Examination of Witnesses (Questions 20-39)
NATIONAL HEALTH
SERVICE AND
DEPARTMENT OF
HEALTH
5 FEBRUARY 2007
Q20 Annette Brooke: Another point
in the Report suggests that there are barriers to achieving good
implementation of clinical governance. Not surprisingly, staff
time and money are mentioned specifically. What is being done
to address the barriers? Those barriers are the root causes of
why clinical governance is not getting right down to the contractors.
David Nicholson: What we can see
across the whole variation that Duncan Selbie has just been talking
about is that some PCTs manage quite effectively to get over those
barriers, so money and time and all the rest of it are not necessarily
issues that should stop people taking things forward.
What we are doing is reviewing the progress
of each PCT individually as part of a fitness-for-purpose programme.
Each PCT has to agree with the strategic health authority on a
set of ways in which it will improve its performance over the
next year. The strategic health authority will identify the resource
it is going to put into the PCT, and we will measure progress
over the year. We are in a good position to measure progress and
identify what support organisations need. It is often about leadership
and information.
Q21 Annette Brooke: Finally, may
I ask one more question that does not strictly keep to the text
in front of us? The Report obviously covers the fact that we now
have 150 PCTs, but in my area, PCT boundaries are not coterminous
with those of local education authorities. Children with special
needs who live in one part of my constituency are forced to go
to school on the other side of the county because they are not
allowed into the next LEA area. That takes them into different
PCT areas and they are saying that they are not responsible for
providing the necessary therapeutic services. What do you think
about that lack of joined-up thinking and adherence to the Every
Child Matters agenda in Dorset?
David Nicholson: Obviously, I
cannot comment on the individual case, but it seems to me that
we should take that away and have a look at it.
Q22 Annette Brooke: As well as looking
at the individual performances of PCTs, however, I think that
it is necessary to look at how they work together when boundaries
are not coterminous.
David Nicholson: I think that
that is very important and we are encouraging PCTs to work together,
not just on those kinds of issues, but on contract management,
so that they can pool abilities when dealing with one organisation.
That is one of the reasons why in the operating framework we have
identified that there should be a lead PCT to deal with each acute
hospital.
Q23 Mr Khan: May I get something
clear? Can I gather from the Report that, up until 1999, there
was no statutory duty of quality on any of our NHS providers?
Obviously, there was a common law tortious duty of negligence,
but no statutory duty up until 1999.
David Nicholson: That is right.
Q24 Mr Khan: Obviously, you have
read the Report. The National Audit Office is pretty pleased that
most PCTs now have policies and structures in place. How are those
being implemented on the ground? Presumably, somebody deserves
a big pat on the back: we started from a standing position in
1999, when we implemented the statutory duty of quality, but in
six years we have made so much progress. Are you reasonably pleased
with that progress?
David Nicholson: Well, there has
been progress. On the main areas of consideration—what patients
say about the service and the Quality and Outcomes Framework—we
are pleased, because we have shown significant improvements in
services to patients in the localities. The most important thing
for us is to get the whole organisation geared up in order to
do that. That is what the duty of quality is about.
Q25 Mr Khan: I understand that the
motivating factors behind the statutory duty of quality were the
tragic Shipman, Bristol Royal infirmary and Alder Hey cases. Quite
patently, these changes will not guarantee that such things will
never happen again. However, the sort of changes that you have
been talking about—below those tragic cases—have been
an additional benefit. The quality of care received by a patient,
irrespective of the provider, has now got a national minimum standard.
David Nicholson: Increasingly,
that is a very important, if not the most important part of an
NHS board's agenda. That is reinforced by the responsibilities
of Chief Executives. Increasingly, we want Chief Executives and
managers of the NHS to talk about quality and safety rather than
other things that they have talked about in the past.
Q26 Mr Khan: I share a concern referred
to by Mr Wright. Some £23 billion is being spent on primary
care services, 78% of which is spent commissioning independent
contractors. How much control can you have from the centre over
the quality of service provided by those contractors to constituents?
In answer to a question from the Chairman, you mentioned that
only three dozen GPs have been suspended—
David Nicholson: 66.
Q27 Mr Khan: 66—I beg your
pardon. Out of how many thousand GPs?
David Nicholson: Some 35,000.
Q28 Mr Khan: That reinforces concerns
about how you can ensure that there is proper control of the quality
of those lower down the food chain. How can you reassure us that
you have got robust systems in place to do that?
David Nicholson: Partly through
the sort of things that Professor Marshall was talking about earlier—the
various connections between how partners operate, how PCTs operate
and how the professional standards organisations will work. All
those things assure us that things are being done. Suspension
is not the only way in which we would respond to poor performance.
Q29 Mr Khan: I was going to reach
that point. How many PCTs are there in the country?
Duncan Selbie: There are 152.
Q30 Mr Khan: So are there 152 Chief
Executives, then?
Duncan Selbie: Not quite.
Q31 Mr Khan: There are some job shares,
are there?
Duncan Selbie: In a small number
of cases, there are arrangements to have a joint Chief Executive,
but I would have to get the precise number for you.
Q32 Mr Khan: Let us say for argument's
sake that there are 125 Chief Executives.
Duncan Selbie: No, it is higher
than that. Let us say 140.
Q33 Mr Khan: Out of those 140, how
many have you called in because they are failing to meet their
statutory duty of quality? You said suspension is not the only
option; another is calling them in. How many have you called in?
David Nicholson: For failing their
statutory duty of quality?
Mr Khan: Yes.
David Nicholson: One way in which
we can measure that is the Healthcare Commission's annual health
check, which identified none of the existing PCTs as giving concern.
There were 24 PCTs about which there were serious issues of quality
and financial performance. Each of those—
Q34 Mr Khan: And none of those were
called in on the duty of quality?
David Nicholson: No.
Q35 Mr Khan: So our constituents
now have a double concern. First, only 60 GPs out of thousands
have been suspended, and secondly no Chief Executive of any of
our 120 or 130 PCTs has been called in because of the duty of
quality. That leads to one of two conclusions: either a fantastic,
consistent, excellent quality of service is being provided around
the country, or there are problems with your system of monitoring.
Duncan Selbie: The Healthcare
Commission has a power to recommend what are known as special
measures, which it has exercised on two or three occasions. Whenever
it has a concern about the quality of care in part of the NHS,
it can say, "Look, we want you to apply special measures."
On each occasion the Secretary of State has agreed. So when we
say that the Healthcare Commission did not raise a profound concern
about quality in the annual health check when it identified the
24 organisations, that is not to say that there were not concerns.
The Commission rated those organisations as weak in the four options
from excellent down to weak. The action that has been taken by
each PCT board and Chief Executive, supervised by the strategic
health authority—
Q36 Mr Khan: But is that right? Paragraph
2.25 refers to the Chief Medical Officer's 2006 report, which
found that "although PCTs now have much stronger powers to
deal with poorly performing GPs, these have only been in place
for a short time, and many PCTs feel unable to take local action
themselves, relying instead on the General Medical Council to
deal with concerns about poor performance." Is that not a
case of people shirking responsibility from pillar to post?
Professor Marshall: There have
been concerns about the willingness of PCTs to manage poor performance
at a local level. That is perhaps why they have been called in
at a higher level by the General Medical Council. That is one
of the reasons why medical regulations have been reviewed, and
the paper produced by Sir Liam Donaldson last July, Good doctors,
safer patients, came up with a series of 44 recommendations
to change the regulatory framework within which people operate.
The Government's response to those recommendations will be published
towards the end of this month, and it will make specific recommendations
that will bring the regulatory process down to a much more local
level.
Q37 Mr Khan: You will have seen in
paragraph 2.16 that only 4% of GPs reported adverse incidents
to the National Patient Safety Agency. Cause for alarm?
David Nicholson: If you compare
secondary and primary care, there is no doubt that there is much
more of a culture of reporting such things nationally in secondary
care. We have a lot to do in primary care. That is not to say
that individual events are not investigated locally, but the information
is not sent in nationally. That is a problem, because—
Q38 Mr Khan: I am sorry to cut you
short, but you will know that our time is limited. I have just
been given an aggressive note by my lovely Chairman about time
being short. My concern is whether GPs have bought into the importance
of the duty of quality. Let me tell you why. We know that 20%
of PCTs have done the cost-benefit analysis and think that clinical
governance is an excellent thing—they have made efficiency
savings and think that they are a great thing—and a further
66% suspect that it has delivered efficiency savings but have
not done the empirical work. The reference is in paragraphs 2.35
and 2.36. Only 2% of GPs have undertaken that cost-benefit analysis.
I suspect that the level of monitoring of GPs
is not great, and that the quality of care that my constituents
and Mr Wright's receive—although it is obviously not as
bad as the Shipman murders—is not as great as it could be.
You are missing a trick. I do not think that GPs realise what
a useful tool it is. You have done the hard work of establishing
policies with the support of this fantastic Government, but the
problem on the ground is that GPs might not realise what an invaluable
tool it is.
David Nicholson: Going around
talking to GPs is part of my job. One of the things that I hear
is that some of them do not recognise that what they are engaged
in is clinical governance. Quality and safety is central to all
of them, but they do not necessarily recognise that their activities
are called clinical governance. That is broadly what we have found
as we have gone around.
Q39 Mr Khan: That is interesting.
What are you doing about it?
David Nicholson: We tell them
so. As part of the process that has come out of the NAO Report,
the Reports for each individual PCT have been fed back. We expect
PCTs to act as part of that. We are encouraging GPs in particular
to report incidents, and we are working with the Royal College
of General Practitioners on guidance to encourage and support
them. We are also setting up patient safety action teams at each
of the strategic health authorities to make connections between
general practice and the centre much easier so that kind of reporting
can be done.
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