Examination of Witnesses (Questions 100-113)
PROFESSOR LORD
DARZI OF
DENHAM KBE, MR
DAVID NICHOLSON
CBE AND MS
RUTH CARNALL
CBE
25 OCTOBER 2007
Q100 Dr Naysmith: I am really interested
in what you were saying, particularly about stroke services. I
have quite an interest in stroke. There are hardly any places
in this country that can do what you just said which is treat
stroke within three hours of an emergency, 24 hours a day, seven
days a week. There is only a handful of centres, as I understand
it, where that currently happens, to move the kind of facilities
that are needed into specialist hospitals, things like scanning
techniques, radiology and one or two other things. Some of these
things will be needed in minor injuries—x-rays for instance—and
if we concentrate all that specialised equipment, which I am very
much in favour of, it is bound to draw equipment away from these
smaller, district hospitals, is it not, or is that not a fair
comment to make?
Professor Lord Darzi of Denham:
You raise an interesting thing. First of all, Oxford has managed
to get this together. Alistair Buchan there has completely revamped
the services when it comes to stroke. He is providing excellence
in relation to exactly the model I have described. He is helping
NHS London to design the five centres in relation to London. We
spend as much money on stroke as Sweden does and yet in London
there are 31 organisations with a banner out saying they provide
stroke services, out of which only two meet the guidelines.
Q101 Dr Naysmith: You are a man after
my own heart.
Professor Lord Darzi of Denham:
We are spending the money. When it comes to the kit, we have CT
scans now in every hospital. My aspiration 10 or 15 years ago
was to have an MRI machine. Now an MRI is in every hospital. I
think technology also moves on and we should not just look at
technology as a centralising driver. That is why I described the
polyclinic. We should have ultrasound facilities in a polyclinic
facility. Ultrasound is no longer a hospital diagnostic.
Q102 Dr Naysmith: Already in this
country there are MRI scanners that are not being used to their
capacity because there are not the people to operate them on Saturdays
and Sundays and it finishes at five o'clock. To introduce this
service will be very expensive.
Professor Lord Darzi of Denham:
If you are looking at stroke, if you do the calculation based
on how much we are spending on stroke, that may not be but in
relation to how do we use our fixed costs that we have and the
overheads that go with that, you are right. We can use some of
our existing capital better and more extended but that needs investment.
Q103 Dr Naysmith: Relating to what
Richard's question was, it could mean in the future some of these
other district hospitals and local hospitals will end up having
to send patients to these specialised units to get things done
that they can get done now much more easily locally.
Professor Lord Darzi of Denham:
As it stands at the moment, stroke services, for the volume, we
need to have specialist centres but in ten years' time what you
do in the specialist centre will be delivered at the local hospital.
We have numerous examples of that. It was a big deal before to
do some of the surgical procedures we do at the moment, doing
a cancer procedure, when in actual fact nowadays you can look
at the technologies and minimally invasive techniques. We could
do it at a local level too so we should not get hung up that every
new technology is going to be centralising when there are ten
technologies. We need to be smarter in capturing them and bringing
them to a local level.
Q104 Mr Scott: Minister, what future
do district general hospitals such as King George's have?
Professor Lord Darzi of Denham:
I think you are referring to what I said in relation to the future
of DGH. Thank you for bringing that up. What I said when I looked
at London is that one size fits all. More importantly, 31 district
general hospitals providing all types of care to the quality we
want them to, is not the future of models of delivery. It is not
just me. That is why the eight clinical working groups came up
with these differentiated models of care which ranged from home
care right up to the complexity of a polyclinic. Local hospital
is what you are referring to. We also made a reference to major,
acute hospitals which are the ones dealing with strokes, the MRIs
and everything. Then we came up to specialist hospitals. One of
the things that we should be very proud of in London is the number
of specialist hospitals we have. In a capital city like ours,
probably we should have more specialist hospitals. What we looked
at was one size fits all versus what should a health care system
moving on look like. That is what we described in London. Let
us not forget the DGH was actually designed and thought of back
in the 1960s. I can reassure you a lot of things have happened
since the 1960s in medicine. I could just give you an example
in the last five years of what has happened in heart disease.
When they did the NHS plan, I remember the biggest capacity builds
were for cardiac surgeons to do coronary artery bypass work. Within
those five years we have seen angioplasty, putting stents in.
Some of these stents have drug eluding properties. We have seen
statins which have had an impact on patients having heart attacks.
We have also more recently seen the impact of smoking. If you
go to Scotland, their heart attack rates have dropped by about
14%. Medicine moves on. What I would like to see, whether it is
London or the rest of the NHS, the NHS as a provider needs to
move on to meet some of these technological advances.
Q105 Mr Scott: Minister, do you think
you were brought into government to give clinical reasons for
the closure of A&E maternity services?
Professor Lord Darzi of Denham:
Absolutely not. At no stage have I suggested in any of my previous
reports or my current work that we are talking about closures
of any sort. What we are trying to have is a mature debate, what
an A&E does, where and how we should provide the best care
at the right time, in the right place. If you have a heart attack
now, you know exactly where you will be heading to management
of that heart attack. If you have a groin pain, you know exactly
where you need to go, which is your local hospital. That is the
type of model that we need to be smart enough, that we have provider
models that are providing excellence when it comes to quality
of outcomes.
Q106 Mr Scott: Minister, would you
agree with me that, as the statement you made earlier, the growth
over the next decade of 700,000, possible 66% increase in A&E
attendances, it would be foolish to close down an A&E service
in the community such as my own area in the borough of Redbridge?
Professor Lord Darzi of Denham:
I do not know about the localities. I just say what I have said
in the report. 60% growth rates in A&E based on the current
models are not sustainable. I do not believe we would be providing
the right quality of care that our patients deserve. The idea
that you may have tonsillitis at night and mum is worried because
the child has tonsillitis; they go and get into a car and go to
an A&E department is ludicrous. What I am suggesting is that
we need to have the right models of providers in managing and
dealing with that. That is how I described to Dr Taylor three
levels: specialist A&E, local A&E and also an urgent care
centre. How do you translate that vision to the local area? That
is very much based on the PCTs and consultation with the local
user, the public and obviously the local MP.
Ms Carnall: The specific hospital
that you are talking about in north east outer London was the
subject of a local review which, as you know, we have suspended
on the grounds of an independent clinical assessment that we had
done that said that, for the time being, the nature of the clinical
leadership that we had over that programme was not adequate. However,
what it did indicate is that the direction of travel was correct
in terms of focusing services on the major hospitals in that patch.
The biggest criticism that was made though was that there were
inadequate plans for the development of outer hospital services.
My view of that changed programme there is that we should be able
to have in place some concrete plans for the development of polyclinics,
or whatever we call them, appropriate out of hospital care, appropriate
access for emergency care, before any of those changes are made.
That is why that consultation programme was suspended, in order
that we can give time to developing those proposals and convince
the public locally that the new models of care that we are now
working on are valid and will deal with the sort of cases that
come forward every day. There are no changes proposed for that
hospital at the moment until that process has taken place.
Mr Scott: I look forward to many discussions
with you on it.
Q107 Sandra Gidley: In your report
you say, "Despite some excellent work taking place locally,
there remains reluctance within the NHS to adopt new products
and procedures." This is something I feel very strongly about.
You propose the establishment of a Health Innovation Council to
deal with this. Is creating another quango the right approach
and should we not be doing a lot more to discover what the barriers
are to people adopting best practice?
Professor Lord Darzi of Denham:
I am delighted you like innovation because that has been something
I have pushed for for many, many years in my practice and everything
else that goes with that. It is not a quango that I have created.
Far from it. What I have created is a council which is represented
from people of all sorts of backgrounds, leaders in their field
when it comes to industry, academia, NHS representation. The whole
purpose of the Innovation council is essentially to scrutinise
the NHS executive in relation to the innovation pathway. Innovation
starts at a discovery and it goes to adoption. You are right.
That end bit, adoption, is the bit that is most challenging for
us. How do you tackle that? Interestingly, it is not just money.
People think it is just financial. Innovation should be the culture
of any organisation, any practitioner. You come to work. You want
to think: how could I improve the care that I am doing at the
moment? It does not just mean kit. How do I redesign what I have
just done over the last ten years to do it better? That is what
innovation is all about. To do that needs leadership at a local
level. More importantly, it also needs to be part of the NHS reform.
If you look at some of the levers we have, we can make innovation
work. Commissioners are a good example. If we had strong Commissioners
who would commission a model or a pathway based on innovation,
whether it is a piece of kit or a drug or a service redesign,
you can just redesign your pathway and proceed with this innovation.
It should be part of commissioning to be the policeman of innovation
but at the same time this should also be represented in some of
our tariffs so I am looking at some of the current payment structures
to see whether innovation could also be embedded in the currency
of the NHS. I strongly believe that. I think we will get somewhere
with that.
Q108 Sandra Gidley: It seems to be
back to local leadership again, which seems to be an emerging
theme throughout today, which I think is the right one. How does
a fairly remote body connect? We already have NICE which produces
guidelines. The problem is they are just not implemented locally
because there is no compulsion to do so. How do you square that
circle?
Professor Lord Darzi of Denham:
I believe that the actual council will be the guardian in scrutinising
the commissioning bodies through the DH but what is more important
at a local level, is that commissioning should be structured in
a way to ensure that, whether it is a NICE guideline, whether
it is a complete service redesign, it should be part of the delivery
of that model of care. It is back to stronger commissioning.
Q109 Sandra Gidley: Is the setting
up of this an acknowledgement that bodies such as the NHS Institute
for Innovation and Improvement have failed?
Professor Lord Darzi of Denham:
No, it has not failed. Completely to the contrary. If you see
what they are doing in relation to all of our activities—certainly
I have seen it a bit closer with a microscope since I have started—there
is a tremendous amount of creativity and innovation. Back to the
same story: organisations take time to mature. We need to give
them the chance to mature in achieving that. I see the Institute
for Innovation as one of the vehicles with which we can disseminate
this culture of innovation. Innovation is not just drugs and kit.
If I spend time, my secretary could have a tremendous impact in
redesigning the pathway in relation to a patient. It is back to
leadership.
Q110 Mr Syms: You are due to present
your final report in June of 2008. Will your proposal be costed
when you produce it?
Professor Lord Darzi of Denham:
I am seeing the vision for the next decade. Can I come back to
you and describe what we are doing? I think I said it in the interim
report but what is unique about this review is not me sitting
down and reviewing health services across the country. We have
eight clinical working groups in nine different SHAs looking at
the best models of care. This is the local element which I think
is the most valuable element of this review, because we are asking
clinicians at a local level. Each of these clinical working groups
have clinicians, social workers, allied health care professionals
designing what the best models of care are. They will be producing
at a local level what their best models of care and provider models
are. That in itself needs to be obviously locally consulted but,
at the same time, at a national level, we are looking at some
of the big things. Leadership has come up and a number of things.
How do we redefine structure of leadership in the NHS? How do
we attract the best staff in the NHS into these leadership positions?
I know David's aspiration is always an interesting conversation.
We need more doctors and nurses leading these organisations, playing
a chief executive role in them. There are national things. Leadership
is one. The quality landscape is another. We need to define what
quality is and how we measure that. Anything in life can only
improve if you measure it and the quality standards are going
to be another major theme. I am looking at education and training.
If you are designing a workforce for ten years, we need to look
at the way we are educating and training them with the competencies
required in delivering that health care in ten years. These national
themes will come up with sets of recommendations through consultation.
The local themes will be consulted locally and developed through
the business plan locally.
Q111 Mr Syms: Can I therefore push
you a little bit on local plans? Will they be published at the
same time in June 2008 or would you see a role out after that
in the wake of your overall vision?
Professor Lord Darzi of Denham:
The same time. I am running some tight deadlines here and we have
absolutely stood up to the challenge. It is going extremely well.
Interestingly enough, some SHAs—this was the sensitivity
over whether it should be SHAs or not because in some parts of
the country what we picked up was the SHA is as foreign as Whitehall
to the locals, so they want to be even more granular. They have
gone down to PCT level and doing some local reviews at that level
as well, which is very refreshing. They want to take the eight
groups. In one SHA there are five groups doing eight things and
they will produce their report through their SHAs who are accountable
in delivering this some time around April to us. We will publish
that together, hopefully in June around the 60th anniversary of
the NHS.
Q112 Dr Taylor: The Stroke Association
points out that the phrase "hub and spoke" implies that
there is a good unit and a second rate unit. Could you desperately
get away from that, use managed clinical networks and throw out
hub and spoke?
Professor Lord Darzi of Denham:
I have never liked the words. They are out of date and they antagonise
both clinicians and the public.
Q113 Chairman: Minister, could I
thank you very much indeed? Because of the narrowness of your
portfolio in dealing with the review and the review only, as I
understand it, we would not expect necessarily to see you back
here when we are doing our general inquiries into wider matters.
Quite clearly we are likely to see you back here in June of next
year, if not before.
Professor Lord Darzi of Denham:
With pleasure. Thank you.
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