Examination of Witnesses (Questions 120-139)
MR IVAN
LEWIS MP, MR
NICK CHAPMAN,
PROFESSOR SUE
HILL AND
MS HELEN
MACCARTHY
8 MARCH 2007
Q120 Chairman: It is the case, is
it, that currently, because of the excessive waiting times in
areas, because a lot of hearing problems are in the elderly and
it is something that deteriorates, that somebody will have an
initial test at a cost to the British taxpayer, who then, because
they have to wait a length of time, will have to have that same
test again before anything can be done? It seems to me that to
organise a system or for a system to be allowed to be run like
that is enormously expensive to the taxpayer.
Mr Lewis: It is completely unacceptable
and, based on the best practice in the best areas, unnecessary.
Q121 Sandra Gidley: I struggle with
this 18 weeks. In the Department's submission it says it would
not be appropriate for people who are directly referred to be
covered by 18 weeks. I am sure the many thousands of people who
are referred direct to audiology services cannot actually appreciate
the difference. It is semantics as far as they are concerned.
Why is it not appropriate for direct referrals to be treated in
the same way, with the same targets, as those who are going via
an ENT surgeon? Are you not actually putting in a perverse incentive
for people to inappropriately refer?
Mr Lewis: The point is that before
the publication of this framework and this clear new policy framework
for the way audiology needs to be done in the NHS, that perverse
incentive was absolutely at the core of the potential problem,
that because those referred directly to ENT would be covered by
the 18 week target and others would not, the system would say
we might as well refer directly to ENT because that is the way
were going to get our patient the quickest treatment in the most
effective way. I believe the publication of the framework this
week, this new policy for audiology in the NHS, will actually
put an end to the danger of that unintended consequence. In answer
to your question, there is only one answer I can give you because
it is a straight answer. There were a number of things excluded
from the 18-week target when the judgement was made about what
treatments and the definition that ought to fall within the 18
weeks and this was one of them. If you then go back to the NHS
and say, "Having looked at this, we are going to include
this category of patients. Having reconsidered it, we're going
to include another category patients," before you know where
you are, you are essentially destabilising the system. That is
the answer, but I genuinely believe and the expectation that has
been made very clear to the NHS is, it has to be acknowledged—and
this is not a new announcement; this has been an expectation that
the NHS has had since 2005 that the maximum six weeks for assessment
everywhere for everybody, whatever the nature of referral, which
they have known about since 2005. Our point is—and I have
these sheets to hand round later which explains the modern technology—if
you look at the modern technology, as I say, there is absolutely
no excuse, once you are able to achieve a maximum six-week wait
for assessment, that you cannot then move to get the digital hearing
aid fitted either immediately or very soon after.
Q122 Sandra Gidley: You said 50%
could be done on the same day but in the short term, if there
is a political imperative to do the diagnostics within six weeks,
are you not creating another unintended consequence, where all
of the effort is put into hitting the target and people just have
to wait; despite the fact that it can be done, the time constraints
mean that it will not be done and people end up having to wait
longer for a fitting if we are not careful. What is being done
to prevent that happening?
Mr Lewis: What is being done is
that the Department, the Strategic Health Authorities, and the
PCTs are making absolutely clear that that would be entirely unacceptable
and that audiology has been elevated this week to one of the NHS's
priorities. If you want me to be very frank, I suspect that until
very recently audiology was not seen as one of the NHS's top priorities.
So every SHA and every PCT now understands that there will be
accountability, there will be transparency, there will be performance
management and there are the resources in the system—let
us be clear about that—to enable them to slash waiting lists
and waiting times. The proof of the pudding will be in the eating.
Q123 Sandra Gidley: You said there
were the resources in July of last year. On 25 July Lord Warner
said 300,000 new service areas for assessment fittings and follow-ups
would be provided. You have just alluded to that. Nothing has
happened since July. When is it going to happen?
Mr Lewis: It is going to happen...
Sorry.
Chairman: You have just jumped down the
agenda by about six questions.
Sandra Gidley: I am sorry. You can answer
it later.
Q124 Dr Stoate: I think you have
a Herculean task on your plate. You said you believed the capacity
exists to make a big difference but we have heard this morning
from the RNID that the NHS does approximately half a million fittings
a year. There were approximately half a million people currently
waiting, in other words there is a year's worth of work currently
in the system where people are waiting for a fitting. We also
heard that there is potentially 6.5 million people in this country
who actually suffer hearing loss sufficient to require a hearing
aid should they make themselves available to have one fitted.
In other words, the task is immense. I am very concerned that
you seem to think that the NHS can somehow cope with all this
within existing resources when we are hearing from lots of people,
including witnesses, including in written submissions, and including
the previous people we talked to this morning, that that is pretty
unrealistic. How do you think you are going to achieve it?
Mr Lewis: I think we have demonstrated
in areas where they work in an integrated way in terms of the
different professionals that are involved in responding to this
problem. We have slashed the cost of the whole process from referral
through to fitting in an amazing way, from thousands of pounds
to, I think, an overall cost of £260 for the entire process.
We have already put significant amounts of resources into the
system for this purpose. I really have to link Howard's question
to Sandra's question. The reason that we have not yet proceeded
with the tendering is because what the shareholders and the PCTs
are saying to us is "We want to be absolutely certain that
the amount of pathways you tender for are necessary because we
do not believe that at the moment we are getting maximum use out
of our existing capacity." That is linked to this as well.
But you are right. Howard makes the point, and you did, Kevin,
that demographic factors are a reality in this area of policy
as they are for the rest of the NHS and indeed for social care.
People are living longer and longer, they have more more complex
conditions, disabled people are these days having fuller lives,
all of which is a good sign in terms of the kind of society we
want to live in, but that does place new questions on the NHS,
on social care, on public policy generally, that we need to reflect
on and we need to ensure that we have a system that can genuinely
respond to those demographic pressures and those demographic realities.
I cannot today say to Howard and any other member of this Committee
that it is not a challenge, because it is a challenge but what
I am trying to say is that the levers and incentives and accountability
that we have now put into the system, and the capacity that is
available, we believe will lead to the slashing of waiting lists
and waiting times for audiology in the NHS in every part of the
country, which will also lead to greater equity. The inequity
in terms of waiting times and waiting lists depending on where
you live in relation to audiology cannot be acceptable, nor is
it consistent with the NHS's values.
Q125 Dr Stoate: The worry is that
you are setting yourself up for a fall, and the reason I say that
is because currently GPs can use the system either by referring
direct to ENT to get into the 18-week target or to audiology if
they feel that audiology is working in their area. I do not yet
see what disincentivises GPs from doing that. I know your aspiration
is for a six-week audiology assessment and, hopefully, a one-stop
fitting, and that would be wonderful if it happened but in areas
where, let us be honest, that is not going to happen, at least,
not very quickly, GPs are simply going to say, "We will have
to go down the ENT route because that way I can at least guarantee
my patients a fair service" and you will not get GPs simply
trying to play fair, if you like, by what you are trying to do,
because they will see in their patient's interest which way to
go.
Mr Lewis: I have a much higher
opinion of your colleagues than you do, Howard.
Q126 Dr Stoate: They are fighting
for their patients and their patients will get a better deal if
they go the 18-week route.
Mr Lewis: One of the things that
is clear is where there is a good relationship between GPs, between
primary care and audiology departments and ENT within acute hospitals,
the quality of the service, the nature of the response, the waiting
lists and waiting times are in much better shape. So one of the
challenges for PCTs particularly is to ensure that not just they
look at this as hitting a target but that they reorganise the
nature of their service and the contribution of the respective
professionals to ensure that in each locality they have a sensible
system, but the consequence of everybody's intervention is significantly
reduced waiting lists and waiting times for patients. I am an
optimist; maybe you are less optimistic. That is the nature of
politics. The other point I want to make today is I personally
and the Department along with the RNID will be monitoring progress.
We will not simply be publishing this document this week, appearing
before the Select Committee and then moving on to the next agenda
item. We will have to monitor progress on an ongoing basis to
make sure the system is shifting, and shifting quickly on this
issue.
Q127 Dr Stoate: The problem with
optimism is that the definition of optimism is it is someone who
has not heard the bad news yet. That is the difficulty.
Mr Lewis: I am a Manchester City
supporter, Howard. I do know the bad news.
Q128 Dr Stoate: Clearly, one of the
ways we are going to achieve this target hopefully is through
a better skill mix. We have talked to witnesses before about improving
skill mix. Why has that not happened yet? Why do we have to have
this inquiry? Why has the skill mix not already been sorted out
to try and increase capacity? Why are you talking about aspiring
to improving capacity? If you can improve capacity, why have you
not done so?
Mr Lewis: I can only take responsibility
for the period for which I have been responsible but the reality
is I do not think the NHS and in fact, to be fair to the NHS,
the Department or our partners in the voluntary sector anticipated
the explosion in demand as a consequence of the modernisation
project. The explosion of demand has implications for resources,
it has implications for waiting times and for patients. It also
has major implications in terms of work force. To be fair though,
if you look at the commissioned number of places in training,
for example, for audiologists, there has been a significant year-on-year
increase. You may want to ask me some questions about this but
in terms of the number of training places that have been created
now and will be coming through over the next few years, because
obviously, as you know, the time lag between training, qualifying
and being fit to practise is significant. We only started really
investing in significant new audiology training places in a relatively
recent period of time and the first graduates are coming out around
now. So let us be clear. Audiology, I guess, was not one of the
NHS's most important services, and that is reflected across the
board; it could be regarded as a Cinderella service. In my view,
the inability to hear properly is about people's quality of life.
It is about their ability every day to function in their family,
in their community, in their place of work, in society. It is
massively important. It is not a minor issue. That is why I would
say to you, all I can say is yes, clearly, it would be a nonsense
for me to sit here today and say things could not have been done
better and could not have been planned more effectively over a
period of time. It would be a nonsense for me to say that, but
my job now is to address the failings and weaknesses in the system,
recognizing what levers I have to pull in a ministerial position
because in the end, we do not want every PCT and every hospital
and every doctor's surgery in the country—we need to be
clear about that—but we do have a duty to put in place the
levers, the incentives, the accountability framework to make sure
that people with hearing impairments get the service that they
deserve from the NHS, which in some parts of the country they
are currently being denied.
Q129 Dr Stoate: That is certainly
very encouraging. So what you are really saying now is you are
honestly able to say that audiology services are now a much higher
priority in the NHS than they previously were?
Mr Lewis: The judgement I would
make about that is, would a chief executive in an SHA or a PCT
regard their responsibilities on audiology to be one of the things
that they need to be keeping a very regular close eye on? That
is how I would define my answer to your question, as well as the
ability then to engage with the professionals on the front line,
to get the professionals to work together, to believe the commitment
is real, they will have the resources and we can make it happen.
If that is the question, the answer is yes.
Q130 Chairman: We will wait with
interest to see how this best practice spreads throughout that
particular part of the National Health Service over the next few
years, Minister. Could I just say, because it is not specific
in the report but we have had evidence which will be published
next week on the website, from the National Deaf Children's Society.
Do you look at the issue of school-age children and waiting times
differently to the general customer? It is normally obviously
demographics that determine the need.
Mr Lewis: I have to be honest
with you. I think we do look at it differently because the basis
of the data I have for the Committee on this is minimal. So it
is clear to me that we do not have anywhere near as much hard
data on this issue as we could or maybe should have and we need
to review that as a consequence of this process. What I will say
to you, Kevin, is two things. First of all, the fact that we now
test newborn babies in terms of hearing is a fantastic step forward
and, as a result of that, we are able to get in really early with
thousands of babies and prevent a deterioration which could end
up in a far worse situation. I also believe anecdotally, by speaking
to professionals on the front line, that even now, with the difficulties,
in practically every health economy children with hearing problems
are prioritised in the vast majority of cases. On the other hand,
the caveat is I do not have as much hard data as I would like
to give you cast-iron guarantees.
Chairman: It is just the issue that denying
somebody of my age to hear better is a lot different to denying
a five-year-old the ability to be educated like all their peers.
Q131 Dr Naysmith: Good morning, Minister.
Welcome back to the Committee. I hope you are enjoying it as much
as you used to enjoy it when you sat here!
Mr Lewis: I am waiting for David
to speak before I can answer that.
Q132 Dr Naysmith: We are saving him
till last today. Obviously, all the things you have been planning
and announcing this week, you are not going to be able to manage
to do it without the private sector, I suspect. We have had some
experience of collaboration between commercial firms and the National
Health Service and the so-called public-private partnership. Do
you think it has been a success?
Mr Lewis: In this area? Overall,
frankly, the modernisation programme, we spent £125 million,
did in the end benefit three quarters of a million people. I think
it is fair to say that those people regard that as a success and
that the private sector's engagement with that really was significant
and we would not have been able to do it without them. I also
believe that, in terms of our ambitious programme to get the situation
under control within a relatively short period of time, we will
need to be able and willing to work in partnership in a sensible
way with the private sector. I would say to you, Doug, that if
you look at the national framework that was set out in terms of
working with the private sector, it also meant we were able to
get incredibly good value compared to how much we were paying
previously. I know there have been one or two exceptions to this,
and I will try and explain why, because some local NHS organisations
have gone out and worked with the independent sector separately
to the national framework that we have actually created and set
out. Wherever that national framework has been used by the local
NHS, the economies of scale, the efficiency of outcome is indisputable.
Where some local NHS organisations have decided to engage with
the independent sector themselves, I am afraid to say they have
got a far worse deal off them, it has cost a lot more money and
the outcome has not always been as good for patients as it should
have been.
Q133 Dr Naysmith: We heard that this
morning from the private sector representative very clearly. He
said he did not recognize the criticisms that I am going to put
to you now but we have had evidence, which unfortunately has not
yet been published but it will be next week, witnesses saying
that the costs to the National Health Service by using the private
sector were twice the costs of doing things under the National
Health Service, and that there were cases of work being paid for
and not being done, because the patients were not supplied—that
brings memories of things that have happened elsewhere in the
system—and also that there were needs for re-referrals and
so on that were not part of the initial contract. We need to wait
and see exactly whether we are talking about the sorts of things
you were saying, ad hoc arrangements and not under the contract,
but we need to be sure that these contracts are properly tied
up, do we not?
Mr Lewis: We do. I would say to
you that variability in performance in this area is not necessarily
about public or private, and I think there are arguments to be
had in other areas of public-private sector partnerships where
there has been shoddy performance, etc, where you might say part
of the problem is the private sector is new to it, they do not
have the capacity, they do not have the expertise, and they do
not invest the resources. In this area I think it would only be
fair for me to say that I think a lot of the variability in performance
is not about whether it is public or private.
Q134 Dr Naysmith: I wonder if I could
ask Ms MacCarthy, because we have heard that you had some concerns
in the supply Purchasing and Supply Agency about the public-private
partnership. Is that true?
Ms MacCarthy: No. We have not
had any negative feedback at all to suggest that the public-private
partnership that we put in place at the national framework level
that the Minister has described about the performance that has
been provided, which is why we were saying earlier that there
are instances where those private partnerships exist outside of
that framework and we therefore encourage that governance comes
back under the framework and we have that kind of control and
monitoring and governance in place to make sure that those sorts
of things do not happen.
Q135 Dr Naysmith: Were these ad hoc
arrangements encouraged by the Department but not overseen by
the Department, the ones that were not part of the public-private
partnership?
Mr Lewis: I would not imagine
so. I can write you on that.[1]
I cannot be definitive. I think what we would encourage is for
people to use the benefits of us having done a tremendous amount
of work nationally to get this guidance or framework right to
say to the local NHS use that, because that has delivered. It
can demonstrate how you get quality outcomes but equally, it demonstrates
how you can get amazing value for money compared to what has been
done previously. I would not imagine we have ever been in a position
where we have been encouraging them to do their own deals with
the private sector outside that framework, no. It would not make
sense. The only other point, obviously, if somebody, for example,
gets an assessment on the NHS and then is so frustrated and is
waiting and then chooses clearly to purchase the rest of the service
in the market, the costs can be excessive. There is no doubt about
that. That is clear, is it not? If you look at where this is done
outside of the NHS, where it is not about the NHS commissioning
from the private sector, people can end up paying an awful lot
of money.
Q136 Mr Campbell: The Hearing Aid Council
has stated that the regulatory framework for dispensing hearing
aids was not fit for purpose.
Mr Lewis: Was this recent?
Q137 Mr Campbell: I believe it would
be recent because they are going to be abolished shortly, are
they not?
Professor Hill: The Hampton review
has been reviewing a number of arm's-length bodies sponsored by
the Department of Trade and Industry and the Hearing Aid Council
is one of those. The Hearing Aid Council has been looking at ways
in which private sector hearing aid audiologists will be trained
in future, and indeed, in partnership with higher education institutes,
they are introducing from this year a new foundation degree.
Q138 Mr Campbell: It says here "
... unregulated professionals, coupled with a lack of common standards
of education" of these people. Is this sour grapes on their
part? I know there are going to be abolished, but why should they
say "not fit for purpose"?
Mr Lewis: All I can say is that
obviously, we believe that the regulatory framework that is in
place is appropriate to secure protection, minimum protection,
for patients and to ensure that we support best professional practice.
We are not going to sit here and say as far as we are concerned
the regulatory framework is flawed. That organisation is probably
going through a period of change, from what I gather, and they
may genuinely be concerned about what that change is going to
mean in terms of protection, and I think they are entitled to
say that if that is how they feel, but we are certainly not, in
my view, leaving the system so unregulated that we are putting
patients at risk of a poor service.
Q139 Mr Campbell: I am beginning
to wonder, if it is, could this affect the running of the PPP?
Mr Lewis: There is a whole series
of things that will affect it. Obviously, regulation is a very
important factor in ensuring standards, protecting patients and
making sure that there is accountability.
1 Ev 125 Back
|
