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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 623 House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE HEALTH COMMITTEE
RESPONSIBILITIES OF THE SECRETARY OF STATE FOR HEALTH
Thursday 27 October 2005 RT HON PATRICIA HEWITT MP and SIR NIGEL CRISP Evidence heard in Public Questions 1 - 116
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Health Committee on Thursday 27 October 2005 Members present Kevin Barron, in the Chair Mr David Amess Charlotte Atkins John Austin Mr Paul Burstow Anne Milton Mike Penning Dr Doug Naysmith Dr Howard Stoate Dr Richard Taylor ________________
Witnesses: Rt Hon Patricia Hewitt, a Member of the House, Secretary of State for Health, and Sir Nigel Crisp, Chief Executive of the NHS, examined Q1 Chairman: Good morning, Secretary of State. Would you for the record introduce yourself and your companion? Ms Hewitt: Thank you very much, Chairman. Patricia Hewitt, Secretary of State for Health, Sir Nigel Crisp, who is the Chief Executive for the NHS and Permanent Secretary for the Department of Health. Q2 Chairman: Could I ask you, first of all - it will be no great surprise to you - about the issue of the last 24 hours or more. Last week the Government made a statement, or, should I say, the Parliamentary Secretary of State for Northern Ireland made a statement - the Hon Member for St Helens South - that his intention was to introduce comprehensive measures to protect all workers and the public from the dangers of passive smoking and second-hand smoke in workplaces and in all enclosed public places in Northern Ireland, including all pubs and all bars. Are we to accept that workers and the public in St Helens South are going to have less protection against secondary smoke than workers and the public in Belfast South? Ms Hewitt: Chairman, the consequence of devolution is that we will have different decisions on some subjects in different parts of our country, although each of those decisions follows very extensive public consultation. The Bill that we are introducing today - the Health Improvement Bill - will mean that smoking is banned in every office, every factory, every shop, every restaurant, every bit of public transport, virtually every enclosed work space and public space in England. It will mean that 99 per cent of the workforce will be able to enjoy a completely smoke-free environment, that 12 million more people will be protected from second-hand smoke, it will certainly help smokers who want to give up to do so and because of that it will reduce over time by thousands the number of people who die from smoking-related diseases. Of course, we are equally concerned about workers in the food only pubs and the membership clubs who are going to be exempted from this ban, and that is why we said, not only, of course, in our manifesto but we have made it clear today, that there will be no smoking allowed, even in those pubs and clubs that choose to continue to allowing smoking, within the bar area. We will now have a further round of consultations on that and, in particular, we will consult on the possibility of creating separate smoking rooms or areas in order to give as much protection to those bar staff as we can. Q3 Chairman: Can you tell the Committee what is the outcome of the summer consultation in relation to these proposals? Have they been assimilated? I have got in front of me the statement that was made last week about the consultation in Northern Ireland, which as I understand it at the moment does not have any devolved powers - they are suspended - but that is probably another debate, but there was massive support during their consultation earlier this year for a comprehensive ban, which it looks like we are going to legislate in our parliament for them to have. What is the outcome of your similar consultation? Ms Hewitt: We had, Chairman, an enormous public consultation last year before the White Paper and of course for the Labour Party before the manifesto was drawn up, and what that public consultation showed very clearly was that the vast majority of people want a complete ban in the vast majority of enclosed work spaces and public places, they want to be able to go out for a meal without being disturbed by other people's smoke, but there was strong support for the view that the significant minority of people who do choose to smoke, despite the health risks, and who want to be able to have a cigarette along with a drink when they go to a pub should be able to do so in pubs that do not serve food, that memberships clubs should be able to make their own decision on this, but, nonetheless, we would do our best to protect the workforce. The summer consultation was, of course, on the details of the regulations that would be needed to give effect to those exceptions, and what came back there was very strong support for the principle of legislation - a very large number of people wanting us to go that one per cent further so that it would be 100 per cent of the workforce rather than 99 per cent in a completely smoke-free environment - and there were also concerns about the particular proposal to have a one-meter exclusion zone - you know, the line on the floor or the wall - around the bar, and that is why we have looked again at all of this. There were very different views on this, as I think everyone knows, and we did what any organisation would do under the circumstances: we discussed it between ourselves and we agreed that, since any way forward has both advantages and disadvantages, we would continue on the lines that we set out so clearly in the manifesto only five months ago but with this further consultation on how we give the bar staff in the exempt pubs and membership clubs as much protection as we can quite possibly through the creation of separate smoking areas or rooms. Q4 Chairman: The Northern Ireland consultation had 91 per cent of respondents expressing support for comprehensive controls. Do we have a percentage for the respondents to this particular consultation on the smoke-free elements of the Health Improvements Protection Bill? Ms Hewitt: I have not got the exact figures with me - of course we will publish the usual summary of the consultation responses - but it was around 91 per cent who supported legislation in this area. There were, of course, people who do not believe we should be legislating at all, but I think the great majority of those who support legislation would like us to go that extra step further and also ban smoking in the drink only pubs. However, I would stress here that the legislation will come into effect in the summer 2007. That is considerably earlier than we originally proposed, because for licensed premises we originally suggested the end of 2008. Most people responding to the consultation said, "Do it faster"; and we will. We will monitor the impact from day one, we will have a full review at the end of three years, and this is a very significant step for public health and a very, very significant step towards the complete ban that I know you and many others would like to see. Q5 Chairman: Obviously other members of the Committee will want to ask you questions on this, but given this issue about private members clubs and the exemptions that we hear about in the media, how is this going to impact on the issue of heath inequalities in England? Ms Hewitt: There is a real concern about health inequalities. If you look back over, say, the last 20 years, of course it used to be the case that almost the same proportion of people in the middle classes and people in working-class communities were smoking. What has happened since then has been a very sharp decline in smoking rates amongst middle-class people and a rise, in a few cases, amongst more working-class communities; so the gap has widened. What we are doing in this Bill will actually help reduce inequalities, because the vast majority of people in the north and everywhere else will be protected from second-hand smoke in their workplaces. We have got superb stop-smoking programmes in the NHS which have helped over a million people to stop smoking since 1998 and we are going to continue developing that, but I agree that one of the problems with the policy we set out in the manifesto and the distinction between the food and the non food pubs is that there are more non food pubs in the poorer communities of our country. That is a disadvantage, and we looked at that, but because every approach has disadvantages, we decided, after proper reflection and discussion, to come back to the proposal that we made in the manifesto which, of course, all of us in government in our party were elected on just five months ago. Chairman: I will not mention top-up fees! Charlotte. Q6 Charlotte Atkins: Will it not be the case that many pubs will decide not to serve food, and so what you will get is smoky drinking dens in less affluent areas encouraging binge drinking, because people will not be able to eat with their drink, and smoke-free food-serving pubs in the more affluent areas? Ms Hewitt: I think there is a risk that some pubs that are currently serving food will decide to stop serving food in order that their customers can go on smoking if they choose to, and that is a real disadvantage, and I readily admit that. The alternative would have been not to draw this distinction between pubs and restaurants serving food and those who do not, but when we looked at our manifesto, when we looked at this very difficult balance that we are trying to strike between protecting employees from second-hand smoke and respecting the rights of a minority of adults to do something that is perfectly legal, then we decided that the right balance was the one that we had struck in the manifesto; but there are disadvantages whichever way you go on this one. I have to say that the disagreements that we have had inside government - and that is perfectly normal - are mirrored by disagreements amongst the public, and I think certainly many of my constituents in a working-class community do feel very strongly that, just as they are free to make that choice to smoke in their own home, they should be free to have a cigarette with a drink. It is a very difficult issue and, of course, there is a strong case to be made for a complete ban, but this is a very significant step towards that complete ban, and I think the disagreement on one per cent of the policy should not blind any of us or the health professionals and the anti-smoking lobby to the enormous step forward that we are making in this Bill. Q7 Charlotte Atkins: How will you monitor the effects so that when the review happens in three years' time we can have proper evidence as to what has been happening in England? Ms Hewitt: We will put in place before the summer 2007 more detailed mechanisms for that monitoring, but, of course, one of the things that we are already doing is measuring, through surveys, the number of people who are smoking, the number of people exposed to second-hand smoke in different places, but we will, through consumers' own reports, through contact with the industry, and such like, and, indeed, through reports from members of Parliament, be able to see exactly what is happening in those food only pubs and in the membership clubs and that will feed into the final review at the end of three years. Q8 Mr Burstow: Secretary of State, you were saying, I think, this morning on the "Today" programme that there is total agreement around 99 per cent of the policy - and you have reiterated that point - but when it came to the Public Health White Paper last year one of the things that it pointed out was that between ten and 30 per cent of pubs were, and would be likely to remain, smoking pubs. How does that equate with a policy that is 99 per cent achieved when an intended 30 per cent of pubs will continue to be smoking pubs? Ms Hewitt: What we are looking at here is the totality of workplaces, and, as I was saying earlier, every office, every factory, every shop, every cinema, virtually every workplace in our country is going to be smoke-free by the summer of 2007, and that is why we are completely confident that 99 per cent of the workforce will be enjoying a completely smoke-free environment. Currently it is about 50 per cent. So there will be 12 million more workers in a smoke-free environment in the summer of 2007 compared with where we are today. That is why this is such a big step forward. Q9 Mr Burstow: Would you accept that there are ten to 30 per cent of pubs that will remain smoking pubs under this legislation? Ms Hewitt: This is going to be a matter for publicans themselves to decide. Nobody is compelling drink only pubs also to allow smoking. That is a choice that publicans will make, just as members of genuine membership clubs will make. My sense is that public opinion on this, public attitudes towards smoking, are moving very rapidly. I remember not so long ago when people on every bus, almost everywhere you went there were people smoking, and that is coming down very rapidly, although it is going to be a lot faster with this legislation. My very strong belief is that by the end of three years we will have seen a further reduction even amongst the drink only pubs, and that is why I continue to believe, as I said to the BMA in June, that it is only a matter of time before we do have a complete ban. Q10 Mr Burstow: If public attitudes are moving so rapidly, surely the Government can be ahead of that public shift in attitudes and actually give a lead by having a clear and comprehensive ban in all public houses and not just those that are serving food. Why is there still this distinction? Is there an evidence base that underpins the policy, or is it just that a manifesto commitment was made as a result of the previous Secretary of State's very strong opinion on this and we are now stuck with the previous Secretary of State's position? Ms Hewitt: We are giving a very clear lead on this. This is an enormous step forward in public health and it will move within a very short space of time. It will go from about 50 per cent of employees in a smoke-free environment to 99 per cent. That is a huge step forward. But the manifesto commitment was based on a very, very extensive public consultation that you will be aware of which was reflected in the position we put forward in the Choosing Health White Paper, and that is what we are legislating for in this Bill. Q11 Mr Burstow: One more thing on this issue about the ten to 30 per cent. Charlotte has already asked you a question about how we are going to measure this over the next three years. What baselines will be set? Will there be data collected so we know absolutely at the outset of this policy how many pubs are still allowing smoking? We can then measure over the three year period whether or not, as you say, a number of those choose to become smoke-free? Ms Hewitt: Of course we will do that. Q12 Mr Burstow: So there will be specific statistics at the beginning of this process? Ms Hewitt: We will monitor this so that we can see the impact both of the near total ban that we are imposing and the exceptions. Q13 Dr Stoate: You have said that this is a huge step forward, but to most people outside it is a confusing mess which is going to be extremely difficult to police. That is the reality which I am picking up from all sorts of corners at the moment. If we have a Public Heath Improvement Bill - and in your own words you have said that the non-food bars are likely to be in the less affluent places - how can we justify better public health protection in more affluent places and less public health protection in less affluent places? In terms of bar staff, that surely must be a very difficult thing to justify. Ms Hewitt: This is an enormous step forward because, as I was saying earlier, it is going to mean that virtually every workplace and every public place that we go to every day will be smoke-free. That is going to make it much easier for smokers who want to give up to do so, often supported by our stop-smoking programmes, it is going to reduce dramatically the number of people who are exposed to second-hand smoke, but we also need to recognise that of course the great majority of deaths from second-hand smoke are the result of smoking that takes place in people's own homes; and I have not heard anybody suggesting that it is an appropriate role for government to ban people from smoking in their own homes. What is important is that we create and reinforce a public culture in which smoking is no longer the norm and we help people to give up smoking, if they want to do so, through the stop-smoking programmes but also through this Bill. This will save over time thousands of lives. Q14 Dr Stoate: I could not disagree at all, in fact; that is absolutely true. Why then have any exemptions at all? If we know this Bill is a public heath measure and the Government's role is to protect the public's heath, why bother with exemptions of any sort? Ms Hewitt: For exactly the reasons that I have outlined and that we set out in the Public Heath White Paper following that public health consultation, because we are trying to strike a balance here between protecting all employees, including the bar staff in the non-food pubs and the membership clubs, and respecting the rights of a minority, but significant minority, of adults who say, "Look, I can smoke in my own home and if I am going to my working men's club down the road or to a pub which is not serving food and I am not upsetting people who are having a meal, I also want to be able to have a cigarette with my drink." It is a difficult balance to strike. There is not a perfect way forward on this, but this, I believe, is the right way forward in the light of the manifesto commitment that we all gave. Q15 Dr Stoate: The problem is that the logic of it is the same as saying: we will only fit seat-belts for 99 per cent of cars and people who live in less affluent areas can have fewer seatbelts in their cars." If we are talking about an issue which saves lives, then it must be right to protect everyone's life to the same extent, and I do not believe that this compromise achieves that? Ms Hewitt: I completely understand, I have considerable sympathy with your view point, but these were issues that we discussed in great detail following the public consultation, and, as I say, we were trying to balance that argument with another powerful and important argument about the rights of the minority to act in a way that they choose and which it is perfectly legal for them to choose. Nobody is proposing that we make smoking anywhere completely illegal. We had that difficult balance to strike, but I do want to stress that I have brought forward the implementation date for this law quite significantly so that we get the benefits of it earlier, and we will monitor it from day one and we will have that full review completed at the end of three years so that we can then make a further judgment on the best way forward, and that is why this is such a significant step forward. Q16 Anne Milton: Decreasing inequalities in health has been a central plank of government policy, is that correct, over the last few years? Yet the partial ban will increase inequalities in health. In fact, we heard last week, and I do not know whether it is in order to quote, from Professor Dame Carol Black, "I would like to emphasise again that this partial ban would simply disadvantage the poor in this country and it would make the gap between good health for the poor and for the rich even larger." This is going to increase inequalities in health. Ms Hewitt: We have set a reduction in health inequalities as one of our major goals, and that is something that has to be achieved through a whole variety of measures. I do not want to get party-political, but I have so say it is more difficult to do that after 20 years of a government that had no interest whatsoever, indeed would barely admit that health inequalities existed never mind do anything about it. These are very deep-seated and we need to look at the much broader picture, not only this Bill, which is going to protect virtually every worker in the disadvantaged areas that I represent and in other parts of the country from second-hand smoking, but the other things that we are doing, for instance, through the neighbourhood regeneration programmes, thorough the development of health trainers, through the smoking cessation programmes, all of which will help us to reduce health inequalities. Q17 Anne Milton: I also do not want to get party-political, because I do not think it is terribly useful and I am not going to. What worries me is what you are going to do, not what has happened in the past. Do you disagree that this will increase inequalities in health? Ms Hewitt: I believe from the evidence we have had that we will see more non food pubs in poorer areas than in more affluent areas. That, as I said earlier, is one of the real disadvantages of drawing this distinction between food and non food pubs; but if we had not drawn that distinction, and we certainly looked at that option, we would have had other disadvantages. We might have had places serving food also deciding to have a smoking room, and there were arguments against that. There is not a perfect way forward on this that balances the different considerations and different rights and responsibilities. I believe that this is not only a sensible way forward but it takes us a very long way forward and we will then monitor and review it, as I have said. Q18 Anne Milton: I want a "yes" or a "no". Do you think it will increase or decrease inequalities in health? Ms Hewitt: If you look at heath inequalities as a whole, I do not think you can make that judgment, because the vast majority of people in poor areas are going to be protected from second-hand smoke in their workplace along with everybody else. Q19 Anne Milton: So you do not necessarily agree with Carol Black? Ms Hewitt: Not necessarily. I think she was talking specifically about the pubs issue, but when you look at health inequalities you have to look at the wider picture. If I look, for instance, at the most disadvantaged community that I represent and similar communities around the country. What I see is a reduction in the number of people smoking and, because of the investment that we are making in regeneration, in helping people to get back to work, in new sports and leisure facilities, in support for better health and more sporting activity, we are actually seeing a really significant improvement in the choices people make about smoking and about exercise and the other things that fundamentally determine our health. Anne Milton: Can I finish off by saying that I think we have to stick to smoking. We are talking about a partial ban against a total ban and not about other public health measures that you might be undertaking. Q20 Mr Amess: Our Chairman is rightly edgy about the time, so I will try and keep this sharp. I will not be seduced by your remarks about 18 years of inequality in the health service. I just wanted to say, I have no argument with you whatsoever about the effects of smoking, and I really do think you are entirely sincere in your endeavours. I hope you are successful in what you want to achieve and I hope you are not disappointed. My only real interest in all this is the practicality of enforcement. Many members of Parliament were very concerned about mobile phones and the effects of people's lives using mobile phones. We introduced a law. In all the parliamentary questions that I have asked it is very, very clear to me that the law is not working: enforcement is very, very poor. As you know, we are doing our inquiry; we are going to Dublin. Dublin is not like London, but I am happy to learn how it works. How do you see this working in practice: because I do not understand. If someone goes into one of these areas, they light up a cigarette. Are the bouncers going to charge in and sling them out? How is it all going to work out in practice? Ms Hewitt: Let me say in relation to Dublin, and we can come back to this after you have had your visit there, we are already starting to hear complaints about the number of people who are smoking on the pavements and dropping their cigarettes butts on the pavements as well. As I say, every course here does have some disadvantages. In terms of enforcement, I think that here, as well as in other countries that have gone for a full or a partial ban, it will very largely be self-enforcing. If you look at what has happened, for instance, in public transport where voluntary bans from the industry and the train and railway operators have been put in place, actually peer pressure from other passengers if somebody lights up generally stops them doing it, and, if it does not, the guard comes along and says, "Excuse me, sir, you will have to put it out", and I think we will see exactly the same self-enforcement from the public but also, of course, from publicans and people in charge of pubs and clubs; but, of course, we will put the detail into regulations, because the Bill, perhaps I should stress, Chairman, will have a complete ban and will then make provision for exceptions to be made through regulations. Those regulations will, of course, be subject to an affirmative procedure in Parliament, so we will have further happy opportunities to debate the detail of the regulations and then to vote on them. Q21 Mr Amess: Just to clarify, Chairman, your idea is to change people's attitudes, to change the climate. It is a little bit like with obesity: you cannot force people to eat healthily, but eventually you want the climate to change. It is not an army of enforcers. Ms Hewitt: Exactly. I think what is important here is that we are using the law to reinforce and speed up a process of social change that is already taking place but needs to take place faster in order to protect people's health. Of course there will be appropriate enforcement, including on the spot fines, but I do not expect that to be, as it were, the front-line of enforcement. I think that will be a last resort for somebody who completely refuses either to obey the law, in the case of a consumer, or enforce the law, in the case of somebody running a particular pub. Q22 Mike Penning: Secretary of State, I think any of the Committee listening to you this morning will have taken on board very much your commitment to the health of the workers within the pub industry. Clearly you would like to have had a total ban, but someone, or several people, within cabinet overruled you. You were rolled over - let us be a little more emotive about it - by others. You are Secretary of State for Health. If you wanted this ban, why have we not got the ban that you want? Ms Hewitt: I have to say, I very much regret and completely disagree with the observations you have made. What we had was complete agreement across government on 99 per cent of the policy. We had a disagreement on the specific issue of pubs that do not serve food, so we did what I would have thought any sensible organisation would do, we discussed it, and we were all in complete agreement that the right way to go forward was on the basis of the manifesto which we had all been re-elected on just five months ago and which itself had followed extensive public consultation on this subject; so I have to say I object very strongly to the personal nature of your remarks. Q23 Mike Penning: You did not at any time want or try to convince your colleagues on a complete ban so that you could protect all of the workers and the vulnerable people that you and I represent? Ms Hewitt: I have already said, there was a whole range of views on this issue and we discussed them. Q24 Mike Penning: I am not asking for the whole range, I am asking you your view. Ms Hewitt: And I have said, both this morning to the committee and to the BMA, I think it is only a matter of time before there is a complete ban and that one per cent of workers in the non food pubs will also be included. Q25 Dr Naysmith: Secretary of State, I apologise for being late. I had to be in the Chamber to ask a question, so I may have missed something that you said earlier on and I apologise if I have. This is a very simple question. This is a public health measure about people inhaling other people's smoke. All of the experts, virtually without exception, the royal colleges, nurses, everybody who normally speaks about health, says that a complete ban would be the right way to go. On the other side we have got the beneficiaries of the current sale of tobacco: the leisure industry and the tobacco industry. Can you tell me another public health measure where the beneficiaries of cutting something out or controlling something are the ones who seem to be controlling the measures you are about to bring in? Ms Hewitt: With respect, that is not the balance that we were trying to strike. The balance that we were trying to strike in the White Paper that followed very extensive public consultation then in the manifesto and now in this Bill was a balance between the need to protect employees from second-hand smoke and the rights of a minority, but a significant minority, of people who do smoke - it is perfectly legal to do so - and want to be able to have a cigarette with their drink, and that was the balance that led us in the White Paper and then, of course, to your party's election manifesto to make the proposals that we did. We looked at other possibilities, because within government, and I have to say across the country as a whole, I think there is agreement, certainly in government total agreement, on 99 per cent of the policy, there is disagreement on one per cent; and while I completely understand the position of the medical profession and the anti-smoking lobby on this, we should not allow the disagreement on the one per cent to mask the very real step forward on the 99 per cent. Having said that there is such widespread agreement, of course we do not yet know what policy, if any, is going to be adopted by the Conservative Party on this subject. Q26 Chairman: We do not have to look at the issues in terms of party politics. Secretary of State, you do know that we are starting to inquire into this matter. Ms Hewitt: I do indeed. Q27 Chairman: I wonder if this Committee could be given the opportunity to be able to report to the House before the House takes final decisions in relation to the Bill that is about to be published today. I know that is not in your hands, but I say that publicly and hope that maybe the whips are listening to what I have just said here. Ms Hewitt: We will do our best, certainly in terms of the regulations, to facilitate that so that you can, if you wish, give us your views before those regulations are submitted to the House. Q28 Chairman: I was very interested in that comment. Sadly, affirmative regulations are not amendable. Nevertheless, I am sure that the Committee would want to give you our opinions on these regulations as and when they come along. Ms Hewitt: And before we draft them perhaps. Q29 Chairman: Thank you for that. That was the add-on question to what we wanted to go through with you today. It has taken us some 36 minutes, Secretary of State! Could I now just ask you what exactly do you mean by a "patient-centred" or "patient-led NHS"? Ms Hewitt: When we talk about a patient-led NHS this is not a slogan or rhetoric, it is a vision of how we want the NHS to develop. I think, as this Committee knows better than many, because of the investment that we have been making in the NHS and the reforms that we have been making, we have already seen enormous improvements, particularly in waiting times coming down, but we are only halfway through the NHS improvement plan and we are still a very long way from meeting public expectations in our health service or, indeed, keeping up with the extraordinary changes in medical technology, and that is why we need to continue with the reform as well as the investment so that we give people more choice and more control over their health and care, we have a greater variety of providers with more freedom to innovate and improve services, we have GPs and primary care trusts acting as a strong voice for patients and particularly bringing more services out of acute hospitals and into the community and, finally, we get better value for money for all of us as taxpayer and contributors as well as users of the NHS, and that is what we mean by a patient-led NHS. Q30 Charlotte Atkins: I know that you have said that your priority is to engage and empower people and, as you have just said, develop a patient-led NHS, but how does that square with destroying local patient-focused PCTs and creating, in some circumstances, giant county-wide PCTs which are even more remote than the old health authorities that we got rid of? Ms Hewitt: No decisions have been made yet on the future boundaries of primary care trusts, but what was very clear as I looked at this before the summer was that we already had several primary care trusts who were talking about merger but had not been allowed to merge, we had other primary care trusts that were struggling to get the staff that we needed and what we need as we move into this next stage of NHS improvement is strong primary care trusts who can, amongst other things, hold acute hospitals to account, ensure that acute hospitals do not dominate the health service, as they tend to dominate every health service, and run away with the money and that, therefore, primary care trusts, working with the GPs and with the hospitals, can pull their services into the community, which is both more convenient for patients but very often gives you better health outcomes for less investment; so it is exactly what we want. That is why we have asked the strategic health authorities and the primary care trusts to look at their structures and see whether they really will work for the future. We have had in the last week or so the proposals back from the health authorities - my officials are currently looking at them; we have an expert panel to help us make judgments on them - but each of those proposals will be assessed against the five criteria we set out, and, as I think we made clear in that but I have also said publicly since, where the proposal is to merge PCTs perhaps into a very large one, the question I will be asking is exactly the one you were asking: how are you going to keep the local focus and the real understanding on the different needs of different communities? Where they are proposing to keep quite small areas and existing boundaries, then the question will be, if you like, the other side of the coin: how are you going to get the weight to the expert commissioners, particularly in relation to acute hospitals? Different areas will have different answers to that, and I have made it clear that one of the criteria - it is not the only criteria but a rather important one - is the PCTs working very closely with social services authorities so that they can also build on what they have already done and get an even better integration of health and social care, and we will make area by area decisions here. This is not being imposed in a top-down, one-size-fits-all way from above. Q31 Charlotte Atkins: Secretary of State, we have had so much change in the NHS over the last 20 years. Is this not a change too much affecting the moral of staff in PCTs and in the community? What would it mean? What would it cost in monetary terms and what would it cost in terms of destroying local partnerships? Ms Hewitt: I do not believe that this is going to destroy local partnerships. That is the opposite of what we are trying to do here. We want to build on strong local partnerships that have been created in many places, but I am very aware of this desire to stop change and the change fatigue, if you like, that you were talking about. If we had been able to move forward in the way we need to without any organisational changes, that is what I would have done, but as I looked at this and listened to the primary care trusts and, indeed, HSAs themselves, it was very clear that we did need to make some changes. For instance, if you look at the proposal that I understand has been made for a single strategic health authority in London, I have certainly not yet been made aware of any objection to that all. In many cases, including my own city where the two primary care trusts are proposing to merge and will then be coterminous with the city social services council, the primary care trusts are leading the way in making these proposals. We will look, my ministerial colleagues and I, at each of these proposals and we will want to see how they match up against the criteria we set out, which I think everyone agrees with, but also, was there proper consultation with the primary care trusts themselves and other key local stakeholders, and if we are not satisfied with the proposal, then it will not go out to consultation. Where a proposal does what we asked people to do, then it will go out for a full statutory consultation in which, obviously, local members of Parliament, as well as everybody else of local interest, will be involved. Q32 Charlotte Atkins: At Health Questions this week you stated that community health staff will continue to be directly employed by PCTs unless the PCT decides otherwise. This seems to me to be a very welcome U-turn that PCTs will continue to be providers of healthcare. Would you comment? Ms Hewitt: It was designed to be a clarification of what we had said in Sir Nigel's letter of 28 July. I know there has been real concern amongst a number of clinical staff, staff based in the community and employed by PCTs, and that is why I have made it clear publicly but also directly to the NHS themselves and, of course, to the unions and professional associations that staff in the community who are now directly employed by PCTs will continue to be employed by their PCT unless and until the PCT locally decides otherwise. We are in the process of a very major consultation, leading up to the White Paper around the end of the year, which will set out the broader policy framework, but any change in services locally, of course, would have to follow full public consultation and consultation with the staff and their organisations in the usual way. Q33 Mr Burstow: It is interesting, because looking at the exchanges at Health Questions on Tuesday, that was a very helpful clarification that was given to several members who asked about it, but it was puzzling when I then looked at the written statement that was made on 18 October, and, more importantly, the chronology of commissioning of patient-led NHS which was deposited in the library as part of that written statement, because in there it says, and I will just read two extracts from two different periods - from 28 July 2005 it says this, "These new PCTs would concentrate mainly on commissioning services and would divest the majority of service provisioning in order to achieve this." It goes on to say under 14 September, "This consultation is the Your Health, Your Care, Your Say Public Consultation, and the resulting White Paper will be used to inform the process of divestment of services from PCTs in line with the wishes of patients and the wider public." So is it entirely the case that this is a decision for the PCT, or is it, indeed, the case that we have a process that will be led through the Department that will use the consultation that is currently going on to provide the context in which PCTs will have to divest themselves of services? Can we clear up this confusion: because there are very clear statements there in your statement of 18 October which appear to contradict what was said on 25 October? Ms Hewitt: I hope that I have clarified this issue in relation to staff. What we stressed in the letter of 28 July and continue to stress is the importance of commissioning as well as provision. In other words, we need strong primary care trusts working with their GPs, and presumably we will want to come on to practice-based commissioning, to ensure that we have got the best possible services for patients and users within each community, and that includes PCTs who are strong enough not only to hold GPs to account but also to challenge and hold their acute hospitals to account; and there needs to be a greater focus on that commissioning function because it will be increasingly important as we move forward in the improvements we are making to the NHS. The other point I would make, which I think we made on 28 July but which we certainly made in a variety of places, is that we already have a variety of different models for community service provision around the country. Brighton and Hove is one example of a community where the primary care trust only does commissioning and the community, clinical and other staff are employed by a care trust. There are some other primary care trusts moving in the same direction. There are others who have decided to have an internal separation so that they have a strong commissioning arm looking at what is it that people in this area really need and how do we get the best pattern of services, and then, within the same organisation, a strong the provider-arm making sure that they are the best people to provide the particular services that they are engaged in. There will continue to be different models in different places, and one of the things we will do in the White Paper is set out the policy framework for that, but the local decisions that will then have to be made following the White Paper will all be designed to build on the strengths of what is happening in each community but do more building on best practice in other places as well. Q34 Mr Burstow: That is a very useful answer, but it does not feel to me as if it is the answer to my question. My question was directing you specifically to the statement you made on 18 October, the written statement, plus the chronology. The chronology says quite specifically that PCTs would diverse the majority of service provision in order to achieve the focus on commissioning, which you have been talking about. How can that be squared with an undertaking just a few days later given in the House that most employees of PCTs on the service provision side will continue to work with PCTs? I do not see how what is said on the 18th squares at all with what is said on the 25th. Ms Hewitt: Simply because different primary care trusts will want to make different decisions and they will be able to do so within the framework of the White Paper which, of course, has not yet been decided on but on which we are consulting. Q35 Mr Burstow: Which would mean that in fact the undertaking could not be given because you cannot possibly know what the outcomes will be? Ms Hewitt: The undertaking most certainly could be given, because the staff delivering those clinical services in the community will continue to be employed by their primary care trust unless and until the PCT decides otherwise, and, as I have just said and indeed said in the House, this is not going to be top-down, one-size-fits-all, it will be different models in different places depending on local circumstances, depending also on what staff themselves want. We had at least one primary care trust where the district and community nurses have led the way in creating what is going to be an employee run cooperative, a social enterprise that will deliver the care services that are currently delivered by the PCT - so that is yet another model - and within the framework that we set out in the White Paper there will be scope for all of these different models depending on local decisions. Q36 Mr Burstow: It is therefore not true that the majority of PCTs will be divesting themselves of the majority of service provision? Ms Hewitt: That will depend on decisions by the PCTs themselves. Q37 Mr Burstow: One other thing which is coming up from one of the strategic health authorities who are looking at the request by Sir Nigel at the end of July was a proposal that they are making in Oxfordshire to look at effectively outsourcing the commissioning function. One of the concerns that has been articulated from those who have a responsibility for scrutinising that level is that there does not appear to be any commitment to public consultation around that. That is the first concern. I hope you can say whether or not there will have to be public consultation about such outsourcing, but can you also say, in such a circumstance where outsourcing and commissioning is taking place, just how public accountability for that will be achieved: because one of the regular answers that I get in written questions when I ask about services that have been outsourced is that much of its activity is then covered by commercial confidentiality. How will we be able to ensure that there will be the same level of transparency for outsourced commissioners as those that are still in-house? Ms Hewitt: On the first point, no decision as yet has been made. That proposal has come to us from the strategic health authority. We are looking at it at the moment along with the various proposals that have been made on boundaries, and we will then make a decision about whether or not that proposal should go forward. If it does, it will be subject to the usual three months' public consultation. On the second point, it is absolutely essential, if the commissioning expertise that is needed were to be obtained from outside the organisation in the way that I think Oxford is proposing, the responsibility for the commissioning decisions would still rest with the board of the primary care trust. It is the board, the publicly appointed board of the primary care trust, who in every case will be accountable and responsible for commissioning decisions, and they will therefore be responsible and accountable not only, of course, to their local community but to Parliament as well, and that, I think we are completely agreed, is essential. Do you want to add anything? Sir Nigel Crisp: No, I think that last point is really the big point, is it not? It is not actually outsourcing governance; it is actually some functions of management and commissioning within the normal government structure. Q38 Mr Burstow: On the issue of access to information and transparency in terms of reporting, for example within the Alliance Medical contracts arrangements, it has been very difficult to obtain any of the performance measures that are used for the management of that contract. The answers have always been that it is commercially confidential. Will that apply, first, to board members, but, more importantly, will it also apply still to members of Parliament when it comes to asking such questions? Ms Hewitt: I do not accept that criticism either of Alliance Medical or, more generally, of independent sector arrangements, and I think we have to distinguish two things. There is commercial confidentiality around the price for a particular contract, and Alliance Medical and any other independent sector provider is subject to exactly the same quality and inspection regime, exactly the same requirements for the registration of medical and other healthcare professional staff; and, indeed, in the case of scanning services, we now have a clinical guardian, a respected leader in radiology, supervising that. I think one has to distinguish between the price, which does need to remain commercially confidential, and the quality of what is being provided, where, of course, we need to have proper supervision. Mr Burstow: I have got to stop, because others need to ask questions, but in an answer that John Hutton gave to me on 23 February, he said that the KPI data contains information on a number of scams to deliver timeliness, quality and customer satisfaction. He went on to say that the Alliance Medical provide a full report on activity and projections, including reasons for this and referring bodies and NHS leads in the local NHS health economy. This information is commercially sensitive and may include information on patients which is confidential. So, in attempting to get the KPI data, the then Minister of State was denying access to that information, so it was impossible to evaluate how effectively the contract was being delivered. Surely that cannot be an acceptable way of running those services? Chairman: Secretary of State, this is obviously an area that we will want to cover because, as you know, we are looking at this in a separate inquiry. I wonder if we could have a note on this issue of confidentiality and commissioning so that it can inform us in terms of our inquiry that is taking place. I think John has a very brief question on this and then I would like to move on. Q39 John Austin: I very much welcome, Secretary of State, your statement today that where PCTs wish to continue to provide direct services they will be able to do so. That does seem to me to be, if not a U-turn, a different interpretation than the document which Sir Nigel set out on 28 July. I would ask for further clarification on the point in that document which says, "Where PCTs continue to manage services, decision-making on commissioning and on provision will be separated in order to enhance contestability". I would like to know what that means and whether that gives any reassurance to those staff who are engaged in the direct provision of service at the present time. Ms Hewitt: The goal here for all of us is to get the best possible services for patients and users in each area and the best possible value for money, and the framework that we are now developing, which we will set out in the White Paper, will take us further forward on this whole issue; but the advantage certainly that has been put to me by various Chairs and Chief Executives of primary care trusts in having that internal separation is that you have one person, a director of commissioning, really focusing on what it is that patients and users need within a particular area; and in most parts of the country there are already a variety of providers - the PCT itself, possibly a care trust, the local authority, voluntary organisations, sometimes the private sector - and then you have a director of services, if you like, within the primary care trust, if that is the structure that they have got, focusing on how the particular services they are running can be the best available, but all the time, I think, both in the policy framework and when PCTs are making decisions, the focus has to be on the best possible services for our public, for our patients and our users. Q40 John Austin: I think we will go into this when we come into the inquiry further on local decision-making, but given the hassle that you had, and I think you have to accept you had a bit of a hassle over the PCT document, I would like to ask a brief question about the timing. Was it really sensible for Sir Nigel's letter to be sent to PCTs two or three days after Parliament had risen, given only until October, before Parliament returned, an opportunity to come forward with complete proposals for restructuring, for implementation the following year certainly at a time not only when members of Parliament were not aware until the middle of August but also when key personnel within the PCTs who would be responsible for providing a response would have been more likely to have been absent because of the summer recess? Ms Hewitt: I completely understand and accept your frustration on that point. We wanted to have it ready earlier - we wanted to get out before the summer break - not least so that parliamentary colleagues could have been properly involved. It simply was not ready in time and that was just, I am afraid, one of those things that does sometimes happen, particularly after an election and a reshuffle when where there has been a change of people. It is very frustrating, but what I did not want to happen was a lengthy, drawn out process on this issue of possible boundary changes or mergers, and so on, because, as we know, there is a real risk, if you drag that out for a couple of years, of people taking their eye off the ball of improving services, and that is why we decided we wanted a very short period for the initial discussions and proposals to come to us so that we could look at them against the criteria that we set out, followed, obviously, where those proposals are taken forward, by the full three-month consultation. There are not going to be mergers or changes in every single part of the country. Although there will be issues in some cases, and there are some that I think may be quite difficult to arrive at a final decision on, we should not assume that is the picture everywhere, it certainly is not. Q41 Dr Taylor: Secretary of State, can we move on to patient choice. During the last Health Committee we had a very slick demonstration in Richmond House of how it would work in theory. So often slick demonstrations are good but it does not actually work. The uptake has been fairly slow for many reasons. Could you tell us what lessons you have actually learnt from some of the pilot trials of Choose and Book? Ms Hewitt: I was just going to check that you were referring to Choose and Book. We have now got 85 per cent of GPs registered with the Choose and Book system as of this month. Q42 Dr Taylor: With the up-to-date equipment to be able to do it, the correct IT? Ms Hewitt: Let me just go through the different figures there, I just want to make sure I have got the right ones in front of me. We have got 85 per cent of GPs as of this month registered to use the Choose and Book system. We have got more than 90 per cent of the main GP practices with an upgraded broadband connection. We have got two-thirds of the hospital trusts who have gone live and are accepting bookings. We have got 35,000 of the PCs that are now compliant with the higher standards, so still quite some way to go in terms of the configuration of the actual desktop PCs. We have got over a third of trusts that have gone live with the indirect booking service. I am aware that is a lot of different figures but I want to distinguish between the patient choice of at least four hospitals, which will be available from December, and the electronic booking service which will be available in some places, is scaling up rapidly but still has a further way to go over the next year. Q43 Dr Taylor: So the patient will be able to choose but not book? Ms Hewitt: No, both. The patient will be able to choose but where the electronic booking service is not yet operational the booking will be done over the telephone or in whatever way suits. The booking will be made but not necessarily by Choose and Book immediately. Q44 Dr Taylor: Have you learnt any lessons from the few pilot sites that have made you change the methods in any way? I do not mean the machinery doing it. Ms Hewitt: Indeed, one reason why there has now been an upgrade to the software and so on is precisely because in the earlier doctor pilots, the GPs and the people using it found improvements that could be made to the software and so on. That is absolutely normal; it is why you do an initial roll-out, a beta release if you like. There have been improvements made and that is why the software is now being upgraded. Q45 Dr Taylor: I believe it is only possible to choose a given hospital. I hate to go back to the good old days but it was the GPs who knew the consultant they wanted somebody to see. Under Choose and Book, can you specify a consultant within a hospital who you wish to be seen by? Ms Hewitt: At the moment it is designed to specify a hospital and we have got two-thirds of hospital trusts with their necessary booking systems to connect to the GP Choose and Book service. The GP in each case is going to be talking to the patient about where they want to go and if it is appropriate to refer to a particular consultant, the GP will be discussing that with the patient as well. Q46 Dr Taylor: I suspect in our constituencies we have all had examples of booking clerks actually changing appointments and changing consultants without the consultant or GP being told. Is there any way you are going to be able to stop this so that it is not just a booking clerk who changes the consultant to whom a patient has been referred? Ms Hewitt: Trying to get perfection in these matters I think is very difficult. My feeling is that as we shift the whole culture of the NHS towards being patient-led rather than provider-led we will get more and more of these things right, but it is about culture change far more than it is about IT systems although it is very important to have good effective IT systems underpinning it. It really is just worth saying that as one of the GPs who is using this has said, for every GP or computing press commentator who has written this off, most of whom have never used the system, there are many, many more who are using it and finding it very useful. Q47 Dr Taylor: Let me just tell you what is happening on the ground sometimes. If a given consultant is popular his lists are very full and the clerks stop booking any more for this particular consultant because it is going to take too long and contravene the targets and, therefore, clerks move them on to a surgeon who at the moment perhaps is less popular. How can one counteract that? Ms Hewitt: One of the issues we need to look at is whether it is desirable for patients who, having discussed it with their GP, want to go to a particular consultant, even though we have got very long waits, are able to do so even though that might break the six month or, indeed, in future the 18 week target. We are looking at it. Nigel, do you want to add to that? Sir Nigel Crisp: I would like to make two points. The electronic system does allow people to see the clinic schedules and to see who has been booked, so you have got a straight feedback but, as the Secretary of State says, that will not necessarily happen everywhere to start off with. Q48 Dr Taylor: The schedules will show the names of the consultants and the lists? Sir Nigel Crisp: Thursday afternoon 4pm or whatever. You will be able to see the schedule and who has been booked. Ms Hewitt: Instead of the patient being told in a sometimes faded typed letter "You will turn up, probably in several months time at some time that is probably very inconvenient to you", the patient will choose when to go from as wide a variety of choices as we can possibly make available. I think that is a real step forward. Q49 Dr Taylor: The GP will still be able to help the patient make the choice? Ms Hewitt: Of course. It is a really important role for the GP to fulfil. Q50 Dr Naysmith: Secretary of State, continuing on the Choose and Book system, I wonder whether any of the pilots you have run have taken account of the fact that some hospitals and, as we have just been hearing, some consultants may well turn out to be much more popular than others. This could have two effects. It could have the effect of making hospital waiting lists get longer and longer again after we have spent so much time, effort and finance getting them down. That would be a great problem. Possibly the other more important effect could be that some hospitals and, indeed, as Richard says already happens, some consultants can be less popular than others and you could end up with hospitals in deficit because the money is following the patient, as we know now, and you will have real problems with individual hospitals in individual areas perhaps cutting services and closing because they are not being referred by the people who know which are the best places to send their patients. Ms Hewitt: As I have said, patients are going to discuss this with their GPs. In some cases I think the patient will simply want the GP to make the choice for them and in other cases the patient will want to look at the information, discuss it with their GP and make the decision taking into account all the factors. There will be information available to patients starting from Christmas about not only the waiting lists but, for instance, the MRSA rates and so on in different hospitals. That will build up until by the end of 2008 there will be a choice of any hospital across the country that is offering that particular treatment to an NHS quality and at an NHS price. Far from risking an increase in waiting lists, this goes alongside and will help us to achieve the hugely ambitious 18 week end to end target. I do not know whether we are going to come back to that, Chairman, but perhaps I can just draw your attention to a consultation that we are putting out to the NHS today about the details of how we deliver on that 18 week target. On the issue of which services will people choose, I think it is absolutely right that people should be able to exercise choice when they want to of which hospital they go to for a particular procedure. I am not going to force people. Q51 Dr Naysmith: I understand, and I want that to happen as well, but what I am really talking about is the inevitable consequences that we could end up with if we have only got one hospital in an area which may well be the most popular one and the one that most people want to go to, or it could be the opposite and it will produce adverse perverse effects. I am not really talking about the choosing and booking, that is great, it is the possibility of perverse effects that exercises me at the moment. Ms Hewitt: I think as patients start to exercise these choices we will see in some cases some departments of some hospitals not getting as many patients as they used to get when patients did not have a choice. Q52 Dr Naysmith: So what do they do? Ms Hewitt: They will then have a pretty strong incentive to improve their service and get patients to come to them, or they may decide that is a particular treatment or specialism that they should not be doing because they cannot do it well enough, in which case they may well decide to move out of that particular treatment or to work with the primary care trust and the GPs and move it into the community and have a different configuration of services. We are going to have to look at this case by case. In the extreme case, and obviously people have raised it, where patients going to a different hospital risk destabilising an essential service, and particularly, of course, A&E, then that is something where the primary care trust and, if necessary, the strategic health authority would be picking up the very early warning signs in order that you stabilise the service, you make the necessary improvements and you protect A&E. Q53 Anne Milton: Just to carry on from this and move from hospitals down to doctors. We could get a situation where people are prepared to wait because Dr A is brilliant, they all want to go to him, so they will wait maybe six months, whereas Dr B has not got any patients for half the week. Where will we step in? Where would you envisage stepping in in a situation like that, or where will the PCT step in? Ms Hewitt: This new NHS, if you like, is going to be driven in many respects by patient choice. Q54 Anne Milton: Yes, I know, that is what I am talking about. Ms Hewitt: If you have a particular doctor or consultant who simply cannot attract patients then I think the management of the hospital will draw the necessary conclusions and either find a way to improve the service or do something else. Q55 Anne Milton: Or sack him or her. Sir Nigel Crisp: May I suggest an alternative which we have already actually seen, which is a hospital in London which was finding it difficult to run a good paediatric service, partly because it was finding it difficult to recruit staff, so it was a slightly different reason why it had a problem. It has now done a deal with Great Ormond Street so that Great Ormond Street will provide the paediatric services on that hospital site. I think that is another sort of response that we will see. If the hospital over there is running services very well and attracting patients in whatever speciality that this one is not then you may see they want the people there to come and work on their site as well. Q56 Anne Milton: I was taking it down to the individual doctors. I think competition can be very useful, as you know it is right in line with what we as a party support. It is what would happen in a hospital between individual doctors where it would create interesting tensions and maybe some difficulties in terms of terminating people's contracts. Sir Nigel Crisp: You would need to find out why that person was not getting the patients, would you not, and then take the appropriate action? Ms Hewitt: You would indeed. You would need to look at whether there was an issue about clinical quality or what is called in the jargon the patient experience and how this doctor was treating patients, what was causing the problem, and then I would have thought the consultant in charge and the hospital management would want to put in the necessary support and training to try and improve the performance. Ultimately, if that could not be improved, and this happens already, then, yes, you might well decide that you are no longer to employ that individual. There is not much of the press left. I do want to stress that is a rather extreme example, I do not think this is going to be the norm. Q57 Anne Milton: It will be interesting when patients have this power to see what happens to individual doctors. Ms Hewitt: That is part of the shift from a provider-led NHS to a patient-led NHS. Q58 Mike Penning: Secretary of State - I am sure this will not surprise you - if we could move on to deficits. I wonder if I could ask you some short questions with some short answers. When was the decision made that the strategic health authorities would be instructed not to allow the deficits to continue in the way they have done in the South East in particular? Ms Hewitt: If I look at the position with deficits, we have got a minority of hospitals and PCTs that had a deficit at the end of the last financial year and in each of those cases, but particularly where the deficits were largest, the strategic health authority has worked with them to agree a financial recovery plan to get the deficit under control. What has been happening over years in the NHS is that some areas have been pretty consistently overspending compared with their budgets and those deficits have been matched by surpluses, under spending in other parts of the country. It is not universally true but, on average, the deficits have been occurring in the healthier and wealthier parts of the country and the balancing surpluses have been in the poorer parts of the country with much greater health needs. What is now happening is we are seeing very clearly with much stronger financial management where the deficits are occurring appropriate financial recovery plans can be put in place, but with more money going into every primary care trust than ever before we expect each of them to sort themselves out if they do have a financial problem and get themselves to a position where they are in balance year on year. Q59 Mike Penning: With respect, that was not the question. You have not answered the question. When did your Department tell the strategic health authorities that you would not continue with the deficits on the basis they are running for this year and for next year? There was a meeting that took place in the Department ---- Sir Nigel Crisp: Let me explain. There are never meant to be deficits and we tell them that when we set the budgets every year. Q60 Mike Penning: So the meeting that took place on 4 May, the day before the General Election, when you met the chief executives of the strategic health authorities and told them you would not allow them to meet their expenditure plans for the following year did not take place? Sir Nigel Crisp: I meet with the chief executives of the health authorities once a month and we discuss how we are collectively managing the NHS. Probably 4 May would be about when we were signing off or not signing off plans. My reply is that every year we sign off people's plans or we do not sign off people's plans. If you are telling me it was 4 May that we signed off or refused to sign them off then it was 4 May. Q61 Mike Penning: What was the size of the deficits across the board then? Sir Nigel Crisp: Let us just remember what we are talking about here. These are budget forecasts. These are people coming forward with what they believe their budget forecasts will be. I do not know if you know the process. Q62 Mike Penning: I know the process very well. Sir Nigel Crisp: You get local delivery plans that come in, the health authority scrutinises the local delivery plans and the local delivery plans are then brought forward to the Department of Health and amalgamated across the SHAs. I cannot remember what number we were looking at at about that point, I just do not know. Q63 Mike Penning: I find it astonishing that we are having this discussion because obviously deficits were going to come up but you cannot tell us what the figure will be. Sir Nigel Crisp: You asked me what figure the health authorities told me on 4 May. Q64 Mike Penning: My strategic health authority for Herts & Beds this year is just under 100 million. That was last year's figures carried forward with these figures this year. Sir Nigel Crisp: Are you talking about their month five forecast? Q65 Mike Penning: I am talking about figures carried forward from last year, which according to them are some 47 million carried forward into the projected forecast for this year of 48. Sir Nigel Crisp: What date is the forecast? Q66 Mike Penning: The forecast was done as on 4 May. Sir Nigel Crisp: It is not the latest forecast. The forecast changes every month. Q67 Mike Penning: I appreciate that, but what the Committee is trying to get to is the size of the deficit problem within the UK. It is all well and good you saying there are no deficits but there are real crises taking place in some areas, particularly in the South East, where there are massive cuts to expenditure being made within trusts and within PCTs. That is because of the budget problems which are taking place, which are called deficits. You can call them whatever you like but at the end of the day they call them deficits. What I am trying to get through to you is traditionally these deficits or overruns, whatever you want to call them, have used the NHS bank to purchase in help from elsewhere. Sir Nigel Crisp: This year as well. Ms Hewitt: If we can just clarify this. At the end of the financial year, in other words for 2004-05, the audited accounts show an overall deficit of around 250 million, less than half of one per cent of the total NHS budget. For this year, nearly half way through the year, as Nigel has said we are looking month by month at the forecasts within those trusts and health economies that have either got carried over deficits or are projecting deficits for this year and we making sure that in each area where there is a sizeable inherited deficit or a sizeable forecast overspend for this year they get them under control because it is not acceptable with more money than ever before going into the NHS to have overspending on the scale that we have seen building up in a very small minority of trusts when the majority of trusts are both improving services and living within their means. We expect everybody to do that. Q68 Mike Penning: I know my colleagues want to ask further questions. To get them to live within their means means in most hospital trusts, in particular the West Herts Hospital Trust that I can speak of, they have got massive cuts in frontline services. Where you have been talking about patient choice, that choice is being cut back because departments are closing, nurses are being made redundant and wards are closing. Is the only way you can hold trusts within their budgets by cutting frontline services? Sir Nigel Crisp: Let me just draw out two things. One thing is this year, as in previous years, some parts of the service will provide surpluses and we do have some informal arrangements around the NHS to support people because where you have got a major financial problem, as you have got perhaps in that particular hospital, the longer the time you can sort it out over the better. That hospital has had a problem for two years, I think. Q69 Mike Penning: It is a trust of three hospitals actually. Sir Nigel Crisp: I meant trust. I know that it has received support in the past. The point I would make is if you do not have financial balance you cannot plan. We have to make sure that we get ourselves into good financial balance so that we can plan effectively for the future. Q70 Mike Penning: The point I am making is that the patients are suffering. At the end of the day it is the patients who are suffering and our constituents in the South East in particular who cannot get the treatment that they deserve. This argument about choice is fictitious if they cannot get the services they deserve. Ms Hewitt: In every part of the country, because of the investment that has been going in and because of the reforms, the quality of service and the speed of service has been improving very, very significantly compared with eight years ago, and that will continue to be the case. I think it is a great mistake, with respect, to assume that the existing organisation of services is always and inevitably the best that it can be. Very often it is far from the best and it is very clear, not only across the NHS but across health services in developed countries generally, the most financially efficient hospitals and health communities are also those that deliver the best quality patient care. In many cases, part of the answer to these overspending problems and these financial management problems is to reorganise services in a way that is not only more cost-effective but, much more important, is going to be better for patients as well. Q71 Chairman: Could I move on. Could I just ask, Sir Nigel, in terms of inherited deficits from the year before and this year's budget, is that type of enforcement you are following this year different from what it was last year or the year before? Sir Nigel Crisp: Why it has got a higher profile at the moment is that in the two or three previous years we were in surplus by 100 or 200 or 300 million. Q72 Chairman: Not all trusts from what you have just said in answer to my colleague, Mike Penning, in some trusts there were deficits. Sir Nigel Crisp: In previous years that is right. Q73 Chairman: This year's enforcement getting them into balance, is that different from last year? Do you understand where I am coming from? Sir Nigel Crisp: Yes, I do. Are we being tougher this year, is that what you are really asking? Q74 Chairman: Yes. Everybody would say you need to keep your books in balance, but if you say, "Your books will be in balance by the end of this financial year", it has a different meaning from saying, "You need to keep your books in balance". Sir Nigel Crisp: Let me be clear. The situation has changed a bit because in the previous four years the NHS overall was in surplus and, indeed, we were criticised for being in surplus as you might recall. Q75 Chairman: Yes. Sir Nigel Crisp: This year we were slightly overspent, as the Secretary of State has said, and that changes the circumstances, does it not? It makes it that much more important that we get a tighter financial grip. That is the one thing that has changed. Q76 Dr Naysmith: I think there is a very important point here which this Committee in its previous incarnation had something to do with. About three years ago we had the Financial Director of the NHS here and we had a big exchange about how deficits were handled in the National Health Service up until about three years ago because trusts could lend money to each other. Those that were in surplus could lend money to the ones who had a deficit, which meant you could cover up these deficits at the end of the financial year. We got a commitment given to this Committee that that was going to stop and it would not happen any more. I suspect that may be part of the reason why we have exposed trusts which may have had problems for a long time. Is that what we are talking about? Sir Nigel Crisp: There are two things. That is certainly true, we have said deficits should lie where they are created. That does not mean that we have not also created an NHS bank so that in certain cases where we think there is a strategic reason then we will allow surpluses to go and support another area, and Herts & Beds had some of that money in a previous year. The second point is that the whole regime has also got tighter because the Treasury has changed the rules within which we work so that you cannot under spend on capital to bail out your revenue, for example, which is a perfectly sensible change but it does make it harder. The environment is tougher. Chairman: I really want to move on. Could I ask you if you could drop us a note in relation to this and what is happening this year and potentially how it is a bit different from last year. I think the Committee would quite like to look at that. Can I move on to Howard. We have not quite finished on PCTs and commissioning, Secretary of State. Q77 Dr Stoate: Can I just direct the Committee to the Members' interests where I declare that I am a part-time general practitioner and, therefore, have a particular interest in what I want to ask which is around practice based commissioning. Could you tell me what is the purpose of practice based commission? Why is it being introduced? Ms Hewitt: We are introducing it because we want GPs to have the responsibility and be accountable for the decisions that they are making which are about expending public money, but also to have greater freedom to design the services that they think will be best for their patients. At its simplest, practice based commissioning means that each GP will have an indicative budget which will include, in other words, the budget for hospital referrals and they will get from their PCT each month a report showing the hospital referral rates and, therefore, their expenditure against their indicative budget but also benchmarked against their peers. As I think happened in the past with prescriptions, there is a real incentive there for GPs to look at their referral patterns, look at how much money they are putting into the local acute hospital and then, if they want to, start thinking about how they might pull some of those services out of the hospital either into their own surgery or perhaps into a community hospital or some other community facility in order to get the services they want for their patients closer to their patients, but also with better value for money. Q78 Dr Stoate: They are not actually responsible for these budgets then, they are just indicative budgets, it is not real money. Ms Hewitt: We are talking about indicative budgets here. Q79 Dr Stoate: How is this different from fund holding in principle, not in the practicalities? What is the principal difference between this and fund holding? Ms Hewitt: There are two biggest differences. One is this will apply to everybody whereas, of course, fund holding created a two tier system. Secondly, we will not have each GP negotiating with each hospital and, worse still, negotiating on the basis of price. There will be a single tariff set through Payment by Results for hospital treatments and procedures and there will be a single national contract which the primary care trust will be able to make some local variations to if that is what they and their GPs decide to do. There will be none of that incredibly expensive and wasteful negotiation and administration that fund holding involved. If I can say, there is one similarity with fund holding. I think the virtue of fund holding was that it gave some GPs the opportunity to make some really good changes in their services. If I can give an example from a GP colleague in Leicestershire, who was saying "We looked at what we were doing with the hospital. We decided to appoint our own physician, so we have cut the hospital referral rates and we saved some money. We then decided to employ a physiotherapist, we cut the hospital referral rates and we saved some more money". That kind of freedom to innovate, which some GPs want and some may not, is a real advantage that will come with practice based commissioning. Q80 Dr Stoate: In what way is it actually commissioning if the GPs are not holding any budgets and are not placing any contracts with trusts? On what basis are they actually commissioning anything? Ms Hewitt: My very strong feeling, having looked at this over a few months, is that this word "commissioning" is a terrible piece of jargon which actually gets in the way of really understanding what is going on. The way I think about it is every time you or any other GP writes a prescription or refers somebody to hospital they are spending, quite rightly, part of the NHS budget. By giving the GPs more freedom but also more responsibility and accountability for those decisions I think we will get better decisions closer to the patients. Alongside that, you have got the crucial role of the primary care trust looking at what the GPs are doing, providing them with that information, and where you have got a GP who is perhaps overspending, who is not getting good value for money, then there will be performance management issues and it will be the PCT's job to challenge and work with that GP and see what needs to be done. The PCT will also be looking at the overall picture for the area and how we can get a better design of services for that area, which in many cases, of course, will involve pulling services out of hospitals, as I was saying, and getting them into the community. Q81 Dr Stoate: I am very concerned indeed about the different power structures between the primary care sector and the secondary care sector. One of the things I was led to believe was practice based commissioning would be in some way accountable to the power of the acute hospital trust. I am slightly concerned about this because with Payment by Results, particularly with Payment by Results including emergency care as of next April, how will it be possible for the PCT or the GP to have any control whatsoever over the amount of emergency work a hospital does and, therefore, the amount of money the hospital effectively claims off the PCT whether the PCT is happy about it or not? Ms Hewitt: This is an incredibly important issue and, as you say, it goes right to the heart of this question about the balance or imbalance between the acute hospitals and primary care and the GPs but also the primary care trust, which is precisely why in July we asked people to focus on how they strengthen the commissioning side. By strengthening the commissioning side and getting very good information about what is happening we can deal with those areas where there are problems about perhaps a very fast increase in the number of A&E attendances that could perhaps be dealt with in other ways or an abnormally high conversion rate between the A&E attendance or the outpatient attendance and inpatient attendance. Q82 Dr Stoate: That is the point because the way things are is up to now the hospital had an incentive to effectively say to patients going into A&E, "You are better off dealt with in the primary care sector" because it would have been more advantageous for hospitals to say, "Go away" effectively. Under Payment by Results, every patient who is admitted to A&E is effectively a cash register on the blank signed cheque of the PCT and every time the hospital says, "Yes, come into our observation ward for 36 or 48 hours", a big ping goes off in the PCT budget and another 2,000 quid transfers and the PCT has no control over that flow of money. Ms Hewitt: There are at least two things we are doing there, and I will ask Nigel to supplement my answer if I have forgotten some other aspects. First of all, the tariff itself will have quite a disincentive to making short inpatient stays from A&E because there is that real danger of, "Oh, do come in and fill our beds" and of course we do not want that happening. We want the inpatient stays to be the essential ones. Secondly, the primary care trust, working with the GPs, who will now have much more information and accountability for their indicative budgets, will look at this problem, if it becomes a problem in a particular area, and then sit down with the hospital and agree a protocol about referral rates or other ways of managing A&E admissions. In some parts of the country we are seeing other ways of providing some of the services that are currently provided within A&E. Q83 Dr Stoate: I understand all that, but the worry I have got is that there is this imbalance. I have already had PCTs contacting me saying they are extremely concerned that as GPs effectively have no control over emergency admissions at all in the real world the hospital will have a whole section of the budget which is completely out of the control of the PCTs. Many have said to me that the only way forward if hospitals do play this game, and I am not saying they would do it deliberately or fraudulently but there is an incentive for them to bring people into a short stay ward for 48 hours, it will destabilise community services because PCTs will have no alternative but to pick up the bill for something beyond their control. Ms Hewitt: That is why we have cut the rate. We are cutting the rate in the tariff for those 48 hour type admissions. Sir Nigel Crisp: The other side of this is that PCTs and GPs, therefore, have an incentive to set up alternative services. Q84 Dr Stoate: You cannot set up alternative services for patients going by blue light ambulance or walking into casualty, GPs have no control over that. Sir Nigel Crisp: It may be something that is worth looking at. There are a number of services just like that around the country. For a start, a number of hospitals now have primary care led services right alongside their A&E departments, do they not? Q85 Dr Stoate: The point I am making is there would be no incentive for the hospital to set those services up. There may be an incentive for the PCTs to do it. Sir Nigel Crisp: We are matching incentives for the PCT because if they can provide a service that is hopefully better for the patient but also more cost-effective and keeps people in primary care there is some incentive for primary care in that. Q86 Dr Stoate: I understand what you are trying to do, it is just that I am just very concerned about the power relationship between the two. I see the big powerful acute trusts are going to have effectively too much control over the PCTs which are going to be struggling with tight budgets. Ms Hewitt: As we move away from the provider-led NHS we have got to strengthen the power in the primary care sector, and that is what commissioning - dreadful jargon - is all about. It is stronger primary care trusts, much more expert and strong relationships with those acute hospitals and more accountability but also more freedom for the GPs. If I can just supplement Nigel's point, I have already seen in various parts of the country not only GP led walk-in clinics alongside A&E, which is one way of dealing with this, but also the walk-in centre or minor injuries centre or, in some cases, ambulance services reconfigured in the way that Peter Bradley is now recommending everywhere where you use emergency care practitioners to go to people in their own homes recognising that by no means all people arriving at A&E are coming with a blue light and not everyone coming with a blue light necessarily needs to even come to A&E, never mind become an inpatient in hospital. Q87 Chairman: We are going to move on but, Sir Nigel, you said it may be worth looking at this relationship and for the sake of our inquiry if you could look at that quickly and give us a note on it, it might be useful to us. Sir Nigel Crisp: We will let you have a note. Ms Hewitt: We will happily do that. Q88 John Austin: I think an idiot's guide would be very useful because I become more confused the more papers I get. The document which went with Sir Nigel's letter in July talked about, "PCTs becoming patient-led, commissioning-led organisations" and two pages later it said, "Under practice based commissioning GP practices will take on the responsibility from their PCTs for the commissioning of services". There seems to me to be a degree of contradiction in that when I picked up the paper in the pigeonhole this morning it said that GPs will not be commissioning any services at all, they will be drawing down on a contract commissioned by the PCT. In my mind there is a degree of confusion and, from seeing the nods around the table, I suspect there is some around the table as well. Ms Hewitt: I completely sympathise. It comes back to what I was saying to Dr Stoate. This word "commissioning" conceals, if you like, a whole series of activities. Perhaps we could send the Committee some of the guides to commissioning that have been produced with the primary care trusts which are very helpful - certainly I have found them very helpful as a relative newcomer - to the different activities that we are talking about under the umbrella of this one rather confusing word. There is a rather important difference between the GP's decision to send a particular patient to hospital and then the GP's decision as he or she looks at the overall pattern of referrals and how that compares with an indicative budget to say "Wouldn't it make sense if, instead of sending all these people to an ophthalmology clinic in the hospital, we had a GP with a specialist interest doing much more of this in the community or a consultant doing a community clinic? We will organise that, either one GP or several of us doing it together perhaps with the PCT." You can have those sorts of things being done by the GP but the actual contract with the hospital, which under fund holding was negotiated individually between each fund holding GP and each hospital so that you had this crazy number of contracts crisscrossing the country with massive transaction costs, is not going to happen under practice based commissioning. There will be a national contract. There will be a national payment system so that the money flows in the right place. If the primary care trust and local GPs decide they want a bit more in one respect from their local hospital to reflect their local priorities they can make a variation to that national contract, but we are not asking GPs to do that ridiculous process of negotiating with each hospital, particularly not on price because there will be no negotiation on price at all, the focus will be on quality. Q89 John Austin: Can I move on. You will know from our past reports and comments that some of us have made in the past that this Committee has been banging on for a long time about the integration of social care and health services. You have said you want this reorganisation to proceed as quickly as possible. At the moment we are in the middle of discussions on the White Paper on health and social care. Are you satisfied that there will be sufficient discussion, sufficient clarification on that White Paper, before the reorganisation comes into effect? Are you confident that social services and social care will not again become the poor relation? Ms Hewitt: Yes, I am satisfied on both points. We have got some really exciting consultations going on around the White Paper at the moment and, indeed, this Saturday we have got around 1,000 people in Birmingham drawn from the public, and pretty much representative of the whole public, focusing on these issues. The public consultation events we have had so far have shown that the issue of integrating health and social care from the point of view of the individual patient or user and their family is a really high priority. What we are also doing is building on the excellent Green Paper that was published at the beginning of the year that John Reid and Stephen Ladyman presented. Although I know there were real fears that when we said it would be one White Paper rather than two social care would again disappear, I am absolutely clear that we have got a wonderful opportunity with this White Paper to create a single policy framework in which primary care trusts in future and local authority social services departments can work together even more effectively, all of it from the point of view of the patient and the user. I recently spoke at the Association of Directors of Adult Social Services' Conference and I hope in that discussion I was able to provide some reassurance that actually the user focus, which is one of the best features of a social services approach at its best, is what we want for the Health Service as well as social care in future. Chairman: On the issue of guides to commissioning, I think it would be very useful if we had the opportunity to have a look at them as a Committee, hopefully before we have your colleague, Lord Warner, to give us evidence in relation to this. Q90 Mr Amess: I think every one of us would applaud any attempt at plain language. I absolutely hate all this jargon. Today's paper that we have got in front of us states: "Commissioning an 18 week patient pathway". It sounds lovely, this little path that you are going down while you are waiting to have a new heart, a new liver or arthritic joint sorted out. I see here that the listening exercise will run from today for six weeks. Specifically on targets, a number of your predecessors were very keen on them and then one of them sort of changed their mind on it. I think everyone would say targets are splendid if they can be scrutinised by Parliament and if they do not distort clinical priorities. Specifically on the 18 week target to achieve the maximum wait from GP referral to treatment initiation by 2008, as at the moment there is no total waiting information collected by the NHS. Could you help the Committee in telling us how you would see the mechanism working? Ms Hewitt: Thank you. You are absolutely right that at the moment we measure the initial wait for the first outpatient and by December we will have that down to a maximum of three months, we then measure the gap between the decision to treat and actually going into the operating theatre, and we will have that down to an absolute maximum of six months by the end of the year, but we do not measure the bit in-between where you are waiting for your scan or other diagnostic test or having a further consultation and so on. In order to deliver the 18 week target, which will put us right up at the forefront of international best practice, we have got to get into this black hole of what happens between the first outpatient consultation and the decision as to what is the right treatment. We are starting to do that for the earlier target we have set for cancer. You will remember we set a target that by Christmas of this year we will have a maximum of 31 days from diagnosis to treatment but 62 days from the initial referral to treatment. That is hugely challenging. We have got an enormous amount of work going on with all our cancer services at the moment because that, in a sense, is the first rung of what we will have to do generally for all illnesses to meet the 18 week target. It does require an enormous investment in diagnostics but also proper measurements so that you know which patients are at which point in the patient pathway, which is how the clinicians describe it, and you can then see exactly where the bottlenecks and the long waits are and reorganise things to get to that maximum of 18 weeks from beginning to end for all services. Q91 Mr Amess: The Department is confident that this mechanism will be possible, is it? Ms Hewitt: We know that it is possible and, as ever, some of our best hospitals are a very long way down the road to doing this but it is difficult and we should not underestimate the difficulties. It is going to be a real challenge to get to where we want to get to very quickly on cancer. If you look at cancer generally, we are very helped by what has been done on breast cancer where there have been massive improvements. Other cancer services are learning from that experience. As we get to where we need to be in cancer, other services will learn from those experiences to ensure that they have got the information about each patient moving from the initial referral through outpatients, through the diagnostic tests to the decision to treat and then the treatment itself. Q92 Mr Amess: I accept that we have not got the mechanism at the moment but could you make some sort of guess in terms of the three year period as to where we are up to in achieving the 18 weeks? Could you comment on where you think we are at the moment? Ms Hewitt: I have indicated where we are on the first bit and the last bit, absolutely on target to deliver the three months for the outpatient and the six months for the inpatient. In fact, we are doing better than where we need to be now to meet the targets by Christmas. That bit is on track. On the diagnostic bit, if I turn rapidly to my figures because I have not got them in my head on where we are on diagnostics, not all of this is measured is the truth of the matter. We know that we have got some people ---- Q93 Mr Amess: It is just impossible to guess really, is it? Ms Hewitt: Certainly I do not want to start guessing, but what we do know, and I think all of us know from our constituents, is that we have some patients having to wait absolutely unacceptably long times for an MRI scan, for instance. That is why I made the announcement before the summer that as of next month where somebody is being asked to wait for six months or more for certain scans and there is spare capacity in the independent sector then, just as we did in the past with electives, they will be able to use that spare scanning capacity in the private sector, but all of it on the NHS and free to the patient. Q94 Mr Amess: I know we are going to go on to the private sector, but before that can you tell the Committee what evidence you had to support the argument that more choice of private sector competition has led to a fall in the number of patients waiting? Ms Hewitt: If you look at the waiting time reduction generally but also in relation to specific conditions, I think you will see that the waiting times were coming down already when we started making the investment but the reduction accelerated as we brought in more capacity from the private sector. I looked specifically at cataracts where, of course, we have had this extraordinary reduction from waits of anything up to two years to just three months maximum and we achieved that four years ahead of the target that we had actually set for ourselves. The reductions have been quite extraordinary, from 100,000 people waiting for a cataract operation in 1997 to less than 50,000 now, so we have basically more than halved that waiting list. The maximum wait from nearly two years is down to three months. What drove that reduction in the waiting list was the combination of more NHS cataract operations being done and the new provision within the private sector including, absolutely crucially, the mobile cataract surgeries that were introduced for the first time in England by the private sector. Q95 Mr Amess: Is it impossible to weight the improvements that would have happened as a result of the investment as compared to using the private sector? You could not say it was 20/80 or whatever. Ms Hewitt: We needed both. The credit for this fantastic improvement in cataracts goes both to our NHS clinicians and providers and to the private sector, we needed both, just as we are going to need both on scans and diagnostics in order to get to the 18 week target. Chairman: We are going to have to move on now, Secretary of State. Hopefully we are going to finish at about 1.30. As David has just said, we are now moving on to this area of the involvement of the private sector in the NHS. I would ask Richard to ask those questions. Q96 Dr Taylor: I have just got to come back ever, ever so quickly on that because you must praise the NHS consultants and nurses in cataract operations more. I have put in a Parliamentary Question to confirm figures I have been given that the NHS did something like 300,000 but the figures I have been given for Netcare in the same period is they only did 10,000 to 14,000. I have not had your formal reply to that yet but this was given to me by people in the cataract surgical work. It is so disheartening to them when they are slaving their guts out in the NHS to get the lists down. I do not know if the answer is available yet. Ms Hewitt: Certainly on the figures that I have, Dr Taylor, the number of cataract operations we are doing now, on the latest year available, is over 300,000. Q97 Dr Taylor: In the NHS, yes. Ms Hewitt: No, over 300,000 in total, so nearly double what we were doing in 1997. What really matters is the extra ones that were done to get the waiting times down. Last year 13,000 extra cataract operations were done in the private sector treatment centres; it will be over 20,000 in the independent sector treatment centres this year. You needed both. I completely agree with you that the credit, the praise, goes to the NHS clinicians as well as the independent sector but the mobile surgeries, which were a particular feature of the Netcare service, have added hugely because they were able to go to the parts of the country where we had the worst waiting list problems and that was why we got the waiting times down so fast. Q98 Dr Taylor: Just going on on the private sector, I think what worries many people is that certainly with first wave ISTCs it has not appeared to be a level playing field, and reading the papers just yesterday foundation trusts feel that they have not been competing on a level playing field. We know that you have got a commercial director in the Department of Health and in his CV at a conference he actually described his job as "maximising commercial opportunities". Is he not increasing the unevenness of the playing field? The NHS on a level playing field can compete, but if PCTs are given the advantage of not having to pay for certain things in independent sector treatment centres then it is not a level playing field. How can we assure the NHS that it is going to be a level playing field? Ms Hewitt: Can I just preface what I want to say about independent sector treatment centres and the like by saying that our Commercial Directorate, which has been a fairly new introduction to the Department, was also responsible for the outstanding negotiation with the pharmaceutical sector that quite significantly saved money for the NHS on our drugs purchases, and all credit to them for doing so. The point you make about an uneven playing field in wave one I think is absolutely right. The fact that we were effectively forcing patients to go to independent sector treatment centres in the first wave is something that a lot of people criticised and we have learnt from. That is not going to happen with wave two because we want this genuinely to be patient-led, not to be forcing patients to use facilities that they may not want to use wherever those actually exist. We are also quite deliberately trying to get more capacity, more innovation and more contestability into the NHS as a whole. Foundation trusts, with the greater freedoms that they have got, are part of that but it is also important that we use the independent sector where they can help benefit patients in those ways. Therefore, we are moving, if you like, through a transitional stage where we need to bring in those new independent sector providers but within a few years, certainly by the end of wave two, we will be in a position where I think there will be a genuinely level playing field and everybody, if they want to contribute to the NHS and care for NHS patients, will do so at NHS quality and on the NHS tariff. Q99 Dr Taylor: In the orthopaedic field will the tariffs compensate and avoid cherry picking? Will the more complex procedures have a higher tariff, so the independent sector will not be able to cherry pick the simple ones for the same money? Ms Hewitt: We are working very hard on what you understand is an enormously complex issue, going through the different diagnostic categories and so on. We are determined to make sure that the more complex procedures are properly reflected in the tariff. I do not agree with the implications of your use of the term "cherry picking" because what I keep hearing from the consultants is that it makes absolute sense to separate the electives, particularly the simpler procedures, from the emergency admissions - I see you agreeing with this - because that way we get rid of the ghastly problem that used to happen of the electives and the planned operations constantly being cancelled because of the emergencies. Q100 Dr Taylor: But you have got to keep some of the simple procedures in the NHS centres for training and tariffs ought to be adjusted to account for training because if a surgeon is training a junior the operation is going to take him twice as lone. Ms Hewitt: I would put it a different way. You have got to make sure that wherever the simple operations are done, the training is also done. That was another, I think, absolutely proper criticism of wave one, because we could not do everything in wave one. We have been talking to the BMA about how we can get more training done in the independent sector treatment centres as well as obviously within the NHS hospitals themselves, and that will be built into the contract for wave two. Q101 Dr Taylor: So you will have NHS junior doctors being trained in the independent sector orthopaedic treatment centres? Ms Hewitt: That is my understanding, yes. In fact, it is already happening. Sir Nigel Crisp: In at least one place. Ms Hewitt: Nigel reminds me that I was talking to a surgeon describing that the other day in relation to a particular centre. Q102 Dr Taylor: I am told by the British Association of Orthopaedics that they have sent in a list of complaints about complications from ISTCs and they have not had a reply. I would be ever so grateful if you could look into that. Ms Hewitt: I have not seen the letter myself but I will chase it up and make sure that there is a reply. Dr Taylor: Thank you. Q103 Chairman: Secretary of State, I wonder if I could just ask you about the evidence that there is on phase two. I visited my local three star foundation hospital trust in September along with the two other Members of Parliament who cover the Rotherham Borough and was shown a letter that was being sent to yourself that united all the South Yorkshire hospital trusts against the second phase on the basis that their belief was that £17 million was going to be taken from their budgets and given to this ISTC that is about to come on stream in South Yorkshire. What evidence is there that they would be unable, as it were, to get down the waiting lists? I am talking about an area that has done marvellously well in terms of reconfiguration, changing and improving services. Practically all of the South Yorkshire trusts are a far cry from where they were ten years ago and a far cry from where they were three or four years ago in most cases. They are deeply hurt by this threat to their improvement plan by the second phase. Was it evidence based? Was it clear evidence that the only way to reduce hospital waiting lists further in South Yorkshire was to set this second phase up? Ms Hewitt: I agree with you about the very big improvements that have been made in South Yorkshire and I think it is very important that I, as well as you, register our real appreciation of what has been done there. All of the wave two proposals that we have put out to the independent sector for tenders have been discussed very thoroughly with strategic health authorities around the country. What we have been looking at is not what is going to be comfortable for providers but what will actually help patients to get the best possible services, quality as well as speed, and support patient choice, get us the greater innovation and so on that we have talked about. I am very aware of the real concern that there is from those foundation trusts in South Yorkshire, and I know Lord Warner had a very helpful meeting with yourself and a number of other parliamentary colleagues to discuss that the other day. We are at a very early stage of this wave two procurement. The description of the proposals has gone out; we do not yet know what responses we will get from the independent sector either to that proposal or, indeed, any of the other proposals in wave two. I think we need to wait and see what responses come in and then, of course, continue to discuss that with colleagues in South Yorkshire. Q104 Chairman: Lord Warner did say that he was going to get back to the South Yorkshire group who met him on the basis of what evidence there was for taking that decision and hopefully we will see that at some stage. Ms Hewitt: He will do that. Chairman: I recognise that it is 1.30 now and we have a whole host of questions. We wanted to ask you about past reports of this Committee and the Government's responses to them. Given the time, I think it would be quite logical if we write to you and ask for those responses on paper, but there are two issues here. Q105 Dr Naysmith: Secretary of State, one of your predecessors sat where you were not all that long ago, two or three years ago, and said, "We are only going to use the independent sector because we lack capacity" and there was no intention to build up the private sector by using National Health Service funds. What you have said in the last ten or 15 minutes contradicts that. Training National Health Service people in independent hospitals and so on is exactly what people were querying at the time. When did this change in policy take place? Ms Hewitt: Obviously I do not know which particular evidence session or which year you are referring to there. Initially the use of the independent sector was driven by the absolute need to get more capacity into the system in order to get the waiting lists down, as will happen with the diagnostics procurement. Nigel will correct me if I am wrong, but for the last couple of years at least the desire to bring in the independent sector in some cases has been driven not only by the need to get more capacity but also by the need to get even faster innovation, more choice and more contestability into the system. Since we started off by discussing the Manifesto, perhaps I can just say that statement about the independent sector was in the Manifesto but also, perhaps rather more importantly, it was in Creating a Patient-led NHS and I think earlier documents as well. I have not got them all in my head but Nigel can correct me if I have got that wrong. It was 2003; it was two years, as I thought. Q106 Mr Burstow: Can we come on to one final thing which I think a couple of us definitely want to ask questions about. Can we make sure that when the note on finance is done that it does cover things like recovery plans and how many there are now compared to previous years and the five monthly forecasts that you have had submitted from SHAs. It would be very useful to have that. The question I want to ask is about the very welcome statement made on Tuesday at the Breakthrough breast cancer event about Herceptin, about the fact that PCTs should not refuse to fund Herceptin on the basis of cost grounds. Can you tell us how that is going to be communicated to PCTs and how its implementation is going to be monitored? Certainly at least one of my constituents, Emma Kearns, who has currently been told that she will not get this particular drug on the grounds that she is not an exceptional case, wants to know whether she is going to benefit from that announcement because she does not understand what it means to be told that she is not an exceptional case when her life is at stake. Ms Hewitt: This is an enormously important issue. We have seen women with breast cancer who could potentially benefit from Herceptin faced with this very difficult situation when, of course, the drug is not licensed for early treatment and has not been through a NICE evaluation. A couple of weeks ago, as you know, I announced that we would both speed up the NICE evaluation but also immediately take steps to get the testing facilities in place for women who have been diagnosed now who could benefit from Herceptin when the rest of their treatment has been concluded around next summer. What I have now done is to build on what already happens with unlicensed or unevaluated drugs where, of course, the doctor has always been free to prescribe them, obviously in discussion with the individual patient. I have made it clear, and of course we are communicating that directly to primary care trusts, that where a clinician, having discussed the risks with the woman, comes to the PCT and says, "I believe this is the right treatment for this individual woman", the PCT should not be rejecting that on the grounds of cost. That was hugely welcomed, of course, by the breast cancer charities and by a lot of patients. We are in this awkward period, if you like, where we have started seeing the results of the clinical trials but the licensing application has not even been made yet by Roche, and I continue to urge them to get that in as quickly as possible. NICE stand ready to begin the evaluation as soon as that licensing application is made so that the two things will run very much in parallel. Once there is a NICE evaluation, if that is positive then the normal rule will apply that within three months we would expect all PCTs to be following it. Q107 Mr Burstow: Does that mean that for any of our constituents who have been recommended by their local cancer hospital, in my case the Royal Marsden, for Herceptin as being a beneficial treatment to have, if they are then turned down by their PCT on the grounds that they are not an exceptional case, the PCT should now revisit such decisions? Ms Hewitt: I think any woman in that position should simply discuss that again with her doctor. One of the reasons why I wanted to make this announcement this week was we have already had a number of primary care trusts saying, "Where the clinician comes to us in this situation we will fund the treatment" and I wanted to make sure that was happening everywhere. Q108 Charlotte Atkins: There is a problem in some parts of the country where PCTs are already running deficits and unless you, as Secretary of State, make funding available then there will be people who are unable, because of funding difficulties, to actually get Herceptin. When do you think that will be available on the NHS to people with early stage breast cancer? Ms Hewitt: It is already being made available to people. Q109 Charlotte Atkins: In terms of PCTs not having the money, that is a key issue. You will be aware that in North Staffordshire there is a very active campaign on the issue of Herceptin and there are a number of ladies there who have got cancer and are not getting funding simply because the local PCTs have not got the money to spend on that particular treatment. Ms Hewitt: I understand exactly the difficulty you are pointing to and, of course, Rosie Winterton met a number of the women in that position just a few weeks ago. The hugely increased budget for the NHS has already been devolved almost entirely to the primary care trusts and, of course, this issue of Herceptin at this stage is going to cause difficulties for those PCTs who are already facing financial difficulties of the kind that you have described. What we are talking about is a relatively short period that falls over two financial years, in other words between now and the end of this financial year and the beginning of the new financial year and the point at which we have both licensing and a NICE evaluation. Given the very significant increases in the budget for every PCT in the new financial year and the continuing work that PCTs are doing to implement the financial recovery plans that they have agreed with their strategic health authorities, although it will be difficult, and I was very clear about that in the announcement I made, I do believe that PCTs will be able to do this. Q110 Charlotte Atkins: Time is not on the side of these women, that is the point. Ms Hewitt: That is right, and PCTs will have to find a solution to that. Q111 Charlotte Atkins: Could you help them find a solution? Ms Hewitt: I do not have a little pot of gold sitting in the Department to give to individual PCTs. Q112 Charlotte Atkins: What about Sir Nigel's NHS bank? Ms Hewitt: Each PCT that has got a deficit is working with its health authority. They should already - we are half way through the year - have a robust financial recovery plan in place. This will put another cost pressure into the system and I realise that is going to be a problem for some of them but it was quite clearly the right thing to do. That will have to be managed in that minority of trusts with a deficit as part of the financial recovery plan. Q113 Chairman: Secretary of State, one more question. You probably do not know this but John Austin has been a Member of this Committee for over ten years and it is his last sitting, he is now moving on to greater things as it were. Ms Hewitt: Congratulations. Q114 Chairman: I thought we ought to give John his last bite of the cherry as far as this Committee is concerned. Ms Hewitt: Not a bite, I hope! Q115 John Austin: If you cannot answer it with a date perhaps you can write to us with the answer. I think one of the most widely acclaimed recent reports this Committee produced was on sexual health and obviously we are all alarmed by the recent reports of increases in sexually transmitted diseases. When do you think we can see some improvements in sexual health in this country? Ms Hewitt: It is an enormously difficult and frustrating area. I absolutely share your concern and the Committee's concern about particularly what is happening amongst many young people and what is starting to look like an epidemic of sexually transmitted diseases amongst many young people. It is incredibly difficult to get the changes in behaviour that will really see the improvements that we want. Caroline Flint, who is now our excellent Minister for Public Health, has made that one of her top priorities and is working very closely not only with the NHS but also the excellent voluntary organisations we have in this sector to try to step up our efforts with parents, with schools, with the sexual health services and, above all, with young people themselves. If I may, congratulations on your longevity. Q116 Chairman: Could I thank you both for coming along. I am afraid it has been rather a long session. We will pick up anything we have not covered by paper. Ms Hewitt: Thank you very much indeed, Chairman. I have enjoyed my first session and I look forward to many, many more. Chairman: Thank you. |