Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 20-39)


Jim Dowd

  20. I take your point about the broader nature of public health. If I can look at one of the initiatives this Government has taken since 1997, and that is Health Action Zones. We have one in my area—Lambeth, Southwark, Lewisham—a Health Action Zone, the whole programme could have been designed with that kind of area in mind, pockets of deprivation in towns and cities, in one of your earlier answers this fits archetypally into the area.
  (Mr Milburn) Yes.

  21. I have a good relationship with them. They are doing a lot of work. They are looking at very original and imaginative ways of approaching the age old problem. There is a lot of money being allocated to the 26 which now exist. How are you going to ensure that they are actually meeting the objectives rather than just doing good work and the acid test of that will be in reduced numbers with coronary heart care and cancer cases etc in some of the inner urban areas, which are not only the most deprived but have some of the most deeply entrenched and worsening public health problems?
  (Mr Milburn) I think the answer to that is the same as the answer to how we ensure that PCTs carry out their public health function, which is that we monitor them. We have an accountable system in this country which is a real strength actually, I think, for the health of the population and we have a means of doing that now. We have got a performance assessment framework which covers a number of areas of activity, whether it is Health Action Zones, PCTs, NHS trusts, Uncle Tom Cobbley and all have got to account against. There was a time, I will be frank with you, when for the first couple of years, we were not monitoring the Health Action Zones as actively as we should have done. I changed that I think last year partially because I was concerned that some of the initiatives that they were undertaking, although they were good things in their own right were not focussing on what we know really makes a difference because if we can bear down on smoking, if we can improve diet and exercise, if we can ensure that in primary care people are taking sensible, pretty straight forward steps to monitor health incidents then we can make a big difference. That was not happening everywhere, I cannot remember whether it was happening in your area or not, I hope it was. We changed the regime so there is actually much tighter monitoring of the Health Action Zones now. What I want them to do is to spend the majority of the resources that they get, which are quite considerable, on precisely the areas that we know will make the greatest difference on dealing with coronary heart disease, on improving cancer outcomes, on dealing with the things that I have been discussing with Dr Taylor. I think that in all of these cases I want to assure the Committee that what we have is a means of the local health service being able to account for its performance, not just on the narrow issues of acute elective activity or recruitment and retention rates but on the broader public health measures too. With one caveat, you have made the important point and it is absolutely right, we should be bold about this and very straight forward with the public. To get where we need to get to in terms of improving cancer outcome rates or heart disease outcome rates is not going to be achieved in one year or two or a Parliament, it is going to be achieved over a period of time. That is why all of the frameworks that we publish and all of the plans that we have published are deliberately long term and I think unashamedly so too. What we have got to be able to do if we have got long term plans in place is to be able to demonstrate year by year improvement. Now in some of these things, to be frank with the Committee, it is pretty hard. You saw that very, very recently, I think, there was reference in the newspapers to improved cancer outcome rates but those figures referred to several years ago because we are always behind the mark in terms of measurement. We need to improve that and we have got some things in train that will allow us to do that. That aside, what we should do with every part of the NHS is make sure that the appropriate monitoring is in place so that we, as decision makers, but more importantly members of the public can actually see where their money is going and what results they are getting.

Mr Amess

  22. I have been listening very carefully to your hopes and aspirations for the Health Service but how can this Committee take your utterances seriously when we consider everything that you and your fellow ministers have said about waiting list targets for the last four years? I am not going to embarrass you by reading out the responses that you have given to Committee Members.
  (Mr Milburn) Generous to a fault as always, Mr Amess. Generous to a fault, well known for it.

  23. Defending staunchly why these targets were so marvellous and how it was sensible to put extra money in, etc. Then breathtakingly in June after four years defending this rotten policy you said "There will be no waiting list target but there will be a concerted drive to reduce waiting times" and yet when Her Majesty's Opposition had tried to persuade you of that position you did not want to know. How is it that you suddenly changed your view on that very important issue after four years?
  (Mr Milburn) I do not think Her Majesty's Opposition liked the change either because you do not like either the waiting list or the waiting times target. However, let me explain what we have to do here because this is very, very important. When we came into office in 1997 the major public concern was about the length of the waiting list because it had been rising and, in fact, I think during the course of the previous administration had risen by about 400,000 from around 700,000 to well over one million. Of course there were public concerns about that and it is right that we deal with public concerns because in the end the NHS, just like any accountable organisation, has to command public confidence. We succeeded in doing what we said we would do, which is to get the waiting list down. We managed to do precisely that, we got the waiting list down by over 100,000. These things do not stand still, we go on from year to year trying to make improvements. Because we have managed to achieve what we set out to achieve on waiting lists, compare and contrast 400,000 rise against 100,000 fall, we can move on to our next ambition and our next ambition is to get the waiting times for treatment down. Let me just finish the point. It is very, very important for people. People do not like waiting 18 months for an operation, whether it be a heart operation or a cataract operation, and rightly so. Actually, I think that we are making good progress on this. I wish we could go faster but the capacity constraints are such, the shortage of doctors, the shortage of nurses, and until very recently the shortage of beds which had been falling for 30 years and are now rising again in hospitals, mean that we have got to take this thing stage by stage. What I can say is from a position where we had a maximum 18 month waiting list, by March next year we will have a maximum 15 month waiting list. In fact, I expect very many NHS trusts to do even better than that. Some NHS trusts are already achieving six months. My own trust in Darlington has long achieved a maximum waiting of 12 months. Within that we will make even faster progress still particularly for coronary heart disease and for cancer, the clinical conditions that affect most people most severely. That is the simple reason for it. You are speaking for the Opposition here today obviously but I just hope that what people have been clamouring for they are now happy with which is, I think, a step in the right direction.

  24. My colleague is bursting to come in but I just want to pursue this point. What you have said is absolutely incredible. Is not the truth of the matter that after four years the general public more than twigged that it was minor operations that were being carried out before more difficult ones in order to get these wretched lists down and it was the friends and relatives of people who had serious operations needing to be carried out and it was through public pressure that you dropped this ridiculous policy? The whole point of this Committee is we are talking about expenditure on the Health Service. Are you actually telling this Committee that you are not admitting that this policy that you pursued for four years was wrong? Are you also expecting us to believe that the extra money that you deliberately put in to pay these consultants—I have had so many conversations with them about what was going on—was not in order to get the smaller operations carried out quickly so that these figures would look good? You are seriously expecting this Committee to believe that, are you?
  (Mr Milburn) Yes, I am. In fact, you can see from the figures, and again I would be quite happy to share the figures with you in due course, when you have a look, for example, the big expansion that has taken place in heart operations. A heart operation is a major operation, heart disease is a serious clinical condition.

  25. Yes.
  (Mr Milburn) And there have been big increases in the number of heart operations. So the charge that somehow or other the only operations that were being done were toenail clipping rather than heart operations just simply does not stack up. I think the other important point to bear in mind is this: there is a direct correlation between the number of people on the waiting list and how long individuals wait in terms of waiting time. If I go to the supermarket, when I have bought my goods by and large I do not go and join the longest queue, I try to join the shortest queue because I am going to get through the till most quickly. What our modelling suggests very, very strongly, and I think you can see some of this already in terms of the impact of the inpatient waiting list on waiting times, is whether you reduce inpatient waiting lists or your focus is on reducing inpatient waiting times the two come down together. That is what we have got to achieve. I think the most important thing from the patient's point of view, from the point of view of the individual patient, is to know that the National Health Service is moving in the right direction, that if you have got a serious condition or any form of condition that the National Health Service is going to be there for you and it can deal with you in a timely fashion. If you ask me right now whether people wait too long for a hospital operation, of course the answer to that is yes, it must be yes. What we have got is a determined effort to get them going down. As you can see from the big reductions that have taken place in the number of people waiting over 12 months already from the peak just a few years ago this can be done and it is being done in certain NHS trusts. The big question that should concern all of us is this: if some NHS trusts, if some hospitals, can manage to achieve a maximum waiting time of 12 months, let alone six months, then why on earth can every NHS trust not achieve that?

  26. I find it more and more incredible but on that specific point, if you turn to Table 4 16.9 you will see that the total number of people being removed from the waiting lists for ordinary and day care has actually been falling since March 2000. Moreover, there is a pattern of falling for admissions since March 1999. That is in that table. How did you work out the new waiting time targets?
  (Mr Milburn) We modelled it. I think it would be reasonable to share with the Committee some of the modelling that we did. We modelled it and I think that is perfectly fine, you can see that for yourselves.

  27. And you took into account falling nursing home beds?
  (Mr Milburn) And we took into account a range of factors. We took into account not just the extra investment that was going in. Remember the investment that is going in is now at twice the rate of the past, which allows us to go at least twice as fast. We also took into account some of the changes that need to take place in how care is delivered. Let me just finish this point because I think this is really important. I do not believe that in the end the way that you will get the big reductions in waiting times that patients nowadays expect to see out there is simply by cranking the machine even harder, it is not achievable by that.

  28. Just one or two very, very quick points. Just for the record then, you are confident that you will achieve these waiting time targets?
  (Mr Milburn) Absolutely, yes.

  29. The final point is when you came before the Committee in November 2000 we had an exchange over naming and shaming Southend Hospital. This was all about the consultants and on this particular proposition of targets. One colleague is going to talk about the hotel star rating. How do you justify that you announced hotel star rating for hospitals when Parliament was not sitting and given we had an exchange last November you actually had the audacity to give Southend Hospital, which serves four constituencies, a one star hotel rating. So in our exchange in November, which is on the record, you said you were going to do a great deal to help, we were going to boost staff with all sorts of initiatives, a Government Minister came down, and now you have given our hospital a one star rating. Who was the idiot, absolute idiot, who thought up hotel star rating and could not see the terrible effect it has had on staff morale in my own local hospital? An absolute disaster.
  (Mr Milburn) I gather that you are not very happy with the policy.

  30. I am not, no, and even the doctors, nurses and consultants are outraged.
  (Mr Milburn) Even I, with respect, Dr Taylor, as a politician got that message.

  31. It is a disgrace.
  (Mr Milburn) I know you think it is a disgrace and I am extremely sorry for that. The reason why it got a one star rating is that is what it deserved according to the figures that were measured. If you do not know this as a Member of the Health Select Committee you should. The truth about the National Health Service is this: there is excellent performance, there is indifferent performance and I am afraid in some parts of the NHS, to be blunt, there is bad performance. Every patient knows that, every doctor knows it, every nurse and every manager knows it; every politician should know it too.

Sandra Gidley

  32. Fun though it may be to attack the record I am more interested in looking forward to what may or may not happen. One of the side effects, if you like, of the 18 month target is that people are now waiting an extraordinary amount of time before they can see a consultant, particularly in the orthopaedic fields. It is locally 52 weeks if you want to see a specific consultant and I was recently quoted somebody who had to wait 92 weeks to see a consultant in the NHS. What is being done to address this problem centrally? I know there are some local initiatives that are working quite hard on this. Will the change to the 15 months actually worsen this problem? The other aspect of the problem which I would quite like to explore is the fact that local GPS are in fact very hampered, they are very restricted in where they can send the patients. It is a fact that if 40 miles down the road there is a hospital with a three month waiting list GPS cannot send patients there. When budgets are devolved to PCTs will there actually be a greater freedom for GPS to spend the money where they want and without excuses such as destabilising the local health economy?
  (Mr Milburn) I think that is one of the very real benefits that we will see. In most parts of the country, it is not true in every part of the country, there tends to be a monopoly health provider. In Darlington there is one hospital. The next hospital is in Bishop Auckland, it is ten or 15 miles away, Durham is the next one, 20 or 30 miles away. By and large people would choose and GPS would choose, quite rightly, to use their own local hospital for perfectly good reasons. If you go to any hospital nowadays one of the most noticeable things you will see is that there are a lot of very, very elderly ladies in the wards, old people who tend not to be mobile and want to be as close to home as possible. The local hospital will remain a very important focus and it will be a matter for the primary care trust rather than anybody else to decide who on earth they should contract with. My own view is that I think we do need to see more choice being made available to patients and to GPS. I think we can get there. Over time I think we can get to a position where as we get improved information technology in the GPS' surgery, in three or four years' time we will be in a position where you as a patient, and your family doctor, will be able to sit down together and decide not just on when the hospital appointment should be at your convenience rather than at the system's convenience but also the location of the hospital appointment. Frankly, if there is a shorter waiting time in a hospital that is ten or 15 miles away rather than the one around the corner, and that is where you as the patient want to go and it is where your GP wants to send you then we have got to be able to facilitate that. That seems to me to be eminently sensible, precisely bearing in mind the point I made earlier that there is good, bad and indifferent performance. Indeed, in neighbouring hospitals, as you well know, you can get quite short waiting times and quite high waiting times, sometimes for pretty inexplicable reasons. The patient, nor the family doctor, should not be the person who suffers the consequence of that. That is the first point referring to your latter point. On your first point you raised, which was about long outpatient waiting times, you are quite right, the outpatient waiting times, just like inpatient waiting times, are too long. We have got a lot of people who wait over 26 weeks for an outpatient appointment at the moment, even more who wait over 13 weeks. I hope you will take some comfort from the fact that over the course of the last couple of years in particular there have been very, very large sharp reductions in the number of people waiting for an outpatient appointment and we have set further targets to ensure that not just do we get to a 15 month inpatient waiting time maximum but we also get to a 26 week outpatient waiting time. We aim to do that by March next year and then we will go further still in the years that follow. Over the course of the next few years we want to get down to our maximum outpatient waiting time of three months and we want to get down to a maximum inpatient waiting time of six months. I think if we can get there stage by stage what people will begin to see is that these things which have only been possible in some hospitals thus far are possible across the whole National Health Service.

  33. This is a problem because there is no mechanism that I can see in the health service for spreading this best practice. I am also very interested in why one trust delivers and the neighbouring trust does not. There does not seem to be much interchange between the two to expedite that.
  (Mr Milburn) That is an accusation that you could have fairly levelled in the past, I hope it is not an accusation that you can level now. We have a whole apparatus for spreading good practice, as it is called, including a new Modernisation Agency whose sole job is to do precisely that. Its whole raison d'etre is to learn from the things that are going right in pockets within the National Health Service and spread their benefits elsewhere in the NHS whether it is a question of how long people wait on trolleys in an A&E department or how long people wait in this city, for example, to get a GP's appointment. You know people wait weeks on end and in some surgeries they wait 48 hours. I think there are profound questions to ask about why is it possible that between a third and a half of GPS already can deliver a maximum waiting time for their patients of 48 hours while other GPS say that is absolutely impossible. It is not impossible because it is already being done. What we have got to have is both the means to spread best practice first of all through the Modernisation Agency and other devices but, secondly, I think we have got to have the incentives in place so that people who have already improved get a reward and people who need to improve see that there is some reward around the corner if they actually get on and improve. That is what we are trying to introduce. Some people do not like it but the NHS is an unusual organisation in that our tendency rather than rewarding the good tends to be to bail out the bad. I think that is a perverse incentive and we have got to change it and we have got to have the courage to do that. Sometimes that will be in the face of people who actually work in the NHS who do not like it but I am afraid that is what needs to happen if we are going to make sure that we do not have short waiting times in some places but we get them everywhere.


  34. I am anxious to bring in the Minister of State on the area you are responsible for of the community care side. Before you have a breather, Secretary of State, can I just throw one final point at you. We set off talking about public health and rapidly got into waiting lists and waiting times but how can we make public health more politically sexy and does Government have a role in this respect?
  (Mr Milburn) I will tell you what is interesting. Every time we do a story about cancer and what we are trying to do it always gets into the newspapers but every time we do a story about coronary heart disease it never gets into the newspapers. I do not know what the answer to that is but maybe the answer lies on the table to my right rather than to me. Frankly, I think part of the reason is that with coronary heart disease it tends to be a much more working class disease. You know that yourself from your own area. Unskilled men run three times the risk. Just because it adversely affects disproportionately one part of the population should not mean that it is not a concern for the whole of the population, because it is, and we have just got to keep ensuring that there are both the focus and the resources there to really make a difference. In terms of so-called sexy initiatives, part of it is through advertising and so on and so forth. The anti-tobacco advertising campaign that the Department is running is pretty effective and winning awards and so on and so forth. It is important to get these messages out to people.

  Dr Taylo

  35. Can I make one very quick point on that, to make it more sexy, more attractive. The public health doctor is becoming more and more a civil servant and this has been raised to me by both public health doctors and citizens. He used to be independent, the voice of the people. If you could make a new breed of public health doctor who really was the voice of the people, that would increase the attraction tremendously.
  (Mr Milburn) I hope you are not alluding to the fact that civil servants are not sexy. The top table indicates it all too well. No, I think you are probably right.

  Chairman: We had better move on from that, Minister.

Dr Taylor

  36. We are going on to community and residential care, if we may. Obviously it is very good that the Government is committed to increase spending on intermediate care beds. We are very concerned that nursing home beds are being lost at quite a rate because of the increased costs, the increased care standards, which obviously they do not object to and they approve of but they are finding it very hard to keep up with those. I got a letter just a day or two ago from the Registered Care Homes Association of Hereford and Worcester, quoting "A growing number of homes are in dire financial trouble, especially those who are unable to attract a sufficient number of self-funding residents who in fact subsidise others". So this local group for these two counties is about to put up the fees per patient by £50 per week. What bothers us is however can you accommodate this tremendous increase in costs in nursing home care and still have money to make the planned increase in intermediate care?
  (Jacqui Smith) The first thing, of course, is I have had that letter as well. There is concern. We are concerned about the capacity within both nursing and residential care homes and that, of course, was part of the thinking behind the announcement last week of the £300 million. It seems to me there are a variety of things that we need to do. Firstly, I think we need to recognise, and care home owners and local social and health care economies recognise this and all of us think it is a good thing, that we are in a situation where we need our services to change. So we do not need to maintain necessarily exactly the level of capacity we have previously because older people have said to us as a Government, and they will undoubtedly have said to us as individual MPS, that what they increasingly want are the sorts of services that enable them to stay in their own homes that prevent them from having to go into hospital in the first place but help to promote their independence and rehabilitate them if they have been in hospital and they come out. So there is a challenge in the system which is about managing the capacity whilst we also reconfigure and develop new services. That was what last week's announcement was about and that is what I know a lot of work at local and social health care levels is also about. How can we maintain that capacity and how can we develop new services? One of the important ways that we need to do that is by making sure that the sort of commissioning that happens locally is better than it has been. There have been authorities where quite frankly I do not think they have involved their independent and voluntary sector partners and their care home providers in the planning of their capacity in the way in which they should have done. That was the reason why John Hutton, my predecessor, firstly brought together the Strategic Commissioning Group at a national level, the results of which were the agreement that we published last week alongside the announcement of the extra money as a guide to the sort of practice that ought to be happening at a local level to ensure that commissioning is better. Involved in that as well, of course, will be much better planning into the future of what sort of capacity of services we need so that care home owners precisely like those who have written to both of us from Hereford and Worcester have a bit more certainty into the future about what sort of services are going to be commissioned and, therefore, how they can contribute to ensuring that those services are there for people.


  37. Can I offer a slightly dissenting voice in this. There was an assumption in your answer that a contraction in institutional care policies may be a bad thing but there are certainly one or two of us here who think it may well be a good thing. I would put to you the concern that one of the difficulties we have in this whole area is that this area of service has for far too long been provider led by the interests of care home providers. This Committee has been on a plane for an hour and a half to Denmark and we have seen a country that has no care, no old people's homes, they have moved away from that. Is that not an objective that we should set and not be ashamed of that, that we actually reduce the number of places?
  (Jacqui Smith) I am sorry if I gave the impression that I necessarily thought it was a bad thing. I think there are two challenges. I said that I think it is important that we change the system because older people want precisely those sorts of non-institutionalised methods of support but we do need to maintain capacity at the same time, which is why, for example, alongside a declining number of nursing and residential care places it is encouraging that, for example, there are 30,000 more intensive home care packages being offered to families since 1997. A symbol of the shift of service that is happening that most of us would accept is right, a shift out of institutionalised care and into the sort of care that promotes more independence. Whilst we are reconfiguring the system we do have concerns about ensuring that we maintain that capacity, that change happens in a managed way, that it happens in a way that brings together partners at a local level to commission more effectively than I think they have done in the past.

  38. The next thing is to confirm that this really is new money, so often money that is announced by ministers when we really look into it is actually included in the allocation that the health authority has already had. Is this genuinely new money over and above the allocation that social service departments have?
  (Jacqui Smith) Yes. This is not money that local authorities believe they were getting, it is not money that has been allocated to social services, it is in addition to the investment that was going to be made. The £700,000 in Worcestershire, for example, will make a significant difference.

  39. Have you calculated how mean extra beds it would fund?
  (Jacqui Smith) It would fund, for example, 7,000 extra nursing home beds, however I do not think that is what it should be funding, I think it should be funding partly some extra beds, where those are necessary. I think in some areas it should be contributing to higher fees for some of the services that are available in order to make sure the supply is there in the future. I think it should be contributing to a better intermediate care provision. I think it should be contributing precisely to the sort of intensive home care packages to the measures to promote independence that are going to be important if we are going to reconfigure the system. We have some strong targets about what we want to achieve with the money but that is not about a given number of beds, it is about how the system is able to change, be managed more effectively so that it delivers the sort of care for people in the right place and at the right time.

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