Examination of Witnesses (Questions 120-139)
THE RT HON ALAN MILBURN, MP, MR ANDY MCKEON, MR RICHARD DOUGLAS AND MR ANDREW FOSTER
WEDNESDAY 12 JUNE 2002
120. I shall write to you about the localised solutions later. Choice is all very well and it is something we all aim for, but evidence in the Wanless Report states that in Denmark just over 2 per cent of the population have actually exercised this.
(Mr Milburn) More than that.
121. Two point one per cent is the figure. What evidence do you have that if we introduced this in this country it will be exercised? What I am quite interested in is the fact that some people are not in a position to exercise choice; they cannot afford to travel. Will this be yet another thing which in many ways is for the "haves" rather than the "have-nots"?
(Mr Milburn) No, and we have to avoid that. I cannot remember the figures from Wanless but I think the latest figure we have from Denmark is that for elective surgery around 6.7 per cent of non-acute patients seek treatment outside their county.
122. That is just non acute, it is not wider.
(Mr Milburn) That is non acute. You ask about the likely behaviour, whether people are going to choose to choose. It is likely, although I do not know, but the international evidence seems to suggest, that most people would choose not to choose; most people. However, a sizeable proportion will. If that means they can get quicker and better treatment, then that is a good thing for those people, provided it does not undermine fairness and clinical need and all those sorts of things and you have to have the right safeguards in place. I suspect that from some of the survey work which has been done in the past, there is quite a large number of patients, particularly with more severe clinical conditions, for example a heart operation. If you have been told you need a heart operation, a coronary artery bypass graft, and you are told you are going to have to wait 12 months, you worry about it. That is why we are trying to get the waiting times down, by expanding the capacity and making some of the changes. It may well be that when patients are offered choice for an operation next month, that most of them will say they prefer to wait to have it locally, they know the local team, that is where their community, family, are and they want to stay put. It may well be that quite a lot will say, "Thank you very much. I just want to get this over because I am worried about the state of my health and what might happen". In which case we, the NHS, have a responsibility to help them, for example with travel and accommodation. We have to make sure we have an appropriate carer and all of those sorts of things in place. You make a very important point about the "haves" and "have-nots". That is what we have to avoid. In Denmark and some of these other Scandinavian countries which are not dissimilar from ours, where they are tax funded public healthcare systems as we would recognise them in this country, but where they have long since enshrined choice, they build in these sorts of safeguards, whether it is patient care advisers, information which is made available to patients. We are trying to do that with the heart patients. From next month every single heart patient will have an identified patient care adviser, usually a nurse, who will be able to talk to them, explain what the choices and some of the dilemmas might be and help them to make an informed choice, regardless of their background. That is the only way we can do it. The NHS will have a facilitating role. It is not just make a choice in the marketplace, it is about how you can ensure that patients make the right informed choice for them, based upon the information that they have and the capacity that is available.
123. You mentioned matching capacity with availability, matching supply with demand and this is the obvious cue to bring in the whole question of information technology, which is absolutely crucial to the reforms you are trying to make. This morning in Birmingham Lord Hunt gave an address which I am sure you know all about outlining the national programme for procurement and implementation of IT for the nation as a whole. He made the very good point that successes in the past two years have been because of trying to take more measured steps and get them right. It strikes me that accelerating the pace and going on to a big bang approach is rather contradicting that. How feasible is it? How realistic is it to connect all NHS staff to the NHS net by March, to have electronic transfer of all biochemical or haematology and microbiology results by next March, which is the claim?
(Mr Milburn) I do not think any big bang is envisaged. The mistake in the past, which Phil touched on in his speech, was that we have had two distinct approaches, one of which was to go for that sort of approach, big bang, Wessex style; everybody remembers the Wessex failure, £50 million and all of that. The other approach has been just to allow local health services to do their own thing on IT procurement. Both have been a disaster in truth in terms of getting the NHS wired and getting decent value for money for the taxpayer. Because of the state of IT in the NHS today, where frankly we are a decade behind where we should be, we have a problem but also an opportunity. What we can do there is learn from some of the past failures which have taken place, not just in the NHS but in the private sector and elsewhere in the public sector, and get a phased implementation in place. You have to get the hardware and software in place, you have to be able to ensure that the systems talk to each other. What that calls for, and interestingly the call has been for this in the NHS too, is for there to be tougher standardisation from the centre rather than just allowing the individual GP practice to do its own thing or the individual hospital to do its own thing. That is fine for the hospital, but when its system does not talk to the neighbouring hospital, or when, worse still, it does not talk to the neighbouring GPs, you have big trouble. Some of this is feasible, but it has to be backed by standardisation, good partnering arrangements with the private sector, because they have the expertise and the public sector does not, and quite a lot of money.
124. I am delighted you are saying that there is not going to be a big bang because that was one of my very severe worries.
(Mr Milburn) No, I do not think that was Phil's intention.
125. It was the impression. You mentioned the Wessex affair and we know that there have been lots of other disasters. Are there really any sufficiently big IT firms to take this on, who have not been blamed for disasters, to have a realistic feel to approach? That is what worries me. Will you guarantee that you will not approach the same firms which have been responsible for Wessex, the Passport Office, the DVLA, RAF Logistics, Air Traffic Control? I can go on and on.
(Mr Milburn) Talking of constrained capacity, there is constrained capacity in the private sector as well. There just is. There is a limited number of big suppliers. You know who they are and I know who they are as well and that is true on both the software and hardware front. For example, we recently did a deal with Microsoft which cost us £50 million but it was far more sensible that we procured the licensing for software for the NHS at the centre rather than every little trust, PCT, GP having to do it, because it saves money and quite a lot of time. They happen to be one of the players in the market. The IT market is characterised by a few big monopoly players, so we are going to have to work with them. What would be a problem, would be if we put all of our eggs in one basket. That would be a problem. We want to keep the benefits of competition alive as far as IT group procurements are concerned.
126. The other thing which worries me is that the South-West procurement, which is way behind its project, was meant to sign contracts in May 2001 and they have not yet even signed contracts, yet although that which was meant to be a pilot has not completed and reported, I gather the same thing has been rolled out to Oxford and Birmingham.
(Mr Milburn) I am sorry, I do not have that information. I shall come back to you in writing, if I can. I am sorry, I just do not know.
127. You will remember on the morning of Budget Day this year the Wanless report was published and the next lunch time you came to the House of Commons and gave a statement launching your own document Delivering the NHS Plan. In paragraph 8.10 of that, it says "We", meaning you and the Government, "have been impressed by the success of the system in countries like Sweden and Denmark in getting delayed discharges from hospitals down. We intend to legislate therefore to introduce a similar system of cross-charging". You then go on to say, "This was also a reform commended by the Wanless Review". Given that the Wanless report had only been published the day before, I was wondering whether you had had an opportunity to read the Wanless report. If you go to paragraphs 6.44 and 6.45 of the Wanless report it does not actually say that they are recommending the reform you are proposing, that is legislation on cross-charging. What the Wanless report actually says is that they had looked at this and although they accepted that sort of system could lead to excess social care capacity, it was something that the Government should look at. That is slightly different from saying you should legislate to do it. They said you should look at it to see whether it is a sensible way to proceed in this country. Why did you disregard or not pay any attention to the Wanless recommendation, but go immediately to announcing that you were going to legislate?
(Mr Milburn) Because we had looked at it. We had looked at it and we did look at it, we had been looking at it over the course of several months. To answer your first question: had I read it? Yes, I had. Yes, I had the benefit of reading it in draft.
128. I assumed you had. If you had read it, why then does your own document put a slightly different spin on what Wanless actually said?
(Mr Milburn) This is slightly dancing on the head of a pin, is it not?
129. It is not if that is the reform recommended by Wanless.
(Mr Milburn) If it asks us to look at it and we had been looking at it and we had looked at it both prior to Wanless and since, I read Wanless prior to Delivering the NHS Plan and then I did look at it and decide it was a jolly good idea and got on and did it, what is the problem?
130. The problem is, and you will correct me if I am wrong, that I am unaware of anyone except possibly a few NHS managers who thinks this is going to be a very sensible suggestion. I do not imagine you have had many representations from local authority leaders, directors of social services or others saying that this is the best thing since sliced bread and we really want you to rush legislation through Parliament to bring in this system, where social service departments are going to have to pay cash to the NHS if someone stays in a bed longer than they clinically need to. First of all I should be interested to know whether you have had any representations from outside the NHS saying this is a wonderful plan. Second, if you had not announced legislation immediately and relied solely on your own judgement on the issue, you would have been able to consult and get a broader range of views. Third, you as a Government and my Government previouslywe started it, you have continued it to a much more natural conclusion because of the timehave sought to break down the barriers between social services and the NHS in dealing with the problems of delayed discharge. To be fair to you, you have made great strides there and I should have thought, given that you are seeking to provide a seamless service with these two historically different organisations working very closely together to get over the problems, that to start bringing in a system of charging is going to start undoing a lot of the good work which has been done. I am just perplexed that you think it is going to work and be a constructive way forward and why you did not consult on it.
(Mr Milburn) Let me deal with the representations and then come to the thinking behind it. In terms of how this has been progressed, to make it work and to get the legislation right we need to work with local government and directors of social services and the NHS and that is what we are doing. Initial meetings have taken place to facilitate that. In terms of representation, I can tell you where I get a lot of representations from: I get a lot of representations from Members of Parliament and members of the public concerned about « to use the pejorative termbed blocking, which is an expression of failure not success. People want a solution to that. That is what they want. Most people would never have heard of the Scandinavian model and if they hear those words they probably think of Ulrika Johnson rather than cross-charging. What they are concerned about is how health and social care work together. The Committee have been concerned about that, I am concerned about it too. I can tell you what I have found about this. When you take a slight step back and look at it, where partnership arrangements are workingand as we know they work pretty well and that is greatit is a real lottery. It really does depend very often upon simple things like local personalities. How well the director of social services in your area and how well the chief executive of the primary care trust and the chief executive of the hospital get on and whether they can agree with one another. That is fine in those areas where it works, but what we are talking about here are vulnerable elderly people, people who are over 75, who are needlessly stuck in a hospital bed for no apparent reason. As it happens delayed dischargesbed blockinghave fallen. It is falling for good reason: there is more money going in. It is falling from the position we inherited in fact. It is, and I am very happy to share the figures with you. I feel the need to share the figures with you but I shall do it in writing to save time. What you do not have, when you look at the system, is anybody within the system taking responsibility for the problem. It is neither the NHS problem, nor is it the social services problem, it is nobody's responsibility. Let me just finish, because you made an important point and I understand that it looks as though it is going the wrong way, so I want to reply to that. Nobody is responsible. The problem is the poor elderly person who falls through the gap. What we know from Scandinavia, and not just from Sweden but other countries too, is that when you get the incentive in the right place such that you provide, in this case, the local authority with the control over the budget to deal with discharges of patients in an appropriate way, provided you can get the incentive right, it gets the delayed discharges down. Point one. Point two: it does so in a non-punitive fashion. People talk about local authorities being fined. That is not what I want to achieve. What I want to achieve is one organisation rather than two or three having sole responsibility for dealing with the elderly patient at the point at which they are clinically ready to leave the hospital. They will have control of the budget such that they can then spend the budget in the right way and provided they are able to hit the appropriate timescale. People should not be stuck there after they have been determined to be ready to go and if they are ready to go, why should they sit there for three weeks? Over 50 per cent of these cases are waiting over 14 days now for discharge, although that too is coming down. Why should they sit there? What we shall do, is we shall set, as in Sweden, an appropriate timescale, based on our discussions with clinicians and with local government for how long it should take. If the local authority can exceed that, and in a lot of cases it will, because I think that local authorities can deliver this once they are given the responsibility for it, if they have the budget and if they exceed what they should do, that means they have free money from the pot they are given, that is free for them to spend. If, however, they fail to do so, and the consequence is that the NHS absorbs the cost, then the local authority will have to pay for that. What do I think will happen? What I think will happen is that the local authorities will succeed because the incentives will be in the right place. I think it will strengthen and not weaken the partnership arrangements. Partnerships work when there is a clear understanding about who does what. When there is uncertainty, that bedevils partnership and that is what we have had.
131. What happens then in circumstances where in an area there are no beds for someone to go to from hospital and it is not suitable for them to have a domiciliary care package and go home? What happens to them if there is an argument between the clinicians and social services about the individual concerned and whether they both agree that the person is fit to be discharged? Finally, I am not sure that I am as optimistic as you are about the impact this is going to have on relations between health and social services. If you are unhappy that in some areas the working together has not moved forward as much as you wantedI am not suggesting this should happen, I am just askingwhy did you not consideryou may have doneas part of the consultation process unifying the process so you do not have the split between social services and the NHS in long-term care but bring it under one umbrella to eliminate the cross-tensions?
(Mr Milburn) If you read Delivering the NHS Plan, the chapter on relationships between health and social care, read the last paragraph. What we say there is that we think this is the right way forward but we do not rule out in the future more radical solutions. We think this is the right step to take for now. I think it is a step which will work. You might disagree with that. We shall find out in practice what happens. All I would say is that sometimes there are important lessons to be learned from the practice, the evidence, the experience from elsewhereand people make a lot of experience from elsewherefrom Scandinavia and when there are important lessons which can be learned and are translatable, let us translate them and let us make the European model work here. That is what we are going to do with this. In terms of the question you ask about who decides the patient is fit for discharge, multidisciplinary working is a great thing, although it has down sides because there are many players on a small playing field. We are thinking through that and trying to work through it. In the end, where we shall get to, is a position where the crucial decision which has to be taken is whether the patient's treatment is finished, whether it is safe therefore for the patient to leave the hospital. That is one decision and that must properly be a clinical decision, probably a decision by a doctor, maybe by a nurse, I do not know. That must be their decision. There is a separate but related set of decisions then about where people can go to. Part of the reason for increasing the social services budgetand last time I was here we were talking about thatpart of the reason for giving reasonable increases in social services funding, is precisely to deal with some of these capacity problems which we have. We have to increase capacity. The news there is quite good. Some of the money we put out, the £100 million and then £200 million, is making a difference. The number of delayed discharges is coming down, more beds and places are being bought, fees for care homes are being increased by a lot of councils, that is helping to stabilise the market and there is interest about bringing new players into the market too. On all of those fronts, extra resources will make a difference to capacity.
132. Nonetheless, Secretary of State, we have been conducting an inquiry into delayed discharges for the last few weeks and we have heard evidence from the voluntary sector, from National Health Service bodies, trusts and so on and from social services and local authorities. Not one single person has had a good word to say for the plan you have outlined. Do you think that is because they do not understand it, because of innate conservatism or because you have just not managed to sell it properly?
(Mr Milburn) It will probably be my fault, I would imagine; most things are. I do not know why that is. Those organisations have to speak for themselves. I have to decide what I think is right.
133. How can it work if there is this kind of opposition?
(Mr Milburn) The Local Government Association have expressed concerns. I hope the LGA and the ADSS and some of the voluntary sector and the NHS Confederation, all organisations which have expressed some concerns about this, will be, and I think they are going to be, working with us to try to make the thing work. I hope that is what will happen. We have had initial meetings with them, but it is like everything in politics, in the end you have to decide what is right and that is why I am here and I shall be held to account. If it goes wrong, it goes wrong, if it goes right, it goes right. I am confident it will go right based on what I know about it. Those organisations and individuals who are concerned about it should really go and look at the evidence and see for themselves. It is not perfect and the Swedes themselves will say that there are very important lessons to learn from some of the problems they have encountered. The good thing about being behind, if there is a good thing about being behind, is that we can learn the lessons.
134. Do you believe that waiting time targets for all conditions need to be underscored by an explicit duty on clinicians and NHS managers to prioritise treatment according to clinical need in order to prevent waiting time targets distorting clinical priorities?
(Mr Milburn) The guidance, which I think you had as a Committee, but maybe you have not, which dates back to Simon's time rather than my time in Government, explicitly talks about treatment according to clinical need more than clinical priority. I cannot remember the phrase, but I am very happy to send you what there is. There is something there already.
135. Critics have argued that current Government policy concerning cancer referral has created a two-tier system and may in fact have increased the length of wait for some cancer patients. Should the two-week target for seeing urgent cancer referrals be extended to all patients referred with suspected cancer? I have examples of where it happens.
(Mr Milburn) The first thing we did was put the two-week cancer wait in. Why? Because we got far too many reports of people who went to the GP, suspected cancer, told it was going to be months and months before they could see somebody in Outpatients, which is just dreadful. Most people think that is dreadful; I think it is dreadful. A two-week wait and that is now being achieved in 95 per cent of cases. In the cancer plan which we published subsequent to the two-week cancer wait pledge, we then set out a further rolling series of improvements. Back to Simon's point about milestones and targets. Those include the time from being seen in Outpatients, getting treated and then in time from GP referral all the way through to treatment. From December last yearI think this is right but I shall correct it if it is wrongthe time from referral to treatment for children's cancers, acute leukaemia and testicular cancer was one month from point of referral to treatment. The big problem is around the diagnostic side of things, scanners and so on, it is not the capital, it is not the equipment, it is the staff that we desperately need, that is the big problem. What we are moving to as we get the capacity in is a situation where, rather than having fragmented targets, from the point of GP referral to Outpatients and then from Outpatients to treatment, we have one time for those particular conditions. We started to role that out and those targets are in the NHS cancer plan.
Mr Amess: If we have the Secretary of State back on another occasion, I want to ask about screening for prostate cancer, because it is Men's Health Awareness Week and we are supposed to be geeing up. I also want to ask about hepatitis C.
136. Towards the beginning of the NHS Plan is a statement about NHS Direct, "A single phone call to NHS Direct will provide a one-stop gateway to healthcare to give patients more choice about accessing the NHS". Are you aware of the tremendous concerns that NHS Direct probably is not working terribly well? What I have here is a briefing paper from the Secretary of the National Association of GP Co-operatives. They say quite clearly that they are going to end the partnership with NHS Direct at national level because none of the exemplar sites are saying the system is working well, some more vociferously than others. One has left, another second wave site is not going ahead. The targets set in out of hours review are not achievable and are not sensible. The single call access for patients is not working and has never been adequately sorted out. Are you aware of this? If you are not, will you become aware of it and take on that this flagship, NHS Direct, does not appear to be working for the people who are trying to use it?
(Mr Milburn) I am not aware of the letter from the GP Co-ops. Is it from Mark Reynolds?
137. Yes, it is from Mark Reynolds.
(Mr Milburn) I have not seen Mark's letter, so if you could send me a copy. Is it to me or to you?
138. No, it is a briefing paper from one of my local GP co-operatives.
(Mr Milburn) Let me see it and I shall have a look at that. I do not think you were trying to do this, but it would be unfortunate if the impression were being given that NHS Direct was not working. NHS Direct is a very good thing.
139. The impression I am getting is that it is not working.
(Mr Milburn) It works for millions and millions of people and gets them access to healthcare and healthcare advice.