Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 60-79)

PROFESSOR LORD DARZI OF DENHAM KBE, MR DAVID NICHOLSON CBE AND MS RUTH CARNALL CBE

25 OCTOBER 2007

  Q60  Mike Penning: Do you consider the NHS today unfair, depersonalised, ineffective and unsafe then?

  Professor Lord Darzi of Denham: The answer to that is no, for all sorts of reasons. I described it as fair. We all know that one of the strongest NHS values is equality, but as I make the case for change, we have serious challenges when it comes to inequalities, and I have highlighted in my report some of the areas across the country where that remains a challenge, whether that is inequalities in health or healthcare. I recently did London. If you take the tube station just outside this building, Westminster, and go six stations up to Canning Town your life expectancy drops by about a year for every station. These are the inequalities that we need to tackle; so what I said by fair is that we need to tackle some of these challenges over the next ten years. As far as personalisation, what I was trying to make the comment around was we need to tailor care around the patients, and what I have learned from that exercise in London, and more recently, is that there is a very strong desire by the population of having care closer to home. Integration, you know, going through that journey, it is fascinating. If you go back and look at what the patient has been through, seeing the GP as the gatekeeper through their journey to secondary care and back, it is not uncommon; your reaction, whether you are a member of the public or a clinician, is fragmented, and that fragmentation of care is not personalised. The personalisation of care is about integration, providing care closer to home. Integration of primary and secondary care, integration of health and social care—that is what I mean by personalised care—and I strongly believe the next decade where the NHS is heading we need to focus our efforts in that area well. The other one, which is the effectiveness and the safety, is what you referred to. Safety, as I said earlier, is a basic principle of what you do. Effectiveness: if this report is to succeed, we need to bring back what we are all about, what healthcare delivery is all about. It is the quality of care we provide, whether that is the outcomes, whether that is the productivity, which was referred to by Mr Barron, whether that is the integration of care. So, these are the principles which I believe, in the consultations that I did with the public and the patients and the staff, should be the principles that will—

  Q61  Mike Penning: The language you have used is your language—fair, personalised, effective and safe—as the vision going forward. Surely the interpretation from that must be, having listened to what you have said, that at the moment there is unfairness within the NHS; it is at times, in places, depersonalised, ineffective and we have heard from other things unsafe. Your vision is to remove those things and to go forward.

  Professor Lord Darzi of Denham: These are the principles that I would like to improve in designing the Health Service over the next ten years. When it comes to the NHS, when it comes to fairness—

  Q62  Mike Penning: This is your language in your report.

  Professor Lord Darzi of Denham: When I say something positive, that does not mean we are living in a negative world.

  Q63  Mike Penning: When you are saying that you want something to be safe—

  Professor Lord Darzi of Denham: Yes.

  Q64  Mike Penning: —there is an assumption, surely, that parts of that are unsafe? No?

  Professor Lord Darzi of Denham: We have challenges when it comes to safety and we have worked through a few of them recently. When I say that we need to improve the safety of a system and move to a safer environment that does not mean we have a catastrophically unsafe system.

  Q65  Mike Penning: In 2002 Derek Wanless also had a vision. He wanted a vision for progress for the NHS and he called for the Government to undertake a full review based on that and the Government declined that. Do you think that was the wrong decision or should we have had a proper review based on Wanless in 2002?

  Professor Lord Darzi of Denham: The Wanless Review 2002 was commissioned by the Government. It is not the full review. Are you referring to the latest one?

  Q66  Mike Penning: Let me try again. The Government was not prepared to undertake the recommendations of Wanless and have a review into the NHS. Wanless recommended a visionary review in 2002. The Government declined that and it ended up being done by the Kings Fund. Should it have been done by the Kings Fund or should we have had a proper review by the Government?

  Professor Lord Darzi of Denham: If I could come to that point, and I am not trying to correct you here. In 2000 the Government asked Wanless to do a review, and it was actually a due diligence exercise, about the NHS Plan and the funding—to support the funding of the NHS Plan and to make the case for it—which he did on behalf of the Government. In 2004 he did another review, in consultation with the department, which led to a better health review which was published in 2004. I think what you are referring to is the most recent review which he did with the Kings Fund.

  Mike Penning: We will not dwell on this but there is obviously a conflict in the information that is coming from our experts and what you are saying, so we will write to you on that point.

  Q67  Chairman: My understanding is that the 2002 review recommended that this should be reviewed again in 2007, or after five years, and what we have had is a review by the Kings Fund and not by the department. That is the real issue.

  Professor Lord Darzi of Denham: Absolutely. I was just going to say, he did another review in 2006 with the Kings Fund on social care and, more recently, he published a review with the Kings Fund. He was essentially reviewing the progress in relation to the recommendations of 2002.

  Q68  Mike Penning: Did the department (and you may need to refer to Mr Nicholson here) fully co-operate with the Kings Fund in that review?

  Mr Nicholson: Yes, we fully co-operated with the Kings Fund.

  Q69  Dr Stoate: I would just like to place on the record that I am still a practising part-time GP, which is recorded in the members' interests register. Lord Darzi, it is very good to have a fellow practising clinician in the position of making decisions. It is what we would expect and I am very pleased to see what you are managing to achieve so far in your short time in the department. I want to ask you a few questions about polyclinics, which is something I have been particularly interested in over the last several years and it is something I would like to question you a bit about. As part of your recommendations in the London review you suggested that polyclinics should be considered as a means of increasing access to health services and making them more personalised. The question I want to ask is: have you yet produced a business case for polyclinics?

  Professor Lord Darzi of Denham: The piece of work I did for London was the vision for healthcare for London over the next decade. What was different about that was the way we did it. Polyclinics was not on our first page or an idea in our mind certainly for the first six months. This is an important process issue, because we have a hang up about buildings, whatever we call them—polyclinics, hospitals, specialist hospitals. I had the privilege of leading 150 clinicians, some of them were primary care physicians, in London, and we looked at models of care. We started from birth, we looked at staying healthy, a very important issue (back to Wanless)—planned care, acute episode, long-term conditions, end of line, mental health, and we challenged these clinical working groups (150 around London) with: what are the models of care at the moment? What is the best evidence in the delivery of these models of care, and how do you make that happen? Because reports are reports; implementation is a completely different task. Most of them came out with a significant shift of care from a hospital nearer to the community and community setting. In actual fact a few of them said we need to repatriate some of the care we used to provide to primary care back into primary and community services. It was the conclusion of that work that led to, you know: if we are to provide care at a community level, then we need to have these primary and community hubs. Polyclinics was not my favourite word, but interestingly it captured the imaginations of Londoners because it was associated by Eastern European countries, the polyclinics and so forth, but you are absolutely right because that is something you also touched on last year in the Fabian Society and the report you published on that. Have I done the business case for that? It was a vision document; it was not to create the business case. We have done the costings, we have done our analytical work to underpin that vision statement, but after we finish the period of consultation—if I am correct, and I am going to hand over to Ruth, because it is going to go through a process of consultation—it is for the local community to put the business cases together. Maybe you want to add something.

  Ms Carnall: Yes. There has been a lot of enthusiasm for these recommendations and some controversy, which you will have seen in the newspapers, and so on, but I am very confident that there will be a significant number of good proposals for the department of polyclinics across London, certainly enough to be able to demonstrate how the model works and what benefits it can provide to people locally. What we are trying to do at the moment is to consult across London, which starts in November, about the models of care that Professor Darzi has recommended but at the same time to avoid losing momentum on what a lot of people think will be a great development, trying to get people to put forward proposals that they have got locally for service improvements of this type, and I am pretty confident that we will have a reasonable range of proposals that will allow us to demonstrate to people some of these models working on the ground before they see other changes happening down the track in hospitals for example.

  Q70  Dr Stoate: Do you see, therefore, some pilot projects being set up?

  Ms Carnall: Yes, and we have written to absolutely everybody in London and we are getting lots of interest back and lots of good proposals. Some, clearly, are better than others. Nevertheless, I am confident that there will be enough to create sufficient momentum.

  Q71  Dr Stoate: I am very pleased about that because, obviously, the pilots are making sure the public is on side for some of these quite valuable changes and, I think, is a far better way to go.

  Professor Lord Darzi of Denham: Absolutely. The other thing which I have discovered since I did the London review, which is quite interesting because, as you probably know, I also hold an academic chair: I used to work with someone who used to tell me whenever we came up with a new idea, "I am sure someone else has discovered it", and it was not just someone else had discovered it, there are 105 polyclinics outside London working extremely well and if you go and question and talk to the users and the public around the areas that I have seen some of the best examples, there is a tremendous satisfaction rate with the services which are provided, that integration which integrates all the services.

  Q72  Dr Stoate: I was pleased by your comment earlier that you want to see some of the services that used to be in primary care coming back into primary care. I think that will be welcomed by many people. I want to move on to the role of pharmacists. Do you envisage pharmacists having much of a role in the polyclinic design?

  Professor Lord Darzi of Denham: Absolutely. The potential of what pharmacy could do in all of these eight pathways that are occurring to you. Just look at the staying healthy and the well-being. We have seen it as smoking cessation, the role they could play in obesity. The role they could play in all the aspects of staying healthy is tremendously important—planned care; even an acute episode out of hours urgent needs. It is far more common that you may seek advice from a pharmacy setting as well, so they have a tremendous role to play, and again from a user perspective, they will like these different providers to be integrated at a local level.

  Q73  Dr Stoate: Do you think pharmacists will be able, for example, to improve prescribing decisions and work with other clinicians to ensure more rational use of NHS drug budgets?

  Professor Lord Darzi of Denham: I have no doubt they could. Not only that, they could also improve the quality of prescribing that people like me do. It is not uncommon that I could get a pharmacist who could come up and say "Actually we might correct that", so they have a role to play in the safety of prescribing.

  Q74  Sandra Gidley: Just a quick supplementary here. I have an interest to declare. I am a pharmacist. I am delighted to hear what you have just said, but I could not help but notice on your advisory board you have five GPs, two nurses, one person from social services; no pharmacist, no therapist on the advisory board for the primary and community care.

  Professor Lord Darzi of Denham: We have a pharmacist.

  Sandra Gidley: It is not in the list in the review.

  Q75  Dr Stoate: That was going to be my next question, so thank you, Sandra, for clarifying that. It is very important.

  Professor Lord Darzi of Denham: Anthony Murdock is the pharmacist who will be joining us.

  Q76  Sandra Gidley: Why have you chosen somebody from a large chain rather than somebody from the National Pharmaceutical Association who has a broader overview?

  Professor Lord Darzi of Denham: If you have other suggestions, I would be delighted to talk to you later.

  Mike Penning: Sandra Gidley!

  Q77  Dr Stoate: Lord Darzi, we are wandering away from the subject. Do you envisage polyclinics as being a private public partnership? Have you, for example, had discussions with private sector developers such as Assura, those sorts of companies that are not prepared to build? Have you looked at that type of model or do you see these as being purely PFI or some sort of partnership arrangement with the NHS?

  Professor Lord Darzi of Denham: I think there are all sorts of models and I think we need to be open-minded in relation to it. We have some called the LIFT scheme, which I think we need to look at and make them more primary care friendly, because there are concerns going around the country about some of the fixed costs that are associated with the LIFT scheme, which I am looking at. It could be a group of GPs, colleagues. Let us not forget, primary care although it is not privatised in the sense you are referring to, they are private providers per se. There are a lot of entrepreneurial GPs, as you probably know. They are much more entrepreneurial than any clinicians working in a hospital setting. They may wish to come in and form a partnership to do that, and I think we need to help them in achieving that because I think one of the things that I have captured talking to primary care colleagues is that they always say, "We do not have the management skills within primary community services", and we need to investigate that. It is something that I have raised with David. It could be so-called independent sector, third sector providers. So, yes, I have met them as well and would encourage them to come forward.

  Q78  Dr Stoate: You are prepared to look at a whole range of possible providers and possible structures?

  Professor Lord Darzi of Denham: I think so.

  Dr Stoate: Thank you very much.

  Q79  Jim Dowd: On the question of polyclinics, your London review indicated that if there was a switch from hospital based care to polyclinics there could be savings of up to 1.5 million on health care in London, a not insignificant sum. Could you indicate where the bulk of those savings would come from and say whether you have included the current cost of PFI schemes in London?

  Professor Lord Darzi of Denham: I have included the PFI schemes and I will come back to that point. The way we did the review, the analytical bit, we had an analytical group of clinicians including primary and secondary care. We picked up the top 20 HRGs which means the top 20 presentations that a hospital is dealing with. This is the bit that comes back to productivity versus efficiency. If you did your calculations based on the current provider models as we stand and if you take into account the following, we are expecting in London a demographic growth of about 700,000 people in the next decade: Thames Gateway, Olympics. That is a big growth in a big capital city. If you do the current growth rates we have had over the last three years, what we call baseline growth rates—in other words, the current population using the service—you will probably increase your in-patient activity by about 47% in ten years. You will increase your A&E activity by 66% in ten years. You will increase your GP use by about 77%. The figures are astronomical, based on what we have seen in the last three years. This is the bit that is unique. For the first time in London we started to predict what might be happening in ten years. We need to be smart. We need to be proactive here rather than reactive, which is what we have been doing. If you look at these growth rates based on the current provider models, the whole system will be paralysed and the cost of it will be astronomical. Back to the clinical working groups and their evidence base. The polyclinics were there to deal with that significant workload that we anticipate in ten years. That is why it is a ten year vision. If you look at the costings for some of these procedures, I will give you an example. Minor surgery. If you come into St Mary's where I work, the cost of that is about somewhere around £895. That is what you pay. If you do that procedure and you cost it, including all the overheads, all the fixed costs in a polyclinic environment, the cost of that is somewhere around £120. You can see savings. If you go to the use of accident and emergency, you probably know in London near enough 62% or 63% of patients attending A&E are attending A&E because they have a minor complaint that they have to deal with, especially in London because we have significant rates of attendance at A&E. The tariff for that from a hospital setting is somewhere around £158. I am not surprised the hospitals are keeping the gates open. It is an income. If you look at the potential of having an urgent care centre in a community, which is part of the polyclinic, then you can see the cost of that being significant. It is not just improving on the cost; it is actually designing a service that has the quality, the access from a patient perspective but at the same time seems to be creating the savings that I referred to. If we keep the system as it is, in ten years we will be spending 1.4 billion more. If we change the system, the growth rates are not compatible with inflation rates that we will be expecting in health.


 
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