House of Commons - Health

Select Committee on Health Second Report

Core Tasks

12. Select Committees have been asked by the Liaison Committee to perform certain core tasks[3] which are designed to provide a framework to encourage 'a more methodical and less ad-hoc approach to the business of scrutiny'.[4]

13. They are grouped under four separate objectives:

Objective A: To examine and comment on the policy of the Department

Objective B: To examine the expenditure of the Department

Objective C: To examine the administration of the Department

Objective D: To assist the House in debate and decision.

Objective A: To examine and comment on the policy of the Department

TASK 1: TO EXAMINE POLICY PROPOSALS FROM THE UK GOVERNMENT AND THE EUROPEAN COMMISSION IN GREEN PAPERS, WHITE PAPERS, DRAFT GUIDANCE ETC, AND TO INQUIRE FURTHER WHERE THE COMMITTEE CONSIDERS IT APPROPRIATE

TASK 4: TO EXAMINE SPECIFIC OUTPUT FROM THE DEPARTMENT EXPRESSED IN DOCUMENTS OR OTHER DECISIONS

14. Our inquiry into Smoking in Public Places provides an excellent example of a Select Committee commenting on policy proposals. The inquiry was prompted by the Government's stated intention, initially in the White Paper Choosing Health,[5] to bring forward legislation to reduce smoking. The Government carried out a consultation in the summer of 2005 and, on that basis, published the Health Bill in October 2005.

15. The Bill contained proposals to ban smoking in public places and workplaces, but with certain exemptions, in particular for private members' clubs and bars which do not serve food. During the oral evidence sessions we were able to investigate the rationale for the partial ban. The evidence we received indicated that ventilation would not be a cost-effective option. We also found that many in the entertainment industry, who were portrayed as being against the ban, actually preferred a full ban because they wanted fair competition. The core of the argument revolved around workers in 'smoking bars', who are most at risk from second-hand smoke. The Committee considered the issue as a matter of health and safety and concluded that workers should not have to work in a smoky bar just as they should not be exposed to asbestos in the workplace.

16. We also found that a comprehensive ban was likely to be easier to enforce than a partial ban. The Government's proposals were based on the premise that the public would only accept a partial ban and therefore compliance with a full ban would be problematic. The Committee received evidence that public support for a total ban was much higher than the Government claimed. We found statements in the Government's White Paper Choosing Health on this issue misleading.

17. The key moment in the inquiry was the evidence session with the Chief Medical Officer, Sir Liam Donaldson, who told us that he had advised the Government to institute a full ban. In his Annual Report for 2005 he referred to 'the scourge of tobacco-related illness and death, which remains the most significant public health problem in our country.'[6] In oral evidence to the Committee Sir Liam admitted it was the first time in seven years that his advice had been ignored and as a result he admitted to having considered resigning.[7]

18. The Committee's Report contributed substantially to demands for a complete ban, and culminated with the Government introducing a new clause removing the exemptions at Report stage and agreeing to allow a free vote on the matter.[8] The Committee's Report was referred to throughout the debate and the Bill was amended. In its response to the Committee the Government said,

The Government agrees with the Health Select Committee that the only genuine solution to the problem of second-hand smoke exposure is to ensure that enclosed and substantially enclosed public places and workplaces become smoke-free. This solution is also the one clearly favoured by the House of Commons, given the amendments made to the Health Bill during Report Stage.[9]

19. The Government published Commissioning a Patient Led NHS on 28 July 2005, the House of Commons having risen for the summer recess on Thursday 21 July. It contained proposals to reduce the number of Primary Care Trusts and Strategic Health Authorities, change commissioning and provider responsibilities and contract out community health services to non NHS providers. Our Changes to Primary Care Trusts inquiry was an examination of these proposals and the potential implications. We found widespread disaffection with the constant organisational change. The situation was exacerbated in this case because the PCTs which were to be merged had been established just three years previously and had not had time to establish themselves. There was also intense dissatisfaction with the consultation process which was carried out over the summer holidays; witnesses described it as insufficient and flawed.

TASK 2: TO IDENTIFY AND EXAMINE AREAS OF EMERGING POLICY, OR WHERE EXISTING POLICY IS DEFICIENT, AND MAKE PROPOSALS

20. The Committee has a long tradition of examining areas where policy is deficient. We have undertaken a number of inquiries since the 2005 General Election which fall into this category. The NHS Charges inquiry aimed to uncover the rationale behind the range of payments that patients are asked to contribute towards the provision of care. The Committee found no apparent underlying principle and a substantial amount of historical baggage. The system is full of anomalies. In particular the Committee were unimpressed to find that the list of medical exemptions from prescription charges was compiled in 1968 and had not changed since. In its response the Government agreed to a review of the exemption list. It also agreed to improve the guidance to Trusts on hospital car parking, continue to review the costs to users of bedside television and telephone systems and consult on how to improve the Hospital Travel Costs Scheme.

21. Our major inquiry has been into Workforce Planning. The longer the inquiry has continued the more relevant and important it has seemed as the years of rapid expansion have given way to reductions in posts and great difficulties for newly qualified staff in finding jobs. We have been looking at why workforce planning structures failed to prevent the boom-bust cycle and how to make changes to stop the mistakes being repeated. Oral evidence sessions conclude in January 2007. The Committee hopes to publish this major report before Easter 2007.

22. We also examined the Government's increasing use of the private sector to provide health care in our inquiry into Independent Sector Treatment Centres. We looked at whether the first wave of ISTCs had provided value for money and what changes should be made in the second wave which was announced in March 2005. The Government claimed a number of benefits for the scheme, in particular that competition would provide a spur to the NHS to improve. We found it impossible to establish whether this was the case or whether ISTCs had provided value for money because the Government either had not collected the relevant data or would not provide us with the data it had. Lack of data also meant that we were unable to establish the quality of care provided by the ISTCs. For the same reasons we concluded that alarmist statements about the care provided by these centres could not be justified. In addition we were concerned that ISTCs had so far failed to provide training and were poorly integrated into the NHS. We concluded that separating elective care from emergency care in treatment centres was a good idea, but we were not persuaded that private sector treatment centres offered better value for money than NHS treatment centres or centres which are based on a partnership between the NHS and the private sector such as at Redwood in Surrey.

23. The one-off oral evidence sessions which we hold to examine the responsibilities of Ministers in the Department of Health also enables us to consider deficiencies in Government policy.[10] For example, we took evidence from Andy Burnham, Minister for Delivery and Quality on hospital acquired infections, waiting time targets, NICE, the MHRA, the home oxygen service and the new community pharmacy contract.[11] In some cases the Committee has decided to carry out a full inquiry into the subjects covered, for example, we will be looking in more detail at NICE later in 2007.

TASK 3: TO CONDUCT SCRUTINY OF ANY PUBLISHED DRAFT BILL WITHIN THE COMMITTEE'S RESPONSIBILITIES

24. The Department of Health did not publish any draft Bills in this session. However, the Committee has examined aspects of bills after second reading. As described above, we looked at the provisions relating to smoking in the Health Bill and reported in time to influence the debate at report stage, We intend to undertake a similar exercise in respect of the patient and public involvement of health aspects of the Local Government and Public Involvement in Health Bill. Evidence sessions will begin in February and we intend to report before Easter.

Objective B: To examine the expenditure of the Department

TASK 5: TO EXAMINE THE EXPENDITURE PLANS AND OUTTURN OF THE DEPARTMENT, ITS AGENCIES AND PRINCIPAL BDBPS

25. The Committee takes very seriously its responsibilities to examine the expenditure of the Department and NHS. For many years the Committee has undertaken an annual inquiry into the subject. Each year the Committee sends a questionnaire to the Department asking for answers to a range of questions under headings such as expenditure, investment, reform and forward planning, spending programmes, activity & efficiency and includes information relating to the Department's Arm's Length Bodies. This year with the assistance from the House of Commons Library we undertook a major revision of the questionnaire to improve the type and layout of the information gathered and make it more accessible to readers. Nevertheless, many of the questions in the PEQ remain the same, seeking updated figures. They provide an important data series.

26. The Department's response to the questionnaire provides a vast amount of detail on the financial situation of the NHS and the Department. After receipt of the PEQ the Committee holds two evidence sessions. The first was with senior officials from the Department, which this year included the Permanent Secretary and the Chief Executive of the NHS, the second with the Secretary of State.

27. The PEQ sessions allow the Committee to explore a range of financial issues not covered in other inquiries; this year they included Private Finance Initiative projects and the National Programme for IT. The Committee's questions revealed details about management consultant spending which were not previously publicly available and which were subsequently widely reported in the media. The sessions also allowed the Committee to question the Permanent Secretary about the running of the Department of Health following the recent reduction in staff posts.

28. We also carried out two inquiries which were directly related to expenditure and NHS finances. In our inquiry into NHS Deficits we examined the reasons for the deficits which have been revealed over the last two years. We found that, although deficits had grown, the underlying deficits were often of long-standing. They have been revealed by increasing transparency, in particular the introduction of the RAB accountancy regime. We found the deficits had several causes. Some large deficits were caused by historic difficulties. Other causes were the funding formula and poor financial management both by the Department of Health and by NHS trusts. We were concerned by the consequences of the steps taken to reduce the deficits, in particular the cuts in training budgets. The Secretary of State told us in evidence that she would take personal responsibility for ensuring the NHS is in balance by the end of March 2007.[12] We will pay close attention to the progress in this area. It is important that it is not achieved by a continuing neglect of training.

29. Our inquiry into NHS Charges looked at how patients contribute to the funding the health service and at the principles underlying patient contributions to the NHS. We could find no rationale as to what was and was not charged for. Charges have been introduced in a piecemeal fashion and there has been no detailed analysis of the consequences of charges for people's health and of other ways of charging. We were surprised to find that the Government has not sought to collect the evidence. We recommended that the Government review present charges and collect evidence about their consequences, and it should also look at alternative charging systems.

30. Other inquiries have had an expenditure element. One of the reasons the Government gave for reorganising PCTs was that it would enable savings of up to £250 million to be made. The Committee doubted that the proposed savings would be made.

31. In the ISTCs inquiry we considered the increasing sums spent on private sector providers and whether they provided value for money. Various rationales have been put forward for the ISTCs. Under questioning the Department of Health admitted that the main benefits of the first wave of ISTCs were not, as is often claimed, additional capacity [which was relatively small] but the spur they gave to the NHS to improve. Given this we were surprised that the Department had made no attempt to measure this effect. Our work was frustrated by the Department's unwillingness to provide the Committee with its assessment of these consequences. As we noted above, we were also on grounds of commercial confidentiality denied financial data relating to the programme. This means that the Committee was unable to effectively scrutinise a £5 billion project. The Committee recommended that the NAO investigate the value for money aspect of the programme.

Objective C: To examine the administration of the Department

TASK 6: TO EXAMINE THE DEPARTMENT'S PUBLIC SERVICE AGREEMENTS, THE ASSOCIATED TARGETS AND THE STATISTICAL MEASUREMENTS EMPLOYED, AND REPORT IF APPROPRIATE

32. We continued the practice of our predecessors in examining Public Service Agreements in our Public Expenditure Inquiry For example, we questioned the Permanent Secretary and Secretary of State on Target 10 from 2000 on Value for Money and Target 12 from 2002 on Improving Value for Money.

33. The performance targets which the Department has imposed on the NHS have inevitably been a feature of our work. We were alarmed by the failure to adequately cost and pilot these targets. In our inquiry into NHS Deficits witnesses stressed the cost of meeting the 4 hour Accident and Emergency (A and E) target, which we were told had made a significant contribution to the deficits. Too little thought had been given to cost/benefit ratio of marginal changes to the target, for example, of ensuring that 98% of patients had a maximum wait of 4 hours in A and E rather than 95%.

34. In our session with Andy Burnham, the Minister of State, we were able to ask more questions about the A and E target. We also questioned him about a number of other targets, including:

Target 1 from 2002 [to reduce the maximum wait for an outpatient appointment to three months and the maximum wait for in-patient treatment to six months by end of 2005 with further progress… by 2008]

Target 4 [to tackle health outcomes for people with long-term conditions by offering a personalised care plan for vulnerable people, reduce emergency bed days, and improve primary care and community settings for those with long-term conditions]

Target 5 [to ensure by 2008 no one waits more than 18 weeks from GP referral to hospital treatment]

35. Many of our other inquiries involved the consideration of PSA targets. At the heart of our study of Workforce Planning is Objective VI: to manage the staff and resources of the Department so as to improve performance. The Sexual Health debate arising from our report in the last Parliament touched on Target 3: to tackle the underlying determinants of health and health inequalities by reducing the under 18 conception rate by 50% by 2010 as part of a broader strategy to improve sexual health.

36. Smoking is such an important determinant of health that our inquiry into the subject involved us in considering several targets, including the following Departmental PSA Targets 2004:

Target 1 'improve the Health of the Population'—substantially reduce mortality rates by heart disease, stroke and related diseases by 40% in under 75s… and reduce inequalities gap from cancer by at least 20%
Target 2 reduce health inequalities as measured by life expectancy at birth and infant mortality
Target 3 tackle the underlying determinants of health and health inequalities by reducing smoking rates to 21% or less by 2010 and in certain groups to 26%.

TASK 7: TO MONITOR WORK OF THE DEPARTMENT'S EXECUTIVE AGENCIES, NDPBS, REGULATORS AND OTHER ASSOCIATED BODIES

37. The Committee has continued to monitor the work of the Department's Arms Length Bodies. In the course of the inquiry into ISTCs we took oral evidence from the Healthcare Commission on the quality of care provided by private sector providers. We also heard from Monitor during the Deficits inquiry. We also received written evidence from NICE on Smoking, CPPIH on Changes to PCTs and NHS Deficits, and from the Healthcare Commission on ISTCs, Workforce Planning and NHS Deficits.

38. In our evidence sessions with Ministers we have been able to address the work and effectiveness of these bodies. We questioned Andy Burnham about the National Institute for Health and Clinical Excellence, the National Patient Safety Agency and the Medical Healthcare Products Regulatory Agency. Rosie Winterton was questioned about the work of the Commission for Patient and Public Involvement in Health and the Healthcare Commission.

39. Since the new Committee was appointed in 2005 the Chairman has held regular informal meetings which other members of the Committee also attend; many of the meetings are with the Chairs or Chief Executives of the Department's Arm's Length Bodies and provide an excellent opportunity to discuss any mutual issues of concern. In these meetings we have met the Commission for Social Care Inspection, Healthcare Commission, Food Standards Agency, NHS Direct, Medicines and Healthcare Products Regulatory Agency, Monitor, Human Fertilisation and Embryology Authority and the Commission for Patient and Public Involvement in Health (CPPIH).

TASK 8: TO SCRUTINISE MAJOR APPOINTMENTS MADE BY THE DEPARTMENT

40. The Committee has not held evidence sessions specifically to examine appointments, but we have taken evidence from senior officials shortly after their appointment. Prior to his early retirement in March 2006 Sir Nigel Crisp was both Permanent Secretary of the Department and NHS Chief Executive. He had two successors. Sir Ian Carruthers took over as acting Chief Executive of the NHS and Hugh Taylor became Acting Permanent Secretary of the Department. We took evidence from Sir Ian Carruthers in April 2006 and Hugh Taylor in April and November 2006.[13] Subsequently David Nicholson took over from Sir Ian Carruthers as the NHS Chief Executive on 27 July 2006. We questioned him as part of the PEQ inquiry in November 2006.[14]

TASK 9: TO EXAMINE THE IMPLEMENTATION OF LEGISLATION AND MAJOR POLICY INITIATIVES

41. Task 9 has been a major part of our work in this session. Both our inquiries into NHS Deficits and Workforce Planning have considered the history of major policies since 1999, in particular the implementation of the NHS Plan 2000. We were surprised to discover that figures for staff growth had massively exceeded the Plan; for example, 80,000 more nurses had been employed that the Plan had envisaged.

42. Our inquiry into ISTCs also addressed Task 9. The first treatment centre where elective surgery was carried out and emergency surgery was excluded was established in 1999. In 2002 the Government announced a programme of NHS Treatment Centres. At the end of 2002 the Government started to commission treatment centres from the independent sector. In our ISTC Inquiry we examined both elements of this policy. We were convinced that the separation of elective and emergency surgery provided major benefits; on the other hand, we were not persuaded that independent sector undertook the task more effectively than NHS centres.

43. The Committee has kept a close watch on the implementation of policies which have been adopted as a result of its recommendations. In the last Parliament the Health Committee published a report on Venous Thromboembolism. The report had the support of the relevant royal colleges and the Government agreed to implement the main recommendations, including the establishment of appropriate committees in hospitals. NICE had planned to produce guidelines; as a result of the Committee's inquiry, the Government commissioned NICE to produce broader guidance to include more patients who might be at risk.[15] When the draft guidelines were published the Committee wrote to the Secretary of State with some concerns and asked whether the Department had fully considered the work of the independent expert working group. The Government is to publish the report of the expert working group and involve NICE and others in developing VTE risk assessment.

44. In 2003 we published a report on Sexual Health.[16] The Government accepted a number of our recommendations to cope with what we described as a serious crisis. In 2005 we held a further inquiry to examine their implementation of policy. The reply was published in this Parliament.[17] Since some of commitments had still not been fulfilled, we sought and were granted a debate in Westminster Hall on the subject in February 2006.[18]

45. We have also taken a continuing interest in child migrants. In 1998 we published a report on the children who were sent to Australia and other Commonwealth countries between the 1940s and 1960s where many suffered severely.[19] We were pleased that the Government accepted our main conclusions and recommendations and acknowledged the responsibility of British Governments for the children's suffering. In particular, it agreed to fund the Child Migrant Trust which helps former migrants make contact with their families. Unfortunately, in 2003 responsibility for this issue was transferred from the Department of Health to the Department for Education and Skills. Subsequently, the funds to the trust were cut and its funding was to be removed entirely from March 2007. We wrote to the Secretary of State for Education to find out why. The reply was initially unsatisfactory so we decided to undertake a short inquiry, holding an evidence session with Department of Health and Education Ministers.[20]

Objective D: To assist the House in debate and decision

TASK 10: TO PRODUCE REPORTS WHICH ARE SUITABLE FOR DEBATE IN THE HOUSE, INCLUDING WESTMINSTER HALL, OR DEBATING COMMITTEES

46. The Committee's reports have been regularly debated in the House and Westminster Hall. Estimates Day debates were held on the Report published in the last Parliament on the Influence of the Pharmaceutical Industry[21] and on deficits in the NHS based on the oral and written evidence we took on Public Expenditure in 2005.[22] There were also Westminster Hall debates on the Changes to Primary Care Trusts Report and the New Developments in HIV/AIDS and Sexual Health Policy Report.[23] The Committee has bid for Westminster Hall debates on two Reports published in this Session, Independent Sector Treatment Centres and NHS Charges.

47. Our reports and the evidence taken before the Committee are also frequently referred to in Health Questions and in other debates on health in the House and in Westminster Hall. A number of the reports have influenced important debates in the House. The report on Smoking in Public Places, which was tagged to the Report and Third Reading debate of the Health Bill, was, as we have seen, the most influential.

3 Votes and Proceedings, 14 May 2002, p 864-5 Back

4 Liaison Committee, Second Report of Session 2001-02, Select Committees: Modernisation Proposals, HC 692, para 16 Back

5 Cm 6374 Back

6 The Department of Health, The Chief Medical Officer on the state of public health, Annual Report 2005 Back

7 First Report of Session 2005-06, Smoking in Public Places, HC 485-III, Qq 446-456 Back

8 The Committee took evidence from the Chief Minister Officer and from the Minister on 24 November 2005. The Committee's Report was published Monday 19 December 2005. The Chairman proposed an amendment to the Bill on 10 January 2006, which was withdrawn when the Government agreed to table their own new clause for the Report stage on 14 February 2006. Back

9 Department of Health, Government Response to the House of Commons Health Committee's First Report of Session 2005-06, Smoking in Public Places, March 2006, Cm 6769 Back

10 Oral evidence taken before the Health Committee on 26 January 2006, Responsibilities of the Minister of State for Health Services, HC 866; and Oral evidence taken before the Committee on 26 October 2006, Responsibilities of the Minister of State for Delivery and Quality, HC 1691 Back

11 Oral evidence taken before the Committee on 26 October 2006, Responsibilities of the Minister of State for Delivery and Quality, HC 1691 Back

12 Q 750 21 November 2006 Back

13 Fourth Report of the Health Committee, Session 2005-06, Independent Sector Treatment Centres, HC 934-III, Q528-616; Oral evidence taken before the Committee on 29 November 2006, HC 94-ii Back

14 Oral evidence taken before the Committee on 23 November 2006, HC 94-i Back