Select Committee on Health Minutes of Evidence

Examination of Witnesses (Quesitons 280-299)


29 NOVEMBER 2007

  Q279  Dr Taylor: Cross department?

  Alan Johnson: And cross-department working.

  Q280  Dr Taylor: On a wide range of health issues.

  Alan Johnson: On a wide range of health issues as well because some of it is about education, some of it is about lack of sporting facilities, and all of this has to be joined up together.

  Q281  Dr Taylor: And you are going to take the lead?

  Alan Johnson: We are taking the lead already as we speak.

  Q282  Dr Stoate: I want to keep on the subject of public health and particularly health inequalities. According to your Department's answer to PEQ 119 health inequality, as measured by life expectancy at birth, is actually worsening despite it being a key departmental target. Why do you think this key measure is worsening despite the efforts that are being put in?

  Alan Johnson: That is a very good question. Incidentally, we have just seen that evidence and it seems to be that there is a gap for males but it is not any wider and the gap has stayed at around 2%. Where the gap is widening is amongst women. From the very cursory analysis we have done already, it seems to be two groups of women, women between the ages of 20 and 29 and women over 70, and it is about respiratory diseases, it is about digestive problems, it is about cancers, so we can focus in on where the problems are to that degree. How do we resolve these issues? First of all, we are the first Government which has made health inequalities a big issue and we measure against it and we have a PSA target. I think that is important because it demonstrates that the Government is determined to tackle it. The investment we are putting in to tackle health inequalities in all kinds of areas is quite substantial.

  Q283  Dr Stoate: Can you tell us how much because one of my questions was going to be how much are you putting into this important issue?

  Alan Johnson: If you add the whole lot together, Richard?

  Mr Douglas: In 2006-07 and 2007-08 we allocated an additional £211 million and £342 million specifically linked to Choosing Health.

  Alan Johnson: So you have got these teams going into the spearhead areas that are very successful, these health trainers in the PCTs. You have got the Healthy Communities focus in these poorer areas. If you are in an under-doctored area, you are going to get something like three new GP-led practices coming along which are as focused on prevention as they are on treating disease that will be real centres of excellence. That is about a £250 million investment. It is frustrating although the other point to make is that this is wider than just the Department of Health, just going back to Dr Taylor's point about obesity. Health inequalities are about education; they are about people's lack of aspiration; they are about people's lack of assertive and not being confident enough to demand certain things. It is much wider than health; it is the social mobility argument, but we certainly can play our role.

  Q284  Dr Stoate: One of the key determinants of health inequalities of course is smoking and we are slightly concerned that the prevalence of smoking amongst the routine and manual groups, which are the groups most likely to smoke, has only fallen from 33% in 2001-02 to 31% in 2005. That is in PEQ121. Are you satisfied that the amount of money you have put into smoking is justifiable for a fairly modest reduction in smoking prevalence?

  Alan Johnson: What you have to remember is those figures, as I understand them, stop in 2005. There are something like 1.6 million fewer smokers between 1998 and 2005 but, you are right, our target is to reduce it to 26%. What has happened since 2005 is a £10 million investment in stopping smoking in those spearhead areas, the poorest areas, the ones with the widest health inequalities. The smoke-free legislation came in on 1 July and the age of purchase went up from 16 to 18. I would like to see the figures. An awful lot has happened since 2005 and I hope that continues to send the figures in the right direction because I think this is one of the areas where governments of all persuasions, back from the early 1960s, have had a success in public health, but I would like to think we have done more than most since we came in to tackle this by getting to the point where you take decisions in Parliament that could be unpopular but which have proved to be, I think all the evidence is at the moment, people are complying with it and it is having dramatic effects on people's health.

  Q285  Dr Stoate: There is no question that your Government has done more than previous Governments in tackling this problem. My question is whether in fact it is having any effect. Is there yet any real evidence to suggest that the new legislation on smoke-free zones is making a difference? It may be too early but is there any evidence?

  Alan Johnson: I think it probably is too early but you saw the evidence from Scotland I think something like a year after they had introduced the legislation which showed a dramatic 18% reduction I think it was—

  Q286  Chairman: 16% reduction measured in nine hospitals.

  Alan Johnson: Of course in July of next year we will be able to judge what has happened in the first year and I think that is one of the reasons why 2005 onwards is probably the most dramatic and exciting period for introducing measures to reduce smoking.

  Q287  Dr Stoate: Perhaps I will ask you this next year.

  Alan Johnson: I hope I am still here.

  Q288  Chairman: You mentioned earlier that the public are very conscious about the issue of hospital-acquired infection in terms of they have a role to play in some senses as well. Public information is still an issue inside the National Health Service. You put considerable emphasis on achieving targets and that is all right and proper but do you agree that the public would understand better what the Department's responsibilities are if was made clear what guarantees are offered to them when they need care now the NHS can be held to account for meeting these guarantees?

  Alan Johnson: The simple answer to that question is yes. We could do far more and need to do far more on the information front. We are going to get to a position soon where we will have this information prescription, I think we are calling it, where people with long-term care needs will get a whole series of well-written, clear, concise help and advice and guidance on where to go in terms of benefits, where to go in terms of support and help, because information is key to actually improving health. I think it has been an overlooked part of health. I went to a hospital—this is going back to what we were talking about about spreading best practice—the other week where every incoming patient gets a very easy-to read information pack about everything about that hospital and the services that are available. It is something that probably was not thought to be important 10 years ago but is now, you are right to say Chairman, extremely important.

  Q289  Chairman: We had discussions last week and David Nicholson answered this question about how NHS Choices could be used better in terms of that. In answer, he said obviously that primary care trusts have a responsibility to publicise what the position was in each individual area and potentially the development of a NHS Choices website to enable people to get on and understand what is available and what is not part of the process is something as well, but there is no target for setting what I would call this public information about what they can expect or not. Are you thinking of setting targets on that?

  Alan Johnson: No, we are moving away from top-down targets, Chairman. We spent about £12 million on NHS Choices and it is part of this exciting agenda where people can access information freely and make decisions on the basis of that information. We are also thinking about introducing a kite mark so that patients can be sure that the advice they are getting is from a reliable source, and we can also encourage other NHS providers to go for this kite mark on the grounds that they are committed to giving good, high-quality information.

  Q290  Jim Dowd: Can I follow that up Alan. I remember a scheme a few years ago about publishing morbidity rates for acute units; whatever happened to that?

  Alan Johnson: I do not know.

  Mr Nicholson: There are all sorts of rates published. The cardiac surgeons are the most obvious ones which are published now and available for people to see. We have just appointed Bruce Keogh as the Medical Director for the NHS who was part of the leadership for this. Part of his responsibility now is to think of how we might extend that to cover other specialties and we would certainly use the NMS Choices website as part of that process.

  Q291  Jim Dowd: It is certainly a fact as it is presented but do you regard it as informative to the average patient?

  Mr Nicholson: It depends. If you look at what has happened in cardiac care, I think it is very informative because they have spent quite a lot of time developing it and improving it. In other specialties my guess is that people are not at as advanced a stage but certainly if I was going to be operated on by a surgeon, I would at least want to have a look at the information about their outcomes and then I would weigh that against a whole series of other issues. I think it is perfectly reasonable for the population to have that information.

  Q292  Jim Dowd: The response to the PEQ indicated that there were relatively few either PFI or traditional capital schemes in the south of England projected over the near future and yet given the very ambitious plans the Government have for the Thames Gateway, for example, how are the two reconciled?

  Alan Johnson: I am not so sure that we do not have PFIs in the south of England. That PEQ that you mention, I saw some information on that, but I think in terms of the number of PFIs in the South East there are 25 PFI schemes in London alone. In the South if you define the South of England as South East, South West, South Central and London, there are 64 schemes open or under construction worth £7 billion, so we will look at that a bit more closely, but I do not think there is an obvious "we do not like PFIs in the south".

  Q293  Jim Dowd: I was not looking at what has been done already; I was looking at the planned new ones?

  Alan Johnson: On the Thames Gateway.

  Q294  Jim Dowd: Which is still in its very early days.

  Alan Johnson: It is at an early stage but we are spending about £1.4 billion on new or refurbished hospital provision for the Thames Gateway. I have got a whole list of things that are happening that will have led to that amount being spent. I think you have to look at this coming year because by the spring of this year we will agree—the Department of Health and the SHAs—the mechanism for supporting improvements for general public health. We recognise you cannot just build this great area. That was the mistake of the past. This estate I was talking about in Barking, which is on the edge of the Thames Gateway, was built at a time when people did not think about any health provision or where they were going to work and you got an isolated community. The Thames Gateway has to have proper education facilities and proper health provision. That is all in the mix and we are spending a lot of money on it.

  Q295  Jim Dowd: There is another aspect of this. I have been involved locally with Picture of Health, obviously, and the George Alberti Review, which indicates, if nothing else, that the feeling is there is very much too much acute provision, certainly in London and the South East generally. Is that your view?

  Alan Johnson: I do know that clinicians in South London, who I know very well, believe that to be the case, that there needs be to a reconfiguration there in the interests of patient care. I also know from reading the Darzi Review of London that people have tried to address this issue constantly over the last 40 years and have always come up against a brick wall, which is usually a political one. I think now is the time to try and move beyond some of these fairly basic arguments of people defending bricks and mortar and not looking at a total vision for healthcare in the 21 century.

  Q296  Jim Dowd: I think you will find the brick walls are those that comprise the great cathedrals of medicine that dominate central London, if nothing else.

  Alan Johnson: I could not possibly comment!

  Q297  Mr Scott: How do you react to press reports that the revisions and slow development of the Independent Sector Treatment Centres will cause firms to withdraw from them?

  Alan Johnson: I react in the way that the King's Fund reacted, that that is nonsense. My letter to the FT might not be thought to be completely independent but Keith Palmer, the senior associate of the King's Fund, said the presumption—and this was a presumption in the FT—that the recent decision by the Department of Health not to proceed with some independent treatment centres signalling a change in policy is unwarranted, and he says, "Alan Johnson, Health Secretary, is right"—I always like these bits—"to say that this does not mean that there is no role for the private sector in the NHS. As hospital productivity improves resources are freed up to expand and improve services closer to home, and in the home". I am bemused by this, quite frankly, because people have been trying since June to try and stack up a story that somehow there has been a change of policy here. I came to this committee in July, I think it was, and said there will be no third-wave centrally driven ISTC procurement because having another top-down from Whitehall procedure seemed absolutely to be unnecessary, and I am absolutely sure that if it was a Blair/Hewitt government they would have been saying exactly the same. What we have said now is for local PCTs we want this to be a bottom-up process, not top-down. That is point one. I also announced a huge investment in an ISTC in the North West. Now, on the second wave some of those procurements that had only got to preferred bidder stage, there had been no contracts signed, were not going to cut the mustard, not least of all if you look at the West Midlands, where we had signed a contract in one or two areas, where the waiting times had come right down, collapsed down to about three weeks, and in one area in particular we were getting 5% utilisation, so a 5% return on taxpayers' money. Now, no Secretary of State in their right mind is going to persevere with that against the fact that there is now sufficient capacity, that there is group productivity in that area, or that there is group patient care in that area, so the independent sector have a really valuable role to play, and I announced some more independent sector involvement in the acute sector, as part of the same announcement, and beyond that, in primary care, where previously there has been practically no role for the private sector, we have announced that we are going to set up these new GP led centres to improve access and the private sector will have a huge role in that as well. So I think this is kind of Orwellian, private sector good/public sector bad or the other way around. I am interested in good patient care and ensuring that we use the private sector efficiently and cost effectively and bring their skills in, but it has to be, as I say, on the basis of capacity, value for money for the taxpayer, and good patient care.

  Q298  Dr Naysmith: It is very interesting what you are saying there, Secretary of State, because when you were here in July I do not remember you emphasising the direct-from-the-centre quite so much; it was really a kind of statement that there would not be another wave of ISTCs, whether they came up from the PCTs or not, but it is interesting you have now made that clarification, I am sure we could look at the record and see. But last week—and he is lucky, I suppose, he gets two bites of the cherry but you only get one—David Nicholson was telling us that there was a big capacity issue for us, and much of the capacity of the National Health Service was saying it could not deliver. But now it has found ways of delivering and that is a bit of a surprise, I think. It has found ways of delivering whereas it said it was not going to have that capacity; they said there was the big capacity issue and they said they could not do it. Why were the contracts lasting for five years given to private companies to deliver ISCTs, while at the same time resources were being pumped into the National Health Service to increase its capacity?

  Alan Johnson: Firstly you will not get private sector involvement if there is not a contract. As I just explained, six of these that we have cancelled were not at the contract stage, just at preferred bidder stage. Secondly, we have cancelled where there was a contract, one in the West Midlands where waiting times had gone down from three years to three weeks. Incidentally, if we had had a shorter contract time than five years, which would have been difficult to negotiate, it would have cost us much more to pull out because the deal for shorter contracts is you pay much more if you pull out, so I do not think there is anything about the propriety or the sound common sense of a five year contract; bringing in the independence sector, and David was absolutely right, galvanised productivity in the NHS, and you would not have got that without a contract of a certain span of time. And I do re-emphasise, six of these that we cancelled were not at contract stage anyway; they were at the, as it were, preferred bidder stage.

  Q299  Dr Naysmith: I know you were not around at the time but what people are arguing now is that it was a shot in the arm to get the NHS to perform better. Some people are saying what a waste of time it was putting that money into ISTCs when we do not really need them.

  Alan Johnson: That was not the main reason for doing it. The main reason for doing it was to get these waiting times down, and if you go to somewhere like Shepton Mallet you see an operation by the private sector in an ISTC that has a 96% satisfaction rating of patients who use it. One of the problems we spoke about last time, and I remember Dr Taylor raising it, was this additionality rule and the fact that they did not feel they were part of an integrated healthcare system, and that is something we can improve upon now, but their role was valuable in improving patient care. As a by-product of that it did raise the game throughout the NHS. The question I asked was if we are going to cancel these contracts, or cancel the preferred bidder stage, does it mean that somehow there would be a slip back, that we will move away from this very benign and happy state that we are in now, and that is not going to happen really because the indicators are in there and people are now involved, they have seen what they can do, and this is a very important point, by including the nursing staff and the clinicians in the way that these things are arranged. I was at a centre in the Derwent Centre in September, Bournemouth District General Hospital, where the Nuffield operated elective surgery on hip and knee replacements; they decided they could not operate it any more and moved out and asked the NHS to take it over, and the NHS engaged nursing staff in how they could do it more productively, and they have gone from an 8-day turnaround to 4-day. Patients come in on a Friday and walk out on the Monday. Huge productivity, very low levels of healthcare associated with patients—

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