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CORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 1691 House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE HEALTH COMMITTEE
THE MINISTERIAL RESPONSIBILITIES OF THE MINISTER OF STATE FOR DELIVERY AND QUALITY
Thursday 26 October 2006
ANDY BURNHAM MP Evidence heard in Public Questions 1 - 101
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Health Committee on Thursday 26 October 2006 Members present Mr Kevin Barron, in the Chair Mr David Amess Charlotte Atkins Sandra Gidley Anne Milton Mike Penning Dr Doug Naysmith Dr Richard Taylor ________________ Witness: Andy Burnham, a Member of the House, Minister of State for Delivery and Quality, Department of Health, gave evidence. Q1 Chairman: Good morning, Minister. I wonder if I could ask you to introduce yourself. Andy Burnham: Andy Burnham, I am the Minister of State for Delivery and Quality at the Department of Health and a former member of your Committee. Q2 Chairman: I was just going to say to you, I do not know whether this is a warning or just sort of general chat, but that has been mentioned in the last few minutes prior to your coming in. We would like to start with questions around healthcare-acquired infection and really the first question is given that MRSA rates have barely changed in the last year, how confident are you that the NHS will meet its targets of halving the rate between 2005 and 2008? It does seem to the Committee that the clock is ticking a little bit on this one. What is your view? Andy Burnham: Well, it is an important subject, Chairman, and I am glad you have started off with it because it is one of my personal priorities. I think it goes to the heart of public confidence in the NHS and it is something that the Department should take seriously from the very top, but also that should cascade down the system so that, from chief executive level downwards within the NHS, there should be a grip on this issue, there should be leadership and it should be a priority for every single organisation in the NHS. On the target itself, it is true to say that there is some improvement and figures are coming down, so the trend is in the right way, but if you were to ask me am I satisfied with the rate of improvement, then I am not and I would like to see much quicker improvement and a much greater focus on the target. The last point to make just on the general situation, Chairman, is that it is true, in the figures that come to me, and obviously we now receive figures on a regular basis, there is a huge variation, as you are probably aware, and some trusts have made real strides by taking a very clear grip, but the variation is enormous and there are a large number of trusts who are not making enough progress. Q3 Chairman: Do you think you have inherited an ambitious or over-ambitious target? Andy Burnham: No, I do not think so for the reason that I began with really, that this is an issue that goes to the heart of public confidence. Interestingly, overall there is a periodical review of all healthcare-acquired infections and I think I am right in saying that every ten years as an overall snapshot healthcare-acquired infections are coming down quite encouragingly, and I could give the Committee the figures. Obviously MRSA is one of a number of superbug-type infections that can be acquired in the hospital environment. No, I do not think it is over-ambitious, but if you are asking me am I confident that everybody is treating it with the seriousness it deserves out in the field, then I am not sure I can give you a positive answer to that. Q4 Mike Penning: Minister, you were referring to the national trend which is great news if the trend is coming down, but London seems to be doing much, much better than other parts of the country. What is happening? Why is that information not given out? The figures we have for London in 2003/04 dropped by 315 and in the North West it went up. If it is the National Health Service, why have we not got the same standards throughout the NHS? Andy Burnham: Well, it is a good question and I think you have put your finger on the issue which troubles me actually. There is very varied improvement being made and actually the Trust nearest to us here, Guy's and St Thomas's, I think particularly at Guy's, there was a clinician who really took a grip of the issue and made significant inroads within that particular Trust, and this is information that we are passing around the system through best practice. In terms of why is the Service as a whole not doing it, you will know that we have been doing a whole series of nationally organised campaigns that are around spreading best practice through the Saving Lives campaign and also through the Clean Your Hands campaign, so, in my view, and officials told me this only yesterday, it is not that we do not know what to do and what works. Q5 Mike Penning: They are not listening in parts of the NHS then? Andy Burnham: Well, I think in parts of the NHS there is not sufficient drive from the top to make improvement. It is true to say again though that rates are coming down and everybody will have seen it; patients will have seen it and I think most patients will have noticed a marked difference in the environment within hospitals in the last two or three years in terms of alcohol gels, posters, materials on the ward. I think public awareness of the issue and of the responsibilities on them too in the hospital environment to wash their hands and generally to keep the environment clean and tidy, there has been a step change in the understanding around the issue which is a welcome thing, but obviously I think making real improvement and really getting underneath the figures means taking concerted action from the top to drive out ---- Q6 Mike Penning: So you freely admit then that there are parts within the NHS that are not listening as well to the best practice which is being set out from the top? This has an enormous effect on people's lives and we have all read of some of the horrific situations where people have gone in for something to do with their leg and then they have lost their leg and I have a constituent in exactly that same situation. If they are not listening, what are you doing to make sure that they do listen because at the end of the day you are the Minister they should be listening to? Andy Burnham: Yes, they should. As I say, the vast majority are making progress of some kind, so I think the message has gone out to the system, but, as I say, there is variation in the extent to which people are driving it from the top within their organisations and prioritising it. Personally, when you say what are we doing, I think there are a few things coming together. You will know that we are obviously working towards a situation where patients have far more choice as to the hospital they can go to and I actually think this issue will be a crucial issue that the public will look to in order to make their choice of hospital. I think one of the things we do have to do is to make readily available information to the public so that they can make an informed choice about where they are treated. In terms of more direct action, if I think of where your question is getting to, you will know that in the Health Bill, which got Royal Assent last year, it put into law a statutory code of practice around healthcare-acquired infection and it gives a power to the Healthcare Commission to serve improvement notices. Now, I would say quite openly today to the Committee that I do not think any of us as parliamentarians believe we pass law for no reason, we pass it for good reason, and I have made it clear that I wish to see the Commission make early use of those powers to serve improvement notices where they believe the code is not being sufficiently enforced and where we are not seeing the improvement in infection rates. Q7 Mike Penning: Has the Healthcare Commission made any enforcement as yet? Andy Burnham: Well, since the Bill received Royal Assent, which I think was the middle of July, they have been working up the terms of the code of practice, so exactly what is in, and the structure of, the code of practice, but I think it is true to say, and if not I will correct myself, that they from today could serve an improvement notice. Q8 Mike Penning: Let us hope they do. Andy Burnham: Obviously there is time to give to trusts to say, "Here is a new code. Are you doing it?" I think there is legitimately some breathing space the trusts should be given to ensure that they are in compliance with the code, but the Commission should, after that time has elapsed, I would say, not hesitate to serve the improvement notices. Q9 Dr Naysmith: Minister, could I just ask a question about that. What part does pre-testing of prospective patients play in finding out whether people are infected with MRSA before they are admitted? How important is that as a strategy because I know that some places have had really good results by doing that. Andy Burnham: You are touching on a very important point, I think, and some trusts or some departments within trusts, and there is variation, are screening all patients, I understand, and some trusts are screening patients who are coming from localities or institutions about which they may have particular concerns where they, having seen a pattern of infection over the years, have realised that a particular nursing home or a particular institution is a cause for concern. I think it is not obviously standardised and there is variation in how that is done. I think also that we have to be careful not to fixate on the hospital environment in this whole debate. As I understand it, the most common time at which the bacteria goes into the blood is obviously when a line is put into a patient's hand and that can happen well before they reach hospital. Q10 Dr Naysmith: But the results are more devastating when it happens after someone has just had an operation and is recovering from it. Andy Burnham: Absolutely, and I think the best trusts are probably screening patients more frequently, certainly more on a targeted basis, and that is, I would say, precisely the kind of thing that we would like to see more of. Q11 Dr Taylor: Minister, I would like to welcome you, having been a very conscientious member when you were on this side which I think most of us enjoyed very much and I remember you and I only had two significant disagreements, I think one where I was right and one where you were right. Andy Burnham: That is not a bad strike rate for a Minister actually! Q12 Dr Taylor: I want to tackle Clostridium Difficile because this is, to my mind, by far the most difficult of the relatively common of the hospital-acquired infections. The figures we have been given to compare deaths are: MRSA, 360 in 2004, whereas there were 1,245 from Clostridium, and the incidence was 22.2 cases of Clostridium per 10,000 bed days among patients over 65 compared with just 1.6 for MRSA. Clostridium is the problem because it is so widespread among healthy adults in soil, in water, in whatever, so it is a huge problem. What are you doing to arrest the alarming increase in the trend? Andy Burnham: I think you are absolutely again on the right question. It is true, the figures you quote are true, but I think the point I would also refer you to is the fact that there has been a significant climb in the last couple of years since the MRSA target was set, so in some ways it is a problem of urgency, but also one in which the conditions have changed in the last couple of years. Some of the action that we have taken in respect of MRSA will have, as you will understand obviously, a broader reach to infection generally than just in terms of tackling MRSA, so that obviously is an important thing, but you are right, there are certain actions which are specific to Clostridium Difficile. In terms of specifics we have done, the Chief Medical Officer and the Chief Nursing Officer reminded the Service, I think, in December last year about the importance of taking targeted action to tackle it and, as a Department, we have issued, I think we call it, a 'high-impact intervention' which lists in a very simple form the actions that can be taken at ward level to prevent the disease spreading in the first place, but to control it when it does. Q13 Dr Taylor: The outbreak which got the most publicity was of course the Stoke Mandeville one and the conclusion of the Healthcare Commission inquiry was that senior managers "failed to bring the second outbreak quickly under control because they were too focused on the reconfiguration of services and the meeting of the Government's targets, and insufficiently focused on the management of clinical risk". Time and again in the report the clinicians, the doctors, the nurses had told the management what needed to be done and yet it was not done largely because of the emphasis of management on getting the targets through. That is my interpretation of the report. What has been done, first, at Stoke Mandeville to address those problems and do you think the same problem is widespread? Andy Burnham: Well, in answer to the second part of the question first, thankfully no. Obviously we asked the Healthcare Commission to prepare its report on Stoke Mandeville and, let me frank about it, it made appalling reading, there is no doubt about that, and quite shocking in some ways. What is being done about it? There are basics, are there not, as you will know better than anybody perhaps, within a hospital environment and the safety of the patients has to be paramount to all other considerations and it seems to me that there was a loss of focus on that priority within this particular case. Having commissioned the report, and we obviously commissioned it and published it, actions have been taken obviously within that particular Trust to prevent a similar occurrence ever happening again, but we obviously believe that it has wider implications for the Service as a whole and I think we said at the time that it was published that we would encourage everybody to read it, the entire Service to read it. Q14 Dr Taylor: I want to go on rather specifically because I regard it as our job to hold the Government to account. You probably do not know, but the Chief Executive who resigned after this job actually came with form from the Worcestershire Acute Trust. I put in an oral question to Alan Milburn on 15 January 2002 and I said this: "I know that the Secretary of State is aware of the recent vote of no confidence in their managers both at trust and health authority level by a vast majority of consultants across the whole of Worcestershire. What does he propose to do about that?" This was me raising the concerns of something like 95% of the consultant staff across the whole county as to the inaccessibility and inability to get the message across. The Secretary of State at the time just said, "In keeping with the spirit of devolution, that is a matter for the management in Worcestershire. If the hon. gentleman is concerned about that issue, he should raise it locally rather than with me". When you are complaining about the highest person in the Health Service, you cannot do anything about that. She then went on to move to Stoke Mandeville and time and again the thing that comes through is that the management would not listen to the clinicians. That, to me, shows that the Government cannot back out of serious complaints that come through to them like that. Any comments? It is unfair to put you on the spot, I know. Andy Burnham: I think where I agree with you 100% is that the report does indeed show that that upward travel of information did not happen and I agree with you, that is a very serious thing. Since appointed, you may have read, I have done some work shadowing in the NHS and I am acutely aware about how information comes down the system indeed from our Department. It originates there in many cases, but information is less good at going back up the other way and I think there is an issue about the way in which staff are consulted and listened to within the system and I think that is an issue that needs to be addressed. On the point about whether or not we should intervene in a situation like that, as I understand it, the way in which most people talk about the Health Service these days is that people would not like to see that kind of political intervention from the Department, but there is always a balance here, is there not, between power at local level and action by the Department. In reference to the question from Mike Penning, I mentioned the improvement notice and obviously that has direct, personal implications for the Chief Executive of that organisation were they to receive such an improvement notice in the case of infection. As I say, I do not believe there could be any higher priority within the organisation than an issue such as that, so that, I think, takes us further forward specifically on the issue of infection where you can enforce responsibility on to the individual at the head of the organisation, as you say. I would be surprised if you really thought we should remove people and I would argue strongly as to the accountability of the board of the organisation concerned, it is their job, their responsibility, and the important thing is to ensure they are doing their job and are empowered to do their job. Dr Taylor: It is not really the time to get on to the accountability of the boards because I have fairly strong feelings about that and I do not think the Chairman would allow me to do that. Q15 Anne Milton: Minister, just to go back to the Stoke Mandeville situation, and your concern about that is appreciated, are you prepared, if you accept the findings of the report, to give trusts some leeway on their targets in order to bring infection under control? There are issues, say, about bed occupancy and there is good evidence out there to suggest that if you take bed occupancy, and I cannot remember the precise figure, but over something like 85%, you are far more likely to have problems with acquired infections. The question is whether you would give them some leeway on achieving government targets in order to do something about infection? Andy Burnham: I think, as I was saying before, we know what is needed to be done to tackle infection and the best organisations around are using their resources well, but they are also keeping infection at low levels and, in my mind, there is no contradiction between the two. It is not if you hit the targets in terms of the use of your finance and the way in which you are managing waiting lists that there is an inherent contradiction there and, therefore, infections must go up. I would argue that this responsibility has to be taken in the round and people cannot say, "This bit we will do and that bit we need more leeway on". These are responsibilities that are being asked of organisations generally to run themselves well, provide a high quality of service, but crucially a service that is safe and, as I say, that is utterly basic, as far as I am concerned, that if you had a serious outbreak of Clostridium Difficile, all other things come secondary until you have that outbreak under control. Now, there are probably more things that we can do at the Department to help in terms of perhaps capital funding, if necessary, for more isolation facilities if that is a problem in a particular trust, and I would always be ready to listen to any trust that came to me saying, "We don't have adequate facilities at ward level to deal with an outbreak should one occur", but if you are saying that they can have leeway here, well no actually, I think it is so important. The best organisations are doing it and I think all patients have the right to expect high-quality, safe care. I do not think it is a case of a set of arrangements for one and a different set for another. Q16 Anne Milton: I think actually that the message from the Minister that if you have an outbreak, everything else becomes secondary to controlling that outbreak is a really important message for front-line staff to hear and for any manager who might be happening to listen to this Committee today and I think that is really, really crucial and hopefully will stop the sort of Stoke Mandeville situation being repeated. The only other thing I wanted to ask you about was infection control nurses. I think that some trusts feel that there is very little ring-fenced money for infection control nurses and that particularly in areas where there are budget deficits, it is exactly those posts that are being squeezed in order to get into financial balance. Andy Burnham: I would certainly agree with you on the importance of the role and I have actually on my travels spent some time with an infection control nurse, so I would agree with you entirely, that that is a crucially important position, and actually it cannot be a position that is seen as peripheral, say, if that person arrives in the ward environment and is kind of not part of the team and it is very important that that person has authority and prominence within any particular organisation. That is how I would see it. Obviously some things like this cannot be mandated and we can, and should, give our best practice to trusts. The point I would want to come back to again is this link with efficiency and running a good ship because the best organisations are keeping the number of avoidable infections to an absolute minimum because that is a good use of resources. It does not mean that people will have an unnecessary long-length stay in hospital, it means that people are not being readmitted. This is actually good housekeeping, good management of the whole hospital and the best organisations are doing it. Q17 Mike Penning: Minister, moving on, and I apologise it is such a short time on such an important issue, but moving on to the 18-week target times, how confident are you that hospitals will be able to measure the referral to treatment times for all patients by the target date of January 2007? Andy Burnham: It is an issue again that is one of my priorities and up there with infection control. If you will permit me to make a very brief comment on the challenging nature of the target, it is a challenging target for the NHS as a whole, but, as with cancer and the A&E target, at the time people said it could not be met and there were obviously doubts about whether it could be achieved, but the NHS has a fantastic capability to rise to a challenge, so the long answer to your question is that I am confident we can meet the challenge overall, but also that will mean by January next year publishing for the first time data for admitted patients. This data will not cover all patients, I should say, but we are confident that data will be published of good quality early next year which will for the first time give the public details on the whole patient journey. I think that is an important step for the NHS to take and I think it is quite a big step forward. By April next year we are confident we will be providing good data for all patients on the 18-week pathway and the reason why I am confident we can do that is that we have obviously been working in detail with eight particular trusts to learn about data collection and to put in place systems so that we can have a system for all trusts. Q18 Mike Penning: If it was such an important priority for your predecessor, and I accept that it is for you, but if it was such an important priority and targets were brought in in 2004, why has it taken three years to come forward with a decent measuring system? Andy Burnham: I would not underestimate the scale of the challenge actually in terms of the culture of the NHS. I became aware a few weeks into the job that this target was actually transformational not just in terms of what patients could expect, but what it would do to internal processes in terms of how primary care relates to secondary care, in terms of how conversations happen within trusts and perhaps did not happen before. Q19 Mike Penning: But that is about the target, actually hitting the target, but that was not the question. The question was: why has it taken three years actually to give us an answer to how the targets are getting on? In other words, why was that measuring system not put in in 2004? It might have been awful and you would not have been hitting the target at all, but at least we would have known the progression rate. Andy Burnham: The way I would put it is that I think we have been on something of a journey really in terms of reducing waiting within the NHS and obviously we have achieved 13 weeks for the initial outpatient appointment and we are now at a point where, with a couple of exceptions, we have achieved six months for inpatient treatment. I think it has been a step-by-step process, having made those improvements, and we are now at a point where we can open up the middle bit of the journey that has always been a bit opaque, to say the least, and a bit of a black hole where people could be passed from pillar to post and they could wait for some considerable time. I would just say that I would not underestimate the scale of this change within the NHS and how the NHS works and the challenge of getting to this point. Obviously you can have a different view about how change should be effective within a large organisation such as the NHS, but I would argue strongly that you do have to make change by steps, and I think, because of the changes we made with other inpatient targets, we are now in a position to put this challenging goal in front of the NHS. Q20 Mike Penning: I still think you have gone round the question, I am sorry, Minister. The question was not about how far you have come with the targets and how much you have reduced the target times, but why was it opaque in 2004 when the targets were first set? Why was that information not made available so that we could have seen the journey you have gone along rather than actually being blindfolded for the last three years? Andy Burnham: Because I would not underestimate the scale of the job you have left us. People were waiting ---- Q21 Mike Penning: I did not leave you any job, I was in the Army. Andy Burnham: ---- 18 months for treatment back in 1997. I think we have been making progressive change. It has been a journey and we are often accused of inflicting too much on, or asking too much of, the system or putting too much change through at the same time and we have got to listen to those complaints. It would be irresponsible of ministers to ask the NHS to do something for which there simply was not readiness within the system to rise to that particular challenge. If I could make this point, the 18-week target, I think, is actually responding to some of the criticism that has been made about targets. It is not just micro-managing a part of the journey, it is giving people an overall goal and it is saying to professionals on the ground, "Now, you tell us how you and your locality can meet that goal". I think it is a different kind of challenge that speaks to people's professionalism and, I hope, can inspire some enthusiasm about how they may break down some traditional ways of working at local level. Q22 Mike Penning: One of the areas that seems to be traditional is in diagnostics, the 'hidden' waiting times in diagnostics, so that means your targets. What have you done to eliminate this kind of fiddling of the 18-week system? Andy Burnham: Well, we have opened the cupboard door. We have basically shone a light on the situation and that is what we have been doing for the first time with the publication of diagnostic waiting times. I would readily acknowledge that that bit of the journey has been concealed, so when the public read information in the newspapers about achievements on waiting times, they may have felt, "Well, hang on a second, that doesn't correspond with my experience". One of the big things that 18 weeks delivers, or moving towards 18 weeks, is that for the first time the way in which the NHS is measuring what it does is directly correspondent with patients' experiences, so I take your question head on, but this has been an important cultural step, I think, for the NHS because it is now there. Q23 Mike Penning: So you are 100% confident that they cannot hide this any longer, that they cannot fiddle it within diagnostics and it is not completely opaque? Andy Burnham: As to whether it was ever fiddled, obviously there is no point getting into that, but obviously there were situations when patients were waiting extremely long periods of time between first outpatient appointment and then being referred to treatment with a number of tests they may have had to go through. I am confident. I have looked at this in detail and we have opened up that middle stage of the journey. It is now before the public and when we publish the full stage in terms of referral to treatment waits in the New Year, it stitches it all together for the first time in a meaningful way for the public. I do not think there is a politician in the whole place who would say that that is not the right thing to do. Q24 Anne Milton: Just thinking about orthopaedic services, which is probably the most challenging in terms of referral to treatment, I understand that pilot data of referral to treatment shows that 25% of patients are waiting more than a year, 55 weeks. There are two questions. First of all, it would be nice to feel that in this climate of complete honesty, and I think you are right that the Government is saying that waiting times have come down and that is not sitting well with people's own experiences and I think it does cause a lot of problems, so the honesty is welcome and, therefore, can I have your assurance that we will not hear the Government talking about waiting times except when they relate to referral to treatment from now on? Secondly, how much is it going to cost, do you feel, particularly with reference to these orthopaedic waiting times? Andy Burnham: On the first question, and it is a good question, I think we will publish this data for the first time in January. Q25 Anne Milton: You can phone a friend! Andy Burnham: I think we have to be honest and say that it may take time until we are absolutely confident about the data. This is a big change, let us be honest, and it will take time before we can be absolutely confident that the data we are putting before the public is of a standard that we can have confidence in. The guarantee I will give you is that we will be clear about how confident we are about the data quality. For the Service and for the people out there managing the progress towards 18 weeks, I think it is right that we continue to measure the patient journey as well in the chunks in which it is currently organised so that we can make a transition between the new way of counting patient experience and the old one because this is a transitional period and this whole exercise, a lot of it, will be about data internally, people being able to monitor improvement. I think you could not just dump one whole way of doing it and then move to this new one on 1 January, but you would run the two concurrently, I would argue, for some time until the system was ready to measure things in a different way. Q26 Anne Milton: How much do you feel it is going to cost? As I say, orthopaedics is very challenging. Andy Burnham: You are right to focus on orthopaedics. That is a challenge in terms of delivering 18 weeks in every locality and access to specialist orthopaedics particularly. There is a serious point there, but in terms of the money, in this Spending Review that money has been factored into the allocations given to PCTs, so with all of the difficulties that there are in the NHS, and I do not pretend it has not been a difficult year, progress towards 18 weeks is on track and whilst I cannot give you a figure to say that 18 weeks will cost X, it is because it is incremental progress that has begun, as I mentioned to Mr Penning, over some period of time with improvements to waiting lists. Q27 Anne Milton: But will new money be going in to achieve this? Andy Burnham: Well, new money obviously has gone in to ---- Q28 Anne Milton: But will it be going in to address this? Will there be new money? Andy Burnham: New money has gone in to PCTs, growth money, as you know, in the last couple of years ---- Q29 Anne Milton: But specifically? Andy Burnham: ----- and partly that funds the 18-week target. We have a commitment to reach it by December 2008 and the commitment I will give to you is that the funds will be in place within the National Health Service to meet that challenging target and, as I said to Mike Penning, we are confident it can be met. Q30 Anne Milton: I have one last question which is slightly off the brief, but I am sure there will be some organisations slightly concerned about this. If you look at orthopaedics in particular, how much of the work do you think will be done by independent sector treatment centres in order to achieve that wait of 18 weeks? Andy Burnham: Well, it will vary, it will vary around the country. I think at times the role of independent treatment centres has been, perhaps in the public mind, overestimated. The percentage will vary region by region. I do have some figures somewhere in my file and if I can find them I will give them over to you, but it would be, I would guess, typically less than 10%. Q31 Anne Milton: So you reckon that less than 10% of the work will be carried out by independent sector treatment centres and the rest will be carried out within the NHS and within existing budgets, albeit they are increasing? Andy Burnham: Yes, I think this is important because it is not just obviously the procedures in terms of elective procedures where the independent sector treatment centres may help, there is also a procurement exercise under way which will procure diagnostic capacity and that is currently the biggest challenge to delivering 18 weeks, the diagnostic capacity around the country. Q32 Anne Milton: But you still believe that it will only be about 10%? I am not fixing you to the figure precisely. Andy Burnham: If I can, I will come back to you with more detailed figures region by region, but it will vary obviously depending on available capacity within every region. The other point I would just make is that people obviously question the use of the private sector in this capacity, but I would argue that we want the NHS to not have stranded capacity on meeting this challenging target and we want to use the private sector pragmatically and I believe that for the public, as long as it is delivered through the NHS, according to need, free at the point of use, I do not think they are hung up on the percentages. I will come back to you with more detailed figures.[1] I have seen figures, but I want to make sure they are accurate. Chairman: Could I pick up on one thing. You talked about the issue of cost for getting the 18-week pathway. Our understanding, and this is a bit before your time in the Department of Health, is that there were eight pioneer health economies that were under a trial measurement now. I wonder if you could just check and see whether they were given any added costs to run those eight trials which, we understand, will be rolled out in January of next year. Obviously you do not need to second-guess it now, but it might be useful to the Committee to know if there was any added money around to run the trials as opposed to what is expected of everybody in January of next year. Q33 Sandra Gidley: It is all very well if your disease or your illness falls into the 18-week category, but why was a decision taken to exclude direct referral audiology services from the 18-week pathway? Was this just an exercise of convenience given that 33,000 patients are currently waiting more than a year to access these services? Andy Burnham: It was not an exercise of convenience, but I certainly remember, because I think I was on the Committee at the time, the issues we had around the introduction of digital hearing aids around the country. We all, I think, know there have been significant issues with regards to not necessarily equipment on the ground, but trained audiologists in parts of the country to deliver services as quickly as we would have liked to see. There is an issue that a significant proportion of audiology services are provided as direct primary care referrals, so the 18-week target is obviously referral for hospital treatment and some services are direct services within primary care, so it is different and for two reasons, I would say. There are different challenges with regard to capacity that have to be addressed and there is also a significantly higher proportion of services that are direct referrals within primary care. Q34 Sandra Gidley: So why should direct referral be such a problem? Andy Burnham: It should not necessarily, but it may not fit on the trajectory that the mainstream 18-week target is based. It is not that we are just saying, "That is something different. That can just be forgotten about". My colleague, Ivan Lewis, who has responsibility for audiology services, is in very close discussion with the RNID about an improvement plan to ensure that we do significantly improve access to audiology services, but there are good reasons why audiology is outside of the 18-week target. Q35 Sandra Gidley: Obviously clearly it is not your direct area of responsibility, but it does come under the remit of waiting times really. The total waits have increased in many areas of the country with six hospitals having waiting times of over 200 weeks which seems to me to be unacceptable and something the Government would want to do something about. Andy Burnham: For audiology are we talking about? Q36 Sandra Gidley: Yes, from referral to the fitting of a hearing aid. Andy Burnham: I agree with you, that the Government should do something about it because in parts of the country the waits are too long and the plan that I mentioned would directly address some of those issues around trained personnel and also capital on the ground. I can assure you, it is not an issue that is being forgotten, it is being worked on in the Department, but it does not fit as clearly within the 18-week pathway because obviously that was for GP referral to hospital treatment and, as I say, many audiology services are handled outside of secondary care. Q37 Sandra Gidley: So which other services have been affected in a similar way? Andy Burnham: In terms of? Q38 Sandra Gidley: In terms of then not a referral to a consultant. Andy Burnham: I may have to come back to you on that point particularly. Obviously the 18-week target covers the broad spectrum of elective activity. If there are other excluded areas, I have to say I will come back to you on that point.[2] I am not immediately aware. Sandra Gidley: I will leave it there, Chairman, as I think it is not fair to press him since it is not the Minister's direct area of responsibility, so I am going to be kind. Q39 Dr Taylor: One area we would be grateful if you did look into it is the area of clinical psychology because that is one of the things that does not have a target and waits are absolutely impossible. Andy Burnham: It is interesting when I have gone around the NHS how many people start lobbying me for a target and that has been something of a surprise actually. Mike Penning: Because they think the money is going to follow the target. Chairman: We are going to move on now to the National Institute for Health and Clinical Excellence (NICE). Q40 Charlotte Atkins: Minister, NICE decisions can often be controversial, at least they can be very controversial for the people affected. Would it help to have a specific threshold which the public and everybody could understand? NICE have always denied that they have a particular threshold, but is there one and should there be one? Andy Burnham: A threshold in terms of? Q41 Charlotte Atkins: For instance, it has always been suggested that they could work to £20,000 and £30,000 per QALY (Quality Adjusted Life Year), so a threshold based on the cost-effectiveness in terms of prolonging life, for instance. Andy Burnham: I think the answer to the question is partly in the terminology and sadly some of the jargon that is used in this area is "quality-adjusted life years" and the effective treatment will be differential, it will not be a single figure. It obviously depends on the health of the patient and the relative improvement they make having used the treatment, so it will be a figure that will change according to the relative effectiveness of the treatment. I understand your point about greater transparency and public engagement in the difficult issues, and that is a fair one. In fact it is a recommendation, I think, which this Committee made or the predecessor Committee made when I was a member of it. There is another reason, I think, that would make me hesitate about going down in that direction and it would be that obviously NICE have got a difficult job to do and in terms of both making the right decision and not causing different responses within the supply, within the pharmaceutical industry, information which may lead to product pricing that might not necessarily be in the public interest. Therefore, whilst I am not opposed to the principle, there are obviously difficulties in going down that path and NICE have an extremely difficult job to do, I think, in making these arguments. Q42 Charlotte Atkins: What advice does the Department of Health give to NICE about the factors that they should prioritise in making their decisions? Andy Burnham: Well, obviously the Department is still involved in referring, and we have a new referral process of treatments to NICE, and obviously that process is informed by which treatments are of most public concern and potentially of most value in terms of their significance in medical science and treatment. The role of NICE is clearly set out and, as a Minister, people may have heard me say it here before or in the House, I believe it is very important to support the independence of NICE in carrying out the job that they do. Having laid out their remit, it is not, I do not think, right that the Department should constantly be asking them to emphasise this, that or the other and I think it is important that they do have a significant degree of independence from the Department. Q43 Charlotte Atkins: That may well be the case, but of course the Secretary of State did intervene in the issue of Herceptin, did she not, rather to speed up the NICE guidance and also in terms of intervening in relation to the Stoke-on-Trent Primary Care Trust when they were trying to make the very difficult decision about whether to fund Herceptin for local ladies with the early onset of breast cancer? Andy Burnham: Well, of course there is a relationship. I was not suggesting that it is very pure and there is no contact. Of course there is a relationship. What I was trying to say is that we do not think it is right that we should tell NICE how to do its job, but of course we are able to influence how NICE does its job because I still sign off the tranche of treatments which are then assessed by NICE, so there is obviously that relationship between the two of us. The Department from time to time will make a comment on NICE and the appraisals it is doing and, as you will probably know, comments were submitted on the appraisal of the Alzheimer's drugs to NICE and the Department made a comment in that case, but I would argue that that is legitimate. The Department is a legitimate stakeholder in the NICE process, but it should be treated in the same way as other stakeholders should be too. Q44 Charlotte Atkins: You mentioned the Alzheimer's treatment of drugs. In particular, NICE was criticised for not taking on board the wider social benefits of those drugs. What is your view about that? Do you think they should have taken on board those sorts of wider issues which would make such a difference, particularly to the families of people who are suffering from Alzheimer's? Andy Burnham: My understanding is that they did take on board, in the assessment that they made, the impact on the carers of people with Alzheimer's, so there was provision made within the assessment of those drugs for the impact on the carers. If you are saying, "Should there be a wider societal assessment?", again that was the predecessor Committee's recommendation. Q45 Charlotte Atkins: Absolutely. Andy Burnham: I think that is something for debate, that Parliament should probably debate. There is an argument for it. In terms of care costs, the burden of care obviously does not fall to one individual, it has a broader impact in terms of cost to the public purse and more broadly. I would say at this stage that I am entirely satisfied, and I have been over this point with officials in respect of the Alzheimer's appraisal, that sufficient consideration was given to the potential beneficial impact not just on the individual, but on any family carers. For the future there may be a broader debate to be had about whether or not the issue should be considered more broadly. Q46 Charlotte Atkins: Lastly, I want to address the issue of Velcade because it does seem ludicrous that we have one decision in England and Wales and a totally different one in Scotland, so whereas Velcade can be obtained on the NHS in Scotland, it cannot be in England and Wales. What I find difficult as a layperson is why experts in England and Wales, or the NICE that covers England and Wales, should make a totally different decision than exists in Scotland and elsewhere. Can you help us with that? Andy Burnham: Well, I am glad you have raised this point because what I find difficult, if I can turn the question around a little bit, is how some of the media reporting of what are incredibly complicated decisions and actually some of the most awful decisions we ask any public servant in this country to take are reduced, quite honestly, to a reporting that just does not inform the public. The public need to be informed. These are some of the most difficult questions facing society and I am disappointed time and again at the way in which the public portrayal and presentation of the arguments that NICE are considering actually does not do justice to these difficult issues. If I could refer to the Scottish situation with Velcade, it was not actually as it was portrayed and that is disappointing because that gives a sense of grievance to people who are obviously desperately ill, but also it raises false hope. Somebody asked me this in the House the other day whether people should just travel over the border, but I am afraid it is not as simple as that at all. The advice, as I understand it, from the, I think it is, Scottish Medicines Committee, the SMC, is that Velcade should be prescribed in limited circumstances only as a very last-resort treatment, so where a patient has not responded to anything else, the other treatments that they will have had in the early stages of the disease, then it could be prescribed in limited circumstances as a last-resort treatment for such patients. Now, clearly that is not the same as it has been reported. The last point I would make on this is that the process that NICE goes through is recognised, actually I think it is true to say, openly by the Scottish Medicines Committee and certainly by the All-Wales Committee that it is unparalleled certainly within Britain, but also Europe and the world in terms of the rigour of the process and the quality of the process. Obviously NICE guidance has an impact beyond England and beyond these shores precisely because of that reason and the plea I am making, I guess, is that these are incredibly complex questions and it is important that they are debated accurately in the public arena and it disappoints me that they are not at times. Q47 Charlotte Atkins: I think NICE does a fantastic job, but if I were a patient suffering from bone marrow cancer in England, I think I would probably want that chance to have that last resort of Velcade. What I think people would still find difficult, although I think your explanation has been very helpful, is okay, if they can have it as a last resort in Scotland, why can we not have it as a last resort in England? Andy Burnham: It is one of the consequences of devolution, is it not, of course? That is a decision that people should take. In saying that people should control their own health system, they have got to take a judgment about where it is best to apply resources. One thing I would say is that in this job, it is amazing, the arrival of new wonder drugs is literally all the time, constantly the next one is coming and, as with everything, nothing in this life is black and white and it is not as if it is going to solve everything, but things are complicated, are they not? The benefit is not quite sometimes as it is claimed and it is a complicated judgment on whether the benefit is actually worth the cost. In this case, and again I had to give another example, it was said that in this case it would extend the life by three, four or possibly more years, but actually the evidence supplied by the manufacturer to NICE during the appraisal was that, on average, that would not be the case and it would be a matter of months, not years. That then is obviously the difficult judgment NICE are making. Is the investment of health resource on a significant scale the right judgment to make given the benefit that that will bring in terms of alleviation of suffering and pain and quality of life? As I say, they are the most complex and difficult discussions we ask public servants to make and yet we are asking them to do that on behalf of us all as a society, on behalf of everybody who has a stake in the National Health Service. NICE should never be static. It is right that we debate and we review it as it develops, but for as long as I hold this job, I will be resolutely supportive of the job they are doing and the difficult decisions that they are making on the public's behalf. Q48 Charlotte Atkins: Do the Scottish experts operate under a different system? Is that why they came up with a different conclusion and is their process less rigorous than the English and Welsh position under NICE? Andy Burnham: I think they acknowledge that. I think they acknowledge that it is less rigorous, that the quality of the process that NICE goes through is the gold standard. It is unparalleled, I think, in terms of its quality or there may be other countries who do as well, but the NICE process is thorough to the point of being completely detailed. It is rightly the consequence of devolution, as I say, that Scotland can organise their affairs differently, but they would not say, I am sure they would not, that the NICE process was inferior because it comes up with results which are more difficult to explain to the public and it is, therefore, a defective process. Q49 Dr Naysmith: Minister, can I stay with NICE and judgments about whether value for money is being provided by various drugs. I agree with almost everything you have said over the last few minutes and, as you know, I have always been a strong supporter of NICE and the work that it does. However, looking at the Alzheimer's drug situation which was in the news just recently, one of the companies concerned has referred the NICE process to the Parliamentary Ombudsman on the grounds that the decision-making process is clouded in secrecy and it should not be like that, and I think I agree with what you are saying in general terms, that we need transparency. If we are making judgments about £30,000 or £60,000 being what a QALY is worth, then we need to know why these judgments are being made, yet when NICE was asked about this, and it was reported in the press, asked about whether there was an informal threshold and how was it arrived at, NICE said that it could not release the full working model used in its analysis because it was developed under a commercial contract protecting confidentiality with the Southampton Health Technology Assessment Centre of Southampton University. I do not think that should be used as a means to stop people understanding what is going on with the process. Do you? Andy Burnham: On the first part of your question, in terms of Alzheimer's drugs and in terms of the transparency and the level of consultation through that process, I think from NICE's point of view it has been unprecedented. There has been very detailed consultation throughout the process and obviously then going into the final appeal. There has been a very protracted period in which people could engage the issues and obviously debate those issues and then raise concerns about the very process itself. Q50 Dr Naysmith: But the crux of it is that it is not being made available to people so that they know how the decisions are being made. Andy Burnham: On the point about whether or not it is right to put into the public domain the methodology that has been prepared for NICE for how it makes judgments, having looked at it, I was persuaded it was right not to, but I understand there is a public interest in transparency, of course there is, and if there is more that can, and should, be put into the public domain, then I will look at that. The commercial confidentiality point is not irrelevant because obviously this kind of system, obviously most, if not all, developed countries are looking at systems of this particular kind and we are talking about an extremely detailed financial and scientific model that allows the cost:benefit ratio to be worked out, so this is a piece of extremely valuable work where I can understand why there would be reluctance to put it into the public domain. Q51 Dr Naysmith: You are going to look at it further. Andy Burnham: I will look at it further, because it is a fair point, Doug, and I think you deserve a very detailed answer. Q52 Sandra Gidley: As you know, Minister, I came to see you about the impact on carers, so I am pleased that you were reassured, but you seem to be, sadly, a lone voice. There are many out there who have yet to be reassured. I would like to pick up on my colleague's point about the transparency of the process. It seems as if there is some magic formula that produces a figure for quality-adjusted life years. There are huge concerns that this is discriminatory in some way against older people, which is one problem with Alzheimer's. People are now more reassured that some of the social care benefits are being taken into account, but nobody other than yourself, I am afraid, appears to be reassured that the wider impacts on carers and their quality of life is being fully taken into account. If we cannot see this model, how can we be convinced that one size fits all, that the process is not discriminatory? Is there a way that some information could be released that would perhaps give the public greater reassurance? Having sat in on a NICE process, I was very impressed, overall, but there are still parts of the inner workings, if you like, that are shrouded in secrecy. Andy Burnham: As NICE grows in maturity, that is the process on which it can go. Since we sat on the Committee, Sandra, I think there has been an improvement in terms of greater transparency. I always remember Dr Taylor was very big on this point during that inquiry and I think there has been improvement, but these are careful issues that need to be done in a phased and progressive way. On the first part of your question, about being the only person convinced, I should clarify. On Alzheimer's, particularly, I asked if a different model that gave greater weight to carers' costs and carer's benefit would have produced a different outcome in terms of the model. Then, I was assured it would not have done. I just want to be clear on that point particularly. However, to clarify the point I was making to Charlotte Atkins: over time, as the balance of spending changes between what individuals spend on their own care costs and what the state spends on care costs and whether or not we should keep that under review to ensure that those costs are properly taken into account during the NICE process, I think there is obviously an argument for that. I would say that should be done with parliamentary scrutiny. The effect of some conditions is to give the individual a greater need for social care - Alzheimer's being an obvious one - and that makes that different from a condition where, even though people are seriously poorly, very unwell, they can look after themselves to the latter stages of their lives. I am entirely satisfied at the moment that the model we have is the right one. As I say, it will receive my unconditional support as minister but I am flagging that there are debates that we will need to continue to have about how NICE does its work. On your points about transparency, yes, there should be a continued push for transparency so that the public can understand the difficult decisions NICE is taking. It is not good enough to say, "These are difficult decisions, there is a room of experts, trust them." I do not think we live in that kind of day any more. There is a healthy scepticism about most professions, is there not, these days, and that is probably a good thing. I am not saying let us have a process like that - a locked room and then a yeah or nay comes out of it - but I am saying that they are incredibly complex considerations - as you probably discovered when you sat in - and you would have to think carefully of the pros and cons of opening up more and more information on that consideration because there could be direct public disbenefit from doing some of those things. Q53 Sandra Gidley: You mentioned the panel of experts and one of the other things that surprised me a little bit when I witnessed the process was that there was a larger number than I expected of people who had a strong financial interest in the NHS. Should the Committee not be composed solely of people with clinical knowledge rather than financial interests? Andy Burnham: I would argue not, because that is the balance that NICE is taking. On the one hand it is looking at clinical benefit, so health improvement - and that is obviously part of the job - but when it was set up the job was to balance that within the constrained and the available resources. The job it is being asked to consider is how effectively do you achieve and secure maximum health benefit for the resources that the NHS has at its disposal? - and, as we all know, at any point in time those resources are limited. I think it is proper that there is expertise in those rooms to cover both sides of that equation: those people who have commissioned care or been managers of budgets within the Health Service and those who are expert in health benefit and health improvement who are scientists and understand the science. Q54 Chairman: I wonder if I could move on to the next stage, as it were, when NICE have come to a decision: the trusts' compliance with NICE guidelines. I am going to bring up a specific incident in relation to infertility in a few minutes, but, in general terms, could I ask you whether or not you are happy with trust compliance with NICE guidelines? Does the Department set specific targets for compliance and does it have the power to sanction trusts which do not comply? Andy Burnham: There is obviously a period where NICE will make its final guidance to the NHS, and a period of some three months, I think I am right in saying, whereby the NHS has to make arrangements to ensure that the guidance is absolved and implemented. You mentioned one example, that of infertility. Q55 Chairman: I will come back to that. I just wondered in general terms whether they were compliant and what powers the Department have if they believe that compliance is not taking place inside trusts. Andy Burnham: There is a statutory direction that requires the NHS to fund, within three months from the publication of final guidance, the implementation. The example I was going to give was cancer drugs. Professor Mike Richards had looked at the take-up of cancer drugs within the NHS after NICE guidance - there have been some similar concerns voiced there and there has been some room for improvement - and, encouragingly, he has found some improvements in recent years on that. Q56 Chairman: Let me talk specifics. In the autumn of 2004, NICE published guidelines in relation to infertility treatment and IVF particularly, saying that women within an age range should have three attempts at becoming pregnant through IVF. That was effectively watered down immediately by the then Secretary of State, in the autumn of 2004, who said they should have one by April 2005. I put the question to the Prime Minister on the day that the NICE guideline was published and he said that they will have one by April of next year and the others will come along - and I cannot remember his exact wording. We are now in the year 2006 and there are areas in this country where one IVF treatment is denied to women within the age range of the NICE guideline, which was effectively changed by the Department when it was published. I am deeply unhappy about that - and I am not within a family that is suffering the inability to be able to get that type of treatment. What do you say to that, when you see these circumstances of people within PCTs and within SHAs using all sorts of reasons why that one IVF cycle cannot be given? Andy Burnham: I have to be honest, Chairman, I do not have the detailed knowledge because it is before my time in the Department. Q57 Chairman: I do realise a lot of this is before your time, but I have been involved in infertility here in Parliament for 20 years, because of the lack of good infertility services in the United Kingdom, and we all of us thought we were making progress when NICE took up the issue. Andy Burnham: I will give you a more off-the-cuff answer, if you like, in that I agree with the point you are making. With NICE, it should apply across the board. The three-month principle should apply to all clinical guidelines, to guidance to the system, to technology appraisals. That is the job we are giving it to do. Given it might make difficult decisions, where it makes a decision that perhaps people will want to support then it should be implemented within that timeframe. In many ways, it takes us back to the question on audiology. Where there is a more complex service being delivered, rather than a treatment being provided, it may be that the system will take time to put in place the infrastructure on the ground to deliver a different service. Some obviously will require the training of individuals - and that is not necessarily the case in infertility, but it could be the case - so I can see why there is a difference in terms of the ability to meet three months. But, as a principle, I would agree with you entirely. Q58 Chairman: It just seems the principle has not gone for this type of treatment. There was an Audit Commission report published on 8 September of last year. It was entitled Managing the financial implications of NICE guidance and it brought this to the attention of everybody. My understanding, however, is that it still has not happened on a universal basis throughout England. I realise I am putting you on the spot, but many people feel very strongly about this. Could I move on. You may want to reply to that specifically or somebody who has direct responsibility might respond to us by letter. Andy Burnham: I will make one quick further point. NICE guidance and the uptake of it is part of the Healthcare Commission's health checks. The speed with which health bodies implement it is part of the health check. Obviously there is a difference between technology appraisals and clinical guidelines which are developmental standards. I will undertake to come back to you on that particular point. Q59 Chairman: I will not read it out, but the Audit Commission report highlighted that and said, notwithstanding that, that this was one that should have been covered and has not been. Andy Burnham: Fair point. Q60 Chairman: Anyway, I will let you look at that. In general terms - and I think you alluded to this yourself a few minutes ago - trusts have been pressurised to improve financial forecasting as a result of recent deficits. Does the unpredictability of the financial impact of NICE guidelines not make accurate forecasting very difficult? You mentioned earlier the new cancer drug. We believe there are probably half a dozen trusts waiting now for licensing to be brought into the market place, as it were, which has major financial implications for the National Health Service in providing them on prescription. Andy Burnham: It is obviously a difficult thing to anticipate the costs that may be coming in terms of drugs coming on to the market. You could never make that a precise science, could you? It is obviously dictated by the pace of science and the activities in which companies are involved. Provision is made within PCT allocations for the funding of new technology that NICE will have approved and that will then come on to the market, because, obviously, as I was saying before, that is not a negotiable issue, it has to be complied with. Provision is made in terms of the PCT allocations for that cost pressure but it is obviously very difficult to do it treatment by treatment or technology by technology. The anticipated impact of NICE guidance is factored into financial planning within the Department, as you would probably guess, and work goes on within the Department about the size of the drugs bill, obviously, and efforts to keep it under control, but also to anticipate what it will be. Q61 Anne Milton: I would like to make a plea, following on from the Chairman's last comments. If there is a general acceptance that the work of NICE is important and critical, trust in it is absolutely paramount. I think that the public trust is waning at the moment. I appreciate the comments you have made about poor press reporting, and on the other side of this big debate is drugs companies with huge amounts of money to throw at the marketing, but I think reassurance from you that things like the implementation of guidelines, taking into account the total cost of health but all social care, and also taking into account the opportunities that exist - the one that is coming up is the vaccine for cervical cancer - are going to be really important in order to readdress the loss of trust in the NICE decisions. Andy Burnham: I understand the point you are making and I think the issue of trust is crucially important. As politicians, I think we have a job of leadership to do in terms of the public debating on these issues. I would also say - and this is depressing in relation to the reporting of the Health Service - that, of the 26 cancer drugs that NICE has looked at, it has approved 25. There is not a great deal of coverage about the 25 but there is obviously a lot about the one or two that do not get approved. That is why I suppose I was making a plea for balance. If all the public reads are difficult headlines about the one that does not get approved, it is not surprising that there is a jaundiced view that develops about bureaucrats who are denying us treatments. This is not just an attack saying that everyone misunderstands NICE; there is a responsibility on me too to explain their job better. In response to Sandra Gidley's point and Doug Naysmith's point, if we can put more information before the public, we should do. That is a duty on us. I think we all have a responsibility in this but my plea to everybody is that inherently there is a balance that NICE are making, a balancing test: clinical benefit versus cost effectiveness, and often the portrayal of it is: "There is clinical benefit but they will not pay." People take away the balancing test from the coverage and it just becomes a very black and white issue and it is disappointing, particularly given the NHS budget is obviously under particular pressure from new technology. Q62 Dr Naysmith: Minister, could we move to a more positive note for a few minutes. You will recall, when you were a member of this Committee, that on more than one occasion we came across treatments and so on that were not very much used. Everybody recognised they were not very much used but they lingered on for historical reasons in the National Health Service - and not just in the National Health Service but elsewhere as well. It was really pleasing, therefore, to see that you have recently introduced a new programme of work for NICE, the aim of which is to identify and stop ineffective interventions. It is clear that this Committee is occasionally useful and it is nice that you remembered that, now that you are a minister. That arises directly from the Pharmaceutical Industry and National Health Service inquiry. There was a lot of evidence of things that were a waste of money: Why did we not get rid of them? Would you tell us how this is going to work? Andy Burnham: Maybe I can put a stunning revelation before the Committee this morning and flatter you all. Being a poacher turned gamekeeper I can assure you that you are all well and truly listened to inside the Department. A considerable amount of work goes on on each committee report. Q63 Dr Naysmith: How are you going to get this programme running? How are you going to identify the treatments at which NICE should be looking? Andy Burnham: With the NHS, it seems to me, we are constantly saying, "Do everything you have done before and then this little bit more." We are constantly loading things on the pile but not taking stuff off the bottom. When I was saying to Sandra about how we move NICE forward, that it should not be a static organisation but it should be a changing organisation, that is precisely what we should do. I personally would like to see some growth in that area. We have funded NICE to do this work. Originally they will look at treatments that cost the NHS £1 million or more. Obviously there are examples of those kinds of treatments that people could think about, but I think it is important. Again, there may be the potential of the negative coverage of some of this: here they are again, denying things. I think this is an issue that the public will understand. As technology changes some things become outdated and you do need to help the NHS disinvest from some of the things it has been doing for a long period of time. But yes, absolutely, that is being taken forward. Q64 Dr Naysmith: How much money do you expect to save as a result of this programme in, say, the first year or couple of years? Andy Burnham: I think it would be too early to give that figure. There may have been an indicative figure that we published when we announced that NICE was doing this work, but obviously we are going for the bigger end, where savings could be reasonably big. But perhaps I could come back to you on that. Q65 Dr Naysmith: That was a trick question really. I wanted you to say the money is not important; it is about stopping people having ineffective interventions and being made ill rather than better. Andy Burnham: Obviously I am just thinking about money, which may say something about my current state of mind. There is obviously direct patient benefit of not having treatments which they do not necessarily need to have. Linked to this work, we issued productivity indicators for the NHS - I think published for the first time this week - which list a grade of information that the system has never really had before. One of the things was levels or procedures for the 15 most common conditions. This kind of information is an attempt to help people understand where they may be carrying out procedures that are not strictly necessary. Q66 Dr Taylor: I am sure you are aware of the very helpful leader in the Guardian on Monday, followed by Polly Toynbee's article on Tuesday. In the leader on Monday it said that NICE embodies the least-bad way of tackling an impossible job. I would like to try to get you to focus on what we ought to be doing to make this job more possible and take you back to our report. I do not expect you to remember it, I have had the chance to look at it - the last two recommendations in our report in 2001-02 were about prioritisation of healthcare extending over the whole NHS. We said: "Prioritisation of healthcare spending is an issue of overwhelming importance and during the course of this inquiry it has become clear to us that a more open debate on healthcare prioritisation needs to take place." The Government's response to this, in a nutshell, was that it was going to be terribly complicated to do. The last two sentences say: "Achieving a comprehensive empirically-based framework could therefore only be achieved in the long term. The establishment of NICE could, however, be seen as an important first step in that direction." What steps do you think you could take as the Minister responsible - and this was written four years ago - to widen the debate on healthcare rationing, so that some of the things that a lot of us would admit the NHS should not provide could be got rid of? That would get more money to go into the pot, so that NICE's QALY level, whatever it is, could come down, and we then could have more of the drugs coming through. You also said that you are seeing new drugs coming almost every week, so the demands are relentlessly increasing. NICE is about to look at the treatment for age-related macular degeneration. Unfortunately the result is not going to be out until next August, by which time several people will have probably gone blind, which is terribly difficult. It is really your views on healthcare rationing - and I hate to use the word "rationing" - as a whole, as releasing money, as well as your drive for efficiency to release money, to make NICE's job slightly more possible. Andy Burnham: An excellent question. In many ways, I think you have answered it yourself. I think that is the role NICE will have. I think it is important to society as a whole and to the NHS as a whole that it just cannot be underestimated, given the pressures that it is trying to reconcile. It is obviously trying to reconcile the pressures and the costs of new technologies with the need for an aging population to have access to the very best. It always must be the case that the NHS makes the very best available to those who need it. You are right, it is a relentless pressure that NICE is under. I remember that report very well. I probably enjoyed that report more than any other. It was a very interesting experience. I do not know how you feel and how Sandra feels, because she too took a huge interest in it, but the extent to which NICE is established now as an authoritative organisation is considerably enhanced and some way down the line from where it was. I think it is an organisation that is growing in stature, in confidence, and it knows the job it is doing. It knows it is a difficult job, but it is confident in the way it handles its communications, in terms of the advice it is giving to the system. Obviously it is at a point, increasingly, where it has caught up with a lot of the technology appraisals and that does open up the scope to move into the work that Doug Naysmith was asking me about. Dr Taylor: I am pushing for a much wider debate on healthcare rationing than NICE alone can do. Chairman: Maybe we could have a discussion on whether we want to do an inquiry on that. Q67 Dr Taylor: You do not want me to go on. Andy Burnham: I will try to answer the question very quickly. People talk about that a lot, that the NHS has to shrink back and become more of an emergency system that provides life-saving or life-threatening treatments. Q68 Dr Taylor: Core services. Andy Burnham: Core services, and then you retreat from a whole sphere of treatment. I am still passionately of the view that the NHS should be a comprehensive service in terms of the population, comprehensive in terms of the care needs that it is meeting, but, within that, it will always have to make judgments about which treatments are best to meet those needs. That is the job that NICE is doing. I think you are hinting at something slightly broader. Q69 Dr Taylor: I am. Andy Burnham: Which personally and politically I do not believe is justified. If you look at the job the NHS does - in terms of the percentage of GDP that it spends compared to other European countries but the service it provides to everyone regardless of the condition they have - it is phenomenal in my view. Personally, I do not think there is an absolute complete necessity today to open up an honest debate about rationing. Q70 Dr Taylor: One example: should the NHS be paying for tattoo removal? Andy Burnham: Some of these things should be, properly, a clinical judgment. You would defend clinical discretion, surely. There are some treatments that I would say are on the edge of whether or not they should be provided - and clearly we all know what those kinds of things are - but that is different from issuing ministerial edicts against any NHS activity in those areas. I would agree with you, life-threatening and life-saving are significantly different from tattoo removal. Q71 Chairman: Could we move on to the National Patient Safety Agency (NPSA). I would like to ask you whether you agree with the Public Accounts Committee's conclusion that the National Patient Safety Agency "has yet to demonstrate value for money." I wonder if you could tell us when and how it will demonstrate value for money. Andy Burnham: I think that was a harsh criticism of a new organisation, an organisation which is beginning to establish itself and I would argue beginning to have real benefit across the NHS. Obviously the NAO is there to provide challenge within the system but I could point to the establishment of the National Reporting and Learning System, which the National Patient Safety Agency is in charge of, which is a major undertaking and a major step forward, and these things take time to become embedded in the culture. Q72 Chairman: There was a two-year delay in relation to that. It should have come out in 2002 but it was not completed until the end of 2004. I am pleased that it now is. The other issue is that we have been told that both the NPSA's joint chief executives were sent on extended leave in August of this year. What are the current arrangements for running the NPSA under those circumstances if that is true? Andy Burnham: It is true. There is an acting chief executive of the NPSA, a gentleman called Bill Murray, a retired experienced trust chief executive, who is in charge at the moment of the agency. The issues to which you refer are subject to internal disciplinary proceedings, so it would not be ----- Q73 Dr Taylor: I understand that, but you are reasonably happy, under current circumstances, that the NSPA is doing its work. Andy Burnham: I have taken a close interest, as you would expect, of the agency during this particular period. The Chair, to whom I speak regularly, is a member of the House of Lords and I have regular contact with him. Clearly, there have been some internal difficulties. You mentioned that the reporting and learning system had taken time to become established, which is correct, but it is now receiving in the order of 60,000 to 70,000 safety reports every month and, as I was saying in my answer, I would not underestimate the improvement that could bring in terms of transforming the patient safety culture. Obviously we want to get the agency on to a solid footing as soon as possible. Q74 Dr Naysmith: One of your other responsibilities, Minister, as you know, is the Medicines and Health Care Regulatory Authority, and it has recently had on its books probably the biggest disaster it has ever had to deal with, the clinical testing at Northwick Park of the new monoclonal TGN1412 and there is the expert scientific group that was set up and its interim conclusion is that the pre-clinical testing of TGN1412 did not predict a safe dose in humans. The drug was tried and all the pre-clinical stuff had failed to show that it was going to be really dangerous when it was put into humans for the first time. How concerned are you by the fact that this is now the case or may be the case for quite a significant number of new pharmaceuticals ... I was going to say, coming onto the market, but we will have to wait and see - coming forward for testing. Andy Burnham: As everybody, I guess, I was very concerned when that incident happened. The fact that such an incident is and has been so rare I would argue does demonstrate that we have extremely high standards within our domestic arrangements for clinical trials and in terms of the strength of our pharmaceutical industry. I should also say that before coming to this job I within the Home Office was responsible for the Animal Procedures Committee and the inspection of animal testing People have made the argument that that in some way disproves the efficacy of the use of animals in the research and development of new medicines. I am led to believe in this particular instance that the dosage used in the testing of the product in animals was significantly larger, and a very large safety margin was left between the dosage given to those participating in the trial, but clearly it does give cause for concern. I think the nub of the matter, as pharmacological or pharmaceutical science develops, is that it is obviously moving to the field of novel molecules which can be very active and can produce change and can be a significant breakthrough. You can obviously tell there is an English student speaking here, but there is an issue. The point in this particular incident was the unexpected reaction that this particular molecule caused in the individuals concerned. Q75 Dr Naysmith: That is the point really, you have to find out why the MHRA's investigation did not reach the same conclusion as the interim conclusion of your expert scientific group. Are you having discussions with people from the MHRA or people in your department to try to make sure this does not happen again? Andy Burnham: Of course. This is of the utmost importance. Public confidence in clinical trials is crucial, of course. We clearly do need people to participate in clinical trials and it is a matter of the utmost seriousness that we maintain public confidence in the regime around clinical trials. The MRHA did go through a thorough process before approving the stage 1 trial. A similar process carried out by the counterpart body in Germany came to the same conclusion that the product was safe to allow it to proceed to a stage 1 trial; so it is not that experts here came to a different view, it obviously was a view shared by counterparts in Germany. Q76 Dr Naysmith: I know it is easy after the event but there are quite a few experts in this country who will say you could have predicted that this kind of drug would have a different effect from previous pharmaceuticals and that the MHRA was not then and still is not set up to undertake much more detailed studies and recommend studies on this kind of agent. Most of that will come out eventually, when we get the expert scientific group's final report. When is that going to be published? Andy Burnham: Obviously we had interim findings from the group in the summer. In November we are expecting to publish the final report. The MHRA has already taken some action on the interim findings. Clearly you are right, Doug, there is a learning process to be gone through and that is why the Secretary of State has set up the expert scientific group. Obviously some of the interim recommendations that the group has already made call for earlier dialogue between the drug developer and perhaps those organising the clinical trials with the agency, so there was a sharing of data and information at a much earlier stage in the process. There are also issues around whether one person rather than a group of people should have been trialled. Q77 Dr Naysmith: Individuals on scientific training have phoned up to say that this was a stupid thing to do, to give this dose at the same time to six people. One of the simple recommendations in the interim report is that the trials should have been staged. Andy Burnham: Yes. Q78 Dr Naysmith: That seems sensible. If a body like the MHRA does not have the power to make recommendations of that sort, then it needs to have. Andy Burnham: Typically, stage 1 trials have typically involved a range of anywhere between 10 and 100 people. That would be a normal range. Obviously in this case it was six people. When we received the Committee's interim recommendations, that was one which leapt out because it makes practical commonsense, but I suppose you do also have to consider what message that would send to the public. Who would be the one person who came forward for the trial? You do have to balance these things because it might in itself discourage people from taking part and these things need to be balanced. The Committee, as far as I can see, are doing an excellent job, a thorough job. It is going to become increasingly important that we give detailed consideration to their work because of the changing nature of products coming on to the market and I think it is very important that we make the appropriate changes. Q79 Dr Naysmith: Could I just clarify that you intend to publish the report in November. That is when you anticipate it will be published. Andy Burnham: Yes, and it will be published. Chairman: Could we move on now to the home oxygen service. Q80 Mr Amess: Is it fun sitting that side? Andy Burnham: Fun is not the first word that would spring to my mind, David. Q81 Mr Amess: The Royal Pharmaceutical Society of Great Britain said "... there is no doubt that delays to the implementation of the service caused confusion and we question why this exercise was undertaken during the winter months." We all appreciate that the aim of switching to new providers was said to save money and to improve the quality of service - wonderful if you can achieve both things - but do you believe that has been achieved? If it has not, when will it be achieved? Andy Burnham: I think we will end up with a better service for the public. But I do not want to give an answer that is evasive. Has it been a good experience for those who used the service this year? For many people, no. In terms of whether or not we should learn from the process, then absolutely the Department of Health should learn from the process. Will it deliver a better service? I am absolutely confident that it will significantly improve the quality of service that patients who require home oxygen get. Q82 Mr Amess: If I may say so, the Committee greatly appreciates your honest and frank reply to the question. That is wonderful. What is being done to resolve the problems in terms of the waiting lists and access to these portable cylinders? Andy Burnham: It may help the Committee if I give some figures from the latest state of play with regard to switchover to the home oxygen service. Obviously I have brought the figures with me. Overall, the number of people now receiving home oxygen - so obviously not going through the pharmacy route - is somewhere between 75,000 and 78,000 people. Looking around the regions at the number of people whom we know about who are yet to be transferred to the service, the transfer has been completed in the North East region; the Eastern region; South West London; Thames Valley; Hampshire and the Isle of Wight; South East London; Kent; Surrey; and Sussex. In the following regions there is still some work to be done: East Midlands (1% of patients have yet to be transferred); West Midlands (1%); North West (2%); Yorkshire and Humber (1%); Wales (2%); North London (1%); and the South West (1%). I am far from complacent on this subject. I meet with officials regularly and, though it has been difficult, I would pay tribute to the job they have done in difficult transitional times. Where you are dealing with such a critical service, I think the Department has managed what has been an extremely difficult situation well. There are complicated reasons as to why in February this year there was a real problem, but, as you can see, the transfer is not complete but it is not far from being complete. While we obviously have to make sure, until that transfer is complete, that everyone has access to oxygen, the emphasis also now is on very closely monitoring performance standards, improving the service to patients, ensuring they get the right equipment, ensuring they get costs reimbursed for electricity - issues such as that, which are a part of the contract with each of the suppliers. Q83 Mr Amess: I am glad to hear that you are the Minister with responsibility for the East of England. Andy Burnham: That is correct. You know where to come! Q84 Mr Amess: I do. I have been tipped off, so I am very pleased that in this particular issue you are doing well. Can you tell us something about the difficulty there was regarding the contract with the South West region and the eight months that it took to switch from Air Products to BOC? Andy Burnham: I was aware of the publicity around the service, David, and officials, rightly, met me very early on to talk about the issues and I tried to come up to speed very quickly on the transition to the new service. It became clear, looking at the figures around the regions, that there was differential performance, let us say, in terms of how quickly patients were being transferred over. There was obviously a cause for concern there, in that supplies within pharmacies, where people were not able to access the home oxygen service, needed to be able to maintain their supplies through traditional routes, so there were clear issues that had to be managed. As you will know, one supplier, if I remember correctly, had seven of the regional contracts and it became clear that we were not seeing sufficient progress, particularly in the South West, towards making transition possible under the terms of the contracts. We had discussion over the summer about what was the right course of action to take, and I am pleased to say that, with cooperation all round, a sensible outcome was reached where the contract was switched to a different supplier. There has been good cooperation all round in facilitating that switch, and, as a result, we have now seen the progress that we were hoping for. It was the right thing to do. It has enabled the other supplier to improve its performance in the other regions where it still has contracts, by being able to focus its resources. Dare I say - and ministers probably should not touch wood - it has gone well in terms of improving the transition, but, as I say, we keep these things under very close review. Q85 Mr Amess: A point has been made to the Committee about the National Pharmacy Association apparently being unaware of the six-month transitional period following the switch to the suppliers in February 2006. Andy Burnham: I am unaware of that point. I have to say that predates my time in the Department, but there was a transitional arrangement that was clearly published by the Department so I would be surprised were that to be the case. Q86 Sandra Gidley: Perhaps I could clarify, Minister. Your predecessor described the process as a shambles on the floor of the House, so I am glad that close attention is being paid to this. Most community pharmacists were advised to run down their stocks by 1 February. Most of them, rather wisely I think, realised there would be problems and, because they are committed to patient service, retained their stocks. If all had gone according to plan, my understanding is that at that stage, after 1 February, a doctor should have been ordering via a different system, which a pharmacist would not have been allowed to supply against. For administrative reasons that did not happen, so pharmacists were able to bail out the system. The original aim was to phase all patients off, to transfer patients, by 1 February, and everybody in the sector understood that, and that is why the National Pharmacy Association said that this had come as a surprise, because they had not expected to be in a position to bail out. I understand it was not your problem and you were not the Minister at the time, but what went wrong? Why was that transfer so badly managed? Andy Burnham: As I have mentioned, there does need to be a learning process from handing over such a critical service. I would agree with you and I would like to put on record my recognition of the role the community pharmacy has played throughout the course of this year to ensure access and supply to patients who need it - and you were right to highlight that fact. With their help, some of the transitional problems have been negotiated. In terms of whether they were informed or how it was that this situation arose, obviously there were transitional arrangements put in place, but it would seem that a combination of factors in the first week of the new service led to the system being unable to cope. It seems that for a whole range of complicated reasons - in terms of people ordering emergency supplies who did not need them, or problems with the way in which the new form (the HOOF, as it is being called) was being filled in so that the information was not sufficient - a whole set of problems came together at the same time. I think you are right - let us not evade the question - consideration has to be given to how that could have been done better, particularly on such a critical service. Phasing, not just in terms of time, but in terms of region, would perhaps, it seems to me, have been a sensible thing to have done, but these are things we will look at - and I am happy to share with the Committee the conclusions we draw with regard to the next contracting round. Q87 Sandra Gidley: Clearly there have been problems, because a parliamentary answer on 24 July said that the Department had received 241 written representations concerned with this service. People do not usually write in if they are ecstatic about something, sadly. It has been difficult to get a figure to compare that with, because parliamentary questions asking how many complaints there were before have been answered - but with a non-answer. I think you are right when you say that the patients are receiving better equipment but the problem has been purely distribution. What was wrong with a system where you had several thousand distributors who were flexible, who knew other suppliers in the network, who generally could manage a very rapid delivery to patients even though there was not an official emergency supply? What was wrong with that system, to want to change over to a smaller number of larger logistics' suppliers without that patient focus? Andy Burnham: I think there was a review of the service by one of the Royal Colleges back in 1999 which advocated moving to a service, in this way, which was home-based and delivered around the patients' needs. As I say, the pharmacies provided a very valuable and dependable service for many years. In terms of moving to a service delivered in this way, pharmacy companies were not ruled out from seeking to take the contracts for any particular region, working with subcontractors, so I do not think it was a case of not wanting pharmacies to be involved, but, as I said to David Amess, I am confident that the service is a better service and will better meet patient needs, both in terms of the modern equipment that it makes available to patients, in terms of lighter cylinders, and the range of equipment to which they can get access. In terms of their convenience, it is a better system, but, as I was saying, we must improve some of the service standards and make sure that it is as good everywhere all around the country. Q88 Sandra Gidley: Are there any plans to do a patient satisfaction survey? Andy Burnham: The other group I would like to pay tribute to during this process has been the British Lung Foundation. Through their Breathe Easy groups they have facilitated patient feedback about the quality of the service in the different regions and that has been crucial to maintaining the quality of the service. They did a survey, if I remember rightly, earlier in the year, not long after the new service had been introduced. I have been meeting the chair reasonably regularly, Dame Helena Shovelton - because obviously that feedback is crucial information for the Department in terms of how the service is impacting on the ground - and when I last met her, in the last couple of weeks, she was talking of another survey to their Breathe Easy groups around the country, particularly with the Christmas holiday period and with other issues about service standards. I welcome that kind of feedback. It is good that the British Lung Foundation have played that role throughout the period. Mr Amess: Chairman, I think this Minister has answered my questions rather well and I look forward to him looking after the East of England. Q89 Chairman: Could I ask a supplementary question to that. The legacy of coal mining in the health profile in your constituency will not be dissimilar to mine. Have you had any letters from patients about the transfer over to the new system for home oxygen in you casework? Andy Burnham: I met my Breathe Easy group not too long ago and, on the whole, they were saying they thought it was a good service. In my constituency office, I do not recall receiving many letters on this. Q90 Chairman: No. I have not received one, which is surprising. I have been actively involved in home oxygen for the last 15 years now, about getting it into people's homes. Andy Burnham: One of the reasons for that might be that a lot of work was done to identify patients in that transitional period to which Sandra Gidley referred. I should say, to develop this, that the PNC and the Department of Health prepared a joint letter at that time to inform pharmacists about the six-month transitional period. When that work was being done, I am sure your PCT, like mine, immediately flagged up as a place where, given the high levels of COPD, there are significant oxygen users, so I would guess that there was a lot of focus given because of the high level of users in those particular areas. Q91 Sandra Gidley: Turning to the new pharmacy contract, why is there a statutory limit on the number of Medicine Use Reviews that each pharmacy can undertake per year? Andy Burnham: There is flexibility within the funding that we have allocated for Medicine Use Reviews to enable pharmacies to go to a certain level, but, if I understand the contract correctly - and sometimes that requires sitting down in a room with a cold towel to my head - there is a limited pot of money allocated within the contract for Medicine Use Reviews and clearly that means there has to be a limit on the number that can be carried out. Q92 Sandra Gidley: Why is there a pure allocation per pharmacy, when some clearly see many more patients than others or are larger and employ more pharmacists? Should there not be more flexibility in that, probably based around prescription volume? Andy Burnham: I think so. As far as I can see, those which have registered early to become accredited to provide patient Use Reviews will end up providing more in this year than those who have been slower off the mark. That is a good thing because it is important that the allocated resources are used to make full use of Medicine Use Reviews. But this element of the contract was a negotiated element with the PSNC. Q93 Sandra Gidley: You mentioned funding. Why has the budget been slashed from £39 million in 2005-06 to £15 million in 2006-07? Andy Burnham: I think there was flexibility built in at the beginning, without knowing exactly how many Use Reviews would be carried out. Obviously we can now plan with figures. I do have some figures if they are of interest to you on the number of Use Reviews that have been carried out. These figures have been agreed and negotiated with the PSNC. The number of reviews is growing at a pretty encouraging rate. Q94 Sandra Gidley: There was a slow take-up, which was rather disappointing, I must admit, but the rate has escalated quite remarkably, and it seems odd to cut the funding at a time when the number being performed is increasing quite significantly. Andy Burnham: Yes. I think it is a realistic figure, based on the number of reviews we expect, so that figure has been brought down. There are 3,843 accredited pharmacies now doing Medicine Use Reviews and there were 148,195 Medicine Use Reviews in 2005-06. I think the figures for this financial year are to reflect that level but obviously to build in some growth for Medicine Use Reviews. That is the reason why that has been done, but, as we continue to discuss and negotiate with the PSNC, it is something that we would keep under review. Q95 Sandra Gidley: Patients and pharmacists seem to like the Medicine Use Reviews. GPs have complained frequently that the format of the review does not fit easily with the systems they use; it has to be manually inputted. Is there any way that the Department is planning to look at streamlining this service more, so that it has greater buy-in from GPs and the information gained from that is of benefit to GPs? Andy Burnham: The point you make is a very good one. I cannot say that I am aware of any work to do that, but it is a very good point so I will take that point away and see if I could give you an answer. I think one of the more exciting things in the Department, which is linked to this and has yet to achieve fruition, is the Expert Patient Programme. It is allied to Medicine Use Reviews, in that you help people to understand their own condition and their need for medication and how to control their condition. I think generally that work does need to be better integrated with primary care and general practice, helping people basically to take more control of their condition. I see those two things as being a crucial part of that. However, I think you have made a good point. Q96 Dr Naysmith: While we are on the subject of pharmacies and pharmacists, Minister, this is a very unfair question, I know, but you will be aware that Pfizer has recently said that it is going to limit the distribution of its drugs through one distributor, and a number of small wholesalers of drugs to the pharmacy trade are complaining about this. Do you have any views on this business of a restriction on the distribution of drugs? Andy Burnham: From my seat the issues that would arise for me, I would say, are principally supply, so continuity of supply to all parts of the country and then, secondly, the issue of cost, whether it would increase the cost of any particular product to the NHS. Obviously this arrangement has not yet taken effect but as we have been assured - and obviously departmental officials have had discussions with Pfizer about the arrangement - we are assured on both points that there would not be any detrimental impact of the new arrangement. However, it is something obviously that we would want to be reviewing to ensure that there was not any detrimental impact. Interestingly, just as an aside, obviously I do not have responsibility for Northern Ireland but I was there earlier this week talking about medical regulation with Paul Goggins, the Minister of State, and it came out that, as I understand, the wholesaler concerned does not have an operation in Northern Ireland at present, so there may be issues for other health ministers within the devolved countries. As far as I am concerned as the minister responsible for the pharmaceutical industry, we have clear assurances on those points about supply and cost. Q97 Dr Naysmith: Just finally, the reason they give for this is because they want to combat counterfeit drugs. Do you think this is a real problem and do you think this is one way of counteracting it? Do you agree with them? Andy Burnham: Yes, in short. I think the industry does have a genuine and legitimate concern about counterfeit drugs and the integrity of the supply chain of their products. Internet sales of certain things are obviously, I do not know how many e-mails everyone else gets but my parliamentary e-mail used to be jammed with the things --- Q98 Sandra Gidley: No! Andy Burnham: Maybe that says something about me rather than you, Sandra. It is probably a derogatory comment about myself; I had better leave that subject! Yes, I think there are genuine issues about the integrity of the supply chain, the quality of the products, the ability to know that the products are of high quality, and the counterfeiting issue, which is, as I say, a very large issue for industry. So there are legitimate reasons. We understand why they would want to do it but from our point of view we just want to be sure that it does not have a detrimental impact on the two crucial areas that I mentioned. Whether or not the OFT take a different view in terms of whether you would describe it as vertical integration, I do not know. Those matters are not for our Department. On the key things that we are bothered about we are satisfied currently. Q99 Sandra Gidley: I was not going to but can I just pick up on the finance. You mentioned that the pharmacy contract involves going into a darkened room with a cold towel on your head. The whole area of discounts and claw backs and NHS finance around the pharmacy contract I think requires double cold towels. It is by no means clear. There are lots of concerns that discounts will be affected and there will be a consequential effect on the claw back by the Department, and there could actually be a financial implication for the Department so I would hope rather than just receiving reassurances that some work is done to assess the financial impact of this move. Can we have your reassurance on that? Andy Burnham: Certainly, there has been considerable research done on the impact of the contract on the ground and work to ensure that the sums that were negotiated with the PSNC as part of the contract are being met. You mention the claw back. Because we are doing that level of detailed work, it justified an adjustment to the contract value in terms of the price of generic drugs. So, you are right, as far as we are concerned this was a contract negotiated in good faith and it cuts both ways. It has got obligations on both sides and the way we want to proceed is with a very constructive relationship with pharmacies. Alluding back to the point I made before, as Minister I am really conscious - and I know this is something you are very passionate about - of the role community pharmacy could have and will have in the future in terms of a greater role in helping people manage their own care and their own condition, and I want a contract that enables people and opens up the kind of extended services and pharmacies that we hope the contract will bring. In principle, I think it is a good thing but it needs goodwill on both sides to make sure that it delivers for both sides. Q100 Chairman: Could I thank you very much indeed. Andy Burnham: It is over! Mr Amess: You did very well. Q101 Chairman: We are very conscious of the fact that having one minister, particularly with a portfolio as wide a brief as yours, that it must be an onerous task just thinking about coming in here and what questions are going to be asked. May I thank you for answering the questions and any things you will write in about we will appreciate as well. I hope that the friendships you have around the table will remain whether you are a gamekeeper or not. Thank you once again. Andy Burnham: Can I just thank you, Chairman, for the good-natured session. It has been a very enjoyable session and I hope it is not too long before I am back again. Sandra Gidley: You could regret saying that! Chairman: That is a challenge! [1] Ev [2] Ev |