Examination of Witnesses (Questions 320
- 339)
TUESDAY 6 DECEMBER 2005
RT HON
PATRICIA HEWITT
MP, SIR NIGEL
CRISP AND
MR RICHARD
DOUGLAS
Q320 Anne Milton: Could we have yes
or no answers?
Ms Hewitt: No, I cannot give you
a yes or no answer because what I said about denying treatment
on grounds of cost related specifically to Herceptin where the
initial estimate, based on the clinical trials so far, is around
a thousand lives saved a year. That is the same number of lives
at round the same cost as the breast-cancer screening programme,
which, of course, is generally regarded as a rather successful
and in a sense low-cost programme. That is the balance, if you
like, that I was drawing the PCT's attention to, but I certainly
would not make that as a blanket statement in relation to all
or any therapies that people might come along with.
Q321 Anne Milton: So you do not think
that PCTs should deny treatment on the grounds of cost in the
case of Herceptin?
Ms Hewitt: That is right.
Q322 Anne Milton: But you would not
take it any further than that?
Ms Hewitt: Where there has been
a NICE evaluation and NICE say that for these clinical indications
this treatment should be given, the PCT should be organised to
make that available within three months of the NICE recommendation.
I am afraid it is horses for courses here.
Q323 Anne Milton: What about delaying
treatment? There are stories about some operations being delayed
until the next financial year. What do you feel about delay of
treatment due to cost?
Ms Hewitt: What I said earlier
was by the end of the year we expect a maximum wait of six months
for an in-patient treatment and we are certainly not prepared
to see trusts go beyond that even if they have financial problems,
but if their hospital is saying, "We would really like to
get rid of all these waiting lists and we can do it all in the
next six months. We want to spend all the money that is going
to be in the system next year and the year after, we would like
to spend it right now and get to a zero waiting time now",
then it is perfectly reasonable for the PCT to say, "Not
quite so fast". Six months now, and then you start moving
that down to 21 weeks, 18 weeks, and so on, and we have set out
the phasing that will happen for that final part of the system
as you wait for the operation as we move towards the goal of 18
weeks from GP referral to operation, and we will get there by
the end of 2008, not the end of 2005/6.
Q324 Anne Milton: It is the fact
that operations are being delayed to save money, but we hear talk
in the broad papers about over-performance, which I think is a
rather sweet term, is it not?
Ms Hewitt: I understand the frustration.
Clearly, if you have got a hospital that believes it has enough
spare capacity to do operations even faster and they would like
to do that, if the primary care trust can afford that and wants
that to happen when it looks at all its other priorities, that
is fine, that is a judgment for the primary care trust, but if
the primary care trust cannot afford to get, not to six months
(everyone has to do six months) but cannot afford this year to
get to five months or four months, that is okay, because next
year and the year after they will get, by the end of 2008, down
to 18 weeks. Of course it is frustrating for people who are being
told, "You are going to have to wait six months", when
maybe the hospital is saying they could do it in four months,
but, compared with where we were not so many years ago, it is
still an enormous improvement and it will not breach the six month
maximum.
Q325 Mr Amess: Chairman, I cannot
help thinking that our proceedings this afternoon are somewhat
overshadowed by the election of the new Pope, or, should I say,
new leader of the Conservative Party, but we will just have to
cope with the event! Sir Nigel, you and I had a robust exchange
last week and, unlike the chief medical officer, you were absolutely
not for resigning, indeed it had never crossed your mind. You
will recall how upset the Committee were that, for whatever reason,
a number of our questions were not answered in full, and I shared
with you that question 3811, where we asked for a set of figures
on patient admissions broken down by in-patient and day care plus
a commentary, was not done. You did not provide a table of figures
and the commentary amounts to one very short paragraph and does
not refer to the data at all and a second paragraph refers briefly
to one series only. You, Sir Nigel, told the Committee that you
accepted fully our disappointment and that you would provide us
with that information this week. I am advised by our clerks that,
in spite of chasing up this information, we still have not got
it?
Sir Nigel Crisp: Mr Amess, I did
on Thursday say that I intended to get you the information. I
can take you through it verbally if you wanted me to, but the
reason that I have not got it for you in detail is there is one
figure which may— May I just remind you, there was a particular
point here, I think. You were saying that the number of decisions
to admit seemed to be going down, so what was happening? That
was one of the questions you wanted to know. I said that I thought
it was to do with the increase in the number of primary care procedures
that used to be done in hospitals and the increase in the number
of procedures that are done in out-patients. I have got all the
rest of the information. I have not got an adequate fix on that
piece of information, which is why I have not given it to you,
because I would rather give you accurate information. I do apologise
for the fact that you do not have a note to the effect of what
I have just said.
Q326 Mr Amess: Sir Nigel, you earn
your money, you have been positively charming. The Chairman would
not want me to delay proceedings by going on about that issue.
I am sure it is perfectly acceptable if, when you do have the
final piece of the jigsaw, you would kindly send it to us. Secretary
of State, your predecessor, John Reid, said that earnest statistics
on productivity being 4 to 5% lower in 1997 compared to 2003 were
absurd. Do you agree with that statement made by your predecessor?
Ms Hewitt: Of course. I always
agree with my predecessor, almost. "Almost", I did say
at the end of that sentence. However, on this particular issue,
yes, I do agree. This issue of productivity in healthcare has
been argued over by statisticians for many, many years and not
only in our country. We have been looking at it and working on
it, our own staff, some academics and ONS itself, because I thought
John Reid made a very pertinent criticism that the productivity
figures did not take account of the improvements in the quality
of care and patient experience (the point that we were referring
to right at the beginning), and we will be publishing, as I think
I said, more detail on this tomorrow, but I think it is absolutely
essential to take a proper account of the real changes in activity
and outcomes that are taking place in the NHS.
Q327 Mr Amess: So that the Committee
gets it clear, what are the figures to which you wish the Committee
to refer to prove that overall National Health Service productivity
activity is increasing?
Ms Hewitt: What I would like to
do, if I may, Chairman, is send the Committee tomorrow the rather
lengthy report, in fact two, I think, lengthy reports and articles
that we are publishing as a sort of accompaniment to the chief
executive's report, and then we would be very happy, and it might
make more sense for our statisticians to come along, but I would
be very happy to come back with them and go through that in much
more detail, because essentially what we are looking at is a whole
series of adjustments to productivity figures. I gave the examples
of statins taking account of the lives saved rather than the cost
of the treatment. There is a whole series of adjustments like
that.
Q328 Mr Amess: If you could send
us that information it would be very useful. Could I recommend
some bedtime reading called Heathcare UK 1991 and a splendid
article written by the notable academic Seán Boyle called,
Minor surgery in general practice: The effect of the 1990 General
Practitioner Contract. I think, Sir Nigel, this goes back
to our exchange last week: because we have in the course of the
week had an opportunity to reflect on this matter and I think
I did describe this whole presentation as a fiddle. Relying on
this data, the Committee is a little bit confused about your relying
on the increased activity of general practitioners because it
seems in 1991 there were about a million of these procedures that
general practitioners were doing in any case. Again, I think the
Committee comes back to the original point: why are the waiting
lists falling? We really do feel very, very strongly that the
waiting lists are falling because in a very real sense there are
less and less people put on these waiting lists, and I think the
Committee feels it is unfair that you are relying on the increased
activity of general practitioners?
Sir Nigel Crisp: Not just that.
The other very big thing that is happening in hospitals is that
there are many more procedures being done in out-patients rather
than in-patients. So people will bring people back to have some
minor surgery or, indeed, in some cases, some quite significant
surgery, coming back as out-patients, and so they are part of
a different system. They are not admitted to the hospital, they
come in for the day and they have the procedure. In addition to
that, there are a significant number of increases in primary care.
We started to try and collect these systematically. I do not know
that particular study. There are lots of studies, as you are probably
aware. We began to attempt to collect this information systematically
three years ago when we systematically went round the country
and asked people to identify the specific changes that were planned
changes: for example, people taking vasectomies out of their hospital
service and putting them in primary care and so on. We have now
got a better set of figures which are measuring the changes. There
is a base-line level of activity, but specifically aimed at identifying
measuring the changes not what the overall activity is. That is
why this is both anecdotally and evidentially happening. Our figures
are not yet as good as they might be, which is why I have not
been able to give you the figure earlier.
Q329 Mr Amess: I shall not labour
the point, and, without wishing to be seasonal, I think the Committee
still feels that you are skating a little bit on thin ice with
these figures?
Sir Nigel Crisp: May I bring back
examples, if you would wish?
Q330 Mr Amess: We are finishing at
five o'clock, and I do not think we are quite halfway through
yet. My final point, Secretary of State, and this again has been
a divide between the Government and the opposition about waiting
lists, the argument is that we feel very strongly that the waiting
lists and the Government's reliance on the figures tends to distort
clinical priorities. Why do you feel so strongly, Secretary of
State, that these waiting lists should be a priority for National
Health Service managers?
Ms Hewitt: Because they were the
top priority for the public, and the public made it very, very
plain to us before 1997 that the thing they were most distressed
about was the length of the waiting lists and the waiting times.
They and we believed it was simply unacceptable to have, for instance,
an elderly person waiting in agony for a hip replacement for months
and months on end, those months often stretching out beyond a
year, sometimes close to two years or even worse. We did not think
that was acceptable, and we therefore made the promise that we
would get the waiting lists and the waiting times down. I think
clearly there is a disagreement between us about the figures.
We believe, not just on the basis of the statistics, though we
think those are robust, but also on the basis of what our own
constituents tell us, that the waiting times have come down very
sharply indeed. The recovery and support team within the department
who go round supporting hospitals that are struggling are very,
very clear, because they can practically tell you the names and
addresses of people who, for instance, at the time when we were
trying to get the maximum wait down to nine months, were in danger
of breaching that point. They went through every one of those
patients with the hospitals concerned to make sure those patients
got their treatment. If the patient no longer needed the treatment,
obviously that was a different situation, but the patient who
needed the treatment got the treatment. That is what is now happening
on the six-month wait, it is what is happening on the much more
complex challenge we have set ourselves of the 32-61 day target,
which is an end to end target, for cancer patients which we have
set as the target for the end of this year and which will give
us very good experience to bring to bear on the general 18-week
target before the end of 2008. We believe it was the right thing
to prioritise, because it is what the public wanted, we believe
we are making enormous improvements and will continue to make
the improvements that are still needed, because although six months
is a lot better than it used to be, it is still not good enough.
So a lot done, a lot still to do on this; and, of course, in order
to achieve the 18 weeks we have got to get into that black box
of the diagnostics and the additional out-patient appointments
beyond the first out-patient appointment where we know people
have long waits at the moment and those waits, of course, have
not even been countered. That is what we are now tackling in relation
to cancer and we will tackle everything as we move towards the
18-week target.
Mr Amess: I understand everything you
say about the pressures from the general public, and I will finish
my questioning there, Chairman, but I would simply say that, while
I understand about the pressures from the general public, the
Committee does increasingly hear from clinicians that they feel
there is a distortion in priorities because of the pressures on
the managers, but in the interests of time, Chairman, I leave
the questioning there.
Q331 Dr Stoate: You talked a lot
this afternoon about targets, and certainly targets can concentrate
the mind wonderfully when it comes to assessing performance, but,
equally, targets can at times have adverse and perverse effects.
For example, the 48-hour target for GP appointments has led many
practices to prevent patients booking routine appointments in
advance and, in fact, have forced some people to have to phone
on the day through busy phone lines simply to get an appointment
at all and hide behind the Government's policy by telling patients,
"Oh, no, the Government insists we do this", and we
all know of an example where this has happened. What can you do
to avoid these perverse effects happening to distort the way targets
are being interpreted?
Ms Hewitt: The first point I would
make is that I think you and I would agree that targets are very
useful, although they can also have some unfortunate perverse
effects, and I want to stress the very useful point, having been
a critic of the Government for having had too many targets in
the past, and I think we have largely dealt with that, but I have
been genuinely surprised by the number of clinicians who have
said to me in the last six months, "Such and such a target
was really brilliant because it forced us to redesign and rethink
the way we did things", and so I think that important. The
48/24 hour example you give is a very good one, a very good one
on perverse results, because we do now have a very significant
number of patients who are very unhappy about the way their GP's
appointment system is working. Again, I would observe, the majority
of GP practices meet their 48/24 hour target and they do it with
a perfectly sensible appointment system: people can get through
on the phone and if they want to book an appointment in advance
they can do so because that was never ruled out, certainly never
intended to be ruled out by our 24/48 hour target. But I think
there is a bigger point here. We can always try and design targets
to be smarter and avoid these odd effects, if you like, that some
of them have had. I think the much bigger gain to be made is by
moving towards this thing we call a patient-led NHS: because if
the patient and the user of the service has got more choice and
a greater say in how that service is designed, then you will not
need to rely on top-down targets nearly so much, and that is the
fundamental point of the reform programme, that we put in place
a whole set of incentives that will enable the NHS to become genuinely
self-improving, because there will be this constant motivation
of incentive to respond to what patients want, to improve the
quality of care and the quality of the patients' experience and
to keep getting better value for money, because without that you
cannot do all the other things as well.
Q332 Dr Stoate: I accept all that,
but there is still going to be a problem with the target culture,
and that is that some areas of NHS activity will inevitably be
target driven. Will that not mean there will be clinical distortions,
because areas that are not target driven could easily find themselves
missing out? I will give you one example, I passionately believe
that GPs should take much more care of obesity. I would like to
see much more notice taken of patient size and appropriate advice
being given. That is not part of the quality and outcome framework
and therefore there is no incentive for GPs to concentrate on
that because they have other priorities. What do you do to avoid
this culture where targets drive you in one direction to the exclusion
of others?
Ms Hewitt: There are a couple
of things you can do. As you say, a target is not a target if
everything has a target, and so you do have the problem that people
will focus on the identified priorities, possibly at the expense
of other things that are very important. We can obviously make
adjustments to the quality and outcomes framework each year so
we embed best practice and then move on to the next priority,
and that will help in some situations, but I think practice-based
commissioning and an indicative budget for every primary care
practice showing them what they are currently spending in the
acute sector is going to concentrate attention on all those long-term
conditions, obesity being one, alcoholism, alcohol abuse being
another, that have appalling effects on people's lives and appalling
results in terms of emergency admissions to hospitals, and so
it comes back to embedding the incentives in the system. There
will be an incentive in there for the GPs, nurse practitioners
and others working with the primary care trust to say, "Hang
on, what is driving our acute bed occupancy?" We have got
a real problem of obesity, alcohol abuse, diabetes, a whole series
of other things, so let us focus on those, look at what we need
to do in terms of prevention and public health, but also look
at what we need to do to enable people to manage their condition
better—diet, exercise, and so on—where we know that
something like half of people with long-term conditions do not
have a proper care management plan agreed with their primary care
practice.
Q333 Dr Stoate: The logical conclusion
of what you are saying then is simply to have even more targets
and let best practice drive clinical practice?
Ms Hewitt: Best practice by itself
does not do it. Almost anywhere you go in the NHS you will find
one or two examples of best practice, and for anything you care
to name you will find best practice somewhere in the NHS, but
you very rarely find an organisation that is systematically applying
best practice across everything and across the entire health community.
That is where we need the system reforms, Payment by Results to
make the costs transparent, practice-based commissioning to give
GPs a real incentive to pull care out of the acute sector and
focus on prevention and better management of long-term conditions.
You can do that, and that will give you the results that you and
I both want—it will not be no reliance—but with less
reliance on targets because you will not have to single out obesity,
or diabetes, or alcoholism because they will be so visible as
you look at the patterns of care and expenditure across the entire
practice.
Q334 Dr Stoate: If that still remains,
if you are going to have diabetes rolled up with heart disease
and everything else, you do not need targets for it because you
are simply going to have the best local outcomes driving activity,
and it is illogical, therefore, to have a diabetes target but
not to have an obesity target because one will inevitably undermine
work in the other.
Ms Hewitt: But it might make more
sense for the primary care practices and the primary care trusts
to identify one of the biggest problems of long-term conditions
in their area, which may well be obesity and diabetes, to look
at the patients who are, if you like, at the top of the pyramid,
who have the worst conditions and are probably being admitted,
possibly more than once a year, to emergency care. What do we
do better to manage those people and keep them out of an acute
admission at all, and then, in the middle of the pyramid, what
do we do for people in the danger zone who need real help in managing
that condition better? You do not necessarily have to have a target
for this, that and the other. What you can do is put the incentive
in the system, make the best practice information available, encourage
people and in some cases possibly require people to benchmark
themselves, and then make sure they are driving the improvements.
Q335 Jim Dowd: Can I look at another
target before our way to A&E. Imagine, if you will, one of
the busiest A&E units in London which is currently regularly
hitting 98%, 95% occasionally 96%, but the investment required
to hit 98% is completely disproportionate to the effect it will
have on other hospital services, requiring something between 8
and 10% additional expenditure on the current A&E budget.
Is that 2, 2½% improvement worth that effort and that expenditure?
Ms Hewitt: I obviously do not
know the details of the particular example you are giving, and
I would really want to talk to our recovery and support people
about what is going on in that individual hospital because I have
heard that general point made before. When I have gone back and
checked with our delivery people, who are superb, fundamentally
what they say is if you redesign the service in the right way,
you can achieve the 98% target even in a really busy, stretched
inner city hospital, which I guess is the kind of hospital you
are talking about, but if you are just box-ticking or drawing
lines on the floor and calling one side A&E and the other
side a medical admission unit, you probably will not hit the targets
or, if you do, you will not hit them through a real improvement
in the experience and the care of the patients going in. I am
perfectly happy to look at the detailed example if you want me
to, but that is the general view of our recovery and delivery
support people. It may be you are referring to one of the small
number of hospitals that is continuing to struggle with the A&E
target, but we would need to look at it in detail to be sure of
that.
Chairman: One question on NHS reorganisation.
Q336 Anne Milton: Foundation trusts.
50% are in deficit, which I think is a surprise to many of us,
and it is the case that the foundation trusts are more likely
to be in deficit than normal NHS trusts. I would like your comments
on that?
Ms Hewitt: I am surprised by that
figure actually. I was just asking Richard to check it for me.
There is a significant difference in the foundation trust regime,
which is that obviously Monitor checks very thoroughly the financial
health of the organisation before clearing it for foundation trust
status, but it then, going forward, allows the foundation trust
to balance its books over three years, so you could well have
a situation where a foundation trust is quite deliberately, if
you like, building up a deficit in the first year while it invests
in new services and reorganises itself, and Monitor would be concerned
about that if they did not think they were going to get back into
balance over the three year period.
Mr Douglas: I am sorry, I have
not got the number of trusts to check, we only have the value
of the deficits there.
Q337 Anne Milton: The figure I have
is 50%, whereas the deficit overall is 28%. In terms of deficit,
they are doing far worse than the normal NHS trusts?
Ms Hewitt: First of all, I think
there is an issue about the size of those deficits and, secondly,
it is a different performance management regime, and perhaps we
could get a note from Monitor for you on that.
Q338 Anne Milton: You have got something
about the size?
Mr Douglas: The value of the deficits
is roughly similar to the proportion for NHS organisations. It
was around £34 million last year. My understanding is that
the foundation trust system as a whole is planning for a break-even
position for this year.
Q339 Anne Milton: So the interim
figures suggest that, do they?
Mr Douglas: I have not got the
interim figures for foundation trusts because they are monitored
and regulated by our foundation trust regulator.
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