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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