Examination of Witnesses (Questions 160
- 179)
THURSDAY 1 DECEMBER 2005
SIR NIGEL
CRISP, MR
JOHN BACON,
MR RICHARD
DOUGLAS AND
MR ANDREW
FOSTER
Q160 Chairman: We have been led to
believe that there is. It just struck me, in terms of forward
planning as a politician and arguing about health matters, that
we should be able to get some sort of measure?
Sir Nigel Crisp: It is specifically
classes of drugs you are talking about.
Q161 Chairman: Various classes of
drugs, yes. The number of NHS prescriptions for various classes
of drugs. It is not about the individual drug, which somebody
may feel is commercially confidential or not in terms of probably
a manufacturer or producer of drugs, as opposed to just seeing
what the general trend is in prescribing to see whether or not
initiatives are working in terms of healthcare?
Sir Nigel Crisp: Let us look at
that again. I am sorry; I would not want to mislead you by guessing.
Q162 Chairman: Could I move on to
the issue of the national programme for IT. We hear or read on
quite a regular basis now that the cost of this is approximately
£6.5 billion. Is that what is thought?
Sir Nigel Crisp: I can ask Mr
Bacon to answer in more detail, but the contracts we let were
for £6.2 billion. They were let at the beginning of last
year.
Q163 Chairman: Is that the full cost
if implementing it locally and nationally?
Mr Bacon: As Sir Nigel has said,
the £6.2 billion, which is the value of the national procurement
programme, includes both the products themselves and provision
for local implementation and training in some respects. We would
expect, and, indeed, the Wanless Report, I think, made this point
quite clearly, that the overall expenditure on IT in the NHS would
progressively increase because we are progressively a more information
dependent service, not just for management but, much more importantly,
for patient safety and for the convenience of patients using a
flexible service. We do expect that number to increase. The NHS
currently spends, and it is quite difficult to track actually
and forgive me for elaborating slightly, but we track the spend
on administrative IT but much of the IT is built into scientific
and technical machines that we do not track specifically, so it
is quite difficult to get an exact figure, but of the order of
a billion a year is spent now by the NHS on IT and progressively
that will transfer into support for the national programme for
IT. I know we have talked at this Committee and in other places
about the overall costs of the national programme in the past.
It is not that we are evasive, it is because it is quite difficult
to track all the transfers of costs that will happen over a ten-year
run, but, to confirm your point, the central contracts are at
£6.2 billion, as Sir Nigel mentioned.
Q164 Chairman: Is that paid for directly
centrally?
Mr Bacon: Yes, the £6.2 billion
is managed by a central programme which I am the senior responsible
officer for, and the contracts are let at national level.
Q165 Chairman: Some of the things
that are being paid for now on this annual £1 billion in
the NHS, it is vital that that equipment has the ability to talk
to anything that has happened nationally. How do you check that
that is the case?
Mr Bacon: Again, part of the national
contract, which is called local service providers—there
are five clusters across the country—over the life of this
programme progressively the local systems will be replaced by
standard systems coming through the LSP contracts which, of course,
will be compatible with other aspects of the programme. We will
have, we admit, a very difficult transition period where because
historically the NHS has not had a centralised approach to this,
we have many suppliers all of whom have had their system tailored
to local use, so the transition period is very difficult and many
of the difficulties you read about are explicit in the ones you
have mentioned where we are having to interface systems to existing
system, and that will progressively ease as we are implementing
the new local service provider contracts.
Q166 Chairman: Is this the secondary
user service?
Mr Bacon: The secondary user service
runs off the back of the core standard; so this is not actually
the secondary user service, no, that is a data service which uses
the data we collect for the management of patients and the management
of the service for other purposes, which Richard Douglas, I am
sure, could explore with you more.
Q167 Chairman: That is not the product
of this?
Mr Bacon: No.
Q168 Chairman: Have you any problem
with that service?
Mr Douglas: There are a number
elements to the secondary user service. One of it is called secondary
user service PBR—without getting into too many initials
it is SUS PBR—which is the system to help Payment by Results
work. It effectively sends data from providers to PCTs by HRG
at its simplest. We were planning to use that effectively for
the second half of this year to manage the introduction of PBR.
We are not using it, not because of problems with SUS PBR itself
but with the data that is going into it. The quality of the data
currently going into SUS PBR is not sufficiently accurate to support
Payment by Results. What we have got is local systems, effectively,
that will be allowed to operate for the next four months until
the next financial year. We will run those in parallel with a
shadow SUS PBR and then have the full system operative when Payment
by Results is extended next year. It is later than we hoped, but
it is not to do with the system, it is to do with the data quality
issues.
Q169 Chairman: Are any PCTs or other
providers going to suffer financially because of this current
situation?
Mr Douglas: They should not suffer
because of it. We should have arrangements in place in all the
SHAs effectively for fall-back systems that allow them to operate
without SUS PBR working. I have been through this in quite a lot
of detail with the Strategic Heath Authority finance directors
at my last meeting with them, and what they are all doing is looking
at managing their own local systems to operate this, so it should
not lead to a significant problem in any PCT.
Q170 Chairman: My last question on
this one is in relation to the issue of Choose and Book. It first
went live in 2004. The uptake was extremely low and remains so.
When are the numbers of patients using this system going to reach
the original levels that were predicted for the system?
Mr Bacon: We appeared before the
Public Accounts Committee on this subject about three weeks ago,
and we can confirm the issues that were raised there. We do admit
that the implementation of Choose and Book as a system, largely
because of the integration issues that I mentioned earlier, not
because the core system does not work, it does, are about a year
behind. This will not, as we said to the PAC, threaten our ability
to deliver our actual promise, which is to enable individuals
to choose a hospital from initially a minimum of four and to book
their appointment remotely. What it does mean is that we will
not be able to use the best technology to do it at the time we
made the promise, which is from 1 January. What we expect to have
done is to have caught up with this by a year later, i.e. next
December rather than the current December. What is encouraging
is that we are seeing really quite rapid growth now in the number
of bookings having taking place. We are now up to over 7,000 a
week from a position where, I think, the total we have done in
August this year was about 250—we are now rattling through
over a thousand a day—so we are seeing real progress in
the implementation, but I would be the last to say this is not
going to be a difficult implementation for all the reasons I have
mentioned earlier and also for some of the individual data issues
around accuracy of data in existing systems that we need to correct.
So, good progress in the last three or four months, but we confess,
as we did recently, that we are about a year behind on the overall
implementation of Choose and Book as a system.
Q171 Dr Naysmith: Can we move to
targets for a minute or two? One of the things I want to ask is
since introducing the 13-week target for maximum out-patient waiting
time performance seems to have slipped a little bit?
Sir Nigel Crisp: On the 13-week?
Dr Naysmith: Thirteen week, yes. Do you
expect to meet the December target?
Chairman: It is 18 weeks.
Q172 Dr Naysmith: No, it is 13 weeks.
Mr Bacon: We have two waiting
list targets. We have two headline waiting list targets in the
general sense, and then some subsidiary targets in specific specialties,
but I think the point you are referring to are the two December
2005 targets of a maximum 13-week wait for out-patient and a maximum
of six months for in-patient. We are, as we have done with every
other of our waiting list targets in recent times, tracking that
down very closely week by week over the whole health system, and
we are confident because the numbers and the way we track it suggests
to us that we will be as near as damn it to the target. Inevitably
when you are talking about literally tens and tens of thousands
of these, there may be the odd one or two that slip through, as
has happened in the past, but we are pretty confident now, because
we are close enough and we can see the numbers. If the Committee
will forebear with me for a moment, we track this on what is called
a targeted list basis: so not only do we track the number we know
are waiting now we track the people we know we have to treat by
the end of December in order to hit the target, and so we are
tracking that, as we have every other one, and we are confident
that we are going to make that target.
Q173 Dr Naysmith: I do not have any
problems with targets as some people do, as long as they are sensible,
they make sense, and they are relatively easy to measure. As Mr
Bacon said earlier with sexual heath, they have chosen the target
that was easiest to measure in working out what was happening
to all the money. Which brings us to the question of why, when
you were accounting the 18-week target from GP referral to start
of treatment, did not the officials and ministers realise that
no definition of that target existed. At the time that you set
the target there was a lot of confusion about what this target
actually meant?
Mr Bacon: That is true. Since
we set that target we have done substantial work. We knew broadly
what the target would be, so it is not true to say we had no idea.
We knew the basic elements of it and we worked through very carefully
in the planning process both the deliverability of it and the
financial consequences of it; so that is built into our planning
assumptions. What we have been doing over the last year or so
is to work through the minute detail in the definition sense,
when the clock starts for certain things.
Q174 Dr Naysmith: When the treatment
actually starts, so it is not just an estimate of something and
then six months after that?
Mr Bacon: Yes. I do not know whether
the members of the Committee will remember, but in the early days
of the in-patient and out-patient waiting list targets we had
similar definition problems. As we move into this 18-week from
GP referral to treatment target some of these definition issues
are much more complex. We have had a very extensive process over
the last year of engaging with the NHS on the best definition
of some of these things. We have just gone out with a document
which sets out our proposals and asks for comments so that the
service has a chance to think about the way in which we define
these targets so that we can refine them before we actually have
to deliver them.
Q175 Dr Naysmith: You have definitely
got a draft definition now?
Mr Bacon: Yes, it is out for consultation.
Q176 Dr Naysmith: Can we see a copy
of it?
Mr Bacon: Absolutely, yes. By
all means.
Q177 Dr Naysmith: Have you got a
deadline for finalising this?
Mr Bacon: I have not got the exact
date. It is early in the New Year. We have asked for responses.
When we send you the document I can give you the deadline date,
if that is helpful.
Q178 Dr Naysmith: Finally on this
area, do you know how well the NHS is currently performing on
a rough 18-week target?
Mr Bacon: No, is the straightforward
answer, and I can tell you why that is.
Q179 Dr Naysmith: It is a bit worrying?
Mr Bacon: There are three components
to the 18-week target, the first of which is the out-patient appointment,
and we have not to date collected anything other than statistics
of people waiting over 13 weeks, but we do know what the cohort
of people in total is below 13 weeks. We know precisely what the
in-patient waiting dimension is, but the bit in the middle which
we are introducing as part of this target, which is the diagnostic
phase, we have never collected statistics on; so the bulk of the
work here in looking at definitions and what statistics we should
collect has been concentrating on that phase. I can give you numbers
for the first element and the third element, but what I do not
have, because we have not collected them in the past, is that
middle element.
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