Select Committee on Science & Technology Minutes of Evidence

Examination of witnesses (Questions 20-39)



Dr Turner

  20. Minister, in planning for financial year 2001-02 how were health authorities expected to define how much of their allocation was new cancer money when they were given no money information about it whatsoever as far as I can tell?
  (Ms Blears) They were given guidance, in fact, about their priorities for their planning. Mike will just talk about that.
  (Professor Richards) In addition to the detailed list of planning there, the priorities and planning framework or priorities and planning guidance, which goes out roughly speaking at Christmas time in the year before—

  21. This is it.
  (Professor Richards) The short document there for that year, to the best of my memory, actually made it clear that £255 million was hypothecated and the word hypothecated was specifically used that year whereas the word earmarked has been used for the current financial year. The word earmarked, as we have discussed in this Committee before, I think, is a stronger word than the word hypothecated.


  22. Ring fencing beats it all, does it not.
  (Ms Blears) Indeed.

Dr Turner

  23. It was not only earmarked for 2002-03—we are still only talking about £76 million out—but each health authority was given a figure as to what their share of the £76 million was. No health authority could possibly have accurately worked out what its share of the £255 million in the previous year was which is then running through and building up.
  (Professor Richards) They could not perhaps have had the same level of detail, except to say that £255 million spread between a population of £50 million, they could have done a rough estimate and they could have been able to divide one by the other and get it being £5 million per million residents. What we saw then was that they had to complete their service and financial frameworks and, broadly speaking, the service and financial frameworks did suggest that money was going to get through to cancer. We think in the end it has not which is why we are now trying to find out retrospectively what actually reached the cancer frontline but the service and financial frameworks at the beginning of the year did give us confidence that the money would get through.

  24. Do you see our problem, Professor Richards and Minister, because although the exposition book mentions things which are not exactly headline as far as the public is concerned, cost of living supplements hardly even match the profile of the cancer plan and yet the cancer plan does not get a mention. It seems very strange and it seems quite logical then that it was not mentioned, whereas it was for this current financial year and this financial year the money is getting through but it is only a part of the money. So, on the face of it, unless I can find evidence to the contrary because I know it is certainly not true in my area, the £255 million has not got through, it has not led to an increase in front line services. So the cancer plan is going to end up being only about 50 per cent funded.
  (Ms Blears) I think it is important to say to the Committee that obviously we share the concerns about money getting through to the front line and that is why we have set up a monitoring mechanism for us to be able to drill down in each cancer network and for them to report to us on what they actually got for their money. I think I would want to couch that in terms of saying that what we want the service to do is to deliver the cancer plan and that means the targets, the increased operations, the increased consultants, the extra workforce, the extra facilities. Therefore if they are able to deliver the outcomes that we have set—very important outcomes for patients and the public—then there is always going to be a tension if we devolve money down to people about delivering on that agenda. At the moment we are satisfied that broadly speaking we are on track with the outcomes we have set in the cancer plan. Therefore I would share your concerns if we feel we are slipping behind with achieving the things the public want us to do. I think we have to just bear in mind this is not a process of an exact follow through of every single penny through the system and seeing what it does because some of that may be absorbed in infrastructure and properly so. I think we have to be a bit flexible with it but I do understand your concerns.

Geraldine Smith

  25. Surely you cannot have it both ways. If there is £407 million almost for cancer for 2002-03 and you have only earmarked £76 million then basically the health authorities can surely spend the money on whatever they want. What happens to the £331 million? Why do you not issue an instruction to them that it has all got to be spent on cancer if that is what you are promising to spend as part of the plan?
  (Ms Blears) I understand the point you are making but I think it does bring me back to what I have just said and that is that if we insist on ring fencing every bit of our expenditure, whether it is on cancer or anything else then we will have a very centrally driven and centrally controlled system which says to health organisations that all the money is in silos for expenditure and if you spend anything outwith that then it is somehow against the system. I think we have to balance that with wanting to devolve the power to the health service to deliver on the outcomes. You said what would happen to a health authority which did not do it? If a PCT and a health community are not delivering on the outcomes that we have set in the cancer plan that is their responsibility, to deliver the increased services, the better palliative care and all the facilities that we have set out in the plan and that is what they have to deliver.

  26. So are you saying that the £407 million has not been promised for cancer care, that it can be spent in other areas as long as they have suitable outcomes at the end of the day? Is the £407 million for cancer or is it not?
  (Ms Blears) Yes, it is. It is extra money to support the outcomes in the cancer plan which is what we have said all along.

  27. Do the health authorities have to spend that money on cancer?
  (Ms Blears) Yes they do in their planning guidance and in the priorities that they set but what we have done—because we recognised there were concerns about the dilution of the funds in the first year—we have said now that £76 million of that will be earmarked which is quite a strong mechanism for saying that we want to see this directed specifically to cancer care. We have got, also, £76 million which is centrally allocated which is an even stronger mechanism from the centre. So you have £76 million centrally allocated on the networks, you have got £76 million earmarked which has to be spent specifically on the front line things which clinicians and nurses have identified and then you have the base line budgets for the organisations which includes the extra money for cancer care from last year, this year and next year. So there are a range of levers here. It is not simply that we would want to ring fence every bit of cancer money because I do not believe that would deliver the best outcomes for the patient. It is a matter of getting that balance right, I think.

Dr Turner

  28. Minister, we seem to be a long way from a balance because so far over two years about £500 million has gone in which has not come through in terms of extra oncologists or facilities or whatever, to the best of my knowledge. This is rather a large slice of money which would show, certainly my local clinicians would be able to tell me and they cannot, which is why they have raised the alarm. It is no fault of the health authority because, to be fair to them—and I have criticised them often enough in the past—they have passed on more than their allocation of the £76 million.
  (Professor Richards) I think we are all reasonably confident that the additional £127 million this year is going to go through.

  29. That is not a problem.
  (Professor Richards) The question is about the £255 million that was hypothecated last year.

  30. From last year and this year.
  (Professor Richards) Did that get through? We know, also, that from last year the central funding got through, there is no doubt about that. That is precisely why we are going back to the individual networks and doing this bottom up exercise of saying what did you actually get in terms of services so that we can actually then put money against services to see what we got for that money. Over the country as a whole we have got more consultants and each six months we are monitoring that and the number of consultants is going up in the areas that we have labelled as cancer consultants. Equally, the number of radiographers is not going up as fast as we would want it to go up but that is because of recruitment problems but it is going up.

  31. I am pretty certain even if there is some getting through, in some places you will identify a huge gap. What do you intend to do about that when you find it?
  (Professor Richards) The first step is to find it, identify it, see what it is, see how varied it is across the country because as the Minister has said in some parts of the country probably almost the full amount has got through and in other parts it may well not have done. When we have got a clear picture then we are in the position to make decisions which are sensible about how to rectify the position.

  32. So if you find you cannot account for £350 million of it, will you put in an extra £350 million earmarked or ring fenced or whatever to make sure that the gaps are addressed otherwise the plan falls down, does it not?
  (Professor Richards) It cannot be that much anyway because it is the £255 million that, as you say, we have got to look into and some of that money has got through anyway. I think we need to see exactly what the size of it is and what the distribution of it is across the country in order to make recommendations to Ministers on what we should do next.


  33. Do you think there are any lessons to be learned? The mental health money is the next sum which is going to be sent out. They will come back and say "We are not seeing it either". What are the lessons to be learned?
  (Ms Blears) I think there are lessons to be learned and I think it is quite a complex situation because once you embark upon shifting the balance of power, and actually saying to people at the frontline "We want you to use your imagination and innovation to come up with new ways of doing things".

  34. Sounds like creative accountancy by another word.
  (Ms Blears) I would prefer to see it as creation and innovation in the Health Service which is a very precious commodity because if people are given the freedom to work in new ways and to develop their skills and potential then quite often it results in advances for patients and that is what is important. Therefore giving people the room to innovate inevitably carries with it the risk from the centre that you cannot dictate and dot every "i" and cross every "t" and that is a tension for Government. I think it is one that we should be continually exploring and I am happy to do that with the help of this Committee because I think as this whole programme unrolls where we get PCTs spending 75 per cent of our whole Health Service budget there are going to be tensions between the national standards that we set and the local devolution. Those tensions are not all a bad thing, some of them will actually create that innovation but equally Members are absolutely right to call us back to the fact that we have said extra money will go in to deliver this cancer plan and therefore we have to track that as carefully as we can to make sure we are delivering the improvements for patients.

Dr Turner

  35. Can I just be sure, Minister, in the last financial year, the £255 million was put into the general allocations. Health authorities were not specifically told "You have X million pounds which is your share of the £255 million for the cancer plan"? Were they or were they not given that information?
  (Professor Richards) You are right, that is the difference between the interpretation of the word hypothecation and the interpretation of the word earmarking. That is why with earmarking you see laid out for you exact figures being given to individual PCTs as to what they should be spending. With hypothecated it was the overall amount of money which was known and it was not given to them in that level of detail.


  36. Why do you not just say "We are going to give you £300 million more. Get on and do with it what you like. You know best"?
  (Ms Blears) Because there will be a need, increasingly I think, to strike the balance and that is what this whole process is about, striking the correct balance between, if you like, central guidance and having a very rigid system which does not allow any space for innovation and creativity at the frontline and actually letting go completely and saying "Here is the money, as long as you deliver this many operations . . . it is entirely a matter for you". I think the balance lies somewhere between in terms of setting the national standards which we are doing not just in cancer but across the piece in the Health Service through the NFs—for cancer, coronary heart disease, mental health, older people and children—and saying the public have a right to expect this standard of service but within that to say to local organisations "You might be able to work with other people to deliver some of that. It is not all down to you but here are some resources to enable you to deliver on it". I think that over the next few years there will continue to be a tension and, dare I say it, not just in health but right across the public service agenda about how you have national standards, local devolution, skill mix and choice and all of those factors, will be a complex equation for us. I do not think it is true any longer that A equals B, I think it is a much more complex situation than that.

Dr Turner

  37. Minister, earmarking does precisely that, it is telling the health authority how much money it is getting. It is not saying "You will spend it on this", in fact the Departments words in here are: "you may wish to spend more". So the flexibility is still there, the local decision making element is still there and have you adopted the earmarking process, which you are going through now, which seems to work quite well because of the question marks over what happened to the money in the first year?
  (Ms Blears) Yes.
  (Professor Richards) I think it is true to say that possibly we have learned from our experience in the first year.


  38. This is confession time.
  (Professor Richards) I am not sure I see that as a confession.

Mr McWalter

  39. I will ask first about my own general area but I think it is of wider significance, it concerns the Mount Vernon Cancer Network. A recent report suggested something like £110 million needed to be spent just on building a new facility. These figures look big until you start thinking about that. Then what is your policy? First of all, is some of this money going to say "Yes, one of these things we are going to do is we are going to build a cancer centre"? The second thing is until that is built in a way you cannot use some of this other money very effectively, you have not got the theatres or the oncologists or whatever, so does that mean within a cancer centre like that you will lose out because it will not be able to take advantage of some of this revenue funding because it has not got the right infrastructure in place? Can they hold it back until future times when they can cash it in? How does that system work? I am taking up the reference to infrastructure that the Minister made which I agree with very much but I cannot quite see how that gets factored in then in the appropriate way.
  (Professor Richards) The monies that have been allocated for cancer do include a measure of capital spend related to specific cancer facilities—CT scanners, MRI scanners and the new accelerators—but they do not include money for major capital developments such as the redevelopment of a whole cancer centre. There are those that are going on anyway within the Health Service and they are not included in these figures.

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