Examination of Witnesses (Questions 60-79)
DEPARTMENT OF
HEALTH, PROFESSOR
PETER HUTTON
AND DR
ANTHONY NOWLAN
26 JUNE 2006
Q60 Mr Mitchell: But you both feel
that the clinicians and the localities were not sufficiently taken
into account and did not have sufficient say.
Dr Nowlan: Yes.
Professor Hutton: That is correct.
In the latter part of 2003, a senior person in the management
of the programme spoke to me saying that he felt that the consultation
as it had been carried out was a sham. We used to meet secretly
at Starbucks on Leeds station to talk about it. I tried to find
out exactly how it had been done. Indeed, I asked Mr Granger—and
he cooperated in this—whether I could have a list of the
names of the people who were involved in that consultation.
Q61 Mr Mitchell: Were you not asked
to pump up the number?
Dr Nowlan: Yes, I was approached
and they wanted hundreds of names of people who supported it and
I refused to support that. I said it was not on.
Professor Hutton: I was sent a
list by somebody within the programme which I have submitted to
the Committee.[4]
I rang up 10 people at random on that list only last week. None
of them has any memory of having any meaningful input into the
programme.
Q62 Mr Mitchell: Let me stop you there.
Mr Granger, there is a point there, is there not? You did not
really want to consult the clinicians and you did not want the
localities making too much fuss because that would stop your husky-taming
ambitions. It would make it far more difficult to negotiate the
contracts. Clinicians are quite a querulous lot, are they not?
They raise all kinds of doubts and hesitations. You did not consult
them because they would have raised all those doubts and hesitations.
Mr Granger: I am sorry but that
is neither my recollection of events, nor is it borne out by the
evidence. In fact there are three clinicians sitting to my left.
Q63 Mr Mitchell: Surely it is borne
out by the evidence now there is so much protest among clinicians
and among the localities that they do not want the system, it
is not going to work and they have had no real input and no benefit.
Mr Granger: There are thousands
of clinicians every day using the systems which we have already
delivered who are quietly getting on with it. One needs to recognise
that a system programme of this scale is going to cause a degree
of controversy and dissent, but to delay and have another decade
of consultation.
Q64 Mr Mitchell: Yes, but the people
who are going to use it centrally, for whom it is going to be
important and who are going to be making their own clinical demands
on it, are crucial.
Mr Granger: There has been massive
input to the original design documents that went into procurement
and on an ongoing basis; hundreds of people.
Sir Ian Carruthers: I do not want
to enter a debate about Professor Hutton and Dr Nowlan, but if
we look back, the issue is, as the National Audit Office Report
says, that steps were taken to engage with chief information officers,
clinicians of the academies of colleges, there was consultations
with 400 or more clinicians, which is the biggest I have ever
known in the NHS. More importantly, there is a lot of work going
on behind that. I can only talk about what happened in my area
where in fact we had clinical inputs to some of the submissions
that were sent back. In fact at the same time, there was a bit
of anger in some parts of the country because more clinicians
had a chance to take part. In the South West we were all ready
to go with our own version of this. In reality, from my experience,
there has been more involvement than ever before.
Mr Mitchell: But there has still been
a chorus of grumbling.
Q65 Annette Brooke: I am particularly
interested in how the top-down approach then actually has an impact
on local services. May I start by looking at paragraphs 3.27 and
3.28, where we have a series of different decisions made in terms
of the GPs' ability to choose and use their own systems? In fact
we have one decision in 2003, something happened in 2004, March
2005, then in March 2006 the Department announced its GP Systems
of Choice initiative. Why all that chopping and changing? Why
was there not an overall vision for the top-down system which
started much earlier than all this chopping and changing?
Sir Ian Carruthers: The best thing
is for us to ask a GP to explain what it was like and why.
Dr Gillian Braunold: The GP contract
that was being negotiated at the same time as these contracts
were going out was being negotiated at the same time by a different
section of the Department of Health. The negotiated settlement
for the new GP contract required the choice of GP systems. It
was therefore required for each cluster to offer a choice of systems
and it started off really being that they were offering an alternative
system or their own reference solution. It became very evident
very quickly that the LSPs were not going to be delivering what
was called the reference solution, their own contracted solution,
for quite some time and GPs understandably were very concerned
that they were not being given a real choice, but a Hobson's choice.
When the GP national clinical leads were appointed we asked from
the word go whether we could tackle this problem and look at it
from the bottom of the problem up, from the fact that we have
got very good GP systems which are capable of integrating with
the rest of the national programme, if we leave aside the integrated
Care Records Service, but the Choose and Book, ETP, GP to GP and
lots of the other work that was perfectly capable of moving forward
and being invested in. Also there was a threat and a problem with
the number of migrations of patient data if people were changing
systems all the time and we wanted to limit that. We have worked
very hard to provide the GP Systems of Choice model which is now
being negotiated with suppliers which provides a safe way for
the NHS to invest in current systems.
Q66 Annette Brooke: May I just cut
across and ask a simple question? Looking at this in retrospect,
was there not a case for consultation with GPs at an earlier stage?
Dr Gillian Braunold: I do not
dispute that, because I was sitting on the other side of the fence
then and we were bashing at the door. The first time we were let
in that was the first thing that we addressed. It is fair to say
that from the general practitioner community the importance of
GP records, where we are already in a paper-free environment,
needed to be explained and articulated very clearly within the
programme and that is what we have done.
Q67 Annette Brooke: So we do have
a gap between local decision making and the top-down approach.
I should really particularly like to ask some questions on Choose
and Book, if I might? You mentioned earlier that 54% of GPs are
now using Choose and Book. What I should like to have is some
understanding, when the Choose and Book decision is made by a
patient, presumably recorded at the GP level, of how the primary
care trust monitors the bill it is going to have to pick up at
the end of the day with all these IT systems.
Dr Mark Davies: The situation,
as far as Choose and Book is concerned, is when a GP is sitting
with a patient and agrees a referral is appropriate to secondary
care what will happen will be that the GP will select a list of
clinically appropriate choices for that patient to choose from.
They may well make the appointment there and then; they may well
issue a document which allows the patient to go off and book in
a variety of different ways, according to their own convenience.
Your question in terms of the monitoring of the contracts depends
on where the commissioning actually sits and historically the
commissioning has sat with PCTs, but increasingly that will, in
the future, sit with the practices themselves. There is an interface
within the Choose and Book system for the commissioners to be
able to monitor that activity. In fact one of the benefits of
the Choose and Book system is that we shall have the kind of quality
of referral data and the robustness of the referral data that
in fact we never have had before in the NHS.
Q68 Annette Brooke: Are you aware
of any problems within the NHS which have actually stemmed from
the Choose and Book system in terms of disputes between a primary
care trust and a NHS trust hospital?
Dr Mark Davies: I do not understand
the question. Could you explain?
Q69 Annette Brooke: There is a situation
locally where part of the issue appears to be that the primary
care trust has not budgeted for all of the choosing by the patients
and there is a stand-off and patients are not going to be admitted
to hospital under certain circumstances, which is seriously worrying.
What I wanted to know in my question was how the bits of the NHS
link up so that we do not have a dispute. You are saying this
might be sorted, but here and now there are patients in my area
who will possibly not be admitted to hospital as a consequence
of this.
Sir Ian Carruthers: I think you
are referring to the Royal Bournemouth Hospital and Bournemouth
Primary Care Trust. That is not about Choose and Book; that is
really about whether in fact there should be an agreement on the
payment by results system. It is not to do with the Choose and
Book methodology. One of the things you will also know about your
area, is that it is one of the biggest users in the country; in
fact it has the most functioning there. It is not related to Choose
and Book itself; it is related to the incentive system of payment
by results where there is a difference of opinion between the
primary care trust and the hospital.
Q70 Annette Brooke: Are you giving
me assurance that the primary care trust can actually monitor
what is happening through Choose and Book in terms of budgeting?
Sir Ian Carruthers: Each month
they will receive how many people have chosen and booked. The
reality is that when you are hitting a rate of only 34% to 35%,
which we are, the issue is that there are many more patients going
into hospital where the system is not being used, but ultimately
that should be the way of doing it. At the present time, until
take-up is fully undertaken, that will not be the case. One of
the things we are looking at is the fact that quite often one
of the problems with GPs' experience is that they want a Choose
and Book within the requisite timeframe, but there are no slots
available in the hospital. One of the things we need to look at
is how we help hospitals make more time and slots available so
that the system can expand. This is work in progress. We have
incentivised GPs, we need now to look at incentivising the hospital
system to make that work.
Q71 Annette Brooke: Finally, can
you actually give me a categorical assurance that all the different
parts of the commissioning, the provider and obviously a strategic
health authority are actually going to be joined up and that there
will not be any gaps at all from now on?
Sir Ian Carruthers: You should
never give a categoric assurance, as you well know. The point
is that Choose and Book is a system that is building up at the
moment. When it gets to its ultimate, we should be able to identify
and GPs should be able identify, where they have referred people
to and they should be able to translate that back into what care
they have had and how they have been able to fund them out of
their practice-based indicative budget. When it is fully operational,
that should be done in large measure.
Annette Brooke: Just to reiterate, I
am concerned about the gaps locally.
Q72 Mr Khan: Can you reassure me
those medical notes lying on the floor over there are not the
Chairman's that he is worried about?
Mr Granger: I can.
Q73 Mr Khan: I just wanted to make
sure that my Chairman's privacy had not been breached. That is
fine.
Mr Granger: These are very important
because these are notes that we have consent to have here and
this is where we are today. This is one patient.
Q74 Mr Khan: Superb. I hope they
are better. Sir John, nobody has criticised the NAO for what some
of us would call a balanced Report, others a gushing Report. Mr
Clark put to you the FT article by Nick Timmins. I am going to
put to you another quote which is quite a serious one. It is written
by a specialist, one of the country's leading IT journalists and
he says, and I quote, "Sources suggest that the NAO was ground
down in a war of attrition with Connecting for Health who fought
a dogged rearguard action to keep back criticisms it found unpalatable
or unacceptable". Were you ground down?
Sir John Bourn: I was not ground
down: the Department may feel that they were ground down. I refute
what the journalist said.
Q75 Mr Khan: I am relieved. The second
very serious allegation and aspersion cast against the NAO is
in this week's Computer Weekly, also by one of the country's
leading health IT journalists, Tony Collins. He is talking about
the senior executive observer at Connecting for Health and comments
"The potential placement leaves the NAO vulnerable to a perception
of a potential conflict of interest. Could the National Audit
Office criticise a programme that has been advised by one of its
senior executives, even if he did not take part in decision making?".
Sir John Bourn: I am not constrained
in any way in what I say.
Q76 Mr Khan: I am surprised that
you are not angrier than you are. People are casting aspersions
at the quality of your work over a long period of time, examining
a major IT project.
Sir John Bourn: I bring my work
to Parliament and I am satisfied that what I have brought to you
is work of high quality, done by my staff. I do not seek to engage
in discussion with the media and play some game of exchanging
slogans and points with them. I come with my views to you.
Q77 Mr Khan: I am grateful. My final
question is to you Sir John. I read from your NAO Report that
the NHS appears to have followed the recommendations made by the
PAC in its Report Improving the delivery of Government IT projects,
before my time, in 1999-2000. One of them, to do with an incremental
as opposed to a big-bang approach to IT projects, is mentioned
on page 11 of your Report; another one is to do with the importance
of risk management and professionalism for successful implementation
of IT systems. Are you reasonably happy that your best practice
advice has been followed by the NHS?
Sir John Bourn: I am. The emphasis
on professionalism has been taken forward. This programme is run
by people who actually have experience rather than by generalist
civil servants. I should pick up the particularly crucial point
that the PAC have discussed in the past that you should only pay
for what you get and this is absolutely following that principle.
Q78 Mr Khan: Hardly surprising that
your Report is gushing.
Sir John Bourn: Yes, you are right.
If doing it properly is gushing, then it is gushing, but if it
is proper, I should say so.
Q79 Mr Khan: Absolutely; I agree.
Thank you Sir John, that was very helpful and the brevity of the
answers was one of the strengths. May I move on to a question
to you Sir Ian? Why does the implementation of the programme feature
neither in the current Department of Health's PSA targets nor
in the supporting targets?
Sir Ian Carruthers: Normally the
PSA targets are about service outcomes in the main. It is clear
though that this particular grouping will have an impact on the
wide range of targets. Whilst it is not specifically mentioned,
it will impact upon them all.
4 Evidence received but not printed. Back
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