UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 634-i

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

THE COMMITTEE OF PUBLIC ACCOUNTS

Monday 31 October 2005

PATIENT CHOICE AT THE POINT OF GP REFERRAL

 

DEPARTMENT OF HEALTH

SIR NIGEL CRISP, KCB, DR DAVID COLIN-THOME, MR JOHN BACON,

BRITISH MEDICAL ASSOCIATION

 

DR RICHARD VAUTREY

 

ROYAL COLLEGE OF GENERAL PRACTITIONERS

 

DR MAYUR LAKHANI

Evidence heard in Public Questions 1 - 196

 

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Oral evidence

Taken before the Committee of Public Accounts

on Monday 31 October 2005

Members present:

Mr Edward Leigh, in the Chair

Mr Richard Bacon

Greg Clark

Helen Goodman

Ms Diana R Johnson

Sarah McCarthy-Fry

Jon Trickett

Kitty Ussher

Mr Alan Williams

________________

Mr Tim Burr, Deputy Comptroller and Auditor General, further examined, and Mr Chris

Shapcott, National Audit Office, examined.

Ms Paula Diggle, Second Treasury Officer of Accounts, HM Treasury, further examined.

REPORT BY THE COMPTROLLER AND AUDITOR GENERAL

PATIENT CHOICE AT THE POINT OF GP REFERRAL (HC 180)

Examination of Witnesses

 

Witnesses: Sir Nigel Crisp, KCB, Chief Executive of the NHS and Permanent Secretary, Dr David Colin-Thome, National Director of Primary Care Trusts, Mr John Bacon, Group Director of Health and Social Care Services Delivery; Dr Richard Vautrey, British Medical Association; Dr Mayur Lakhani, Chairman, Royal College of General Practitioners, examined.

Q1 Chairman: Good afternoon and welcome to the Committee of Public Accounts where today we are dealing with Patient Choice at the Point of GP Referral. We are joined once again by Sir Nigel Crisp who is chief executive of the NHS and Permanent Secretary in the Department. Mr John Bacon is group director of health and social care services delivery. Dr David Colin-Thome is national director of primary care trusts. Dr Richard Vautrey, I think, is coming later. Dr Lakhani is the chairman of the Royal College of General Practitioners. Thank you very much for coming. Perhaps I could direct my questions mainly to you, Sir Nigel. Will you please look at the document which have been given to the Committee on the GP Service, the Knowledge of the Choose and Book Programme Amongst GPs in England. Will you look at page 27, figure 22? 61% of GPs responding to the NAO survey said they would not offer the choice of four providers. Why do you conclude in your memorandum that there has been good progress in introducing choice?

Sir Nigel Crisp: I will ask Dr Colin-Thome to talk specifically about how he sees this survey. As you will see in the document we sent, there are a significant number of more GPs who have become aware of the programme. We have a significantly larger number of practices and PCTs now registered with the programme. We have a significant increase in the number of GPs using the programme. We are also aware of the fact that as GPs start to use the programme we start to see the enthusiasm for it grow. This 61% is a serious matter and we have asked the question: does this mean that these GPs are not interested in offering choice at all and is it the four that is the particular problem here? The other evidence suggests that GPs are willing and able to offer choice but that for some of them four, at least in this survey, were considered to be too many.

Dr Colin-Thome: The issue is the number rather than GPs not wanting to offer choice. Maybe they just think that is too many. I do not know the exact reason why they say that. Since we are moving towards offering free choice anywhere in the Health Service, GPs will eventually get engaged because their patients will ask it of them. Even though it seems a lot with 39% saying yes, there have been enormous new developments in clinical practice so there is a reluctance to take on board some of these changes and the product tends to be delivered. I think you will find in the next few years GPs will very enthusiastically do this because patients will want it.

Q2 Chairman: You say that GPs will become more enthusiastic. Let us look at the evidence when it comes to the survey of GPs. Look at the GP survey, figure 45 on page 47. You will see there that knowledge amongst GPs of Choose and Book is becoming greater. That is good news. However, if you look forward to figure 57 which you can find on page 54, you will see that the conclusion from those two bits of information is that doctors are becoming more aware of this and as they become more aware they are becoming more negative. Does this suggest that the reference to GPs does not seem to be working?

Sir Nigel Crisp: I can take the point that you are making and see what those figures are telling us. What we have done over the period since the first publication of this report is to increase the amount of involvement with GPs, with Dr Colin-Thome and others. All the evidence we are getting in both the way in which GPs are taking up the programme and in our discussions directly with GPs is that we are seeing a big increase and we will be confident that ----

Q3 Chairman: Let us try and pin you down on this and see exactly when we are going to achieve real progress. If you now look at the main report, please, paragraph 3.23, page 28, it states there, "The June 2004 NHS Improvement Plan stated that there would be 100 per cent e-booking by December 2005." Are you going to achieve that target?

Sir Nigel Crisp: No.

Q4 Chairman: How much will you fall short by?

Sir Nigel Crisp: I do not have a figure as to where we will be at the end of December. What we have said in our report is that we think at the moment that we are running about 12 months late on the electronic booking support form for those patients choosing and booking, but we have every expectation that we will meet the PSA targets on choice and on booking.

Q5 Chairman: You cannot give me any more accurate figures than that? Judging by the GP survey, you may fall well short.

Sir Nigel Crisp: We are confident. If you looked at the figures that we produced in our update, you will see a very big increase from a low base in the number of GPs using the system and the number of bookings being made.

Q6 Chairman: Will you now look at your memorandum, please? Look at annex B which you can find on page 16. You tell us that 25,000 GPs have registered to use Choose and Book. That sounds good. Only 15,000 electronic bookings have been made. That is less than one booking each. Why has the take-up been so feeble?

Sir Nigel Crisp: Because the take-up is on the basis of a whole series of factors. It is not just registration. You have chosen one of the things where we are ahead of our targets and milestones with 85% of GP registration.

Q7 Chairman: My problem is one booking each. There is no point in registering it if they are not using it.

Sir Nigel Crisp: If you are going to use it you need to do several things. You need to register people which is part of the process, but you also need to do a whole series of other things, including making sure that the connections at the hospitals are working, the connections with the GPs' systems are working and that people have the appropriate training and so on. Those are the areas that are behind.

Q8 Chairman: They certainly are, are they not? If you look at page six of your memorandum, paragraph 3.4, adding choice added a year to rolling out the Choose and Book system. Is that right? Would it not have been easier just to delay the deadline for introducing choice rather than having interim IT systems to meet the deadline?

Sir Nigel Crisp: No, because our main objective and indeed the purpose of your inquiry is about offering patients choice. Choice is the policy that it is our intention to deliver. Electronic booking is the best means of doing that. We took the view that it was a perfectly good thing for us to do, to offer patients choice and we will be able to do it. We fully expect to be able to do that and we are already well on the way. We will expect to be able to offer patients choice and we expect people to be able to book appointments but during 2006 that increasingly will be supported by the electronic system.

Q9 Chairman: Let us press you further on that choice for patients. Look, please, at paragraph 2.22 of the main report, page 18. It is clear from that paragraph that you know what information patients want in order to make a choice and yet you do not plan to give it to them right away. Why is that? You will see, "... it does fall some way short of patients' express preferences, as noted in Building on the Best for information on outcomes and quality to make choices."

Sir Nigel Crisp: Absolutely. This is the start. We expect that as patients make choices we will be able to provide them with more information increasingly over the years. This is the starting point but we have to start somewhere.

Q10 Chairman: It seems that they know what they want already though.

Sir Nigel Crisp: The point here is that we would prefer to role choice out with the existing limited set of information rather than to wait until we have a very substantial set of information. I am quite sure that we will continue to learn what patients want because patients are not all the same.

Q11 Chairman: Let us now look at your survey in more detail, page 25, figure 19. You will see that 47% of GPs already offer choice. Do you see that?

Sir Nigel Crisp: I know the figure, yes.

Q12 Chairman: Why is it necessary to have a brand new Choose and Book system which costs hundreds of millions of pounds if already this large proportion of GPs offers choice?

Sir Nigel Crisp: I am sorry; I do not know precisely what the question is.

Q13 Chairman: 47% of GPs already offer choice. Why is it necessary to have a brand new Choose and Book system that costs hundreds of millions of pounds when 47% of GPs already offer choice?

Sir Nigel Crisp: I do not know what level of choice GPs currently offer. I suspect it is different in different places. Our view is that if we are going to offer people a significant choice of hospital - i.e., four in the first place - and all relevant hospitals by 2008 we need an electronic booking system to do that. You would not need it if it was offering perhaps a choice of one or two hospitals, but if we are moving to a point where by 2008 patients will be able to choose to have their operation done near where their family lives, for example, as opposed to another local location you need an electronic system to back that up.

Q14 Chairman: If - it is a big "if" - this system does work, which clearly it does not at the moment, and patients do exercise choice, will it not mean that inevitably some hospitals will not attract enough patients and they will have to close?

Sir Nigel Crisp: Firstly, I have no doubt at all that this system does work. All the difficulties in implementation are about the interfaces, both human and system, with other parts of the NHS. The ATOS system that is at the heart of it does indeed work and we will get the implementation right. In terms of choice, what we expect to happen is that if I happen to be running a hospital where patients are not choosing to use one of my particular services, whatever it is, I have no doubt that I would want to find out why. Why are patients not choosing to go there? Was it because it was bad quality? Was it because there was a very bad MRSA rate? My expectation is that smart chief executives, as is already happening, will see this as a spur to improve their services, to make sure that they are popular with patients. We have seen this, as I think this Committee may know already, in paediatrics in north London, where one of the services is having difficulty in surviving, not because of patient choice but for other reasons, and they have negotiated with Great Ormond Street so Great Ormond Street now runs that service. I think it is likely that when people find they have a service patients do not like they will do something about it.

Q15 Helen Goodman: Is it the case that the chief executives of the hospital trusts do not know what the strengths and weaknesses of their services are?

Sir Nigel Crisp: They do to an extent but when patients genuinely have a choice you are going to get another level of information. I do not think, if I were chief executive of a hospital, I would know whether or not people thought my gynaecology service was better or worse than that one over there. I would have some view as to whether my service was better or not but I would not know what patients think to the extent that they are not going to exercise choice. This is new information.

Q16 Helen Goodman: To make patient choice a reality, there will have to be over-capacity in the system overall. What estimate have you made of the extent of that over-capacity and the cost of it?

Sir Nigel Crisp: At the moment, we are running our hospitals at something of the order of between 85% and 90% capacity. We have a degree of over-capacity, of occupancy rates, in the system. What hospitals are going to have to do as part of that is to get better at opening and closing capacity to recognise need so that if they are getting fewer patients coming in they will reduce capacity. If they are getting more they need to open capacity. We do not have an overall figure for where we estimate the cost of extra capacity for choice to be. We are looking for capacity to increase slightly overall to make sure we are able to run our services efficiently anyway. It is not just about choice; it is about how we respond.

Q17 Helen Goodman: You are going to increase the extent of over-capacity in the system as a whole?

Sir Nigel Crisp: We are at the moment.

Q18 Helen Goodman: What is the cost of that going to be?

Sir Nigel Crisp: If you are talking purely of hospitals, I would have to come back to you and let you know what we expect to spend on hospitals this year as opposed to previous years, but it will be part of the five billion extra we are spending every year.

Q19 Helen Goodman: There will be costs associated with this opening and closing, this new flexibility, will there not?

Sir Nigel Crisp: There may be costs but there may be savings.

Q20 Helen Goodman: How could there be savings if they are opening and closing? They are having to be flexible and respond to changing demands.

Sir Nigel Crisp: Maybe we could give you a worked example. The fixed costs presumably will be the same but if you close down capacity because you are having fewer patients into your particular area and you can see that is happening, you reduce your use of theatres or whatever, you will save something on marginal costs.

Q21 Helen Goodman: One of the things that comes out of the report is that GPs think that running this system is going to involve them in more time. Have you an estimate of the cost of that?

Sir Nigel Crisp: Yes. You might want to ask Dr Colin-Thome about that but if you look at the number of referrals made from primary care to secondary care, it works out at about one a day per GP, between five and seven a week.

Dr Colin-Thome: That is about an average figure. Once you get slick with the system a GP seeing you might only take 45 seconds to a minute in a consultation, because a lot of the other bits of the Choose and Book system can be done by administrative staff.

Q22 Helen Goodman: Do you not think that patients will want to discuss with their doctor which is the best choice for them? Do you not think that will take more than 45 seconds?

Dr Colin-Thome: Yes. That is what many of us are offering already now. We will have a bit more information to help us. That is one of the jobs of a GP as referrer, to offer patients more information. That should be part of our normal practice and I as a GP would take this as part of my job.

Q23 Helen Goodman: At the moment we only have 1% of possible referrals using the system. Once we move up we will have 100 times as many so there will be quite a lot more time and I am wondering how much of GPs' time this is going to take.

Dr Colin-Thome: It is difficult to evaluate because already 47% of GPs offer some choice. Offering choice is part of the GP's job in referring. What this system will do is give a lot more information, to offer people more of a sensible choice about what are the facts of hospital A and hospital B. The technical bit is the bit that is extra but that is part of our job anyway.

Q24 Helen Goodman: I understand that. In looking at the costs and benefits, the documents only look at costs of setting up the electronic system. If there are extra costs in terms of capacity and GP time, those should also be factored in so that we can see whether this is value for money.

Dr Colin-Thome: That is right. We have had quite a big investment in general practice in the last couple of years. We have the biggest number of GPs we have ever had. We have an increased number of practice nurses and a substantial investment so the capacity has already expanded in general practice.

Q25 Helen Goodman: That is true, but do you think patients, when they are paying extra taxes, are paying the extra taxes in the hope that medical outcomes will improve, not that it will be used in GP time talking to people and in over-capacity?

Dr Colin-Thome: GP time is about talking to patients. That is why we have a reasonably trusting relationship, whatever they ask us. Sometimes it is nothing to do with the Health Service; it is about general health care, about hospitals. We get a multitude of requests from patients and that is part of our job.

Q26 Helen Goodman: GPs are closest to patients and the best informed about patients. Could you explain to me what you have done about the findings on page 34 of the report on the knowledge of GPs which says that 46% of GPs think this system is going to increase health inequalities. Only 3% think it is going to reduce inequalities. Given that GPs are well informed, has this finding made you in the department reflect on the system? Have you asked yourselves whether GPs might be right about this?

Sir Nigel Crisp: This is consistent with a very clear set of perceptions which people have which is that, if you introduce choice, there is a risk you will introduce health inequalities. We recognise there is a risk. The question is how do you mitigate against that risk. What do you do to make sure that is not the case? Part of that is what are the choices that you are going to design for people. Are they going to be choices that are going to make it easier for people to access services or harder? If you look at what happens at the moment with health inequalities, there is a whole range of people who find it very difficult to access our services and would probably appreciate a wider range of different ways in which they are able to do it. We see these as being able to serve people better but we have to work at it to make sure that happens.

Q27 Helen Goodman: Why do you think that when only 3% of doctors think that and 46% of doctors think that will not happen? What is the difference in your perspective and their perspective?

Sir Nigel Crisp: I have to make it happen whereas they are commentating about it.

Q28 Helen Goodman: They have to make it happen. They are the ones who are going to do it.

Sir Nigel Crisp: I do not know if the exact question was asked but I assume it is, "Do you think that choice could lead to increased health inequalities?" Of course, there is a risk that it could do so we have to make sure we implement it in a way to make sure that it does not.

Q29 Helen Goodman: Looking at the things on which people can choose, they fall into three categories, do they not: time, location and quality of care? This is set out in figure ten on page 19. Given that location is a key factor for many people, particularly people already suffering from very serious health inequalities, how are they going to avail themselves of the other aspect of choice, if that is a driver for those people, with your system?

Sir Nigel Crisp: Coming back to the question you asked earlier about what is the effect on hospitals if patients choose to go to them or choose not to go to them, the first thing we will start to see is which hospitals people want to go to. This does not sit by itself. You will probably be aware that we have PSAs about improving health inequalities and reducing the gap on life expectancy. How are we going to deliver that? The PCT needs to be able to analyse what choices people are making and make sure that it is delivering services that will suit the choices of the people it is particularly trying to target. That is how it will work. It may well be that the local hospital will have to change the way it delivers the service to make it maybe culturally more sensitive or whatever else is the reason why it is not popular with its patients.

Q30 Chairman: We welcome Dr Vautrey who has now arrived.

Dr Vautrey: Thank you. I apologise to the Committee for being late.

Q31 Chairman: If either Dr Vautrey from the British Medical Association or Dr Lakhani from the Royal College of General Practitioners wants to comment on anything Sir Nigel has said, please do so. Do you want to comment, Dr Lakhani, on what you have heard so far from Sir Nigel?

Dr Lakhani: This issue about GPs not being willing to offer a choice to their patients is more about them wanting to do this in a supportive way, giving the right information. Their concern is about capacity, workload and the impact on the consultation length. I do not think it is that they do not want to offer choice because already we offer choice. For example, in my area we have four to five providers locally and they are already having discussion with patients around what they would prefer and where they would like to go. Informally and in an implicit way, choice is already being offered. We would like to do more but the survey results reflect the concern that GPs have about the impact on their working practices, particularly around the time that would be added to the consultation at a time when the consultation, the amount of clinical material they have to cover, is already very large, through new contracts and lots of other initiatives. I do not think it is that GPs are negative about patient choice and involving patients in decision making and sharing choices with them. That is a very positive and powerful thing which should be encouraged. What we are seeing in this survey is the GPs' concern that this may be implemented in an unsupported way. I think the answer lies in doing this in a supportive way and something around clinical engagement, which is the key issue.

Q32 Chairman: You heard me put to Sir Nigel that only 15,000 electronic bookings had been made, less than one booking for each GP. Why do you think that is?

Dr Lakhani: There are two reasons. Our practice has signed up as one of the earlier adopters of Choose and Book but we had some problems with the technology, in getting the GP clinical system to talk with the secondary care hospital system. The technology sometimes has not been quite there when clinicians wanted to use it. It is a training issue and there is a learning curve in this area. If we separate the issue of the administration which can be handled by booking centres and patient care advisers, if you like, the travel agent function of this, from the clinical discussion, it can be done in a supportive way so GPs are involved in helping patients make clinical choices, helping people choose hospitals or interpretation about the quality of information. All the administrative stuff could be seen as a second or subsequent stage procedure. Many GPs would welcome that. I talked to one this morning around the whole issue. They are frightened that they might have to do the whole lot: booking, choosing a time, changing a time, which is not intended. I think that clinical dialogue is the important thing but again the impact of that is easy to underestimate. At the initial consultation when you make the decision to refer, there will be a substantial impact on the consultation length. There will be subsequent occasions when patients might want to come back to the general practitioner to make inquiries about something else that has cropped up. That is a significant issue that many GPs report to me as a concern.

Q33 Jon Trickett: I understand that 100,000 reward or incentive was offered to each PCT which might get 50% of its monthly referrals on the Choose and Book system as long as that was achieved by August 2005. Is that correct? Did any single PCT manage to hit the target?

Mr Bacon: We are still collecting the information. Our expectation is that very few will have done so.

Q34 Jon Trickett: The answer is none, is it not?

Mr Bacon: I do not know that. We certainly expect there to be very few.

Q35 Jon Trickett: It is November tomorrow. This was a target which you said had to be achieved by October so you do not have a clue at this stage whether or not even one has achieved the target?

Mr Bacon: We are close to the position where we will be able to answer you.

Q36 Jon Trickett: Will you be able to provide us with a note?

Mr Bacon: Yes.

Q37 Jon Trickett: Was an appraisal done of the capacity of PCTs to achieve this at the time you set this incentive, because it looks like an incentive which was never intended to be spent, does it not?

Sir Nigel Crisp: No, I do not think that is true.

Q38 Jon Trickett: How many PCTs are there?

Sir Nigel Crisp: 300. You are quite right. It will be none or a very small number who will receive the incentive money. It is an incentive, not a target. When we have done this with other things -- as you probably know we did the A&E system last year -- most people did manage to achieve those incentives.

Q39 Jon Trickett: Will any of them achieve it by Christmas, do you think?

Sir Nigel Crisp: I know that some already have. The latest figures I have are that ----

Q40 Jon Trickett: 50% of referrals by October.

Sir Nigel Crisp: One PCT which made its first referral five weeks ago is now on 55%.

Q41 Jon Trickett: This is my PCT but I think it has national implications. My PCT says that there have been risks identified ranging from system defaults, registration difficulties, training issues, technical deployment and other constraints. They were precluded from achieving the targets you set them by the fact that the technical problems had not been resolved.

Sir Nigel Crisp: I do not accept that. It was not a target; it was an incentive to encourage people to do it, which is very different. The fact is that some people have and some people have now achieved it, because I looked at a figure before we came in. If you look at the details of why, some of those details will be about local systems and local ways of doing things. Some will be about systems that are used across the NHS and how they are being used and so on.

Q42 Jon Trickett: When you provide the Committee with the number who have achieved it, perhaps you will give us some sort of written appraisal of the time the work was done when the date of October was set so that we can set that against the reality which will have emerged at that time.

Mr Bacon: We have used an incentive based approach in other areas of activity. We used an incentive based approach at an earlier stage in this programme, where the first incentive was around registrations of GPs. Indeed, 98% of our primary care trusts achieved that and received the incentive. This time, we agreed that the incentive perhaps was not feasible. We did contemplate whether we should reset it but our view is that once we have set these incentives we should stick to them. We are considering a fresh incentive for the turn of the year and we are confident that we will set something that ----

Q43 Jon Trickett: You are in danger with the donkey and the carrot it can never quite reach. Eventually it stops trying to pursue the carrot and it no longer has any confidence in the person who is offering the carrot. The phrase "opening and closing facilities" trips easily off the tongue but my PCT and the chief executive in my trust -- I presume this is a national phenomenon -- are talking about possible bankruptcies effectively, however you describe it in the language you use, "opening and closing". It belies the fact that once demand begins to fall for a service or even for a hospital, when that is connected to payment by result as it clearly will be, if people are not going to choose to go to this facility it will close because it will be in financial collapse. That is the truth of this opening and closing which is really a euphemism for bankruptcy, is it not?

Sir Nigel Crisp: No. The reason I say that with confidence is that you can look at this system being implemented in other countries -- Australia, for example, where over a five year period only one hospital ended up closing. What did happen is that a lot of people reshaped their services to make themselves more attractive to patients. In some cases that may have been amalgamating their services with their neighbours; it may have been bringing in ground leaders like Great Ormond Street paediatrics department. Our first view from the centre is that if patients do not like your hospital you need to know why. You need to sort it out.

Q44 Jon Trickett: Does it not inevitably follow that there could be financial collapse and closure? There could be a number of other options but it does seem to me that your officials and chief executives, some of them very senior and experienced, are describing the process as potentially calamitous in some cases since they are on the end of a very short plank and expected to take quite a long walk.

Sir Nigel Crisp: I am delighted to know that chief executives are looking at the risks but what I expect you will probably find in your local hospital is that your chief executive thinks that some of his services will prosper and some may not, because he may well think ----

Q45 Jon Trickett: We are talking about cross-subsidy and bankruptcy rather than care and health needs. That is the language we are talking.

Sir Nigel Crisp: It is in terms of talking the language of service improvement. There will be some difficulties but our first job when somebody starts to get themselves into trouble is to see what we can do to help. One of the things is not to send patients to hospitals they do not want to go to.

Q46 Jon Trickett: I totally accept that is the objective. It is a question of the means being used to achieve that. Earlier in questions from Helen Goodman, you said that there are risks of inequality being produced by choice. I suggest it would be something like this: in London, it is straightforward, it seems to me, and all your examples have been London based. In my constituency and for vast tracts of the country there is only one local hospital. To offer people who are ill, poor and perhaps elderly, who do not have access to transport, a choice of going 30 or 40 miles -- 40% of the households in my constituency have no private car -- means that the people who are mobile will move maybe to other hospitals, the middle classes if you like, the ones who are more able, younger and so on. Older, poorer people, perhaps people with linguistic problems are going to be left with facilities which you yourselves have described as probably going into decline and perhaps into what I described as bankruptcy or collapse. Is that not a fact? That is the real risk of inequality, is it not, which you describe?

Sir Nigel Crisp: There is a risk but what I also said to Helen Goodman is that this policy does not sit in isolation. Our PCTs are tasked to reverse inequalities where they can. Secondly, as part of the payment by result system, GPs and primary care trusts are going to have the incentive to create services more local to home. What are they going to be doing -- this is what I am going to be saying to them -- about the fact that in your constituency perhaps there is only one local hospital and it is in trouble? What are they doing to make it better? This is not some simple buying and selling mechanism; this is the Health Service.

Q47 Jon Trickett: Do you accept that there is at least one possible dynamic which will be unleashed by these reforms, which is the one I have described, where the poor, the unhealthy, the people who are not mobile and possibly people with linguistic problems, ethnic minorities, may well be left in hospitals or with providers that are in decline? Is that one of the dynamics which may be unleashed?

Sir Nigel Crisp: No. It is one of the risks. There are many other risks and you have alluded to some others. What we need to do is to make sure that we do not let those risks occur.

Q48 Jon Trickett: It strikes me that whilst choice is one of the drivers which the government has chosen, there also have to be some strategic interventions of the kind you are describing by the PCTs. To some extent, to countervail against the other, the choice agenda has to be protected or safety netted by some sort of strategic intervention. Do PCTs have powers to intervene strategically any more?

Sir Nigel Crisp: Absolutely.

Q49 Jon Trickett: Will they by 2008?

Sir Nigel Crisp: They will have the money so that gives them a lot of power. You have improvements being driven in hospitals that offer choice where they are attractive to patients. You also have the money sitting with the PCTs. Understand, we are talking about practice based commissioning. We are looking to GPs alongside PCTs to be thinking about what is the service we need and how we are going to make sure we get it. They will have the power because they will have the money.

Q50 Kitty Ussher: I would like to probe the overall cost benefit analysis of the entire policy, if I may. In terms of costs, figure two on page eight gives an estimate of an annual cost of 122 million. Is that a figure you stand by or would you like to adjust it?

Sir Nigel Crisp: Our expectation is that this is still within the budget.

Q51 Kitty Ussher: Do you have an equivalent figure for the benefit in terms of efficiency?

Sir Nigel Crisp: What you have here, if I remember rightly from these figures, is an analysis that shows, on the following page, that 71 million had already been identified against that. We then have a series of other benefits which are not cash releasing, which we have identified in general terms. We are in the process now, as this rolls out, of making sure we secure them.

Q52 Kitty Ussher: Could you amplify a little more about what those non-cash benefits are?

Sir Nigel Crisp: The easiest one to mention is stopping people not attending out-patient appointments. We believe, if it is a short time and you are booking it yourself, you are more likely to attend it. That is a straight reduction in cost, effort and so on, because we are at 10% at the moment.

Q53 Kitty Ussher: Are you also presuming that the health outcomes will improve and that hospitals will be managed more effectively?

Sir Nigel Crisp: Yes. We expect that wherever you involve patients in decision making their happiness with the service, their use of the service and how they conform to the service works better. We would expect that but we have costed things like not attending out-patient appointments.

Q54 Kitty Ussher: Overall therefore for the taxpayer, is this a net cost or benefit for the whole policy?

Sir Nigel Crisp: It is a net improvement in quality and value for money, taking the two together. I am not going to try and measure the quality in terms of money.

Q55 Kitty Ussher: Quality and value for money have improved but not simply value for money?

Sir Nigel Crisp: It will be quality, yes, because people will get quicker treatment as well.

Q56 Kitty Ussher: For each buck that we put in we get a larger bang at the other end as a result of this policy?

Sir Nigel Crisp: That is what we are planning, yes.

Q57 Kitty Ussher: Will you in time be able to put a financial tag to that?

Mr Bacon: We can measure improvements in things like the failure to attend rates. In some earlier evidence from Barnsley, which is the community where this is most developed, we have seen some quite significant improvements in that. Over time, as this programme develops and as we get whole communities operating in it, it will be relatively straightforward to measure improvements in things such as that. Conversion into pound notes is a bit of an artificial concept. You can work it out because you know how much an out-patient really costs, so yes, we can and we will but at the moment we are rather early in the process to draw any firm conclusions from the very earliest figures but we do know, where this has been working for some time, that there has been significant impact already.

Q58 Kitty Ussher: I read in the newspapers that we have a highly productive Health Service. Our productivity is higher than other European countries. Do you think the introduction of choice will raise our productivity in the NHS even further?

Sir Nigel Crisp: I think it will, yes.

Q59 Kitty Ussher: I read elsewhere that on a pilot scheme, I think, in London about 18 months ago when someone had been on the waiting list for more than six months they had been offered a choice. It was quite expensive because the health authority presumably had to spend money to commission the extra capacity to make choice a reality. Am I right in my recollection?

Sir Nigel Crisp: Mr Bacon ran it.

Mr Bacon: I was the London director who introduced it. You need to look at this rather differently from this particular development because at the time we introduced that we were offering to people who had been on the waiting list for some significant time, six months, the opportunity to go to another provider. That in organisational terms is quite complicated because it requires you to get information passed from the hospital you are booked into to the one that you are choosing to go to. There are quite a lot of mechanics and advice that go into that. The purpose of that was as an experiment as to whether people wanted to exercise choice if we offered them the opportunity. There was demonstrable evidence in the London pilots that when people were offered choice they indeed took it. Something like 70% of people in the first phase of the London patient choice project opted to exercise that choice. I do not think you can derive a comparative cost from this, which is offering choice from the outset, so you do not have the complexity of having to move from one hospital to another, having already been booked in.

Q60 Kitty Ussher: Surely there is something which is still the same, which is that the health authority still has to commission other providers in order to provide a real choice which costs money because you are commissioning?

Mr Bacon: The way in which this will work essentially is that for elective care, which is what we are talking about in this case, what the primary care trust will do will be to establish a framework agreement with a range of providers. As people choose them, their primary care trust will reimburse the hospital the patient has chosen. You are not setting up formal volume contracts in the way we do now with each of a whole series of providers. As we introduce this, that volume concept will go and it will be based on where people choose to go. That is why in a sense there is an incentive for hospitals to offer the very best service so that they attract patients and the money that will come with them.

Q61 Kitty Ussher: What will the contract look like? Will it say, "We think you may have to provide, for example, 3,000 ----"?

Mr Bacon: In planning terms, primary care trusts will take a view about the volume of elective activity that their community is likely to want during the course of a given period. One of their jobs strategically will be to ensure that that volume of activity is broadly in the system and that there is a choice in people being able to deliver that volume. The contracts between PCTs and the providers of those services will be very much around quality, standards of access, standards of facilities. They will not be about the volume. Volume will not be written into the contracts.

Q62 Kitty Ussher: The contracts will not have to change?

Mr Bacon: No.

Q63 Greg Clark: Sir Nigel, I understand that your department has a public service agreement which requires by the end of this year that every hospital appointment will be booked for the convenience of the patient. Are you on target to meet that?

Sir Nigel Crisp: Yes.

Q64 Greg Clark: Despite the fact that the new Choose and Book system will not work by then?

Sir Nigel Crisp: We have two targets. One is that people will have the opportunity to book which we have been rolling out for some time, doing it manually. The figures on that are encouraging. Secondly, we have this target to introduce that GPs will offer a choice of four providers. We expect both of those to be met essentially on 1 January. By "essentially" I mean within a few percentage points of 100%. On the electronic booking that will make it easier, smarter and able to be better, we are behind.

Q65 Greg Clark: The target does not depend on that?

Sir Nigel Crisp: No.

Q66 Greg Clark: You will not meet the target for the electronic booking system. Do you have a revised target for when you might aim to meet it?

Sir Nigel Crisp: No. At the moment, we do not have a PSA for it anyway at all. What we are saying on that is that we believe we are just about 12 months late. It is moving very fast at the moment. The increase is very substantial. We will have a much better position in two or three months' time.

Q67 Greg Clark: You have had a target; you are not going to replace it with another?

Sir Nigel Crisp: No.

Q68 Greg Clark: The new system, as I understand it, allows bookings to be made between zero and 13 weeks from the point of referral to GPs?

Sir Nigel Crisp: Yes.

Q69 Greg Clark: The waiting time target however is 18 weeks by 2008, I understand. Can you explain the anomaly?

Sir Nigel Crisp: On 1 January the maximum waiting time will be 13 weeks. We have to cater with the situation from 1 January to 2008. The system is configured to enable us to do that. The 18 week target will obviously mean that in principle, by the time we get to 2008, the maximum wait for an out-patient will be of the order of five or six weeks. We will not use all the slots.

Q70 Greg Clark: In the last quarter 200,000 people were waiting more than 13 weeks from the point of referral from their GP. That being the case, at least in some hospitals, what is going to happen? When the GP logs onto the system are all the slots going to be taken from the beginning or are we going to have the situation that we have had with GPs recently that you have to get in to see your GP the day the booking is open in order to get a slot?

Sir Nigel Crisp: There are two slightly different things here. One is the 200,000 that I think you are referring to are people who have waited more than 13 weeks. By the time we come to 31 December or 1 January, we believe we will not have anyone waiting more than 13 weeks.

Q71 Greg Clark: There will be no possibility?

Sir Nigel Crisp: That is a PSA target and one that we expect to be able to hit. That will be the position then. There will then obviously be a build up because each GP only makes about one referral a day.

Q72 Greg Clark: That does not resolve this matter. Suppose it drops down to 12 weeks. It is still the case that most of the slots in any particular 13 week period will be occupied by people on the waiting list so what happens? You need to go to the GP the day the booking opens for that precious last week of availability?

Sir Nigel Crisp: No, it does not quite work like that. I understand the point you make, that there is going to be a residual number of people waiting at any given time. How many slots will genuinely be open to them?

Q73 Greg Clark: You have a 13 week period. Suppose by great good fortune you get below the target and the average waiting time of 12 weeks. That means that 12 out of those 13 potentially available slots are taken. There is not a choice.

Sir Nigel Crisp: The average waiting time at the moment is about six or seven weeks. The maximum is 13 weeks. We will have many of the slots taken but people do not fill up the slots from the beginning, if you see what I mean. Somebody may have a clinic and they will not necessarily fill all the slots in that clinic and wait for the next week's clinic and so on, for reasons which I am sure we can ask any of the clinicians to talk about in terms of how they do it.

Q74 Greg Clark: You have a window that is open and the longer the waiting list the fewer slots are available. That is right, is it not?

Sir Nigel Crisp: That must be right but that does not mean they are all in the 13 week period.

Q75 Greg Clark: Are we not heading to the situation we have had with GPs that, when this window opens, you need to get to your GP pretty quickly. Otherwise he is going to say to you, "I am afraid there are no slots available in this window. Come back and see me in 13 weeks' time".

Sir Nigel Crisp: No, it will not be anything like that.

Q76 Greg Clark: Why not?

Sir Nigel Crisp: There are 13 million first out-patient appointments a year, 1.1 million a month. On 1 January, presumably we will have a waiting list and the 13 weeks will cover 3.3 million slots. All those slots will not be filled. The average waiting time at the moment is about six weeks, something of that sort, so I guess there are probably about 1.5 million waiting. There will be plenty of slots for people to be booked into and we will maintain our guarantee that nobody will wait more than 13 weeks, unless they choose to.

Q77 Greg Clark: Can you book an appointment beyond 13 weeks?

Mr Bacon: It would be perverse, we think, if choice meant that you could not choose to wait longer than 13 weeks. That would be a perverse policy to adopt. What we are saying though is that a hospital needs to be able to offer an appointment within the 13 week guarantee. If a patient chooses to wait longer, that is their choice, but hospitals must be able to offer that slot.

Q78 Greg Clark: Will you be electronically able to book an appointment in three months' time with the system?

Mr Bacon: Yes. Eventually, as the system gets fully embedded ----

Q79 Greg Clark: You say "eventually" but I understand from the diagram that hospitals will release 13 week blocks of appointments. If that is the case, how is it possible to make an appointment for 20 weeks hence?

Sir Nigel Crisp: Can we come back on that? The policy is very clear. We will not force people to come in early and we therefore need a mechanism for the fairly small number who want to wait 20 weeks.

Q80 Greg Clark: It is also the case that patients can book appointments 13 weeks ahead but consultants can schedule leave six weeks ahead. Is it not the case that sometimes patients will have an appointment that is going to be cancelled because the consultant is on holiday? Is that correct?

Sir Nigel Crisp: They might do but this is also why consultants work in teams. Depending on whether the consultation you are going to is ----

Q81 Greg Clark: The appointment will not be cancelled because the appointment will be for a team rather than an individual?

Sir Nigel Crisp: It may be because that is what it is at the moment.

Q82 Greg Clark: If it is for a particular individual, the system will allow that appointment to be cancelled if the consultant exercises his right to go on holiday within six weeks.

Sir Nigel Crisp: We have designed for the point now. The first point is that we are getting these waiting lists down to well within that six weeks. By 2008 we expect the maximum waiting time to be four to five weeks. Equally, we do have patients now who are being booked for longer than six weeks.

Q83 Greg Clark: Surely you are hoping to improve on that, Sir Nigel. You objective is that appointments will be booked for the convenience of the patient. We have a situation where a patient can book an appointment and have it cancelled because the consultant has booked to go on holiday within six weeks.

Sir Nigel Crisp: You are quite right that a consultant could decide at a later date to go on holiday after six weeks but what we are trying to do is firstly to bring in the maximum so that it is under six weeks, so that does not apply. Secondly, for an awful lot of out-patient attendances, it is the team that the patient will see rather than the individual.

Q84 Greg Clark: Is that an improvement on the service if a patient sees a team rather than a named individual?

Sir Nigel Crisp: It depends on the circumstances.

Q85 Greg Clark: Is that a change of policy?

Sir Nigel Crisp: No. We are not changing policy on this.

Q86 Greg Clark: Is it a policy now that patients see a team rather than an individual?

Sir Nigel Crisp: It depends on the particular service.

Q87 Greg Clark: The benefit will depend on whether they have to see an individual or a team?

Sir Nigel Crisp: It depends whether we are talking about relatively high number, relatively small impact reasons why people are going to see a consultant or whether they are going to see a consultant for something very highly specialised, in which case I am sure any GP would say, "The person you need to see is this individual." If you have somebody who needs a hernia treated, you may be willing to send them to somebody else.

Q88 Greg Clark: Two thirds of GPs say that they are not going to offer this choice. How are you going to make them?

Sir Nigel Crisp: I do not think they have said that. I think what was said was that, in a survey carried out in August, 61% were unwilling to offer this level of choice. Let us see what happens in practice when those GPs both have seen the system, have used it, have as much of the support as Dr Lakhani and Dr Colin-Thome talked about and have a patient in front of them. Let us see what happens then. You will also notice in this that we have been having discussions in terms of what the contractual arrangements are with GPs and whether we should negotiate something as part of their terms and conditions.

Q89 Greg Clark: Is the NAO wrong when in our brief they conclude that most respondents said they are unwilling to offer the department's policy goal choice of four providers by 31 December?

Sir Nigel Crisp: That is exactly what they said, yes.

Q90 Greg Clark: The NAO said that most people, 61%, are unwilling to offer the choice of four.

Sir Nigel Crisp: Yes.

Q91 Greg Clark: How are you going to make them conform?

Sir Nigel Crisp: My answer was let us first of all introduce the system to those GPs so that they can see what it involves. When that happens we will see people taking them up. Let us roll out the information for patients so that maybe the patient is coming into the GP's surgery saying, "I gather you are going to offer me this range of choice. I am pleased about that." Let us also see how we can do what Dr Lakhani asked for, which is to provide all support for GPs so that GPs are not against this and worried it may add to their workload. Those are all the reasons why we have people like Dr Colin-Thome working to make sure that this will work.

Q92 Chairman: Dr Vautrey or Dr Lakhani, do you want to comment?

Dr Vautrey: Yes, please. On the issue of choice and whether GPs will want to adopt this or not, it is a question of whether they are offering choice with a capital "C" or a small "c". GPs want to offer their patients as much choice as possible. If I have a patient in front of me with relatives who live 200 miles away, I would like the option to refer them to a hospital near their relatives' house so they can recuperate after the operation has taken place. What GPs are commenting on in that particular survey is whether they are offering the four or five politically driven choice agendas that have been alluded to. As has been mentioned elsewhere, in many places it is not an important factor for that particular patient. There is not any meaningful choice because they are in a community where there is only one, possibly two, hospitals. In London, the choice of four or five is too small. We want a choice of six or seven to be provided.

Q93 Chairman: What do you mean by "politically driven"?

Dr Vautrey: It is about the sense that the GP will be forced to go down the road of saying to the patient, "Look, I have been told to tell you that there are four or five choices of hospital and it happens that the fifth choice is 60 miles away, but I have been told to tell you this choice is available"; whereas, taking the patient's needs into context, you may well feel that the service 60 miles away is the best for that particular patient. In that case, you will want to be able to refer them in that context.

Q94 Greg Clark: The question arises for me, despite the reservations, are they going to do it? Are they going to offer four choices as required?

Dr Vautrey: Sir Nigel is right that the Department and the BMA are currently in negotiations about how that mechanism might operate but it certainly will not be in place for 1 January; there is no facility to see that happen. Just on the issue of the risk the appointment slots being booked up before a patient walks through the door, one of our fears is that you could have the situation you see in general practice at the moment where there simply is not the capacity in the system to provide the choice people want. What might happen is a perverse lack of choice, so you might find your local hospital, the one you want to go to, has been booked up because it is seen to be a good hospital and people outside the local community have been referred to it, and then because you happen to be coming in on a Tuesday afternoon your choice is limited to what is available maybe 60 miles away. So there is a risk that could happen if the capacity is not there to fulfil those possibilities.

Dr Lakhani: Can I say, talking about the issue of choice of referral to a team or a named consultant, I think this is quite an important issue which is of concern to patients. Many consultants work in teams. For example, in vascular surgery which is a very specialised area you are referred to a unit or a team, and the team decides which consultant will see that patient. Similarly for orthopaedics there is a directorate approach, so referrals are made to a unit and the patient is seen by any number of people. The issue arises where a patient wants to see a named consultant, and I have had a specific example of that where a patient had a prior clinical relationship with a consultant many years ago and wanted to see the same consultant again but under current local guidance that was not possible because we have to refer to the directorate. So I would like to suggest under patient choice there should be a facility, an ability, for patients to choose a named consultant and, similarly, for general practitioners to be able to nominate a consultant if that is appropriate for the clinical condition of the patient.

Dr Colin-Thome: Many of us have developed alternative services to senior consultants, it does not have to be that every patient has got to see a senior consultant, so choice in your area could be GPs who have taken a special interest in a clinical area who are suitably accredited who provide a range of services. That is one choice. The other is that this is set in the context, as Sir Nigel says, of a much broader reform. About 30 million out-patients are follow-ups and many of them we think could be more appropriately done in primary care or, with the right advice, patients will not have to have them at all because they are not of clinical value. That way, you will get more capacity for the first appointments which we would like them to have, so it is part of that wider issue. 31 million is a lot of people and we think we could provide a lot of those services in primary care settings.

Q95 Ms Johnson: I would like to explore a little more the named consultant and the things I am interested in as a patient. I have looked at the latest report and the information a patient would require in order to make an informed choice, and I just wondered if you could comment on the clinical data that is available to patients at the moment. If they want to make an informed choice about going to a certain department or a certain named consultant, what information is actually available to patients?

Dr Colin-Thome: At the moment not a lot, and that is why I want to have that information readily available in the Choose and Book system. As a GP I might know one or two consultants but I would not know the range of services they offer. At the moment in the Choose and Book system you will get some view about waiting times, hospital cleanliness and food. What we will be driving as practice-based commissioners is hospitals putting much more clinical information in - what are the qualifications of the hospital team, what are their outcome measures and so on - and this will be a rolling programme. We just need more information. Currently we do not have enough of that and neither, by extension, do our patients. That will improve.

Q96 Ms Johnson: Do hospitals at the moment have records about, for instance, the mortality rates of certain individual doctors and departments?

Dr Colin-Thome: The answer is they have hospital statistics, which you can actually attribute to individual consultants.

Q97 Ms Johnson: Will that information become available to GPs who will then give an informed view to the patient?

Dr Colin-Thome: Yes. There have to be caveats because some consultants are seeing a case mix which is much more severe and you will want to compare them with like consultants rather than consultants who are seeing the same old day cases. Within that caveat, that information needs to be available and that is what we are working on, including having bench-marking around different hospitals.

Q98 Ms Johnson: I know Sir Nigel said that as we start to make choices the NHS will be able to provide more information. Have you any idea when this kind of information will be rolled out?

Mr Bacon: We must be clear that we do not have a huge amount at the moment and we need to start modestly, so it would be wrong of me to boast that by 1 January we will provide all the information that patients could possibly want. We are commissioning at the moment, and it will be available for each PCT by 1 January, a leaflet which will inform the patients of the choices which are available to them in their locality, the services which are offered and some basic information. As David Colin-Thome has said, progressively both through hard information, leaflets, but more importantly through the Choose and Book system, a data base of information will be built up. Again, as Sir Nigel said, it would be in the hospital's interests to put as much of their data as they can on the screen to demonstrate to patients that they are a hospital that patients would want to choose. So modest beginnings, we admit, but this is information which is not currently available, so it will add to what is already available to patients, and then progressively that information will be increased. Up to a point, if I may just add, in a sense we will be asking patients what information they think is relevant, because at the moment a lot of this is driven by what we think patients would want and progressively we will ask patients what other information it would have been useful for them to have in making their choice.

Q99 Ms Johnson: Do you have a view about the role the PALS might play in all this? Do you see them having a role advising patients?

Mr Bacon: David Colin-Thome may have a different view but I would hope this is very much the stuff of general practitioners and their patients which is the core source of this. That is, up to a point, what general practitioners already do, and this gives them more opportunity to do it.

Dr Colin-Thome: It gives them more information on clinical issues, but we do not have as much feed-back from our patients. We have funded the Department of Health to expand what has been developed in South Yorkshire where patients in their hundreds put their views onto a web page so we got accumulated rather than isolated information. Since we do not refer that many to hospital, you need a bit more support in getting information, but the clinical information we would be very keen on. I am not just picking on hospitals because now, with GP contracts, people have access to information about primary care performance too.

Q100 Ms Johnson: How will we practically know GPs are offering the right number of choices? Is there a form which is ticked? Is it on the computer? How do you know?

Mr Bacon: Initially at least we know that all of our primary care trusts have made arrangements which will offer the number of choices which are required, so the opportunity for GPs to offer those choices will be present from 1 January. As you have discussed with this panel during the course of this afternoon, there is a second and much more important stage to ensuring GPs actively engage in this process, and we encourage them to do so. The way we will tell whether that is happening is by patient surveys, and the best way to find out is asking the patients whether they were offered meaningful choice, and we will do that on a regular basis to see how this is developing. As Dr Colin-Thome mentioned, we are in discussion with the BMA about how that might be added to the contractual arrangements.

Sir Nigel Crisp: We will ask the patients.

Q101 Ms Johnson: Can I ask about the PCTs and the role of the practice-based commissioning. What kind of time lag will there be? You have practice-based commissioning or patients choosing to go to a certain hospital provider, the PCTs will obviously be there in this strategic role, what is the time lag before the PCT can recognise there are problems developing in the hospitals in their area, because it seems to me this might take quite a long time for it to become apparent there is a problem and the PCT then has to take some action?

Sir Nigel Crisp: If it is a big shift of the sort that Mr Trickett was envisaging, I think that will be spotted within the first two months of the change happening. I think people will notice that the referrals to their particular service have gone down. I suspect that will be relatively rare. I think it will take longer to see some of the subtler shifts, such as which people are making the choices and why, and I think you are on a longer feed-back loop there. I suspect when this happens you will find one or two places around the country where actually patients do not want to get to a particular service, in which case we will spot it very quickly.

Q102 Ms Johnson: You might be about to tell me you are going to survey patients, but how will you be able to tease out exactly why patients are not choosing to go to a particular hospital, a particular provider? There is a whole range of reasons why they might choose not to go to that particular hospital, how will you tease that out?

Sir Nigel Crisp: The wonderful "I won't", if you see what I mean. This is something which needs to be done locally, this needs to be reflecting the GP feed-back from "What are people saying to you in your surgery about why they are preferring to go there". Certainly the PCT will have a responsibility to do that, looking at what patients are doing and getting feed-back from GPs. But I am sure the providers, ie the hospitals themselves, will want to try and find that information out very quickly because, as Mr Trickett has said, this is very serious.

Dr Colin-Thome: We as GPs, with that feed-back, would not want to be referring there, so our engagement with the hospital, "We need to shape up" would be quite stark.

Sir Nigel Crisp: Remember, this is still a National Health Service, these providers and PCTs are still working together to improve services to patients.

Q103 Ms Johnson: My concern about asking patients all the time is that I have certainly come across hospitals and PCTs where the response rate by patients being asked questions is very low. If you have perhaps patient groups which come from certain ethnic minority communities it is often more difficult for them to respond. So I am concerned there is not an onus put on the clinicians to be feeding back rather than waiting to ask questions of patients at a later date.

Sir Nigel Crisp: You are obviously absolutely right, and you will have noticed, for example, with the event which took place in Birmingham in October, that we are trying different ways of getting closer to patients, and that was meeting with a wide group and cross-section of patients from across the country and looking at the details of what they wanted. We need to find ways of reaching people who do not normally fill in surveys. You are quite right, we need to do all that.

Q104 Sarah McCarthy-Fry: I would like to pick up on Jon Trickett's point about travel costs and whether choice is a realistic choice if it means further to travel. On page 19 the report says that patient's ability to travel is taken into account with those who currently get free transport continuing to get free transport. What are the criteria for people getting free transport?

Sir Nigel Crisp: I might need to give you a note on that, unless one of my colleagues immediately knows the answer.

Q105 Sarah McCarthy-Fry: Does it tie in with income support, benefit levels?

Sir Nigel Crisp: I will tell you why I am hesitating. I think it varies around the country. Can I come back to you on that? I am sorry I cannot give you a precisely accurate answer.

Q106 Sarah McCarthy-Fry: If it varies around the country, is that not going to be a bit strange when you are asking people to go to different parts of the country and some people are going to be paid for travel and some people are not going to be paid for travel? Is that not something you should look at?

Sir Nigel Crisp: It is slightly more complicated than that because there is free travel and there are also people for whom we provide hospital transport, so it is not one thing. It is not that we give you a bus fare necessarily, it is actually that we may provide an ambulance depending where you are in the country.

Q107 Sarah McCarthy-Fry: Is free travel just for patients or does it include family visiting as well?

Sir Nigel Crisp: I think it is almost exclusively just for patients.

Q108 Sarah McCarthy-Fry: Something which alarmed me which was mentioned earlier by one of the doctors, I cannot remember which one, I am sorry, was this scenario that my local hospital in Portsmouth is so popular that everyone from the surrounding area decides to choose my local hospital. I can imagine absolute uproar with my constituents if they thought that Southampton people were filling up their local hospital. Can we clarify, is that the scenario?

Dr Vautrey: It is. I am a GP in Leeds and Leeds has one of the biggest teaching hospitals in Europe. GPs in Leeds recently received a circular saying the pain clinic was closed to new referrals. That was because patients from outside the city have been referred into an excellent service but it simply cannot cope with the capacity that it was expected to provide a service for. So it now means we have not got a local pain clinic service and I can see these sorts of scenarios potentially replicating themselves. Somebody mentioned Great Ormond Street taking referrals and you can imagine the scenario where people say, "Ah, Great Ormond Street, that's the place for my child", even if they live 200 miles away. There is a risk that centres of excellence may find themselves bombarded by referrals, and also from referrals by patients with unmet needs, people who would not normally have been referred because the waiting times have historically been so great. Waiting times for the pain clinic have been inordinately long but if, as we would hope, the waiting times come down, then you can imagine that patients who would not historically have been referred will be so and that will put even more pressure on the services.

Sir Nigel Crisp: It seems like an argument for choice, in that case.

Q109 Sarah McCarthy-Fry: I find it rather worrying actually. Coming back to the point I was making about paying for travel, about people who do not get free travel to a hospital: imagine your local hospital is full but your most pressing need is that you want to be treated as quickly as possible, if you want to be treated now you are going to have to pay to travel to another hospital; you can only go to your local hospital if you wait a bit longer. Is that a realistic scenario?

Mr Bacon: What you and others have been describing are some transitional risks as we change the way in which the system operates. Coming back to your point about local people being squeezed out by others, there is a risk of that and one of our challenges is to manage that. Over time what we will see in the scenario you mentioned is hospitals will adjust their capacity upwards to enable them to absorb that or, if you take the Great Ormond Street example, Great Ormond Street are now actively placing their services, under their management, in other hospitals by agreement because they are very well regarded providers. We would expect these short-term issues to be resolved as the system matures. What we will have to look at is if there are cases of particular hardship. The rules are flexible, as Sir Nigel has said, they are based around low income or medical need and you could, in the scenario you have mentioned, take the view that medical need dictated that we would support transport costs. These are issues which could be resolved locally. So I do not think it is as rigid as perhaps is thought and there will be occasions where people can recognise the scenario you have mentioned. We would not make that a universal rule, that would be for local determination.

Q110 Sarah McCarthy-Fry: Can I come back to the point about adjusting capacity. You say we are currently running 85-90% capacity so there is some flexibility. When I spoke to the chief executive of my hospital trust, she said the optimum capacity was 85% and she would not want to operate above that, and some professionals think a high occupancy capacity could be a contributory factor to infection. Do you think there is a danger in increasing capacity to meet demand in that it could compromise other medical factors?

Mr Bacon: It very much depends on the specialty. The number you quoted, which is roughly the average of the country, 85, 86% occupancy, is a whole-hospital occupancy rate. Depending what specialty you are looking at, there are conditions which would make it safe to operate at a higher or lower level, so that is a composite rate. What a hospital will want to do for elective care, and that is what we are talking about in this scenario, is ensure it runs with just the volume of capacity to ensure it is able to deliver the choices people make without running significant excess levels and it will need the flexibility at the margin, as we said earlier. We need to split the occupancy rate between the various specialties. If you take the cross-infection rate, for example, obviously the more an invasive wound you have the more risk there is of cross-infection, so there you would want to keep your occupancy rates lower to ensure you have time to clean and keep cases of infection separate. So it is quite a sophisticated figure to embrace within one average statistic.

Q111 Sarah McCarthy-Fry: Coming back to capacity, in paragraph 1.21 there is a statement which says that in the long-term over-subscribed providers can cope with an inability to meet demand by increasing capacity with additional revenue. However, you appear to be describing a self-balancing system where over-subscribed providers scale back demand by withdrawing from the PCT menu, waiting lists will go up and patients would not choose to use them. It sounds like a self-balancing mechanism. They would no longer then be over-subscribed. Where would they get the additional revenue to make the additional capacity?

Sir Nigel Crisp: To create the additional capacity?

Q112 Sarah McCarthy-Fry: Yes.

Sir Nigel Crisp: From the fact that money follows patients.

Q113 Sarah McCarthy-Fry: So you are only talking about going up to their maximum, you are not talking about them expanding and building new facilities?

Sir Nigel Crisp: I am quite sure that will happen in some cases. They will need to go through the normal process, depending whether they are a foundation trust, an NHS trust or a PCT for that matter, of securing capital against a view on future revenue stream, which is the process we go through at the moment. If you have a very evident picture that actually the people of Southampton would rather go to Portsmouth - I had better be careful about something like that - or whatever picture you are seeking to paint, and you can see that is what is happening, that would enable capital to be released through the normal way to expand if that is what needs to happen. But people could also make the decision that the most sensible thing to do would be to concentrate on trying to improve the services at the other end. So it is not a single thing here. We are talking about an awful lot of organisations and people will make decisions which are sensible in their local circumstances, or we will try to help them to make the decisions which are sensible locally.

Q114 Sarah McCarthy-Fry: In the example, you mean a decision to build capacity in Portsmouth or to put in additional funding to improve Southampton?

Sir Nigel Crisp: Again it depends whether we are talking about a foundation trust or a hospital trust but basically the hospital would need to do that.

Mr Bacon: First of all, I would hope this would be in many cases a community decision because, as I was answering earlier, one of the jobs of the PCT is to ensure in its local community there is sufficient capacity and there is choice. So the PCT itself might stimulate a popular provider to think about expanding its capacity. If that is what is required, if they are an NHS trust in the current circumstances, if it is a small-scale investment they would have discretionary capital to do that through their own decision-making; they would not need to ask anybody if they could do that. If it was a bigger development and there was a proper written case approving the process, they could access either a Government-funded scheme or go the PFI route. If they are a foundation trust, that is a matter for their agreement with the regulator whether they can make that investment. So once the community, the trust or the PCT, or in most cases together, has decided they want to increase capacity, then there is a clear route to access the facility to be able to do that.

Q115 Sarah McCarthy-Fry: One very quick question which should have a yes/no answer: will all hospitals offer treatment at the same price? All providers?

Sir Nigel Crisp: Yes, there is a national tariff. We are not negotiating on price, we are negotiating on quality.

Q116 Mr Bacon: Mr Bacon, the Department of Health said last week that there were now 20,297 bookings. This was as at Wednesday 26 October. How many of those are telephone bookings?

Mr Bacon: I do not know the exact answer but I will tell you why I do not ---

Q117 Mr Bacon: That is the thing I am interested in.

Mr Bacon: I will tell you why ---

Q118 Mr Bacon: Can I just pursue my question in that case. In June it was 1,000, now it is 20,000 and the Department of Health were saying last week that the increase was based on fully electronic bookings. After further questioning, the Department of Health conceded that these statistics included telephone-only bookings, and because some GPs are unable to access the system they are giving patients a print-out which they take away and then make a phone call. What I want to know is, of the total 20,297 bookings which you have had so far - a big increase from the 1,000 in June, although admittedly a little short of the 10 million per year you are looking for - how many of those extra 19,000 have been done over the telephone. It seems a fairly simple question.

Mr Bacon: I can tell you why I do not know. The answer is that the number we quoted, and we quote regularly, is the number that the Choose and Book system itself clocks of the transactions which have gone through that part of the system. So that is an accurate number of the transaction bookings which have been utilised through the Choose and Book software. There are a number of ways that can happen. The first is the one we would like ----

Q119 Mr Bacon: The answer to the question is you do not know. Can you find out?

Mr Bacon: I can certainly try but that number is derived from the Choose and Book software itself which has a part-repayment mechanism to our supplier.

Q120 Mr Bacon: I am interested in how many were unable to be completed save through the telephone.

Sir Nigel Crisp: With respect, that is not the point.

Q121 Mr Bacon: I am sorry, it is my point, Sir Nigel. There were bookings which were unable to be completed ----

Sir Nigel Crisp: No, they are not unable to be completed. You are perhaps aware of the system, that people may then choose to go to the telephone ----

Q122 Mr Bacon: The system if it were any good, and you have spent hundreds of millions of pounds of taxpayers' money on it, ought to show you how many had been completed through the system. I would have thought it was fairly obvious. If you can send us a note, that would be very helpful.

Mr Bacon: I do not need to send you a note to tell you that is how many have been recorded on the Choose and Book software, because it is part of the contract that we need to know.

Q123 Mr Bacon: That you need not know?

Mr Bacon: That we need to know how many transactions have been processed through the Choose and Book software, so that is an accurate number.

Q124 Mr Bacon: Yes, but I am trying to find out how many have been completely booked through the telephone.

Mr Bacon: I was explaining that there are a number of ways in which patients can now and will in the future be able to use this system.

Q125 Mr Bacon: I will move on if I may. Can you tell me what a pin number is?

Mr Bacon: It is what you have on your ---

Q126 Mr Bacon: What does it stand for?

Mr Bacon: Personal identification number.

Q127 Mr Bacon: The P stands for personal?

Mr Bacon: Yes.

Q128 Mr Bacon: What is a pin number designed to promote?

Mr Bacon: Security.

Q129 Mr Bacon: So if a PCT issues smartcards to its staff with identical pin numbers for every user, that would be an egregious breach of security?

Mr Bacon: It would be a serious breach which has happened, as you no doubt know, and we have investigated and taken action accordingly.

Q130 Mr Bacon: It is correct, is it not, that this particular PCT had also put the pin number on the back of the card, just to make sure its users, who in any case only had one number to remember between all of them, could remember that number and still use the card? That is correct, is it not?

Mr Bacon: This is a serious breach of the rules, we have ----

Q131 Mr Bacon: I am asking if this was correct.

Mr Bacon: Yes.

Q132 Mr Bacon: Could you tell me, since I put down a Parliamentary Question on 14 July and I still have not had an answer other than a holding one, which PCT it was which did this?

Mr Bacon: I do not know the exact one but I know it was one in Essex.

Q133 Mr Bacon: I presumed, from the article I read on E-Health Insider, it was one in Essex because it was a GP in Essex who reported it. Would it be, by any chance, the Castle Point PCT?

Mr Bacon: I would be guessing if I told you.

Q134 Mr Bacon: Could you find out and send us a note?

Mr Bacon: I will do that.

Q135 Mr Bacon: That would be very kind. Where patients' security is broken, it is true, is it not, clinicians, GPs, are individually responsible for breaches of security and theoretically could end up in front of the GMC?

Mr Bacon: If the GP was the person who did that, yes.

Q136 Mr Bacon: If the GP uploads the patient's data to the National Care Record Service and someone else then gets it using a smartcard and then uses the information inappropriately, are there any circumstances in which the GP could still be held liable for breach of the information?

Mr Bacon: I do not think so but I have not looked at it from a completely legal standpoint.

Q137 Mr Bacon: If you could send us a note on that, it would be very helpful. I have talked to GPs who have said they are very worried about this very point. I think it ought to be cleared up.

Mr Bacon: My GP colleagues might be able to answer.

Dr Vautrey: Certainly there have been concerns about the referrals up until the point the consultant takes ownership of the referral. In that grey area, in referral management, it is unclear and needs to be clarified whether the GP has responsibility if, for instance, somebody within a referral management centre does something inappropriate.

Q138 Mr Bacon: It has never been legally clarified?

Dr Vautrey: Not that I am aware of.

Q139 Mr Bacon: Mr Bacon, how many smartcards will there be?

Mr Bacon: In theory, we could be into several hundred thousand.

Q140 Mr Bacon: So quite a difficult population to control.

Mr Bacon: It is worth emphasising here that we have designed a system to the highest level of security. Access to the system, to start off, is like the new chip and pin system, so you need both to have something, a smartcard, and a piece of knowledge to access it. So we have set it at the highest possible level and the system itself has been designed with security in mind throughout.

Q141 Mr Bacon: In the case I have just mentioned in Essex, and I quote from the article in E-Health Insider, "One of the practices I work at has gone live with the smartcard. Using it you can get into Phoenix for the practice data without using a user name or a password." So the information might be available and no one would even know you had it.

Mr Bacon: There are some very clear rules governing both the issue and the use of them. We have set up what we call a registration authority to ensure these are carried through and wherever we come across a breach of the regulations, as the one you are talking about, we thoroughly investigate and we will - and have indeed - take action.

Q142 Mr Bacon: Has anyone been sacked for that?

Mr Bacon: I think I am right in saying that the individual concerned was a contractor and his contract was terminated.

Q143 Mr Bacon: What about the integrity of the data? I talked to a GP who said that, with my permission, he would like to look me up. I gave him my name and my date of birth and he, within two seconds, found my address, except it was an address I have never lived at because it was after I left school and before I went to university, although my mother lived there, and it was 23 years out of date. How is that sort of problem going to be overcome?

Mr Bacon: The general point is, as we load personal information on to the system so we will want to make sure it is continuously clean. The data which is on there is data which was in the records, as it were, relating to you from whatever source it was and the system picked it up. In the manual system, your information, whatever system we picked that up from, would have been incorrect. What we have to do, as we try progressively to put the whole population on the system, is try to ensure that as the system becomes populated it is as accurate as we can possibly make it and that it is constantly up-dated.

Q144 Mr Bacon: Is it correct that one of the fears hospitals have at the moment is that their recent, up-to-date, clean data is being overwritten by old garbage data of the kind I have just described when GPs access the system and try and put in information, and that is one of the reasons they are reluctant to hook up?

Mr Bacon: One of the reasons ---

Q145 Mr Bacon: Is that correct?

Mr Bacon: One of the reasons this system has taken longer to implement than we had expected is just those interconnectivity aspects. The reason we are taking longer and more care is to ensure those problems are kept to an absolute minimum.

Q146 Mr Bacon: When you say "just those interconnectivity aspects", is what I have said correct, that clean data is being overwritten by garbage at the moment, which is why people are reluctant to hook up? Is that correct?

Mr Bacon: I do not think so but again I will double-check. I am afraid I just cannot comment on an anecdotal example.

Q147 Mr Bacon: Dr Colin-Thome, you are a GP but you have a PCT background too. Do you think PCTs have enough money to fund and implement this system?

Dr Colin-Thome: Yes, I do. We have given the PCTs quite a growth in money in the last two years and the three years to come. The real issue, which ties in with some of the discussion we had before, is what we should be spending the money on and some of these areas of clinical practice we think we could alter, and that is why we want GPs to be involved. If you do that and change the way we provide the services nearer the patients, with more done in primary care, I think we have sufficient money to not only deliver all the services but have much more responsive services to patients where we can use Choose and Book more effectively. It will help me as a GP.

Q148 Mr Bacon: Dr Vautrey, I was speaking to a GP the other day who said, "It is difficult to understand how you can build a system which is not built around an understanding of the supporting business process. The failure to do this has had huge knock-on consequences on confidence. PCTs try to encourage GP practices to go down routes which have nothing to do with clinical business processes." Would you like to comment on that? Does it make sense to you?

Dr Vautrey: One of the problems is that we have tried to run before we can walk and before the system is functionally robust enough to work in the way we would like it to. As you alluded to, most of the bookings have been telephone bookings rather than direct computer-to-computer bookings. That is for a lot of complex reasons, because we are talking about a very complex system here, particularly the variety of primary care systems connecting with the plethora of patient administration systems in hospitals. It is no mean task to connect those two together, or the number of different connections which are required. One of the problems has been the various incentives and drivers to use the system, which has not been robust enough and ready to use, have caused a lot of frustration and made people question whether they wanted to engage in this particular service at the moment.

Q149 Mr Bacon: Do you think some of these problems could have been avoided if GPs had been consulted earlier?

Dr Vautrey: Absolutely. One of the fundamental problems all along has been the lack of clinical engagement at the early stage. That is now improving but it was certainly a flaw at the beginning.

Q150 Mr Bacon: Mr Bacon, you are the senior responsible owner of the project now, are you not? Who was the first senior responsible owner?

Mr Bacon: I think Sir John Pattison.

Q151 Mr Bacon: Who was the second?

Mr Bacon: I think that was Aidan Halligan.

Q152 Mr Bacon: What about Mr Granger? Was he not the senior responsible owner at one point?

Mr Bacon: Richard Granger is still the senior responsible owner for the IT implementation. My role is the over-arching ownership of both that part of the programme and all of the implementation of what is a very large and complex programme.

Q153 Mr Bacon: Is it correct that Mr Granger had specifically no responsibility for ensuring clinical engagement? It is a yes or no answer.

Mr Bacon: At the stage he was engaged in design there was a great deal of clinical engagement.

Q154 Mr Bacon: Is it correct that Mr Granger did not have responsibility for ensuring clinical engagement?

Mr Bacon: It depends what you call clinical engagement. I am not trying to avoid the question. Richard Granger's team ---

Q155 Mr Bacon: He is on record as saying it was not his responsibility. I want to hear you confirm that.

Mr Bacon: His team has in it, then and now, a significant number of clinical staff. What he did not have, and indeed has never had, is responsibility for the engagement of clinicians out of the service as part of the ---

Q156 Mr Bacon: Stop there and I will ask my next question. Dr Aidan Halligan, whom you mentioned, was appointed specifically with the purpose, as the senior responsible owner - he was Deputy Chief Medical Officer, was he not ----

Mr Bacon: Yes.

Q157 Mr Bacon: --- of securing clinical engagement. When was he appointed?

Mr Bacon: In the spring of 2004.

Q158 Mr Bacon: So quite a long way into the programme.

Mr Bacon: Yes.

Q159 Mr Bacon: Why was he not appointed at the beginning? Why was not somebody who had responsibility for ensuring clinical engagement appointed at the beginning?

Mr Bacon: Sir John Pattison was a very eminent clinician and ----

Q160 Mr Bacon: And he did have responsibility?

Mr Bacon: As part of the overall programme, yes.

Q161 Mr Bacon: By the way, where is Dr Aidan Halligan now?

Mr Bacon: He is now in Leicester. He is not employed by the Department.

Q162 Mr Bacon: Who has responsibility now for ensuring clinical engagement? You?

Mr Bacon: In overall terms, yes.

Mr Bacon: Thank you.

Q163 Mr Williams: Sir Nigel, can we return to one or two facts which have already been clarified as the basis of where we go in questioning? As of last December it is agreed there have been 63 bookings under the choice system as opposed to the 205,000 that were answered straight back. That is factually correct?

Sir Nigel Crisp: Yes.

Q164 Mr Williams: So at that stage for every 3,000 people who had been expected to benefit from choice, just one person was doing so. That is a pretty massive failure, is it not?

Sir Nigel Crisp: Yes. Clearly we expected to be further ahead a year ago.

Q165 Mr Williams: You are still in the situation, as I understand it from your replies, where you cannot give an estimate of the current numbers who are having full choice?

Sir Nigel Crisp: Yes, I can. As of 1 January, I expect basically all patients to be receiving full choice and the ability to book.

Q166 Mr Williams: How does that fit in with the evidence we have had from the National Audit Office, in the briefing, that at present more than half of the hospitals which are delivering Choose and Book are doing so through the Indirectly Bookable Service rather than the fully integrated Choose and Book?

Sir Nigel Crisp: This is the point I have been trying to make all along. Our responsibility is to deliver choice and to deliver booking arrangements. We would much rather do this through a fully integrated electronic system, but that is not actually the target which was set as part of the PSA, and it is that bit which is a year behind. The other two are on target.

Q167 Mr Williams: The Indirectly Bookable Service, as we are told, constitutes about half, is the most available way of accessing Choose and Book, but it does not allow patients to see appointment dates or dates before choosing a hospital. That is not choice, is it?

Sir Nigel Crisp: But the majority ---

Q168 Mr Williams: Is that choice? Is it any better than we have at the moment?

Sir Nigel Crisp: My point is that most of the people are going to have this handled manually in the short-term and only some will be using even the indirect system.

Q169 Mr Williams: We are back to this fact that other than the fully-fledged system, a major portion of the people are certainly at this point in time not able to make an appointment and know the appointment time and date before they choose a hospital, but that is what it is all about, is it not?

Sir Nigel Crisp: At the moment most people are able to do that. What happens at the moment with the GP referral system, what used to happen and still happens in a number of cases, is that you might just get a letter telling you, "Can you come next Thursday" and giving you a date. The arrangements we have been introducing for something like three years, part of it through something called the Partial Booking System, is that people then get a telephone call from the hospital ---

Q170 Mr Williams: If people have had to have made a commitment to the hospital before they get the information about the time and date, they have not had a meaningful choice, have they? That is a key element in the choice they might wish to make.

Sir Nigel Crisp: But as of January they will get a choice and then you will have a booking system which, as now, will be operated mostly through telephones. The point is, and I totally agree with you, the electronic system, which will make it better and make it operate better, is running behind.

Q171 Mr Williams: Okay. Let's come to the business case which was presented for this project. It was put forward that the Choose and Book estimated cost would be 153 million over six years, about 25 million a year, give or take. But the latest estimate shows that that has gone up to 260 million over six years. That is an increase therefore of 107 million, in other words a 66% increase in the annual cost. Is that correct?

Sir Nigel Crisp: Can you refer me to where you are quoting from?

Q172 Mr Williams: This is information from the business case we have had in our briefing from the National Audit Office. NAO, is there anything to suggest these figures are not accurate?

Mr Shapcott: The information is coming from paragraph 2.15 of the NAO Report which quotes 150 million as the original estimate and then a more recent estimate of 45 million a year.

Q173 Mr Williams: Where did that latest figure come from? Did that come from the Department?

Mr Shapcott: The latest figure was an up-dated estimate of one part of the service.

Q174 Mr Williams: You were not aware of this, Sir Nigel, that it has gone up 100 million or two-thirds?

Sir Nigel Crisp: I am not quite sure that is right. Paragraph 2.15 says there was an additional cost of 153 million for the Booking Management Service function ---

Q175 Mr Williams: We are told by the NAO the business case was 153 million over six years but later estimates put the annual cost at 45 million, suggesting it will cost 250 million over six years. The arithmetic is impeccable. You have apparently agreed the figures with the National Audit Office, so you have had an increase of 100 million or 66%.

Mr Bacon: If I may ---

Q176 Mr Williams: Of course you may. I am just trying to clarify the facts. You do not seem to be aware of them.

Mr Bacon: If I can run through the costs. The last figure quoted there, as I understand it, is derived from a volume of calls and the cost will depend on the volume of calls. The number there is a very high estimate of the number of calls we would expect to have. It depends very much, if you like, on the success of the project because the contract as we have let it is a fixed sum and then a variable element depending how much is used.

Q177 Mr Williams: Can I put it to you that had these figures been available at the time the business plan was put forward, you would perhaps have had greater difficulty in justifying this? Would you have had greater difficulty getting the business plan accepted by Treasury?

Sir Nigel Crisp: Let me come back to you on that because the two figures are not quite comparable, as Mr Bacon has just said.

Mr Bacon: At the moment we expect the system to accommodate just under 10 million calls. You then have to derive from that the fixed element because we pay an availability fee to the contractor and then a variable element as the number of calls increases. At the moment our cost estimate is based on the current activity which is 9.8 million. The 18 million is a top end range of what this system might produce.

Sir Nigel Crisp: In which case we might do another business case for the expansion.

Q178 Mr Williams: The information we have is information which the NAO has provided and is derived from information you have provided, and it is that the cost has gone up 100 million on 150 million. If we look at the report again and turn to page 9, paragraph 1.12, it says, "... benefits should eventually amount to 71 million per year, divided between primary and secondary care ...", 28 million for the primary and 43 million for the secondary. But now the costs have gone up by 20 million, I assume that the benefits will come down to 50 million, do they?

Sir Nigel Crisp: Can I just ---

Q179 Mr Williams: Just answer the question.

Sir Nigel Crisp: The costs have not gone up. If you go back to that earlier paragraph it says that if we used it 18 million times a year it would cost 45 million. We do not anticipate using it 18 million times a year, we anticipate using it 10 million times a year.

Q180 Mr Williams: So your failure is being used to justify the fact ----

Sir Nigel Crisp: No, I do not think that is what that paragraph is trying to say.

Mr Bacon: What we are saying is that the current number of out-patient bookings is 9.8 million and at that rate the cost is significantly less. The potential is there for the system to be expanded into other areas and for the bookings to go up. If it were 18 million, it would cost this number. The best thing is if we give you a model of the contract structure to demonstrate this. That might be helpful.

Q181 Mr Williams: If the costs have gone up, the savings must go down, must they not?

Mr Bacon: No, because if you are using the system much more extensively then the benefits will expand as well as the costs, because you will be exposing many more episodes to the benefits.

Q182 Mr Williams: Coming back to Sir Nigel, on this business plan, would these figures have been acceptable had they been in the business plan instead of the original figures?

Sir Nigel Crisp: I would ask what the additional benefit was and that is exactly the question I am asking now. If we were to presume the rate went up from 10 million to 18 million with all those additional costs, I would ask what the additional benefit was, which is what I think you are asking, but that is not what our expectation is at the moment.

Q183 Mr Williams: As I see it, on the basis of the figures we have just discussed, the annual cost has gone up 66%.

Sir Nigel Crisp: No.

Q184 Mr Williams: They have, according to the figures the NAO gave us. You and the NAO can argue about that. The whole point about these inquiries is that the figures are supposed to be agreed. As far as I can see, annual costs have gone up 66%, benefits have fallen 30%. That is not a very dramatic success, is it?

Sir Nigel Crisp: I do not think this paragraph says what you think it says, if I may put it like that.

Q185 Mr Williams: You read on. It says quite clearly what it says.

Sir Nigel Crisp: "... could have to field around 18 million calls a year ...", actually it is fielding 10 million. On that basis, the figures add up. If it did end up doing 18, you are quite right we will need to look at the benefit. Perhaps we can send you a note on that which we will agree obviously with the NAO.

Mr Williams: Yes. In the meantime I will take my figures as standing until I see anything which disproves them. Thank you.

Q186 Greg Clark: I am trying to capture the essence of this new system. Is it fair to say that under this new regime hospitals are going to be like football clubs? If your local hospital happens to be top of the premiership, the Chelsea of the NHS, shall we say, you are going to find that just like getting a seat at Stamford Bridge you have to be there as soon as the seats go on sale, in other words as soon as the booking slot becomes available, otherwise you have no chance of getting in. Is that right, Dr Vautrey?

Dr Vautrey: It is certainly a possibility in the short-term. Long-term there is a risk those big centres could start building bigger stadiums to take more population from outside and you will find the small hospitals are second division or third division.

Q187 Greg Clark: Is it fair to say if you are the Chelsea of the NHS you are going to have to be in your GP's surgery the morning booking opens for that period if you are to get in?

Sir Nigel Crisp: No, because happily we are a health service and our responsibility is very clear, it is to provide services to every person in this country regardless of their ability to travel to Chelsea or anywhere else. This policy does not sit alone, it sits alongside other policies which will ensure in Mr Trickett's area of the country we will continue to provide health services just as we may do in other areas of the country. It does provide an incentive for good providers to get better, but it also provides an incentive for good GPs to get better and, as you know, GPs are everywhere around the country as demonstrated by these three gentlemen from three different parts of, I think I am right in saying, the Midlands and the North.

Chairman: Thank you, gentlemen, this has been a very interesting inquiry. Obviously choice is desirable but there are clearly shortcomings in terms of clinical engagement in the way Choose and Book was rolled out initially and we will be reporting on those further. I am sorry, Mr Bacon has a further question.

Q188 Mr Bacon: Sir Nigel, Dr Lakhani said that the ability to book an individual particular consultant was in the opinion of many GPs essential. Is that going to happen? Is that going to be possible at some point?

Sir Nigel Crisp: If you have looked, and I suspect you have, at the Choose and Book system you will see that hospitals can specify the range of services which will be available to people and that will include exactly the sort of things that Dr Lakhani was talking about - you can book for the orthopaedic team because that is how they ---

Q189 Mr Bacon: No, I am talking about an individual.

Sir Nigel Crisp: ---- or you can book for the shoulder man if that happens to be the way they do it.

Q190 Mr Bacon: Dr Lakhani, you were referring to a named individual consultant because of a previous clinical history. Will it be possible to book a named individual consultant?

Sir Nigel Crisp: Where the hospital puts that on to the system as one of the options it is offering, the answer is yes.

Q191 Mr Bacon: But only if the hospital does that?

Sir Nigel Crisp: Indeed.

Q192 Mr Bacon: Dr Lakhani, is that from your point of view as a GP sufficient or would you like the system to be able to call for GPs to be able always to specify a named individual consultant?

Dr Lakhani: I think the relationships between GPs and consultants are very important; historically they have been very good. Increasingly there has been a certain distance between general practitioners and consultants and I think we have to be careful that any policy around choice does not increase that distance. I would like us to work at developing a system where choice includes naming a consultant if that is what a GP and the patient decides is best.

Dr Colin-Thome: We have influence over hospitals and that is what we do. If we want named consultants, we make certain we have them and that is what a practice-based system is about.

Q193 Mr Bacon: Sir Nigel, how much has Atos Origin been paid?

Sir Nigel Crisp: It will take me a minute to find the figure. As you know, we have a policy of not paying for things until they are delivered and are working, and that is a policy we have followed here, unlike many other people who buy things. That is what we have done here and we can give you precise figures.

Mr Bacon: The original specification for development plus the additional functionality we added last year cost 30.2 million. We have been paying an availability fee over the last year of 648,000, but the way the contract is structured means much of the payment is triggered when we reach a certain level of activity.

Q194 Mr Bacon: Could you possibly send us a more detailed note?

Mr Bacon: Yes.

Q195 Mr Bacon: Finally, how many public relations agencies have been employed on this? Given that Choose and Book is now less popular with GPs than it was a year ago, was it value for money?

Mr Bacon: I do not know the answer to that question, I am afraid. We certainly have some support in communications at the moment and I can give you details of the history, I just do not have the history myself to hand.

Q196 Mr Bacon: If you could send us a note of the number of agencies and how much has been spent, I would be very grateful.

Mr Bacon: I am happy to do so.

Chairman: Thank you, Mr Bacon. Thank you, gentlemen.