so on, because, as we know, there
is a real risk, if you drag that out for a couple of years, of
people taking their eye off the ball of improving services, and
that is why we decided we wanted a very short period for the initial
discussions and proposals to come to us so that we could look
at them against the criteria that we set out, followed, obviously,
where those proposals are taken forward, by the full three-month
consultation. There are not going to be mergers or changes in
every single part of the country. Although there will be issues
in some cases, and there are some that I think may be quite difficult
to arrive at a final decision on, we should not assume that is
the picture everywhere, it certainly is not.
Q41 Dr Taylor: Secretary of State,
can we move on to patient choice. During the last Health Committee
we had a very slick demonstration in Richmond House of how it
would work in theory. So often slick demonstrations are good but
it does not actually work. The uptake has been fairly slow for
many reasons. Could you tell us what lessons you have actually
learnt from some of the pilot trials of Choose and Book?
Ms Hewitt: I was just going to
check that you were referring to Choose and Book. We have now
got 85% of GPs registered with the Choose and Book system as of
this month.
Q42 Dr Taylor: With the up-to-date
equipment to be able to do it, the correct IT?
Ms Hewitt: Let me just go through
the different figures there, I just want to make sure I have got
the right ones in front of me. We have got 85% of GPs as of this
month registered to use the Choose and Book system. We have got
more than 90% of the main GP practices with an upgraded broadband
connection. We have got two-thirds of the hospital trusts who
have gone live and are accepting bookings. We have got 35,000
of the PCs that are now compliant with the higher standards, so
still quite some way to go in terms of the configuration of the
actual desktop PCs. We have got over a third of trusts that have
gone live with the indirect booking service. I am aware that is
a lot of different figures but I want to distinguish between the
patient choice of at least four hospitals, which will be available
from December, and the electronic booking service which will be
available in some places, is scaling up rapidly but still has
a further way to go over the next year.
Q43 Dr Taylor: So the patient will
be able to choose but not book?
Ms Hewitt: No, both. The patient
will be able to choose but where the electronic booking service
is not yet operational the booking will be done over the telephone
or in whatever way suits. The booking will be made but not necessarily
by Choose and Book immediately.
Q44 Dr Taylor: Have you learnt any
lessons from the few pilot sites that have made you change the
methods in any way? I do not mean the machinery doing it.
Ms Hewitt: Indeed, one reason
why there has now been an upgrade to the software and so on is
precisely because in the earlier doctor pilots, the GPs and the
people using it found improvements that could be made to the software
and so on. That is absolutely normal; it is why you do an initial
roll-out, a beta release if you like. There have been improvements
made and that is why the software is now being upgraded.
Q45 Dr Taylor: I believe it is only
possible to choose a given hospital. I hate to go back to the
good old days but it was the GPs who knew the consultant they
wanted somebody to see. Under Choose and Book, can you specify
a consultant within a hospital who you wish to be seen by?
Ms Hewitt: At the moment it is
designed to specify a hospital and we have got two-thirds of hospital
trusts with their necessary booking systems to connect to the
GP Choose and Book service. The GP in each case is going to be
talking to the patient about where they want to go and if it is
appropriate to refer to a particular consultant, the GP will be
discussing that with the patient as well.
Q46 Dr Taylor: I suspect in our constituencies
we have all had examples of booking clerks actually changing appointments
and changing consultants without the consultant or GP being told.
Is there any way you are going to be able to stop this so that
it is not just a booking clerk who changes the consultant to whom
a patient has been referred?
Ms Hewitt: Trying to get perfection
in these matters I think is very difficult. My feeling is that
as we shift the whole culture of the NHS towards being patient-led
rather than provider-led we will get more and more of these things
right, but it is about culture change far more than it is about
IT systems although it is very important to have good effective
IT systems underpinning it. It really is just worth saying that
as one of the GPs who is using this has said, for every GP or
computing press commentator who has written this off, most of
whom have never used the system, there are many, many more who
are using it and finding it very useful.
Q47 Dr Taylor: Let me just tell you
what is happening on the ground sometimes. If a given consultant
is popular his lists are very full and the clerks stop booking
any more for this particular consultant because it is going to
take too long and contravene the targets and, therefore, clerks
move them on to a surgeon who at the moment perhaps is less popular.
How can one counteract that?
Ms Hewitt: One of the issues we
need to look at is whether it is desirable for patients who, having
discussed it with their GP, want to go to a particular consultant,
even though we have got very long waits, are able to do so even
though that might break the six month or, indeed, in future the
18 week target. We are looking at it. Nigel, do you want to add
to that?
Sir Nigel Crisp: I would like
to make two points. The electronic system does allow people to
see the clinic schedules and to see who has been booked, so you
have got a straight feedback but, as the Secretary of State says,
that will not necessarily happen everywhere to start off with.
Q48 Dr Taylor: The schedules will
show the names of the consultants and the lists?
Sir Nigel Crisp: Thursday afternoon
4pm or whatever. You will be able to see the schedule and who
has been booked.
Ms Hewitt: Instead of the patient
being told in a sometimes faded typed letter "You will turn
up, probably in several months time at some time that is probably
very inconvenient to you", the patient will choose when to
go from as wide a variety of choices as we can possibly make available.
I think that is a real step forward.
Q49 Dr Taylor: The GP will still
be able to help the patient make the choice?
Ms Hewitt: Of course. It is a
really important role for the GP to fulfil.
Q50 Dr Naysmith: Secretary of State,
continuing on the Choose and Book system, I wonder whether any
of the pilots you have run have taken account of the fact that
some hospitals and, as we have just been hearing, some consultants
may well turn out to be much more popular than others. This could
have two effects. It could have the effect of making hospital
waiting lists get longer and longer again after we have spent
so much time, effort and finance getting them down. That would
be a great problem. Possibly the other more important effect could
be that some hospitals and, indeed, as Richard says already happens,
some consultants can be less popular than others and you could
end up with hospitals in deficit because the money is following
the patient, as we know now, and you will have real problems with
individual hospitals in individual areas perhaps cutting services
and closing because they are not being referred by the people
who know which are the best places to send their patients.
Ms Hewitt: As I have said, patients
are going to discuss this with their GPs. In some cases I think
the patient will simply want the GP to make the choice for them
and in other cases the patient will want to look at the information,
discuss it with their GP and make the decision taking into account
all the factors. There will be information available to patients
starting from Christmas about not only the waiting lists but,
for instance, the MRSA rates and so on in different hospitals.
That will build up until by the end of 2008 there will be a choice
of any hospital across the country that is offering that particular
treatment to an NHS quality and at an NHS price. Far from risking
an increase in waiting lists, this goes alongside and will help
us to achieve the hugely ambitious 18 week end to end target.
I do not know whether we are going to come back to that, Chairman,
but perhaps I can just draw your attention to a consultation that
we are putting out to the NHS today about the details of how we
deliver on that 18 week target. On the issue of which services
will people choose, I think it is absolutely right that people
should be able to exercise choice when they want to of which hospital
they go to for a particular procedure. I am not going to force
people.
Q51 Dr Naysmith: I understand, and
I want that to happen as well, but what I am really talking about
is the inevitable consequences that we could end up with if we
have only got one hospital in an area which may well be the most
popular one and the one that most people want to go to, or it
could be the opposite and it will produce adverse perverse effects.
I am not really talking about the choosing and booking, that is
great, it is the possibility of perverse effects that exercises
me at the moment.
Ms Hewitt: I think as patients
start to exercise these choices we will see in some cases some
departments of some hospitals not getting as many patients as
they used to get when patients did not have a choice.
Q52 Dr Naysmith: So what do they
do?
Ms Hewitt: They will then have
a pretty strong incentive to improve their service and get patients
to come to them, or they may decide that is a particular treatment
or specialism that they should not be doing because they cannot
do it well enough, in which case they may well decide to move
out of that particular treatment or to work with the primary care
trust and the GPs and move it into the community and have a different
configuration of services. We are going to have to look at this
case by case. In the extreme case, and obviously people have raised
it, where patients going to a different hospital risk destabilising
an essential service, and particularly, of course, Accident and
Emergency (A&E), then that is something where the primary
care trust and, if necessary, the strategic health authority would
be picking up the very early warning signs in order that you stabilise
the service, you make the necessary improvements and you protect
A&E.
Q53 Anne Milton: Just to carry on
from this and move from hospitals down to doctors. We could get
a situation where people are prepared to wait because Dr A is
brilliant, they all want to go to him, so they will wait maybe
six months, whereas Dr B has not got any patients for half the
week. Where will we step in? Where would you envisage stepping
in in a situation like that, or where will the PCT step in?
Ms Hewitt: This new NHS, if you
like, is going to be driven in many respects by patient choice.
Q54 Anne Milton: Yes, I know, that
is what I am talking about.
Ms Hewitt: If you have a particular
doctor or consultant who simply cannot attract patients then I
think the management of the hospital will draw the necessary conclusions
and either find a way to improve the service or do something else.
Q55 Anne Milton: Or sack him or her.
Sir Nigel Crisp: May I suggest
an alternative which we have already actually seen, which is a
hospital in London which was finding it difficult to run a good
paediatric service, partly because it was finding it difficult
to recruit staff, so it was a slightly different reason why it
had a problem. It has now done a deal with Great Ormond Street
so that Great Ormond Street will provide the paediatric services
on that hospital site. I think that is another sort of response
that we will see. If the hospital over there is running services
very well and attracting patients in whatever speciality that
this one is not then you may see they want the people there to
come and work on their site as well.
Q56 Anne Milton: I was taking it
down to the individual doctors. I think competition can be very
useful, as you know it is right in line with what we as a party
support. It is what would happen in a hospital between individual
doctors where it would create interesting tensions and maybe some
difficulties in terms of terminating people's contracts.
Sir Nigel Crisp: You would need
to find out why that person was not getting the patients, would
you not, and then take the appropriate action?
Ms Hewitt: You would indeed. You
would need to look at whether there was an issue about clinical
quality or what is called in the jargon the patient experience
and how this doctor was treating patients, what was causing the
problem, and then I would have thought the consultant in charge
and the hospital management would want to put in the necessary
support and training to try and improve the performance. Ultimately,
if that could not be improved, and this happens already, then,
yes, you might well decide that you are no longer to employ that
individual. There is not much of the press left. I do want to
stress that is a rather extreme example, I do not think this is
going to be the norm.
Q57 Anne Milton: It will be interesting
when patients have this power to see what happens to individual
doctors.
Ms Hewitt: That is part of the
shift from a provider-led NHS to a patient-led NHS.
Q58 Mike Penning: Secretary of State—I
am sure this will not surprise you—if we could move on to
deficits. I wonder if I could ask you some short questions with
some short answers. When was the decision made that the strategic
health authorities would be instructed not to allow the deficits
to continue in the way they have done in the South East in particular?
Ms Hewitt: If I look at the position
with deficits, we have got a minority of hospitals and PCTs that
had a deficit at the end of the last financial year and in each
of those cases, but particularly where the deficits were largest,
the strategic health authority has worked with them to agree a
financial recovery plan to get the deficit under control. What
has been happening over years in the NHS is that some areas have
been pretty consistently overspending compared with their budgets
and those deficits have been matched by surpluses, under spending
in other parts of the country. It is not universally true but,
on average, the deficits have been occurring in the healthier
and wealthier parts of the country and the balancing surpluses
have been in the poorer parts of the country with much greater
health needs. What is now happening is we are seeing very clearly
with much stronger financial management where the deficits are
occurring appropriate financial recovery plans can be put in place,
but with more money going into every primary care trust than ever
before we expect each of them to sort themselves out if they do
have a financial problem and get themselves to a position where
they are in balance year on year.
Q59 Mike Penning: With respect, that
was not the question. You have not answered the question. When
did your Department tell the strategic health authorities that
you would not continue with the deficits on the basis they are
running for this year and for next year? There was a meeting that
took place in the Department—
Sir Nigel Crisp: Let me explain.
There are never meant to be deficits and we tell them that when
we set the budgets every year.
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