Examination of Witnesses (Questions 1-19)
PROFESSOR LORD
DARZI OF
DENHAM KBE, MR
DAVID NICHOLSON
CBE AND MS
RUTH CARNALL
CBE
25 OCTOBER 2007
Q1 Chairman: Good morning and welcome.
Could I welcome you to the single evidence session we are having
in relation to the NHS mid-term review. Could I ask you to introduce
yourselves and the position you hold for the record, please?
Mr Nicholson: David Nicholson,
NHS Chief Executive.
Professor Lord Darzi of Denham:
Lord Darzi, I am Minister in the Department of Health and I am
also a consultant in an NHS trust in London.
Ms Carnall: Ruth Carnall, I am
Chief Executive of NHS London.
Q2 Chairman: Once again, welcome.
I have to say, Minister, the poachers turned game keepers are
normally not from our advisers in past reports but actually from
people who sit around the table as members who then move over
into the Department for Health. I think this is probably a first
given that it was only last year that you were advising us on
our independent treatment centre report, but welcome to the committee.
Could I ask you if you could tell us why you are the right person
to lead the national review of the National Health Service?
Professor Lord Darzi of Denham:
Yes, Chairman. Firstly, I am a clinician, secondly I am still
practising and, more recently, as some of you will be aware, I
also had the fortune of doing a review of London's healthcare
as a clinician. That in itself was a unique experience to me as
a clinician, being involved probably with the biggest engagement
that I have ever been through, whether through clinical colleagues
in London but also with the public and the users of the service.
As far as credentials go, I think I have the right credentials
in doing the job. As far as choice goes, I think that was the
prerogative of the Prime Minister and the Secretary of State in
their choice of who does lead this review.
Q3 Chairman: Do you think that clinicians
are the right people to design and manage reform programmes in
the National Health Service?
Professor Lord Darzi of Denham:
I believe so, for a number of reasons. Firstly, there is a lot
of evidence out there, and I see it on a weekly basis actually
in the response to the patients that I see on Friday, Saturday.
The first thing is: "How are you getting on with the new
job", and delighted to see someone who is actually practising
to be part of the team, but I think modern healthcare is a very
complex system. I am, as I work back in the hospital, part of
a much bigger team than I have ever been; in the department I
am part of a team as well. As far as the public and the patients
are concerned, I think most of us will know that if you look at
the NHS Confederation report, if you look at some of the media
analysis, the public and the user have greater confidence in clinicians
than they do with politicians and managers.
Chairman: That is quite interesting.
I was going to ask you if there is any evidence based on that,
but I will forego that question for now and move over to Mike
Penning.
Q4 Mike Penning: Minister, the interim
report Our NHS, our future, which you released on
4 October, could have been released when Parliament returned a
few days later. Why did you release it before Parliament was back?
Professor Lord Darzi of Denham:
Firstly, let us go back to July when I was asked to do the interim
report. Actually the review was launched on 4 July and, to be
honest, it was said in the terms of reference for the review that
I should publish an interim report in three months. That in itself
was a bit of a shock to me, because three months is a very short
time to come up with an interim report. The justification for
that was that we had to have an interim report before the CSR.
Three months from 4 July was the first week in October. I knew
I had to publish it before the CSR, I also knew that the CSR was
going to be published in the first week when Parliament returned.
That is why I published it before. Why did I not publish it in
Parliament? It is an interim report, it is not my final report,
and I would like to stress that. This is quite a big undertaking
when it comes to reviewing the future of the NHS over the next
ten years.
Q5 Mike Penning: The Prime Minister,
who appointed you as a minister, said he would put Parliament
first, and it would only have been a few days later that your
report could have been brought before this House as an interim
report, which you have quite correctly described it as, so that
parliamentarians did not read in the press your plans for the
future of London hospitals, et cetera. Surely there is a degree
of naivety by bringing that out early.
Professor Lord Darzi of Denham:
As I said earlier, the CSR was on the Tuesday, if I am correct,
the second day after Parliament returned. I felt very strongly
that I should have the interim report before the CSR.
Q6 Mike Penning: Your officials did
not advise you that this would cause problems. Did they not advise
you, as a new minister with a huge amount of experience of politics
in Westminster, that this would cause huge ructions if you released
it a few days before Parliament returned?
Professor Lord Darzi of Denham:
The answer is, no, because it was an interim report. That is the
advice they gave me.
Q7 Mike Penning: No-one said to you,
"Get it out early" or, commonsense prevailing, "Wait
a couple of days." It was your decision.
Professor Lord Darzi of Denham:
No. It was my decision to be publishing it that week. It happened
to be on the Thursday.
Q8 Mike Penning: Can I push you for
a second on that. You were not advised at any stage to either
release it early by other ministers or the Secretary of State
or advised, "Wait a minute. It is going to cause a huge problem
if you release this a couple of days before Parliament returns"?
Professor Lord Darzi of Denham:
I was not advised that it is going to create a huge problem if
I do not publish it, if I do not announce it in the House.
Q9 Mike Penning: I think you need
some better advisers then. You talked about being the honest broker.
You must have realised, when the reports and everything was around
the non-election, that that would damage your ability to be the
honest broker within the NHS, when you got sucked into this election
fever?
Professor Lord Darzi of Denham:
Firstly, why am I doing this ministerial role? I strongly believe,
as a clinician, that being given the role of leading this as a
minister certainly will give me the responsibility and the power
in making sure that this report is done very much based on the
terms of reference which we set in July, which was clinically-led,
patient-centred and evidence-based. As far as whether my credibility
has an impact being a minister, the answer is, no, I do not believe
that. I think the privilege of serving is the way I compare it
to the great privilege to treat patients. Beside that, having
the privilege of serving the country is the second best thing
I do. As far as the question you are asking, the publication of
it in October, it is something we decided in July. I cannot remember
an election fever in July.
Q10 Mike Penning: The public do not
know you made that decision in July. What we all know is what
you have released on the date, and even though I respect fully
your commitment to the NHS and to patients, you are Minister of
State, you have taken the Labour Party Whip, you have collective
responsibility with government. What was going on at the time
to do with election fever you were implicitly involved in, so
by releasing it then surely this has affected your credibility
as the honest broker.
Professor Lord Darzi of Denham:
I promise you, Mr Penning, the election and the timing of the
election is well beyond my pay grade. I was asked to do a piece
of work in July on this and they gave me three months. I challenged
that, because I was not comfortable producing a piece of work
in three months, but that had to be published before the CSR,
so I spent all my three months this summer during recess, when
most of you were away, doing this piece of work, going around
the country and coming up with a publication in early October.
Mike Penning: The whole point is that
we were away in our constituencies and you could have waited two
or three more days and released it to the House.
Chairman: We will move on. Richard.
Q11 Dr Taylor: Can I express my sympathy
to you, Minister, in a way, because you say you want to remain
as a doctor and not a politician. I came into this job thinking
I could do just the same but, in fact, one cannot. My huge advantage
is my independence, and I just hope you will be able to assert
your independence as a doctor throughout this. My question really
relates to the reforms, because the Health Service is pretty well
punch drunk with reforms. You in your own assessment say we are
perhaps two-thirds of the way through. So, the question is: why
is the review necessary now? Why should we not have waited until
the reforms had pretty well got through and then reviewed them?
Professor Lord Darzi of Denham:
The review is not about reviewing the reforms. Maybe I should
put it within this context. I say this as someone who has been
working in the NHS for many years, but if I could take you back
to the NHS Plan, I think most of us agree in this room, it was
the biggest capacity build the NHS has ever seen. I think we have
increased its size by about a third. I do not think anyone has
seen an investment in the NHS since the birth of the NHS back
in the forties. When you are making an investment of that nature,
that quantitative investment, there were sets of target which
were raised at the time, and I will come back to those. Then there
was another interesting period, which was the period of reforming
the system—in other words putting reform levers in the system—and,
I am sure you will agree, it is transforming the NHS as a business
unit. I think one of the concerns we had as clinicians is how
would this chief executive know what is my contribution—how
many cases I get through, what am I doing in my clinic? So, it
is the system, the NHS itself that had to be reformed. As a clinician
I could tell you, the bit that probably we pushed too far is that
we did not address the language when it came to reform of the
system. The best example is here. If I am in the surgeons' coffee
room between cases, or I am in the nurses' station up on the ward,
we do not talk about PFIs, commissioning. We might talk about
choice, because choice does actually drive our behaviour as clinicians,
but we do not talk about commissioning. We talk about quality,
we talk about outcomes. The bit about the language is that, although
the reforms were the right things as far as the system is concerned,
we did not carry the staff with us when it came to reform. So
the whole purpose of this review is really to re-concentrate the
mind on what matters most, which is the product of healthcare.
The product of healthcare is the quality of care we provide to
those who we serve. That is what matters. So, this whole review,
and the case I made in my interim report, is about how do we engage
the staff, how do we look at the models of care we are providing,
improving the quality and the outcomes of care we provide? The
answer to your question, I think, is this is still part of the
journey and I am refocusing the minds of those who work in the
service, refocusing the minds of those who use the service and
refocusing the minds of those who pay for the service. That is
what we are trying to achieve in the next ten years. So this is
not to furnish the last third of that journey, it is also to design
where we need to head in the next ten years.
Q12 Dr Taylor: Can you clarify what
you mean by changing the language? You mean you want people to
get talking in the coffee rooms and the restaurants in what way?
Professor Lord Darzi of Denham:
Not restaurants. I am talking about, within the organised unit,
refocusing what we do. What we do is based on improving the quality
and the outcome of care, and that is why I came up with the four
themes in the interim report which are based on the fairness of
the service, the personalisation of the service, the effectiveness
of the service and the safety of the service. That is what I captured
by going around the country. I will come back to that. That is
what I captured by seeing 1,500 clinicians. We have had enough
talking about commissioning, we have had enough talking about
PFIs, we want to talk to you about what we do every day, which
is patient centre care. That is the language that is attractive
to those who work in the Health Service. That is what they want
to talk about. That is the language.
Q13 Dr Taylor: Thank you. That is
helpful. Looking back over the last ten years, can you pick out
in your mind mistakes that have been made?
Professor Lord Darzi of Denham:
Mistakes in what sense?
Q14 Dr Taylor: Things you would rather
not have seen happen the way they did happen?
Professor Lord Darzi of Denham:
Firstly, I believe we have had all the right policy ideas, if
that is what you are referring to.
Q15 Dr Taylor: Yes.
Professor Lord Darzi of Denham:
On the other side of the fence, I could say that probably we were
not as good in implementing some of the policies, firstly, with
speed but, more importantly, we could have seen some of the outputs
or some of the benefits quicker than what we have seen so far.
Q16 Dr Taylor: What about some of
the very rapid changes that have been made which then, within
two years, have been reversed and gone back, if you are talking
about reorganisation of SHAs and things like that?
Professor Lord Darzi of Denham:
I think that is one of the reasons we made a strong statement
in the beginning. The idea that reorganisation is going to fix
some of the challenges facing the healthcare is not the right
answer. We have made a very strong statement that this review
is not going to look at reorganising, it is certainly not going
to be the top-down reorganisation that we have seen before. So,
you are right, when you re-organise you have to give some of the
structures the time to mature in developing their competences,
and that is why there was a very strong statement made when the
report was launched. This is not about re-organisation; this is
about the actual models of care that we provide. It is not about
structures and systems.
Dr Taylor: I am glad you have mentioned
quality. We are coming to that later.
Q17 Jim Dowd: Following on immediately
from what you were talking to Dr Taylor about, I think the Secretary
of State described the exercise you are undertaking as a once
in a generation opportunity or may even have said a once in a
lifetime opportunity. If that is so, how can it be as wide-ranging
and as unencumbered if you start from the premise that there is
going to be no change to the structure of SHAs and PCTs?
Professor Lord Darzi of Denham:
Because I do not believe the structures actually are the drivers
for improvement, I think it is the maturity and the competency
of the structures that matters most. I believe we should take
stock and allow some of these structures to mature. PCTs would
be a good example. If you look at the challenges that face PCTs,
we need to give them the time to mature in delivering some of
the competences we have asked them to deliver at a local level.
So, I do not think there is a conflict there. If I could come
back to you as far as restructuring to make this specific point,
it is the top-down restructuring, it is someone sitting in Whitehall
and trying redesign what the structures are at a local level.
However, at a local level we should have a dynamic change, whether
it is the provider, whether it is the Commissioner; we should
always look and enhance the competences that they have at a local
level.
Q18 Jim Dowd: I accept that they
are not the driver, as you describe them, but they are a significant
factor in the way that healthcare is both designed and delivered,
are they not?
Professor Lord Darzi of Denham:
They are, but I believe at this stage, we have just been through
restructuring a couple of years ago, we just need to give these
structures the time to mature. We cannot keep changing systems
as a solution to some of the challenges facing healthcare at a
local level.
Q19 Jim Dowd: Sure, I accept that,
but not all change is necessarily progress, is it, and so if it
is just not working you really ought to do something about it.
I take the view very strongly. For example, there are far too
many PCTs in London. I think it was right to base them on the
boroughs originally, I think the coterminosity is significant
benefits certainly to the relationships with the local authority
in adult and children's services, but there are just too many
of them, and the quality of commissioning has been highlighted
as a deficiency, not just in London but elsewhere. If you are
not going to change the structures, how are you going to improve
the quality of commissioning?
Professor Lord Darzi of Denham:
I take your point. It is a challenge that faced me when I was
doing the London review that you have 31 PCTs in London and how
do you allow the competences in 31 organisations to develop? Perhaps
I could ask Ruth Carnall, who runs the SHA, to share with you
some of her thinking post the launch of the London report in July,
because I think in many ways it is an important question.
Ms Carnall: I think re-organising
PCTs right now would completely detract their focus from things
like improving stroke outcomes in London. So what I have tried
to do, working with PCTs, is to get them to work in groups where
that makes more sense, either because they can share expertise
between them or because some of the things that they are trying
to do require looking at a different population base. When I first
started in the job I was anxious about whether 31 PCTs could be
made to work, but, to be fair, in the year I have been there they
have been very, very supportive and co-operative in terms of working
together in groups, where that makes sense, and more widely strategically.
Certainly they have been very supportive of the work that Lord
Darzi did and willing to work in groups to see it implemented.
|
