Examination of Witnesses (Questions 80-99)
PROFESSOR LORD
DARZI OF
DENHAM KBE, MR
DAVID NICHOLSON
CBE AND MS
RUTH CARNALL
CBE
25 OCTOBER 2007
Q80 Dr Stoate: You are saying that
there is an incentive for hospitals to keep the gates open. Are
you saying that the result is causing a distortion in the way
the health service is being provided?
Professor Lord Darzi of Denham:
I do not think it is a conspiracy. I am sorry to say this. There
is no alternative at the moment and the patients are going to
A&E. That is their only access in most of London to get care
outside hours. That is one of the recommendations I made in relation
to access. That is why I believe that we need to repatriate some
of the cases that used to be managed within a primary care setting.
Q81 Jim Dowd: What you are saying
is that it is not just an overall saving of 1.5 billion from where
we are now; unless the changes that you anticipate are implemented
it will not be possible to meet what you expect to be these expanding
levels of activity?
Professor Lord Darzi of Denham:
Yes. We will be back to what we were with the challenges we had,
with people waiting on trolleys in A&E departments and everything
else that goes with that.
Q82 Jim Dowd: London is particularly
prone to institutional sclerosis, basically. Are you sure that,
with these changes to polyclinics and away from traditional hospitals,
the current providers are willing to engage constructively?
Professor Lord Darzi of Denham:
You are right. I can say this now wearing two hats. You are right
about some institutional history when it comes to a lot of organisations
in London. That is one fact but, to be honest, I really did see
the appetite with the clinical community when I did London. The
amount of support, the amount of people who came out and said,
"We need to do this. We cannot keep going on." London
has had many reviews. It had one called Tomlinson many years ago.
In 1997, a colleague, a distinguished physician, Lord Turnberg,
did another review. They highlighted the same problems. I did
not come up with any new sets of problems. They are the same challenges
and that is why they were very engaging. I have been around London.
I had, through the SHA, a major consultation with all the sectors
prior to the publication, so I think the appetite is there to
make it happen. I think we are seeing more doctors and nurses
standing up there, saying, "We need to see this change in
London", for a number of reasons. You said London has had
institutional sclerosis but look at all aspects of London. In
business we lead the world. It is a capital city that leads in
business. When you come to science and technology, I work in an
organisation, Imperial College, that is the fourth biomedical
research centre which competes globally. That is what London is
all about. Why can't we get the health care system in London to
the standards that we were talking about before? People are accepting
that fact. To be honest, the differentiated models of care that
we came up with have been well received within the medical and
clinical community, nurses and doctors, and also managers.
Q83 Jim Dowd: Ms Carnall, do you
believe that NHS London, which is a comparatively new organisation,
has the authority and the experience yet to be able to implement
the wide ranging reforms that Lord Darzi's review would indicate?
Ms Carnall: It is not the job
of the health authority to implement them. These changes will
be implemented by doctors, nurses and other clinicians on the
ground and local leaders. The question for me and my organisation
is, having got the authority to provide the leadership for that,
to create the right environment for it. I think the answer to
that is yes. This is the first time there has ever been a statutory
health authority for London. It absolutely makes sense to have
a vision like this for the capital city and I have found it a
vision that has really energised not just people who work directly
for me but people who work within the NHS more widely in London.
Of course there is opposition to some aspects of it. There is
controversy about some of it. We have to explain these proposals
in detail to the public to get their commitment to them but I
am certainly confident we have the authority to implement it.
I have found it a joy to recruit a really good team. We got Ara
along in the first place to do this review for London. There is
a number of clinicians who have come along in his wake who want
to take it forward with us to in terms of creating the right environment
for change I am confident that we can. The implementation will
be done on the ground.
Q84 Mr Syms: Minister, in your latest
work Our NHS, our future you do not make any explicit mention
of polyclinics but you talk about GP led health centres and making
the NHS fairer, 150 new GP run health centres and easily accessible
locations open from 8am to 8pm. Is this a rebadging of the polyclinics
proposal or do you envisage the GP led health centres to be something
totally different?
Professor Lord Darzi of Denham:
It is not rebadging as health centres. One of the unique features
of the visits we have done is the number of health centres we
have seen, 105 of them across the country, tremendous examples
of PCTs and the local government coming in together in creating
some of these hubs of health care provision. What we wanted to
do there is mostly to address the access issues. We wanted some
injection of new, innovative models of provision of care that
has the extended hours, that deals with the urgent care provision,
that does have the integrated models of care that I was referring
to earlier. That is what is driving that, very much in line with
the clinical working groups we will be coming up with some time
around March next year as far as their outcomes. It is not new.
It is very important I say this. There are 105 health centres
across the country that are delivering examples of practice which
I would strongly recommend. If you have not seen them, go and
see them. In London there are only one or two of them but outside
London they are best examples of care.
Q85 Mr Syms: You say there are 105
at the moment so your 150 would be in addition to that. Is that
what you are talking about?
Professor Lord Darzi of Denham:
Yes.
Q86 Mr Syms: Why 150? Is that based
on the experience of those 105? Do you think that would be appropriate?
What was the evidence? Was it a guesstimate?
Professor Lord Darzi of Denham:
We have about 150 PCTs but that does not mean that every PCT will
be getting one because we all know for some PCTs the diversity
of the population, the geography, is an issue that needs to be
tackled at a local level. The numerical thing was based on the
number of PCTs, but some PCTs may have greater challenges than
others. The ones that are targeted are the funded, primary care
centres which we referred to in more of the areas that have the
biggest challenges when it comes to inequality of health and health
care. In other words, the areas that have the smaller number of
GPs across the country.
Q87 Sandra Gidley: The principle
that we need to increase access to services in the areas of greatest
deprivation is the right one, but very often the problem in some
of these areas is issues of social exclusion as well. People cannot
access what exists already because the public transport networks
do not exist. What evidence is there that they will move to something
or attend a clinic which may be further away and in many ways
may be less physically accessible for them? It may be open longer
hours but if it is not physically accessible you will not achieve
that very laudable aim.
Professor Lord Darzi of Denham:
I could not agree more. To be fair, if I started designing where
they should be I would get it ten times more wrong than they would
at a local level. That is the bit that we tend to get wrong, designing
where these things should be in Whitehall. This is out of the
question. At a local level, they should consult with local government
and other stakeholders in designing where these centres should
fit best.
Q88 Dr Stoate: The original report
points out that a child born in Manchester will have an average
lifespan of ten years less than a child born in Kensington. What
evidence do you have that health care is the most significant
factor in improving public health and reducing inequalities?
Professor Lord Darzi of Denham:
It is much more complicated than health care. I could not agree
more. This brings in the challenges when it comes to housing and
schooling, employment, and that is the only way we can look at
this if we want to achieve an output in relation to these inequalities.
You probably know that the Secretary of State has also announced
three or four weeks ago a major piece of work on inequalities
in one of his speeches. That is very much in the forefront of
the Secretary of State and the government in relation to that.
I think cross governmental working has to be the way forward in
tackling that. When it comes to health care needs, we have to
do something about that because we have data that will show that
the health care outcomes correlate very strongly with the number
of GPs at a local level. That is a well known fact. Jarman and
others demonstrated that before, so that is one. We also know
in these areas that the QOF—Quality and Outcomes Framework—output
also is poorer than the rest of the country. We need to deal not
only with the numbers but also enhance the quality of provision
in some of these areas. That is one part of a fairly complex inter-governmental
initiative.
Q89 Dr Stoate: What practical steps
would you leave us with that you think can help address inequalities
in London? You have mentioned much wider areas which you are not
responsible for but what practical steps do you think could be
taken, particularly in London, to address inequalities?
Professor Lord Darzi of Denham:
I remember when I did the London review I spent a lot of time
with the councils. I met them on a regular basis. I met the Mayor
on three or four occasions. He has a tremendous interest in this.
As you probably know, he just recently published this "Health
Inequalities" document. It is through that that we need
to work together. You say I am not responsible. Somehow or other
we need to get that collective responsibility for this. Someone
needs to lead this thing because it has been there for a long
time and we need to tackle it.
Q90 Dr Stoate: Do you think health
should lead it or a different government department should lead
it?
Professor Lord Darzi of Denham:
I think the health aspect health should lead and take responsibility
for. To be honest, we have for the first time in London one of
the advantages of bringing the five strategic health authorities
together. We have a single health authority to deal with because
the most confusing thing when we come back to the number of PCTs
was we had five sectors in London with five SHAs. At lease we
have provided structure from the NHS perspective to take on that
leadership.
Q91 Mike Penning: Moving on to something
very close to my own heart, the future of the NHS estate, when
do you expect to earmark NHS properties and estates which will
be surplus to requirements?
Professor Lord Darzi of Denham:
There is a big piece of work that needs to be done in relation
to the NHS estates for all sorts of reasons. Firstly, we need
to know what estate we own. Secondly and more importantly, we
need to be smarter in the use of the NHS estate because there
are a significant amount of fixed costs associated with that.
At the same time, we need to improve our utilisation of it. That
is something that I am very much part of this review in looking
and coming up with some creative ideas in which we can use this
estate in the best interests of patients.
Q92 Mike Penning: With all due respect,
creative ideas often mean closures. In my own constituency, £18.5
million in the business plan next year has been lost out of my
estate. You have already said that you have done a business plan
for London. Clearly within that business plan must be an assumption
of the income from the sale of the estate. Otherwise you could
not have done a business plan. When do you expect to make that
public as to what hospitals and what units are going to be closed
and sold off? When do you expect to come forward with that?
Professor Lord Darzi of Denham:
The business plan does not include anything about selling the
NHS estate in London. I refer to the paragraph. I recommended
that the SHA should have an estate strategy in July. When I said
"smarter" is selling off estate is not necessarily the
right way forward. I do not believe it is, on a personal basis.
I think we could be much more creative in managing our estate
and raising funding on the back of the estate in all sorts of
partnership working with other inter-governmental partnerships,
in helping to deliver the health care we are looking for.
Q93 Mike Penning: Can I push you
very quickly on the business plan? How have you sat down with
them? If I went to my bank manager with a business plan and said,
"This is the plan I have for my business" and I could
not indicate to him what my assets were and what some of my assets
might bring in, he would laugh me out of the shop. How have you
gone forward with a business plan for the future of the NHS in
London without the knowledge as to what income you will receive
from the sale of assets?
Professor Lord Darzi of Denham:
I am sorry; you are misunderstanding me. I made it very clear
to Dr Stoate earlier. I did not do a business plan for London.
What I did was to create the vision framework for London for the
next decade. I did some modelling of cost, of provider models,
what it means running certain services through these different
provider models. The business plan, as I said before, will be
done at a local level once the consultation is over.
Q94 Mike Penning: You have some 150
polyclinics. Not all of these units may necessarily be in a facility
or in an area where you own NHS land. Are you planning obviously
wherever possible to build them on NHS land? Are you planning
to have to purchase what is in London very expensive land for
the polyclinics?
Professor Lord Darzi of Denham:
The answer is no. We are planning to use NHS land which we have
a lot of. We have a tremendous amount.
Q95 Mike Penning: That is why I assumed
you knew how much you had.
Professor Lord Darzi of Denham:
We need to identify where they are. We need to find out what their
value is.
Q96 Mike Penning: We do not know
at the moment?
Professor Lord Darzi of Denham:
We have not done that. I certainly did not have that information
when I did the London review but I strongly recommended, as you
are pointing out, that NHS London should look at its estate strategy.
Q97 Dr Taylor: Changing tack and
coming on to centralisation of health care, I very much welcome
the Academy of Medical Royal Colleges recent report of a working
party headed, "Acute Health Care Services". For
the first time, this appears to me to be something that brings
together the needs and aspirations of doctors with the needs,
wishes and hopes of patients. I think it is an absolutely earth
shaking document. I would just like your comments on one or two
bits in it. Right in the foreword it says, "There is evidence
that for some very serious conditions care in specialised units
is associated with better outcomes." Nobody would argue with
that. It goes on to say, "However, these conditions together
only account for a small percentage of acute care episodes. The
evidence is much less clear for the majority of common conditions
that make up 95% of acute care." It ends up, "Big is
not necessarily better." Do you accept that for common conditions
one needs to keep things as local as possible?
Professor Lord Darzi of Denham:
Absolutely. To be fair, we published the London report in July.
The one unique thing that happened in the London review with the
clinical colleagues, I think as clinicians we have been through
this process of maturity. That maturity even further enhances
when you talk to the public and patients. The idea that if you
unplug a specialist service like stroke and then you are going
to see this domino effect that you saw in Kidderminster for example
is no longer looked at as being right. That is how the local hospital
model was developed. We did say in the local hospital model, "You
should not have patients coming in with a stroke. You should not
have patients coming in with an acute MI" but at the same
time no one turned around and said, "If you do not have these
services, the whole of the service effect is going to have to
go ... ", so that is how we came to the conclusion at the
end that, from a public perspective, because that is another challenge.
Sometimes we come up with these jargons about different levels
of A&E. We came up with a very simple three ways of describing
what accident and emergency is all about. We have the specialist
A&E which deals with specialist services. We have a local
A&E which deals with, as the Academy has pointed out, the
majority of acute illnesses. We have an urgent care provision
at a local and community level. I could not agree more.
Q98 Dr Taylor: They give a spectrum
of five types of acute care starting with primary care; then,
community hospitals and urgent care and then a local hospital,
then a district hospital and then the major hospital. It is the
local hospital that I am obviously particularly interested in.
I know from your work in Bishop Auckland you supported the continuation
of acute medicine without surgery. I would commend to you, if
you have not seen it, the Grantham Hospital protocols because
they are absolutely excellent for what you can take and what you
cannot take. Can I come back to heart attacks and strokes because
I think we have to be realistic about where we are at the moment.
In the Academy paper in 2006 it says that heart attacks were managed
in 208 hospitals. At the moment, only urgent coronary angioplasty
can be carried out in 30 hospitals and only 14 of those were providing
a 24 hour a day service. Will you accept that one of the key issues
in the Academy paper, plans to redesign services which involve
moving services from a particular site, must not be fully implemented
until replacement services are established and their safety audited?
This may involve running services in tandem for some time. These
extra costs must be factored into plans for reconfiguration.
Professor Lord Darzi of Denham:
Absolutely. I think that is a process. What should be our aspiration
in the NHS over the next ten years? Our aspirations should be
that we get the right patient at the right time to the right place,
to be treated for their heart attack, nothing below that. At the
moment, as you pointed out, about 50% of our patients are getting
an angioplasty in London. A number of these 14 are in London.
Why did that happen? That happened because we had leadership in
cardiology. They decided that six units in London would provide
a 24 hour seven angioplasty service. More importantly, we had
a leadership in the ambulance service. That is the crux of it.
We had the London Ambulance Service that took this pathway on
their hands, designed it, trained up paramedics in their decision
making and equipped them. That is why we have 70% of patients
entering into the right place. If I am going to have a heart attack,
I had better be in London because I am going to get that. That
should be the aspiration over the next ten years in achieving
that elsewhere. I think what you are suggesting in the Academy
paper is sometimes it does take time to build up capacity. It
takes time to build the angioplasty suites, to train cardiologists.
The newer ones coming through have the skills in angioplasty;
some do not. That is the capacity that we need to build but our
aspiration, whether it is me or the Academy or you, should be
identical.
Q99 Dr Taylor: That is reassuring.
As you gradually move away all the specialist things from the
local hospital, you will still see a need for local hospitals
to cope with the common, not only the minor injuries but the relatively
common medical emergencies?
Professor Lord Darzi of Denham:
Absolutely. For every technology that is centralising, there are
about ten technologies that are decentralising. We should not
just concentrate on the centralising ones. We should start also
thinking about the decentralising ones. Stroke services are a
good example. When I was in training, stroke service was a rehab
treatment. We could not do anything about stroke patients. We
know now what we can do with a stroke. You get patients in; you
scan them in the three hours. You have a clot. You give them a
CBA, which is a clot busting drug, and you can treat that. Their
chances of survival and the quality after that outcome is significantly
better. At the same time, as you know, we are treating patients
with heart failure at home, connected through their mobile phone,
through Blue Tooth technology, sending data about their heart
function into a central station. Innovation does not all mean
centralising. The challenge for the NHS is how do you innovate
at a local, community level, whether it is a polyclinic or home
care.
Dr Taylor: I am very pleased to hear
of your aspirations. Thank you.
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