Examination of Witnesses (Questions 140-159)
MR IVAN
LEWIS MP, MR
NICK CHAPMAN,
PROFESSOR SUE
HILL AND
MS HELEN
MACCARTHY
8 MARCH 2007
Q140 Mr Campbell: So when the Hearing
Aid Council goes, what regulation will be in place? What organisation
will take its place?
Professor Hill: There have been
ongoing discussions between the Department of Health and the Department
of Trade and Industry about the future direction for the Hearing
Aid Council. The discussions have been considering private sector
hearing aid audiologists being regulated by the Health Professions
Council, which regulates a number of professions who also practice
in the independent sector. Those discussions are ongoing, so that
there would be a seamless transition from one regulatory arrangement
into a new regulatory arrangement. The Committee will be aware
that we recently published the White Paper on regulation of both
medical and non-medical staff, and those discussions will continue
now that that work has been outlined.
Q141 Mr Campbell: What you are saying
is that we really do not have anything to worry about and that
"not fit for purpose" may be a bit over the top?
Professor Hill: I think the White
Paper also made reference to Hearing Aid Council and those hearing
aid audiologists, so in terms of the regulation of the professionals'
practice.
Mr Lewis: We are not going to
leave the system without adequate regulation. It may be done differently.
Q142 Mr Campbell: That is what I
am trying to get at.
Mr Lewis: It may be done differently
but we would not leave the system without the appropriate regulation.
I think that is the message.
Q143 Chairman: It will come under
the changes that will come out of the White Paper that was published
two weeks ago now?
Mr Lewis: Yes.
Q144 Mr Amess: Welcome back, and
welcome back to the hot seat. Those who were colleagues of yours
when you were on the Select Committee can certainly vouch for
the fact that you took your duties very seriously and, as you
have said, you regard this as an important occasion and, whatever
the background to it is, I am delighted that an announcement was
made on Tuesday. I think you have been brilliant in your tactics
this morning. The wind has been taken out of the sails of the
Committee by you very cleverly and very sensibly more or less
agreeing with all our concerns. I really do congratulate you on
your approach. I would simply caution, however—and I will
come to Mr Chapman in a moment—that in a year's time, if
you have delivered on all these aspirations, marvellous, but in
a year's time, of course, this ploy may not work so well. I do
not know you, Mr Chapman, and I do not know how much you are paid
or whether you are going to be here in a year's time. We have
the Secretary of State for Health who is going to resign if everything
is not sorted out financially. I do not know what you are going
to say but you are going to have a bit of a challenge with Bromley,
where they are waiting two years—I am sure you have been
on the hotline there—Plymouth, 108 weeks; Mid Staffs, 104
weeks. These are big, big challenges for you, are they not?
Mr Chapman: Certainly I would
accept that, both in the context of 18 weeks overall and for patients
waiting for audiology and hearing aids, yes, we have a big challenge,
as the Minister said earlier on. What we know is that, in order
to ensure that the appropriate attention, either in terms of redesigning
the way that patients go through the system or in terms of resources,
or work force, flows from good data, and good data about the extent
and nature of the problems that exist in different localities.
During the course of last year we instituted the first proper
national data collection and modified that in October to ensure
that we were capturing better information about long-wait patients.
I have been involved in discussions with every SHA about their
plans for hitting the diagnostic milestones that the framework
talks about and 18 weeks, and serious planning around the levels
of activity that are needed to reduce the numbers of patients
currently waiting.
Q145 Mr Amess: You share our Minister's
optimism?
Mr Chapman: I share my Minister's
determination.
Q146 Mr Amess: I would like to be
privy to the conversation at the end of this session! To get back
to our Minister and Lord Warner, who decided he wanted to retire,
my colleague earlier got on to this particular issue with the
statement that he made about these 300 patient pathways being
procured. Could you tell the Committee what progress has been
made?
Mr Lewis: Yes. First of all, welcome
back to you as well, David. Nothing has changed. The thing is,
first of all, in response to your original comments, I do not
think any Minister should be in denial about reality, and what
is real is that we spent £125 million, we benefited three
quarters of a million people who got hearing aids who would not
have got them if we had not done that, and prior to that there
had been no modernisation whatsoever of audiology in this country.
Having done all of that, we still have thousands of people waiting
too long for their treatment and we have a duty and a responsibility
to do something about it. That is what this is all about. On the
pathways, essentially, we are ready to procure but the SHAs and
the PCTs are saying to us "Hold on a moment until we are
absolutely certain about our in-house capacity and if we did things
better and differently within our areas we may not need you to
procure 300,000 pathways." However, if we find that they
are not actually able to back up that perspective with a great
deal of evidence, we are still going to say to them "We believe
we need to get on with the business of procuring that number of
pathways." We have to respect the fact that they are saying
to us they think if they can do things differently in some areas
they can do this in-house, which would reduce, if you like, the
number of pathways we would have to procure from the independent
sector. The commitment from us is that there is up to 300,000
there to procure, and you are right to make the point about timing
because, frankly, we are going to need to move on this relatively
quickly and we are at the end of our period of dialogue with the
SHAs on this and we expect them within a matter of, hopefully,
a couple of weeks—not months—to be definitive in their
position on how many pathways they think they can deal with within
their existing organisations and how many will be necessary to
procure from the private sector to meet these new requirements
we have placed on them as a result of the framework we published
this week.
Q147 Mr Amess: So, putting it in
context, which I think we have all been listening to carefully,
for very good reasons, nothing has really happened.
Mr Lewis: On those pathways.
Q148 Mr Amess: Yes. Again, you have been
honest. Just before I get to the main question, I just wanted
to tip you off that when you were going for it and saying fitting
these hearing aids on the same day and it is all going to be done
very quickly, there was a bit of grimacing behind you in terms
of the practicalities of that happening. I have no expertise in
fitting these things but—
Mr Lewis: Who was grimacing?
Mr Amess: There may be a bit of concern.
Chairman: All the audiologists in the
audience.
Q149 Mr Amess: I have to tell you,
Minister, we nearly had audience participation this morning, where
a representative from Specsavers wanted to put his hand up to
join in one of the responses. It is worth reading the transcript
on this. Will individual commissioners be free to decide whether
they want or need to commission services from the private sector,
and will there be any central commissioning of private sector
involvement for these 300,000, which obviously you have now put
in context?
Mr Lewis: Can I just be clear
about the different involvements with the private sector that
have gone on? We need to be clear about sequence. There was the
first public-private partnership, which was about the modernisation
project, and that basically ran from October 2003 to 31 March
of this year. That is one stage of this. Phase two in terms of
diagnostics procurement—and this is already agreed, so this
is not about the dialogue we are currently having about the 300,000
pathways—40,000 audiology pathways will be procured between
2007-08 and 2011-12 per annum. That is already committed to and
that is already taking place. The way that the tendering will
take place on stage three, if you like, would be that we would
issue a spec and we would ask providers to bid. The successful
bidder would then be the provider that the local NHS would do
business with. As I understand it, we would not really be encouraging
necessarily the local NHS to enter into their own arrangements
with the independent sector. We have heard today, I believe, that
where that has happened in the past, it has not always worked
out in a very satisfactory way. On the other hand, I have to say
that if a local PCT chief exec said, "I could do business
with a private sector organisation get my waiting lists and waiting
times down incredibly quickly over a short period of time,"
I am not sure that we could get in the way of that person who
has the responsibility for making that decision. But our preference
is for them to be absolutely clear about what is needed from the
independent sector in terms of pathways, in terms of them being
able to get these waiting lists and waiting times down in their
particular localities, and then we will proceed with the national
procurement. On the question of the people behind me—and
I would be interested for you to name them privately later—let
me be clear about this. I have brought to hand round the Committee
an explanation of this new way of doing things, if I can. It explains
in some detail in a technical way that I cannot explain, if I
am honest. Essentially, we believe—and this is based, David,
on what is happening in certain parts of the NHS right now—that
around 50% of those that end up being assessed and needing a digital
hearing aid could, in the right circumstances, have that done
on the same day. That is a major step forward. What this diagram
attempts to do is explain to you why we know that to be possible.
I agree in certain areas it will require them to reorganise their
systems, their technology, the way they do this, but it most definitely
is doable. That is the point. The other point I would make you
is the other 50% who clearly could not have it done on the same
day, because they will only be waiting a maximum of six weeks
for the assessment, which is a major step forward, we should only
be talking, as I say, about a relatively few number of weeks to
move from that point to actually getting your digital hearing
aid fitted. That is the grounds for optimism. It is not based
on some fanciful hope, not backed up by evidence. I think there
is hard evidence to believe that we can be optimistic and confident
that we can get waiting lists and waiting times down in all parts
of the country significantly.
Q150 Mr Amess: You are the chap in
charge, and I think we salute you in your endeavours. I would
imagine that when you chat privately, it is probably the human
element in the practicalities of day-to-day management, I would
guess. I do not know.
Mr Lewis: It is. You are right.
In a sense, we are putting in place the levers and the incentives
that central government should be putting in place to ensure that
waiting lists and waiting times are slashed everywhere but, of
course, we are dependent on the leaders and the managers and the
front-line professionals to make this work in every health economy
in every part of the country. But we do have confidence in them
doing that and, as I say, I think what has probably changed as
a consequence of this week is that it if you are the chief executive
of a Primary Care Trust or a Strategic Health Authority, you know
that one of the items that is at the top of your list in terms
of getting your act together where things are not going as well
as they could be doing is audiology.
Q151 Dr Naysmith: Is this happening
anywhere in the country? Is there a pilot? Can you give us the
names of any?
Mr Lewis: Yes, there has been
a series of pilots. I do not have them on me but we can certainly
give you examples of where this has been deployed.
Q152 Dr Naysmith: Acoustic testing
and fitting on the same day?
Professor Hill: Yes, this device
has been tested in 12 sites in the NHS, including eight NHS sites
that the Department of Health is working with and, not only looking
at the benefits that new technology like you have in front of
you can bring, we have also been looking at how this can be utilised
in combination with greater efficiencies for better waiting list
management, scheduling of appointments and also removal, for example,
of some of the management and admin functions from qualified audiologists
into a more central admin-based arrangement, improving the quality
of referrals or the time that it is spent by audiologists supporting
ENT clinics into a more manageable arrangement so that they can
see more patients who are direct access patients. So it is looking
at the combination of the technology—and this is one piece
of technology, illustrating one type of open ear tip, used in
predominantly mild to moderate patients. Another tip, the Comply
tip, can be used in the more moderate to severe patient groups.
So it is the benefits of the technology, streamlining the processes
and matching the work force to that that has been trialled.
Q153 Dr Naysmith: And pre-selecting
the patients?
Professor Hill: Yes, these approaches
have been used on triaged patients but they have also been tried
on new patients presenting to the service who have not been triaged
at all.
Q154 Mr Amess: We are absolutely
delighted that you have made audiology a priority.
Mr Lewis: I think the Select Committee
helped us along the way. Can I describe these figures to you,
which in a way illustrates the point. In the East of England the
average wait for assessment in November 2006 was eight weeks.
On the south-east coast it was 33 weeks. That is not about resources,
in my view. It cannot be. That variation has to be about ways
of working, prioritisation, focus. You cannot justify that level
of disparity.
Q155 Mr Amess: Finally, in mutual
admiration, I think, from our point of view, it is jolly useful
to have two of the Health ministerial team who have been on the
Health Select Committee, because you know the way we work and
we do not want to waste our time and public money on having these
inquiries and nothing happening. It is brilliant that it is appreciated
and we can deliver on our report. Finally, the additional 42,000
pathways already procured by the Department: did you ensure the
input of local commissioners in this? Why were NHS departments
not able to bid for the business?
Mr Lewis: In terms of the 42,000,
basically, that is specifically going to cover five regions, five
Strategic Health Authorities.[2]
They, in a sense, have worked with us and said that together we
want about 40,000, and I suspect the answer to that question would
be that they are the ones that said, in terms of our existing
capacity, our existing organisational frameworks, the best way
for us to make rapid progress in audiology is to actually do business
with the independent sector. If they said that to us, we have
to accept that. Other Strategic Health Authorities, looking at
the next 12 months, two years, getting these waiting lists and
waiting times down considerably, are saying "Actually, we
have a pretty good service in-house and we think we can do some
of this through our in-house service getting even better."
That is what is holding up a decision on the 300,000.
Mr Amess: Thank you for your frankness.
We wish you well and we look forward to finding out whether Mr
Chapman is in his job in a year's time.
Q156 Chairman: Before we move away
from that, could I just ask you this. You say in five SHAs, so
this is geographical?
Mr Lewis: On the 40,000, yes.
Q157 Chairman: We do not know where
they are but on what basis were they selected as opposed to the
other four of five SHAs?
Mr Chapman: They selected themselves.
They said, "We want to take this forward."
Q158 Chairman: So you did not look
at the waiting times or anything? You have done this comparison
between the east of England and the south coast; that was not
one of the reasons why these shareholders were selected? Is that
what you are telling us?
Mr Chapman: What I am saying is
they were not selected; they selected themselves.
Mr Lewis: They said, "We
need to do something about audiology in our region and the only
way we can really do that effectively quickly is to procure from
the independent sector. Can you do this in terms of 40,000?"
But now we are having a dialogue, as you know, with all of the
SHAs on this 300,000 and, to put it bluntly, if some of these
worst performers come back and say they do not need any independent
sector pathways, I do not think we would just say "All right
then" and let them get on with it. We will be asking some
hard questions about "You have not been able to shift this
in-house so far, so how are you going to do it in the next 12
months?"
Chairman: I am trying to see this thing
about decision-making being evidence-based in the National Health
Service. I will keep trying.
Q159 Sandra Gidley: We heard earlier
that, as a result of one of the private contracts, the hospital
was the only place where some of the facilities could be provided.
So effectively, NHS equipment and staff were used, unpaid, while
the private provider took the money. What are you doing to ensure
that that is not possible in any future commissioning?
Mr Lewis: Again, I cannot be absolutely
certain, but from what I am aware of, this was an arrangement
that the local PCT made with an independent sector provider outside
of the national guidance and national framework that we issued,
and in the national guidance and national framework that we issued,
one of the things that we specify is the nature of the relationship
between the NHS and the independent sector, the best practice,
the outcomes, the value for money that can be achieved. Certainly,
that should not happen in any circumstances. Clearly, I am not
in every hospital and every PCT, so when you say what can I do
to guarantee it, once we procure the independent sector pathways,
the private sector starts working with the local PCT and National
Health Service, frankly, it is managers' and professionals' job
at a local level, engaging with the private sector, to make sure
that that works properly.
2 Note from the witness: there will be five
schemes across seven SHAs. South West SHA and South Central SHA
will share one scheme, North East SHA and Yorkshire and the Humber
SHA will share one scheme, and South East Coast SHA and South
Central SHA will share one scheme. The West Midlands SHA and the
North West SHA will each have their own scheme. Back
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