UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 1106-i

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

 

 

OUR NHS OUR FUTURE

 

 

Thursday 25 October 2007

PROFESSOR LORD DARZI OF DENHAM KBE, MR DAVID NICHOLSON

and MS RUTH CARNALL

Evidence heard in Public Questions 1 - 113

 

 

USE OF THE TRANSCRIPT

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Oral Evidence

Taken before the Health Committee

on Thursday 25 October 2007

Members present

Mr Kevin Barron, in the Chair

Jim Dowd

Sandra Gidley

Dr Doug Naysmith

Mike Penning

Mr Lee Scott

Dr Howard Stoate

Mr Robert Syms

Dr Richard Taylor

________________

Witnesses: Professor Lord Darzi of Denham KBE, Parliamentary Under Secretary of State for Health, Mr David Nicholson CBE, NHS Chief Executive, and Ms Ruth Carnall CBE, Chief Executive, NHS London, gave evidence.

Q1 Chairman: Good morning and welcome. Could I welcome you to the single evidence session we are having in relation to the NHS mid-term review. Could I ask you to introduce yourselves and the position you hold for the record, please?

Mr Nicholson: David Nicholson, NHS Chief Executive.

Professor Lord Darzi of Denham: Lord Darzi, I am Minister in the Department of Health and I am also a consultant in an NHS trust in London.

Ms Carnall: Ruth Carnall, I am Chief Executive of NHS London.

Q2 Chairman: Once again, welcome. I have to say, Minister, the poachers turned game keepers are normally not from our advisers in past reports but actually from people who sit around the table as members who then move over into the Department for Health. I think this is probably a first given that it was only last year that you were advising us on our independent treatment centre report, but welcome to the committee. Could I ask you if you could tell us why you are the right person to lead the national review of the National Health Service?

Professor Lord Darzi of Denham: Yes, Chairman. Firstly, I am a clinician, secondly I am still practising and, more recently, as some of you will be aware, I also had the fortune of doing a review of London's healthcare as a clinician. That in itself was a unique experience to me as a clinician, being involved probably with the biggest engagement that I have ever been through, whether through clinical colleagues in London but also with the public and the users of the service. As far as credentials go, I think I have the right credentials in doing the job. As far as choice goes, I think that was the prerogative of the Prime Minister and the Secretary of State in their choice of who does lead this review.

Q3 Chairman: Do you think that clinicians are the right people to design and manage reform programmes in the National Health Service?

Professor Lord Darzi of Denham: I believe so, for a number of reasons. Firstly, there is a lot of evidence out there, and I see it on a weekly basis actually in the response to the patients that I see on Friday, Saturday. The first thing is: "How are you getting on with the new job", and delighted to see someone who is actually practising to be part of the team, but I think modern healthcare is a very complex system. I am, as I work back in the hospital, part of a much bigger team than I have ever been; in the department I am part of a team as well. As far as the public and the patients are concerned, I think most of us will know that if you look at the NHS Confed, if you look at some of the media analysis, the public and the user have a greater confidence in clinicians than they do. Again, I do not want to sound in any way difficult here, but politicians are managers.

Chairman: That is quite interesting. I was going to ask you if there is any evidence based on that, but I will forego that question for now and move over to Mike Penning.

Q4 Mike Penning: Minister, the interim report Our NHS, our future, which you released on 4 October, could have been released when Parliament returned a few days later. Why did you release it before Parliament was back?

Professor Lord Darzi of Denham: Firstly, let us go back to July when I was asked to do the interim report. Actually the review was launched on 4 July and, to be honest, it was said in the review that I should publish an interim report in three months. That in itself was a bit of a shock to me, because three months is a very short time to come up with an interim report. The justification for that was that we had to have an interim report before the CSR. Three months from 4 July was the first week in October. I knew I had to publish it before the CSR, I also knew that the CSR was going to be published in the first week when Parliament returned. That is why I published it before. Why did I not publish it in Parliament? It is an interim report, it is not my final report, and I would like to stress that. This is quite a big undertaking when it comes to reviewing the future of the NHS over the next ten years.

Q5 Mike Penning: The Prime Minister, who appointed you as a minister, said he would put Parliament first, and it would only have been a few days later that your report could have been brought before this House as an interim report, which you have quite correctly described it as, so that parliamentarians did not read in the press your plans for the future of London hospitals, et cetera. Surely there is a degree of naivety by bringing that out early.

Professor Lord Darzi of Denham: As I said earlier, the CSR was on the Tuesday, if I am correct, the second day after Parliament returned. I felt very strongly that I should have the interim report before the CSR.

Q6 Mike Penning: Your officials did not advise you that this would cause problems. Did they not advise you, as a new minister with a huge amount of experience of politics in Westminster, that this would cause huge ructions if you released it a few days before Parliament returned?

Professor Lord Darzi of Denham: The answer is, no, because it was an interim report. That is the advice they gave me.

Q7 Mike Penning: No-one said to you, "Get it out early" or, commonsense prevailing, "Wait a couple of days." It was your decision.

Professor Lord Darzi of Denham: No. It is my decisions to be publishing it that week. It happened to be on the Thursday.

Q8 Mike Penning: Can I push you for a second on that. You were not advised at any stage to either release it early by other ministers or the Secretary of State or advised, "Wait a minute. It is going to cause a huge problem if you release this a couple of days before Parliament returns"?

Professor Lord Darzi of Denham: I was not advised that it is going to create a huge problem if I do not publish it, if I do not announce it in the House.

Q9 Mike Penning: I think you need some better advisers then. You talked about being the honest broker. You must have realised, when the reports and everything was around the non-election, that that would damage your ability to be the honest broker within the NHS, when you got sucked into this election fever?

Professor Lord Darzi of Denham: Firstly, why am I doing this ministerial role? I strongly believe, as a clinician, that being given the role of leading this as a minister certainly will give me the responsibility and certainly will give me the power in making sure that this report is done very much based on the terms of reference which we set in July, which was clinically-led, patient-centred and evidence-based. As far as whether my credibility has an impact being a minister, the answer is, no, I do not believe that. I think the privilege of serving is the way I compare it. It is a great privilege to treat patients. Beside that, having the privilege of serving the country is the second best thing I do. As far as the question you are asking, the publication of it in October, it is something we decided in July. I cannot remember an election fever in July.

Q10 Mike Penning: The public do not know you made that decision in July. What we all know is what you have released on the date, and even though I respect fully your commitment to the NHS and to patients, you are Minister of State, you have taken the Labour Party Whip, you have collective responsibility with government. What was going on at the time to do with election fever you were implicitly involved in, so by releasing it then surely this has affected your credibility as the honest broker.

Professor Lord Darzi of Denham: I promise you, Mr Penning, the election and the timing of the election is well beyond my pay grade. I was asked to do a piece of work in July on this and they gave me three months. I challenged that, because I was not comfortable producing a piece of work in three months, but that had to be published before this year, so I spent all my three months this summer during recess, when most of you were away, doing this piece of work, going around the country and coming up with a publication in early October.

Mike Penning: The whole point is that we were away in our constituencies and you could have waited two or three more days and released it to the House.

Chairman: We will move on. Richard.

Q11 Dr Taylor: Can I express my sympathy to you, Minister, in a way, because you say you want to remain as a doctor and not a politician. I came into this job thinking I could do just the same but, in fact, one cannot. My huge advantage is my independence, and I just hope you will be able to assert your independence as a doctor throughout this. My question really relates to the reforms, because the Health Service is pretty well punch drunk with reforms. You in your own assessment say we are perhaps two-thirds of the way through. So, the question is: why is the review necessary now? Why should we not have waited until the reforms had pretty well got through and then reviewed them?

Professor Lord Darzi of Denham: The review is not about reviewing the reforms. Maybe I should put it within this context. I say this as someone who has been working in the NHS for many years, but if I could take you back to the NHS Plan date, I think most of us agree in this room it was the biggest capacity build the NHS has ever seen. I think we have increased its size by about a third. I do not think anyone has seen an investment in the NHS since the birth of the NHS back in the forties. When you are making an investment of that nature, that quantitative investment, there were sets of target which were raised at the time, and I will come back to those. Then there was another interesting period, which was the period of reforming the system - in other words putting reform levers in the system - and, I am sure you will agree, it is transforming the NHS as a business unit. I think one of the concerns we had as clinicians is how would this chief executive know what is my contribution - how many cases I get through, what am I doing in my clinic? So, it is the system, the NHS itself that had to be reformed. As a clinician I could tell you, the bit that probably we pushed too far is that we did not address the language when it came to reform of the system. The best example is here. If I am in the surgeons' coffee room between cases, or I am in the nurses' station up on the ward, we do not talk about PFIs, commissioning. We might talk about choice, because choice does actually drive our behaviour as clinicians, but we do not talk about commissioning. We talk about quality, we talk about the outcome. The bit about the language is that, although the reforms were the right things as far as the system is concerned, we did not carry the staff with us when it came to reform. So the whole purpose of this review is really to re-concentrate the mind on what matters most, which is the product of healthcare. The product of healthcare is the quality of care we provide to those who we serve. That is what matters. So, this whole review, and the case I made in my interim report, is about how do we engage the staff, how do we look at the models of care we are providing, improving the quality and the outcomes of care we provide? The answer to your question, I think, is this is still part of the journey and I am refocusing the minds of those who work in the service, refocusing the minds of those who use the service and refocusing the minds of those who pay for the service. That is what we are trying to achieve in the next ten years. So this is not to furnish the last third of that journey, it is also to design where we need to head in the next ten years.

Q12 Dr Taylor: Can you clarify what you mean by changing the language? You mean you want people to get talking in the coffee rooms and the restaurants in what way?

Professor Lord Darzi of Denham: Not restaurants. I am talking about, within the organised unit, refocusing what we do. What we do is based on improving the quality and the outcome of care, and that is why I came up with the four themes in the interim report which are based on the fairness of the service, the personalisation of the service, the effectiveness of the service and the safety of the service. That is what I captured by going around the country. I will come back to that. That is what I captured by seeing 1,500 clinicians. We have had enough talking about commissioning, we have had enough talking about PFIs, we want to talk to you about what we do every day, which is patient centre care. That is the language that is attracting those who work in the Health Service. That is what they want to talk about. That is the language.

Q13 Dr Taylor: Thank you. That is helpful. Looking back over the last ten years, can you pick out in your mind mistakes that have been made?

Professor Lord Darzi of Denham: Mistakes in what sense?

Q14 Dr Taylor: Things you would rather not have seen happen the way they did happen?

Professor Lord Darzi of Denham: Firstly, I believe we have had all the right policy ideals, if that is what you are referring to.

Q15 Dr Taylor: Yes.

Professor Lord Darzi of Denham: On the other side of the fence, I could say that probably we were not as good in implementing some of the policies, firstly, with speed but, more importantly, we could have seen some of the outputs or some of the benefits quicker than what we have seen so far.

Q16 Dr Taylor: What about some of the very rapid changes that have been made which then, within two years, have been reversed and gone back, if you are talking about reorganisation of SHAs and things like that?

Professor Lord Darzi of Denham: I think that is one of the reasons we made a strong statement in the beginning. The idea that reorganisation is going to fix some of the challenges facing the healthcare is not the right answer. We have made a very strong statement that this review is not going to look at reorganising, it is certainly not going to be the top-down reorganisation that we have seen before. So, you are right, when you re-organise you have to give some of the structures the time to mature in developing their competences, and that is why there was a very strong statement made in the terms of reference. This is not about re-organisation; this is about reorganising the actual models of care that we provide. It is not about structures and systems.

Dr Taylor: I am glad you have mentioned quality. We are coming to that later.

Q17 Jim Dowd: Following on immediately from what you were talking to Dr Taylor about, I think the Secretary of State described the exercise you are undertaking as a once in a generation opportunity or may even have said a once in a lifetime opportunity. If that is so, how can it be as wide-ranging and as unencumbered if you start from the premise that there is going to be no change to the structure of SHAs and PCTs?

Professor Lord Darzi of Denham: Because I do not believe the structures actually are the drivers for improvement, I think it is the maturity and the competency of the structures that matters most. I believe we should take stock and allow some of these structures to mature. PCTs would be a good example. If you look at the challenges that face PCTs, we need to give them the time to mature in delivering some of the competences we have asked them to deliver at a local level. So, I do not think there is a conflict there. If I could come back to you as far as restructuring to make this specific point, it is the top-down restructuring, it is someone sitting in Whitehall and trying redesign what the structures are at a local level. However, at a local level we should have a dynamic change, whether it is the provider, whether it is the Commissioner; we should always look and enhance the competences that they have at a local level.

Q18 Jim Dowd: I accept that they are not the driver, as you describe them, but they are a significant factor in the way that healthcare is both designed and delivered, are they not?

Professor Lord Darzi of Denham: They are, but I believe at this stage, we have just been through restructuring a couple of years ago, we just need to give these structures the time to mature. We cannot keep changing systems as a solution to some of the challenges facing healthcare at a local level.

Q19 Jim Dowd: Sure, I accept that, but not all change is necessarily progress, is it, and so if it is just not working you really ought to do something about it. I take the view very strongly. For example, there are far too many PCTs in London. I think it was right to base them on the boroughs originally, I think the coterminosity is significant benefits certainly to the relationships with the local authority in adult and children's services, but there are just too many of them, and the quality of commissioning has been highlighted as a deficiency, not just in London but elsewhere. If you are not going to change the structures, how are you going to improve the quality of commissioning?

Professor Lord Darzi of Denham: I take your point. It is a challenge that faced me when I was doing the London review that you have 31 PCTs in London and how do you allow the competences in 31 organisations to develop? Perhaps I could ask Ruth Carnall, who runs the SHA, to share with you some of her thinking post the launch of the London report in July, because I think in many ways it is an important question.

Ms Carnall: I think re-organising PCTs right now would completely detract their focus from things like improving stroke outcomes in London. So what I have tried to do, working with PCTs, is to get them to work in groups where that makes more sense, either because they can share expertise between them or because some of the things that they are trying to do require looking at a different population base. When I first started in the job I was anxious about whether 31 PCTs could be made to work, but, to be fair, in the year I have been there they have been very, very supportive and co-operative in terms of working together in groups, where that makes sense, and more widely strategically. Certainly they have been very supportive of the work that Lord Darzi did and willing to work in groups to see it implemented.

Q20 Jim Dowd: I accept that readily. In my own area we have got the de facto outer south-east London under review where we have got the four PCTs acting together and deciding the future of the acute sector, in particular between Queen Mary, Queen Elizabeth, Farnborough and Lewisham. That in itself is an indicator that the PCT is not the right unit to make these far-reaching decisions. You need de facto a sub-regional PCT to do it.

Ms Carnall: I think you can get the best of both worlds. I think they can come together to look at issues that span the population, such as the future of major hospitals. Equally, when they are working with local GPs, trying to work with smaller communities, trying to look at the interface between health and social care at local level, I think they are better based around borough boundaries, and certainly the local authorities in London will very jealously protect the 31 separate PCTs and see real value in the opportunities for integration at local level that that gives. I take the approach you are trying to get the best of both by enabling them to work together in sectors where that seems appropriate and supporting them in local activities where possible.

Jim Dowd: I am sure they will welcome the increased co-operation between PCTS and the borough councils; I am not sure they would defend the PCTS as an entity beyond that. Nonetheless, I leave it there.

Q21 Sandra Gidley: Moving on now to quality of care and infection levels, spending in the NHS has doubled over the last ten years, so why do we still have dirty hospitals and why are infection rates as high as they are in some hospitals?

Professor Lord Darzi of Denham: What you say is very, very important, and that is why, if you look at my interim report, safety in healthcare is and should be our priority. It should be part of our culture, it should be part of our every day working, and the two challenges within safety is hospital acquired infections and cleanliness. This is not new cleanliness and hospital acquired infections. If you go back even 40 years ago, the only defence we had against infection at the birth of the NHS was cleanliness, we did not have antibiotics in those days, and cleanliness is part, and should be part of the safety culture of every healthcare provider.

Q22 Sandra Gidley: I would agree, but why has it not been over the past few years?

Professor Lord Darzi of Denham: As I said in my interim report, quality, whether that is cleanliness or hospital acquired infections---. Certainly as a clinician, cleanliness is part of my culture as a practising surgeon. If you do not aid the patient on that journey with preventing infections, whether these are hospital-acquired or intra-operative infections or post-operative infections - let us not forget about MRSA here or clostridium difficile - infection is associated with healthcare provision, and whether it is a nurse, whether it is a doctor, whether it is a chief executive, ultimately the most important thing as part of that pathway is the cleanliness of the provider, the unit that we work in, which should be the pride of the organisations we work for. It is a very, very valid point. and the answer is what I suggested in the interim report: cleanliness and hospital acquired infection should be our priority. That is why I did not want to wait until June or July next year, I wanted that to be in the interim report and that is why I made set of recommendations in relation to that.

Q23 Sandra Gidley: Are you saying, in effect, that cleanliness has not been a priority in the past and that perhaps the amount of money spent on other targets has taken health professionals' eye off the ball? For example, we had before us last week Professor John Appleby and he intimated that the vast amounts of money that have been spent on reducing waiting times might have been better spent on improving the quality of care for patients. Do you agree with him?

Professor Lord Darzi of Denham: I think we are comparing apples and oranges. Cleanliness is not a target; it is not something that should be a priority: cleanliness should be part of our every day work. You cannot go to a hospital, you cannot be a healthcare professional if cleanliness is not part of your every day life.

Q24 Sandra Gidley: I think everybody in the country would agree with you, but clearly that has not been happening. Why has it not been happening and is it because of the focus on targets?

Professor Lord Darzi of Denham: I do not believe it is the focus on the target. In actual fact, I also believe, if I am correct - you probably saw Sir Ian Kennedy's response in relation to that in relation to the outbreak recently - managing healthcare systems is a very complex system. You do not prioritise one against the other. Waiting lists and waiting targets were things of the past. I remember seven years ago my waiting list was under 18 months. I had another target: I could not cancel a patient more than three times. These were the days we are talking about. It is not because we concentrated on that and got our eyes off the ball in relation to what matters most. I could not be dropping washing my hands before an operation or seeing a patient. It should be part of the culture of any healthcare provider.

Q25 Sandra Gidley: It should be, but clearly it is not.

Professor Lord Darzi of Denham: It is a leadership issue.

Q26 Sandra Gidley: Possibly. If it is not targets, could it have been financial pressures? We had figures released last week which showed that many hospitals have bed occupancy rates between 95 and 100%. That gives them a 60% increased probability of infections in those hospitals. So, are financial pressures to blame for people not concentrating on what is really a basic?

Professor Lord Darzi of Denham: I do not believe it is financial pressure. I believe it is a leadership issue. I believe it is one of these things when you are working in a complex system that there should be a collective accountability to the infection. Infections do not just arise in the operating theatre. They could arise prior to the patient coming into the hospital from the community setting. That is why one of the recommendations I made, which is evidence-based, which is something close to me, is that every patient coming in for elective surgery should be screened. That might challenge some organisations in identifying the funding to support it. That is why we made the announcements of about £130 million to screen patients coming in for elective and eventually, within three years, emergency surgery, because if we screen patients prior to coming in we can isolate those patients who are carriers of MRSA who could actually self-infect themselves. At the same time we also introduced a number of different other parameters, screening was one and the other one which was announced by the Prime Minister is deep cleaning of hospitals, all to refocus the mind in bringing that collective accountability of what I am referring to, which is cleanliness. It is part of the culture of any healthcare staff, any ward, any structure, any building that is involved in healthcare provision.

Q27 Sandra Gidley: So you think the problem in the past has been poor leadership in the NHS on this issue. If it is a leadership issue, and there is a problem the problem, presumably, has been poor leadership?

Professor Lord Darzi of Denham: It has been poor leadership in some of these organisations that have had significant outbreaks of the type that we have seen in the last week. I work in organisations which deliver healthcare and I know exactly the ones who have the right leadership in ensuring that that is part of the culture of everyone who works there.

Q28 Mr Scott: Minister, a brief point on that. What you have said, as Sandra quite rightly said, no-one could disagree with about cleanliness, et cetera. The question comes back to, I know you are saying poor leadership, but somebody is above that leadership and why has this been allowed to happen for such a prolonged period of time with so many people, unfortunately and tragically, losing their lives?

Professor Lord Darzi of Denham: Firstly, let us look at what happened last week. I could not agree more. What happened in Maidstone was more than tragic. What we need to do is to be mature enough and understand why an organisation like that has been through what it has been through. Leadership is one, but if I could look at it from more of a scientific perspective, it seems that they had a systems failure within that organisation. It is not an individual, it is a collective number of individuals where we have failed at a local level to identify the hazards and these hazards led to that outcome that we have seen, as I said, a most tragic outcome, but that is not happening in every NHS organisation. It is very important that we recognise that.

Q29 Mr Scott: In fact without going into personalities, because that would be totally wrong, the partner of that very administrator, surprisingly enough, was the administrator of my trust and chose to resign at a similar time through problems, so it obviously is wider than just the one area of Maidstone.

Professor Lord Darzi of Denham: Firstly, I do not know the partner of that person.

Ms Carnall: I can pick up the HRT trust; David can perhaps pick up the wider questions about the country as a whole. There were a series of problems in that hospital, as you know. It is a brand new hospital. We were not satisfied with the quality of care being provided there. There were large numbers of complaints, some quite serious. There were significant financial problems, but, most importantly, a rapid deterioration of that financial problem during the course of the year. It does have an accumulated deficit, but what worried me more was the way that went dramatically worse in-year when, frankly, most organisations in London are putting themselves in a much stronger financial position. So it was against the grain. Certainly there was a lack of confidence in local partners in the organisation as a whole, Members of Parliament, local authorities and local PCTs, and subsequently, in pretty extensive discussions with us, the Chief Executive there decided to resign and leave the trust and we have put new leadership in there. In addition to that, we are going to put independent clinical teams into the trust in order to review in more depth some of the concerns that we have about quality of care. So, there will be no attempt to disguise anything that has happened there, any of the quality care issues that are there. There the independent clinical teams that we have put in, or will put in, will come from University College London and the Royal National Orthopaedic Hospital. Those clinicians will not have any constraints put on them, either to do with the finances of the trust or its leadership or anything else, they will be entirely free to come up with recommendations focused exclusively on issues of quality of care. I believe the trust is in a good position now to move forward. I do not believe it has got any intrinsic problems in terms of structure or anything else. It is a fantastic new hospital, it is in the right place to serve the population and I have every confidence that it will be turned round quickly.

Q30 Mike Penning: What happened in Maidstone is terrible, but it is happening around the country. We do not know what is happening in other areas. Can you tell me how many people died from hospital acquired diseases last year?

Professor Lord Darzi of Denham: I will be more than happy to get you the figures of that. David.

Mr Nicholson: Hospital acquired infections are something that are affecting every health service in every developed world and we are battling on to get at it. One of the issues, of course, is that many of the things were historically not measured - for example c.difficile. We are only now getting proper measurements so we can tell what the scale of the issues are, because these things are dynamic and are developing over time.

Q31 Mike Penning: As a department you have no idea how many people died in NHS hospitals from hospital acquired diseases in the last 12 months?

Mr Nicholson: There is an audit that began that I understand is going to be reported in the next two or three weeks which will identify deaths in relation to MRSA. That is the information that we are hoping to be published in two or three weeks' time.

Q32 Chairman: Can I pick up on two or three things about Maidstone and Tunbridge Wells Trust. The ex chief executive said that there had been a fixation there in terms of waiting times and financial targets. That was denied by the department and by the Healthcare Commission. Would you like to give your personal view about that statement that was made by the then chief executive?

Professor Lord Darzi of Denham: I probably should bring David in here, because this is a management issue, but I do not accept that statement, as a clinician who works in an organisation, that because of this we failed to do this. I made it very clear early on: cleanliness and hospital acquired infections is part of what we do every day we go to work. David.

Mr Nicholson: It seems to me, as someone who has worked in the NHS for 30 years, completely unacceptable to say that. It is an absolutely basic part of anybody responsible for managing healthcare systems and a hospital. It is completely unacceptable that someone would say that. Their first priority is the quality of service and safety to their patients. That seems to me to be absolutely clear. We have made that absolutely clear to all chief executives.

Q33 Chairman: Do you think there is a balance to be struck between leading a trust and guarding against hospital acquired infection? Is there a balance in that, or do you think there is no way that one becomes a priority over the other?

Mr Nicholson: Any manager in any system has to manage a whole variety of things at the same time. The idea that as a manager you only do one thing and then you go on to do something else simply does not work. Managing healthcare acquired infection is a basic part of any manager's responsibility, and I think what we have seen over the last few years is that managers in the system have needed help and support to do that, hence the whole raft of policies and money, resources and activities over the last four or five years to enable and support people to do it better, hence the things that are in the report in relation to healthcare acquired infection.

Q34 Chairman: I have got that page in front of me. In relation to this current report, how will the review ensure that hospital trusts get the balance right between all these wider issues and tackling MRSA and c.difficile?

Professor Lord Darzi of Denham: There will be major sets of recommendations in relation to that, but it is like telling me when I go and see a patient that I am responsible for the operation but I am not actually responsible for a patient who might develop a chest infection after the operation because they could not breathe properly. It is ludicrous to think that we can---. This is part of what we do, and that should be part of the ethos of any organisation. It is a collective responsibility. If there is one thing I have heard in politics, it is collective responsibility. The days in which I was responsible as an individual for the patient has changed into the collective responsibility of all the team that I am a member of, whether that happens to be a nurse on the ward or that happens to be a junior member of staff, and that collective responsibility in its priority is the safety of that patient. Every single of member of staff has to wash their hands if they are seeing a patient or touching a patient. That is part of what we do every day. Every member of staff who prescribes antibiotics to a patient needs to be aware of the side-effects of antibiotics. The reason we have clostridium difficile is because we have not been prescribing antibiotics based on proper evidence-based guidelines. That is where c.difficile has come from. It is an inhabitant bacterium in our guts. If we get rid of the good bacteria with antibiotics, the clostridium difficile starts producing spores; so you need to know how to prescribe. These are basic principles. It is something for which all of us need to take the responsibility, all the team members who are responsible for that patient.

Q35 Chairman: In the national press on Monday there was a report that the department had sat upon a report from the Healthcare Commission since, I think, 3 May this year in relation to hospital acquired infection. Is that true? You will have seen this. It was in Monday's Daily Telegraph.

Mr Nicholson: No.

Q36 Chairman: It was said that there was a draft report from Maidstone and Tunbridge Wells. Is that true?

Mr Nicholson: There was a draft report that came into the department in May that related to Maidstone and Tunbridge Wells. What it did not have in it was any conclusions or recommendations, and at the time the factual base of it was being challenged by the trust; so it was not, by any stretch of the imagination, what people would describe as a full draft report with everything in it.

Q37 Chairman: If a healthcare commission inspects NHS establishments on our behalf, both as patients and members of the public, how long does it take for an inquiry, if you get an adverse report from a healthcare commission, before you actually look into this in detail?

Mr Nicholson: In terms of Maidstone and Tunbridge Wells, I think it was the Strategic Health Authority that brought the Healthcare Commission in and, as soon as the Healthcare Commission came in to do their review, action started to be taken; so right from literally the day that the Healthcare Commission came into that hospital things started to change. What we do not do is wait until the very end to do the work that we need to do in order to improve services for patients.

Q38 Chairman: So what implications, if any, were there in this draft report being held in the department and not being published by it? Were there any implications in terms of C.diff?

Mr Nicholson: No, absolutely not.

Chairman: We will move on then. Richard.

Q39 Dr Taylor: Can I go back to what you said about introducing MRSA screening for elective and emergency patients. What is the evidence that screening will produce a lower incidence of MRSA?

Professor Lord Darzi of Denham: If you look at a number of European countries, Holland being one, Denmark being another, it is part of the practice that if you come in for elective surgery you get screening and, if you are carrier, you can at least decolonise the patient.

Q40 Dr Taylor: So in the list of countries we have been given Holland is best, Germany second best, then Spain and we come way down the list. The best countries do this screening, do they?

Professor Lord Darzi of Denham: They do, absolutely, and to be fair also, if you look at the data in the National Health Service, the organisations who already screen for elective surgery, and this is the bit that we do not---. In my visits - I have been around the country for three months - I have come across a number of organisations who actually had screening before even my announcement was made. That is where I picked it up. Screening is part of their everyday activity when it comes to elective surgery, like orthopaedic surgery, and they have the least MRSA incidence.

Q41 Dr Taylor: On the same line, deep cleaning: what is the evidence that that has an effect particularly on C.diff?

Professor Lord Darzi of Denham: Deep cleaning is an interesting one. I think there is evidence, if you look at the data that I have seen in the department, that those hospitals in which there is something called the PEAT score (patient environment action team score) - it is a cleanliness score - the hospitals that have the highest cleanliness scores, in other words the cleaner ones, also seem to have the lowest infection rates, so there is a very strong correlation. Whether that is an impact on the culture of the organisation, it could be, and that is a point to make. The second point when it comes to deep cleaning is that it is also about public confidence building, and patients and the user and the public in the engagement meetings I have had truly believe the organisations who have the least cleaning are the those who are associated with the highest infection rates. So the answer to your question is that there is a correlation, yes.

Q42 Dr Taylor: A week or two ago some of the papers had a list of the 20 or so worst hospitals for c.diff infection. Is it known that they had bad PEAT scores, because obviously this would tie it up very neatly if their standard of cleaning were known as judged by that? Could we find that out?

Professor Lord Darzi of Denham: I could do, yes.

Q43 Dr Taylor: One or two other basic questions that I think would be helpful to know. Is there any evidence that where hospital cleaning has been privatised it is different from where it has remained in-house?

Mr Nicholson: No.

Q44 Dr Taylor: No. You are absolutely sure about that. The other thing with the deficits and the vacancy factor is that nurse staffing has been cut. Is there any evidence that nurse/patient staffing ratios have any bearing on the incidence of infection?

Professor Lord Darzi of Denham: Not that I am aware of, no.

Q45 Dr Taylor: I did ask if you were aware of it. Is there any?

Professor Lord Darzi of Denham: There is no evidence in the scientific literature. There is plenty of evidence that you do have to apply some of the good standards of hygiene, including the beds, the mattresses, changing patients, the turnover of patients, and so on and so forth.

Q46 Dr Taylor: Do you remember from the Stoke Mandeville inquiry into c.diff? From my memory the reports were that clinicians were desperately trying to get the management to act and it was a complete stop by the management at that stage because they were fixed on targets. Is there any likelihood that that sort of thing will happen again?

Professor Lord Darzi of Denham: I made a statement about that in the interim report and I said that every clinician, whether it is a ward matron, whether it is a doctor working there, could report that to the Board of that acute trust and if he has difficulties with that we will encourage them to report it to the regulator.

Q47 Dr Taylor: Coming back to the leadership issue, which I agree is absolutely crucial, do you think we should go back to the days of the one top matron who sails around like a battleship in full sail, who has everybody leaping to attention? The standards in those days were pretty high. Should we go back to that? Do to you think these modern matrons are just office sisters given a new title without any further power? Why do we not go back to the real old matron as the real leader?

Professor Lord Darzi of Denham: I think what you are describing is the leadership rather than the old matron. Old matron had different challenges than the matron that is working in the Health Service now. I remember those days very well when you had an old matron. I think what you really bring to attention is who is in charge, which is the commonest question I ask, the commonest question the patient asks. Who is in charge of this ward? You arrive into your ward and you say, "Who is in charge?" and that is the bit that I think we need to develop. We need to empower the person who is in charge, and that person, who is also in charge, do not forget, needs to be accountable. You cannot empower people without making them accountable. So, the answer to your question is that all it wants is someone who knows who is in charge in every part of the hospital, let alone the top dog - who is the matron, as you probably said, who is the chief nurse, who should be ultimately accountable - and, let us not forget, the accountability, if I could come back to that word, is collective accountability.

Q48 Dr Taylor: That is my next point, because collective responsibility is fine but I still have to say that no longer can a consultant on the ward really make sure that the nursing standards are up to his or her standard because that is the ward sister's responsibility and the two are no longer able to co-operate as they were.

Professor Lord Darzi of Denham: Yes.

Q49 Dr Taylor: Can you do anything about that?

Professor Lord Darzi of Denham: Yes, I can. I do it every day I go to work. I bring everyone together, we sit down and decide exactly how we are going to do this, and that is the bit that is very important. That is leadership.

Q50 Dr Taylor: How can you get that happening across the whole country?

Professor Lord Darzi of Denham: That is what we need to work on. One of my nine themes is redefining the structural leadership in the NHS. The idea that I walk in as a consultant as I did 15 years go and gave orders and walked off and everything happened: that does not happen. I think what you have been told is the right thing. You need to sit down, you need to build on a team. We all know how you build a team. You need to provide the leadership within that team. These are basic principles. Some organisations, if I could come back to that, Dr Taylor, do that brilliantly in the NHS, do it better than anywhere I have seen even across the Atlantic, they do it brilliantly, and what we need to do is analyse those, understand those and build these teams around the same principles as you are referring to.

Q51 Dr Taylor: If you look at the Healthcare Commission's recent health checks, I think there are 19 trusts that are labelled as weak on quality of care. Is this the sort of issue you will be addressing with them?

Professor Lord Darzi of Denham: Yes, absolutely. That is why we have an institute for innovation and leadership. The reason we have that institute is to help. It is interesting you say 19. What is important to recognise here (and I say this as a clinician who works in these organisations) is that the vast majority of them have the right structures, have the right cultures, have the right leadership. What we need to do is help the 19 that you are referring to in making sure that we implant the basic genes of leadership and the skills in delivering it.

Q52 Chairman: Is there a correlation between bed occupancy and hospital acquired infection?

Professor Lord Darzi of Denham: Whenever you talk about epidemiology and science there are always two schools of thought in relation to this, and it depends who you ask and what the background is. There is some evidence, if you look at our data from the NHS, that those who have a bed occupancy above 90% have had a higher MRSA bactoraemias but, interestingly enough, the same organisations who have had that occupancy have also managed to bring their MRSA rates down without the change in bed occupancy.

Q53 Chairman: This Committee has commented and ministers have often commented about the efficiency or the productivity inside the National Health Service, and, obviously, one of the measures is bed occupancy. Presumably productivity is related to that and risk is related to it as well, but what you are saying is there may be that but really there should not be?

Professor Lord Darzi of Denham: There should not be. If you applied the principles of cleanliness and all the principles, as I said, when it comes to clostridium difficile---

Q54 Dr Taylor: But if you have got a bed occupancy of 95% or 100% you do not have the time to do the cleaning between; so is it not absolutely essential that you cannot have your bed occupancy rate above 90%, whatever the pressures on you to meet targets?

Professor Lord Darzi of Denham: I think in what you are saying on the one hand you are right, bed occupancy rates above 95% or 100% are a challenge to any healthcare provider. The question is would that bed occupancy lead---. I think it leads to other hazards in the system besides infection is what I am concerned about. I think what you are bringing in here is: is it directly related to infection? The answer to your question is: we have looked at this. Those who have a bed occupancy above 90% have had higher amounts. They have managed to drop it by lower bed occupancy rates.

Q55 Dr Taylor: C.diff in particular relates to the high occupancy rates?

Professor Lord Darzi of Denham: Yes, you need time to change. You absolutely need time to turnover patients. You absolutely make sure that you apply all the principles of cleaning in between the turnover of the patients.

Q56 Dr Taylor: And this is pretty well impossible with 95% and above, well, 90% and above occupancy rates.

Professor Lord Darzi of Denham: Yes.

Q57 Dr Taylor: However well the leadership is.

Mr Nicholson: It is possible. Some of our best performing organisations have very high occupancy rates, so just driving the occupancy rate down will not in itself necessarily deliver a better position: it is how you manage the bed, how you organise your cleaning teams, how you get the operation of the ward sorted out. That is much more important than that.

Q58 Mike Penning: Minister, in your interim report you identified a vision for the NHS looking forward?

Professor Lord Darzi of Denham: Yes.

Q59 Mike Penning: You wanted a fair, personalised, effective and safe NHS?

Professor Lord Darzi of Denham: Yes.

Q60 Mike Penning: Do you consider the NHS today unfair, depersonalised, ineffective and unsafe then?

Professor Lord Darzi of Denham: The answer to that is no, for all sorts of reasons. I described it as fair. We all know that one of the strongest NHS values is equality, but as I make the case for change, we have serious challenges when it comes to inequalities, and I have highlighted in my report some of the areas across the country where that remains a challenge, whether that is inequalities in health or healthcare. I recently did London. If you take the tube station just outside this building, Westminster, and go six stations up to Canning Town your life expectancy drops by about a year for every station. These are the inequalities that we need to tackle; so what I said by fair is that we need to tackle some of these challenges over the next ten years. As far as personalisation, what I was trying to make the comment around was we need to tailor care around the patients, and what I have learned from that exercise in London, and more recently, is that there is a very strong desire by the population of having care closer to home. Integration, you know, going through that journey, it is fascinating. If you go back and look at what the patient has been through, seeing the GP as the gatekeeper through their journey to secondary care and back, it is not uncommon; your reaction, whether you are a member of the public or a clinician, is fragmented, and that fragmentation of care is not personalised. The personalisation of care is about integration, providing care closer to home. Integration of primary and secondary care, integration of health and social care - that is what I mean by personalised care - and I strongly believe the next decade where the NHS is heading we need to focus our efforts in that area well. The other one, which is the effectiveness and the safety, is what you referred to. Safety, as I said earlier, is a basic principle of what you do. Effectiveness: if this report is to succeed, we need to bring back what we are all about, what healthcare delivery is all about. It is the quality of care we provide, whether that is the outcomes, whether that is the productivity, which was referred to by Mr Barron, whether that is the integration of care. So, these are the principles which I believe, in the consultations that I did with the public and the patients and the staff, should be the principles that will---

Q61 Mike Penning: The language you have used is your language - fair, personalised, effective and safe - as the vision going forward. Surely the interpretation from that must be, having listened to what you have said, that at the moment there is unfairness within the NHS; it is at times, in places, depersonalised, ineffective and we have heard from other things unsafe. Your vision is to remove those things and to go forward.

Professor Lord Darzi of Denham: These are the principles that I would like to improve in designing the Health Service over the next ten years. When it comes to the NHS, when it comes to fairness---

Q62 Mike Penning: This is your language in your report.

Professor Lord Darzi of Denham: When I say something positive, that does not mean we are living in a negative world.

Q63 Mike Penning: When you are saying that you want something to be safe---

Professor Lord Darzi of Denham: Yes.

Q64 Mike Penning: ---there is an assumption, surely, that parts of that are unsafe? No?

Professor Lord Darzi of Denham: We have challenges when it comes to safety and we have worked through a few of them recently. When I say that we need to improve the safety of a system and move to a safer environment that does not mean we have a catastrophically unsafe system.

Q65 Mike Penning: In 2002 Derek Wanless also had a vision. He wanted a vision for progress for the NHS and he called for the Government to undertake a full review based on that and the Government declined that. Do you think that was the wrong decision or should we have had a proper review based on Wanless in 2002?

Professor Lord Darzi of Denham: The Wanless Review 2002 was commissioned by the Government. It is not the full review. Are you referring to the latest one?

Q66 Mike Penning: Let me try again. The Government was not prepared to undertake the recommendations of Wanless and have a review into the NHS. Wanless recommended a visionary review in 2002. The Government declined that and it ended up being done by the Kings Fund. Should it have been done by the Kings Fund or should we have had a proper review by the Government?

Professor Lord Darzi of Denham: If I could come to that point, and I am not trying to correct you here. In 2000 the Government asked Wanless to do a review, and it was actually a due diligence exercise, about the NHS Plan and the funding - to support the funding of the NHS Plan and to make the case for it - which he did on behalf of the Government. In 2004 he did another review, in consultation with the department, which led to a better health review which was published in 2004. I think what you are referring to is the most recent review which he did with the Kings Fund.

Mike Penning: We will not dwell on this but there is obviously a conflict in the information that is coming from our experts and what you are saying, so we will write to you on that point.

Q67 Chairman: My understanding is that the 2002 review recommended that this should be reviewed again in 2007, or after five years, and what we have had is a review by the Kings Fund and not by the department. That is the real issue.

Professor Lord Darzi of Denham: Absolutely. I was just going to say, he did another review in 2006 with the Kings Fund on social care and, more recently, he published a review with the Kings Fund. He was essentially reviewing the progress in relation to the recommendations of 2002.

Q68 Mike Penning: Did the department (and you may need to refer to Mr Nicholson here) fully co-operate with the Kings Fund in that review?

Mr Nicholson: Yes, we fully co-operated with the Kings Fund.

Q69 Dr Stoate: I would just like to place on the record that I am still a practising part-time GP, which is recorded in the members' interests register. Lord Darzi, it is very good to have a fellow practising clinician in the position of making decisions. It is what we would expect and I am very pleased to see what you are managing to achieve so far in your short time in the department. I want to ask you a few questions about polyclinics, which is something I have been particularly interested in over the last several years and it is something I would like to question you a bit about. As part of your recommendations in the London review you suggested that polyclinics should be considered as a means of increasing access to health services and making them more personalised. The question I want to ask is: have you yet produced a business case for polyclinics?

Professor Lord Darzi of Denham: Yes. The piece of work I did for London was the vision for healthcare for London over the next decade. What was different about that was the way we did it. Polyclinics was not on our first page or an idea in our mind certainly for the first six months. This is an important process issue, because we have a hang up about buildings, whatever we call them - polyclinics, hospitals, specialist hospitals. I had the privilege of leading 150 clinicians, some of them were primary care physicians, in London, and we looked at models of care. We started from birth, we looked at staying healthy, a very important issue (back to Wanless) - planned healthcare, acute episode, long-term conditions, end of line, mental health, and we challenged these clinical working groups (150 around London) with: what are the models of care at the moment? What is the best evidence in the delivery of these models of care, and how do you make that happen? Because reports are reports; implementation is a completely different task. Most of them came out with a significant shift of care from a hospital nearer to the community and community setting. In actual fact a few of them said we need to repatriate some of the care we used to provide to primary care back into primary and community services. It was the conclusion of that work that led to, you know: if we are to provide care at a community level, then we need to have these primary and community hubs. Polyclinics was not my favourite word, but interestingly it captured the imaginations of Londoners because it was associated by Eastern European countries, the polyclinics and so forth, but you are absolutely right because that is something you also touched on last year in the Fabian Society and the report you published on that. Have I done the business case for that? It was a vision document; it was not to create the business case. We have done the costings, we have done our analytical work to underpin that vision statement, but after we finish the period of consultation - if I am correct, and I am going to hand over to Ruth, because it is going to go through a process of consultation - it is for the local community to put the business cases together. Maybe you want to add something.

Ms Carnall: Yes. There has been a lot of enthusiasm for these recommendations and some controversy, which you will have seen in the newspapers, and so on, but I am very confident that there will be a significant number of good proposals for the department of polyclinics across London, certainly enough to be able to demonstrate how the model works and what benefits it can provide to people locally. What we are trying to do at the moment is to consult across London, which starts in November, about the models of care that Professor Darzi has recommended but at the same time to avoid losing momentum on what a lot of people think will be a great development, trying to get people to put forward proposals that they have got locally for service improvements of this type, and I am pretty confident that we will have a reasonable range of proposals that will allow us to demonstrate to people some of these models working on the ground before they see other changes happening down the track in hospitals for example.

Q70 Dr Stoate: Do you see, therefore, some pilot projects being set up?

Ms Carnall: Yes, and we have written to absolutely everybody in London and we are getting lots of interest back and lots of good proposals. Some, clearly, are better than others. Nevertheless, I am confident that there will be enough to create sufficient momentum.

Q71 Dr Stoate: I am very pleased about that because, obviously, the pilots are making sure the public is on side for some of these quite valuable changes and, I think, is a far better way to go.

Professor Lord Darzi of Denham: Absolutely. The other thing which I have discovered since I did the London review, which is quite interesting because, as you probably know, I also hold an academic chair: I used to work with someone who used to tell me whenever we came up with a new idea, "I am sure someone else has discovered it", and it was not just someone else had discovered it, there are 105 polyclinics outside London working extremely well and if you go and question and talk to the users and the public around the areas that I have seen some of the best examples, there is a tremendous satisfaction rate with the services which are provided, that integration which integrates all the services.

Q72 Dr Stoate: I was pleased by your comment earlier that you want to see some of the services that used to be in primary care coming back into primary care. I think that will be welcomed by many people. I want to move on to the role of pharmacists. Do you envisage pharmacists having much of a role in the polyclinic design?

Professor Lord Darzi of Denham: Absolutely. The potential of what pharmacy could do in all of these eight pathways that are occurring to you. Just look at the staying healthy and the well-being. We have seen it as smoking cessation, the role they could play in obesity. The role they could play in all the aspects of staying healthy is tremendously important - planned care; even an acute episode out of our urgent needs. It is far more common that you may seek advice from a pharmacy setting as well, so they have a tremendous role to play, and again from a user perspective, they will like these different providers to be integrated at a local level.

Q73 Dr Stoate: Do you think pharmacists will be able, for example, to improve prescribing decisions and work with other clinicians to ensure more rational use of NHS drug budgets?

Professor Lord Darzi of Denham: I have no doubt they could. Not only that, they could also improve the quality of prescribing that people like me do. It is not uncommon that I could get a pharmacist who could come up and say "Actually we might correct that", so they have a role to play in the safety of prescribing.

Q74 Sandra Gidley: Just a quick supplementary here. I have an interest to declare. I am a pharmacist. I am delighted to hear what you have just said, but I could not help but notice on your advisory board you have five GPs, two nurses, one person from social services; no pharmacist, no therapist on the advisory board for the primary and community care.

Professor Lord Darzi of Denham: We have a pharmacist.

Sandra Gidley: It is not in the list in the review.

Q75 Dr Stoate: That was going to be my next question, so thank you, Sandra, for clarifying that. It is very important.

Professor Lord Darzi of Denham: Anthony Murdoch is the pharmacist who will be joining us.

Q76 Sandra Gidley: Why have you chosen somebody from a large chain rather than somebody from the National Pharmaceutical Association who has a broader overview?

Professor Lord Darzi of Denham: If you have other suggestions, I would be delighted to talk to you later.

Mike Penning: Sandra Gidley!

Q77 Dr Stoate: Lord Darzi, we are wandering away from the subject. Do you envisage polyclinics as being a private public partnership? Have you, for example, had discussions with private sector developers such as Assure, those sorts of companies that are not prepared to build? Have you looked at that type of model or do you see these as being purely PFI or some sort of partnership arrangement with the NHS?

Professor Lord Darzi of Denham: I think there are all sorts of models and I think we need to be open-minded in relation to it. We have some called the LIFT scheme, which I think we need to look at and make them more primary care friendly, because there are concerns going around the country about some of the fixed costs that are associated with the LIFT scheme, which I am looking at. It could be a group of GPs, colleagues. Let us not forget, primary care also is not privatised in the sense you are referring to but it is a private provider per se. There are a lot of entrepreneurial GPs, as you probably know. They are much more entrepreneurial than any clinicians working in a hospital setting. They may wish to come in and form a partnership to do that, and I think we need to help them in achieving that because I think one of the things that I have captured talking to primary care colleagues is that they always say, "We do not have the management skills within primary community services", and we need to investigate that. It is something that I have raised with David. It could be so-called independent sector, third sector providers. So, yes, I have met them as well and would encourage them to come forward.

Q78 Dr Stoate: You are prepared to look at a whole range of possible providers and possible structures?

Professor Lord Darzi of Denham: I think so.

Dr Stoate: Thank you very much.

Q79 Jim Dowd: On the question of polyclinics, your London review indicated that if there was a switch from hospital based care to polyclinics there could be savings of up to 1.5 million on health care in London, a not insignificant sum. Could you indicate where the bulk of those savings would come from and say whether you have included the current cost of PFI schemes in London?

Professor Lord Darzi of Denham: I have included the PFI schemes and I will come back to that point. The way we did the review, the analytical bit, we had an analytical group of clinicians including primary and secondary care. We picked up the top 20 HRGs which means the top 20 presentations that a hospital is dealing with. This is the bit that comes back to productivity versus efficiency. If you did your calculations based on the current provider models as we stand and if you take into account the following, we are expecting in London a demographic growth of about 700,000 people in the next decade: Thames Gateway, Olympics. That is a big growth in a big capital city. If you do the current growth rates we have had over the last three years, what we call baseline growth rates - in other words, the current population using the service - you will probably increase your in-patient activity by about 47% in ten years. You will increase your A&E activity by 66% in ten years. You will increase your GP use by about 77%. The figures are astronomical, based on what we have seen in the last three years. This is the bit that is unique. For the first time in London we started to predict what might be happening in ten years. We need to be smart. We need to be proactive here rather than reactive, which is what we have been doing. If you look at these growth rates based on the current provider models, the whole system will be paralysed and the cost of it will be astronomical. Back to the clinical working groups and their evidence base. The polyclinics were there to deal with that significant workload that we anticipate in ten years. That is why it is a ten year vision. If you look at the costings for some of these procedures, I will give you an example. Minor surgery. If you come into St Mary's where I work, the cost of that is about somewhere around £895. That is what you pay. If you do that procedure and you cost it, including all the overheads, all the fixed costs in a polyclinic environment, the cost of that is somewhere around £120. You can see savings. If you go to the use of accident and emergency, you probably know in London near enough 62% or 63% of patients attending A&E are attending A&E because they have a minor complaint that they have to deal with, especially in London because we have significant rates of attendance at A&E. The tariff for that from a hospital setting is somewhere around £158. I am not surprised the hospitals are keeping the gates open. It is an income. If you look at the potential of having an urgent care centre in a community, which is part of the polyclinic, then you can see the cost of that being significant. It is not just improving on the cost; it is actually designing a service that has the quality, the access from a patient perspective but at the same time seems to be creating the savings that I referred to. If we keep the system as it is, in ten years we will be spending 1.4 billion more. If we change the system, the growth rates are not compatible with inflation rates that we will be expecting in health.

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 because 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 institutions 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 cannot 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 of 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 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. 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 major 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 across governmental working it 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 QAF - quality article frameworks - 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. What I meant by "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 on ...", 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.

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 is not the future of models of delivery. It is not 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 bills 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 stents. 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. We do not want quangos in this. 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 Israelis 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 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. The Commission is a good example. If we had a strong Commission that would commission a model or a pathway based on innovation, whether it is a piece of kit or whatever the drug might be or it is a service redesign, you can just redesign your pathway and proceed with this innovation. It should be part of commissioning as the policeman of innovation but at the same time there should also be represented some of our tariffs so I am encouraging you to look 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 more importantly at a local level, how commissioning should be structured in a way to ensure that, whether it is a NICE guideline, whether it is a complete service we design, 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. There is a 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. 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 quality standard is 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 and the competence 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 60^th 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.