Examination of Witnesses (Quesitons 280-299)|
MP, MR DAVID
NICHOLSON CBE AND
29 NOVEMBER 2007
Q279 Dr Taylor: Cross department?
Alan Johnson: And cross-department
Q280 Dr Taylor: On a wide range of
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
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
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
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 hospitalthis is going back to what we were
talking about about spreading best practicethe 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,
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
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
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
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 agreethe Department
of Health and the SHAsthe 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
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
presumptionand this was a presumption in the FTthat
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 weekand
he is lucky, I suppose, he gets two bites of the cherry but you
only get oneDavid 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