Editorial Wednesday 25 July 2012: Interview - Stephen Dorrell MP, Health Select Committee chair
Stephen Dorrell, MP for Charnwood, is the widely-respected chair of the Commons Select Committee on Health. He was health secretary at the end of the Conservative government under John Major, after having been a junior health minister.
Click here for details of The red ties that bind Comrade Sir David: postmodern NHSCB to commission itself (oh yeah, and what cowboy drafted this mandate?), the new issue of subscription-based Health Policy Intelligence.
What is the best piece of work the select committee have done since the election?
Stephen Dorrell: In terms of work that’s had the best outcomes – three bits, I think. The first two were both relatively early, and created some important dynamics in debate.
Our first substantive report was on The Nicholson Challenge (a phrase I now hear quoted back at me, and which was the title of a Times editorial), and we deliberately did it first to focus minds on what we saw as the key challenge, and it had the desired effect of focusing minds, and reinforcing the need for productivity and efficiency – we didn’t invent the challenge; Sir David Nicholson did, but I think we raised its profile.
The second was the set issues around commissioning, and we produced two reports. They both had an effect on the debate, helping change they ways in which governance systems work around CCGs in ways that I hope will be seen in retrospect to have had significant impact on how CCGs develop.
The third was our series of reports around professional regulators, and the importance of strengthened professional accountability as by far most important quality assurance system in healthcare.
You must be looking at the Nursing and Midwifery Council with keen interest currently?
SD: Indeed …
In terms of The Nicholson Challenge, how do you understand that the McKinsey work for DH in 2009 decided on the figure of a £15-20 billion efficiency savings range?
SD: I get to a similar figure, though perhaps by a different route, which was just to look at demand trends in this and all other western countries. You can see over a very long period that the trend for rising demand is c. 4% a year, and if you apply that on the c. £100 billion budget in 2008-9, and imagine no increase in resource, then over 4-5 years, you get something like £15-20 billion.
I’m unsure that there’s a huge amount of value in micro-analysing the method – analysis becomes paralysis. It’s much more important to get on and do something.
How concerned should we be that the latest Kings Fund quarterly survey of Finance Directors and Monitor’s quarterly report show providers drifting away from their CIP / TNC targets, especially given today’s GDP figures?
SD: It’s always been true that system started out relatively liquid – with a fair sum of cash in system, and that progressively as budget growth ends in real terms and demand pressures grow, pressures will grow unless resources are used more efficiently and effectively.
Stress is now being felt in some fairly predictable and some less predictable providers. This shows those effects working through. What is clearly starting to happen is that some providers are facing the need for radical change forced by events, rather than as planned management choice.
Labour have just published some data suggesting that PCTs’ decommissioning and closures of Walk-In Centres and reduction of extended hours and weekend GP access schemes have led to significantly increased use of A&E, at higher cost to the system. Does that seem probably cause and effect?
SD: I’m aware that A&E attendances have just bounced back up again, and I think we need to look further to check evidence for that analysis. But it’s clearly true that for some years now, there has been much evidence of A&E attendances rising as people find it difficult to access care easily, they will naturally use any other way.
Access is the purpose of primary and community care, and services should provide easy access to care and avoid unnecessary reliance on acute providers, through A&E or inpatient care. If commissioners don’t take opportunities for intervention to avoid acute cases arising, then there will be more demand in acute settings - the most expensive and from a patient point of view, worse because they generally don’t want to be in hospital for relatively straightforward health needs.
CCGs are statutory commissioning organisations which must be called ‘NHS + local area name” whose boards must meet in public and who are accountable to Sir David Nicholson for their decisions, and so completely unlike PCTs. (SD laughs.) The CCG authorisation process reminds people quite a bit of World Class Commissioning. What do you think has really changed? How can we make the NHS clinician-led & patient-centred, rather than McKinsey-led & corporate-centred?
SD: I’ve said many times on the record that I think some changes in the Health and Social Care Act are significant changes, and I voted for the Act as I think it was a move in the right direction, but the rhetoric around the Act was grossly overblown, both for and against.
I think it brought three significant changes: 1. requirement for greater clinical engagement in the commissioning process: a good and in fact a fundamental to successful commissioning. 2. a greater engagement with Health and Wellbeing Boards and local authorities in commissioning, not least with potentially greater integration of healthcare and social care commissioning. 3 the transfer of public health into local government.
But apart from that, it’s essentially the same system legislated by Alan Milburn in 2000 and Kenneth Clarke in 1990.
The select committee report was critical of prescriptive nature of CCG board composition Sir David Nicholson indicated movement on the non-conflicted secondary care clinician to Pulse magazine.
SD: We recommended that the NHS Commissioning Board should have broad clinical engagement to its board and through secondary care for two reasons.
These were: 1. to ensure there was genuine clinical engagement beyond the primary care sector in the clinical decisions that commissioners make – a quality issue, bringing necessary expertise and clinical buy-in to changes; and 2. it’s also relevant for a specific application of perspectives of local providers, so commissioners have to look at broad clinical outcome measures and what is good practice seen from a general clinical viewpoint, and the need for managing change in local health economy to get provider buy-in, and the perspectives needed in the commissioning process through broader clinical membership of governance body.
You’ve previously said you’re not sure a SC inquiry needed into whistleblowing is needed. In light of Dr Peter Brambleby’s recent resignation in connection with alleged financial fraud at NHS Croydon, do you think it may be time to reconsider that?
SD: I’ve always sought to distinguish the word ‘whistleblower’ from the broader point of professional accountability.
The issue has two separate angles: for people who are members of a regulated profession, and especially for doctors and nurses in healthcare, but in any professional practice, there is a requirement to report clinical practice that is not good, practice which they see undertaken by others.
Every professional clinician has a responsibility to raise concerns, and we said that we think the CQC, when inspecting healthcare providers, should make it their business to ask how often professionals in this organisation raised concerns about clinical standards. In any other than the tiniest organisation, if the answer were ‘nobody in the last 12 months’, that would seem implausibly good for organisations which are employing human beings. In a large acute provider, the possibility of no-one raising concerns in a year would be very small.
We need a culture when raising concerns is not being a ‘whistleblower’, but means being a good professional. I’m not attracted to a world where individuals raising concerns become oddballs, misfits and meet the ‘whistleblower’ caricature. It should be part of every process of good governance: it should be normal, and not abnormal to raise concerns.
What is the Health Select Committee’s role in holding the NHS Commissioning Board to account, and do you have any concerns yet?
SD: The NHSCB is legally accountable to the Secretary Of State, not the Health Select Committee, and the SOS is accountable to Parliament, and we discharge our function on behalf of Parliament.
We’ve not yet established relationship with the NHSCB as it’s a very new organisation, but I’m sure we shall establish a relationship that asks the chair and CE of the NHSCB to appear on a regular basis to explain the change process (authorisation and bureaucratic accountability) but much more importantly, to look at the impact and how effective the NHSCB are at achieving better outcomes and value improvement - which should be their twin aims.
HSJ reports that the NHSCB is to regulate commissioning support services more heavily, where the previously stated intention was to have more choice and market. Why do you think this has changed?
SD: My instinct, without having studied it at great length, is that the NHSCB needs to be careful here.
I’m strongly in favour of CCGs being accountable to the NHSCB for how they use public money, and to the extent CCGs rely on commissioning support organisations, I’m sure the NHSCB will have a view on the quality of support, but what matters is value and outcomes delivered by system rather than quality of individual CSS.
I am open personally to the idea that a CCG or some CCGs may want some commissioning activity (more likely some than all) to look beyond the traditional NHS structure for commissioning expertise. There is plenty such expertise around the world to teach us how to structure things to deliver better patient outcomes and value.
With Monitor, what is your view about conflict between economic regulator role and provider sustainability role, especially as they can allow providers to charge over tariff without commissioner consent?
SD: This is a subject we shall want to explore with Dr David Bennett. I, and we as a committee, shall certainly want to examine which of the two sides of Monitor will be likely to be the dominant side – both are important activities, and it is an odd mix in the same organisation.
You were the first mainstream political figure to admit to the need for serious provider reconfiguration. You’ve been followed by Mike Farrar of the NHS Confederation and now Terence Stephenson of the Academy of Medical Royal Colleges. How does being a political Jeremiah feel, and what do you think of all other parties’ health leaders’ silence on this issue?
SD: I’ve been quoting Enoch Powell’s famous ‘Water Towers’ speech on closure of mental health hospitals a lot recently! But I’m not a Jeremiah at all: this is about improving the quality of care delivery, so that fewer end up having falls in end up in acute care, more experience integrated diabetes care or support in the onset of dementia. This is about offering a better future. Jeremiahs think there’s only one way: into hospital!
I’ve learnt to live with this over the years. I have formed my own views on what is likely to happen, set out what they are and why I hold them.
And I think there is an increasing recognition across the political spectrum that healthcare delivery is not fit for purpose as it is, and that we will continue to miss an opportunity if we miss this chance to do system redesign.
Of SOS Lansley’s four tests on reconfiguration (clarity on clinical evidence base; support of clinical commissioners; genuinely promoting patient choice; genuinely engage public and local population), only one (commissioner support) is empirically measurable. Is that a problem?
SD: I don’t disagree with any of the four in principle. The idea that in managing any change process, you have to focus on evidence, engage with the community – it’s all no more than common sense.
But it’s important the four tests don’t become obstacles to progress which will deliver better care.
Nonetheless, as a set of reminders of what delivers change effectively, successfully and quickly, it’s fairly right. The obvious danger is that the four tests become excuses for inactivity and small ‘c’ conservatism, which would be against the interests of patients and taxpayers
How should the NHS set about abolishing involuntary waiting for treatment? Targets, or something else?
SD: I’m cautious to promise that we can end involuntary waiting. I think we have to define what is an acceptable standard given the clinical risks involved, but that done, what we all want is to minimise waiting. It’s about ensuring the system is as flexible as possible, using resources as efficiently as possible.
That means two principal things. It’s one thing to be told ‘you’re in a queue and must wait’ when doing so is not good medicine or practice. It’s slightly different to say ‘you have a diagnosis, and you will be treated, now let’s work out how to secure that as quickly as possible’.
Integrating care became a theme during NHS Future Forum, so why were care trust plus such as Blackburn With Darwen not allowed to get on with it?
SD: There was an interesting reply by the Secretary Of State in a Health Select Committee evidence session on the last day pre-recess.
He was asked if, as someone previously said, the care trust idea didn’t get out of the laboratory, and he disagreed with analysis, and he was open to the model, not as exclusive model. And I don’t think it’s the right single model which would work everywhere, but there’s certainly no antipathy from Mr Lansley.
But he changed the law to end the status of local NHS bodies being anything other than a CCG …
SD: But not the concept of an integrated care structure. Indeed, he puts a focus on integration in commissioning as a process to get different bits of the system to work together. He talked to us about looking at different options for different bits of the system, but explicitly care trusts as one form that could be allowed to continue.
What are the consequences of pushing funding social care reform into the long grass, as has happened?
SD: Again, I commend to you the SOS’s evidence to us just pre-recess, where he said that he was open to including clauses in a social care bill next year (if it is in the legislative process) to give effect to cross-party agreement to fund the Dilnot proposals, provided such an agreement could be reached.
He is open to a solution and to re-engage on a cross–party basis to find solutions to write into legislation, so I’ve not lost hope.
As an academic point, I asked him in that session whether, if a local authority and a CCG wanted to constitute the Health and Wellbeing Board as a single budget-holder over a health and social care economy, what answer he would give. Given that there should be due challenge over genuinely integrated pathways of care, and no single solutions, but if that were attractive in a particular health economy, he would have no objection. And I hope that message is heard.
Where do you stand on top-up charges for NHS care?
SD: I’m not in favour of top-up charges. It’s the same in health and education, if you allow top-ups over state funding, you very soon get into the question of how does that justify allocation of the base funding budget?
I’m in favour of a universal system, with the current changes on co-payment - but not of top-ups.
I crowd-sourced some of these questions from Twitter, and the one I can’t not ask is whether you are still not interested in doing the Health Secretary job again?
SD: I’ve never said that I’m not interested, but I have said that I’m not available.