Examination of Witnesses (Question Numbers
23 NOVEMBER 2009
Q60 Keith Hill: That is also encouraging.
Is it the case that this kind of holistic approach is expensive
and need it be expensive?
Mr Belfield: No, I do not think
that it should be expensive. If you get this right first time,
as the Report says, and you help identify the need early enough,
then in the longer term it saves money. Certainly the Department
of Health has a very strong view that quality should not cost
because getting it right first time should save taxpayers' money.
Q61 Keith Hill: It sounds like a
propitious development, Mr Nicholson. Is this something you are
going to put your back into?
Mr Nicholson: Absolutely. Gary
is absolutely right. This is not an issue about huge amounts of
extra resource. This is about organisation, management, planning
Q62 Keith Hill: Smart solutions,
in other words?
Mr Nicholson: Yes. It is all of
those things. That is why it is so important we set national benchmarks
and set out our expectations.
Q63 Keith Hill: This I think is one
for Mr Nicholson: do you recognise the risk that the focus on
getting the newly identified rheumatoid arthritis patients through
the system can lead to slower or indeed deficient treatment of
Mr Nicholson: No, I do not see
the connection at all. We have grown capacity significantly in
the NHS over the last few years. As you have heard me talk about
on numerous occasions, before we had the capacity to deal with
this, it is for relatively small numbers of patients.
Q64 Keith Hill: It is mentioned for
example in the DVD that patients already in the system seem to
perceive they have problems in accessing the services they are
looking for because of the concentration of units on meeting the
18 weeks target. That is not something that you recognise?
Mr Nicholson: No, I do not think
so. To be honest, with the 18 week pathway and the way it is designed,
we would not expect that to be one or the other.
Q65 Keith Hill: Could I ask the NAO
to come in on this point?
Ms Taylor: If you look at paragraphs
4.6 and 4.7 and also to an extent 4.10, some of the evidence we
collected is that people are having problems when they have a
flare up or in continuing to get treatment after the initial diagnosis.
There are a number of examples given there that were reported
to us by both the acute trusts and through our patient survey.
The figure you have given for rheumatology is that about a fifth
of the cases are for rheumatoid arthritis. If we could get, as
we have in some places, primary and community services working
with our hospitals, some of the repetitious work for people who
are not having flare ups could be done quite well in primary care.
Certainly in my practiceand I know in Alan'swe used
to have a rheumatoid arthritis nurse working with us for the general
reviews of patients once significant symptoms had settled. Working
with our physiotherapy colleagues, we could obviate the need for
a lot of referrals to orthopaedics or rheumatology because we
needed an opinion about better care. One of the issues for us,
which practice commissioners will have to major on, is how do
we get that better system. A lot of the reason we have expense
in our health care system is because of duplication. You find
that a lot of patients are seeing the specialist when they are
not acute and also seeing their GP and so on. That is the area
where we could make a significant improvement in quality, release
our consultants for more time for flare ups and acute care and
yet still look after patients in a systematic way. I think that
is the real test for us where there are examples already happening,
but not widespread enough yet.
Mr Nicholson: I hear these comments
about choose and book, which is the issue that is raised. I do
not believe that these are reasons why we cannot organise the
services better than we do. It is, at the end of the day, a mechanism
for planning capacity and there is no short cut for PCTs and acute
trusts planning their capacity properly. Choose and book makes
you do things in a much more transparent way which I think is
a good thing and I do not believe that choose and book is the
reason why people are having problems with that service; I think
we need better organisation.
Q66 Angela Browning: We have read
that the average age for this condition to start is about 40,
or people in their 40s; it is not necessarily a condition of old
age. It seems to me increasingly that where people have developed
it in their 40s or 50sI have a certain personal interest,
not that I have rheumatoid arthritisand where people present
with chronic conditions, they get specialist treatment up to a
point and then they pass a certain age barrier and they suddenly
become the responsibility of geriatricians. I wanted your assurance
that in a case like this, for rheumatoid arthritis, that people
who are, say, over 65 or over 70, would continue to get the specialism
from the consultants and not from a generalist?
The answer is yes, and in fact a key responsibility lies with
the general practitioner deciding, once they are referred, who
is the most appropriate. If you are a care-of-the-elderly specialist
it is more to do with the organisation of care for people with
lots of chronic problems, but for specific things like diabetes
and so on they will need to see a specialist, and that generally
happens. If there was a rule to say otherwise, I think you would
find a lot of people like Alan and I would say that this was a
nonsense and challenge it quite strongly. The answer is, you have
to find the specialist who is most appropriate for the presenting
problem, and to say you have to go off to a different system is
not right. As Alan says, this report and the NICE guidance will
reinforce that even more strongly.
Mr Nicholson: There should be
no age cut-off, either implicitly or explicitly for rheumatoid
Angela Browning: That is very encouraging,
Q67 Chairman: We have had a very
helpful submission from the National Rheumatoid Arthritis Society
and they have submitted an analysis to the Committee highlighting
the difference in spending on rheumatoid arthritis between PCTs£5.68
per head in Bexley and £17.58 in Gateshead; the English average
is £10.97. What is going on? Are they just diagnosing it
much better in Bexley and need to spend less, or are they just
being mean in Bexley? What is happening?
Mr Nicholson: I think there is
a whole set of issues. People are collecting the information and
sharing it and looking at it for the first time, and you may find
in those circumstances that people are collecting it and showing
it in different ways.
Q68 Chairman: We need to get to the
bottom of this, this is very important.
Mr Nicholson: I agree. That is
one of the issues. The other issue is that the populations are
different as well, in terms of the age structure of the population.
What we have not done is connected those two things together.
Q69 Chairman: It is hard to think
that there is such a difference in the age structure in Bexley
and Gateshead. There is something else going on here, I suspect.
The Society is unable, they tell us, " ... to conduct an
assessment to ascertain whether there is any correlation between
levels of spending and service quality since the findings of the
NAO's survey of the quality of acute care are anonymised. The
Public Accounts Committee may wish to consider investigating this
directly, or asking the Department of Health to do so." I
am now asking you to do so.
Mr Nicholson: We would be happy
to investigate because it raises a whole series of issues.
Q70 Chairman: We do not want a postcode
lottery here, do we?
Mr Nicholson: No.
Q71 Chairman: You mention Dame Carol
Black, who is mentioned right at the back of the Report. Do you
think she would be satisfied with progress if she were here?
Mr Nicholson: No.
No. Whenever you write a report, and we have all written our reports,
you are frustrated by the pace of progress, and I think that is
an issue. In answer to your previous point, of course Carol's
work straddled both the DWP and the Department of Health, to try
and get more coherent working together, but in terms of the programme
I think she would have expected more to have happened. We are
putting a lot of store on these fit-for-work pilots, because that
is a more comprehensive look at it, not just whether GPs have
fit notes but getting more occupational health people working
at earlier interventions and so on and so forth to see if that
is possible. But the answer is, whenever any of us write a report,
we are always frustrated by the pace of progress.
Q72 Chairman: That is a very honest
answer. Thank you for that. I think that concludes our hearing,
gentlemen, thank you very much. I think it has been an important
and interesting hearing. As I often say on these occasions, we
are very proud of the fact on this Committee that we have managed
to put a spotlight on certain conditions, such as hospital-acquired
infections, dementia, stroke, over the years, and we are very
grateful to Karen Taylor for all the wonderful work she does for
this Committee in the field of health. She has done a lot of work
over the years to bring these subjects forward. So we are very
grateful to you, Karen. May I just say that although we were told
that a GP may only see one case a year, this is still an enormous
problem. There are, we are told, an estimated 580,000 adults in
England who have rheumatoid arthritis, and there are 26,000 new
diagnoses each year. It costs the NHS £560 million a year
in health care costs but the cost to the economy is £1.8
billion a year. What is even more worrying is that three-quarters
of people with rheumatoid arthritis are first diagnosed when of
working age. Women are more than twice as likely as men to have
the disease, and one third of people will have stopped working
within two years of being diagnosed with rheumatoid arthritis.
So I am sure you would agree, Mr Nicholson, this is a very serious
problem indeed. It is extremely worrying that the public awareness
of the disease is so very low. Before I got involved in this,
my own personal awareness of this disease, I have to accept, was
very low indeed. We need to ensure that diagnosis comes much quicker
because it is undoubtedly true from what we have heard today that
if you are diagnosed quickly you can arrest this disease. We expect
to have a very helpful but hard-hitting report, Mr Nicholson,
to encourage your efforts in this field.
Mr Nicholson: Thank you.
Chairman: Thank you.