Health Committee

Oral evidence: Public expenditure on health and social care, HC 679
Tuesday 9 December 2014

Members present: Dr Sarah Wollaston (Chair), Andrew George, Robert Jenrick, Barbara Keeley, Charlotte Leslie, Grahame M. Morris, Andrew Percy, Mr Virendra Sharma, David Tredinnick, Valerie Vaz

Questions 502­­ - 667

Witnesses: Rt Hon Jeremy Hunt MP, Secretary of State for Health, Una O'Brien CB, Permanent Secretary, Department of Health, Richard Douglas CB, Director General, Finance and NHS, Department of Health, and Simon Stevens, Chief Executive Officer, NHS England, gave evidence.

Chair: Thank you very much. I am going to hand over to Robert now and leave David to Chair the meeting.

The Chair being called away, Mr David Tredinnick took the Chair in her place.

Q626 Chair: Thank you. Just before we move off the TTIP subject, can I ask you a question myself about this, Secretary of State? Do you think it is fair to say that one of the aspects of TTIP is that they will bring innovative ideas to this country—that they will bring in new ideas on health care from the United States? Is that a fair thing to say?

Mr Hunt: Were you thinking about homeopathy in particular, Chair?

Q627 Chair: I was actually thinking about what the Americans call integrative health care. Where we talk about integrated health care, they talk about integrative health care. In fact, I do not think it is any secret that this Committee was hoping to visit Canada at one point, and I think at Toronto we were going to look at a clinic there, but we were not able to do so for various reasons earlier in the year. I am trying not to be too ideological here, but I put it to you that one of the effects—shall we say?—and not advantages of TTIP would be to bring in innovative processes and ideas.

Mr Hunt: What TTIP is really trying to do is to remove hidden barriers to trade. It is not trying to second-guess Governments about whether services are provided by the state or by the private sector. The broader point here is that opponents of TTIP have turned this into a public versus private battle, and I do think it would be a mistake for the NHS to close its eyes to the innovation that happens by people who are not formally part of NHS structures. There is a huge amount of innovation in the voluntary sector, in the private sector and inside the NHS. If we are going to succeed going forward, we have to be open to innovation wherever it happens.

Q638 Chair: For the record, can you tell the Committee how much above flat real the spending would be? You just mentioned it being beyond flat real.

Mr Hunt: It is about 1.5—

Richard Douglas: Over this spending period it would be around 4% real terms growth overall at the end of this year.

Q639 Chair: Over what period?

Richard Douglas: Over this Parliament it is about 4% real terms.

Q640 Chair: That is a 4% increase above flat real in this 2010 Parliament.

Richard Douglas: Yes.

Chair: Thank you very much.

Q646 Chair: Staying with transforming care for a moment, witnesses have warned us that transforming care may produce benefits in the quality of care for patients and service users, but it does not necessarily bring savings or efficiencies. You touched on this in the questioning from Grahame and you might expand on it. Do you agree with the proposition that transforming care may produce benefits but not necessarily bring savings?

Simon Stevens: It depends on what we mean by savings and what is the counterfactual. As we were just talking about with Mr Morris, when we did the modelling on the pressures that the health service would continue to face over the next five or six years, we looked at the likely increases in demand in patient need that would present based on the growing population, an ageing population and the availability of new treatments, and then compared that with different funding levels and identified the gap. We are not saying that we need, as it were, to cut services or take cash out to the tune of 2% efficiency. We are saying we need to be able, in an expanding cake, to absorb some of those pressures through better ways of doing things, through new ways of working. I cannot remember whether we have previously discussed this or whether it was with one of the other Committees, but the Nuffield Trust, I think, for example, project that, if we carry on doing the same old, same old, then over the course of the next five or six years we would need 17,000 more in‑patient beds just to deal with the extra emergencies that would show up, which is equal to 34 hospitals. We do not have to build those 34 hospitals. That is a choice. What is going to be the nature of the care that we provide?

Our choice is, instead, to redress some of the imbalance in out‑of‑hospital services, including primary care services. Using the £250 million—£1 billion over four years—to kick- start that process will, I think, improve the quality of care and, as the Royal College of General Practitioners have just shown with a report they themselves have commissioned, will offset a lot of that extra demand going into hospitals. They published that report 10 days ago. It makes that case.

Q647 Chair: What troubles me overall is that there is an emphasis on increasing supply and not enough emphasis in our general health strategy on reducing demand. In our exchanges earlier in another meeting, Mr Stevens, we touched on Public Health England's view that we should be dealing with risks rather than conditions. Duncan Selbie, in his paper which was published at the same time as your strategy document, said that we should be focusing on five key risks, starting with tobacco; the second is blood pressure; the third is diet; the fourth is lifestyle; and the fifth is alcohol. Do you feel that that is the correct strategy and, if so, how are you going to incorporate the philosophy that Public Health England have set out?

Simon Stevens: Yes. I completely agree that is the right strategy, and, of course, the NHS Forward View was co‑authored by Public Health England. As you recall, it was Public Health England, Health Education England, the Care Quality Commission, the Trust Development Authority, Monitor and NHS England—all six of the national leadership bodies of the NHS—that came forward with this document for the NHS. PHE are saying that the extent to which we can make greater progress on the prevention agenda will offset what would otherwise show up as the need for new supply in the health service and so that all counts towards our 2% or 3% efficiency that we need.

A number of us have been speaking at another meeting today, Britain Against Cancer, which the all‑party parliamentary group on cancer has been sponsoring. One of the points that we have been making there is that over 40% of cancers are potentially preventable through tackling tobacco, obesity, exercise and alcohol. The extent to which we get serious about that will, in turn, help offset the demands that will show up for funding in downstream health services.

Q648 Chair: When you came before the Committee, Mr Stevens, last time, you very generously shared your personal experiences of working in the United States when you told us, if I recall correctly, that the company you had been working for offered financial inducements to reduce weight. You told us that you had actually been on that scheme and lost a lot of weight.

Simon Stevens: Three stone.

Q649 Chair: Would you then—presumably you would—be very much in favour of financial inducements to reduce these conditions, which are costing the health service a fortune?

Simon Stevens: We should certainly be open-minded.

Q650 Chair: In the workplace.

Simon Stevens: We should look to test these models in the workplace. I know this can be a controversial topic, but I am certainly going to be next week with a group of NHS staff and employers in Sheffield who are already making progress on this workplace health agenda. I am going to be discussing with them what their successes have been through different approaches. I do not think there is one particular recipe that we should be mandating across the board, but that is something that, yes, the NHS as an employer, as a healthy workplace and as an ambassador for the broader sorts of changes we want to see across the workplaces of this country, needs to get serious about.

Q651 Chair: I have two other questions to ask on different but related subjects. What is your view, Secretary of State, of the use of properly regulated practitioners who are not necessarily doctors or nurses in the national health service? I am thinking of the groups that are now regulated by the Professional Standards Authority and, in particular, the acupuncturists, who have just been brought under the regulation and oversight of the Professional Standards Authority. Also, Mr Stevens, we had an exchange about lower back pain, and I think you said—

Simon Stevens: We did, and I am very supportive of acupuncture in that context.

Q652 Chair: I think you were really arguing that it should be widened, whereas, of course, the use of acupuncture in China would be used for so many more conditions, and they would argue they have 2,000 years of usage. It is often put to me by conventional practitioners—or has been over the last quarter of a century in this House—that they cannot refer to complementary practitioners because they are not properly regulated, but most of them now are properly regulated through the Professional Standards Authority or the Complementary and Natural Healthcare Council, which is itself regulated by the Professional Standards Authority. The Secretary of State touched on homeopathy, which I happened to have been debating on the "Today" programme yesterday morning. You might have heard my exchanges with Lord Winston, whose wife follows homoeopathy as her mother was a homeopathic doctor; we had that out in our exchange. If we are going to regulate acupuncturists and now the Society of Homeopaths—2,000 of them—who are non‑medical homeopaths, what is the point if we do not make greater use of them? Surely we have to trust the practitioners. The doctors who are homeopaths have been regulated not just by the General Medical Council but they are double-regulated by the Homeopathy Act 1950. Parliament specifically brought in an Act of Parliament. We have had this enormous weight of campaigning against them by a very small number of people, but these therapists are properly regulated. So why are we not using them to reduce demand for services and to take the weight off doctors and surgeons?

It is a very long question, but, as you know, it is something that is close to my chest and I was not expecting to be in the Chair and have the opportunity to not be called to order.

Mr Hunt: I have thought about these issues a great deal, not least because I know that you will always be very consistent in asking me about them. There are three points about this. The first is that we must be open to the scientific evidence and follow that evidence. That is a very important principle that everyone would subscribe to. We need to make sure that we follow what the evidence says is going to work in particular cases. Secondly, we need to make sure that the public are safe. That is why I welcome the fact that increasing numbers of alternative medicine practitioners are being properly regulated. Thirdly, with respect to whether or not an individual patient receives that kind of treatment, in the end that is a matter for their GP to do. There are GPs who prescribe homoeopathy and GPs who prescribe acupuncture, but the system we have is that we allow GPs to decide whatever they think is in the clinical interests of their own patients.

I do not want to give you false hope, but one thing that is quite interesting is that GPs are taking a broader view of what the appropriate thing to prescribe is. We are seeing a big growth, for example, in social prescription, where GPs are saying things such as, "The root cause of this person's problem is isolation and loneliness, and so, effectively, I am going to prescribe that you join a lunch club," or something like that, "to make sure that you have company in your life." We need to be open-minded to CCGs which say, "This is the kind of thing that is going to help deal with the root causes." There are other CCGs that look at housing problems, which have been sorting out the damp in someone's flat because they have realised that is a root cause of some of the problems they face. The NHS is taking a more holistic view of what it takes to address people's medical problems than it did before and I do not think that is something we would want to stand in the way of.

Q653 Chair: There are two intellectual issues here, if I may call them that, in not very elegant English. The first, going on from what you are saying, is that, with complementary medicine, the practitioner is asked to provide scientific evidence that it works—double‑blind placebo‑controlled trials. But the same standards are not applied to general medicine. There are a lot of products out there that have not gone through that rigorous process.

Going on from that, to go back to what I was saying about regulation, if you have properly‑regulated practitioners—for example, homeopathic doctors, acupuncturists or the Society of Homeopaths—surely you can trust them, particularly given their safety record, which is extremely good, and the oversight, which is extremely strong. Why do we have to say to them, "What you are administering has to be tested in such a way"? The Medicines Control Agency and the other agencies are never, ever going to be able to test all these products. So what is the point of having properly regulated practitioners if you do not leave them to get on with it?

Mr Hunt: The regulation helps to address the second issue that I raised of the three issues, which is: is what someone is offering safe? That is the bit that you hope effective regulation will deal with. It does not necessarily deal with the question of whether a course of treatment actually works.

Q654 Chair: Is that right?

Mr Hunt: The sensitivity here in terms of NHS money being used for these treatments is that we are now not allowing all treatments that we know scientifically work to be made available on the NHS because no health organisation can say that absolutely every single medicine that works is going to be available in unlimited quantities. That is why it is the sensitivity to start making it much easier for people to access alternative medicines.

Chair: I am very grateful for your reply. We are going to move on. We are nervous that we might lose our quorum, for various reasons, to do with other Committees in the House. Thank you for those exchanges.

Science and Technology Committee
Oral evidence: Current and future uses of biometric data and technologies, HC 734
Wednesday 26 November 2014

Members present: Andrew Miller (Chair); Jim Dowd; Stephen Metcalfe; Stephen Mosley; Pamela Nash; David Tredinnick

Q5 David Tredinnick: Good morning. Some of my questions will cover partly what has already been discussed.
What evidence do you have that public acceptability of biometric technologies is resting "on a knife edge"? Putting it another way, how finely balanced is public opinion in favour of or against biometric technology?

Professor Amoore: It is extraordinarily difficult to make judgments about public opinion. Usually when you see these kinds of surveys, the kinds of questions that are asked are, "Would people be satisfied with the submission of this biometric in return, for example, for greater border security or for greater integrity in terms of their identity—identity theft protection?" One of the difficulties with making assumptions about public acceptability is that we tend to tie the biometric to a promise and that promise is not necessarily deliverable. What gets lost in that public debate is that it is a probabilistic science, and it is never going to offer complete border security or complete protection from identity theft.
I would need to be more convinced about the way those questions are asked of the public. Something very specific would need to come out, and that would be the extent to which biometric technologies are now about automated recognition. That is an area where there needs to be greater public debate about the relationship between machine recognition, algorithmic decisions and the intervention of a human person.
That is a matter also for the Government, of course. Where we see electronic borders and automated border controls, the promise is that you can have 10 automated gates reading your biometric chip and your passport, supervised by a control room, or by one border guard instead of 10 border guards; that promise is being made about security on lots of levels. The question is whether trust in the biometric would involve some understanding of the role that biometrics play in that broader system.

Q6 David Tredinnick: I have been through the new terminal 2 at Heathrow, which was a wonderful experience because it was so fast. That is because of the biometric screening, which is on the positive side.
What sort of impact do you think is made on public opinion by stories such as the one in the papers last week of Russian hackers being able to view home security videos of somebody in their own bathroom? What sort of impact do you think that has on public opinion, and do you have any suggestions as to what can be done about it?

Professor Black: That is a very big question.

David Tredinnick: It is a difficult question. It may be an impossible question, but we are here to ask questions.

Professor Black: It is about fear.

Q7 David Tredinnick: People are worried and frightened.

Professor Black: They are frightened. One's security, one's identity, is one of the things that people probably hold most dear to themselves, because it is the representation of self. The willingness to hand that over and entrust it to somebody also has the implication that there will be others who will not be trustworthy but who will want to enter into that space that you have. Every time we have media scare stories, true or otherwise, they chip away at the public confidence in our ability to hold our identity secure and who we are going to trust to hold it. It is very much about trust and fear.

Q8 David Tredinnick: The problem is that the absolutely trustworthy organisations that we believe in are absolutely trustworthy until they are hacked.
Professor Black: Yes.

Q9 David Tredinnick: I have spoken to one colleague this week, who is on a very sensitive Committee, which involves passing information to other people. He is not using e-mails; he is using the post. I put it to you that we have reached a point now where we are going to have to go back to the past to get security, because there is no security with Governments hacking into systems.

Professor Lodge: This comes back to the earlier point that there has to be trust in the technology. There has to be trust in the biometric application. There has to be trust in the procedures that are used for transferring the data or reading the data, which may be the weakest link in the chain, and the way in which the data is handled. You spoke about public trust. Any breach in any of those little areas is going to have far more of an effect on the public belief in the system than one might expect.
The other thing is to make sure that people do not think that the biometric is foolproof. It is not foolproof. It may induce convenience, speed and efficiency gains, but it does not necessarily produce the high degree of certainty displayed.

Q10 David Tredinnick: Do we then have to divide or categorise the safety of others? We can use it for border control, where you have a supervisor; it is a great aid there. But there are some things that it cannot be used for satisfactorily. Is it not part of the problem that we are not properly differentiating the risk levels?
I do not want to occupy all of the Committee's time, but I have one other question to add to that. What efforts do you think the Government have made to engage with the public about biometrics since the ID scheme was scrapped in 2010? Do you think that the Government have been engaging properly with the public since its scrapping, which some would call a fiasco?

Professor Lodge: No.

Q11 David Tredinnick: Would you expand on that, please?

Professor Lodge: There is a little bit that is done through the introduction of biometrics in schools, where people frequently do not have the choice. In theory, they have a choice as to whether the children provide a fingerprint for registration, library books and payments. They know a little bit around that, but they do not necessarily make the inference that it is about electronic ID management.

Professor Black: I go back to your point about whether we have to go back in time. The answer is that probably we do. If we are moving so fast that we are running to meet commercial needs and security needs, have we forgotten the scientific base line? I wonder how much core science we still have to go back to and look at. If we do not do it now, will we ever do it? We run the risk perhaps of failure at a later date, when we ought now to go back and look at the foundation. Now that we understand the market better, do we need to go back and give it a stronger foundation? You are right in that respect.

Q26 David Tredinnick: Following on from what Stephen said—he has covered some of the supplementaries that I wanted to ask—it seems that one of the key issues is the human factor—the irresponsible user use of systems.

Professor Lodge, you talked about unanticipated use of biometric data. We could substitute, could we not, the irresponsible use of biometric data? Professor Amoore, you talked about internet online abuse. Is not part of the problem something that Stephen touched on? That is the tendency for people who are using e-mails to be trigger-happy. It has become a culture where it is such fun to press the button and forward something that is of no business to another person. It is a sort of chit-chat thing.
That goes back to what I was saying about using the post; you do not write an envelope and stick a stamp on it to send something unless you really mean to do it. Overall, if we are going to be successful in managing biometric data in e-mails and in stopping abuse, we need to have much more emphasis on human usage and teaching people how to do it.

Professor Black: It is about human education. We run a course with our students, and it is amazing when you go online exactly what you can find out about them; they are shocked that you can retrieve all that information about them. It is because they have almost a laissez-faire willingness to share everything and anything. There is a public education element as well. It is not just a nefarious use of information: it is a glib and laissez-faire approach.

Q27 David Tredinnick: Correct me if I am wrong, but I think the hackers who got into the celebrity websites looked at all the likely passwords that people would use—dates of birth, name of dog, name of street, all the simple things—which was clearly their downfall.
We went to the forensic labs when I had just joined the Committee. I remember poignantly our forensic experts saying how essential it is that people use obscure passwords. It is fundamental, but people are not doing it. A lot of this is just human nature, us being lazy. When we went into Libya, there were some special forces who were captured, and they had their passcodes for computers on them. That was absolutely against their training, and it caused all sorts of problems. I am not saying that they were ours, but it was a country's special forces.

Professor Black: It is about the fact that, on a day-to-day basis, we want to gain access and do not want to be inconvenienced. I can barely remember one password, let alone three, four or five. We become lazy and careless. It is a trade-off that the public often make to ensure that they gain access to do what they want to do. We know that we should not do it, but we all do.

Professor Amoore: It is for the convenience of the public, and it is also convenient in terms of governing various spaces. If you think about the smart cities agenda or the smart borders agenda, that is about trying to generate efficiencies by looking at various data sources and managing the flow of traffic or the flow of people using that data. The question of facilitation and convenience is part of this.
It is linked to how we live, and that is why these questions are so pressing. We live in a world where we want greater facilitation, and we want to be able to move. You mentioned terminal 2 and said what a great experience it was to move through that space, but in the background to your moving through terminal 2 were a series of automated algorithmic decisions about what sort of risk you posed as you moved through that space. Both of those things are involved.

Professor Lodge: One has to look at what you were saying about cyber intrusion. That is a big area of public ignorance. It exists on public misconceptions as to the balance between legitimate surveillance of some description and the kind of laissez-faire intrusion and laissez-faire approaches to privileged access, controls to one's own account and all kinds of other social media data that one may access.

Q33 David Tredinnick: Sir John, just going back to what you said—I am a member of the Health Committee as well—would you, please, write to the Chair of the Health Committee, Sarah Wollaston, about your views on biometrics for the health service?

Sir John Adye: I would be delighted to do so.

Q34 David Tredinnick: Thank you. Secondly, when you said that identity cards were cancelled for good reason, you went on to say that the Cabinet Office was not doing something, and I did not quite catch it. You said that they were doing some things but there was something you picked up that they were not doing. Can you tell us what that was, please?

Sir John Adye: Yes. I should make clear that it is not intended as, in any way, a criticism of what the Cabinet Office is doing.

David Tredinnick: Of course not. Just let us know what you think.

Sir John Adye: They have got to start with what is essential for putting in place an identity assurance programme for the delivery of public services in this country. They are making excellent progress with that relating to things like drivers' licences, tax records and whatever, which will be dealt with under the programme which is now in the initial stages of being rolled out. It was just an observation that, at this stage, none of the systems that I am aware of which are going to be provided under that programme use any form of biometrics. I may be wrong. There may be others of which I am unaware.

Q35 David Tredinnick: Thank you. It is just that you were the Director of the Government Communications Headquarters, so your views carry a lot of force, if I may say so. Could you tell the Committee if you think that biometric data is more valuable than other data that can be used to identify a person, please? Is biometric data inherently more valuable than other data that can be used to identify a person?

Sir John Adye: Yes, it is.

Q36 David Tredinnick: Would you explain why, please?

Sir John Adye: I believe that because, as came out from the three professors on your first panel, there is this absolute tie to the physical characteristics of the people. It depends on the form of biometrics, because biometrics can change over time in certain physical characteristics more than in others, but there is that absolute tie to the individual's inherent physical make-up or behavioural make-up. There is nothing that can easily be lost in that, such as a pin or a password. There is nothing that can very easily be faked by a criminal without the criminal being subject to the developing means of ensuring that the biometric credential is being submitted live at the time of transaction. For those reasons, I believe biometrics do add something.

Ben Fairhead: It is a deeply philosophical question because it depends what you mean by value.

Q37 David Tredinnick: I can help you there. Does it do the job better than other systems in terms of improving security? That is what we are trying to get at, is it not? It is not philosophical, I would say to you, with respect. It is about getting a result. We do not want to get lost in philosophy. Does it do a better job? It is a simple question. Is the system of biometrics more efficient than what has gone before?

Sir John Adye: May I point to another way in which it can do a better job? That is in enabling the anonymisation of data that is used at the point of transaction in an operational system. Systems of that kind can be used in ways which, through anonymisation, comply with the data protection regulations and laws in this country, the EU, the US or wherever it may be. For those purposes, you need to have, alongside the technology, the design of the way it is used. In some of the written evidence that this Committee has elicited, there is a particularly useful set of guidelines put in by the Information Commissioner's Office relating, among other things, to that process of anonymisation. Once anonymised properly, the data falls outside the provisions of the Data Protection Act.

Erik Bowman: If I can add to that, it depends on what the system is going to be doing. In a commercial system, where the system is being asked, "Are you who you claim to be?"—if that is the question that is being answered—then biometrics can be a little more absolute in terms of probabilistic matching than, perhaps, a pin, because you may, forgive the term, fat-finger the pin. I think the error rates for fat-fingering a pin are up around the 5% to 10% range, whereas biometrically it is 99% accurate.

Q38 David Tredinnick: Do you mean hitting the wrong digit or the wrong number?

Erik Bowman: Correct; yes. On the other hand, if the system is being asked the question, "Do I know who you are?", that is a far different question to answer. It is a one-to-many type of a search. You are trying to find a needle within a haystack. It is valuable because you are initiating the search based on a physical or behavioural characteristic, but the probability of that being matched among many, many images might be lower. Therefore, coming back to your original question of whether biometric data is more valuable, it is helpful if you are trying to find that needle within a haystack and you can aggregate data. However, when you are building a system that is doing a one-to-many or answering the question, "Do I know who you are?", you have to be careful on how you construct and secure the data so that it is not easily aggregatable by a person who has bad intent, because once you put that information together you have got that person absolutely. That is what you were touching on a little bit.

Ben Fairhead: Yes. Just to add to that, if you think of value in terms of security—you understand the concept of two and three-factor security—what you know, who you are and what you have, which are all ways of being able to identify yourself, whether biometrics is more secure than those other factors is very dependent on the specifics. It is an encrypted smart card versus something like a simple user name. There is a big difference.

Q39 David Tredinnick: Thank you. Mr Bowman, you told us that the security of biometric systems is all too often an afterthought. What steps need to be taken to ensure that security is considered from the outset when designing a biometric system?

Erik Bowman: That is a very good question. What needs to happen from the onset when you are thinking about putting in a system that is going to involve biometric and non-biometric data? It has been my experience that security is an afterthought because it is costly. In some cases, the agencies will not think all the way through a complete requirement that states you must protect the data in such a way, let the systems integrator figure out how to do that and then hold them accountable for protecting that data from the standpoint of having service level agreements or penalties levied against them if they don't meet those requirements. It has been an unfortunate afterthought, but, as biometrics become more prevalent within systems, the security will be thought about, architectured and implemented up front before the system goes live. It has been my experience that it just has not. It needs to be done from the outset.

Q40 David Tredinnick: Google has been in the news in the last couple of days with the problems relating to the murder of soldiers and whether the security services had the right information. Do you think that search engine organisations should have penalties? I think that was the word used. Do you think that there should be much stronger sanctions against those who manage data systems to encourage them to be more security-conscious?

Erik Bowman: When you put in systems that are going to have data such as the ones you are mentioning, security is of paramount importance given the value, as you pointed out earlier, of the data inside that system. If security is breached in any sort of way, they should be held accountable for the requirements they did not meet. That is why I would rather see those stringent requirements up front so that everybody knows what they are getting into prior to bringing the system forward.

Ben Fairhead: From my experience in the UK, security, certainly on the Government side, is very well thought about during the whole procurement stage and it is designed in from the outset. That has certainly been my experience.

Q41 David Tredinnick: Thank you. Finally, what mechanisms are already in place or being developed to protect stored biometric templates?

Erik Bowman: When the data are at rest, meaning not being used or in the process of being authenticated, they can be encrypted. The template itself is a small representation of the image itself. It is fairly hard to reconstruct into the actual image. The images are kept separate along with the security scheme and can be encrypted, but that comes at a particular price from system performance. So it is a trade-off depending on what the system needs to do. You need to trade off the security with the performance aspect of it.

Sir John Adye: If I might add to that, with which I fully agree, the new development that we have to take account of here, which is actually a very positive one, is the beginnings of the availability of the use of biometric sensors on mobile phones, on mobile devices, where the notable factor is that the use of biometrics is unsupervised by the relying party in this case. If you go to an ATM to put in your credit or debit card, that system is going to be supervised by the bank in some way, but when you are using your smartphone, or even your PC at home, there is no physical supervision of the system. So you need to design security methods to apply to that mobile use that are going to be strong to protect the interests both of the individual who is using the phone and the relying party at the other end, which is the bank or whoever it is, which is providing some service to them.

Q42 David Tredinnick: Forgive me for interrupting, but are you saying that the mobile phone companies are not using biometric data systems properly at the moment in that they are not secure?
Sir John Adye: No. They have made a good start.

Q43 David Tredinnick: But you are not happy about it.

Sir John Adye: No, I am not happy. It needs to be developed further. The main problem is that there is no public visibility of what measures they have put in place. For example, you just cannot get at what Apple is doing on the iPhone 6, where they have introduced it. You can only infer from the way they are doing it what the security procedures are. We must find ways of corralling these big giants of the internet so that they work properly.

David Tredinnick: Thank you. I have just realised that I have strayed into my colleague's question. Forgive me for that.

Q44 Pamela Nash: Can I just clarify the explanation that you just gave about your concerns about the security of using biometrics in mobile devices? Is that what you meant in the written evidence of your company, which stated that it was "technically challenging to implement" biometrics remotely? Was that your full concern or is it that the miniaturisation of that technology is not yet of high enough quality to cope with those risks?

Sir John Adye: The technology does need to be developed further in some respects, but the primary problem is this one that I referred to earlier—that the smartphones, or whatever, are outside the control of the relying party, and, in consequence, it is necessary to have the right kind of security and cryptographic techniques designed into the systems which are on the phones themselves and then the systems which use the information transmitted from the phones to make some kind of a match of credentials—not necessarily biometrics; it can be other credentials as well—in giving access to the individual, let's say, to their bank account. So it has to be designed as a whole system all the way through. The same principles need to be used for all such systems so that public trust can be developed in them. So far, that is not the case. At the moment, all this area of use on the internet is a jungle. I don't know, although I am quite experienced in this field, what happens to my personal data when I use them on a smartphone for proving my identity. Is Google going to use that data also to target advertising at me? Is some other commercial company or maybe some hostile foreign Government going to use it to target me in some other way? I don't know. We need to find ways of getting that kind of system properly organised.

Q57 David Tredinnick: Ms Carr, your Big Brother Watch raised concerns about technologies that can collect biometric data covertly and use it to identify people without their knowledge. Are these technologies, in your view, widespread in their use and, if so, who is using them?

Emma Carr: It is hard to tell whether it is widespread because it is covertly.

David Tredinnick: It is like "The Secret Policeman's Ball".

Emma Carr: In terms of the research that we are conducting—we are not specifically looking at biometrics; we look at many things—one of the things that really jumped out to me when we were putting our written consultation together was the story about the NSA collecting facial recognition photos from the net. They said that they will not access these photographs for identifiable purposes, but they do not have access to the databases of photos for things like passports and drivers' licences. So, instead, they were reverting to going through people's online posts, video messaging and that sort of thing to try and get the images in that way.
Clearly, consent is a huge issue there. As much as I would not advocate them necessarily having direct access to our photos via the passport and driving licence database, at least, if that was the case, you could go through a system of informing the public that it would then be used in that way and go through a consent process of informing the public. However, if it is essentially trawling through the net to see what we have posted on it, it is probably not as accurate; after all, if you look at anybody's Facebook page, for instance, they may look very different in lots of different photos, depending on what they are for. So accuracy is a huge problem, but, indeed, for us, consent is the biggest issue here.

Q58 David Tredinnick: Dr Waggett, you have previously said that stopping people being observed via biometric systems is not going to be feasible. Can we control how that biometric data is collected and subsequently used or not?

Dr Waggett: Yes. A lot of focus has been, effectively, on trying to prevent images being taken. What I was trying to get across was that that is not really an option because of the proliferation of cameras all around the place. Every smartphone now has two or three cameras in it and it has a video capability. There is a lot of imagery being collected of individuals. The bulk of it is not by Governments. It is by organisations and/or peers, just people passing it around. We need to focus on providing the other aspect of privacy, which is not being disturbed by that observation, and providing technologies that can help with that. For me, that is a big issue in how we ensure that people are not impacted, even though they may be just under general surveillance through cameras that happen to be in place.

Q59 David Tredinnick: This is a question to all of you. Do you think that the current legislation adequately addresses the challenges that these covert techniques present to privacy and control over personal data?

Andrew Tyrer: I think the legislation for Government use is adequate. The challenge is legislation for private use when you are not given that privacy and consent. In other words, if a commercial organisation is taking a video of you in a street and you have not consented to give that information, they use that information and it becomes personal information, then you have not consented to use that. From a Government perspective, of course, I am sure that Government agencies would act according to the regulation. Therefore, I do not think it would be a challenge in Government, but certainly out in the private industry it can be a challenge. You would not even know it was going on, to be quite frank, so that could be a problem.

Emma Carr: There is a huge need to strengthen the potential punishments for people who maliciously abuse access to our information. Big Brother Watch has called a number of times for custodial sentences and criminal records to be introduced for the most serious of data breaches. I believe it would be a relatively easy thing to do. What we do not want to end up doing, especially for private companies, is for them to see these relatively small fines as a cost of doing business. We need to avoid that at all costs.

Q60 David Tredinnick: Are you saying that the sanctions should be personal rather than corporate?

Emma Carr: Yes, in some cases.

Q61 David Tredinnick: Directors should personally be liable rather than companies.

Emma Carr: Or, indeed, the individual. We have seen, especially within NHS cases and medical record cases, individuals who have ended up maliciously accessing people's medical records receiving a relatively small fine; so there is nothing really stopping them from doing a similar job elsewhere, having similar access to people's records. That is something that needs to be addressed.

Health Committee
Oral evidence: Public expenditure on health and social care, HC 679
Tuesday 18 November 2014

Members present: Dr Sarah Wollaston (Chair), Rosie Cooper, Andrew George, Robert Jenrick, Barbara Keeley, Charlotte Leslie, Andrew Percy, Mr Virendra Sharma, David Tredinnick,
Valerie Vaz

Questions 299 -395
Witness: Dame Kate Barker CBE, Chair, Commission on the Future of Health and Social Care in England, gave evidence.

Q329 David Tredinnick: Thank you very much; good afternoon. The commission proposes "an independent official body making regular assessments of the health and social care needs of the country, and of the spending needed to meet those." How would you see such a body working in practice, please?

Dame Kate Barker: The proposal for this came out of the lengthy discussion we had about hypothecation. There was a sense that, if you did not have hypothecation and clarity about what was needed, there was not, as it were, anything to hold people's feet to the fire to make sure that we were funding this properly. In a way, it was a slightly compromised proposal. I would see this body as being independent. I would not see it as making the decisions. In the end, decisions need to be taken by politicians. What I would see this body doing across health and social care, rather as Simon Stevens did for health care, is setting out very clearly what they thought the choices were between funding and entitlements and what you might get out of it, for the politicians then to take a decision. Somebody asked the question about whether I thought the bidding war was quoting the right figures. I thought the Five Year Forward View went quite a long way towards saying, "You are all talking about £1 billion or £2 billion, but we think the figure is nearer £8 billion."

Q330 David Tredinnick: You said earlier on that some of these decisions are for politicians and yet this proposal would mean the Government giving up control over a large area of public spending, would it not?

Dame Kate Barker: No, not at all. This body would make recommendations and it would say—having looked in more detail than we were able to at the productivity potential of the health service—what it felt might be the consequences of different quantities of funding. It would still absolutely be for Government to make a choice along that bound, but it would mean that, instead of the Department of Health telling us, "It is all fine; we can fund it out of this," you would have an independent body that said, "We are not sure that is right." It would absolutely not mean politicians giving up control.

Q331 David Tredinnick: Is this proposal very different from NHS England's role for health? In other words, would you see NHS England becoming "NHS & Social Care England"?

Dame Kate Barker: That would be a possibility. I do not think it is very different from NHS England's role in that sense. I would see it as a body that set out clearly an expert view on what we might get for different levels of funding.

David Tredinnick: Thank you.

Q360 David Tredinnick: Chair, as a gentle introduction, having had this enforced break, I was reflecting, having served here for something like 28 years, on how much time I had spent in Divisions and it would be a very long time. I do remember serving on another Committee—the Channel Tunnel Rail Link Bill—which sat for long enough to walk from here to Madrid at a leisurely pace. So we do spend quite a lot of time doing various things here.
I wanted to ask you, moving on—after what I hope was a fairly light-hearted introduction—to talk about integration from another angle. We pretty much have a consensus that there should be greater integration of health and social care services, and the commission that Kate Barker chaired, whom we saw earlier on, has advocated moving to a single, ring-fenced budget. Do you agree with these proposals? Mr Webster, you look anxious to answer.

Rob Webster: No, I was wondering if someone else wanted to answer first. In the places where we serve populations, we should look at what care people need and we should do that together. My concern about being too prescriptive about the structures through which we do that is that we start to focus on the structures and not the needs. We would very strongly advocate—and did so in our All together NOW! joint publication—that there needs to be a joint settlement for health and care over a five-year period; that that needs to be considered jointly at a local level in terms of how that is spent; and that you should do that in ways that preserve and support relationships so that people can focus on what people need, which is joined-up care.

Carolyn Downs: We are entirely in that same place as well, perhaps more in relation to Kate Barker's larger and wider proposals. We absolutely support the need for more money into both health and social care. There needs to be a really high-level conversation with the public about health and social care and how they are funded going forward. We would not want to dismiss out of hand her proposals about how to get more money into health and social care, but that needs to be a conversation directly with the public around the issue of a public information campaign as well.
We are very supportive of the idea of a single budget for health and social care. We would like to see it over a five-year period, as Rob has said, and we would want to see a transformation fund that sits alongside that. We understand that local government does not like ring-fenced budgets because we feel it definitely restricts local discretion. However, if the proposals that are on the table are for such a significant level of additional funding into social care, then that is something that local government needs to be very mature about and discuss and consider going forward. We have always had a real dislike of ring-fenced budgets. On that point about ring-fencing, if you look at the level of funding over the four years of austerity that have gone into social care, both for children and adults, those budgets, while not ring-fenced, have been significantly protected.

David Pearson: As an additional contribution to that, I totally agree with the points that have been made around not seeking structural solutions. Also, in terms of aligning, or a single budget, I cannot see this divorced from the assessment of how much it needs to be, given the need for transformation change and integration and what that can deliver in savings. But, as Simon Stevens has coined the phrase, joining two leaky buckets together does not necessarily make them watertight, so there is an overarching issue about how much is in the pot.
The second issue is about the local oversight of that. I totally agree that we do not need structural solutions, but the role perhaps of something like the health and wellbeing board, with teeth, could be a way of bringing services together without changing those structures.
Finally, the announcement on 4 September between NHS England, the LGA, ourselves and Think Local Act Personal about integrated personal commissioning about perhaps joining up individual personal budgets around the needs of people who have substantial numbers of long-term conditions—possibly around 3 million people in this country—could be something that, if we can see a way through that, could break down a lot of the barriers automatically between them.

Q361 David Tredinnick: When you say "see a way through"—
David Pearson: It would help to ensure integration around people's needs in a very effective way.

Q362 David Tredinnick: I want to ask about personal budgets a little bit further down the road in a minute or two. How difficult do you think it will be to bring together different eligibility and co-funding rules, and what do you think the costs will be? We have had some figures bandied around. It seems to me pretty obvious that, if you are going to do away with means testing, there is going to be a huge increase in cost, and I mean social; it is completely different funding, is it not? Health and social care are funded in a completely different way at the moment.

Carolyn Downs: Yes.

David Pearson: Yes.

Q363 David Tredinnick: How difficult is it to do this? What do you think?

Rob Webster: At the moment local leaders take a positive decision to work together for the benefit of local people. In some places they share the risk around that. They try and design services in ways that will meet their needs, recognising that there will be an element of means and needs assessment, and there will be an element of payment potentially for some part of that care. It would be better if the rules allowed for that work to be developed in ways that were simpler and supported those local leaders, and there are a number of things that could improve that around how people are held to account and what the outcomes are expected to be. You do not necessarily need to get away with needs assessment in taking forward those proposals. That is one of the choices that needs to be debated with the public and comes back to this issue of, "What do you want to invest in? Do you want to invest in care, in health, or health and care together? If you do that, how much money do you have? How much does it save in simplifying the system by making it more efficient, and what is the gap?" All of these issues are packaged together in a future system that we have not yet designed. It is clear that there is a need for a significant amount of activity through local relationships, good intentions and local commissioning to make this work.

Q364 David Tredinnick: You would see significant savings down the road through the amalgamation of the two services, would you?

Rob Webster: There is limited evidence on this. If you look at the submissions we have had from people like the Health Foundation and the King's Fund, they point to the evidence base. It is clear that we have multiple assessments and multiple services supporting single individuals, and there must be some element of double running or duplication there. As one of the questions from one of the members of the Committee mentioned earlier, at the moment there is a bit of unmet need too, probably. These things all have to be taken into consideration when we are thinking about how services are developed, what the costs would be, what the impact is and what the overall mechanisms are. But at the moment we do not have an alignment between the policy intent, the funding mechanisms, the incentives and the delivery. Until we have that, I do not think we will have the kind of integration that we want.

David Pearson: If I can add briefly to that, as Rob said, the research evidence around savings is mixed, but the savings do not come necessarily from joining up structures or pooling budgets per se. It is about applying that to, for example, the 30% to 40% of older people in hospital, where consistently the research evidence says that if there are better community-based services they could be cared for in an alternative place.
In relation to your point about eligibility and the differences between health and care, clearly we have just had the Care Act with the national eligibility criteria and, although these things are complications in the local systems, they are not insurmountable in terms of joining up the services. It is like information sharing and all the other barriers that there are: they are things to be overcome and worked with at a local level.

Q365 David Tredinnick: The Health and Social Care Act has facilitated that through health and wellbeing boards and clinical commissioning groups. I sit on the local board in Hinckley in my area and I am very impressed with the way the different services are working together; you have a sense that both sides are delighted to have been put into an alchemical vessel where they can work it through.
What do you think has been learned from initiatives such as care trusts, integrated care pioneers and the Better Care Fund? Ms Downs, you are smiling wryly, so maybe you are wondering about where that question is coming from.

Carolyn Downs: I can certainly talk about the Better Care Fund and I sponsor an integrated pioneer as well. In relation to the Better Care Fund, this is a concept that we would all warmly endorse. We definitely endorse the bringing together and the integration as a concept. It was rather unfortunate that in the agreement it was for one year only, which is starting from April next year. I genuinely think that the placing of the £3.8 billion in both spending power for health and local government has done absolutely nothing to help the whole process. That has been a real block.
The policy around the Better Care Fund changed halfway through the process, effectively, of putting the plans together. The issue of a £1 billion-worth of savings that were required to the NHS when we started the whole process of the Better Care Fund was perceived as a performance element that was £1 billion-worth of benefit to the NHS. That change in the whole policy intention of the Better Care Fund was deeply unhelpful, and it became a discussion in local places not so much about integration and better outcomes for patients or residents, but a competitive process as opposed to a collaborative one. It became a very transactional discussion about which budgets fit where, as opposed to a transformational discussion. Nevertheless, and as a result of that, it has slowed down the process, and some councils would definitely say that it has set the process of integration backwards because it has not allowed local relationships to flourish on the basis of a mutually agreed understanding of what needs to happen in that community as opposed to a more top-down process imposed from Whitehall.
In relation to the Better Care Fund there are a lot of lessons that can be learned. It needs to be agreed over the course of a much longer period; it needs to have a transformation fund sitting alongside it; there needs to be a far greater level of local discretion, and let local leadership, through health and wellbeing boards, determine the type of integration as opposed to it being imposed from Whitehall.
Having said that—I am sorry this is a bit of a rant—£5.3 billion has been pooled over and above the £3.8 billion; 64 health and wellbeing board areas have pooled more than was required of them. Savings of over half a billion have been identified in the process and the overwhelming majority of plans have been approved. Actually, there are good outcomes that are coming from the plans in benefits to residents in all our communities. The concept is good and I personally think it will be beneficial in the communities, but the process has been too top-down.

David Pearson: Just to add to that, the lessons from the Better Care Fund emphasise, when embarking on a transformational programme of this nature, how important are the national policy parameters—the performance requirements and aligning the levers to make sure that those changes can be made at a national level—and then enabling the local health and wellbeing boards and organisations to get on with it. From a social care point of view, we were disappointed that the performance requirements for social care got relegated in the redesign, but I suppose, taking the next step, we need to make sure that, in terms of that policy performance and those levers being aligned, there is flexibility about how local areas implement it, because there are differences between places such as Wigan and Nottinghamshire just in terms of size, scale, rurality and all those things, which need to be taken into account by local clinicians, politicians and communities designing the future together.

Rob Webster: The other thing I would add to that is that everybody agrees with the intention behind it and the principles are good. Giving the health and wellbeing boards some teeth and a decision to make was a really powerful thing to do for health and wellbeing boards. The lack of engagement of providers was a significant issue throughout the process, and it is still the case, I think, that a fifth of providers signed the plans off with caveats or reservations, which demonstrates a lack of maturity of the system at the moment. We must make sure that we are learning the lessons from the process so far, because all of us would agree that the actors around the table are going to be instrumental in thinking about a different future.

Q366 David Tredinnick: Following on from that, much of the discussion focuses on commissioning bodies, but what role do you think the providers should have? We have not heard so much about the providers. Do you have a view on that?

Rob Webster: It is all about the providers. We have to start from a position of understanding that commissioners do not deliver any care directly. We are asking, in total, 1.4 million health staff, 1 million social care staff, 3 million volunteers and 6 million or 7 million carers to work differently in the future. Embracing and engaging the staff around the different model of care, the different way they are going to engage with families and the different way they are going to work with each other—the cultural aspects of that—are instrumental in the success of any integration in the future. That integrated provision, backed by an integrated single view around commissioning, is incredibly important; so providers have to be engaged and their insights and understanding harnessed in coming up with the potential solutions.

Carolyn Downs: As to some of the integrated pioneers, their health and wellbeing boards are specifically working with the providers directly as a mechanism to get a quicker and deeper level of change. There are different ways of doing that. Some health and wellbeing boards have the providers sitting on the health and wellbeing board. That was not prescribed in legislation, but places are doing it. Personally, I think that is a really good idea. Other health and wellbeing boards are working on the basis that they have sub-committees where the providers are fully involved in discussions that impact on the services they provide. We have to work on the basis that health and wellbeing boards have to engage directly with providers to make sure that that buy-in is there, otherwise we are not going to get the level of change that we need going forward.

David Pearson: Can I add, from a practical point of view, that my own authority, Nottinghamshire, is a fast-track Better Care Fund area with six clinical commissioning groups, seven district councils and three acute trusts? We would not have been a fast-track area had it not been for the engagement of the providers in the change plans that we were making because they are absolutely crucial to the delivery. They sat on the sub-area of transformation boards in each of our areas and helped co-design those processes.

Q367 David Tredinnick: Let us go back and pick up a point we were on earlier to talk about personal budgets for a minute but also to link it to patient choice and the recommendations in the Five Year Forward View. What role will personal budgets play in the integration of health and social care? What lessons do you think can be learned from the experience of personal budgets for social care?

David Pearson: We now have 80% of people in social care on a personal budget, and in some authorities it is higher. In my own, it is over 90%, and it is only not 100% because there are some people who are not in the system long enough—because they have been reabled—to receive a personal budget. In Nottinghamshire, 46% are on a direct payment and so directly receive the funding to help organise their care.
That can be helped by other organisations. I have seen some very interesting joint work with the Alzheimer's disease Society about using things like direct payments for people with advanced dementia, which have made a significant difference in keeping people at home for longer, utilising the carers and helping the informal carers—the family—to shape and co-ordinate that care in a way that helps to put them in control of what can be quite a bewildering situation. That can have a profound effect, but, clearly, if we can shape together the health and social care budgets, then a lot of the joins that people have to overcome to receive their care and the multiple telling of stories about getting the service would be, potentially, significantly helped in terms of joining up the services.

Q368 David Tredinnick: I looked at some of the trials of personal budgets and they were extraordinary because they were breaking new ground in several ways. First of all, it was empowering the patient.
David Pearson: Exactly.

Q369 David Tredinnick: Secondly, it was empowering the carer, who very often—in some cases, maybe not very often—was able to go back out to work because of the change. Thirdly, it gave extraordinary choice to the patients in what they were able to choose as treatments. I have mentioned before in the Committee that I can think of some of the less conventional therapies that have been chosen, such as tai chi, yoga, mindfulness and piano therapy. Patients could choose whatever they like and were not told that these therapies had to have double-blind, placebo-controlled trials to authenticate them. They were told to go and get them. The last point is that these personal budgets have reduced costs. All the time we are hearing about demands for more money and very little about reducing costs, and I would put it to you that giving patients and their carers more choice is improving the services and reducing the cost.

David Pearson: If I could come back on that—and other colleagues might want to contribute—I hope it was clear in my earlier submission that Directors of Adult Social Services and local authority councils have taken very seriously the responsibility of managing austerity by reducing costs. We do recognise our financial responsibilities and take those very seriously.
In relation to your analysis, I would entirely support it. Clearly, the social care experience tells us that we need to make sure that the support planning around the use of the personal budgets is good, to make sure that the moneys from the public purse are used for the most effective treatments and approaches as well as the choice. So there is a balance here. If we are talking about something that is absolutely known to be evidence based, a good sort of service or treatment in delivering outcomes, it is quite important that we make those available and encourage people to use them. The choice, the control and some degree of saving is absolutely right, but, rather like integration, it is not the silver bullet for all of our financial challenges.

David Tredinnick: I am suggesting to you that, if we are really going to go down the route of patient choice, "the NHS will take decisive steps to break down the barriers in how care is provided"—I am quoting from the Five Year Forward View—and people will have "far greater control of their own care". There are recommendations running to a whole page on empowering patients—"more to support people to manage their own health". Then it says: "A third step is to increase the direct control patients have over care that is provided for them." I also chair the All-Party Parliamentary Group for Integrated Healthcare, the old Complementary and Alternative Medicine group, and a lot of people out there are asking for what you might call ancillary services. Some of them have taken quite a beating over the years, and I am thinking in particular of the homeopaths. However, the homeopathic doctors have been regulated by Act of Parliament since 1950, and the Society of Homeopaths, which are the non-doctor homeopaths, have just been taken under the wing of the Professional Standards Authority—about 1,000 of them, from memory. The acupuncturists, the largest society—

Chair: Do you have a question to ask?

Q370 David Tredinnick: I have; thank you, Chair. The British Acupuncture Council has also been taken under the wing of the Professional Standards Authority. A lot of these treatments are less expensive. I am suggesting to you, "Is there not a third leg on the stool here?" You can have your integration of health and social care, but you cannot really have patient choice, as aspired to by the two Secretaries of State—the current and the last one—and these reports, unless you broaden the range of treatments available, as demonstrated by the way patients have been choosing services in the personal budgets.

Carolyn Downs: Yes, I think we would all agree with that, and we are all represented on a body working with NHS England directly specifically looking at the whole issue of integrated personalised care budgets. We are just starting. They are very clear that health needs to learn from local government in the work that we have done in that area. I would not underestimate how challenging it is going to be in bringing those wider health budgets into a personalised budget, but we are all committed to moving in that direction. I am not sure how significant the savings will be, although I accept there will be some savings. More important is whether there are better health outcomes for people as a result of using personalised budgets. Our experience would say, yes, there are better outcomes for people.

Rob Webster: That is one of the critical points. The evidence is really mixed on cost savings for personal budgets in health. What is proposed in the Five Year Forward View, in line with a well-designed experiment to see how personal budgets might work for people and recognising who they would work for and how and what the arrangements would need to be around them, is something we would welcome. We must not underestimate what we would require in terms of the information that is shared, information that is available for people to make choices that they want to make—a switch, I would say, towards outcome-based approaches rather than input based approaches to health care, particularly for people with long-term conditions. Many of these things are welcome but are part of the fundamental shift in the way that we think.
Sir John Oldham in his Whole Person Care Commission—another important piece of work—said there are three things that we need to think about together. One is supported self-care for people with long-term conditions; another is re-stratification, so that you are looking at how you segment your population; the third is integrating the services with the right information to support that. If you do not put those three things together, you do not get the kind of benefits that you need.

Q384 David Tredinnick: I certainly do. I was going to ask a general question about the Better Care Fund link with the proposals in the Five Year Forward View. I do not know whether you want to comment on that if there is anything there that has not come up already.

Rob Webster: The other thing I would say is that we all believe that longer-term joint settlements that allow us to plan services that are joined up are essential for the future, and the Five Year Forward View sets out an intention to focus on prevention and on integrated services. It does not talk enough about social care for me in terms of the connections between what we do every day and the social care support that is required. We would want to strengthen that commitment, and the Better Care Fund is an example of working together.

Q385 David Tredinnick: Do you think there is enough scope for organisations to make innovations and test models when the current financial situation is alleged to be precarious?
Carolyn Downs: People are doing it all over the country; people are innovating and testing new models. Sometimes the burning platform pushes you together in a way that might not happen in times of plenty. My view is that, yes, people are doing it. One of the challenges to us all, both in the NHS and local government, is, if some places can do it really successfully, why can't everywhere? That is something that we really need to do in terms of sharing best practice and rolling it out across the country. That is definitely both for the NHS and indeed ourselves.

Q386 David Tredinnick: Finally, would you agree with me that, if you give patients more choice, it is inevitable that they will exercise it in a way that does not necessarily appeal to the existing establishment and that we may have to think out of our box if patients come back with new ideas that have not already been considered?

Carolyn Downs: It would be positive if patients were taking control over their own care and their destiny. That would be a real positive.

Rob Webster: We should always ask ourselves: why do we exist—

David Tredinnick: That is very philosophical.

Rob Webster: —as organisations, or as individuals and organisations? We do not exist to be organisations: we exist to deliver the best possible care and outcomes we can for people who live in England. It seems to me that, if people want something different, we need to listen. My worry is that the inverse care law persists and people who need the most care get less than they should. We need to find a way of ensuring that people who deserve better get better and we find ways for them to access care. I personally would like to remove any references ever to hard-to-reach groups—that we have created services that they find hard to access. At one end of the spectrum we need to make sure that people are informed and can make their own choices about the outcomes that they want for themselves, but we must not do that to the disbenefit of others who already get a bad deal.

David Pearson: My final contribution to that, as well as agreeing with my colleagues, would be to say that it is absolutely our experience in social care, and the first statutory responsibility to offer direct payments was as long ago as 2001. The cultural shift over that period of time, in thinking about what people say they want as a way of meeting their needs, has been a continuing journey. What you are saying is absolutely right; in fact it does challenge us, but it is right that, as Rob says, that is what we are here for.

Q387 David Tredinnick: Finally, in the Science and Technology Committee, on which I also have the honour to serve, we have looked at length at antimicrobial resistance—the resistance to antibiotics—something that has much exercised Dame Sally Davies, the chief medical officer. One of the sad things when we were looking at this was that there really are very few antibiotics down the road, if any, that are likely to come on stream soon that would be seen as general antibiotics such as penicillin or tetracycline, and there is a problem for the market there. If we do not have antibiotics, will it not make sense to make more use of well-established medical systems, such as herbal medicine and acupuncture, which have been around for thousands of years? Do you have a view on that?
Rob Webster: I think we should always focus the interventions we use on the evidence that is available and their efficacy. I am not an expert and I am not a clinician, so I could not comment on that.

Carolyn Downs: I cannot comment.

David Pearson: Neither can I.

David Tredinnick: Jolly good. Thank you, Chair.

Health Committee
Oral evidence: Public expenditure on health and social care, HC 679
Tuesday 11 November 2014

Members present: Dr Sarah Wollaston (Chair), Andrew George, Robert Jenrick, Barbara Keeley
Grahame M. Morris, David Tredinnick, Valerie Vaz

Questions 160 - 298
Witnesses: John Appleby, Chief Economist, King's Fund, Anita Charlesworth, Chief Economist, Health Foundation, and Nigel Edwards, Chief Executive, Nuffield Trust, gave evidence.

Q183 David Tredinnick: Mr Edwards, just to go back to you, you said there was a problem with junior doctors not turning up for work in the evening that creates agency demand. How big a problem is doctors not turning up for work?

Nigel Edwards: It is no more problem than it was before. It is just that they seem more reluctant to work additional shifts because there is an attractive—

Q184 David Tredinnick: Are there adequate sanctions against those doctors who do not turn up for work?

Nigel Edwards: Most hospitals, I think—

Q185 David Tredinnick: In other words, is it a management problem that people are just—

Nigel Edwards: Sickness rates in health care do tend to run ahead of the rest of the economy. There are recent staff surveys suggesting that staff are more under stress. The last time I looked at it, my impression is that sickness absence among medical staff is reasonably well managed. I would not want to give you the impression that that is what is driving the financial crisis by any means. There is more to do to improve staff welfare in the NHS. It is reflected in the NHS Forward View. That would be a costeffective investment. It is probably more an investment in welfare and work conditions than it is performance management of unauthorised absence. In health care you are exposed to infection and heavy manual lifting labour, so you are more likely to be off sick perhaps than in an ordinary office job. But there is definitely more to do.

Q221 David Tredinnick: Good afternoon. I want to explore efficiency gains a little more; we have touched on that already. To close the £30 billion gap in funding that is anticipated if no change is made, the service would, among other things, be required to achieve efficiency gains of 2% to 3% net per year, against reported gains of around 1.6% in recent years. Do you think a 2% or 3% net annual efficiency gain is a credible target, given that NHS England has already acknowledged that it is not possible to rely on some existing measures such as wage restraint in the future? I know we have touched on some of this, but I want to get this on the record.

John Appleby: The 2% to 3% NHS England's Five Year Forward View refers to is for the entire NHS budget, as I understand it, more or less. When you start to think about different parts of the NHS, like the hospital sector, that number is going to get bigger. It will not be 2% or 3% for an individual hospital on average; it will probably be more like 3%, 4% or 5% a year, which is more or less what the hospitals have been trying to do over the last four or five years. To ask for another five years of that seems to me overly optimistic—I mean really optimistic.

Anita Charlesworth: As I understand it, it is 2% for three years and then 3% for the next three years after that. I do not think that in the long run that is realistic. There is a question from the work that was done for Monitor about the scope for some catchup efficiency gains. There is a whole raft of studies that show, if you look either geographically or at individual providers or different sectors, that productivity varies, as everything in health care and performance varies, and that there is significant potential if you could get everyone closer to the best.

Q222 David Tredinnick: That is Simon Stevens's point, isn't it? He told the Committee that a combination of bringing less efficient providers to the same level as the most efficient and the gains that come from new technology and treatments could realistically bring an efficiency gain of more than 2%. You do not really agree with him.

Anita Charlesworth: No. There is clearly catchup potential in the NHS. If the trend rate of efficiency is closer to 1% than 2%, there is for a period scope for additional savings from catchup. There are also things like the PPRS deal that has been negotiated that give us, for a fixed period, some relief from some cost pressures. We have all written endlessly about different aspects of the way in which, when you look across the system, the money is not spent as coherently as possible. There is clearly potential to unlock that.
I would not rule it out completely. Having a go—a really serious attempt to unlock more of those structural efficiencies and the catchup efficiencies—is unambiguously the right thing to try to do. Putting the resourcing in and having a real plan to try to unlock that must be the right thing to do. The alternative is to say to the public, "We give up. You must not only dig deep but dig even deeper." The consequences for other public services are potentially profound. However, if we try—I think that backing the Five Year Forward View is the only sensible thing for the health service and the public finances to do, which must mean properly funding it—we need to recognise that it is not a guarantee; it is not a slam dunk. This would be one of the most ambitious reform programmes the NHS had ever embarked on. It is a real reform programme. Those are much more difficult than the normal structural reform programmes that we do, yet we all know that even structural reforms are quite difficult.

Nigel Edwards: A very substantial amount of the NHS budget is, of course, pay—staff. As Anita said, there are things that we can do. The standard management consultant's approach to a hospital in trouble is to say that if you are in the top decile of performance you are more efficient or cheaper than everybody else. Over the years we have found that it is very difficult to get every single service very quickly to that level of performance. You need a very high level of management effort. Many of the service models that we are hoping will produce improved efficiency produce improved productivity—not necessarily reduced cost, by the way, so there is still an issue about things that require extra cash, where the prices have gone up—but require a level of managerial effort and skill that is quite hard if you are busily running to deal with the type of activity increases and requirements for shortterm performance that are asked for at the moment.
One of the biggest risks here is that, while in theory this sort of productivity is possible, the question is whether in practice the system has the headroom for it. I am thinking about a little anecdote that might illustrate this. A friend of mine who is a vascular surgeon has redesigned his operating list in such a way that he can do 20% more procedures through that operating list in a day than he did previously, with fewer instruments and at reduced cost. That is one operating list for one particular set of procedures. It has taken him some considerable time and effort and it has to be replicated across his hospital and across the system, very reliably and at very high speed. That requires an investment of time and effort—and, indeed, skill. As well as being a vascular surgeon, he happens to be trained as a production engineer and computer programmer, so he may not be as typical as we might wish.

Q223 David Tredinnick: That is making better use of existing resources—a 20% increase in procedures without actually increasing resources, meaning expenses, other than know-how.

Nigel Edwards: Those sorts of improvements would—

Q224 David Tredinnick: It is a good model, really.

Nigel Edwards: Those sorts of improvements would give you the ability to absorb the very rapidly growing demand driven by ageing and population size and would allow you to treat more people for the same money. However, not all new technology saves you money in health care. There are price rises and we may have to pay our staff more, for which you will need to release cash. That is the bit that is most difficult. We can probably squeeze more work through the same plant. We need 17,000 more beds in the next five years, but we do not need to build them; we can get that figure through the ones that we have. The challenge comes where we need extra cash.

Q225 David Tredinnick: I will ask Mr Appleby and then come back on that, if I may.

John Appleby: Historically, virtually all of the efficiency gains that the NHS has obtained, such as they are, have been through reductions in length of stay of people in hospital and the movement from inpatients to day cases. There will be other examples, like a particular vascular surgeon doing whatever, but, when it comes down to it, what we have done is keep people in hospital for a far shorter time, year after year. We have been able to get rid of some beds but also use the beds much more intensively. That is how we have increased output in the secondary care sector. Whether there is much more to be squeezed out of that—and there probably is—

Nigel Edwards: It is not easy.

John Appleby: If you look historically, there is a rule—I have said this already—that, if something cannot go on for ever, it will stop. There comes a point where you cannot not keep somebody in hospital. There is a finite time. The issue is whether we could carry on with some of this stuff. That is where the doubt creeps in. If that is not the case, where are the opportunities?

Q226 David Tredinnick: We have been dealing with the supply side issue much of the time this afternoon. We have not talked very much about cutting demand for services. I am surprised at that. In particular, there is the potential impact of the extensive use of personal budgets on the funding. We now have personal budgets that have shown that, if you give patients and their carers control of the money, they actually make more effective use of it, the costs come down and patient and carer satisfaction goes up. Secretaries of State—the current one and the last one—have said that patients have to be at the centre of the health service. It is about what patients are asking for. They may not necessarily want antibiotics; they may want to try herbal medicine, for example, or something else. Are you thinking out of the box? Have you thought through alternatives—different methods of treatment that are not necessarily available on the service—to reduce the cost? It seems to me that the whole conversation is about ratcheting up more money for the health service. I wonder whether the demand side has not been looked at enough.

John Appleby: The Five Year Forward View takes a view on how the public's lifestyle, behaviours—

Q227 David Tredinnick: Obesity, for example.

John Appleby: Exactly—public health interventions and so on. That is clearly an issue on the demand side. As an economist who spends all of his life looking at this, I have heard people talk about how we may go upstream, how we will stop people getting ill and how they will not need hospital services. Well, guess what? We have done some of that, but hospitals are still here. We keep inventing things to do to people and people keep wanting those things. Obviously I am not against trying to do something on the demand side, but I would not pin all my hopes on our being able to reduce demand and find that suddenly we can live within our budget. I do not think that is the nature of health care and health.

Nigel Edwards: There are some areas about demand that are worth mentioning where we know that there are some significant opportunities. One particular one is the care of people in nursing and residential homes. There are 400,000 people in the UK in residential and nursing homes. They have multiple conditions and are often on very large numbers of medications, not necessarily to their benefit. The adoption of a series of preventive strategies—end-of-life planning, advanced care planning, ward rounds and medicines reviews—seems to have a very significant impact on the quality of care, so that we do not get a situation where people who have expressed a wish to spend their last hours in what is their home spending it on an A and E trolley because someone got nervous. There is definitely a big group where we can do something.
We are spending a lot of money at the end of life generally. That is one of the reasons why prevention as a strategy has sometimes been disappointing, because it turns out that dying is one of the most expensive things. A lot of what we do is still quite futile, poorly planned and inhumane. There are some things we could definitely do there that would improve the quality of patient experience and would save money. I do not recommend that we should sell it on that basis, by the way.

John Appleby: It is about the treatment as well. There is the variation bit. As I said, there is a supplyinduced demand, if you like. Not all of that supply is necessarily the stuff that we should be considering.

Q228 David Tredinnick: I have a final question on this. Staying on the supply side on treatment, there are some conditions that doctors find very difficult to treat. I was at a reception yesterday evening, where we were talking about autism. This was for the Society of Homeopaths, which is now regulated by the Professional Standards Authority, and was to mark that occasion. It is producing research that shows that homeopathic medicine can treat autism and be of great benefit. Maybe we could look at that particular wellestablished treatment service. I know that it is controversial and that there have been attacks on it, but the doctors have been regulated since 1950 under the Faculty of Homeopathy Act.
You can link that to the massive problem of antimicrobial resistance, which the Science and Technology Committee, which I also sit on, has been talking about. There is Dame Sally Davies's book "The Drugs Don't Work". Amazingly, in the last few years there has been a 24% increase in the use of antibiotics by doctors to treat colds and flu, which can also be treated by homeopathic medicine very easily; I use it myself. I wonder whether we are weak on thinking about broadening supply; we have already addressed cutting demand. I will leave it at that. If you want to comment on that, I will hand back to the Chair.

Anita Charlesworth: I would say one thing on that. One of the things we should be very proud of in our system is NICE. One of the positive things about the NHS reforms was the remit to NICE to develop quality standards. Whatever we do in the system, if we are going to spend more on health care—history and all international comparisons that come out would suggest that, over time, we will spend more on health care—the most important thing is that we derive real value from that, really embedding the approach of ensuring that we have consistent adherence to quality standards. That quality standards of treatment are well evidenced and embedded in our system can only be to the good.
I worry a bit in all of these conversations that the potential power of NICE and those quality standards is not being followed through and that they sometimes feel a bit disconnected from some of these debates. I do not think those things will stop us spending more money—I agree with John on that—but from a macroeconomic point of view and, more importantly, a moral and social point of view, it is absolutely imperative that we get value from that and strengthen that element of our system.

Science and Technology Committee
Oral evidence: GM foods and application of the precautionary principle in Europe, HC 328
Wednesday 5 November 2014

Members present: Mr Andrew Miller (Chair); Mr David Heath; Stephen Metcalfe; Stephen Mosley; Pamela Nash; Sarah Newton; Graham Stringer; David Tredinnick

Q146 David Tredinnick: Following on from that, we have been told that massive sums of public money have been invested in genetically modified research compared with other areas of plant science. Do you think that is fair?

Dr Burrows: That is not something I would recognise. As I said in my introduction, BBSRC are the major funders of plant science and we invest around £70 million a year in basic plant science. A proportion of that will be used in genetic modification as a very helpful laboratory tool to begin to dissect plants—a bit more of this gene and a bit less of that gene and what impact it has—to understand how they work. There is that piece. I estimate that about £10 million of that portfolio is to that sort of research, for GM as a laboratory tool.
We fund some research looking specifically at GM traits in potential crops. Mike has listed a couple of those. The high omega 3 oils in crops is something the BBSRC has backed, and the purple tomatoes—again from the John Innes Centre—is something that the BBSRC has backed, but it is a relatively small proportion of our funding.

Q147 David Tredinnick: So that I am quite clear, your funding overall is £70 million, and £10 million is the proportion of the total spent on genetically modified crops.

Dr Burrows: On using GM as a laboratory tool in plants. About £4 million is spent on the sorts of programmes Mike mentioned, exploring the potential for a GM trait in a crop. I should emphasise to the Committee that the BBSRC funds basic and strategic research. Once the interesting science has been done and proof of concept is there, BBSRC would not use public funding necessarily to come in and take that commercial crop to market. We would expect to see public-private partnership with the academics who developed the crop in the first place.
Professor Bevan: I would echo that. Genetic engineering is a critically important research tool used probably in almost every research project funded by BBSRC, the EC and industry. There are a few special projects, two of which I have described, and a handful of others, that are funded by BBSRC, to genetically engineer a crop plant and, as part of that, to have a test in the environment.

Q148 David Tredinnick: Have you made any commitments to the Government about future levels of research funding in this area?

Dr Burrows: We have made no specific commitments on figures.

Q149 David Tredinnick: What is the reason for that?

Dr Burrows: Our budget comes through the science budget, and it is up to our governing council to apportion that budget across our whole remit. The challenge for us is to get the right balance across our remit. There are areas of our remit we would expect to see grow. We are keen on funding the sustainability of agriculture much more. We are blind to the particular technologies that would allow us to develop that strategic approach to sustainable agriculture. We would not necessarily just pick out a technology and say to Government, "We will spend x million pounds in this direction."
Professor Sang: For example, there is discussion about developing a big focus on animal and plant health in the UK, and that may or may not include GM.

Dr Burrows: Exactly. We set the strategic directions, and one of those at the moment is to fund profitable, productive but also sustainable agriculture. We are delighted to fund any of the range of technologies or approaches which will help us achieve productive yet more sustainable agriculture, and we will be expecting to fund more as we go forward, but it all depends on forward budgets and spending reviews.

Q150 David Tredinnick: In 2009 the Royal Society recommended greater investment in non-GM fields such as agro-ecology and soil science. Has that had a bearing on your thinking? Has that made a difference?

Dr Burrows: Yes, it has.

Q151 David Tredinnick: In which way?

Dr Burrows: We refreshed our strategic plan about 18 months ago and made specific commitments in the strategic plan that we would do more on taking a systems approach to agriculture, so it is exactly that—looking more at agro-ecology and the soil science. We have had an initiative recently with our sister research council, the Natural Environment Research Council, on soil science—actually, the interface between root surfaces and soils, technically the soil-rhizosphere interface. We have had a grant call and grants proposals on that initiative. NERC itself has a programme on sustainable soils, which is leading out to 2018, so we are investing more in that space, and have the intention to do so, simply because we recognise, with that strategic aim of having more sustainable agriculture, that that is where the evidence base lies. That is where research is required.

Professor Bevan: Some of the biggest investments the BBSRC has made in plant science recently have been in the area of genomics. The objective of this work is to help accelerate more traditional types of breeding and non-GM approaches. This has proved to be catalytic in accelerating the rate of progress and generating new crop varieties.

Q152 David Tredinnick: Has that been widely advertised? Do you think it is well known that you are doing this?

Professor Bevan: The science is in early days. Nevertheless, from my scientific perspective it is absolutely clear that this investment in sequencing the genomes of very large and complicated organisms, like oilseed rape and wheat, is going to bear fruit very quickly in all methods of crop improvement.

Health Committee
Oral evidence: Integrated care pioneers, HC 560
Tuesday 4 November 2014

Members present: Dr Sarah Wollaston (Chair), Rosie Cooper, Barbara Keeley, Mr Virendra Sharma, David Tredinnick, Valerie Vaz

Questions 292 - 369
Witnesses: Rt Hon Norman Lamb MP, Minister of State for Care and Support, Department of Health, Clara Swinson, Director of Social Care Policy, Department of Health, and Ian Dodge, NHS England, National Director, Commissioning Strategy, gave evidence.

Q301 David Tredinnick: Good afternoon. I want to start on the point you have just raised about the scope of integration. Given that we now have patient choice and personal budgets at the centre of the health service, how do you react to patients who ask for specific therapies that are not necessarily mainstream? Do you have a sympathetic view of that? Do you have any views on how you integrate into the system other types of medicine that are seen by some people as fringe—and by some as not?

Norman Lamb: First, I do not think there is anything incompatible between giving power to a patient and joining up care. In fact, for me the best integrator of care is the individual themselves. That is why I am very strongly supportive of Simon Stevens's integrated personalised commissioning, bringing together personal budgets and health and social care. The power of the patient to make decisions, in collaboration with the clinician, has to be central to this. You can go about all sorts of institutional integration, completely forget about the interests of the patient and achieve nothing in terms of advancing their interests. It has to be focused on their needs. It should be possible to have a discussion between the individual and the clinician in determining the right package.

Q302 David Tredinnick: Your chief medical officer, Dame Sally Davies, has written a book, "The Drugs Don't Work", which is largely about antimicrobial resistance—something the Science and Technology Committee, on which I also serve, has looked at in some depth. Isn't it a fact that patients now are very worried about the increasing use of antibiotics and resistance and are looking for other alternatives—and there are some out there in the landscape?

Norman Lamb: I would agree with that. When we look at personal budgets in local government, in social services, people have chosen to use the money in all sorts of ways. For me the bottom line is, is the outcome better? Has their health and well-being—their enjoyment of life—improved as a result of that initiative taking place?

Q320 David Tredinnick: I want to ask you a question about finance in a minute, but while we are on patient choice, I wonder if you have had a chance to look at the Cancer Act 1939, which is very tight about claims that can be made about certain therapies in respect of cancer. Just to use one example, if an aromatherapist wanted to use lavender, which can be very good at reducing stress, they would not be able to make any claims that it was effective. I encourage you to go and look at that Act; it is from 1939 and is very out of date. If we are going to broaden choice, that is something that should be considered.
The second point I want to make—this relates specifically to cancer care—is that I am reliably informed that the food in some cancer hospitals is not suitable for people who have cancer. The basic problem is that there is too much dairy in the diet, I am reliably informed; I am not a physician, but that is what I have been told by people who are reliably informed. That is something you might want to look at.
Moving on, on financial risks, if a pioneer attempts to implement an ambitious programme that ultimately does not achieve its objectives, will the pioneer receive financial support so that they are not left exposed by the cost of experimentation and failure?

Norman Lamb: Ian may well be in a good position to talk about the view from NHS England—the emerging view, particularly based on the Five Year Forward View—but I think there is a legitimate issue about how we facilitate experimentation. The last thing we want is a system where people feel so constrained and risk-averse that nothing ever changes. You are then stuck with the same model of care, which may well be sub-optimal both in achieving good results for patients and in the way we use resources. We have to be able to encourage and facilitate experimentation. Ian may well have views on how NHS England seeks in the future to sometimes facilitate this issue of double running costs, as you try to change the model of care. I will hand over to Ian.

Ian Dodge: I will distinguish between two things—the risk, and how that risk is managed and shared within a locality. That gets to the heart of the question of the payment and financial flows within the system. One of the five supporting workstreams that have been established nationally, working with the pioneers, is looking at pricing mechanisms. Monitor is closely involved, with NHS England, in designing new models of paying for services. That work includes, as the Minister said, things like developing new capitated approaches. Linked to that, I believe it is also looking at things like alliance contracting and risksharing arrangements, so that there are robust mechanisms in place to support these new models. Potentially, some of those models may deal with financial risk more effectively than current models. If you think of the payment by results mechanism, which is payment by activity, there are significant risks within the current system for commissioners and, indeed, providers.
Being very frank, I think we have a lot more to do around designing those models. Doing that requires considerable technical expertise. It does not make sense for every part of the country individually to have to invest in understanding the mechanisms and how they might be changed and designed. That gets to the heart of what we articulate in the Forward View as a different kind of national-local dialogue. How can we avoid the overrigidness of a single blueprint that we impose everywhere or, equally, the inefficiency of simply allowing a thousand flowers to bloom? Looking across the 14 pioneers and, potentially, some of those that may get through the second wave process or some of the new models work that we are articulating in chapter 3 of the Forward View, to what extent are there some common patterns arising, where a number of different sites are trying to do similar things? If they are trying to do similar things, to what extent can we work with clusters of them to try to design, in essence, prototypes that can potentially be rolled out across the NHS more widely? That is the practical challenge that we need to try to address. We are just at the beginnings of that process.
Secondly, on your question around investment, this Committee has heard—and many observers of the NHS and historians will have observed—that, historically, things like changes in mental health services relied not only on technological change, such as the invention of new drugs, but also on some investment in those new models. There were double running costs associated with that. In the Forward View, we set out a view that, if we want to move beyond the current pace of change, we need to examine whether there is a need for some potentially significant additional investment in being able to unlock the new models of care. I think that in his evidence last week Simon said that we would be working with areas across the country to try to end up with a clearer view of that over the coming months.

Clara Swinson: As you know, the pioneer programme does not fund the services directly, but it should be aiming to give areas support if, as you say, they are taking a risk and thinking, "What is the new programme?" and are wondering how to evaluate that, what the metrics might be and whether they need leadership support. Hopefully, being part of the programme and the fact that they have been chosen should encourage them to think about different ways of doing things and, maybe, to take that risk, but also to get the support that they need if they are taking a bigger risk.

David Tredinnick: That is very helpful.

Q339 David Tredinnick: I would like to ask a few questions about the reforms of the payment system, some of which we have touched on already, if I may. Your written evidence refers to capitated budgets being a "fundamental building block" of new ways to reimburse providers in integrated care. Do you think it is possible to deliver fully integrated health and social care within the current mix of activity-based payments and block contracts, please? That is my opening question.

Norman Lamb: It is rather akin to an answer that Ian gave earlier about joining up teams. It is not just getting the culture right of bringing different groups of workers together, but it is making sure that the regulatory system is aligned to trying to work more collaboratively, and that the payment systems are aligned and work with the grain of trying to join things up. At the moment, my view is that the payment systems are not aligned with that and there is an urgent need to review the system of payment for activity. Everything that I have read suggests that it produces sub-optimal results in terms of patient outcomes.

Q340 David Tredinnick: We will link this to patient choice in a moment, but are there any examples of where capitated budgets are being regularly used to fund care for the highrisk and highuse patient groups targeted by integration projects?
Norman Lamb: There are examples in the United States of integrated care organisations which in effect have a capitated budget and are working with those groups along with other groups. Valencia is another example of that, and there are emerging examples in the UK. I think Salford is developing the idea of a capitated budget and a sort of alliance contract for frail elderly people. That is my understanding. But we are in the very early days. From recollection, the east London pioneer and the north-west London pioneer are working closely with Monitor and NHS England in developing alternatives to the payment-for-activity model.
Ian Dodge: May I add to that? I would say that on payment systems the key thing is to have a "horses for courses" approach. So, on occasion, block contracts over multiple years can be a good thing. What Sally Davies did around research funding some years ago, which was contestable block grants, was the right thing for research. There will be occasions when payment for activity may make sense. I am conscious of an experiment in the west midlands some years ago where smoking cessation services were deliberately trying to get greater throughput, and they ended up adjusting it for deprivation because they were trying to target people whom they had struggled to reach. For some elective activity it will continue to make sense to have some kind of feeforservice activity. We already have, in the UK system, a long tradition of capitated funding for general practice. If you think most of the—[Interruption.]
Chair: I am very sorry to interrupt you, Mr Dodge, but we have a Division, so is it possible to expand further on the capitated systems for general practice when we return after the vote? Thank you.
Sitting suspended for a Division in the House
On resuming—

Chair: Apologies. We had two votes. I beg your pardon for keeping you waiting a long time.

Q341 David Tredinnick: We have a lovely old tradition here where, if you are on your feet in the Chamber, there is an interruption and you have forgotten where you are, you can say, "I am not quite sure..." so a colleague will get up and say, "My honourable Friend was talking about this," and you say, "Yes, thank you so much." That is a good way of doing it, so I am going to do the same for you. We were talking about reforming payment systems and you were in full flow. You were talking about activitybased payments and block grants. Perhaps you would like to start all over again.

Ian Dodge: In response to your question on capitated payments, I was offering some wider observations around payment systems overall and suggesting that the key thing is that we have a "horses for courses" approach around the right payment mechanism for the right thing you are trying to buy. I observed that block grants are not necessarily a bad thing, citing the example of Dame Sally Davies's work when she was the director general for research and development in the Department and the work that she launched under the banner of "Better Research for Better Health", where she constructed a new system of contestable block grants for research, which led to major and significant reform.
Referring to trying to drive increases in throughput, in activity, I cited the example of some pioneering work that West Midlands strategic health authority did some years ago where they developed a currency for smoking cessation services that was adjusted not just for quit rates but for deprivation, and that seemed like an interesting model. Within the UK health system, we have a long tradition of capitated payments based around the registered list in general practice through the global sum in GMS and EMS. So I think we have a foundation on which we can build.
In relation to delivering more integrated care for the frail elderly and for people with longterm conditions, there is certainly a case that expanded capitated payments will intuitively make a lot of sense. The average sum is something like £120 or £130 in general practice per patient. One of the interesting questions is: can we construct models that are for a wider range of services than just the narrow range of things delivered currently through GMS based around, potentially, the registered list? Those are exactly the kinds of things that some of the pioneers are interested in, and the Minister alluded to North West London, who I suspect are further ahead on this, perhaps with the Waltham Forest, East London and City pioneer as well. We have said in relation to the multi-specialty community provider model and the primary and acute care systems model that we will be looking to develop new models of capitated payment. I imagine that that will form a core part of the forthcoming longterm pricings strategy agenda work which Monitor are developing with NHS England.
So there is a lot of potential and a potential that we plan to capitalise on through expanded capitated payments. That said, I do not think it is necessarily a precondition for people being able to join up care. We have good examples of local leadership designing what is the right thing for patients. The challenge is that, if we want to accelerate that work, we need to make sure that provider governance systems, regulatory structures, commissioning systems, and payment and contracting mechanisms all support rather than hinder that desire to get the right care models.

David Tredinnick: Thank you.

Clara Swinson: To look at your question from another point of view, what can be done for the national funding flows and what should be done to make those models more appropriate? There is also what can be done at the individual level. The integrated personalised commissioning and personal budgets that can bring together the funding for the individual is another way of looking at the same question about funding flows.

Q342 David Tredinnick: I want to ask a supplementary question to try and look at the practical aspects of patient choice and the narrow range you have spoken about in connection with availability of funds. You have mentioned Dame Sally Davies a couple of times. She was in fact in front of the Science and Technology Committee this morning at 8.30 talking about Ebola, and last week Simon Stevens was presenting to us on the Forward View. The Science and Technology Committee is extremely concerned about antibiotic abuse, which is packaged up as antimicrobial resistance. We had a report last week that doctors are now prescribing 24% more antibiotics for colds. Dame Sally has written a book, "The Drugs Don't Work", that majored on that.
I raised the Cancer Act, which is out of date, and I want to raise another old Act—the 1950 Faculty of Homeopathy Act, which regulates homeopathic doctors. They are regulated as part of the health service by Act of Parliament in 1950. They have been relentlessly under attack in the last couple of years, but that whole attack seems to be fading away, not least because the Professional Standards Authority have just agreed to oversee the 1,000 or more people in the Society of Homeopaths who are nondoctor homeopaths. They are qualified—

Chair: Is this really to do with pioneers, though? Can we jump to the question about pioneers?

David Tredinnick: Not everybody is in favour of homeopathic medicine, Chair; we know that. With Dame Sally herself—thinking of Halloween—it is like a cross to Dracula: she does not like it at all. But there are people out there who will use homeopathic medicine to avoid using antibiotics. The problem is—and we have heard this under the old medical system—that the funds do not necessarily flow to those qualified doctors to prescribe that. The Science and Technology Committee has had this problem—and Dame Sally is noted as saying—that there are no new antibiotics on line and there is nothing down the road because there is no money in it, or we are desperately trying to get Government incentives to do it. But my point is this, Chair, and then I will finish, and I know this—

Chair: No, it is just a question of, "Can we have a question?"

David Tredinnick: I have not really had a chance to explore this, so I would be grateful. What I am saying to you is that we have the Cancer Act 1939, which I referred to, and we have these people who are already providing a medical service which is available throughout the world, and could provide alternatives and stop people taking antibiotics if there is a greater range of funding there. I am just appealing to you, Minister, to look particularly at this ancient art, which is part of our health service, and now we have another layer of Government regulation that has come to bear on that. I do think that it is ludicrous to be advocating that we need to be just looking at the potential of new treatments when you have old treatments there, which may not appeal to everybody but they are there and they are regulated by law.

Norman Lamb: You appeal for me to look at it and I will do so, absolutely.

Q343 David Tredinnick: Will you do that?

Norman Lamb: Yes, absolutely.

Chair: Thank you.

Q344 David Tredinnick: Is that it? Mr Dodge looks like he might say something.

Ian Dodge: NHS England and its partners are certainly committed to choice, not just of provider but of treatment, and, as my colleague Clara alluded to, as part of the work on personal budgets and the integrated personalised commissioning programme, our ambition is that the type of services that patients receive is determined by patients themselves rather than just by professionals. Obviously, they will want to do that bearing in mind the evidence that they see around what does and does not work.

David Tredinnick: Thank you.

Q347 David Tredinnick: Thank you very much. I was just looking through some of the notes here. The University of York has called into question the whole notion of reducing costs and emergency admissions through better integration of health and social care. I do not know whether you have seen their report, but why do you believe that these are viable ambitions for the pioneers to achieve?
Norman Lamb: I have seen it—it is a while since I saw it, so I hope my memory is accurate—but, first of all, they are pretty clear that it can achieve improvements in care. Let us start by focusing on the most important thing, and that is that if we can improve a patient's experience by joining up care more effectively, even if it was to achieve no cost saving, then surely it is something that is worth doing. Beyond that, they also highlighted the fact that there are examples out there of interventions joining up care that do appear to achieve cost savings.
I come back to my starting point with all of this that the evidence base, globally, is still embryonic, and we need, therefore, to build up the evidence base. It is fair to say that virtually every leading health care country across the world is heading in this direction, recognising that the care of people with longterm conditions, which is the big challenge of our age, is not well served by episodic care and payment systems that pay for those episodes without looking at the whole experience of that patient and without focusing sufficiently on preventing deterioration. There is a growing consensus around this, but the evidence of the interventions that are most effective is still very embryonic and that is why the sort of experimentation that this programme allows is so important.

Q348 David Tredinnick: Fine. Do you believe that patient experience is important? Before there were double blind placebo controlled trials and all the science stuff came into play, the one thing that we really had was observation. The only reason cholera was discovered was because someone took a pump handle off a water pump in Soho and then established that the people who had been using that pump were catching cholera.

Chair: It was the other way round. It was after the—

David Tredinnick: I defer to the doctor.

Chair: They did the epidemiology and then they took the pump off.

David Tredinnick: Anyway, I am sure we are agreed that cholera was identified through that episode. Is that right?

Chair: Yes, but we will argue about that.

David Tredinnick: Anyway, patient experience does seem to be an extremely important part of this.

Norman Lamb: I totally agree.

Q349 David Tredinnick: I sometimes wonder if the health service, and certainly those who take very fixed positions, against any innovation tend to poohpooh patients' experience. In my view they do.

Norman Lamb: Incidentally, there were pilots in the last decade on integrated care, and the evaluation at the end of those pilots recognised that the patients' experience and their own views were not sufficiently central. That is why the work of National Voices is so important in this—that we concentrate completely on the individual patient.
I was very struck in Greenwich last week by how, when an individual is referred to the joinedup integrated team, they start by asking the question, "What is most important to you?" They gave a wonderful example of a man who was schizophrenic, who was a very heavy user of ambulance services and A and E departments. When they asked him the question, "What is most important to you?"—this was after years of the GP getting nowhere in identifying the solution and the GP in the end referred him across; a GP, incidentally, who is one of the inspiring leaders of all of this—the first three things he came up with had nothing to do with health care. It was damp in his house, his gambling problem and concerns about the behaviour of a relative. But the team was able to address those issues because they moved beyond the narrow confines of health. So everything has to be focused on the individual, on the person.

Q350 David Tredinnick: I wanted to ask you about Greenwich, which I know quite well because I stood for election there many years ago. Is there not going to be a firestorm of new thinking going through the health service if we really pursue this route of patient choice? We are patently going back to antibiotics. A lot of people are terrified of them. We are going to be looking for different solutions because they are worried about using them up before they have something really serious. We are going to have to have this spread of new thinking and it is going to be patient-driven. There will be great challenges there for health professionals.

Norman Lamb: It is a challenge for all of us, but your Chair was talking very eloquently—

David Tredinnick: I have to be very careful of the Chair; she is a doctor.

Norman Lamb: But she was talking very eloquently about the financial pressures on the system and the challenge we face. It is an existential challenge to the health and care system, whoever is in power—that is the truth of it—because of the rising cost across the developed world. So we have to think afresh.

Q351 David Tredinnick: Thank you. If we go back to Greenwich, they have claimed that their programme has achieved £900,000 in savings but could not provide us with any detail. On what basis can you be confident that these pioneers will deliver care more cheaply if they are not really able to provide hard numbers?

Norman Lamb: I come back to the fact that, again, we are building the evidence here and not all of them will succeed, I am quite sure. I am pretty confident that, through the work they are doing, all of them will demonstrate better care and a more personalised approach, but in terms of cost savings it is inevitably going to be variable. If you look at the emergency admissions, that data in itself is fascinating. You could, of course, be spending more money on the preventive work that stops those admissions from happening, so you have to make sure that you understand what the investment is and what the saving is. But the impact that they are having on people's lives must be dramatic because they are saving crises from occurring.

Q352 David Tredinnick: Running on from that, one of the problems of the new system, if it is successful, is that it creates new demand. Therefore, if you try and meet a previously unmet need, you are going to increase demand, and does that not compromise efforts to reduce the overall costs? I will help you with the answer. Is it not ever the case in the health service that, as you improve treatments, people live to a longer age and then you create a whole lot of new demand?

Norman Lamb: I do not think it is necessarily the case.

Q353 David Tredinnick: The answer is yes, is it not?

Norman Lamb: I give you the example of Cornwall and the work of the volunteers working alongside GPs in combating loneliness. The objective of that is to reduce dependency. I fundamentally believe that the wider community has a critical part to play in finding solutions to these problems; the state cannot provide happiness on its own. It has to be down to people. The incredible power of this experiment in Cornwall is that, if it reduces dependency, then it is reducing demand on both the social care system and the health care system, so I do not take it as read that it inevitably leads to more demand.

Q354 David Tredinnick: Finally, is your confidence in the patient and this new paradigm of getting away from diseasespecific treatments to holistic patientcentred treatments partly driven by the success of the personalised budget trials in the health service, which have reduced costs and improved outcomes for patients?

Norman Lamb: It is most of all driven by what I believe in. Giving power to individuals to determine what their priorities are must be the right thing to do, but you then look at the evidence from personal budgets and it does seem quite powerful that people's experience of the system seems to improve. If that has happened in social care, then there must be scope for it to at least be explored within a mix of health and social care.

Ian Dodge: May I add one comment on the demand point? Certainly NHS England is mindful of the risk that if you introduce new services—potentially things like better access— then there is a risk of creating additional demand. The real challenge is how we look in the round at the resource utilisation for the individual. In an ideal world, we would have integrated systems to be able to assess the outcomes for individuals across all health and care services, and indeed the costs, because the real question here is, "What are the aggregate costs across health and local government services for individuals?" Having block contracts for community providers, NHS and social care systems that do not talk to each other—in terms of the IT—makes that really difficult. So there is a big practical question before we can fully answer the question and be able to make sure that what we are doing is reducing cost and understanding what that looks like at the level of the individual. That will be one of the first elements we will undoubtedly look at in the development of the integrated personalised commissioning programme: how do we construct joinedup budgets for individuals across the NHS and local government?

Norman Lamb: In some areas increasing use of services is something that we should absolutely welcome. Your own report, coming out soon, looks at children's mental health and the fact that access is so poor to children's mental health services as a percentage of total prevalence. We should directly address that, say it is not acceptable and find ways of improving it.

Q355 David Tredinnick: Within that report, which we released earlier on today, there are big questions about where the money is coming from for that and whether the size of the budget allocated to mental health is the right size—whether the segment of cake allocated to mental health should be prized open a little.

Norman Lamb: I will tell you; it goes back to an earlier question you asked about payment systems. I am absolutely clear that if you have one payment system in physical health of payment for activity and a block contract in mental health, combined also with a whole series of access standards in physical health and nothing in mental health, this absolutely determines where the money goes and mental health loses out. I have no doubt at all about that, and that is why I am so determined that we change that so that we achieve equality between the two systems.

Q361 David Tredinnick: I want to deal with the emphasis on evaluation. Much of the emphasis appears to be on removing system barriers to integration—and I think you have explained that throughout this presentation. At what point will that emphasis shift from measuring the success of the pioneers in making structural changes to determining whether they have delivered improved patient outcomes, please?

Norman Lamb: Ian may well have some views on this now he is in charge of the whole project, as it were, but certainly from my point of view the objective has to be the latter. The only purpose of removing barriers is to achieve a better result for patients. That has to be ultimately what we focus everything on, so that is what, ultimately, we have to be able to evaluate.

Clara Swinson: The focus for the pioneer areas is already on what changes they are making in their local areas for patients and users, and that should absolutely be the focus from the start. In terms of the evaluation, what we are not doing from the earlier evaluation is being able to compare those outcomes. Because of some of the difficulties that your Chair mentioned, that is what is coming in at the second phase of the evaluation, but, absolutely, pioneers should be doing what they are doing because of the outcomes for patients.

Ian Dodge: Going back to the earlier observation of the desire to introduce some greater method, structure and rigour into how we run local experiments and secure national learning, there is something around the real-time evaluation of assessment of what are the common elements across the different pioneer sites, to what extent we can discern and articulate those patterns, and how well different pioneers have gone about constructing and putting in place the new models. There is something around the learning from that as well as the learning from the outcomes—the costs involved.

Q362 David Tredinnick: So it is two elements, then: you have the outcomes of the new models and the outcomes of the models—

Ian Dodge: Absolutely. I would emphasise that, in order for us to have replicable findings elsewhere, we need to have an articulation of the models and how well people have gone about implementing them.

Q363 David Tredinnick: So you evaluate the models themselves.

Ian Dodge: Certainly, as we look to construct the new models set out in the Forward View—the multispecialty, community providers, the primary and acute systems and so on, and we have talked about building up that realtime evaluation capability—if we are then going to spread learning, it is essential that we do that. An observation I would make from 20 years in health policy is the extent to which we have had lots and lots of pilots in the NHS and we have quite often then rushed to say, "Success. Let's spread them across the country," without first of all defining what it is that we are spreading. In most walks of life innovation has three parts: it has the invention of something; it then has the subsequent adoption, and then the spread—and that process takes many years. It is really important that we are clear about what it is we are actually inventing that can be adopted and then spread.

Science and Technology Committee
Oral evidence: GM foods and application of the precautionary principle in Europe, HC 328
Wednesday 29 October 2014

Members present: Mr Andrew Miller (Chair); Jim Dowd; Mr David Heath; Stephen Metcalfe; Stephen Mosley; Pamela Nash; Sarah Newton; Graham Stringer; David Tredinnick

Q73 David Tredinnick: I was going to ask a general question on the need for further public dialogue, but I think that is superfluous having listened to the discussions over the last 10 minutes. From what you are saying, it does seem to me that there is a real need for the public to put forward their views, so it should not just be a lecture process from people in authority. Is that right?

Professor Wynne: Yes, definitely.

Dr Stilgoe: I think that is right.

Q74 David Tredinnick: Wearing the hat of someone who worked in the advertising industry many years ago and trying to boil things down to a very simple concept, if I am asked to present this, it seems to me you have a situation where GM to the general public means weird plants with funny things coming out of them which are potentially a threat, unfortunately. For tabloid newspapers, black top or red top, it makes a terrific headline—"Terror"; it is a good story, although it is definitely not true in the way it is presented, whereas food security has a very warm feeling. That is about saving lives and making more people happy across the world, and you can explain the difference between what is going on in Germany and Spain. In Germany you have very large food security and you can perhaps have the luxury of being not very keen on GM, whereas in Spain, which is an arid country and subject to more flood and famine, it is more open to the possibility of developing ways of avoiding that sort of thing. Do you have any resonance with what I have just said?

Professor Wynne: In terms of the specific factors and a comparison between Germany and Spain, I do not think I have any comment on that. The research we were doing and research I have seen since that time has not really dwelt on specific questions of that kind.

Dr Stilgoe: I would repeat a recommendation that came out of the Royal Society's report "Reaping the Benefits" on food security, which I think came out in 2008. The recommendation there was that public dialogue should start with the issue rather than presupposing any particular solution whether or not it is GM, which immediately forces people into a yes or no polarised discussion.

Q75 David Tredinnick: It is a means to an end, is it not? The end is food security; GM is potentially a means, but there is biodiversity and all the other issues, like seed pollination.

Dr Stilgoe: There is the potential for a constructive conversation if you frame it in those terms and start from that end. I would not necessarily agree with the reasons you identify for doing so. However, in terms of the potential for constructive public engagement, I would say yes.

Síle Lane: There is a lack of awareness about the challenges we are facing in agriculture, food security being one of them, but there are other challenges. Did you know, for instance, that the plum pox virus, which has now come into Europe a bit more after opening up trade borders in the east, is now prevalent in 16 member states? It is very hard to contain because it is carried by an aphid. Did you know that soil is being polluted by phosphorus because of the use of pig manure? It is making soil very polluted, and we need to find solutions to that. There are real challenges faced by agriculture, but there is a huge lack of awareness of them. Because of that, there is a lack of ownership. Right now it is nobody's problem that soil is being polluted by phosphorus from pig manure, but those challenges explain why certain research questions are being pursued. The way to do it is probably by more awareness and ownership of the huge problems that we are facing as a society in terms of food security and beyond.

Q89 David Tredinnick: Changing tack slightly, why do you think consumers choose to pay a premium to buy organic products?

Jon Woolven: People buy organic for a whole variety of different reasons. From our research, the top two drivers are "more natural", whatever that means exactly, and it is desirable for those consumers, and also "environmentally friendly". That is followed up by "tastes better", "healthier" and "better animal welfare standards". In terms of the GM aspect, one quarter of organic shoppers in our surveys mention GM-free as one of the reasons to purchase organic.

Q90 David Tredinnick: To what extent has the organic brand become linked with other attributes valued by consumers—for example, extensive farming and animal welfare?

Sue Davies: Our research shows similar findings in terms of why people buy organic, and it will vary for different people. Some people may be more focused on animal welfare. It is seen as something less intensive, and generally I do not think that GM is seen as compatible with that. People who opt for organic are going for a more extensive and natural form of farming. Given the traits of the first crops that have largely come on to the market, particularly herbicide-tolerant crops, in particular it has not been something people buying organic would associate with that.

Q91 David Tredinnick: If, as I think you have just said, consumers consider genetic modification and the organic movement to be mutually exclusive, do you think that one day GM foods could be successfully marketed as an environmentally-friendly alternative to conventionally grown crops?

Jon Woolven: It is conceivable. As we sit here today, it is very hypothetical. You would need to have products developed that had clear environmental advantages, and this would then be an interesting test.

Sue Davies: It goes back to the point about looking clearly at the specific challenges we are facing in the UK and the different options to address that. There could be environmental benefits from using GM crops. Whether or not that becomes compatible with organic, given that organic is also associated with a range of values, is probably quite different.

Q92 David Tredinnick: Are you happy with the current legal definitions of organic products? Do you think they are misleading?

Sue Davies: We have not had any concerns about it generally. We think that the regulation fits with people's expectations, but we have not done up-to-date research on that, to be honest.

Jon Woolven: I do not have an opinion on that. We are a non-lobbying body that does not focus on regulations.

Health Committee
Oral evidence: Public expenditure on health and social care, HC 679
Tuesday 28 October 2014

Members present: Dr Sarah Wollaston (Chair), Rosie Cooper, Andrew George, Barbara Keeley, Charlotte Leslie, Andrew Percy, Mr Virendra Sharma, David Tredinnick, Valerie Vaz;
Questions 1 - 159
Witnesses: Simon Stevens, Chief Executive Officer, Professor Sir Bruce Keogh, National Medical Director, Paul Baumann, Chief Financial Officer, NHS England, gave evidence.

Q89 David Tredinnick: I want to ask you about new care models, and start with a general question. Then I would like to ask you about a couple of specific examples of new care structures in London and one in Nottingham, and see where we go from there. The Forward View discusses a number of new care models and ways of working. Do you consider that these new approaches will provide efficiency gains, and, if so, how have they been factored into your calculations?

Simon Stevens: Yes, thank you. We certainly do think that they will provide efficiency gains for more integrated care, particularly for frail older people. I do not know whether Bruce wants to talk a bit about some of that—then I or Paul can come back on some of the numbers around that—in terms of changing clinical practice and bringing together health and social care, primary care and secondary care for the folks we are talking about.

Professor Sir Bruce Keogh: We know that one of the big demands is particularly with older, frail patients. We also know that, if they get admitted to hospital, they tend to stay there for a while because people cannot easily get them out because of the support that is needed. So we are looking at a

Science and Technology Committee
Oral evidence: Mitochondrial Donation, HC 730
Wednesday 22 October 2014

Members present: Mr Andrew Miller (Chair); Jim Dowd; Mr David Heath; Stephen Metcalfe; Stephen Mosley; Graham Stringer; David Tredinnick

Q12 David Tredinnick: Professor Braude, you said earlier that you thought there had been too much research on some aspects of this work.
Professor Braude: Not too much research. We spent a lot of time. The accusation against the panel is that we did not consider it. Our counter is that we spent a huge amount of time on it.

Q13 David Tredinnick: Can you estimate how much more research is needed before we will be ready for the first in-man, or if you prefer, in-person, trials in the UK? What will we need to know?

Professor Turnbull: The evidence that has been presented to the scientific panel has shown clearly that this technique is feasible. There is very little carryover, and it would prevent disease. The research currently being carried out is to try to ensure the safety of this technique, making sure that any embryos generated by it look and behave normally. That work is currently at least being reported in human embryos—it is in the process of being reported in human embryos. We are really talking about safety and efficacy. The HFEA scientific panel has already seen some of those crucial bits of information; others would be presented to a licensing authority. We are going to come to licensing later. What would those people want to see if we applied for a licence?

Professor Lovell-Badge: We suggested a couple of things that we felt were important to do or to finish off. There are different techniques. The spindle transfer technique has been pioneered in the US. Most of the evidence we requested is already published. We were a little worried about efficacy. It seemed to be a little inefficient. The data we have seen from the Newcastle group suggest that the other method—the nuclear transfer method—is probably more efficient, but the analysis we have seen has not gone as far as the analysis on the other technique, so we cannot say which is going to be best.

Q14 David Tredinnick: On that point, although maternal spindle transfer was successfully tested in macaques, it was then decided not to pursue non-human primate testing for other techniques. Can you elaborate a bit on that decision?

Professor Lovell-Badge: There are several reasons. We changed our minds. In our very first report we suggested that experiments on PNT in macaques would be useful, but we heard in evidence from Mitalipov's group in the States that they had tried to do PNT with macaques and failed. Experiments fail all the time for all sorts of reasons, but that meant that, if you were going to force someone to do those experiments, you would be starting off by saying, "We have no idea how to do it in macaques because it did not work using standard methods." You are going to have to use an awful lot of monkeys to do the work. There comes a point where it becomes unethical to propose doing experiments on nonhuman primates anyway.
We felt that the reason why it had probably failed when people tried to do this was that there are differences between the very early embryology of different mammalian species, including macaques and humans, and that was becoming evident from other little bits of information we were getting about the efficiencies of different methods—specific aspects of timing and how things work. We felt that in the end it becomes pointless doing an experiment on an animal model which is not good enough. There is no point doing experiments if macaques are not going to give you the exact answer you need to get from human embryos. In the case we knew, from all the work done in Newcastle, pro-nuclear transfer could be done efficiently with human embryos, so there came a point when there was no reason to justify it.

Q30 David Tredinnick: How do you think patients will be assessed for their eligibility to utilise these techniques? What will the criteria be?

Peter Thompson: There are criteria clearly set out in the Act, and they are the two I referred to earlier. There is a big role—we will need to talk to the clinics involved—for the particular package of evidence that comes with each application. If I look at how we currently do something related to PGD, pre-implantation tissue typing, which is still done on a case-by-case basis, there is usually a detailed letter from the treating clinician setting out the particular details of the case and why they feel this is the most appropriate treatment. In the regulation of PGD and pre-implantation tissue typing, there are already models we can successfully use as a basis for thinking about how we go about regulating mitochondrial donation.

Q31 David Tredinnick: Is it correct that generally new technologies are more lightly regulated as their use becomes more commonplace? Regulation can become less onerous. Might that apply in this instance later on?

Peter Thompson: It might. When we first started to license PGD, it was done on a case-by-case basis. Some years ago we moved to a condition-by-condition basis. Instead of approving every case, we approved every new condition. Over time, the range of conditions that can be tested has increased enormously as testing technology has developed. We have a number of clinics across the country that are licensed to do PGD. When one of them makes an application to do a new condition, if we grant that condition as sufficiently serious to warrant PGD, any of those clinics can offer that condition as part of a suite of conditions. That has developed over time. It is quite possible over time, should Parliament decide to pass this, that that may be the better view. Robert Meadowcroft has already hinted at it. I think there is a sense early on that with new and novel techniques a particularly rigorous form of regulatory oversight is probably appropriate.

Professor Montgomery: From an ethical perspective, it depends whether the questions are new ones or old ones. If the issue is about the seriousness of the risk prevented—from the particular condition—it makes sense to resolve that once carefully and not reopen it every time but keep it under review. If the issues are uncertain and developing, you would want to keep close scrutiny. I am not sure whether light or rigorous regulation is quite the right model; it is about questions which remain very uncertain and questions which seem to be getting some clarity. It makes sense not to have a bureaucratic hurdle that asks a question every time to which we already know the answer, but in the areas where we do not know the answer we should be able to keep looking closely.

Robert Meadowcroft: I would agree with that. I think that a case-by-case basis initially is the way to go forward on this. Patients will be cautious but not overcautious. If there is evidence that this technique will help them and their families, they will be keen to explore it further and discuss it with their consultant, and measure the benefits and potential risks very carefully, but when evidence emerges that this is shown to be safe, all being well, I think there will be less concern on the risk side but more concern about the appropriateness for them and their family of the choices they will be looking at.

Q48 David Tredinnick: Could you tell us how many people in the United Kingdom you believe could benefit from these new techniques?

Professor Davies: In the first place, we think it is about 20 families that are very severely affected, but if it proves to be as safe as we believe it will be—only time will tell—we expect that may rise to about 80 families a year, if we go forward. Let me put on record that I hope we will, both scientifically and for those families; you would not want to deny that life-saving opportunity to families where children will die before they have become adults.

Q49 David Tredinnick: We are talking about a relatively small number of people—a small number of families. Would you consider making these treatments available to overseas citizens, Minister?

Jane Ellison: Over time, we might expect that the procedure might be offered by centres to overseas patients, but it would be for individual clinics to assess each case, and of course they would all have to work within the regulatory framework. The clinics would assess the cases and prioritise, but we would expect them to have a protocol for doing that to ensure that NHS patients were the priority. I would expect it to be something the HFEA would look at on a case-by-case basis, but our expectation would be that NHS patients would be the priority.

Professor Davies: Of course, overseas patients pay the full cost. The NHS would not be subsidising that treatment.

Q50 David Tredinnick: That is another question I had. Given the current debate, it is probably helpful to have that on the record. Who would be responsible medically and financially for the ongoing care of overseas citizens? You have already said that overseas citizens would be responsible for the full cost of the treatment. What about the responsibility for their long-term care? Is that responsibility divided, given what you have just said, into responsibility for cost and moral responsibility for the care of patients? Possibly an advisory service would write to make contact if they are uncertain about how they are.

Professor Davies: I do not see the children who are born as a result of this, as with Louise Brown, as patients; I see them as future healthy children and citizens, but we would like to follow up nationals and people who live in this country so that we get the data. I would expect that the centres, if they take overseas patients, would ask for followup, and will be in close contact with the physicians who look after that family abroad, because they would need to be referred from a physician who looked after the family. We have a long and proud history of collaboration on research and follow-up between many countries through our academic networks. I think we would get some, if not all, of the data.

Science and Technology Committee
Oral evidence: GM foods and application of the precautionary principle in Europe, HC 328
Wednesday 15 October 2014

Members present: Andrew Miller (Chair); Mr David Heath; Stephen Metcalfe; Stephen Mosley; Pamela Nash; Graham Stringer; David Tredinnick

Q20 David Tredinnick: In your written evidence, GM Freeze and Greenpeace point to a European Environment Agency report entitled "Late Lessons from Early Warnings." Could you explain what you consider the early warnings to have been in the case of GM? That question is for you, Ms O'Neill, and for Dr Parr.

Dr Parr: I would say that the early warnings in this case were the recognition that unintended effects do happen associated with the GM technique, and that random insertion during the process of genetic modification produces unpredictable outcomes that can potentially lead to unpredictable effects when released into the environment.

Q21 David Tredinnick: I am going to ask the professors to come in on this in a moment, but would you agree with that position, Ms O'Neill?

Liz O'Neill: Certainly on a molecular level, that seems to be in tune with the advice that GM Freeze has received, but we also have to look at the real world level. The phrase "early warning" almost seems ludicrous in this instance, but if we look to north and south America, where a large amount of GM is grown, we have seen a huge growth in pesticide-resistant weeds, a massive decline in the monarch butterfly, and a large number of serious contamination incidents. A form of bentgrass that was developed for golf courses is growing wild along American watercourses. In Switzerland, there is herbicide-tolerant oilseed rape growing alongside roads and railways; it is not even permitted to be imported for animal feed in that country, so it does spread. When a transferred gene offers a competitive advantage in the environment and if it gets out into the world, it will be extremely difficult to contain. Our own farmstead evaluations showed that GM farming is damaging to wildlife and biodiversity. They are not really even early warnings; they are huge red flags.

Q22 David Tredinnick: Professors, if you could answer these specific points in your contribution I would be grateful: the issue of weeds that are resistant, the decline in butterflies, the problems of the special grasses being grown for golf courses and oilseed rape growing along railway lines. It would be helpful if you were able to comment on each of those specific points.

Professor Leyser: I would like to comment in a general way, rather than going into the detail of exactly how many of these and how many of those. All the things that you mentioned, absolutely all of them, are not to do with GM. They are to do with the trait that has been introduced. If one takes herbicide tolerance, for example, and all the issues about weed resistance and so on and so forth, there are non-GM, single gene, herbicide-tolerant crops out there. There is no scrutiny whatsoever before they are put in the field, just the standard breeding applications. They have exactly the same, or possibly slightly worse, issues associated with them. This is exactly the point.
If one is concerned about particular environmental issues, such as the spread of herbicide tolerance, campaigning against GM is the wrong way to go, because it is not caused by GM. It is caused by herbicide resistance. If your concerns are those environmental issues, you should be campaigning against herbicide resistance, however it is introduced. We need a regulatory system that looks at traits, however they are introduced, not GM. Banning GM tomorrow will have no impact whatsoever on any of those problems, because there are other ways to achieve those things.
One has to be really clear about this, and a lot of what we have been discussing is exactly the kind of problem that has happened over the years. GM has attracted, as a magnet, all the issues that people are concerned about in agriculture. They are real and important issues, but none of them has anything to do with the technique. As a result of the absurd focus on GM, we are ignoring all these broader issues, and the problems that we would like to address are going unaddressed because everybody is banging on about GM.

Professor Baulcombe: I would agree with that. It has been highly unfortunate that herbicide-tolerant crops have been mismanaged in the United States. I would have been happy to join a campaign that argued for the environmentally sensitive management of such a valuable trait. It is wrong to argue against GM herbicide tolerance as such. One should be trying to develop a rational strategy for the management of the trait. On the question of the butterfly, it may be a correlation—

Q23 David Tredinnick: I chose butterflies because, as a politician, it is an emotional issue. We see butterflies floating around. We love them. The fate of the butterfly, in a sense, is something that my constituents in Hinckley and Bosworth can identify with, and if they hear me talking about it here it is something that is very understandable. Is it good for the butterfly or not?

Professor Baulcombe: Industrial agriculture is bad for butterflies. Intensive agriculture, where you have a monoculture without wildlife in the farming environment, is bad for butterflies. Herbicide tolerance has given you very good weed control, it has reduced the number of wild plants in the agricultural environment, and in north America it may be associated with the decline in the population of monarch butterflies. That raises again the question of the management of technologies, so there is a discussion about intensification of agriculture. If one combines that with a strategy for land sparing—setting aside land for wildlife—we could maintain the diversity. It is the wrong issue to argue against GM crops. Again, if one wants to save the butterfly, one should be arguing about the management of industrial agriculture.

Q24 David Tredinnick: Are you saying that the GM crop is a problem for butterflies or not?

Professor Baulcombe: I am saying that an agricultural environment which has very few weeds in it is a problem for butterflies. GM and non-GM herbicide-tolerant crops will give you such an environment, because they allow the farmer to get good weed control. Do we want farmers to be able to grow their crops with good weed control? Yes, we do. Do we want to keep butterflies in the environment? Yes, we do. Can we find a strategy to manage to reconcile the two? Yes, we can. That is where the focus should be, rather than on opposing one part of the equation, which is a technology to give one particular agricultural trait.

Q25 David Tredinnick: Finally, and this is for all of you, can you see in the future any scenario in which GM might be able to make a positive contribution to global agriculture? If not, why not?

Dr Parr: I shall answer that question, but I want to pick up on the traits question, and why I was particularly keen to draw a distinction between the molecular side, which we have covered, and the traits that are delivered by GM. When one looks at what is actually on the table rather than at the theoretical potential, it is very much the traits that are supporting what we could call a quite industrialised agriculture—heavy input agriculture is how I would describe it. Concern about GM is not restricted simply to the GM technique; it comes from what social scientists have called the technology constitution. What comes along with it? It is not simply a technique; there is a structure for how it is going to enter society.
In the case of GM, which has heavy intellectual property protection, it is nicely set up for delivering some of those traits, which are essentially about homogenising the environment around the crop plant. It is particularly well geared for large corporations to deliver those kinds of outcomes with the seeds that they choose to produce, in many cases to reinforce their existing chemicals businesses. Separating out the traits from the GM technique is not quite as clean and straightforward as it might first appear. Sorry, I have now forgotten your second question.

Q26 David Tredinnick: It was simply this. Is there any way in which you see GM making a positive contribution to global agriculture?

Dr Parr: It could. At the moment, we continue to see the problems that I have outlined, but foretelling the future is a dangerous game. We will see what happens.

Liz O'Neill: Absolutely. The crops that are currently awaiting approval in the EU are all herbicide tolerant and insecticide expressing, so the traits are very connected with the technology at the moment. GM Freeze would have difficulty imagining how those could be used in a positive way, but the technique could be used for all sorts of good. Indeed, our memorandum and articles of association delineate what needs to be done to make that happen. It is about open access, liability regimes and protecting choice. We are certainly not against the technique—the technology—on its own terms. It is the reality of what is being done with it in relation to farming today.

Professor Baulcombe: May I make a point about the technology constitution? It is not inevitable that GM would be linked to large multinational corporations, to an oligopoly in the food chain. GM is highly compatible with an entrepreneurial culture in which you could have non-governmental organisations and charities all developing GM technologies that would help us to drive the economy and the agricultural environment, producing more sustainable crops and food. There is no reason—well, there is one reason why this is not happening right now, and that is the regulatory process. The roadblock in Europe on the regulatory process is such that nobody wishing to invest in a start-up company would do it in the GM area at the moment because there is no route for them to get their product out into the field.

Health Committee
Oral evidence: Integrated Care Pioneers, HC 560
Tuesday 14 October 2014

Members present: Dr Sarah Wollaston (Chair), Rosie Cooper, Andrew George, Robert Jenrick
Barbara Keeley, Andrew Percy, Mr Virendra Sharma, David Tredinnick, Valerie Vaz

Questions 68 - 291
Witnesses: Dr Giles Maskell, President, Royal College of Radiologists, Professor Chris Ham, Chief Executive, The King's Fund, Jan Sensier, Chief Executive, Healthwatch Staffordshire, and Val Lewis, Healthwatch, Stoke on Trent, gave evidence.

Q149 David Tredinnick: When deciding how to improve cancer and end of life care, what other models did you examine and reject in favour of the prime provider model?

Andrew Donald: This goes back two and a half years so I will try and keep the story fairly brief. The first thing was that we wanted to understand what the problem was. There is no reason for coming up with a solution if you don't understand what the problem is. We spent two and a half years talking to lots of different people—patients, the public and clinicians—to understand what the challenges were with the system in which they worked. We are not trying to make a judgment on the care people receive; it is a judgment on the system of the health service, which seems to be bounded by organisational boundaries.
We understood the problem. What people were saying was about continuity of care, poor communication, and not being able to navigate the system, and it led to really poor outcomes for some patients and poor experience. There are lots of patients who talked to me who have had really good outcomes. We have to learn from that.
We then looked at the evidence and said, "Right, what models would help us try to drive and commission better outcomes and experience for patients?" We used the work of the King's Fund because, as Chris said earlier, the evidence is pretty limited on the different types of models. We could have just used a traditional commissioning model, but we did not think that would work. We looked at the prime provider. We looked at alliance space contracting. We looked at two or three models. Alongside a bit of evaluation that we got from the Office of Public Management, we came to a conclusion that the prime provider model, or service integrator model, would be the one that we would want to explore further and start to move down a procurement route with, which is about one organisation taking responsibility for multiple contracts and multiple providers to develop an approach to integrating care. That evaluation has continued, so we continue to learn through the pioneer programme and adjust our approach as we move through the programme.

Dr Shapiro: If I can add to that, I joined the programme fairly recently. Given that I have done quite a lot of evaluations, I was able to almost do a bit of internal consultancy and get a bit of the story. The thing that emerged for me was, first, there is a long history of dissatisfaction amongst patients and the public about the degree of integration and the experience that they have.
Somebody asked about Macmillan's input into this. There is a starting point long before this. The feedback that Macmillan was getting nationally was that patient experience is not very good and there was room for an experiment, and in some way to try a different model. That led them, if you like, into this arena. There were also poor outcomes. Again, somebody asked about the figures. The reality is that the incidence of most cancers is higher in Staffordshire than nationally. The spend is higher than most places nationally and the outcomes are poorer than most places nationally. In terms of somewhere that needs something doing, it is clearly very strong.
The evidence is that some of that is to do with deprivation in the sort of population it is. Quite a lot is a British phenomenon: we tend to go to services late. Part of what we want to do is to get in much earlier with primary and secondary prevention.

Q151 David Tredinnick: You are saying that the other models were before your time. Does that mean you did not look at them and evaluate them as possibilities?

Dr Shapiro: Not me personally. There is a list here of many that we went through.

Q152 David Tredinnick: What I am trying to bear down on is this: why did you reject the other models in favour of what is essentially a radical scheme? What evaluation did you do of the other ones? Convince the Committee, please.

Andrew Donald: I have been a commissioner probably longer than I remember—about 20-odd years. I have seen every commissioning change since 1990. One of the ways I describe it is that over the last 15 or 20 years I have felt a bit like a commissioning electrician. We would commission parts of services and then the commissioners would spend the next 10 years wiring it all together. We had a debate about how we could get an organisation to work with CCGs—they remain the commissioner statutorily—who have the experience to do that wiring of those providers to work together effectively. We have used as much evidence as there is available, but actually we are creating new evidence because there are lots of questions in this process to which we do not know the answers. As part of the pioneer programme, that is the learning bit. We have to make adjustments as we move along, but that is where we came from with this. It was about patients not getting a good deal and not getting a good outcome. If you are in Cannock and you have cancer, you die early and we spend lots more money than anywhere else, but you do not have a good outcome and experience.

Q153 David Tredinnick: Much of the work of this Committee has been looking at integrated healthcare. We have been looking at the Health and Social Care Act and the authorities that govern the different medics and the organisations therein. There is another meaning of integrated healthcare prior to that, and that is integration of mainstream allopathic medicine and complementary medicine. I happen to have chaired the group on integrated healthcare, alias complementary medicine, here for many years and been a member since 1988.
My experience of talking to cancer patients over the years is that they have been helped enormously by, for example, reiki, therapeutic touch and healers. The National Federation of Spiritual Healers does a lot of work. There are aromatherapists, reflexologists, homeopaths and herbalists. In this new integrated model, are these people, who alleviate suffering at end of life so effectively, getting proper representation?

Andrew Donald: That is the opportunity. One of the things we know about end of life care is that many people who die do not get a choice of where they die. Significant numbers of people die in a hospital bed when they wanted to die at home. That is a significant cost to the NHS. One of the things that we know is there are major gaps in service provision in end of life care. If you talk to members of the public and to patients they will tell you what those gaps are. With some of the services that you are talking about, particularly in end of life care, there is an opportunity to fill some of those service gaps with services like that. At the moment, we do not get that.

Q154 David Tredinnick: A lot of the ones I have mentioned are very cost-effective options and they are very popular. What you were saying about care out of the home is a different issue. I am talking about the availability of treatments which are non-mainstream and which particularly help those who are at the end of their lives.

Dr Shapiro: It may be worth rehearsing the procurement process. It is rather akin to procuring PFI, when that was still around. We procure on the basis of outcomes. We can tell our potential bidders, "These are the outcomes we want clinically: better survival, better patient feedback, better experience" and so on. What we do not do—and by the procurement process we are not allowed to do—is prescribe the mechanism. In the next phase—the competitive dialogue phase—the potential bidders will come up with ideas that we will then discuss with them. We will hone and refine their ideas, but, in essence, the difference between old commissioning and new commissioning under this idea—and it is not just the prime contractor—is that you procure for the outcome. The bidders then will tell you some of the mechanisms, and you agree the mechanisms with them. If they come up with complementary therapies, we can discuss it. It is not for us to prescribe.

Q155 David Tredinnick: I understand your point about prescription, not to be confused with prescriptions in this instance. Going back to Mr Donald's point about care at home that I rather moved away from, this is linked to my next and last question. One of your stated objectives is a significant decrease in occupied bed days. That sounds brilliant, but I do not see anything here about a specific target that the prime provider must achieve. It is the sort of thing you might see in a manifesto document, not from my party of course, but perhaps from one or two others. Can you be a bit more specific?

Andrew Donald: Yes. The reason it is not in a document yet is because that will be part of the negotiation of the contract through the competitive dialogue. Let me give you some statistics that might be helpful to you. We know, for example, that in University Hospital of North Staffordshire about 2,700 people die every year in the hospital. A significant proportion of those—something like 75% of those individuals—would have been known to services and yet they still do not get the choice of where they die. Their average length of stay is seven to eight days in their last emergency admission. They have probably had two to three emergency admissions before that. That is at a cost of about £20 million.
If we could give people more choice, and more services at home and in the community, and release that resource, that would allow us to plough more money back into the NHS for better services for people at the end of life. That is the sort of statistical stuff and the sort of thing that will go into a contract on end of life.

Q156 David Tredinnick: If I were to talk about personal budgets, would that ring any bells?

Andrew Donald: Yes, absolutely.

Q157 David Tredinnick: The early trials showed that, if you give patients their budget, not only did the patients use the money more effectively and have a much better quality of life but the providers were more empowered and the costs to the health went down. Are you taking an interest in that?

Andrew Donald: People asked about the contract. There are two parts to the contract. The first two years will be about understanding what we do not know. As Professor Ham said, there are issues about understanding what things cost and how the pathways work. As part of that, the prime provider will produce what is called a set of commissioning intentions. One of the things that we want the prime providers or the organisations to do through the competitive dialogue is come up with innovative ideas about how they use public policy to drive change. I think personal health budgets are a good way of doing it.

Q158 David Tredinnick: In summary, if I am talking to my constituents in Hinckley and Bosworth this weekend, what reassurances can I give them, having talked to you this afternoon, about your work?

Andrew Donald: You can give them reassurances that what we are trying to do is improve the outcomes and experiences of patients. We are trying to do that through a new mechanism called a prime provider or a service integrator. I think the language is a little unhelpful, but the CCG retains responsibility for commissioning and will ensure that throughout this programme patients and the public are involved in ensuring that there are checks and balances on the prime provider to make sure that we hit the outcomes and experience that we want, and avoid the number of unintended consequences that could occur with a programme on the size and scale of this one.

Q211 David Tredinnick: Dr Shapiro, you have talked a lot about the structures of the organisation. I want to ask Mr Attwood whether he is content with the way things are going. You have come out of retirement and got involved, as I understand it and according to the notes I have here, because you believe "that it was possible for people to have a say in the way we are treated by becoming part of the decision-making process." It says that you are "an advocate of putting the patient at the centre of care, seeing a patient as a person, not as a disease or condition and...a believer in the patient voice as an effective agent for beneficial change."
I have heard a lot about structural change in the form of centralisation through the prime provider service integration model. I am slightly concerned that I have not heard a lot from you. I would like to be convinced that, in your involvement as a non-executive director of transforming cancer and end of life care, you are content with the way this process is going. My colleague here has questioned some of the accountability aspects. How does it feel for you, as somebody who is primarily there to stand up for patients?

Barry Attwood: We have two organisations where we officially feed in information. We have patient champions. To get these patient champions, we went and stood in market squares in the snow and in supermarket foyers. We handed out leaflets to people and interviewed people. We asked them for their stories and people came forward and gave us their stories. When we asked these people, "Would you like to be a patient champion?" some refused and others did not. They came and we meet every month. They all come together and usually about 25 people turn up at our monthly meetings. We have a further 30 people or more who are in touch with us by e-mail all the time. They are constantly feeding us their stories and information. They are talking to other patients. We are trying all the time to recruit more people by going out and having our roadshows, going to little community groups and so on. We want to get these people to come in and talk to us and tell us what their experience is. This is to somehow find a way of improving the system.
The information from them is then taken by us, the non-executive board members, to the board and we bring it into the programme. We also have a forum of various organisations throughout the county. They are pressure groups, if you like, and various community interest groups who come along. Healthwatch are independently involved, apart from Mr Sneddon, in this. They come along and discuss the same things. We get information from them and we feed that back to the board. We feed it back all the time into the team. We go out all the time and talk to community groups anywhere. In Stoke on Trent, we have something called Community Health Voice. I shall be there on Thursday evening. We go and talk to people there. About 30 people regularly turn up there. They feed me the information because I am a member of it and I bring it back.
We go and talk to PPGs. We talk to any number of groups. We try to get this information and feed it back to the team so that this information is part of the design process. Furthermore, the patient champions are part of the procurement process. We have just done the pre-qualification questionnaire. The questions that came back from the bidders were looked at, not just by professionals but by these patient champions and other members of the community. We can look at this and get a fair assessment of what it is that people need. That is all part of the design process. I think you must take this into account when you are thinking about what we are doing. It is very much the patient voice.

Health Committee
Oral evidence: Work of NICE, HC 612
Tuesday 2 September 2014

Members present: Dr Sarah Wollaston (Chair), Rosie Cooper, Andrew George, Robert Jenrick,
Barbara Keeley, Mr Virendra Sharma, David Tredinnick, Valerie Vaz

Questions 1-89
Witnesses: Professor David Haslam, Chair, and Sir Andrew Dillon, Chief Executive, NICE, gave evidence.

Q18 David Tredinnick: Sir Andrew, do you feel you have done enough to make value assessments of well established existing treatments, such as acupuncture? NICE have now agreed that acupuncture can be used for lower back pain, but that is widely at variance with its use in China, where, for example, it is used for many other different ailments. I have myself been treated successfully by the use of acupuncture for a number of other things, including carpel tunnel syndrome. Do you not think you should make more effort to look at treatments that have been out there, in this case for over 2,000 years?

Sir Andrew Dillon: There are a number of ways in which we assemble the topics we look at. In most cases, we agree with the Department of Health—now with NHS England, as the main commissioner—what it is we look at. For example, we have a library of clinical guideline topics that we think tackle the principal causes of morbidity and preventable mortality that the NHS deal with on a day-to-day basis. Once we have got that topic we scope it out—in other words, we identify the key questions, particularly those that relate to uncertainty among health practitioners who are working in those areas. We try to identify new interventions and variations in the use of existing interventions. Once we have assembled that, we can do the research necessary to produce the guidelines. If, as part of that process, we identify treatments beyond what might be described as conventional western medicine, we have the opportunity to take them into account, but they need to be supported by the evidence. We have been able to support the use of acupuncture and herbal medicine in certain circumstances.

Professor Haslam: I have always been clear about this. It all comes down to the evidence. I do not think there is a discrimination between complementary and conventional medicine. If there is evidence, it is medicine.

Q19 David Tredinnick: Absolutely. The chief medical officer has herself written a book called "The Drugs Don't Work" and has expressed huge concerns about the failure of antibiotics, but acupuncture and herbal medicine can help where antibiotics help. Given the publication of that book and the panic we now have about antibiotic failure, surely there is a greater requirement to look at what is already around the landscape. I raise just one other point. Homeopathic medicine is used widely across the world. In France, about 80% of pregnant women use it; it is available in all chemists, but here there is a vociferous anti campaign, which I think has had too much influence over people like yourselves in authority. Don't you think that, if it is claimed there is not enough evidence, it behoves you to go out and try to find out why people are increasingly using this form of medicine and see what can be done to make an effective substitute?

Professor Haslam: We deal with the evidence that is there; we are not the research organisation that produces the evidence. If the evidence is presented to us, why would we wish to be prejudiced against something that is demonstrated to work? What we require is that evidence, but we are not the organisation that generates such evidence.

Q26 David Tredinnick: I want to ask you about some specific decisions you have made. Recently, you were much in the media with your decision not to approve Kadcyla as a treatment. Could you elaborate on your decision-making process?

Sir Andrew Dillon: Kadcyla is a treatment manufactured by Roche Pharmaceuticals for treating metastatic breast cancer. The simple reason for our inability to support it for routine use is its cost per quality-adjusted life year, which was in the region of £160,000. As we were discussing earlier on, even the extended range goes up only to £50,000. It was well beyond the advisory committees' ability to apply flexibility.

Q27 David Tredinnick: I have a slightly lower figure here. The company has produced the drug, it is effective and it has been knocked out of the frame on the ground of cost, which has been proved to be over double the parameters within which you work. Did you feel that the company could have helped themselves a bit more on this?

Sir Andrew Dillon: It is always in the gift of the company to make a proposal, generically described as a patient access scheme, which has the effect of discounting or reducing the price of the drug to the NHS. In this case, Roche did do that. On the basis of an agreement between the Government and the pharmaceutical industry, these discounts are confidential and so I cannot reveal it, but it did not make any significant progress towards enabling us to support the use of the drug.

Q28 David Tredinnick: Do you think that, looking at the drugs landscape, the costs are increasing, staying the same, or decreasing generally? This is a huge sum of money for a particular treatment. Is this representative of challenges that you are facing across the board?

Sir Andrew Dillon: I think Kadcyla is an outlier for the broad group of cancer treatments we are looking at. There are drugs that are very expensive but they are designed for very small groups of patients. Kadcyla is a particularly expensive treatment for that kind of patient population. Its headline list price, which is different from its quality adjusted life year, was about £90,000 per patient per year. It is certainly the case that the cancer treatments we have looked at recently are generally more expensive than treatments for other diseases and conditions. I guess this is a function of the companies' assessment of health systems' willingness to pay for drugs to treat cancer, but I do not think you can say it is a general trend that applies to all drug treatments.

Q45 David Tredinnick: I want to go back to an answer to a question that you gave the Chair just now. I thought you said that NICE had not said that statins should be available to a much wider group, as widely reported in the newspapers. You said that effectively the advice was that if you and your doctor thought it was a good idea, because they are now so cheap, you should have them. Is that an accurate representation of what you said?

Professor Haslam: I said that because of the falling price of statins, the threshold at which they were cost-effective had changed. What we certainly did not say was that we wanted doctors to go out there and put 5 million people on statins, as some newspapers reported. What we did say was that if doctors and patients, working together, having looked at things like lifestyle issues and all the other really important things, felt statins were appropriate, the point at which it was appropriate to prescribe them was different.

Q46 David Tredinnick: Is it not very strange that the media should have grasped this the way it did, and we have seen the representation in pretty much all the national newspapers that it is NICE's advice that statins should be much more widely used? How could there be such a public relations fiasco?

Sir Andrew Dillon: We have recommended them to an extended population. That is the nature of the guidance. The threshold that we are suggesting is appropriate for intervention should be lower, so inevitably there is a larger group of people who become potential users. It is not simply that once your risk is assessed as being within the frame we have recommended you are automatically required to take a statin. Your risk is assessed and then there is a conversation about ways in which that risk can be reduced. If there are things that we could do as individuals through diet, exercise or other modifiers of lifestyle, that have the desired effect, we do not need to take statins. It may be there is nothing we can do and statins are the only option, and that is the advice the GP would give the patient, but it remains a decision for the patient.

Q47 David Tredinnick: Thank you for clarifying that. Moving to general attitudes to health, what is the role of NICE in educating the public about their responsibility for their own health?

Sir Andrew Dillon: It is largely through our public health programme. We are commissioned by the Department of Health to look at a wide range of topics since we took on that responsibility in 2005. The guidance we produce is intended largely to support the work of public health professionals in the NHS, as it was until recently. Now the lead role in public health is being taken by local government, much of our advice is directed to public health professionals and other colleagues working in local government.

Q48 David Tredinnick: Do you think that generally there is too much emphasis on putting new drugs out into the marketplace and not enough emphasis on people's lifestyles and healthy living? I have been told that the Department of Health spends about £100 million a year on healthy living advice, but one of the very large companies that produces hamburgers spends £2 billion. I was not able to establish whether that was this country. It probably covered a wider area. I think it is accepted that meat with a lot of fat in it can cause obesity, particularly if it is consumed late in the evening when the body is trying to shut down. Do you have a view on eating habits?

Professor Haslam: It is a fascinating question. There has been so much research done into the social determinants of health which are linked through poverty, education, diet, exercise and all these things. The bit of NICE that tends to make the headlines is the area where we deal with drugs and our technology appraisals, but our role now is right across the spectrum from assessing drugs for ultra-rare conditions all the way through to social care quality. As Andrew says, the public health guidance that we put out focuses very much on a lot of these issues and recommendations that can make a real difference. When it comes to drugs, part of our job is to look at them; it is not say whether those drugs should or should not exist as compared with more exercise, better schooling or whatever. It is a huge topic, as you rightly say.

Q52 David Tredinnick: We have had evidence in this Committee and the Science and Technology Committee, on which I also sit, about the problems of poly-morbidity and poly-pharmacy and the whole issue of multiple quantities of drugs being prescribed. I think that in Scotland over half the population over a certain age are on more than five drugs. Does it worry you that there really is not a proper medical assessment of how drugs are used in multiple combinations? There may be assessments about how one or two react with one another, but is it not true that we have a large part of the population out there on many, many drugs all together and no one really has a clue of what the side effects are?

Professor Haslam: It worries me a great deal. NICE have been asked to develop a clinical practice guideline on multi-morbidity. The draft scope of that is currently out for consultation. It is an area that I think is extraordinarily important, and we are going to major on it because of the great benefits to patients from not being on multiple therapies, many of which may not be necessary, or the fact that the more drugs you are on the greater the risk of side effects. I think that, by the age of 65, 65% of the population have two or more long-term conditions and there are more people with two or more long-term conditions than there are with one long-term condition. So in other words, multi-morbidity is more common than single conditions, yet most of the NHS has been focused on single conditions: cardiology, respiratory medicine, urology or whatever. We are at a really interesting time when many people are beginning to look at this, but NICE are working very much on guidance around this.

Q53 David Tredinnick: One of the reasons I have supported complementary medicine—herbal medicine, acupuncture and homeopathy—for nearly 30 years here is that there are very few side effects. If you take homeopathy, you can take the entire box and it will not do any harm.

Professor Haslam: I cannot argue with you on that one.

Chair: No one speaks for it more than you, David. We are now going on to the next section, on guidance.

Q61 David Tredinnick: Are you satisfied with the progress you have made in combining the quality standards set that will underpin NHS commissioning boards' outcomes framework?

Sir Andrew Dillon: Their quality standards programme is aligned directly to our clinical guidelines and public health guidelines programme, so every clinical and public health guideline will eventually have a quality standard associated with it. It started off by publishing those quality standards on guidelines that had been recently published, so we can be confident about the evidence base for it. We produce a quality standard after we publish each new clinical guideline and we review quality standards that have been published when the underpinning guideline is updated for one reason or another. Inevitably, it is going to take us time completely to finish the quality standard catalogue, and then there will be a maintenance programme to make sure that they are kept up to date, but given the resources that we have, we are making as good progress as we can reasonably expect to make in putting together that library of quality standards.

Q62 David Tredinnick: Do you think you will meet your commitment to have 150 standards completed by July 2015?

Sir Andrew Dillon: I'm afraid that I don't have with me the detail of where the programme is or its ambition by that date, but I can provide the Chair with that information, if that would be helpful.

David Tredinnick: Thank you very much.

Health Committee
Oral evidence: Children's and adolescent mental health and CAMHS, HC 342
Tuesday 15 July 2014

Members present: Dr Sarah Wollaston (Chair), Rosie Cooper, Andrew George, Robert Jenrick, Barbara Keeley, Grahame M. Morris, Andrew Percy, Mr Virendra Sharma, David Tredinnick

Questions 336 - 461
Witnesses: Norman Lamb MP, Minister of State for Care and Support, Department of Health, Jon Rouse, Director General of Social Care, Local Government and Care Partnerships, Department of Health, Professor Sir Bruce Keogh, Medical Director, NHS England, and Kath Murphy, Assistant Head of Specialised Services, NHS England, gave evidence.

Q362 David Tredinnick: Building on what Grahame Morris said to you, Jon Rouse, and listening to you, isn't the fundamental problem that there was no guidance from the Department to the clinical commissioning groups on how they should deal with this? Is this not a failing of the Department?

Jon Rouse: I really do not think it is, but let me set out—

Q363 David Tredinnick: You have lots of different landscapes that are all completely different, not talking to each other. We have already heard about patients who are crossing over from Birmingham, going to one place, and patients going the other way. There is no coordination. I put it to you that the fundamental problem was that there was no guidance in the first place.

Jon Rouse: That was the situation that existed pre-1 April 2013 in terms of the primary care trust responsibilities.

Q364 David Tredinnick: So it goes back to pre-2013.

Jon Rouse: In terms of the geographical issues that we have around the—

Q365 David Tredinnick: There is an inherited problem from before the landscape changed; is that what you are saying?

Jon Rouse: Correct, yes.

Q366 David Tredinnick: You are saying that it was a terrible situation before the change of the landscape and now it is improving. Is that what you are saying?

Jon Rouse: It was certainly an imperfect situation; that is for sure. What NHS England are trying to do—maybe Sir Bruce or Kath can come in on this—is make sense of that inheritance, work out where there is a lack of provision and make sure we have adequate provision in every geography.

Q367 David Tredinnick: I do not know if Sir Bruce was trying to come in there.

Professor Sir Bruce Keogh: No. I think Kath has covered it.

Kath Murphy: We did inherit differences, and, as I said earlier, west midlands have done a lot of work. We know that the Oxford model has worked, but their frustration is that they now have children from other areas, where there was not sufficient provision, coming into those beds and then disrupting it.

Q368 David Tredinnick: A related problem is that young people are staying for too long in inpatient units. We have had cases put to us of up to two years. Is it fair to say that NHS England—I think you touched on this earlier—needs to do a lot more to take ownership of admissions, to make sure patients are not kept in any longer than is necessary?

Norman Lamb: Let me say a word on this. We have operated in many respects in mental health in a bit of a fog. We have not had access to the data—the information that other parts of the health system benefit from. We are now making significant steps to improve the data that is available so that we can really scrutinise which areas have excessive lengths of stay. We find that there is enormous variation in lengths of stay. In some cases there may be justification for that because of the case mix, but at least when you get the data you can start to understand what is happening around the country and then seek to address it. On the face of it, the variation does not look as if it can be clinically justified. But at least having access to that information allows us to tackle the problem.

David Tredinnick: Thank you.

Q406 David Tredinnick: Thank you, Chair. On the eating disorder issue, there is very clear evidence that E additives in orange juice and other additives in food actually cause those problems. What weight do you put generally on looking at dietary issues as a function of those mental problems?

Norman Lamb: I will give a very quick view.

Q407 David Tredinnick: While you are thinking about that, Minister, if I may, might I just say that I worked in HMP Coldingley with prisoners, some years back? We looked at how a variety of treatments, including cranial osteopathy, were helping to deal with mental disorders. It found that with some violent prisoners—this is serious—the plates of their skulls had crossed over when they came down the birth canal when they were born, which is normal, but they had never gone back to the correct position. This made them unbelievably angry about life in general. Cranial osteopaths could release the plates, put them back into position and their behaviour changed completely. They would never have gone to prison—

Chair: Can I stop you there because what we should be doing is asking whether there is any evidence base for that rather than asserting it?

Norman Lamb: I would like to defer to our resident clinician.

Professor Sir Bruce Keogh: I have no idea.

Q408 David Tredinnick: The evidence was at the prison; that is where they had them.

Kath Murphy: Can I speak from personal experience, having a stepson that had ADHD? Yes, there was a definite link with what he consumed and his behaviour.

David Tredinnick: The Chair wants me to move on, but I just draw these points to your attention.

Q409 Chair: Perhaps it would be helpful if the panel could have some evidence base behind that to reflect on.

Professor Sir Bruce Keogh: Are we talking about the additives or the cranial osteopathy?

Chair: Both. Thank you.

Q410 David Tredinnick: It was HMS Coldingley. They were allowed into the prison, so presumably they had some evidence for that.
Moving on, Mr Rouse, you have talked—almost offensively—about the need for local organisations, local people, to use the new tools of Healthwatch to engage in local democracy—health and wellbeing boards. Obviously we are in a new landscape where, as you said, Minister, or your Secretary of State said, patient choice is at the heart of the health service. Do you think there is a real problem with these new tools from the health Act not actually being used properly?

Jon Rouse: No. I hope I was talking more passionately than offensively. I was talking as an exlocal authority chief executive. I was overjoyed when I found out that public health was coming back to local government after a hiatus—back home, as I would put it—having had that responsibility for 100 years from 1874 to 1974. I think that is where it belongs, because local government can take a much more holistic view. Also on top of that are the strategic responsibilities of convening the health and wellbeing boards. I just want them to make the most of that opportunity, to really drive great quality joint strategic needs assessments that really understand the needs of different sub-populations, including children with mental health issues, and that can then drive really great targeted commissioning. It was because I want it to work. I think they have made a pretty good start. They have only been up and running for just over a year. Clearly, there is variability around the country, but most of them now have health and wellbeing strategies for their areas, which are particular to their local circumstances and thoughtful about what they are prioritising. They just need to make sure that that is carried forward into the commissioning plans of each of the local commissioners.

Q411 David Tredinnick: Thank you. NHS England in its submission says that "transition from child centred to adult services is currently poorly planned, poorly executed, and poorly experienced. This can lead to the 'Cliff edge' where support falls away," and the first adult experience is the accident and emergency department. Indeed, when we had a seminar here with young people who had these problems, that was one of the points that came up. They said that there was woefully inadequate transition and, secondly, no appropriate ongoing medication review. Do you recognise that scenario?

Norman Lamb: I feel very strongly about this. I find it hard to understand why a system chooses to withdraw all established services from someone at the age of 18. I am the father of two boys who have gone through their teenage years. When I think of the degree of pressures and angst that an 18yearold has, I think it the most bizarre stage to suddenly have a complete transition. I am really encouraged by those parts of the country, including my own county of Norfolk, where they have introduced a youth service, from 12 to 25 typically. This seems to be going with the grain of other developments; the combined education and health plan takes you through to, I think, 25.

Jon Rouse: Correct.

Norman Lamb: There is recognition that these years need some continuity. In the pioneers, or whatever we are going to call them—the trail blazers where we are going to try to identify best practice and trial joinedup commissioning of services—I want to develop the concept of moving away from this cliff edge at 18. We set it out as one of the steps in our action plan "Closing the gap" as something that had to end. I think across the system there is widespread recognition that this has to change.

Chair: Thank you. Robert, you wanted to come in with a quick point on the back of this.

Q412 Robert Jenrick: It was really just an example of where it is not always clear that the age of 18 is applied consistently across the country. Some areas, from my anecdotal experience in my constituency, have used leaving school as an age when the transition is made, artificially really, from child to adult services. Is that an experience you have seen elsewhere in the country? It seems very peculiar for a child to have to stay on at school to receive consistent care rather than perhaps going to a college to do further education. I do not know if that is an experience that you have had elsewhere in the country.

Norman Lamb: It is variable, but whether it is leaving school or 18, either of those is inappropriate, to be honest. Many youngsters are going off to university, and some continuity through that transition is incredibly important. Too often that does not happen at the moment. This is one of the changes that, in my view, have to happen.

Chair: Thank you.

Q425 David Tredinnick: I want to ask a question about the Care Quality Commission, if I may. In its written evidence to us, it says: "CQC routinely visits CAMHS services, both as part of its regulation of health services under the Health and Social Care Act, and in the course of its monitoring of the operation of the Mental Health Act." However, we had young people in front of us, and from other sources we have been told by commissioners that CAMH services receive very little scrutiny from the CQC; one witness told us that they had "never seen a CAMHS team inspected in the same way that they see other parts of the public sector inspected." Another witness said that in her view the Care Quality Commission do not see CAMHS "as part of their remit." Do you think that is a fair assessment?

Norman Lamb: It may well have been a fair assessment, but I think it is changing. Now that we have someone with a dedicated responsibility for mental health, Paul Lelliott, who is an extremely able individual, I do not think there is any risk that children's mental health services will be ignored in the future. They are introducing a much more rigorous inspection regime. They are testing it at the moment; they have done a number of different trusts before it is applied formally from the autumn, with ratings being applied to services. That gives us an opportunity, as I indicated earlier, to put the spotlight on mental health and to really identify good practice, but also unacceptable practices, in a way we have never been able to do before.

Q426 David Tredinnick: Are there any other mechanisms for assuring the safety and quality of CAMH services? If there are, do you think they are working effectively?

Norman Lamb: There are local mechanisms of course. There is the health and wellbeing board; there is the local authority, which is responsible for part of the service at the lower tier end; and, of course, there is also NHS England in their work with clinical commissioning groups. But the regulator is the Care Quality Commission and, as I said, I think we have a real opportunity to improve standards.

Kath Murphy: I am aware of the CQC asking tier 4 units to close to admissions in order to improve their services, so they have done it voluntarily; and just as we have done it as NHS England, we have talked to the CQC about what we have done. So for the tier 4 units we work with the CQC, but I have examples of where admissions have been halted to allow time for improvements to be made.

Q439 David Tredinnick: Yes—it is really cyber-bullying. We have had witnesses who said that this was a great worry to them. I know a lot of action has been taken about pornography, but one of the witnesses said to us that there is a lot of evidence that there is cyber-bullying but, "I have not seen a filter or a block that deals with peeronpeer abuse. That is an ongoing conversation." I know you have been meeting internet security companies, charities and other Government Departments, according to our briefing, and social media companies, but how are you dealing with the specific issue of bullying and the fact that it goes beyond the classroom and does not just end at 3.30 but goes on for 24 hours a day sometimes?

Jon Rouse: This is very much a partnership with the Department for Education and, to a certain degree, the Home Office. The Department for Education actually has three or four programmes aimed at reducing cyber-bullying. That is partly about working with the software providers, but it is also about specific grantaided initiatives, often working through thirdsector organisations, to ensure that there is support going to the young people themselves, and that there is access to helplines and also to peer mechanisms and peer networks that can be built up within the school. Quite a lot of it is supporting young people themselves to become anti-bullying champions and anti-bullying mentors, so that with any given school there are people other young people know they can go to and get support and help from when they are facing those issues. I do not think there is just one solution to this; there are a variety of different ways.

Q440 David Tredinnick: Do you think that the solution is only partly to do with hitech and that it is more basic than that—sort of getting a lot of samaritans out there, or Esther Rantzen helpline people? It is really more a oneonone solution that we need, is it?

Jon Rouse: I think you need to do both, but there is a very important role for oneonone support.

Science and Technology Committee
Oral evidence: School practical science, HC 329
Wednesday 3 September 2014

Members present: Andrew Miller (Chair); Jim Dowd; Stephen Metcalfe; Stephen Mosley; Sarah Newton; Graham Stringer; David Tredinnick
Questions 1-41
Witnesses: Janet Holloway, Head of Reform, Ofqual, Dr Steven Evans, OCR, Darren Northcott, National Association of Schoolmasters and Union of Women Teachers, Nicole Morgan, Royal Society of Chemistry, and Steve Jones, Consortium of Local Education Authorities for the Provision of Science, gave evidence.

Q34 David Tredinnick: Building on what you are saying, do you think there is a fundamental problem in the increased emphasis on practicals that some schools simply do not have the right equipment to deliver proper experimentation? There is an inbuilt disadvantage for the least well-resourced school.

Philip Britton: That is a question around one of the points I would make, which is aspiration. In terms of this proposal, which is an aspiration to have investigative work in schools, which requires professionalisation of teachers, and looking at resources and at proper ways of making assessment valid, I think the counsel of despair that "The best we can do is whatever the best we can do now is," is not wise. One of the outcomes of the current phase of discussions ought to be an aspiration to work towards a better system in the future while attempting to make the system we have now as workable and productive for practical science as we can.

Q35 David Tredinnick: Sir John, how much contact did you—the Council for Science and Technology—have with Ofqual when you were developing these proposals?

Sir John Holman: We had several discussions; Glenys may correct me. The Council for Science and Technology had quite extensive correspondence with Ofqual, and it must have been—

Glenys Stacey: Several meetings, yes.

Sir John Holman: At Glenys's level—a number of interactions.

Q36 David Tredinnick: And the chief scientific adviser?

Glenys Stacey: Yes, I met the chief scientific adviser, with John as well actually.

Q37 David Tredinnick: Having listened to all the sessions, do you share my concerns with Ofqual that there is a danger that some coursework is not actually part of the formal assessment on the grounds that it increases the likelihood of cheating and that this is something that needs to be addressed?

Glenys Stacey: The validity of the qualification is influenced by a number of things: obviously, the content, the nature of the assessment and the quality of the assessor, but also the pressures that the qualification might be put under. Those pressures might be, for example, if the student's, the teacher's and the school's performance is judged by the grade, and then the financial pressures as well—the equipment and so on. You have quite a complex interplay when you are thinking about the validity of the qualification, not just about its design but about the resources that are applied to it and the pressures that are imposed upon it as well. Yes, of course we are concerned to produce the qualification that is best fit for purpose and can best deliver the right educational outcomes, actually taking into account those pressures. If we do not do that, we produce something that is potentially not fit for purpose.

Q38 David Tredinnick: The last question, building on Sarah Newton's point, is do you think we really need a town and country solution, because outside assessments in very sparsely populated counties would be a major challenge?

Glenys Stacey: I believe that the Ofqual solution, as it is called, is a town and country solution. It is deliverable whether the school has 20 students or 200, and whether it is in Norfolk or Nottingham. It is deliverable.

Health Committee
Oral evidence: Complaints and raising concerns, HC 350
Tuesday 8 July 2014

Members present: Dr Sarah Wollaston (Chair), Rosie Cooper, Andrew George,
Robert Jenrick, Barbara Keeley, Charlotte Leslie, Grahame M. Morris, David Tredinnick, Valerie Vaz
Questions 395-528
Witnesses: Dean Royles, Chief Executive, NHS Employers, Rob Webster, Chief Executive, NHS Confederation, and Chris Hopson, Chief Executive, Foundation Trust Network, gave evidence.

Q412 David Tredinnick: I want to ask some questions about support for patients wishing to complain and, if I may, address the first question to you, Mr Webster. In your memorandum you raise concerns that the complexity of new commissioning arrangements can leave patients confused about to whom they should complain. Is it fair to say that the new arrangements themselves have caused confusion?

Rob Webster: Yes. I think the NHS is a system, not a single organisation. Many patients think, and much of the story in the media and in broader society is, that the NHS is an organisation, and it is not: it is a system. I do not think there is a widely held understanding of what the role of the commissioners is, or who commissions different bits of the services that patients receive. Without that understanding, it can be difficult for people to know to whom they are going to complain.

Q413 David Tredinnick: Do you not think it is astonishing that, after all the effort that has gone into these reforms, you should be able to agree with me on that?

Rob Webster: It is not astonishing. It is a fact that, if you have a child with multiple issues, then the organisations that commission services for that child, if they have physical and mental health needs, might include NHS England, the local clinical commissioning groups, the local authority and the schools. Therefore, if you have a complaint about one element of their treatment, it will be confusing for you on the end of that, but what you will want as a patient and a family is to make sure you have joinedup services.

Q414 David Tredinnick: Is that your solution? What is the solution to this problem that we have teased out?

Rob Webster: There is a developing maturity around the arrangements, which I think is helpful. We are seeing people who pay for services—the commissioners—working much more closely together. Then I think we are seeing more joinedup services by providers. Whether you are complaining to the provider or the commissioner, you should be able to know that, whichever provider it is, or whichever commissioner, they will coordinate your complaint on behalf of the whole of the system. That is what is supposed to happen. If you look at what the Care Quality Commission were saying—that people should know their rights and have information about where to complain, and there should be a culture of openness around complaining—that leads us to a point where we could get somewhere where people understand who to complain to and it gets dealt with.

Q415 David Tredinnick: Through you, Chair, I do not know whether Mr Hopson wants to come in on that; he was making animated gestures then.

Chris Hopson: I thought the Parliamentary and Health Service Ombudsman case which came out a couple of weeks ago absolutely illustrated the fact that, quite often, patient journeys are not simple, and that you will cross potentially GP, community and acute services, and it is not entirely clear, if there has been a failure in care, exactly where that responsibility should sit. If you wanted to complain, as the parents of the child did, it was not entirely clear.
There are two things I would completely echo. We are getting a growing system maturity; people are learning how to coordinate effectively. There is also a duty on any provider or commissioner who receives a complaint to ensure that they liaise with the rest of the system, but I would argue that part of the problem here is that we have a fragmented health and care system, in which responsibility for providing care is split across a number of different organisations. Therefore, it is not entirely surprising that it is not clear who to complain to.

Q428 David Tredinnick: With your permission, Chair, I would like to move on to patient advice and liaison services—PALS. Robert Francis, for one, has been very sceptical about the effectiveness of hospital PALS in helping patients wishing to provide feedback about services or to make complaints. In fact he told this Committee last year that, in his view, there should be a more independent and active element to patient advocacy—for instance, assessing a complaint and suggesting a course of action to a patient. How effective, against that background, can PALS really be in supporting patients who have a concern about their treatment? It is a pretty damning statement from the man who has produced a great report.

Chris Hopson: I recognise that. Our very clear view would be that hospitals can be quite intimidating places and that, if you have a complaint or concern to raise, having a place where you can clearly go, whose job it is to make it clear where you can go, and to give you some initial support in doing that, is very important. That is the role of patient advice and liaison services, and we think they do that job very well. We would then be the first to acknowledge that, if that concern cannot be dealt with and if it then develops into a serious complaint, it is important that the complainant should get access to independent advocacy services and that the PALS service should then pass on that complainant to the independent advocacy service.
Rob was talking earlier about the changes that have been made. One of the things that we are concerned about is the fact that the Independent Complaints Advocacy Service was effectively broken up as a result of the 2012 Act, and each local authority is now responsible for commissioning advocacy services in its local area. It is very clear to us that that is now being done on a patchy and, to be frank, less effective basis. So I completely agree with you that there is a very important role for an independent advocacy service, but, in our view, it sits very happily and appropriately alongside a patient advice and liaison service in a hospital, and it is perfectly possible to have the two working together.

Q429 David Tredinnick: You could argue that the system has been broken up and you could say it has been more localised, but is not the key issue here to what extent the trusts are making use of the feedback provided by the PALS services? What evidence is there that they are making use of it?

Chris Hopson: We would say, as part of this whole kind of change, that that is something that trusts are doing significantly more effectively. I could reel off a series of case studies or provide a note, if you would like one, on a whole range of ways in which hospitals and community ambulance and mental health trusts are all using patient feedback to improve services. I keep coming back to the last visit I did because it is at the top of my mind, but when I visited Hillingdon hospital 10 days ago, they were able to tell me five or six different things they had improved as a result of patient feedback. So it is happening.

Q430 David Tredinnick: Thank you. But is not the reality that PALS—these patient advice and liaison services—are becoming almost part of the trust themselves? They are kind of being sucked in. Is that right?

Chris Hopson: I would not say they are being sucked in. They are a formal—

Q431 David Tredinnick: Mr Webster smiled at that. I don't know whether he wants to comment on what I have said.

Rob Webster: There is a tradeoff here—I am just thinking about my PALS services that I have used in the past—between people who understand the organisation and the system that they are in, and people who are independent. You need to appoint great people whose first view is, "How am I going to get this issue sorted for this patient, because there has been a failure of communication, service or understanding that has led to an issue which we can probably resolve?" PALS resolve the vast majority of issues without them becoming formal complaints and tend to be fairly effective. If you have organisations that look at the four Cs of compliments, complaints, concerns and comments and look at the trends in those and receive their reports quarterly or annually, which they will do, then you can look at the trends. There is always a tradeoff between separating something for it to be independent and for it to be connected enough to do its job. I think Chris's points about ICAS, the independent advocacy services, is well made. We must make sure that we are protecting vulnerable patients so that they can be supported to access good advice and resolution of issues when they arise. What we hear from members is that they are concerned about that.

Q432 David Tredinnick: You think the balance is about right, notwithstanding what Robert Francis said, do you?

Rob Webster: I think that PALS, as a service, is not widely understood by the public in the way that, say, PALS might be understood by people who use the service.

Q433 David Tredinnick: Is that because there has been poor or little advertising, it is just another one of these new bodies and no real effort has been made to get across who or what it is, or what it does?

Rob Webster: I think across this whole agenda there is a narrative that plays out in public which is different from the facts. It is not to say that there are not issues that need to be resolved, but there is a narrative that plays out in public which is different from the facts and there is a journey we are on which requires us to work with the public and engage them in ways which help us to explain to them, just as the CQC said, what their rights are, and where they go if they want to get some information about services, some resolution of issues that they have had and to make sure that their concerns are addressed.

Q434 David Tredinnick: Did you know that Healthwatch bills itself as a consumer champion?

Rob Webster: I do know that.

Q435 David Tredinnick: Do you think they have achieved that objective?

Rob Webster: It is very difficult for any organisation when it is just over a year old and it is trying to work in this environment to do that. We have good examples from local Healthwatch, where they have been focusing on the right kinds of areas, and national Healthwatch I think made some announcements. It can be stronger, and I think we have to try and give the system a chance to mature and work.

David Tredinnick: Thank you very much.

Q443 David Tredinnick: Just running on from Charlotte Leslie's passionate point about the fate of whistleblowers and some of the casualties—the people who have given up their career to bring to light things that have been wrong—do you think there should be some more proactive mechanism to help people back into work within the health service? Does it not reflect very badly on the service that there are these stories about people who have been brave enough to come out and shout it from the rooftops? Should we not be doing something for them?

Dean Royles: This is one of the challenges around this debate. I am really aware that this is a very live issue and, if you talk about some of the context of it, it can look as if you are in denial. We have all tried to say here that we recognise there are some issues, but if the Committee wants to look at some real areas where we could make improvements, there is something about understanding that the context in which the NHS works is that sort of systemic context. The way that Parliament scrutinises, that regulators regulate and inspectors inspect, plays its part in the culture that is set within the organisation. There is an overall view that we have to get right about getting the culture right within the organisation. If we get that right, people will feel freer to be more open about the sorts of issues that we have within the organisation.
Then we have this issue where people are raising concerns internally in the organisation, and if we can get more of those things right we prevent whistleblowers from needing to come to the surface in the first place. I think we can get that right by getting better at getting back to people when they do raise concerns, to reassure them, and that might be some sort of composite information, it might be individual information, but it is also about the processes and procedures that NHS organisations have to work under. If you look at something like "Maintaining High Professional Standards," which is the doctors' disciplinary procedure, it is tortuous, legally bound and complex, such that as soon as an issue involving a doctor comes to light everyone runs for the lawyers to try and get it right in the first place. That is not the right way of resolving the issue or setting the culture in the organisation so that people feel free to raise concerns. If we can get those sorts of things—those thousands—right in the organisation, then we will get a much better culture.

Chris Hopson: I think there is also a chance to use the Robert Francis review of whistleblowers to answer the question that has just been asked as well, so we welcome the review and think there is an opportunity there. I recognise what both Charlotte and David have said—that there are some issues around supporting whistleblowers, and that is precisely one of the reasons why the Secretary of State announced the review.

Q459 David Tredinnick: Minister, in the last session we heard about what I might describe as a complaints fog: patients really don't know where to go to make their complaints now because of all the changes in the structure. One of your proposed initiatives is to put up notices in hospital wards. Could you start by saying what progress you have made with that simple initiative, please?

Dr Poulter: That was the issue I was just referring to the Chair of the Committee. We are looking at putting in place a very simple, as I put it, bedside guide or a complaints guide for patients which much more easily directs people on where and how to complain, and facilitates access to the system for people who may not understand how to do so otherwise. That is something that will be disseminated across the NHS.

Q460 David Tredinnick: Fine. I may have missed that when I was looking at my notes just now, but in the Army, which I served in very many years ago, if the general in charge wanted a notice put up in a barrack room, it would happen the next day. I cannot really understand why it takes so long to put a simple notice up in a ward that belongs to the health service. You have just said that you can have notices by the beds, but is it not very straightforward to put a notice up on the doors? I cannot understand how it can take so long for this to happen.

Dr Poulter: Part of the process was that we wanted to engage, work out and understand from the ClwydHart review, and also from further engagement, what people felt some of the barriers were to raising complaints. Then some guidance and a complaints pro forma, if you like, was drawn up. My initial impression of the first draft that I saw was that it was not giving us the simplicity that was required, so we have now gone back to make sure that it is in a better place. There is something that will be coming forward, I would imagine, over the next three to four weeks, or certainly by the end of the summer.

Q461 David Tredinnick: That is very helpful; thank you. Going on from that, could you comment on the number of outcomes that HMG—Her Majesty's Government—"wants to see" from its complaint reform programme? We have a list of different issues, but could you perhaps give us the priorities here?

Dr Poulter: I tried to focus earlier on some of the clear priorities.

David Tredinnick: Some of these questions inevitably overlap.

Dr Poulter: Indeed. One of the things we have focused on, as the gentleman from the Foundation Trust Network highlighted a moment ago, was how we can drive and improve quality of care and responsiveness in the NHS through greater transparency. One of the other key pieces of work that is going on at the moment is how we collate the right data and information about complaints, how we look to be open and transparent, and how we can potentially publish that, so that we can compare different healthcare providers. That, as well as the simple support for patients, is one of the other key ingredients of the ongoing work that is going to come forward in 2015.

David Tredinnick: Thank you very much.

Q481 David Tredinnick: So far in this animated session we have heard absolutely nothing about Healthwatch, despite the fact that Healthwatch bills itself as the consumer champion. Minister, you smile at that, but how exactly does Healthwatch fit into the complaints scenario? What role do you, Minister, envisage for local Healthwatch organisations in complaints advocacy and complaints monitoring, please?

Dr Poulter: We all accept that there was considerable variability in Healthwatch's predecessor organisation, the LINks organisation, at a local level; I am talking about a local Healthwatch organisation tier at a local level. I think LINks organisations are incredibly variable in their reach, and I believe I am on record as saying that, as a doctor, I did not even know LINks organisations existed, which was not a good thing from a patient's point of view if medical professionals working on the ground did not understand what was available.
So the challenge was—and they have been in existence for a brief period of time—to make the successor patient voice organisation much more effective at being the patient's voice. How is that being done? First, we know that the Healthwatch organisations have an inherent link to local authorities now, and that gives them a much more systemic reach across the health and care system and they have a voice on health and wellbeing boards as well and reach into health and wellbeing boards to raise concerns. Also, I believe—I stand to be corrected—that there is a Healthwatch representative on the quality surveillance groups of commissioners at local level that NHS England had set up. Healthwatch are embedded in not just the health system but the health and care system through the link with local authorities, and their role of patient advocacy is much more embedded in the quality surveillance of the local NHS. I think they are in a much better place than LINks organisations to be effective in raising patient concerns.

Q482 David Tredinnick: Is there not a problem, in that at the moment local Healthwatch is involved in complaints advocacy only when commissioned to do so by local authorities? It is a reactive rather than a proactive organisation.

Dr Poulter: Local authorities, in terms of patient advocacy services, can commission their local Healthwatch organisations to do that, and that is something that clearly has a number of merits in helping to understand, in particular, how well the system is working in looking after more vulnerable patient groups, or how well the system is dealing with some of those more complex complaints that we discussed earlier. There is a lot of merit in that, and that is something I would certainly believe, as long as that is the best advocacy service available. There may be other providers of advocacy services which are more appropriate and better in that locality, and we have to be mindful of that, but there are a lot of advantages to Healthwatch being commissioned to provide those services.

Q483 David Tredinnick: Running on from that, you mentioned health and wellbeing boards, which are much more evident on the ground and have, I would suggest, been very effective in getting health and social care people involved if they are not directly commissioning services—at least people who are involved in local services and also local sports services at council level and things like that. Do you think there is a sufficient link between Healthwatch and health and wellbeing boards, which seem to have overlapping briefs?

Dr Poulter: If we want Healthwatch to be an organisation that is a genuine voice for some of the major issues that affect patients, there is clearly a role in how they feed into health and wellbeing boards. The health and wellbeing board is a focus for joinedup thinking and helping to deliver more integrated care, which is something I believe we are all signed up to, and that is more effective if there is a voice there articulating the patient's needs and concerns, and also it helps to bring a more coordinated approach to that patient voice across the whole system of healthcare, housing or the other priority areas that the health and wellbeing board is addressing.

Q484 David Tredinnick: Certainly, sitting on the Hinckley health and wellbeing board in West Leicestershire, I feel there is a strong case for Healthwatch making itself known and offering to attend, possibly, on occasions. I would like to suggest that to you.
Finally, local Healthwatch organisations currently do not have access to details of complaints data from providers and commissioners, which I would suggest to you hampers their monitoring role. Is this something you are prepared to review, please?

Dr Poulter: That is something that we are clearly looking at as part of the piece of work that the Department is coordinating on the complaints process: how we can collate complaints, can have greater transparency in future about the complaints process and potentially publish details—obviously protecting patient confidentiality—of how responsive they are, or how different providers compare with each other when it comes to complaints. That is part of our ongoing work, and something that could bring real benefits as part of our general drive for greater transparency in the system. Transparency about complaints is clearly an important issue and something that I am sure we would all want to see, as long as patient confidentiality is protected.

Q485 David Tredinnick: That is very helpful. I think, through you, Chair, Mr Churchill wants to come in.

Neil Churchill: To go back to the quality surveillance groups, Healthwatches are members of the quality surveillance groups, and the quality surveillance groups will see all of the anonymised data on quality. It is intended to be a single conversation looking at complaints, surveys, soft intelligence and clinical audit, and it is an opportunity, if there are concerns, to call risk summits and look particularly at organisations. Healthwatch is in a very good position to see all of that data, obviously on an anonymised basis. Those organisations, like Healthwatch in Merseyside, which also provide advocacy services, are taking their own portfolio of complaints management into those quality surveillance groups as one of the sources of intelligence that are used.

Health Committee
Oral evidence: Integrated Care Pioneers, HC 560
Monday 14 July 2014

Members present: Dr Sarah Wollaston (Chair); Grahame M. Morris; David Tredinnick

Questions 33-67
Witnesses: Dr Carl Ellson, Chief Clinical Officer, South Worcestershire Clinical Commissioning Group, Dr Bernie Gregory, Well Connected Clinical Lead, and Dr Richard Harling, Director of Adult Services and Health, Worcestershire County Council, gave evidence.

Q36 David Tredinnick: Good afternoon. Looking at the briefing that we have received and listening to you this morning, it seems that the typical political law of unintended consequences—I am not saying you justify as a politician but it certainly applies to us—might be applying to where we are here in that in trying to develop a system of integrated care one of the things you manage to achieve or will achieve through this is discovering new health requirements, new issues that need to be dealt with. On the one hand, we are talking about decreasing costs by integration, but isn't perhaps the opposite the case in that what you discover through this new integration, this crowbar under the flagstones as it were, is a whole range of new issues that have to be addressed? I put it to you that perhaps both increasing costs and increasing demand will at the same time do completely the opposite of what was intended.

Dr Harling: First of all, we need to understand that this probably is not going to be a revolution. We are not starting from a point where care is completely not integrated and then moving to a point where it is completely integrated. This is a journey that we have already been on for a number of years. Like a lot of other areas, we have a number of what we believe are real strengths where care is very well integrated, very high quality, but we also recognise ourselves that we have other areas and other services where that is not as good as we want it to be. As we move forward, we are going to have to look at those individual service areas and think about how we can continue to improve the quality but also contain the costs. While I accept the risk as you put forward, which is that we do identify unmet need, we are simply not going to have the budget to deal with that, so we are going to have to construct integrated services in the future to deal with what is going to be a greater demand within the budget that we have. We simply do not have an alternative.

Q37 David Tredinnick: To what extent do you think through bringing these services together you can reduce duplication? Or is it the case that rather than reducing duplication you are running systems in parallel because it is easier to do that?

Dr Harling: I think you are quite right that the evidence base at a system-wide scale that integration will save lots of money simply is not there, or it is not there yet. When we reflect on aspects of our own system, which again could be reflections that are applied nationally, we know there are examples. If you take the example of a patient assessment, we know there are examples of where different groups of professionals are asking the same people the same questions over and over again. Now, that is not good for the customer but you can also see how if you can ask one set of questions once there is potentially an efficiency there. Intuitively, greater integration ought to save money, but what we need to do is to make sure that we realise those opportunities. We have a lot of learning to do and one of the benefits from being a pioneer is that we can try things out, learn from them, share our best practice for other areas to benefit from, and obviously vice versa because I do not think there is any area that does everything really well. Every area has pockets of good practice and what we want to do is to take all of them, learn from the best and build on that.

Q38 David Tredinnick: Isn't the situation further complicated by the fact that the Secretary of State has said that he wants to put the patients at the heart of the health service and that, if that is to be the case, then patient choice flows from that statement? Indeed, the Health and Social Care Act has put in place health and well-being boards and Healthwatch. The remit of Healthwatch is to be the consumer champion, I read, so how are you going to cope with patients who may be demanding different kinds of therapies that are not normally being offered by physicians?

Dr Harling: What we need to understand is whether we deal with those choices at a population or individual level. One of the examples that we have seen in the last week or so is comments about individual patient budgets in the NHS, which is a fantastic opportunity for greater patient choice because it means that individuals will control their own allocation of money. What there are also likely to be from that are consequences. For example, if everyone chooses to go to one hospital rather than another, then the second hospital becomes unviable. The question will arise: what do you do about it? Now, that is not a matter that historically we have been particularly keen on grasping, and we all know of examples where hospitals have lost activity but have been bailed out by other bits of the system. As we want to evolve patient choice, we also need to understand that it comes with consequences in terms of where the money flows to. We also need to understand the political implications of those consequences.

Q39 David Tredinnick: I absolutely understand that coming from Leicestershire where we have Leicester Royal Infirmary and George Eliot Hospital in my constituency and patients have choices and preferences. I am thinking more about patients' personal preferences and I think what you were alluding to in the answer to my last question was about personal budgets. There have been these very successful trials conducted by the Department of Health, which have shown that if you allow patients with long-term conditions, it should be said, to have some control over how their budget is spent, several things happen. Three things specifically happen. The first is that the actual costs of the care tend to decrease. Secondly, and perhaps I should have made this point first, the patient satisfaction goes up. It also has shown that life becomes immeasurably easier for the carers, who can then reorganise their lives so they can go out to work. The fourth point is that some of the therapies that patients have been asking for may not be very popular with doctors, such as piano therapy or even going to a sporting event, tai chi, having reflexology, aromatherapy, which is very powerful from the point of view of helping patients who have anxiety. Are we not in a whole new paradigm here where we are going to have to as part of this package listen to patients and what they want?

Dr Harling: I think the whole personal budget debate opens up some really interesting discussions. I get the impression that areas around the country will have the opportunity to go further in terms of piloting some of these NHS personal budgets. There are two things for me that we will need to think through. The first is that there are consequences about people's choices. If they are choosing to spend money on one thing rather than another, what do we do about the thing that they are no longer spending money on? We will not have the money to double run it. The second thing, on the example of some of the complementary therapies you have identified, again if people choose to use those and they are unsuccessful and they appear then at the door of A&E as a consequence, what would the NHS say to them? Would it say, "Come in and have some treatment" or would it say, "Unfortunately, you have spent up to the limit of your personal budget and, therefore, we are going to have to charge you 50% of care"? So, again, it is a really interesting discussion and it will open up some of these difficult political, moral and financial issues that come as a consequence of that.

Dr Ellson: Can I just add one as well? As a commissioner, we are responsible for the services that we commission to the public that we serve. If you remove our responsibility and pass that over to individuals, do they become responsible for the quality of the services that they individually commission? At the moment it is manageable, but in due course, yet again, it is an unanswered question. How do we start to police these services that are given to those patients that they are in turn commissioning themselves?

Q66 David Tredinnick: I would like to finish off by making a comment and asking a question. I wanted to ask one more question, but first say that one of the areas that I have seen that I think has been a huge success so far and where you probably are well ahead of other parts of the country is in your use of communications, use of information technology. I was particularly impressed to see a television screen in the office at Timberdine, which was online in real time to the local hospital. The local hospital knew exactly what was going to happen in terms of discharge of patients so they could plan. That seemed to be very good, and what you have said this afternoon about the different health organisations maybe having the same software and being able to communicate. The third point, of course, is the virtual wards, which the Chair has just asked about, where I think I am right in saying you are communicating with keeping patients out of establishments through the system. To what extent do you think that this information technology system that you are using is important to your work? How highly do you rate the use of effective information technology in this pioneer project?

Dr Gregory: It is seen as one of the key enablers and I will say it is one of our highest priorities. We have talked today, both this afternoon and this morning, about the importance of care planning, of an anticipatory care plan, but that is only of value if all those who need to see it are able to see the care plan. In very many ways, we are ahead in Worcester in having all our GP practices on the same system, the whiteboard system you just described, around capacity, amounts of beds around the county. We are in the process of developing what we are calling an IT roadmap with a really big picture view of how we join up all our information. We have numerous different IT systems across the county. The idea of having one single system that will do the job is what Connecting for Health tried to do over many years for a lot of money and failed to do, but the reality of IT technology now is you do not need one system. The technology is out there to join systems as long as the gateways are open and you are using the right sort of interconnectivity. We are developing a whole programme of how we can integrate all our different networks between health, social care, and particularly around care plans where you would have that placed centrally, where the patient would own that, where if they want family members to see it the family member can see it. Not all that software does exist at the moment, but I think IT companies are very much now on this wavelength and I think we will soon be in a position, I hope, to be able to bring this together. As I say, we are looking at that as a five-year plan. I think we have more quick wins to do, but to have the most effective joining together is going to take a bit of time.

Dr Harling: I was just going to add the other role we are looking at for technology is in supporting service users on patient choice. The council is doing a lot of work in terms of access to information and advice online, so how to look after yourself, how to plan for your old age, how to find support in your community is all done online, and aspects of the adult social care assessment online, and then the idea of an e-marketplace where with your personal budget you can choose from a whole range of services. You have information about the quality and cost that allows you as a consumer to make an informed decision. The role of technology here is potentially huge and it is one of the things we are quite excited about.

Science and Technology Committee
Oral evidence: National Health Screening, HC 244
Wednesday 9 July 2014

Members present: Andrew Miller (Chair); Mr David Heath; Stephen Metcalfe; Stephen Mosley; Pamela Nash; Graham Stringer; David Tredinnick

Q242 David Tredinnick: Why was the decision made to put the UK National Screening Committee within Public Health England? Does that not jeopardise its independence?

Jane Ellison: It is not actually within Public Health England. Public Health England provides the secretariat—I think that's right, David.

Q243 David Tredinnick: Perhaps subsumed is the correct word.

Jane Ellison: I would not use that word, Mr Tredinnick, but perhaps David will want to comment further.

Professor Walker: It is hosted by Public Health England—that is all.

Jane Ellison: PHE, of course, will often carry out a lot of the evidence finding and the further research that is needed; the expertise to do that will sit within PHE. It is quite logical, but it is only hosted by it with its secretariat. Its members are not part of PHE in that sense.

Professor Walker: Another issue is that it is a UK-wide committee, so the devolved Administrations are quite keen that it is not seen to be part of Public Health England but is a four-nation committee.

Q244 David Tredinnick: It is not an issue of independence. You think that there is no problem there, from what you say.

Jane Ellison: I am not aware of one. Public Health England also has a role in terms of giving evidence-based advice to Ministers. It is part of the Department of Health—it is an executive agency. Nevertheless, particularly in this sort of area, where you are looking at evidence-based advice and scientific study and all of those things that it gets involved with in supporting the committee, PHE has a role beyond that of an executive agency.

Q245 David Tredinnick: Who has authority in respect of a screening programme? If a decision is made to implement, amend or withdraw a screening programme, I put it to you that it is not clear if the decision rests with Public Health England, NHS England or the Secretary of State. Would you tell the Committee who has the authority?

Professor Walker: The committee makes a recommendation, but that is only an advisory recommendation. It then goes to Ministers. Then, there is the ministerial decision, and that is then implemented through the section 7 agreement of the NHS Act. It is an agreement between the Secretary of State and NHS England, and NHS England then has the responsibility to implement the programme.

Q281 David Tredinnick: Minister, we have been told that the age range for routine breast cancer screening is going to increase to cover 47 to 73-year-olds. Is that right?

Jane Ellison: Yes. It has been expanded at both ends of the age range, but it is part of a large trial, essentially, and I shall ask David to comment further on it.

Professor Walker: It is a randomised control trial, a very large one, and it comes out of the Marmot review, which recommended that we look particularly at the 47-to-50 age group to ensure that every woman had the opportunity to be invited by the time they were 50, because there seemed to be benefits in that. We are doing a study to find out, but it will take a long time to get the answer.

Q282 David Tredinnick: Are you going to implement that before the trial is completed or are you going to wait for the results of the trial?

Professor Walker: That is being piloted at the moment. In effect, it is a randomised control trial. We are also looking at the older age group, and that is consistent with what happens in many other European countries. A lot of the data that are being used to determine whether this programme should be in place include that older age group, often up to 74 or 75.

Q283 David Tredinnick: Did you have advice from the UK National Screening Committee on implementing the age extension?

Professor Walker: We have not decided to implement the age extension, although we support the trial to see whether we should be implementing it. Once the trial is complete we will make a recommendation, but that will be some time in the future.

Q284 David Tredinnick: I want to ask a question about statins. There seems to be widespread confusion among the public about the use of statins now. Does that worry you? For example, there are conflicting reports in the press about their safety. Is that something that you think you need to address, Minister?

Jane Ellison: In more general terms, there is conflicting information in the media about lots of things in the health field.
Going back to the earlier part of our evidence, one of the reasons why it is so important to get scientifically backed expert advice translated into sound advice for the public is that we want to provide clarity when there is a lot of public discussion—but it is not easy. Obviously, as people come out with new studies and whatever, if they are newsworthy, they will tend to be minus all the footnotes and caveats that David was describing earlier when he receives new scientific advice.

Q285 David Tredinnick: It has been suggested that statins should be used by a wider range of people. NICE has been making recommendations based on evidence that it has received, but is it not a fact that the organisations that have provided the studies would benefit from an increase in the use of statins across the country?

Professor Walker: NICE reviews all the published evidence available, and some of that evidence will have been produced by individuals with links to companies that produce some of these products. When that is the case, they have to declare it. Any conflicts of interest are considered both in the peer review process and in the published articles. That is routine for any scientific study, so we should be aware of where there are such affiliations.
I would say that there is a scientific consensus that statins are valuable for people who are considered to be high risk. The discussion at the moment is where that cut-off should be. There is a grey area, and in that grey area the quality of the evidence being considered becomes very important. There is a serious debate at the moment, but NICE has made its position clear

Q303 David Tredinnick: Just following this theme, have you looked at the portion sizes on offer in fast food outlets? I put it to you that there has been a general increase in the amount of food that is offered. I had an experience myself one morning when I had to get off the M1 because there was a traffic accident, and I stopped at a so-called American diner for breakfast. I was served a plate that was clearly enough for three people. It was an astronomical amount of food. Following on from that, coffee cups used to be a certain size, and now people are being invited to drink half or three-quarter pint mugs of coffee. I just don't think that is necessarily very healthy. Would you like to comment on that?

Jane Ellison: It is a huge challenge—absolutely. It is what health experts call the rise of the obesogenic environment—I think that is the phrase. Portion size is a great public health challenge. It is certainly something that the Chief Medical Officer has spoken to me about on a number of occasions.
People like Public Health England and a lot of public health experts and clinicians spend a lot of time thinking about what we can do. Through the responsibility deal, with some of our responsibility deal partners, we have looked to address some of that in terms of calorie- labelling of meals. Work has been done, for example, to try to ensure that single-serve portions of treats and snacks are below a certain threshold. What we do about that is a major challenge, but some of it is also about educating the public. Through NHS Choices, people can look at the eatwell plate and see the advice.
I am passionate about trying to drive the informed consumer and give people as much information as possible about making better choices in their own lives, but we all know that we are not there yet. That is a very non-clinical take on it, and David might want to add some science around it.

Professor Walker: No; that is very fair. The science is quite conflicting on portion size. Portions are increasing but the value of reducing them is disputed. Essentially, we have a society where exercise is being designed out of our lives and high-fat and sugar foods are being designed in, and we have to find ways of turning that around. This is difficult when it comes to informed choice, because we want to advise the public on what is healthy but we come up against other forces that are advising the public to act in unhealthy ways.
There is a balance to be struck between regulating or advising people to do things that are healthy as opposed to resisting commercial forces, usually, that are trying to encourage us to do unhealthy things.

Science and Technology Committee

Health Committee
Oral evidence: Complaints and raising concerns, HC 350
Tuesday 17 June 2014

Members present: David Tredinnick (Chair); Rosie Cooper; Andrew George; Charlotte Leslie; Grahame M. Morris; Andrew Percy; Mr Virendra Sharma; Valerie Vaz; Dr Sarah Wollaston

Questions 263-394
Witnesses: David Behan CBE, Chief Executive, Care Quality Commission; Professor Sir Mike Richards, Chief Inspector of Hospitals, Care Quality Commission and James Titcombe, National Advisor on patient safety, culture and quality, Care Quality Commission gave evidence.

Q263 Chair: I would like to welcome you this afternoon. Before I ask you to introduce yourselves, I am David Tredinnick, acting Chair of this Committee in the interregnum before the election for a new Chair tomorrow, Stephen Dorrell having given up the post a couple of weeks ago. We thanked him very much last week for his great work.
The other point is that there is a film crew coming in this afternoon, by permission of Mr Speaker, who are making a documentary about activities in the House. So you will be on film.
David, would you like to introduce yourself first, then Professor Sir Mike and then James Titcombe?

David Behan: Thank you, Chair. My name is David Behan. I am the chief executive of the Care Quality Commission. Good afternoon.

Professor Sir Mike Richards: I am Mike Richards. I am chief inspector of hospitals at the Care Quality Commission. I am responsible for inspecting acute hospitals, mental health services, community health services and ambulance services.

James Titcombe: My name is James Titcombe. I am the national advisor for patient safety for the Care Quality Commission.

Q264 Chair: In your memorandum you say that, as part of the Care Quality Commission's new strategy, you want to encourage feedback on care services to understand the quality of care and to identify risks of poor quality. What effect do you think this new approach is having on your work in regulating the quality of health and care services?

David Behan: I will start, Chair, and then Mike will probably add to this. To set a more general context—and I will be very brief in doing this—in 2013 we published our three-year strategy, which set out that we were going to undertake a rootandbranch reform of the way that we regulate and inspect health and care services in this country. From April of this year we changed our organisation, so now all inspections will be led by three chief inspectors—Mike, Steve Field and Andrea Sutcliffe—for adult social care. They will lead directorates of inspectors who will specialise and work with other specialists in the way that they undertake their inspections. This reform will take us another two years—the remainder of this year and next year—to bring about the changes that we want to see. We will ask five key questions on all of our inspections. How safe are services and the people who are using them? How effective are those services? How caring are those services? How responsive are those services to the needs of people whom they serve? Fifthly, how well led are those services?
The reason we are asking that fifth question is that we know the culture in organisations is set by the leadership—the board, the executive team. We will ask our questions around how those organisations listen to concerns from people using those services—in the case of health trusts, patients and their families—and we will arrive at a judgment about how well led those services are based on how those organisations listen to complaints and listen to people who blow the whistle. I think Mike might want to add about how we are taking that forward.

Professor Sir Mike Richards: If I set out the general framework for how we go about our new inspection programme, I think how feedback comes into that will become apparent. Effectively, for any acute trust—but this could also be a mental health trust or community health service—it is a threephase process. We start by getting a whole lot of information in. Do you want me to pause?

Q265 Chair: Order. We have a Division. I am sorry to do this to you when you are in midflow, but we have to adjourn now for 10 minutes. Then we will be back.
Professor Sir Mike Richards: I will pick it up from there.

Sitting suspended for Divisions in the House.
On resuming—

Q266 Chair: I am sorry about those two Divisions. Part of life in the House of Commons is that we are often called away to vote in the middle of other things.

Professor Sir Mike Richards, you were in midflow. Would you like to remind us of where you were and answer the first question?

Professor Sir Mike Richards: I will set out very briefly what it is we are doing around the new hospital inspection programme. The same approach applies to mental health, to community health services and will apply to ambulances as well. Effectively, there are three phases to our approach.
There is a very important preinspection phase, where we gather as much information as we possibly can about an organisation. We gather that from all the datasets that we have plus going to the trust itself to ask them for information, asking colleagues at the GMC, NMC, the Royal Colleges, and so on. So we gather in all that information. We then plan the inspection knowing what we might be going to find when we get there. It is very important to say that whistleblowing incidents are one of the main sources of information that we would use, and any complaints and concerns we have heard from patient groups would also come into that.

Q267 Chair: That sounds very sensible, but do you have any evidence of how the new arrangements have improved or not improved outcomes?

Professor Sir Mike Richards: It really is early to say about that, but with the inspections we rate each of the services against the five key questions that David mentioned of safe, effective, caring, responsive and well led. We have already seen that giving a rating that something is inadequate mobilises action very quickly. In fact, those same trusts want us to go back quite soon to show us the improvement that they have made. So, to that extent, we hear from them of the improvements they have made and we go back and look at it.

Q268 Chair: You have said that you want the Care Quality Commission to become a role model. You have only just got this new mechanism going. Do you not think that is—shall we way—a slightly aggressive approach? You have hardly even bedded in the new arrangements and yet you want to be a role model across health and social care.

Professor Sir Mike Richards: Yes, I think we want to be a role model both in terms of how we treat our own staff and also then in showing people how we expect staff—and indeed other complainants—to be handled in NHS services. What we are expecting of NHS services we would expect to do ourselves. We know that in the past we have not always done that, which is why we are changing the culture very rapidly within the CQC so that we can genuinely be a role model.

Q269 Chair: How actually are you assessing progress, apart from word of mouth? Do you have any formal process?

Professor Sir Mike Richards: Do you mean assessing progress within the NHS?

Q270 Chair: No, within your operation of the Care Quality Commission.

Professor Sir Mike Richards: Within our own operation there are a number of different ways in which we can assess our own progress. One is that, in terms of our own staff, we run staff surveys. In the same way as we run staff surveys in the NHS, we run staff surveys in the CQC and I am very—

Q271 Chair: What are they telling you, please?

Professor Sir Mike Richards: They are telling us that things are improving. There is still further to go by a long way, but there is absolutely no doubt that we are seeing major improvements in quite a number of the questions that we are asking. I think we can point to that as very positive progress.

David Behan: May I add, Chair, we know that complaints generally in the NHS are increasing and we know that referrals to ourselves about concerns in the NHS are increasing? Yesterday I met Katherine Murphy of the Patients Association, and she described an increase in referrals to the Patients Association but also an increase in requests from trusts for the Patients Association to help those trusts deal with complainants. I asked Katherine what she thought that might be driven by, and her answer to that was, in part, it is driven by the fact that the CQC is now asking all trusts, as part of their inspections, how they manage and handle complaints. The fact that we are paying attention to this is driving changes in the way that trusts are behaving in relation to complaints.
The second point that you were exploring with Mike, Chair, is that we want to be a role model in being open and transparent. It strikes us that, if we are to hold others to account for how they are open and transparent, then we must be meeting those standards as well. We are not there yet, but I think the way we dealt with the Orchid View case a couple of weeks ago, where we knew we got that wrong—we carried out a rootcause analysis on that and then published the findings—is an example of how we held up our hand where we were found wanting and then described what we were going to do to put that right. I would like to think that that was a demonstration of us reaching to be a much more open organisation.

Q272 Chair: So you agree that sunlight is the best disinfectant, do you?

David Behan: It is one of the disinfectants.

Q273 Chair: Making people aware.

David Behan: Yes. Being open is absolutely key, yes.

Q287 Chair: Thank you. Before I go to Charlotte, I want to ask James Titcombe, as an independent advisor, what is your assessment of change in the Care Quality Commission?

James Titcombe: I have seen a huge amount of change since joining the CQC. The focus that everyone asks about all the time now is what this means for people; what does it mean for patients? There has been a huge transformation in the approach that we are taking, putting people at the heart of it. We obviously have some distance to go before we get everything right, but the approaches, the work we are doing on complaints and whistleblowing, is going to make a big difference. We now need to turn those ideas and embed them into what we do.

Q288 Chair: Do you think they are adequately funded? I can't believe you are going to say yes.

James Titcombe: Look, more funding, obviously, and resources is always something that helps, but—

Q289 Chair: I do not get the feeling there is a crisis from what you are saying.

David Behan: You have put James in a difficult position. He is a fully paidup member of staff, rather than an independent member of staff, and, therefore, I think the questions about funding—

Q290 Andrew Percy: Of course he will want more money.

David Behan:—for which the settlement has been set for this year—

Q291 Chair: So he is independent but on the payroll.

David Behan: Yes.

Q292 Chair: Okay. Is that because—

David Behan: Why is James with us? James can speak for himself about this, but I was keen that we had somebody right at the heart of the CQC with access to the board, to me, to Mike and to our basic staff, someone who had experience of the system and the way the system didn't work in the interests of people, but also somebody who understood systems and safety from his experience in the nuclear industry. That is why James has come to join us. It is a permanent appointment. It is funded for that duration.
As to the adequacy of our funding, we have had discussions with the Department of Health and we have been given an additional £40 million for this year to allow us to discharge our responsibilities. I expect for this year that that sum will be adequate for what we need to do.

Q293 Chair: I will ask James what recommendations for change you are making.

James Titcombe: As David has said, I have daily meetings in the strategy team with him, so a lot of the input I have had is already shaping what we are doing. As to the plans, in terms of taking Ann Clwyd's recommendations about standards in complaint handling forward, I have had a big say and am very involved with the work. As to the culture of the organisation, I think it is very important that we continue to listen to people and bring them in. Together with Mike and David, I have met with many patients about their experiences. So I think a lot of the recommendations I have made are happening and I will continue to have that input.

Chair: Thank you very much.

Q317 Chair: When are they coming?

David Behan: That recruitment campaign is under way. They start arriving next month, in July, and will also arrive during August, September and October. Once they have arrived with us, if they are brand new staff to us, we need to train them so they are good to go. They will start being "productive" in September/October and beyond. Then we will run a recruitment campaign later in the autumn to get the additional numbers in.

Q335 Chair: Finally, David, before I thank you all for coming, I think you have appeared in front of the Commons Health Committee four times.
David Behan: It feels like more than that, Chair.

Q336 Chair: It probably does. I think your organisation has appeared in front of us six times. You touched on the impact of these annual accountability hearings twice in the discussions we have been having. Could you elaborate a little bit on what you think we have contributed to the change process, please? I am thinking actually—

David Behan: Is there an election on?

Andrew Percy: Massage our egos a bit for the record.

Q337 Chair: That is not the objective. It is fair to say that in fact it was our former Chair, Stephen Dorrell, who has now left the Committee, who put to the Committee in the first place that we should have these accountability hearings. So I think it is an appropriate moment to ask you candidly to tell us a little bit about what you think it has done to contribute, or not, to your organisation.

David Behan: I think it is a really good question, if I may say, and Stephen Dorrell was right to ask us to come here as part of an annual accountability process. I think it is right in terms of our accountabilities, and I think the CQC has multiple accountabilities. I have accountability to the board, I feel we have accountabilities to the people who are using health and care services, but I think the accountability to you in Parliament is a really important accountability. Therefore, while these meetings have not always been comfortable, I have seen it as being an absolutely essential and fundamental part of a parliamentary democracy operating to oversee public services in this country. So I come at this from a slightly ideological position. I spent my earlier career in local government. I am used to elected politicians scrutinising senior officers and see that as a legitimate activity to take place. You have all been voted to sit there: we have been appointed to sit here. Therefore, I think your legitimacy to challenge us on behalf of the people you represent is real and significant. So I begin my answer with respecting the role of the Committee and the legitimacy of you asking people like us to come and account to you and represent the people who have voted for you.
What are the differences that you have made? I have experienced the Committee during the time I have had this job as being challenging. You have asked questions that have made me feel uncomfortable, but nevertheless I think they have been legitimate questions. That has made us go away and think about how we are doing the job. It concentrates the mind to know we will be back in 12 months' time and that you will ask us, "What have you done over the past 12 months?"
What are some of the things that we have put in place? I think our approach to transparency, which was Grahame's question but has been a theme through all of your questions, has been a key part of it. How we respond to complainants and whistleblowers has been a key part of it, and I think we have done our own bit on that, not just because you have asked us. We have invited James to join us and Kim Holt has come to join us. We have opened ourselves up to the people who have been blowing the whistle. You have made recommendations in all your inquiry reports, as part of our hearings, which have set objectives for us to deliver on. I do not mean this to be sycophantic, but the good way that you have done that is to make those recommendations consistent with what Robert Francis, Ann Clwyd and Trish Hart were saying around complaints. That has meant we have not been trying to serve too many different people on too diverse an agenda. I think it has acted to focus our attention and drive improvements in the way that we operate.

Q338 Chair: From what you have just said, I am sure we will ask you back.

David Behan: Good. Thank you for that and I will look forward to it.

Chair: We are running a bit over now. David Behan, Professor Sir Mike Richards and James Titcombe, on behalf of the Committee, thank you for coming. We will move on to our next session.

Witnesses: Niall Dickson, Chief Executive, General Medical Council; Anthony Omo, Director of Fitness to Practise, General Medical Council; Jackie Smith, Chief Executive, Nursing and Midwifery Council and Sarah Page, Director of Fitness to Practise, Nursing and Midwifery Council, gave evidence.

Q339 Chair: Thank you very much for coming. Would you like to introduce yourselves, please, starting with Anthony?

Anthony Omo: I am Anthony Omo, the director of fitness to practise at the GMC.

Niall Dickson: I am Niall Dickson, chief executive of the GMC.

Jackie Smith: I am Jackie Smith, chief executive of the NMC.

Sarah Page: I am Sarah Page, director of fitness to practise at the NMC.

Q340 Chair: Thank you very much. I am going to address the first question to Niall Dickson and Anthony Omo. You made various undertakings to the Clwyd/Hart review of the hospital complaint system about the way the GMC would operate in the future to support the complaints process and those seeking to raise concerns. What changes can we expect to see in the GMC's method of operation as a result of implementing these pledges, please?

Niall Dickson: I hope a fairly significant step change. I suppose one of the key areas that we highlighted in the pledge to the Clwyd/Hart review was about how we support complainants through our process. Traditionally, it has to be said that the GMC—and I suspect all other professional regulators—historically have dealt with complainants by writing them letters, often fairly legalistic letters, which are sometimes difficult for complainants to understand, and then the only time that they would see the complainant would be when they turned up for a hearing, if there was a hearing in that particular case. So we have started a process—we are piloting this at the moment and we will produce an independent report on it later this year—whereby we actually meet complainants, which is new for us, as it were, at the start of the process and—

Q341 Chair: So that is new, yes.

Niall Dickson: This gives us an opportunity first of all to set expectations, because sometimes complainants have unrealistic expectations of what our processes can do, but also to listen to them, what is really concerning them and what they wish addressed. There is that initial meeting and then there is somebody there to whom they can go during the process. We are also meeting them at the end of the process, when the process is concluded, to explain what has happened during the process and why the decisions, whatever the decisions are, have been made in that. That process of facetoface meetings is, as I say, obviously at a very early stage—it is a pilot—but the early signs are that patients and relatives really welcome this. Inevitably, you will get more positive at the beginning than at the end because, in our business, inevitably, some people are disappointed at the end of the process, whether they are the doctor or indeed the patient who is complaining. So that is one area. I can happily go through some of the other pledges if you would like.

Q342 Chair: You pledged to act to support patients through the fitness to practise cases brought against medical professionals. What do you think was deficient in the way the General Medical Council treated patients in the past?

Niall Dickson: Pretty much as I have just indicated. I think in the past we have seen our process as legalistic and we have not supported patients sufficiently through that process or explained perhaps clearly enough how to engage with us and what they can expect. The other thing we have recently done is to introduce a new online complaint form. I know that is boring and bureaucratic, but it is really important in terms of how easily accessible it is to anybody who wants to complain, whether they understand the process going through, and also, if it is not the GMC they want to go to, that they end up in the right place. That is part of our function too.

Q343 Chair: The GMC was quite a stuffy organisation, was it, and now it is more open?

Niall Dickson: Interestingly enough, an awful lot of the organisations that you will have in front of you will be new organisations with new names. You have just had one. I think various Governments managed to change the letters for the system regulator in the first 10 years innumerable times. The GMC and some other organisations—

Q344 Chair: It happens with Government Departments.

Niall Dickson: Indeed, with great regularity. The GMC has been around a long time and I think it is a mistake to think that behind the letters the organisation is the same, because it is not. If you asked any of our staff who have been around for a while, they would say it is like working for a different organisation.

Q351 Chair: Before I go to Andrew George, I have a point on communication. The NMC has committed to having a new operational protocol and datasharing agreement with the CQC in place to share, where appropriate, complaints information and feedback. Are you confident that your operational protocols for sharing data with the CQC and other regulators are adequate to protect the public?

Niall Dickson: Yes. We have this document "Operational Protocol a practical guide for staff," which, as you can see, is from the CQC and the GMC. In the past, organisations like our own did sign memorandums of understanding with other organisations, and they were well meaning and signed by chief executives, but I think the challenge would have been as to what actual impact they had on the behaviour of the organisation. We believe this document is starting to have an effect. We jointly train our staff in it. We have identified individuals who are expected to share information with each other down the organisation. So I think we would say it is adequate.

Q352 Chair: Is your software compatible? Are the systems actually operating? We have had plenty of examples in Government in the past where different organisations simply cannot interface because one is using ICL and the other IBM, or whatever it is. I just want to know from a technical point of view, having worked in the industry once in another incarnation.

Niall Dickson: At the level that we are exchanging information now, it works.

Q353 Chair: There are no problems.

Niall Dickson: It works, but that is not because the CQC can dive into the GMC's files because they can't. It is up to us to—

Q354 Chair: There are protocols, but there are communication systems running.

Niall Dickson: Yes.

Q359 Chair: Thank you very much. What measures do you have in place in your different organisations to assess the policies of trusts and other providers to support your registrants in raising concerns?

Niall Dickson: I am happy to start on that one. I think it is very important—and it is a difficult distinction—to understand the difference between a system regulator and a regulator that is responsible for individuals. Our focus is on individuals, not on the hospitals themselves. That does not mean, of course, that we are not concerned with or do not seek to influence the culture within organisations, nor does it mean we do not have to rely on—which we do—the recommendations, for example, for revalidation, which are based on clinical governance arrangements within these institutions. But we have neither the statutory powers, nor the resources, frankly, to start second guessing and inspecting the clinical governance arrangements, including the culture of safety. That is the job of the gentleman you saw earlier this afternoon and it is very important that we both understand that. I think the new leadership of the CQC does understand that and it is one of the reasons why we are working very closely together, so that they feed information back to us when there are individuals or, when we come across things where we think there may be a systemic problem, we pass that information to them. Secondly, we have assurance from them that there are systems in place to assure the clinical governance arrangements, for example, that the responsible officers' recommendations to us are based on a proper system of appraisal, that that is quality assured, that they select and train their people for appraisal and all those things. That is a clear division of responsibilities.
Just to take that point further, we will look at the recommendations and the patterns of the recommendations, and we will be trying to understand if there are any patterns that raise concerns for us, but the underlying clinical governance arrangements have to be a matter both for the organisation itself and the boards of that organisation. We strongly stress that, and we are about to write a letter to all the chairs of boards throughout the country with the regulators, with David Behan, the head of Monitor and the head of the Trust Development Authority, making it absolutely clear about boards' responsibilities in relation to the performance, the management of their doctors and understanding the culture that they create around that that supports revalidation.

Q360 Chair: What about confidential helpline issues? You indicated that your confidential helpline for your registrants to raise concerns has received over 1,000 calls since it was launched in 2012. It has led to 71 fitness to practise cases being opened. Is that correct?

Niall Dickson: That is right.

Q361 Chair: How would you split those calls up? What proportion have raised concerns about safe operating?

Niall Dickson: I do not know the breakdown of all the calls at the moment. They vary enormously.

Q362 Chair: Can you write to me?

Niall Dickson: Absolutely. We will provide you with that information. They vary enormously, from people who simply want to understand who they should go to within their organisation to ones where there are very serious concerns about something that they have just witnessed.

Q363 Chair: What sort of advice are you giving to those who raise concerns on your helpline?

Niall Dickson: Our guidance is very clear. First of all, if there is something immediate that needs to be done, the doctor needs to take immediate action at that point.

Q364 Chair: So would you take it up with trust management? I am sorry to interrupt you, if I may.

Niall Dickson: Step 1 is that you take immediate action. The next thing is you find the next nearest responsible person who is responsible for that area of care. Often, in the kind of whistleblower issue you are getting people who have raised concerns and do not feel that those concerns have been answered. Again, we give advice about organisations they can go to if they want to explore that further or, if we think there is an issue about an individual doctor, whether that is a matter that we should be investigating; and the 71 cases that you have referred to would be examples where we think there is an individual doctor.

Q365 Chair: What about the NMC? Do you have similar procedures?

Jackie Smith: No, we do not. We are obviously very interested in the GMC's experience and we are watching it closely, but we have had our own difficulties, as you know, and our own caseload to get on top of. We certainly do not want to launch new initiatives until we are in the right place to be able to do so.

Q366 Chair: So you are not ruling it out.

Jackie Smith: We are absolutely not ruling it out.

Q367 Chair: Is this where you would like to get to? You would like to have a similar system to the GMC.

Jackie Smith: I would like to have a conversation with Niall first before we make that decision.

Q370 Chair: Before I turn to Charlotte, what sanctions, if any, can both of your organisations impose on trusts that are managing medical or nursing midwifery services who are not GMC or NMC registrants?

Niall Dickson: We have no powers beyond those powers for individuals. The only other powers we have—the ones we have sort of touched on already—are in our role as having responsibility for postgraduate education and training; we have powers in relation to those trainees. That can have a massive impact on the service that is provided within a particular trust.

Jackie Smith: Yes, and, equally, we can remove students.

Q371 Chair: We are publishing a report tonight on the accountability hearing with the Health and Care Professions Council. If you have not given it to us already, do you have a view on regulation of registrants who would not fall within your scope, for example? Do you think that there are bodies out there that should have some oversight that do not? Have you identified any?

Jackie Smith: Healthcare assistants.

Chair: Thank you.

Jackie Smith: I think you have asked us about this before.

Q372 Chair: I cannot tell you what is in the report; it is embargoed—not for very long.

Jackie Smith: Our view on this has been that the NMC has not been in a position to take on regulation of one and a half million healthcare assistants, and I think that is still our position. There is also something to say about whether regulation is the answer, bearing in mind the lessons that we have all learned postFrancis: is it the normal, natural response to a work force and are there better ways of delivering this?

Chair: Thank you very much.

Q376 Chair: I want to develop this theme a bit. You both stress the importance of finding a local resolution to problems. How do you go about deciding whether to go for local resolution? Is there a bar of ghastly behaviour that has to be crossed to take it up to your level? Can you explain a bit about that?

Niall Dickson: There are two ways of looking at this. If you look at a complaint, how do we think, if we had a fully functioning and good system, a complaint would normally work? Then I guess our view would be that it would be good if that complaint was raised locally and it was dealt with effectively at local level. But if there were concerns about a doctor's fitness to practise, then the responsible officer within that organisation would make a referral to us. That may have originated from a patient complaint, a series of patient complaints, concerns raised by other staff or concerns raised by the clinical managers of that doctor, or whoever, whatever the source. Then that complaint would come up to us and be dealt with. Of course the world is not as tidy as that. Sometimes patient complaints come directly to us. and that is fine and we have a system for that.
We then have to assess those patient complaints, assess where they are in seriousness, and, exactly as you are describing, there is a bar which has been set by Parliament about when we have to investigate and when we do not. As to the ones that are below, some of them are clearly not for us. It may be that somebody is complaining about their doctor as a landlord or their doctor as a tenant, or things that are not relevant, or it may be, "The doctor prescribed me this drug and I wanted that drug." These are clearly things that are not going to reach our threshold. It may have been, "The doctor picked up a mobile phone and started talking during the middle of our consultation." As a oneoff, that absolutely would not engage our processes and it would be ludicrous for us to do that. So we have a system there for dealing with those ones which are not absolute nonsense and we put out the door but which may be something that the doctor ought to reflect on and perhaps the responsible officer ought to know about. Anthony might just explain that new process.

Q377 Chair: Can I interrupt? What duties are there on a responsible officer to communicate with a complainant?

Niall Dickson: They are under statute. This is NHS complaints procedures, not the GMC, because it is not part of a GMC process in terms of them communicating with patients. We do not govern NHS complaints procedures; that is a matter for the NHS. If they are within our procedures, I have explained how we would go about that.

Q380 Chair: Fine. You will be aware of cases where a trust's management has sought to open fitness to practise proceedings against a GMC registrant. What investigation do you undertake in those circumstances?

Niall Dickson: I am sorry?

Chair: You have a situation where a trust's management has sought to open fitness to practise proceedings against a GMC registrant. What investigations do you undertake?

Niall Dickson: That would happen all the time—constantly. As Anthony explained, we now have employment liaison advisers who deal on a daily basis with the responsible officers, who will make the referrals, as you have described, into our proceedings. Often, now, that would be as a result of a discussion they would have with us where they would say, "We have these concerns about this doctor. We think this should be referred in," and we would discuss that and have support. Occasionally our employment liaison adviser might say, "We do think you should refer this case because it requires that level of seriousness."

Q381 Chair: Do you not think there is a risk that a trust's management may seek to use a GMC referral as a means of punishing a GMC registrant who has raised very legitimate concerns?

Niall Dickson: Yes. This is an issue that we have discussed before and there is history around this of individuals who are classic whistleblowers. We were discussing earlier how you differentiate between a genuine whistleblower and somebody about whom there are genuine concerns, and I think we all—

Q382 Chair: Don't the lawyers call them vexatious litigants—the people who come back?

Niall Dickson: We have those as well, yes. But trying to sort this out, as it were, is part of what our investigations have to do. We have to try and establish where the truth lies. We should not automatically accept, because it is a trust's management, as you put it, putting in the complaint, that they are right and that the individual is wrong. You have to take it on the basis of the evidence that we are presented with.

Chair: We are getting very close to the end of this session. I will ask Charlotte Leslie to ask a couple of questions and then Sarah Wollaston wants to come in with another question.

Q394 Chair: Having actually chaired the Joint Committee on Statutory Instruments for the whole of the 1997 Parliament and 2001 as well, with Martyn Atkins as the clerk, I do have a recollection of the 1997 Health Act, section 60, which provides simply for a lot of this work to be done on statutory instruments. Part of the problem is you have the SI, positive or negative, but once you actually have it, then there is a whole cumbersome process beyond that to do anything. So it is not just a case of whipping it through the Committee on a Monday afternoon at five.

Niall Dickson: No. Section 60s have provided a degree of flexibility around this but not sufficient flexibility. They have driven the Department of Health mad themselves, I think.

Jackie Smith: Insane, yes.

Niall Dickson: They certainly have caused huge amounts of frustration, and of course we have had an element of planning blight because we were dangled the prospect of "Don't worry. The Law Commission is doing this work. It will produce legislation. It will free you." And of course now we have been told that we are still in the cage; we have not been let out.

Chair: What a lovely phrase to leave it on. Thank you so much, everybody, for coming.

Health Committee
Oral evidence: Children's and adolescent mental health and CAMHS, HC 342
Tuesday 10 June 2014

Members present: : David Tredinnick (Chair); Rosie Cooper; Andrew George; Barbara Keeley; Grahame Morris; Andrew Percy; Mr Virendra Sharma; Valerie Vaz; Dr Sarah Wollaston

Questions 147 - 226
Witnesses: Dr Liz Myers, Consultant Child and Adolescent Psychiatrist/Clinical Director of Children's Services, CAMHS, Cornwall Partnership Foundation Trust; Dr Vinod Diwakar, Chief Medical Officer, Birmingham Children's Hospital NHS FT; Dr Madhava Rao, Associate Clinical Director for CAMHS, Black Country Partnership NHS Foundation Trust gave evidence.

Q147 Chair: Before I ask the panel to introduce themselves this afternoon, I would like to pay tribute on behalf of the Health Committee to our Chairman, the right hon. Stephen Dorrell, who has stepped down. Stephen was an outstanding Chairman, and I speak for the whole Committee on this. He was a former Secretary of State, and I think we and the House were very fortunate to have someone of his experience in the Chair. We produced during his tenure 40 reports, which is a very considerable number, on a whole range of subjects, and he instituted some major changes to make sure that we held the Government to account more effectively—in particular, calling organisations like the Care Quality Commission and others before us to make sure that they were doing their jobs satisfactorily. So our thanks go to Stephen Dorrell and we wish him well in the future.
This afternoon we are considering children's and adolescent mental health and services, and I would like the panel to introduce themselves, starting on my left and your right with Dr Liz Myers.

Dr Myers: Good afternoon. My name is Dr Liz Myers. I am a consultant child and adolescent psychiatrist and clinical director of children's services in Cornwall.

Dr Diwakar: Good afternoon. I am Vinod Diwakar. I am a consultant paediatrician at Birmingham Children's Hospital NHS Foundation Trust and I am a medical director of the trust. We run the child and adolescent mental health service for the whole of the city of Birmingham, which is around a quarter of a million children and young people.

Dr Rao: Good afternoon. I am Dr Madhava Rao. I am a consultant child and adolescent psychiatrist. I am also the associate clinical director for CAMHS for the Black Country Partnership, running mental health services for the Black Country and children's services for Dudley.

Q148 Chair: I want to open by asking a general question. How has the demand for children's and adolescent mental health services changed in your local area and what are the consequences of those changes, please?

Dr Myers: Over the last five or six years, since we have been collecting records, our referral rates have gone up approximately 20% year on year to the extent where we are currently commissioned to see around 2,000 referrals, but we have 4,000 a year. This has meant that we are necessarily having to prioritise those who have the most urgent and pressing need, and we have no capacity for earlier intervention and very little capacity for seeing those perhaps with the less lifethreatening or urgent risky presentations but for whom we could also do very useful pieces of work, such as those with neurodevelopmental disorders. It has also meant that the staff are feeling extremely run-ragged. There is increasing sickness, a lot of burnout and we absolutely recognise that there are increasing waits. It is not okay. We do not want that for our children and young people, but we have to just keep prioritising. So there are cancellations and times when at any one time we might be trying to manage situations where there is a need to have an inpatient bed but there aren't any. That takes us away from more of the frontline work that could possibly be preventing admissions.

Dr Diwakar: The first thing to say is that in Birmingham the population is rising extremely fast. There is a baby boom in Birmingham, and it is expected that by 2025 there will be 14% more children. So demand is going to rise because of background population rise anyway. With regard to mental health, we are seeing an increased demand in terms of the number of referrals—over the last few years we have seen about a 14% rise—and it is not clear, in the absence of the prevalence dataset that we would hope would be conducted soon, how much of that is due to an underlying increase in mental health disorders itself, how much of it is due to an increasing acceptance of mental health and how much of it is due to underlying population rise. What we are seeing, though, is increased complexity. The average child has around six visits to our service. That is now rising, on average, to up to eight to nine visits to the service, so that might be one of the proxies one might use.
In terms of the impact on our service, the first thing to say is that although the demand is having an effect on staff, it has also driven innovation. Because of the need to see more and more children, there has been a greater need to redesign services so that we are seeing children in their home more and to integrate better with other services. All that said, however, there are issues that have arisen because commissioners have generally directed us to move away from supporting tier 2 services. We have had a strong history of working with general practice, schools and so on, and in general we have had to retract from that kind of work, which is rather against the spirit of early intervention earlier on in the care pathway.

Q149 Chair: Thank you. Dr Rao?

Dr Rao: In the Black Country we have seen over the last couple of years a 15% increase in the number of referrals. Dramatically, what has affected us more is the nature of the referrals that we are seeing. In 2012 we had to admit 16 patients in our patch. In 2013 we had to admit 35, so it has more than doubled in number. So far this year we have had to admit 9 children. It is very unclear as to why there is this level of complexity and this level of citizens in the presentations that we are seeing. Where it comes from is unclear. We do not have any prevalence data for a long time from this.
We run two services: a CAMHS service in Sandwell and a CAMHS service in Wolverhampton. The commissioning structures are different. In Wolverhampton we have a tier 3+ service and we are able to deliver some amount of care and prevent admissions. But in Sandwell we do not, so we are unable to provide any crisis intervention, even to A and E or divert any patients from A and E or the paediatric beds. So more and more of the children are staying for longer periods on paediatric wards, which is a completely inappropriate place for children with acute mental illness to stay. There are a small proportion of children who are so resource-intensive for us that it results in a huge chunk of perhaps the neurodevelopmental disorders, especially autism spectrum disorders and ADHD, falling way behind in their waiting times. We have changed the way we work to compensate for this. We have implemented what is called the CAPA—the Choice and Partnership Approach—to streamline the way the children move through the service. Even with that, we are only able to maintain the waiting times—I have it here—to around 16 weeks to choice and eight weeks to treatment. That is still not good enough. We would like that to fall even further, but we are unable to do so because a huge chunk of our work is taken up by the change in the nature of presentations that we are seeing.

Q150 Chair: Thank you very much for that overview. I have a couple of specific questions to ask before I hand over to colleagues. For you, Dr Diwakar, in Birmingham Children's Hospital in your evidence you state that the Choice and Partnership Approach has reduced waiting times. How does this work? Do you think that waiting times for starting treatment are acceptable? I think you touched on this already.

Dr Diwakar: As I think the evidence says, when the Choice and Partnership Approach was implemented, around five years ago when I first became the medical director, there could be up to 200 to 300 children waiting 18 weeks or longer for their initial appointment, which was clearly unacceptable. By implementing the Choice and Partnership Approach, we have been able to bring down the waiting time for the choice approach to four weeks and then for the partnership appointment to 11 weeks. The choice meeting involves an initial meeting with one of the professional staff. Most of our professional staff have been trained in how to do these choice appointments. It essentially involves not only taking a history and discussing the problem with the family but also working out with them what they are hoping to achieve for their child or young person and how best to deliver that care. With some people it may mean that they talk through the problem and they are quite happy. For other people it may mean that they want some help from one of our professionals and then they come back to the partnership appointment.
I am a general paediatrician, so that means I make referrals into the CAMHS service—I am not a psychiatrist—and I certainly have personal experience over the 10 years that I have been a consultant of a huge improvement in the access to the CAMHS service. Now, when I refer patients, it is much better to be able to say, "Colleagues will see you within four weeks and then we will discuss appointments," and so on.

Q151 Chair: There is better access, and presumably that is why we are getting more pressure.

Dr Diwakar: Quite. Of course, when you get better access you do drive up the pressure at the same time.

Q152 Chair: Let us leave it there for a moment. Dr Myers, turning to Cornwall for a moment, you said that the increases in more severe cases—fairly naturally—have put pressure on the other services and that the young people with neurodevelopmental disorders such as autism, ADHD and things like that are suffering. Is that right?

Dr Myers: Absolutely. That is because we do not have enough of everything to go round and, absolutely mirroring the trends here of increase in severity and acuity backed up by data from the Derriford hospital, whose casualty department we look after as well as the Treliske hospital, we are getting about double the amount of urgent referrals from A and E over the last couple of years. That is just one instance. We are also probably admitting about twice as many youngsters.

Q153 Chair: Is it because access has improved—the same thing as in Birmingham?

Dr Myers: Not at that high end; I don't think so. Because they are presenting in crisis with very severe difficulties, there is an increase, probably, in problems at every sort of level, but one thing that is clearly impacting on us is the big increase of acute, very risky presentations.

Q178 Chair: So it is "ownership" again, the same language as Dr Rao.

Dr Diwakar: Yes, exactly. There is no one looking across the system and saying, "If these two parts separate, who is looking after the children in the gap?" Presumably, if you have made a referral and your tier 3 service refuses it, that means—

Chair: Just before I continue, is that all right, Grahame?

Grahame M. Morris: Yes.

Q179 Chair: Just before Sarah comes in, from what you are saying so far, ownership is a key issue and the misapplication of resources is an issue, with ambulances buzzing to the wrong parts of the country where parents cannot follow. A general misallocation of resources comes through to me as one of the issues. Is that right?

Dr Myers: Yes.

Q180 Chair: It is a misallocation of resources and the resources are not actually going in the right direction.

Dr Rao: They need to be more linked up. The resources need to be linked up from the CCGs and NHS England to provide a seamless care from tier 3, 3+ to 4.

Chair: Seamless care. Let us leave it there.

Q183 Chair: Did you want to come in on that, Dr Rao?

Dr Rao: I think the voluntary sector and tier 1 and tier 2 have a significant role to play. It is a way to pick up parental mental illness, a way to pick up on strategies like parenting programmes. Parental mental illness needs to be emphasised again; the earlier it is picked up, the better. We usually end up picking it up by the time the child comes to tier 3. That means they have had to experience quite a lot of difficult situations at home before they come to us. If that was picked up earlier, then maybe help can be delivered at an earlier stage. Whether there should be an integrated budget there, I don't know. I do not have an opinion on that particular issue.

Chair: Thank you very much.

Q185 Chair: Thank you. I have one more question. Then I am going to ask each of you if there is anything you want to say that has not been covered in the questions. But if you do not have anything extra to say, you do not need to say anything because we have another session to come on straight afterwards. What services do children's and adolescent mental health services provide to lookedafter children? Is this support being affected by recent pressures?

Dr Rao: Can you repeat the question, Chair?

Chair: What services do CAMHS provide to lookedafter children? Is this support being affected by recent pressures, please?

Dr Diwakar: In the past there was a commissioned service where social workers and CAMHS workers were integrated together. What has happened more lately is those have been separated and so the lookedafter children are now looked after by a socialwork based Therapeutic Emotional Support Service, I think they are called, and they only reach CAMHS when there is a placement breakdown or some sort of mental illness arises. My sense about this is that it would be much better for these children to be spotted early and to have interventions early from CAMHS professionals rather than separating them and waiting for a crisis to happen.

Q186 Chair: Thank you. Is there anything else you want to say?

Dr Myers: Could I make a comment on that? There is variation across the country. In Cornwall the local authority has a psychology service and I also work in it a day a week. Lookedafter children have access to CAMHS but they have to meet the thresholds. What is missing is targeted interventions and also specifically for care leavers and those in transition.

Dr Rao: I agree. It is different in Sandwell. They were providing a psychology service and there was a full lookedafter children's team that the local authority had funded. They decommissioned the whole psychology service and transferred all the care to CAMHS. So they now have to meet the CAMHS threshold to have any help from us. But for them we have a different way of working. We cannot simply turn round to these children who we are seeing, who are quite in need, and say, "You have to meet this threshold," so we have changed the way we work. We have turned into a part-consultation mode in which a huge chunk of the clinical time is given to consultation with the social workers regarding the lookedafter children and directing appropriate help when required.

Chair: Thank you, all three doctors, for your time. It has been very helpful.
Witnesses: Dr Jenny Taylor, British Psychological Society, Dr Amanda Jones, Professional Lead & Consultant Perinatal Psychotherapist, Perinatal Parent Infant Mental Health Service, North East London NHS Foundation Trust, Dr Sebastian Kraemer, Consultant Child and Adolescent Psychiatrist, Whittington Hospital, gave evidence.

Q187 Chair: Good afternoon and welcome to the Health Committee. Would you be kind enough to introduce yourselves? Would you start first, please, Dr Taylor?

Dr Taylor: Hello. My name is Dr Jenny Taylor. I am a consultant clinical psychologist and a lead psychologist for a CAMHS service in an NHS trust, but I am here representing the British Psychological Society, the professional body for clinical psychologists, but also educational psychologists, counselling psychologists and other practitioner psychologists who work with children and young people.

Dr Jones: Hello. I am Dr Amanda Jones. I am the professional lead and consultant perinatal psychotherapist from North East London NHS Foundation Trust, which has a specialist perinatal parent/infant mental health service, which I work for.

Dr Kraemer: I am Sebastian Kraemer, chartered psychiatrist at the Whittington hospital, paediatric department.

Q188 Chair: Thank you. I will start by asking this question. What, in the view of your members, is the state of children's and adolescent mental health services—CAMHS? We have noted that 70% of the people you surveyed raised concern around provision of services in the area of deliberate selfharm and suicide prevention. What, in your view, should be the priority areas for improvements in these services?

Dr Taylor: As you say, our members' views—who responded from working within NHS trusts—fitted with the responses we heard in the earlier session about generally increased pressure. There is not necessarily great clarity about where that is coming from, but there is a clear experience on the ground of increased pressure. In terms of what we do about it, one of the things I was struck by when we were listening earlier to the evidence given is that we are talking a lot about access to services, but we also need to make sure that the services we are delivering are effective and making a difference. So there is an element of access and funding that everybody seems to be fairly clear is what we are experiencing at the moment, but I think what we have not spoken about as much is ensuring that the interventions that we offer when children and young people do come to our services make a difference to whether or not they return and deliberately selfharm or whether they actually attempt suicide.

Q189 Chair: So that is results-based.

Dr Taylor: To some extent, but also using the information we already have. We have, for example, a lot of NICE guidance about children's and adolescent mental health services. One of our colleagues who spoke earlier talked about the need for commissioning groups to ensure that there were certain provisions. That would be a starting point, making sure that CAMH services are providing, at the least, what the NICE guidance recommends needs to be provided, as opposed to emphasising needs for numbers of staff, for example, or particular disciplines. But, yes, I think it is about looking at whether or not we are making a difference to those children and young people who are coming into our services and presenting with deliberate selfharm: is that continuing? It is not just about how quickly we are seeing them but whether we are making a difference to that behaviour. At the moment many services feel that there is a far greater requirement for them to report on targets, such as waiting lists or the number of children being seen, rather than a great interest in whether or not they are making a difference to those children and young people.

Dr Kraemer: While we are waiting for the evidence, there are things we know we can do effectively, usefully and helpfully with deliberate selfharm. In a crisis you can more easily get hold of young people's families. Separated parents will come from various parts of the country for a consultation on a paediatric ward where a girl, typically 15, has just taken an overdose and been admitted. Although this big study called SHIFT—"Selfharm intervention, family therapy"—is not complete, I hope and expect it will show that family intervention at the crisis stage is vital because there are a lot of things that can be said in such a crisis that cannot be said in the cold light of day, even two days later when the young person says, "I am sorry I did that. It did not mean anything," and it has all been put under the carpet. So there are things one can do and there are things we have to do.

Q190 Chair: Would you like to add to that, Dr Jones?

Dr Jones: I am not placed to speak about CAMHS in this regard but more about perinatal parent infant mental health, which I suppose is the earliest possible intervention that can be made in the hope that one might protect a baby from becoming a young toddler and a young child who will need CAMH services later on. I have been asked to come to the Committee to call attention to the disparity of services that there are across the UK to provide an intervention to a woman, and obviously her partner, during pregnancy and in the early postnatal period. In the service that I work for, we see over 1,200, often, referrals a year of really quite catastrophic situations. So one only has to imagine that the babies of those mothers and fathers are going to go on possibly to have considerable difficulties in the CAMHS interventions later on.

Q196 Chair: We are trying to have a better integrated health service and it is quite clear from the Health and Social Care Bill that we are trying to bring things together. Do you think that training generally is out of date and that there is too much focus on particular disciplines and not enough on interface with other disciplines? Do you think, for example, that it might be something we should look at? We should look at just how the training is done. It sounds, from listening to your answers to Dr Wollaston, that it is all so rigid—these separate silos—and that there is almost a degree of defensiveness. It is not a criticism, but it is a statement of fact. Is that fair?

Dr Taylor: I think there is a degree of defensiveness, but I am not suggesting that we should not have people trained in particular types of therapy, in the same way that—I don't know—for example, a general practitioner might want to refer to a physiotherapist who knows how to do physiotherapy. They are not going to suddenly start doing another type of therapy; that is their training. But you need to know how many physiotherapists you need. You need to have people who are generally trained, like psychiatrists and psychologists, to look at what the problems are, but then you also need to have sufficient therapists trained in particular modalities to deliver them. In terms of knowing whether we need to revisit the training, what we really need, as has been discussed here and elsewhere, is to revisit the epidemiology: what is our level of need? We are not clear. We seem to be feeling there is far more coming in. We need to look at the levels of need, the different presentations and use that to help plan what specific modality therapists we need and what else we need.

Q204 Chair: Can I come in on this point? I was quite struck by what you said about social disintegration at all levels—all classes. Can you point your finger at one particular cause, and to what extent do you think that electronic communication—Twitter, Facebook and all of that—has a part to play, and also access to pornography? Is that actually bringing about some of these problems we hear so much about now?

Dr Kraemer: It makes intimidation more alarming and more chronic. You can be teased in the playground and it has gone with the wind, but if you have got your photograph on Facebook then it stays there for ever. I do not believe these children are any different from the children I met when I started in 1980, but they have different means of upsetting each other—girls in particular. The medium is not the cause, but it certainly facilitates different ways of harming each other, of abusing each other, and that is what young children do. Some of these girls have been bullied into a state of despair because their attachments at home are not strong enough, so they rely on their friendships to be a family for them, and when that family crashes they feel they haven't got any, until family then appears like magic in the paediatric ward the next day and maybe some restoration can be created then.

Dr Taylor: I have one followon point with regard to the media. I completely agree with Sebastian that it is not the cause, but it is creating a different environment. I did read a very interesting paper recently when we were discussing this very issue also looking at there being some evidence that for some young people the greater accessibility to other young people across the world who have similar interests to them has increased their sense of not being alone, not being the odd ones out. We just need to bear in mind that it is a different way of accessing other people and having social interactions that has huge possibilities for greater isolation but also potentially, for some young people who were previously feeling disconnected, for connection. We need to be aware that the access to media is not a clearcut thing.

Q208 Chair: Thank you very much. Just coming on to definitions, do you think that the term "mental health problem" is poorly defined? Do you think we need better definitions of problems?

Dr Kraemer: How long is a piece of string? I am worrying about wanting to talk about the work we do at the Whittington. That question is the one I deal with every day working with paediatricians who think that mental health is a strange phenomenon because it is not easily defined, as you rightly say. So I do not define it. I just say, "What's the problem here? What are we dealing with? What's the matter with this child? Why are you asking me to see this child?" From our point of view in paediatric liaison, working in a hospital, we do not need definitions; we need conversations. I am really quite passionate about that. I could talk about this but I think it would not be dealing with the submission that I have sent in. I do not think it would help the Committee.

Chair: Thank you.

Dr Taylor: I think that might be a quote from our submission, so I feel I possibly should—

Dr Kraemer: I am sorry, I should not have answered.

Dr Taylor: No, no. But I am also aware that we have experts here from other fields.

Q209 Chair: Please let it be drawn out. We need this information. We need colour and depth as well.

Dr Taylor: As I say, I am only responding because I think it may have been asked because it was in our submission.

Chair: Yes.

Dr Taylor: The reason why that particular comment is in our submission is again related to how tier 3 services have, to some extent, been pushed into a corner, about how they manage with increases in incoming referrals. The corner they are being pushed into quite often is saying, "We will only accept this referral if the young person is suffering from a clea

Commons' Committees

David Tredinnick was an elected Member of the Commons Health Committee and Commons Science and Technology Committee during the 2010-2015 Parliament, which are Committees appointed by the House of Commons to examine and scrutinise the Government for Health and Science policy respectively.

These Committees choose their own subjects of inquiry, which may simply consist of a single day's oral evidence or last for several months and give rise to a report to the House.

Find out more about the work of the Health Committee and Science and Technology Committee here.