UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 937-i

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

NHS NEXT STAGE REVIEW

Thursday 10 July 2008

PROFESSOR STEVE FIELD, PROFESSOR NICK MAYS and MR DAVID PRUCE

PROFESSOR ADRIAN NEWLAND, NIALL DICKSON and MR NIGEL EDWARDS

Evidence heard in Public Questions 1 - 129

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the Health Committee

on Thursday 10 July 2008

Members present

Mr Kevin Barron, in the Chair

Charlotte Atkins

Mr Peter Bone

Jim Dowd

Sandra Gidley

Stephen Hesford

Dr Doug Naysmith

Mr Lee Scott

Dr Howard Stoate

Dr Richard Taylor

________________

Witnesses: Professor Steve Field, Chairman, Royal College of General Practitioners, Professor Nick Mays, London School of Hygiene and Tropical Medicine, and Mr David Pruce, Director of Policy and Communications, Royal Pharmaceutical Society of Great Britain, gave evidence.

Q1 Chairman: Good morning, gentlemen. Could I welcome you to our first evidence session of our inquiry into the NHS Next Stage Review. I wonder if I could, for the record, ask you to introduce yourselves and the position that you currently hold? Could I start with you, David.

Mr Pruce: I am David Pruce; I am Director of Policy and Communications at the Royal Pharmaceutical Society.

Professor Field: I am Steve Field; I am the Chairman of the Royal College of General Practitioners.

Professor Mays: I am Nicholas Mays, I am Professor of Health Policy in the Department of Public Health and Policy at the London School of Hygiene and Tropical Medicine.

Q2 Chairman: Welcome once again. Could you tell me briefly, in two or three sentences, what is your opinion about the NHS and the Next Stage Review? Do you accept that the NHS required another review at all?

Mr Pruce: Did we require another review? Possibly we did need another review; whether we need another reorganisation is a different matter. I think pharmacies look forward to contributing much to more to improved patient care, and we were pleased that the Darzi Review mirrored a lot of what was in the Pharmacy White Paper. Pharmacies are open for extended hours. We offer an alternative route to healthcare within 20 minutes to 99% of the population. We think that is a key advantage. The report by Lord Darzi, coupled with the Pharmacy White Paper, is our way forward to making real changes, we believe, to experiences of patients.

Professor Field: Given that there was a White Paper only very recently in 2006, our first feelings about it were, "Why are we doing another review?", but when we considered what was being proposed, we thought it was actually a timely stock-take of the Health Service as a whole. We have been pushing, as you know, for many years, for high quality patient-centered care, moving care out into primary heath care teams, who manage most illness in this country, and moving the focus to more about health promotion and prevention. We saw this as an opportunity to look at the whole health system in this country, and just doing it for primary care on its own was unreal, so we welcome the chance to look across the board and the focus on quality, particularly, we have supported very strongly.

Professor Mays: I think the main reason that the Government wanted a review was to have a different kind of perspective on the Health Service. I think the main justification for the Darzi Review is not so much, necessarily, that there needed to be a substantive new review - I am sure that the previous White Paper still has not been fully absorbed by the system - but I think it appealed to the Government to have what was ostensibly a clinician-led review. The test of Darzi is to what extent is it actually different from the kind of White Paper that one would otherwise have seen, and that is quite a big claim that is being made. It is a distinctive kind of approach. For example, the argument about whether the White Paper includes enough information about implementation is a question about whether you think that maybe previous White Papers were too directive. I think its main justification is actually in style and in who was directing it and who was engaging clinicians across the NHS in the process, not so much whether we needed, once again, to review the NHS. We review the NHS persistently.

Q3 Chairman: Steve, can I go back to you. You mentioned quality. Is poor quality the most single, the most individual challenge facing the National Health Service at the moment?

Professor Field: If you are looking at the Health Service today and over the next ten years, I think it is a question of providing high quality care, as I said earlier, moving towards prevention, putting more power, if you like, towards patients so that they can take more responsibility for their own health. Those are important because of the demographic change. What is happening is that, as patients are getting older, they are having more complex conditions, physical conditions as well as psychological conditions, and with that comes an increase in cost to the Health Service, and so the challenge is about how you manage an increasingly aged population with complex medical conditions and how you maintain value and quality within that. It is quite a complex number of issues. From a GP's perspective, we have seen a real change in what we are doing from workload for more elderly patients who do not have single disease issues like you see from NICE guidelines, like diabetes or renal failure, we are managing an increasingly elderly population with a lot of what we call co-morbidity complex problems. It is how you manage that in a much more effective, safe, high quality system. That is where we are coming from.

Q4 Chairman: Quality is the thing that is in this report, but do you think it should have concentrated a bit more on the issue of value for money? We have got something getting near a £100 billion per annum budget now. Would that have been a better way of approaching it, do you think?

Professor Field: I think it is more complex than that. As I said, it is how do you shift care from the doctor or the health professional being the centre to the patient being the centre? How do you move healthcare so that the patient can take more responsibility? Then, how do you provide a much safer, much more high quality system? Certainly we are then talking about productivity, we are talking about reducing risk, reducing waste. It is a mixture of quality and cost-effectiveness, I think. We were never going to have the amount of money that they throw into the system in Massachusetts, but they have realised in Massachusetts, when they have moved to a health insurance system, that they are short of GPs to act as the gate keeper. So, in fact, whatever you do, it is going to be a balance between safety and cost-effectiveness.

Q5 Chairman: Nick Mays, have you got anything to add to that?

Professor Mays: Yes, I think I would agree, from the tone of your question, the document is written as if resources are not a problem, and Lord Darzi tends to point to the fact that, "Well, we have got £100 billion", but, of course, the prospects for the next few years are not quite as rosy as they were in the period when we were trying to implement the NHS Plan and other such things. I think it is interesting that the document does not really talk very much about the implications for efficiency. For example, it is very much in the style of a document that wants to make the NHS a richer environment for patients. In primary care we are going to have other parallel primary care centres alongside conventional GP practices, which, of course, is designed in order to encourage choice and also some degree of competition between conventional general practice and these new GP-led health centres, but, of course, that will come at a cost, and to do that consistently across the entire country, particularly in the less well doctored areas, I would have thought, is a fairly major undertaking. I have got no figures to hand, but Darzi does not really make any inferences about how easy that will be to do. Likewise, the measurement of quality on a routine basis across the wide range of clinical effectiveness, patient experience, quality of life has not been attempted, I do not think, across a wide range of services in any other health system and, again, it will be a resource-intensive activity, quite apart from the need to develop the methods in the first place, because these methods are used in research studies at the moment, they are rarely used routinely on 100% of the patients passing through busy primary care or hospital institutions.

Q6 Chairman: Obviously there are quite a lot of aims and objectives in the report. When it gets round to implementation, of course, you are talking about eight paragraphs, which is not a lot. Do you think it is deficient in terms of how you would achieve or provide adequate information? Does it do that in terms of implementing quality, or do you think it is deficient in that area? It just seems to me there are plenty of aims and objectives, eight paragraphs on implementation, and big question marks hanging over all of it in a sense.

Professor Field: The big issue is about how you implement the ideas locally. I think one of the issues the college has had has not been really about the Primary Care Review Group, which I think we have had a lot of influence on over the last five or six months, it is really how you implement locally, because the SHA work-streams were very silo-driven. The contribution of jobbing general practitioners from the college was not that great in some of the SHA committees, and so you had anomalies, for example in the Yorkshire paper, about who was looking after children and the emphasis on childcare. My concern is not about Lord Darzi's paper nationally, it is ensuring that we have more appropriate local implementation with very good, high quality clinical input, and that is where I would put my emphasis for the next phase.

Mr Pruce: I would agree with Steve. It is all about how well it is implemented. We are particularly concerned about how variable implementation is by PCTs. For example, the Pharmacy White Paper and Lord Darzi's review talk about minor ailment services through pharmacies, yet only 24% of PCTs actually commission those already. They are seen as something that should be a national service. When we went through the SHA vision statements we saw enormous variability and a lot of variability also about who was involved. Pharmacists were involved in very few of those groups, even though we tried to get on them. Just as one example, in the Staying Healthy clinical pathway three of the SHAs identified pharmacy as a vehicle for that, and yet Lord Darzi's review suggests that vascular health checks should be done through GPs and pharmacies; so there is a disconnection between the two.

Chairman: We may want to want to pick up on one or two of those things, David. Let me move on now. Peter.

Q7 Mr Bone: I want to ask a couple of questions about health centres, or polyclinics. The first one is what evidence is there that they will be more cost-effective at delivering primary care trusts than the existing model? Perhaps Professor Mays might answer that, please.

Professor Mays: My reading of what is in the report is that actually what Darzi has put forward is not the original, as floated, concept of the polyclinic. If I understand it correctly, the polyclinic idea was bringing community health professionals and generalists from the community alongside hospital specialists in a single entity. What Darzi is proposing is what we call GP-led health centres, which are, if you like, extended primary care centres, both extended in terms of the range of services and professionals than you might normally expect in a typical general practice and extended in terms of extended hours. The question is more will this slightly different kind of primary care provide value for money? Darzi does not couch it in that way. The way he couches it is in terms of providing an alternative for patients to conventional general practice, albeit that GPs are now being told, or they make the contract adjustment, to extend their opening hours. This is a further addition to that accessibility and perhaps a different style, and essentially it is very much a New Labour idea of choice and competition. It is saying initially, "You can use these centres as a walk-in centre", so it is an extension of the walk-in centre concept where the non-registered person can just avail themselves of a convenient episodic bit of primary care, and then, over time, if you feel that that extended hours centre is where you want to go, you can enrol. The gist of it, again, is not so much cost-effectiveness as choice and competition, which will generate improvements in quality and put the asset, essentially, on the conventional general practice.

Q8 Mr Bone: You said something quite interesting there. Do I understand from that, you will not have to register?

Professor Mays: You will not have to register to use them.

Q9 Mr Bone: You will be registered with another GP?

Professor Mays: You will stay with your ordinary GP, and then the document talks about the probability, possibility, that you will then in the future, if you choose to, decide to transfer your enrolment, and I think that is something that the BMA will be quite sensitive to. It is very much the continuation, if you like, of the reinvention of the market, this time in primary care. We know it was considered at a much earlier point in the development of the post-2002 reinvention of the market that there would be some attention given to a market in primary care. The Government tended to say, "Let us deal with the hospitals for a start." This is the next phase.

Q10 Mr Bone: Can I stop you. I think the answer to my question is that there is not any evidence here that there is going to be more cost-effectiveness.

Professor Field: From the Royal College's perspective, we have tried to find some evidence and have not found any. That does not mean we are against large health centres.

Q11 Mr Bone: No, having cleared that point, that there is no evidence perhaps either way on that issue, I want to try and get my head around the concept, which Professor Mays started to talk about, of the health centres. We have walk-in centres now, and I understand that some hospitals have GPs at their accident and emergency. In my patch most of my GPs do extended hours and there is already a proposal to have a much enhanced new medical centre attached to what is, laughingly, called a hospital but it is not a hospital any more, but that was done before any idea of health centres came along and it was evolving in relation to local needs. I am not quite sure where these health centres fit into all those existing models.

Professor Field: There is a considerable body of evidence about the value of the generalist GP, family health centre, family practitioner, gate keeper role. From an evidence point of view, we know about the role of a GP, Barbara Starfield and others, and we welcome the investment, frankly, in primary care. In many of our inner city areas there has been very poor investment in infrastructure for many years. In many of our inner city areas there are insufficient numbers of GPs to manage the service. So, of course, as a college we have been plugging away, lobbying for more investment for many years. The problem with the polyclinic idea is not that large centres are not needed. If you look in constituencies adjacent to where I practise, they have been planning large centres and knocking down the big hospitals, moving to primary care for some time. This is not new. The problem seems to be that the investment, which is welcome, has been sprinkled down to PCTs and PCTs are implementing large, let us call them, polyclinics in areas where there is high-quality general practice, and they are not needed, whilst in other areas they probably need more investment. If I was to manage this system - and this is what we are saying from the college - we would say the investment is welcome but it is the implementation which is the problem, and perhaps there is still time to review that, to look at where perhaps we could invest better for patient care. The danger is that some good quality practices would be destabilised through this procedure. The danger is that some practices that need investment will not get it and will perpetuate, in some areas, the poor investment, the poor number of GPs that we have already got. It is quite a complex argument, but we do welcome the investment.

Mr Pruce: I think we also have to look at the wider impact of bringing GPs together into one place. Most of the polyclinics that are being invented have pharmacies within then, and we would certainly support that. However, most pharmacies are dependent on dispensing volume. They get maybe 80% of their income from dispensing. Our main concern is if you bring together GPs in an area, patients have to travel further, carers have to travel further and they are going to rely on the pharmacy much more. The local pharmacy is going to be their local healthcare professional. If you have most of the dispensing done in these polyclinics, that could make your local pharmacy unviable, so you end up losing the local pharmacy as you have lost the local post office, the local parade of shops, and the knock-on effects for the local economy is quite significant, let alone the fact that patients and carers will have lost immediate access to healthcare advice and support that they increasingly begin to rely on. There is good in the ideas. How it is implemented is going to be quite significant, and, although Lord Darzi seems to have pulled back from the idea of the super polyclinic, we do not see that PCTs are pulling back from that and there seems to be pressure on PCTs to have at least one of these in each area.

Professor Field: Could I add to that? I do think it is a local implementation issue and solution, but I have been impressed by Lord Darzi in how he has listened to what we have been putting forward. As you know, we were working on what we called the "road map" two years ago and published it before this review was announced, and the federated model of practices, working together with large and small practices, is the way forward, and we have been pleased that during the consultation period, the development of the primary care part of the strategy, that has become much more prominent; but in order for that vision to happen (and we would welcome that because then you could target the investment to where patients need it) you actually need to say to PCTs, "Have you consulted with what is really needed? Do you really need to put in that walk-in centre or that large GP health clinic", or whatever they are called this week, "in that particular area?" I think there is time. Why is it being rushed? Why do we have to have implementation and procurement by December? Why can we not say, "Let us have another good look. Why do we not invest in some of the high-quality general practices we have already got in the areas where we need it? If you look at rural areas, why are we not using that money to invest in already built large centres to extend the services? Why are we not using that money to invest in community hospitals in those areas? I think this is a very wide issue that affects both rural and inner city practice.

Q12 Sandra Gidley: I want to pick up on the investment, because it seems to me, and correct me if I am wrong, that there is money available for brand spanking new GP-led health centres. If local GPs, to quote an example, want to use a community hospital to strengthen the use of a community hospital and work in some sort of federated fashion to provide services through them, maybe involving other local health practitioners as well, the money does not seem to be being allowed to be used for that, and I think Darzi himself has confirmed this. Does this not mean that this is all just a front, if you like, to bring in a greater element of the private sector or do you not see it that way?

Professor Field: You might see it that way.

Q13 Sandra Gidley: I was asking how you saw it.

Professor Field: I know you were. I think one of the dangers is fragmentation. The money, as far as we understand, is only for three years, I think. The problem is, on the one hand, in some of our inner city areas we found it very difficult to attract GPs to work. In some of our inner city areas, frankly, there has been a lack of investment in premises. So we support what Lord Darzi wants to do about investment. In other areas there has been quite a lot of investment, there are good community hospitals: why say there has to be one in each PCT? Why not say this money needs to be invested based on need? The argument is not with Lord Darzi, it is the local implementation of the policy we have concerns about.

Q14 Dr Stoate: I would just like to put on the record that, in addition to being a practising GP, I am also a Fellow of the Royal College of GPs, and I therefore know where the bodies are buried! I would like to ask you, Steve, whether you think that Darzi's proposals undermine the traditional gate keeper role of the GP?

Professor Field: The answer is, I do not think they do, the policies as a whole. I have been part of the advisory board since it was set up in November, and questions were raised then about the role of the GP, the role of the pharmacist, the role of nursing, and that is a big issue as well, and as we looked at the evidence, the evidence supported the role of the gate keeper, which is a cost-effective system, which increases the incidence of true disease presenting to specialists. All the evidence is about hospital outcomes being better if you have high numbers of high quality GPs. So, by the end of the review period, Lord Darzi and ourselves were at one over that. I think the question the Chairman mentioned about competition in the private sector is such that we also know that some quality of care is not good in some areas and, frankly, it is PCT's responsibility to do something about that. As a college we are involved in setting standards for practices and individuals, and we can highlight what is good practice, but patients, unfortunately, do not have the information to make choices. So, we do not think this is an attack on the role of the GP, it is actually the system, and how do you move influence and power to the patients so that they can make those two choices? I think that is the underlying theme. Put the money in, create a bit of competition so that patients can choose to go to the good practitioners. The worry is that that might undermine some of the good ones, but I do not think it is an attack on principles.

Q15 Dr Stoate: Good. I am pleased to see that the college's view on this is rather more measured than the BMA's view. I am very pleased with the constructive way you are looking at this. What I want to talk about is your federated health centres. You have already talked about that. I know that the college is currently consulting about your model. What I would like to ask is how the federated health centre model differs from what Darzi is proposing?

Professor Field: You have got to define what Lord Darzi is proposing, and he is proposing federated models of general practice; so he does not differ at all now. He talks about practices and pharmacies working together, and I would own this as well personally, having been part of the advisory board. The integration horizontally with social care, with nursing, is absolutely key for the future. Integration with specialist services is key. The only way you can really do that is by the general practices working together. Where the college has moved the agenda on is to say that, first of all, gone are the days where single-handed GPs should work on their own in splendid isolation. They should work by sharing clinical outcomes, by sharing guidelines, critical events, audit together. We have moved it on by saying that could be done much more effectively with terms of reference and terms of agreement and, in fact, then moving on perhaps to a far more integrated company or organisation across practices. What we are trying to do is say there are things that need to change, and the federation will allow individual small practices to survive but be able to use resources more effectively in the bigger centres. It will be able to share expertise. I was really heartened this week. I went to Croydon and met with the 14 practices in Croydon that have set up as a federation of single-handers and large practices. They have got leads for chronic obstructive pulmonary disease, for heart failure, for diabetes. They are sharing, not just expertise, but guidelines, and their next phase is to try and encourage the specialists, and some of them are not keen on coming out into primary care and there is still this difficulty with secondary care wanting to lose market share. They are encouraging specialists to work in much more of an integrated manner. So I have seen where we can go and I think the future is really, really bright.

Q16 Dr Taylor: For the record, may I declare that I have known Steve for rather a long time, because he was my houseman at some stage rather a long time ago. I want to come back to the GP-led centres, the 150, and the money available. I think I am right in saying there is £250 million available for these 150 GP-led health centres and 100 new GP practices. Is that right, and is that going to be anything like enough, or is that what is constraining things? I have tried to push to have three smaller GP health centres in my area, and there is not possibly enough to have three of these small ones as opposed to just one large one, so is it not money that is dictating that there has to be just one for each area?

Professor Field: I think the initial investment, the way I think it has happened is that the money has been allocated and, therefore, they have worked out how many centres could be afforded. As I have said all along, the college's position is we welcome that investment but it needs to be used appropriately. There is not enough money in order to change all practices and bring them all up to the standard that we would want. One of the ideas about the federated model is that we could start to look across geographical locations about how you use that money more appropriately. So in Wyer Forest you will have specific needs and you will have a specific small district hospital which might also need some investment in one way. We are saying one size does not fit all, but the role of the gate keeper is important.

Q17 Chairman: You said on several occasions, Steve, the issue about the PCT should see whether it is needed there or it should invest in need. How do you measure need?

Professor Field: Gosh, that is a very good question. I think there are a number of parameters that we as a college would look at and are highlighted, actually, in some of the papers. To start with, the number of general practitioners in a locality seems to have an effect on quality, from the literature. So you can look at those under-doctored areas - that would be one thing - you could also look at the infrastructure needs, but, of course, what really should happen is we should have a constructive dialogue with patients, the public and the local doctors and other healthcare professionals about what is needed in their particular area. There are some gross statistics which would be useful. Unfortunately general practitioners historically have gravitated, even before the Health Service began, to areas which might not be as challenging. There are some others, like myself, who go the other way, but how do you encourage GPs and pharmacists to work together with other healthcare professionals in very deprived areas and, conversely, in very rural areas, and need might be very different in those two different extremes?

Q18 Chairman: I am quite interested in this, because the Government put the first tranche into spearhead areas where there is disease about. My own constituency is above the national average in most areas of ill-heath, yet I have GPs complaining about the building of a primary care centre in the next constituency to mine. The pattern and spread of GPs has been around in the same way as it is now since, we assume, the last 60 years, and yet the disease burden in constituencies like mine is far higher even than in some neighbouring constituencies. I am not convinced that anybody is measuring the proper need, and that is the need of the patients as opposed to the need of the practice on the ground in my constituency, which I have some disagreements with, I have to say.

Professor Field: I would agree with that. In my own practice area, if you can survive crossing the busy road in two halves of the area, life expectancy is ten years longer in one part than the other, and so you can look at that. The workforce distribution is a health inequality issue, the make-up of the local population, the deprivation, is another issue, and these are the sorts of things that public health departments look at. Again, the investment is welcome, it needs to be targeted at need, and in some areas they want more investment.

Q19 Chairman: Do you think the Royal College ought to have some sort of matrix that says: this is the disease burden in communities and we need more GPs in these areas, because, looking round at research in America, the more primary healthcare practices you have on ground the more likely the population will be healthier?

Professor Field: We do, and we have published a series of documents supporting that assertion, but it is the role of the local PCTs to make sure that they have appropriate numbers and appropriate buildings for providing primary care. It is their job. Our job is to highlight what the standards of care should be and highlight these anomalies. What we have been trying to do all along is provide solutions for SHAs, for the Government, for PCTs. What we are not doing, unless my message has not come across, is we are not opposing anything, we are saying investment needs to be targeted. Clearly, in inner city Birmingham that investment is very different to rural Herefordshire. There is a lot of deprivation in rural Herefordshire but how you handle that from a healthcare provision point of view is very different to where I work in Borsal Heath.

Chairman: I know, I am just sharing my frustrations with my own constituency and one or two practices, and only one or two out of many, that seem to be obstructed. What I believe they should do is to try and lessen the work loads of general practitioners in my constituency who are carrying patient groups with very high disease burdens.

Dr Naysmith: Can I just point out that a very distinguished Fellow of the Royal College of Practitioners, Julian Tudor Hart, pointed all this out many years ago. In fact, he gave evidence to the committee about it.

Chairman: He did.

Q20 Dr Naysmith: That was all laid out 50 years ago.

Professor Field: Absolutely. The inverse care law. If you go back in health policy, one of the problems we had was the Health Practices Committee, which limited the number of doctors. When that went it actually took the lid off the flow of doctors as to where they could go. Before that you had to make a case for where the GPs were. In fact, it is much more of an open market now. As a college we have made many statements about addressing inequalities by making sure there are enough doctors, addressing inequalities by making sure there is enough infrastructure. Where we are also with Lord Darzi, when you talk about how you need to change, in some areas, unfortunately, where there might not be the will to change, you do have to use different tactics, and we do accept that in some areas you might need to put in a health centre, even though your local practices do not agree that it is needed, if the health data shows that from deprivation, health outcomes you need more doctors there. I think we are brave enough to say that there are issues and you cannot just effect change always by consensus, but the way it has gone is difficult.

Mr Pruce: I think it is much more than just using general practice better, it is using all the tools we have, it is all the health professionals, and also getting information from them about the local needs. Most PCTs have undertaken a pharmaceutical needs assessment, trying to get at what are the needs of patients for medicines in a particular area. We know that there are health inequalities in the use of statins, for example, but very few PCTs actually take much note of these and take action as a result of it. So it is not just doing the needs assessment, it is actually using those to redirect services and commission better.

Q21 Mr Scott: David, you have just been talking about the very issue of the review's greater emphasis on health maintenance rather than illness management. How do you see pharmacists fitting into the new regime?

Mr Pruce: Pharmacists already do a lot around helping people stay healthy. A lot of pharmacies will get involved in helping people stop smoking, we are beginning to see obesity management clinics, and so on, and one of the things that Lord Darzi has proposed is that vascular health checks could be done through pharmacies. That is really building on one of pharmacy's key strengths: that we are accessible. We are not seen particularly as a "health" centre, we do not have the same baggage as going to see your doctor, people wander into pharmacies, including those that are well and those that are really hard to get, the young to middle aged men who do not go and see their GPs, yet smoke. I was in that situation, and I smoked for 15 years, but I bought a heck of a lot of cough medicines. So there are lots of opportunities to get to people like me. I have stopped now, I must say. We can also, though, help to free up general practice. We estimate that there are something like 51 million GP appointments for minor ailments, for conditions that could be treated through a pharmacy, that do not have any other complicating factors. That is something like 18% of all GP's consultations. If even a proportion of those were shifted from general practice to pharmacy, think of the amount of consultations that would be saved so that general practitioners could concentrate on perhaps more complex patients, patients who really need their attention and who cannot self-treat.

Q22 Mr Scott: But, surely, you are not suggesting that there should be fewer GPs and more pharmacists?

Mr Pruce: Not at all, no. We work very closely with general practitioners, but if you are going to shift care from secondary care to primary care, you also need to free up capacity within general practice, and what we suggest is that, where those patients could present either at a pharmacy or at the general practice for exactly the same condition, perhaps they should be encouraged to use the community pharmacy so that it does not take up valuable general practitioner time and we can then have a role in reducing the burden on general practice.

Professor Mays: Just an observation. When you start talking about vascular health checks, I think there is a question for the committee about whether that would be a really top priority for the use of resources. Cardio-vascular disease is in steady decline. The main focus, I had thought, was improving the quality of treatment through stroke centres, and so on, and making sure that everyone got to a stroke centre. I wonder whether it really is the top priority for a universal screening system, irrespective of whether it is provided by GPs and pharmacists. I would not have said that the evidence is very strongly in favour of that. I have nothing against it, obviously, as someone over the age of 40 who may well need vascular checks, but given that it is something that is, I would say, a mainstream general practitioner activity anyway, it is being used as a symbol of the new wellness-focused Health Service, I am not so sure it is the most efficient symbol of a wellness-focused health system.

Q23 Mr Scott: Professor Field, do you accept that the 51.4 million GP consultations could be handled by pharmacists?

Professor Field: What you have got to look at in primary care is how you use the primary healthcare team. It is not just pharmacists and GPs. I think we need a radical review of nurse training as well, the role of the nurse in primary care, and actually the school nurse in prevention, which has been a recurring theme in the Darzi review, not GPs, actually in that instance. There is no doubt that the pharmacist's role can be expanded, because we know that the footfall in pharmacies is high and they can take on more of a preventative role and they have made a fantastic impact in general practice in medicines management in surgeries. We need to keep an eye on a couple of issues. One would be the evidence-base. On the one hand, pharmacies sell a lot of cough mixture. The evidence-base is zero on the effectiveness of cough mixtures for most of the public and, therefore, are you going to be actually increasing the national healthcare bill by giving out and prescribing things and getting people to buy things which do not work. That is my view on cough mixtures; just to get it off my chest! I would agree with everything else you said. General practitioners are highly skilled diagnosticians. We train for a long time, not long enough actually, and that is another issue in the Darzi review, and acquire high level skills. It is an important issue. What we need to do is concentrate the GP's time on managing all those complex issues. Consultations in general practice are too short generally now for the complexity of the individuals coming in, and I do think working more closely with pharmacists and nurses is important. There are other issues about pharmacy, about confidentiality in the shops, about being able to do the consultation in an appropriate way, which I understand pharmacies are trying to address. There are also issues about the training of pharmacists. We should not pretend that pharmacists are cheap, less trained doctors from a diagnostic management point of view. They have different skills and there may be something about their continuing professional development in order to be able to identify more serious disease: because one of the criticisms of GPs has been why do we not pick up cancer earlier? Why do we not do this, this and this? Actually, it is extremely difficult in primary care when you are seeing undifferentiated, what is called, minor illness, and that cough could well be an early sign of lung cancer. So I think pharmacists and GPs need to work for more closely together and, yes, the time of GPs does need to be freed up to manage any increase in the complex problems of ageing. I think we are not speaking in a different way on that, but it has to be based on evidence and guidance and pathways for the patient that we can work together on.

Q24 Sandra Gidley: I should declare my interest too as a Fellow of the Royal Pharmaceutical Society. A quick question for Professor Field. You mentioned the evidence-base, and I think you are quite right and that there is a limited evidence-base sometimes in the advantage of pharmacists, but would it not also be fair to say that there is a limited evidence-base to some of the things that GPs and doctors do? We have already heard from Professor Mays that people could be treated in completely different ways in different parts of the country. So it is a slightly unfair comment, is it not?

Professor Field: No, I think it is fair, because I would agree with you about doctors as well. What the college is trying to do is say we should be based on an evidence-base which should not just look at randomised control trials of drugs, it should look at social care and the effect on the person as a whole, and that is one issue you might want to talk about with NICE, the way they look at social care in the context of patients. So, yes, I would agree. Also, I think we need to be brave nationally to say why are we putting so much money into things which have no evidence-base. Homeopathy, for example, some of the alternative therapies, actually, cost money and the evidence-base is zero, so let us look what the evidence-base really means. Yes, hands up, we agree.

Q25 Sandra Gidley: Okay, that is a fair point. You talked a bit about co-operation. It seems to me that it is very patchy throughout the country, and, particularly if we are to make the best of GPs and pharmacists, there needs to be closer working. Professor Field and David Pruce, how do you see this happening in practice? I do not see any signs of it happening locally or nationally.

Professor Field: I think I can give you lots of evidence that it is happening at a local level. In Croydon earlier this week the person who came to say hello first was a pharmacist who was a partner in one of the GP surgeries who was part of that federation. In other areas they are looking at federating with pharmacies. In our own surgery we have a pharmacist working in the surgery helping us with medicines management. So there are lots of models, but I think at the moment it is a very diffuse sprinkling of pharmacies which have come out of shops, have they not, chemist shops, and the pharmacist's role is developing. Perhaps when we are planning local services, federations are a good example of how we can do that. We should be looking at how pharmacists work more closely locally with the GPs, about where they are located. We have tried to get a pharmacy actually right next-door to our surgery, because patients get mugged going to the pharmacy in daylight where we work. We have a bodyguard working in the surgery. They get mugged, but we have not been able to secure investment from the PCT to build a larger centre adjacent to us to bring all the services in one. This is not just about professionals working together, it is about health service managers looking at how we co-ordinate services, it is about getting pharmacies more involved in practice guidelines and how things are taken forward with the patient at the centre. There is lots of room for improvement, but we need to build on what is good.

Mr Pruce: Unlike Steve, I do not think it is about co-location. We are in danger with co-location of falling into the same trap as we are with polyclinics, thinking everything needs to be in the same place. The relationships between GPs and pharmacists are good in lots of areas. In lots of areas they do not even know each other; so there are things that need to be overcome. One of the interesting things I heard from the recent King's Fund Report looking at polyclinics was that you can bring lots of different professionals together in one place, but that does not mean they are going to work together, and the effort needs to be put into how we get GPs and pharmacists, in particular, to work together. NHS Employers are setting up a working group to look at just this point. We have had success in facilitating meetings where perhaps GPs and pharmacists come together for education, for audit, for joint working on projects, and often it is getting that understanding of each other's roles, each other's gripes, the things that are acting as barriers that seem to work. I did one piece of work with some colleagues in Bromley and the pharmacists were to report back to their local GPs around prescriptions that had very little instructions on, and patients did not understand it. For some of those pharmacists it was the first time they had gone to their GPs with something that was clinical and was solving a joint problem. The relationships that were built up out of that have lasted for a long time and, in fact, one of the pharmacists ended up being employed by one of the GP practices part-time. It needs facilitating, it needs effort to go into it and it is a key role for PCTs to facilitate in that.

Q26 Sandra Gidley: Are PCTs doing any of this?

Mr Pruce: It is very patchy. Some are, but I would say the majority are not.

Chairman: I am conscious of the time. We are about a third of the way through the questions and about two-thirds over time at this stage; so maybe we can be a bit crisper on questions and answers.

Q27 Dr Naysmith: Can we turn to equality of outcomes, and we can probably be quite crisp on this because you touched on it in the early questions with the Chairman at the start of this session. One of our advisers was reminding us at the start of this session that way back in Barbara Castle's time there were documents that focused on outcomes, and more recently, when Frank Dobson was a minister in the early days of this Government, there were documents discussing outcomes, and the vision that we are talking about for primary care says, "Making services personal and responsive to all, promoting healthier lives and striving to improve the quality of care provided". Recently we have been concentrating on other things other than outcomes, on targets and so on. Does the review contain the right proposals for achieving this vision? Professor Mays, you have not had much chance to speak for a bit.

Professor Mays: Are we talking specifically about primary care or more widely?

Q28 Dr Naysmith: More widely?

Professor Mays: I think there are some good ideas in there. As your adviser says, this has been around for a long time. One specific thing I would comment on: the review tends to assume that you need to pay more for quality. They talk in relation to amending the hospital payment system, the Payment by Results system, that you might augment the national tariff for high quality. Of course, a lot of the evidence suggests that high quality costs less because you do not get repeat operations, you do not get readmissions, you do not get the cost of treating infection, and so on. So one of the things you might want to talk to the Minister about is to what extent you might use his proposals for national standard setting to say that you will not pay for things that are below standard. You might want selectively to pay more for quality, particularly in the early days of this policy, but if you take that to its logical conclusion, it is inflationary, it is potentially quite inefficient to assume that you have to pay a lot more than the national tariff for high quality. One of the things I would be pushing a little bit harder: if we really are serious about using quality measures as a way of influencing payment, either for general practice or for hospitals, would be to say, if we have got some standards we think are really important below which we do not think it is decent to fall, why do you not do as some American payers do and say: "30% of your patients received a quality of care or an outcome that we thought was suboptimal. We are not paying for that 30%. We will pay for the other 70%. That is fine." It would be quite a tough discussion, but if you really are paying for results, given that we know that better care is not always more costly, you have to think carefully about the incentive effect of paying for quality and how you do it best.

Q29 Dr Naysmith: That also implies that you have to have some way of measuring quality of outcomes, and that is going to cost money as well.

Professor Mays: It is. A lot of the things that are being discussed are, if you like, commonplace in the research that people like me do - we have been measuring patient experience, patient satisfaction, health-related quality of life, clinical effectiveness, symptomatology, for 25 or 30 years, often to the incredulity of practising clinicians, who say, "Why are you doing this?" We know that the aftercare is good, we know our patients get better and people like this say, "Show us, prove it."

Dr Naysmith: You probably assume that because they do not come back they have been cured, but that is not always the case.

Q30 Jim Dowd: They could be dead!

Professor Mays: Yes. So it is a triumph for Health Service research and your application of social science to health services. People like me would applaud it. It has not been done routinely over 100% of patients in all areas of care ever, so it is a huge task to move it up from a research activity to a routine relatively low-cost, high take-up. This is the other thing. Response rates need to be decently high, particularly if you are then going to relate resources to those patients' responses. You are going to need 70-80% responses to patient reported outcomes, questionnaires, for example, and there are some quite interesting dynamics when patients say, "Actually I have had my care. I am out of the hospital. Thank you very much for the care, but I do not particularly want to fill in these forms and post them back or go online."

Q31 Dr Naysmith: Professor Field.

Professor Field: I would support what Nick says. What I would say for primary care at the moment is the QUOF, which is a series of proxy measures, is making a difference. There are papers in the pipeline showing it is starting to address some of the inequality issues in the provision of care, but it is how we move to those outcomes, and I think the paper does not go into the detail because you need expertise outside to help us develop those outcome measures.

Mr Pruce: I would lay down a query over the metrics and the development of metrics. I was involved in a number of the national audits that Royal Colleges have developed, including one on evidence-based prescribing in older people, and we found it very difficult to come up with measures of good prescribing that could be measured. I have here a previous consultation on performance indicators that had hundreds. Most of them did not actually get to outcomes and were what was easily measured. They did not measure true outcomes. The problem is, if you end up measuring the wrong thing, you skew healthcare, and I am very cautious about these metrics that are being developed.

Q32 Dr Naysmith: There is also a lot of talk about providing personalised healthcare plans and personal budgets to improve patient outcomes. Is the NHS equipped for this kind of innovation?

Professor Field: No. I, as well as the advisory board, are pushing hard to pilot the budgets, because there is evidence in social care that if you empower the patients to make those decisions, they make much more cost-effective and appropriate decisions based on what they really need. I felt it was something we should try for long-term conditions.

Q33 Dr Naysmith: So there is evidence for it.

Professor Field: There is evidence for social care, but we have not done it, for all sorts of reasons, for healthcare here in this country.

Q34 Dr Naysmith: Would you be willing to try it?

Professor Field: Yes, from a college's point of view we have debated this, and we support piloting that to see how effective it is but putting an evaluation around it - just sprinkle it out and wait and see.

Q35 Dr Naysmith: So the plan will be discussed with professionals and then money would be given to the individual to go and purchase the care from somewhere?

Professor Field: Yes, and I think that needs to be done---. When you have got a long-term condition, you have got health and social care needs and what your needs as an individual would be would be very different to yours and, therefore, it needs to be built into a project where it is evaluated so that we can learn the lessons.

Q36 Dr Naysmith: Do any of you have anything to add?

Professor Mays: Just that there are many different ways of doing it. You can actually hand cash over and say, "Go forth, here is some information", you can give people a budget and say, "From a range of services that we specify, what would you like to choose?", and you can say, "Work with your principal professional adviser to deploy a budget". So there is a spectrum of degrees of freedom, degrees of direction, degrees of information. To be fair to Darzi, I think he presents that as experimental and he says we are going to pilot it, so I think that is spot on. It seems to me it is robust innovation and, if they wait until the pilots have been evaluated, that would be a welcome innovation. If we are talking about innovation and policy, then that would be an innovation that I would welcome.

Mr Pruce: I would agree with that, but we find that lots of patients have difficulty navigating the Health Service, possibly more than they do social services. So it would be right for some people, but some people would find it incredibly difficult to navigate and to work out exactly what they do need, particularly when it comes to medicines. I think doctors and pharmacists have enough difficulty navigating medicines. So the expert patient will benefit from it, but it does need careful evaluation before roll-out.

Q37 Sandra Gidley: Professor Field, you just mentioned QUOF, but the review proposes "a new strategy for developing the quality and outcomes framework, which will include an independent and transparent process for developing and reviewing QUOF indicators". I would like to ask you to start with, what evidence-based interventions you think would incentivise improvements in prevention?

Professor Field: It is a very hard question. I can talk about the policy of where we are, and the policy is important, because I chair the expert panel for QUOF now and our expertise comes from the University of Birmingham and Manchester and elsewhere. What we are frustrated about is that when we find evidence and that goes forward to the negotiators between the employers and the BMA, always the evidence-based interventions come out and sometimes there is pressure from both sides. So, from a policy point of view, we would support it becoming more independent. We are concerned about NICE because the track record with primary care is not great. The guidelines that they produce for primary care are not implemented by GPs across the country.

Q38 Sandra Gidley: Is that because they do not read them?

Professor Field: As well as the SIGN guidelines in Scotland, partly because there is so much to read when you go into the surgery. You have to force your way through the door behind NICE guidelines, but SIGN guidelines, with more college activity in Scotland, are used by GPs more. So from a policy point of view, we support NICE doing that, but they need more college input. We support independent advice, and what I would say to your question directly is we would have to base it on what the evidence is, and I am not an expert on the evidence, so I would seek advice on that.

Q39 Sandra Gidley: What you seem to be hinting at is that what we have at the moment is not really based on evidence.

Professor Field: A lot of it is based on evidence, some is not on as hard evidence. Some of the indicators which have better evidence have not been allowed into the QUOF, and, as you are probably aware, we are piloting nationally a practice accreditation, provider accreditation system. Alongside that, we are also piloting some of the indicators. One of the problems is that when indicators and ideas are put forward, many times they are not actually evidence-based because they have not been piloted to see what the effect will be. So, what we are advocating is a more evidence-based approach to it, and why we are supporting NICE working with the college and academic bodies is to make sure the QUOF is based on evidence. The other problem with QUOF, of course, on prevention, is that it is too great a proportion of GP's pay. What it needs to be is a lower proportion so that you can really start to look at how you influence change.

Q40 Sandra Gidley: Professor Mays, you were nodding at one stage.

Professor Mays: Was I?

Q41 Sandra Gidley: Involuntarily obviously.

Professor Mays: To be fair to the architects of QUOF, on the spectrum of health policy it was one of the more evidence-influenced policies that one has seen, but, as you say, because we still have a national GP contract, it is always going to be an industrial relations issue as well. They can invent an independent panel that will review the evidence and suggest measures or proxies that can be used to pay GPs and practices to their heart's content - after all, that is sort of what happened before, as Steve was saying, Birmingham and Manchester Universities were feeding in information about indicators - but then it is an NHS Employers verses the BMA slug-fest.

Q42 Sandra Gidley: We have some nodding here.

Professor Mays: And, ultimately, because it is turning these evidence-based indicators into hard cash, people are looking at what effect is it going to have on the BMA side of the distribution of income across practices, for example, never mind the health benefits - that is a separate issue. Unless you can completely recast the IR side of this, and maybe you could, maybe you could say, "Actually we are going to use QUOF-like contracts, but they are going to be local contracts, we are not going to have national bilateral negotiations any more around the clock."

Professor Field: There is an issue on QUOF about the content. When we move towards provider accreditation, the management parts of QUOF, there are ways we can move management out and focus on more prevention and on healthcare itself, clinical care. I think Nick is absolutely right, the problem is the inevitable negotiation between an employer and a union, and what we have got to try and do is make sure that this is based on what the patients need to improve the quality of care. The problem is, if the percentage per income is so great, it makes that much more of a hard bargaining between employer and union. That is one of the problems.

Q43 Sandra Gidley: I was going to ask what could be dropped from QUOF to provide preventive care. Would the answer be management or is there more to it?

Professor Field: I think management will have to move out eventually, but as a college with the BMA watching---

Q44 Sandra Gidley: They are up in Scotland. Do not worry about that.

Professor Field: It is not our responsibility to get involved in terms and conditions of service. We are involved in trying to improve the quality of care for patients. It is for others make those decisions.

Professor Mays: One thing which would be good in principle would be that at the moment, as I understand it, historically the weight given to different indicators in the QUOF is related to their workload implications, rather than their ability to improve health or reduce inequalities or improve patient experience. It would seem to me one sensible thing one could put into the negotiations would be that to pursue the logic of the evidence-base you would pay more for things, consistent with Darzi's notion of paying for quality, that were more health promoting, irrespective, in a sense, of the workload implications. So people were basically calibrating the points on how much staff time it would take rather than whether it is a good thing or not. It is understandable, and I would do the same if I were negotiating for the doctors. I would be saying, "Yes, but how much is it going to cost me?", not from the NHS point of view, "How much health gain am I going to get?"

Q45 Dr Taylor: To Steve and Nick. How good a measure of quality are PROMS?

Professor Mays: In the research environment, with some development work that has been going on in the last few years, but it is still, if you like, a nascent industry and, of course, it has largely been applied in surgery, but in terms of validity, very good.

Q46 Dr Taylor: Even though I think you said earlier many people do not bother to fill in the surveys and forms?

Professor Mays: I said, I think, that maintaining a high response rate is going to be a real challenge when we do it on a routine basis outside the research study. As to how they are going to be administered, presumably they are going to be administered by the providers themselves, or is it going to be an independent agency that collects the data, I do not know, but response rates become critical when you start allocating money based on those responses.

Q47 Dr Taylor: So, in theory, good?

Professor Mays: Absolutely fantastic.

Q48 Dr Taylor: You also mentioned that you thought that where quality was not high people should think of paying less. Can PROMS data be translated to payment by results?

Professor Mays: The implication is that a range of quality measures, not just PROMS - so if it was a hospital or a speciality in a hospital - could be used to generate some sort of index. So you might have some weight for patient experience, some weight for the PROMS, some weight for other more conventional effectiveness measures like readmissions or something, and you could generate some kind of quality indicator which you could then use. So it would be part, I suspect, of an overall measure of quality. Of course, the big argument would be which dimensions of quality and which measures do we include and how much weight do we give to each, and I can imagine that would be a fascinating dialogue when you start using to it drive resources.

Q49 Dr Taylor: Has it been done anywhere?

Professor Mays: It has been done to a small degree in the States by certain health payers, it has been talked about a lot in the States, but to give you an indication of how far England is intellectually at the cutting edge, when the QUOF was developed in the GP contract, the amount of interest from the US was absolutely enormous. So, once again, we are being heroic in health policy. We might not be great at implementation, but by golly we have plenty of good ideas.

Professor Field: I do not think you should underestimate the effect of the QUOF on changing the culture in general practice. On the union, the BMA side as well as the college, it has made a real change across the board. The problem we have is that patients do not know what is good and what is bad and what high quality and what is not high quality. So it is not just the PROMS, which I theoretically I know the research is there, but in primary care it is not there. What is important to do very quickly is to give as much information to patients as possible in as digestible form as possible so that patients can make a real choice about the quality of their care and where to access it. I think that is one of the big problems in the system, and that does come out throughout Darzi's papers. It is high-quality service, cost-effective service, but in order to do that, you need to tell people what is high quality. That is something we need to work on with NHS choices, as we are with Dr Foster(?).

Jim Dowd: Can I start by declaring an interest. I am not a member of any Royal College of any kind whatsoever!

Sandra Gidley: That is a lack of interest.

Q50 Jim Dowd: It is disinterest as opposed to uninterest. I want to test something that Mr Pruce and Professor Field were saying earlier. For years pharmacists have been regarded as an unused resource in primary care. In response to an earlier question, the question of whether 50 plus million consultations could be avoided if pharmacists were used more actively, which my colleague to my immediate left here tells me would be something like one in six of all current consultations, is not the problem a structural one without co-location? Unless you change the gate keeper and say to patients, "Look, do not come and see me next time. Go and see your pharmacist first and, if he or she refers you on to me, then that is fine", where they are not on the same side, does that not become extremely difficult to achieve?

Mr Pruce: If I can respond to that. Pharmacists already do this. It is down to a patient whether they see a GP or whether they go to a pharmacy and treat themselves. We saw a rapid increase in the number of people coming to pharmacies, particularly on Saturdays when GPs surgeries are closed at weekends. What we do is we talk to a patient, talk about their conditions. We try and work out: is this something where the patient can treat themselves or is it something more serious that needs to be referred on, and we refer on to GPs where necessary. You do not necessarily need to know of a GP. If patients go on holiday and they go to a local pharmacy, we will still refer them back to their GP, who may be hundreds of miles away. So, yes, it is better if you have a relationship, but that does not mean co-location. As I have mentioned before, the King's Fund Report suggested that co-location is not the answer to everything and does not mean relationships work any better necessarily. It is about one professional being able to make a judgment on whether it is safe for this particular patient to treat themselves or if they need to be referred to someone else.

Q51 Jim Dowd: But the Saturday issue you raise will, of course, be addressed by GP-led health centres, which will be open on Saturdays and Sundays.

Mr Pruce: Hopefully, yes, but people still choose to go to a pharmacy, they choose not to wait for an appointment with the general practitioner, they choose not to disturb the GP.

Q52 Jim Dowd: Or else they end up inappropriately at A&E?

Mr Pruce: Absolutely. What we want is the most appropriate health professional seeing the patient and referring if necessary; so that could be achieved through a national campaign. If you have these sort of symptoms, check it out with your pharmacist first, which is what NHS Direct is tending to do, to refer patients with minor conditions to a pharmacy first so that they can then assess the patient and refer on, again, if necessary.

Q53 Jim Dowd: If pharmacists were able to prescribe, would that not save even more time?

Mr Pruce: I would argue pharmacists can prescribe, because we are able to supply medicines that no other healthcare practitioner, apart from a doctor, can. There is a group of medicines that can only be supplied through pharmacies. If there was a national minor ailments service that had a set number of medicines that pharmacists could supply on the NHS, that would be incorporating pharmacists much more into the NHS Service. We have a number of pharmacists that can prescribe. It is about 1,000 so far.

Q54 Jim Dowd: Out of?

Mr Pruce: Out of 47,000.

Q55 Jim Dowd: It is not a great proportion.

Mr Pruce: Not yet.

Q56 Jim Dowd: You look quite animated, Professor Field. I am not sure whether you want to add something.

Professor Field: I am just interested in the debate.

Q57 Jim Dowd: That is why we are here, of course!

Professor Field: There are two issues. One is about the patients. Inevitably, as healthcare becomes more complex and technology advances, we will be able to produce much more of a rules-based system for a lot of the care we are providing now. Inevitably, the emphasis will move from not having to see a specialist through to being managed by a generalist, to being managed by a pharmacist or a nurse where appropriate, to the patient taking care for themselves. We can see that with diabetes. Everybody died early in the early 1900s because we did not have insulin. When insulin came in you needed endocrinologists to manage them all because it was so difficult. Now, particularly in the States - we do not quite have it here yet enough - insulin pumps and managing your own sugar provides fantastic care, better care than having to go to see an endocrinologist at interval. I predict that patients will inevitably, over the next years, be moving more towards managing their own care with advisers, and that should be a pharmacist or a doctor where appropriate. GPs need to be freed up spend more time with more complex problems. We are skilled diagnosticians and risk managers. Pharmacists have different skills. We would support prescribing from an evidence base on some conditions. We do not want to move radically to what they are trying to sell very hard in America, which are things like the Minuteman Clinics, where you have, say, ten conditions or 20 conditions, and where they give antibiotics out for ear infections or sore throats. They call that access; we call it lack of evidence. There are all sorts of sexy things you can do about access for patients, but they have to be based on evidence. That is where I think pharmacy and general practice are coming from absolutely together. We have supported prescribing at pharmacies right from the start.

Q58 Jim Dowd: The main thrust of this section is about choice and trying to identify choice. Professor Field has talked about managing care packages. That is all based on information and knowledge. The review advocates the introduction of patient involvement in this, but Lord Darzi has stated that this does not mean specifying an individual practitioner either at GP level or at consultant level. If that does not exist, how real is the choice likely to be? How do we give people enough information to exercise informed choice?

Professor May: Threaded throughout the review is a whole lot of proposals about extending information available to patients and to health professionals. This talks about augmenting the NHS Choices website, NHS Information or evidence or whatever it is called, which is like an encyclopaedia of what we think we know. In that sense I would say the review's heart is in the right place. It is very much about saying that we must provide more and more accessible, more palatable, more digestible information, both for professionals and for patients. The assumption, also, which I think is good, is that professionals in a sense are under informed, given the range of things they have to do. I suppose the real practical question is how soon would the vast majority of the population become familiar with these databases and with these information systems and able to use them. Certainly, reading Darzi, I gained the impression of a world in which health professionals and patients and prospective patients are quite familiar with spending several hours every day sitting down at a computer, reviewing graphics and bar charts and diagrams showing them how good things are or what is the best way of doing things. It is a lovely vision of a rational consumer world but it did not seem to me to tie in quite with how you feel when you feel ill, and whether you are going to be in that position in quite the same way. It did seem to me, again, a very worthwhile social experiment to see whether the English Health Service can really use new technology and the distillation of what we think we know in a way that other health systems have not done. I notice that we do have quite good information systems and quite good databases and so on, and we are trying to use them in a more creative way than some other countries, so maybe we have made a reasonable start, but you can be sure, from what we know about the various pilots in hospital choice, that support and interpretation to people making choices, particularly when they are distressed or sick, is really, really important. One of the things, for example, that the London Choice pilots did three or four years ago was to provide what they called patient choice advisers. Some people rather mocked that and said, "This is a new health profession that we are creating," which is an appropriate criticism and it was alluding to the fact that all of this information needs to be interpreted. That may be applicable to some sort of expert system, where the patient can sit at a screen and touch the screen and listen to people attempting to explain what these differences in MRSA rates mean in terms of the odds that you as a patient will come out of hospital with an infection. I have no doubt that with new technology we can do that, but I suspect that we will also need to provide opportunities for people to have a conversation with some human being about whether these data are credible, whether they are meaningful. Obviously one response is to say, "That's why people have GPs" - and maybe pharmacists and others - "in a primary care team." So, as well as the websites and the portals and all the sorts of things that Darzi talks about, there is the question of the human professional and advisory time and effort that would be required in this new world. I am not saying it is not going to be worthwhile, but it is a big part of it, because we do know that making choices can be quite stressful. Darzi describes Choice as intrinsically good in all situations, whereas we know that it is not always particularly easy. When choosing which mobile phone company to go with, I do not find that stress-free. I find it bewildering and irritating, but if I was also sick at the same time, I think I would want someone to talk to as well as going to the requisite portal.

Q59 Jim Dowd: I accept that explicitly. One of my local GPs who was talking to me once said that the internet was effectively the hypochondriac's charter, because people go on there, find something and say, "That's what I've got," and go in and say to him, "Look, this is what I've got," despite evidence to the contrary. Is the point not the final point you were making, that the issue of choice in itself is a good thing even though it may risk - as the expression has it - a suboptimal outcome. Even if the professional knows that the exercise of that choice will not be in the patient's best interests, if exercising choice is an end in itself then we will just have to live with that. Is that right?

Professor May: If you are doing a detailed textual analysis of Darzi, I think you might find there is a little bit of tension in the document between to what extent we are encouraging choices from a menu of evidence-approved treatments and procedures and processes on some NHS website or whether we are encouraging choice, which includes, as you say, a preference to do things which are not necessarily indicated. When it comes to the point of treatment, the Darzi review tends to assume that you will be in some way limited by the outcomes. In terms of choosing your GP, for example, there is more of a focus on having a plurality and, essentially, letting competition generate information for patients that ultimately they can judge, so that it is not entirely constrained. But I do think there is a tension.

Q60 Jim Dowd: Finally, is there any evidence that increased choice improves quality of outcomes?

Professor May: It is limited. The problem we have at this point is that the evidence is mostly from systems not like the NHS, so they are not universal tax-based systems which have, also, a strong emphasis on equity. The way we introduce choice in the English NHS as a requirement at the point of referral, for example, to a particular range of providers, is that whole setting and our concerns about making sure that this is a fair choice and that everyone can participate. The systems that have a lot of choice in them are not like the English NHS. I think it is very hazardous to extrapolate from other more pluralistic systems to the NHS, although the NHS itself is becoming more pluralistic and there is more de facto choice.

Q61 Jim Dowd: Shall I take that as a no, then?

Professor May: You can take it however you want.

Q62 Jim Dowd: So what value is it?

Professor May: It suggests that there is a degree of doubt. You cannot uniformly assume that this will improve outcomes. I think it is assumed in the Darzi document that choice is intrinsically valuable and that it puts professionals on their mettle and, thereby, they will improve quality.

Professor Field: It does depend on what you mean by choice as well. The individual patient will have choices about being treated and not being treated - which we forget.

Q63 Jim Dowd: But that exists now, patently.

Professor Field: Often healthcare professionals want to do what they perceive is best for that patient. The choice might be that the patient does not want anything to happen and that is not explicit in the communication with the patient. It is far more than just which hip surgeon you refer to in which hospital and with which MRSA rate. It is whether you know when you go into a surgery or to a pharmacy that you can access emergency contraception; or whether you know when you go into that surgery that you are going to have an unbiased discussion about termination of pregnancy or whether you know somebody is going to try to do something. It is much more than referral to secondary care. It is so important that we put the focus of care on the patient. From a college's perspective, that is why we are pushing very hard for the federated model of different practitioners working together, why we need an integrated care model. Just choice because it is competition might not be the best for the patient.

Q64 Dr Stoate: Do you think Darzi's creation of integrated patient pathways really will improve co‑ordination between primary and secondary care?

Professor Field: I think we can already see evidence on the ground in Bolton, with the management of diabetes. I can give you lots of examples of how that can work and we need to disseminate good practice - so, yes.

Dr Stoate: That is what I wanted to know. Thank you.

Q65 Dr Taylor: Is Darzi introducing unnecessary layers of bureaucracy in trying to achieve clinical quality? With the Coalition for Better Health; quality accounts; quality boards; national quality frameworks; quality observatories; modular credentialing, is this going to achieve what previous work has not achieved?

Professor Field: I do not know.

Mr Pruce: I do not know. The devil is in the detail. It is how it is implemented.

Professor Field: We need to do something to reduce the variation in care. In some parts of the country, primary and secondary care is the best in the world; in other areas, it is not, it is third world. We need to improve the quality of care across the board, trying to sort out where care is not good and try to use some of the good things that are happening and disseminate those across the rest of the country. If those structures do that, fantastic. The jury is out.

Q66 Sandra Gidley: Does anybody have a clue how world-class commissioning differs from practice-based commissioning and if either are properly achievable? Complete silence.

Mr Pruce: We would like practice-based commissioning to be world class. At the moment it is not.

Q67 Sandra Gidley: What does it mean?

Professor Field: If you take the words out, it means that if you could try to provide high quality care by getting general practitioners and other healthcare professionals, including specialists, to design those pathways of care that you need, then that is going to be a success. For me it is moving towards a more integrated model, as Howard was suggesting, I guess. How do you plan the pathways of care for the patient, recognising that patients have complex problems? For me it is not just about buying appropriate operations from X, Y and Z; it is about putting the patient at the centre and trying to provide the best quality care. If that is world-class commissioning, fantastic. Practice-based commissioning take-up has been patchy around the country, partly because GPs, many of them, do not understand what it is; partly because we hear through the grapevine and our networks that PCTs think they are losing their influence if they hand over commissioning to groups of healthcare professionals. That is all tied up with the argument of who provides the care. I think one of the things we need to do is to work very carefully on how we implement, based on what is needed locally. All of the Darzi review - and I would support the thrust on quality, as I said before, and on clinical leadership which we have not mentioned - has to be about the quality of implementation. I do believe that with this document, or four documents - we have not talked about the NHS Constitution, which I think is an excellent document - how we can get that implemented locally is key. I do not think at the moment we have the quality of clinical or managerial leadership to make it happen. That is what really worries me.

Q68 Sandra Gidley: To sum up: locally delivered, local use of a range of health professionals to get an overview, but ensuring implementation.

Professor Field: Absolutely. The thrust for commissioning is right, but moving towards integration, I believe, over time.

Q69 Sandra Gidley: Is there any agreement or disagreement on that?

Mr Pruce: Practice-based commissioning is an unfortunate term because it suggests it is only about GP practices. I think it is beginning now to move away from that, and recognising you need all the players involved, including patients. We need patients. We need all the professionals who are likely to be able to be involved in commissioning, involved in those groups. Very few have done that yet.

Professor May: It seems to me that the improvement and the effectiveness of commissioning as an activity in the Health Service partly depends on what happens on the supply side. It partly depends how much either contestability or competition there is. Why people often say that commissioning is the weakest link in the NHS is that commissioners often have very limited room for manoeuvre. Typically, until very recently, they were confronted, for example, with a local hospital that was virtually a monopoly and with strong political and popular support. Therefore, even if the evidence or their own priorities or their own consultation suggested they wanted change the pattern of care, if that in any way affected the viability or integrity or certain aspects of that hospital they found it extremely difficult and did not get much support from within the rest of the NHS hierarchy. I think we are moving towards a messier, more pluralistic, possibly more costly, supply side, with a lot more duplication. I think that is part of a deliberate long-term strategy, maybe to make commissioners lives a little bit easier - because if they have very little choice as commissioners, they are also very handicapped. Yes, by all means build up their capability, but do not forget they need to have some options on the supply side.

Q70 Charlotte Atkins: Mr Pruce, your society has very much welcomed the speed up of the NICE appraisal of drugs, but what implications does that have for the NHS in terms of extra costs. Your society made the comment that the "NHS must approach these issues with its eyes wide open". Would you like to expand on that and say what you think the implications are for the NHS?

Mr Pruce: If you speed up the appraisal process, it means that medicines that are highly innovative are likely to be available to patients quicker. That is a good thing. If NICE is able to speed up its processes so that decisions are made, you will not have patients waiting for years and possibly ending up challenging PCTs over the funding of them. We have to think carefully about the balance between highly expensive innovative medicines and, if you like, the bread and butter medicines that are used for the majority of patients. You do get a potential skewing towards the highly innovative new medicines. I have worked in the Health Service for many years and had to manage complex, strict drugs budgets that could be skewed as soon as a new medicine came out. The NHS needs to come to some decisions over what it is going to fund and what it is not. It is a very difficult area to make decisions on.

Q71 Charlotte Atkins: But will it get rid of the ludicrous situation we have at the moment with Lucentis, where you have people potentially going blind because PCTs are unwilling to bite the bullet and say, "Yes, while we are waiting for NICE to change its guidelines, we will fund the extra amount to fund those drugs." You have people there who are desperate, perhaps, to pay themselves, even when they cannot afford it, because they are worried about the time span and the fact that they are likely to lose their sight.

Mr Pruce: Absolutely. That is why the decision process should be speeded up, so that people are not waiting for years for a decision on that. They can plan, and if it does end up that NICE says no then they can work out if they can afford to fund it themselves and what the implications are. But to be in limbo is the cruellest possible thing to happen to a patient.

Q72 Charlotte Atkins: Will it help ensure that pharmaceutical companies reduce their prices?

Mr Pruce: That is something for the Government to deal with in its negotiations with the pharmaceutical industry.

Q73 Charlotte Atkins: With Lucentis we have this issue about a deal; that if it is not effective, the NHS does not pay. Do you reckon it will have more of those sorts of deals?

Mr Pruce: I certainly hope so. It sounds like a good deal for the NHS and it suggests that the pharmaceutical companies are very confident in their products.

Charlotte Atkins: Thank you.

Chairman: Could I thank all three of you very indeed for coming along and helping us with our inquiry this morning.

Witnesses: Professor Adrian Newland, Vice-Chairman, Academy of Medical Royal Colleges, Mr Niall Dickson, Chief Executive, King's Fund, and Mr Nigel Edwards, Director of Policy, NHS Confederation, gave evidence.

Q74 Chairman: Welcome to our first evidence session on looking at the National Health Service Next Stage Review. Would you introduce yourselves and the position you hold for the sake of the record, please.

Professor Newland: Adrian Newland. I am President of the Royal College of Pathologists but I am representing the Academy of Medical Royal Colleges today.

Mr Dickson: Niall Dickson, Chief Executive of the King's Fund.

Mr Edwards: Nigel Edwards, Policy Director of the NHS Confederation.

Q75 Chairman: Perhaps I could ask a question to all three of you. Very briefly what are the strengths and weaknesses of the review? What input did you have into the Next Stage Review as individuals or institutions?

Mr Dickson: In a way, one of the greatest strengths is a negative, which is that there was no top-down reorganisation and no dramatic change in direction. Either of those things would have been a disaster for the Health Service. The fact that they have embraced information and seen that as a key driver of quality and the emphasis on quality will be widely welcomed throughout the service. Enshrining choice where it is appropriate seems to me, again, an underlining of a trend that was already underway but is a positive one. Finally, a clear signal that responsibility for shaping the quality of care is going to be or should be led by staff at local level. On the weaknesses side, the first question is, I guess: How much is all this going to cost? - a question that one of the earlier witnesses asked. I know Lord Darzi has said that there will be some costs over the national bit, and he is going to reveal that in time, but they have not done that as yet. I am still slightly cautious about his notion of clinical engagement. I think the rhetoric is absolutely there. A real effort was made during the review to engage forward-looking clinicians, but I do not think we should con ourselves into believing that the whole of either the medical profession or, indeed, other professions are all now absolutely engaged and onside on this, and have read the report and are part of this movement. I think we have to keep a sense of realism. Part of bringing about change is getting hold of those who are engaged and getting them to lead the process through. It is not so much a criticism as a warning that we can convince ourselves that everybody is all into this and is driving it forward, but I do not think there is evidence of that yet. I have a slight worry that there are - inevitably in a document like this - some contradictions, and particularly around the national/local side of things. In the first place, we have the ordering of health centres - which, again, was earlier in the review - that we will have a health centre in every single area. That is classic top-downism and yet we are told that classic top-downism is all over now. Likewise, I have a little concern around the way that they are looking at taking on leadership. There seems to be a concentration at national level. Again, I have been assured that it does not mean that at all, it just means there will be a lot more money for it, it will be devolved through the system, but I think we will have to watch that. Likewise, of course, there are quite a lot of new powers for SHAs and their relationships with primary care trusts. If they go on being what they have been in the past, traditionally, which is performance managing, very much a stick beating the system, then the NHS will continue to do what it has always done, which is look up the system. We desperately want to stop people looking up the system. We want to start making them look out towards their patients and to the local public. That leads me to my final point, which is that I think there is still something around local accountability. There are some welcome adoptions of some of the suggestions which came out of the Local Government Association Commission, which I chaired and which Richard sat on as well, but I think they could have gone further. I am slightly worried that they will talk the talk. We need to move towards a situation where members of the public know what a primary care trust is - changing their name will help - and that they understand what these people are doing, the amount of public money, their money, they are spending, and the kinds of choices that they are making at local level. I am not sure there is enough in this report to drive that forward, but there is an opportunity within the consultation to do that.

Professor Newland: We were certainly pleased that many of the building blocks that Darzi proposed to develop quality are areas on which the colleges and the Academy have worked quite a lot over the last two to three years. In terms of the input from the Academy: of the 2,000 clinicians that Darzi has talked about consulting, a number were our members. The Academy was also involved with the colleges at a high level in terms of discussing with Darzi what we were doing and what we wanted to do, but I think there was a gap in the middle with the involvement of the colleges in developing some of the areas to take this forward. I think that is a gap in the Next Stage Review: it is strong on aspiration but fairly light on the detail of how it will be achieved. I think we, like Niall, are worried about the disconnect between what happens at a local SHA level and what happens nationally. We are worried that consistency of standards may not be spread out across the SHAs, because SHAs may have different aspirations. We would certainly want to have more input into using the colleges' influence and the Academy's influence to try and homogenise those quality standards across the SHAs and point out where there are differences and how we should bring those all up to the same standard.

Mr Edwards: I would agree with that. We did a piece of work with the Joint Consultants Committee, which is the Academy and elements of the BMA, about a year ago, looking at what the medical profession and managers thought a reformed healthcare system would look like. We discussed that with Lord Darzi. Much of what we were being told was needed, is in his report. Most of it relates to systems to measure quality, and quality that matters to patients and clinicians rather than to external performance managers and regulators, so that is very welcome. In terms of weaknesses, I guess one of the issues is that, because this system very much relies on information of quality and professionals responding to the signals which that sends them - although there is a lot of emphasis on patients doing that, the international evidence is that it is largely going to be the professionals, as they are competitive and often want to strive to do better, who will respond to that - that takes time, because many of the measures are not in place or not in place everywhere. In community services and out-of-hospital services those measures do not even exist. There is a task to define the measures, collect the data, and then start having the conversation about quality. Quite a long lapse of time is built into that, which is pretty inevitable. Of course, since that will take time, and policymakers are often impatient, there is a fear that people will forget that the underlying driver for this was a relatively long-term project dedicated to improving quality and will want to start doing things again. Understanding that some of this may take some time is a bit of a risk. I think there is still a risk around some of the promise around NICE and NICE drugs that are of some concern to us. I would echo both the points that Niall made. There does need to be an intermediate tier but there is a danger of creating a very powerful one which causes people to continue to look up. Most of these strategic health authorities are about the size of Denmark in population terms. "Local" is not really a word that you would use to describe them. They have an important role. The difficult challenge for them is how to do the often incompatible tasks of development and improvement with performance management. The latter tends to corrupt the former. The second question is the extent to which we have clinical and other engagement right. There is very big agenda for local managers and local clinical leaders in making all of this happen. Indeed, that is probably the major lever for change. Whether we have enough of that and whether we have enough engagement I think is a question that is open and certainly is patchy around the country.

Q76 Chairman: Could I pick up on one thing you said about the issue of quality of care. The Prime Minister said when this was published, "the challenge of ten years ago was capacity, the challenge today is to drive improvements in the quality of care." Have we spent an increased £45-£50 billion in the last few years without making significant improvements in quality?

Mr Edwards: No, I disagree. I think there have been very significant improvements in quality. One of the difficulties is that quality was not seen as the major driver by most of the people in the NHS, it was seen as hitting a series of targets. I do not want to sit here and reel them off but, collectively, between the three of us, we did come up with a very long list of quality improvements. Probably the biggest single one would be the huge investment in the prescribing of statins which we have made. Over £800 or £900 million has gone into the prescribing of statins. It has probably saved a very large number of lives and it has certainly improved the quality of the way that we manage people with ischemic heart disease. Then there is the cancer strategy stuff. There are also areas which have been neglected. We perhaps have not improved maternity, as a topical example that we might talk about today, but, in general, I think we could say that there has been an improvement in quality. The trick that has been missed over the last ten years perhaps is not capturing the profession's real enthusiasm for wanting to improve and wanting to do better and often wanting to do better than their colleagues.

Q77 Chairman: On that last point about the profession, quite clearly costs have been a major issue and there is a lot of money gone into the National Health Service. Do you think this review will use the amount of funding that has gone into improved outcomes and to redesign services? Redesigning services is a central part, I suspect, of it, in which the clinicians will be either engaged and it will happen or perhaps not.

Mr Edwards: If redesigning the services is the project, then I think people are less likely to get excited about it than if it is improving the quality of care. There is something about how one describes this in terms of getting people engaged. When one looks at the financial environment in which the Health Service is going to be existing in the next few years and imagines that in an environment in which there is much more transparent information about how you are doing - and, indeed, some of your payments may be linked to how you are doing - it is likely that people will want to get more engaged in that. The thing we often fail to get people to understand in the Health Service is that many of these improvements in quality will produce huge reductions in how much it costs to provide the care. A lot of the cost in health care is reworking things that were done before, salvaging mistakes that could have been avoided, and the cost of patients waiting about for things to happen. The sort of redesign that will deliver improvements on the quality rate, the sorts of quality measures that are being talked about here, ought to provide a real incentive to get people to redesign their care in ways that help them do better medicine. If the story is about that, then there is much more chance of getting people engaged than, "We've got to do this because we have a financial target" or "We've got to do this because the regulator tells us to."

Mr Dickson: Responding to your first point about the Prime Minister's comment, all governments rationalise what they do. Did Alan Milburn sit in 2000 and say, "I'm just going to expand the service. I'm not going to bother about quality at all"? Of course not. In a way, their post hoc rationalisation diminishes some of the things that have been achieved: the creation of NICE, the introduction of national service frameworks. Some of these things were national things which were partly designed to create equity but, also, to introduce notions of quality into the service across the board that had not been there before. I also think there are probably quite a few areas where you can say - though difficult to measure - that there have been increases in quality. For example, if you increase the number of nursing staff, you may well reduce the stress of the team and you may improve the quality of nursing care, but that is quite a difficult thing to measure and I think we have not been very good at measuring it. There have been some quality improvements. There have been quality improvements in cancer care and in coronary heart disease, and Nigel mentioned statins as a good example of that. So I think they have done some things in the past, but I agree with Nigel that the focus probably has not been enough. It comes back, in a way, to the fact that the need to try to make sure that the money was spent on something that they could measure meant that there was a lot of emphasis on the access, which was an important issue for patients, and they drove the system hard in order to do that. I think it is right - now that we certainly have a much better position, not a perfect one, in relation to waiting times - that more emphasis is put on quality. It will be important to get the right data to drive this, because if we do not have the data it will not work.

Professor Newland: I think it is harder to show quality in comparison with simple targets. A lot of things have happened. As Niall has said, quality has not just happened there, it has been happening for many years and there a number of very good examples. The Cancer Networks have been highlighted: they have shown, quite clearly, that when clinicians take charge, look at the balance of services that care can improve. They can reorganise the services themselves. We have seen the same in coronary heart disease; we are seeing it in strokes; we are seeing it in diabetic management. More global systems such as accreditation of services - well established in pathology, there in psychiatry, developing, as you heard earlier, in general practice - are areas where we have worked to improve services. I think the establishment of confidential inquiries has also begun to look at outcomes. The emphasis on patient safety, I think, is also looking very clearly at what we are doing. Certainly, with the Academy pulling together, the colleges developed a document 18 months ago on reorganisation of acute services for David Nicholson. That very much presaged and was later mirrored by some of Darzi's suggestions on how you look at specialist services through to care in the community. We are very much signed up to the development of patient pathways and integrated care in that way. From that point of view, we are fully behind that, and I think these will show, over a period, of time the improvements that we hope. It is turning around the tanker: it takes a while.

Q78 Dr Taylor: You have all mentioned doubts about clinical engagement. Nigel mentioned the importance of better medicine. We have known for a long time that there are tremendous variations in clinical practice. The Academy paper states that "a disappointing feature of the NHS has been its comparative failure or tardiness to close gaps in performance". Why has this not been addressed? We have been told by our advisers that Barbara Castle told us about this in 1976, and advocated reductions in clinical practice variations. Why have we not got to grips with this?

Professor Newland: A lot of this reflects resources and local priorities, whoever decides those local priorities. We can see from Darzi's work in London, in Health Care for London, that if you start at the west end of the Central Line your life expectancy is seven years better than at the east end of the Central Line. I do not believe that is because the quality of care at the hospitals in the East End is any worse. A lot of that is to do with social demographics and the money that has been put into dealing with those.

Q79 Dr Taylor: But local priorities should not dictate clinical practice. If there is a right way to do something and a less good way to do something, why are we not getting everybody? Clinical freedom is okay, but it is a bit of a sacred cow if there is a best way of doing something and a less good way. Why are all doctors not doing things the best way?

Professor Newland: I think many doctors know the best way to do things and would like to do them and we have the guidelines and the enthusiasm to do that. What we are allowed to do is sometimes developed by local priorities and it is not always clinically led.

Mr Dickson: I am sure that is partly true, but I also think we are undergoing a revolution. That revolution is about the medical profession and some of the other healthcare professions moving away from the idea of individual mastery and individual decisions about something, to a profession which is much more about guidelines and about evidence and about data. The data sometimes has not been there. Sometimes it has been there. Somebody quoted a Lancet article from the 1950s in which it was said that there were still bits of the NHS that were not following the advice at that particular time. It does sometimes take an awfully long time to bring in new bits of practice. I think this is where the digital revolution will have an impact, because it enables information to be brought quicker to professionals. It enables it to be put in digestible forms. The huge volume of information means that even a specialist now cannot possibly know everything within their own specialty. I think the onus will be on people not to give up the uncertainty which is at the heart of a good medical practitioner - dealing with uncertainties is what it is all about - but it does mean that people will be expected more to follow guidance, that there will be standards that are set more by the Royal Colleges than they have been in the past and they will be more prescriptive. Only in that way, by exposing what is going on and by having good minimum standards, and higher standards as well, will you be able to drive up standards in individual units and services.

Q80 Dr Taylor: Would one of the roles of the Academy be to try to enforce guidelines?

Professor Newland: One of the roles the Academy has very recently taken on is the national clinical audit and patient outcome programme, which I think will also later encompass some clinical accreditation as well. We have developed that in conjunction with the Royal College of Nursing and Long-Term Medical Conditions Alliance. That is going to be a very important role of ours, both to highlight the guidelines have produced but then to look at outcome through mechanisms such as that group.

Q81 Dr Taylor: Is it not a criticism of the colleges or the Academy or both that we have not really addressed this in three decades?

Professor Newland: It is a criticism that has not been taken up to the same degree that it should have been. Many of the individual colleges have had audit programmes which I do not think have been promulgated to the wider world in the degree that they should. I think that it is one of the roles the Academy has realised it has to take on to make sure that what individual colleges are doing is put out as best practice and is incorporated and is part of routine daily work.

Q82 Dr Taylor: Are clinicians as difficult to herd as cats or is there a way of doing this?

Professor Newland: I think that is probably fair comment.

Mr Edwards: I was going to quibble with the idea that a variation in resources is a reason for a variation in clinical practice, which I think you dealt with. There have been two or three issues. The first has been a complete lack of transparency, and often not even measuring what has been done. The second, if you do measure it and make it available, has been a lack of willingness to challenge, including by the professionals themselves. The Royal College of Physicians has introduced excellence guidance on strokes and yet many of the people who have fellowships with it still operate services which completely fail to the standard that their own college sets. It may be unreasonable to expect the colleges to do this - they have no particular managerial line to their members - but it does seem to be possible to be a fellow of a college and operate a service that really is quite below standard. A bit of leadership from the profession would perhaps have obviated the need to have to set out some of the requirements for this. But, it having been done, it does seem to be, as Professor Newland said, a resurgent Academy and a real role for the colleges, working with NICE, to now take some of that leadership role. I think people would welcome that.

Q83 Dr Naysmith: Is there not a role for continuing professional development and accreditation in this? It certainly works with the GPs. Would it not work more widely?

Professor Newland: I think that is part of what has come through with the way we are trying to develop revalidation. I think clinical professional development is an important role in that. The point I was going to make there was that, yes, the colleges, the Academy and the specialist societies do set standards, do set standards, do set guidelines in conditions. It is how those are applied on the ground, both being picked up at local appraisal but also through local peer review. I think we have the example of the Cancer Networks, which have really shown quite remarkable changes in practice. I give the example in the North East Thames, where it went from six units that did surgery for gynaecology/oncology down to one. That was developed by the clinicians themselves. Having looked at the figures, having looked at the outcome data, they realised that the best way to do it was to concentrate resources rather than look at individual ambition in terms of the hospital. When clinicians are given that information, they will make those decisions and will follow it. It is a question of giving them the information and encouraging them to get on with it and giving them the resource to reorganise.

Q84 Chairman: You mentioned revalidation there, which is still waiting in the wings, as it were, to be introduced at some stage. Do you think revalidation will improve clinicians and their practices or should it?

Professor Newland: I think it should do. I think it depends how it is developed and what the building blocks are. Certainly a number of colleges, my own included, are looking at clinical audit as part of the revalidation process. We are looking at interpretative quality assurance schemes, so that you can do revalidation and present documents that are relevant to your current day practice, not popping off to a meeting and ticking the box that you have been to a meeting and therefore you have learned something. This is in your everyday practice. Every three months or so, you do an exercise that then becomes part of your electronic record that you present at your appraisal every year, and after five years you pool all that together. That means that we can pick up people who are failing early and deal with that. It becomes part of routine practice; it is not a once every five years two-day exercise where you scrabble all the bits of paper together. We want to make revalidation an integral part of routine, everyday practice. If we can do that and if we choose the right things, it will work.

Q85 Dr Stoate: Just to pick up on that point, for the last ten minutes we seem to have been avoiding the issue. The fact is that for the last 30 years we have known that there are variations in quality. We have known there are good GPs, bad GPs, good consultants, bad consultants. You ask any GP in the land and he will tell you which are the good consultants and the bad ones. He will also tell you which are the good practices and the bad practices. The PCTs all know which are the good practices and the bad practices. Yet for some reason we have never managed to do anything about it. Nigel made the real point, that there are still people carrying out suboptimal clinical care in things like stroke management and it is not being picked up. What are the colleges doing in terms of progressing this? Just developing new tools of validation has been going on for the last 30 years and we have not got there yet.

Professor Newland: The colleges and the Academy are in a position to lay down standards to review audit but they do not have a managerial role on the ground. It would be nice if we could, but, as charities, it would be impossible to do so. I think we can lay down clear standards of what we think practice should be, however, and then that is for the local trusts, PCTs, commissioners to take on board.

Mr Dickson: I think this is why Darzi is a real hope, in the sense of having more information around. When this is all closed away and you as a doctor know about all the GPs, I, as a patient, do not have a clue. In fact you may be a really nice chap but a bad clinician - which may be the judgment of some of the doctors as well - but once the information is out there, that the patient reported outcomes are very poor for that clinician or that practice, then certainly the pressure will start to come on the system. Once Pandora comes out of the box - and I am unclear how quickly this is going to happen or whether the quality of data is going to be good enough, and those are caveats - I think we are on a journey here. I think your question should not be able to be asked in ten years time. Somebody will not be able to ask that question, because it will have started to be exposed.

Q86 Dr Stoate: I would not mind betting that in 30 years time we come back and say, "Those chaps in 2008 recommended something that has not happened yet."

Mr Edwards: We do need to be real. This operates as a bell curve, and it may well be that the difference between good and great, the middle of the bell curve, is relatively small differences in practice but multiplied over large numbers of patients. We have been very bad at dealing with the tail. I am aware, however, that a number of trusts which have been focusing on quality in the last ten years have really got to grips - often using disciplinary procedures - with poor practice by their clinicians. Obviously, it is not just doctors; although it has tended to be doctors where that has been hardest to deal with because of the various bits of employment protection that they have uniquely enjoyed. It is still a case in primary care, as you will know, that the levers are not as well developed as they might be. There are some new ones in here, and, to some extent, that is also the reason that lies behind some of the focus on using some competitive tools and choice in primary care. Whether that will be effective, we will have to see. I would say that there are signs of increasing use of managerial methods to address poor performance. That tends to be supported by, and often in the acute hospital setting led by, the medical director. Signs of hope, I would say.

Q87 Dr Stoate: I am prepared to accept that, but bear in mind that quite a few of Harold Shipman's patients thought he was an all round decent chap and the fact that he had murdered a few people should not take that away from him. We have to be a bit careful with consumer satisfaction.

Mr Edwards: Consumer satisfaction sometimes is quite a good clue that there are other things going on as well. Most disciplinary issues have been about clinical practice. Doing the wrong thing; not having the right skills.

Professor Newland: We increasingly find through the colleges, with the guidelines and standards and workload advice that we put out, that these are being increasingly used by local trusts to look at performance locally. We have had a lot more requests for advice over the last three to four years from local trusts about local clinical activity.

Q88 Dr Stoate: Fair enough. I am prepared to watch this space, but I am not at all satisfied that anything much has changed since Barbara Castle's day. I would like to talk about a new theme which is being bandied around, patient records and outcome measures. Niall mentioned those a minute ago. What evidence is there that linking PROMs to payment by results would do anything to deliver quality?

Mr Dickson: I think we should be careful about it. The first point - and Nigel has made the point already - is that the assumption that providing a quality service costs more is wrong. Often, by providing a quality service you may be able to save money. I think we need to see the detail of how they are going to make this best practice tariff work. Instinctively, the idea that you should reward quality seems a good one, but whenever you introduce these financial incentives, you have to watch for perverse behaviours. The NHS Institute looked at cataracts, for example, and found that 60% of providers were over tariff but it also found that once you improved quality you saved costs, you reduced the amount it cost you to do. There are already incentives within the system for people to save money by providing quality care.

Q89 Dr Stoate: Yes, but what evidence is there that PROMs will improve quality?

Mr Edwards: There are a variety of different things proposed in the review. One is payments based on patient experience. That is probably the one that is most worrying, because we do not yet know how much of that is under the control of the organisation. There is certainly evidence from MORI that suggests that certain areas, particularly of high levels of ethnic diversity, have trouble creating services that satisfy their patients, so we could end up penalising the people who have the biggest problems, so there is an issue with those. The evidence for payment by results system (called pay for performance system in the US) is a large study run by the centres for Medicare and Medicaids CMS, with 200 hospital groups looking at five different conditions. It does appear that these incentives, which were relatively small, did produce significant improvements in quality. There were two things that seemed to be affected here. First, hitting the indicators was the way you got paid, but to hit the indicators you needed to redesign the way that you did the pathway for coronary artery bypass grafting or community acquired pneumonia, so you got quality improvement across the board. The second was the effect of publishing these data nationally: there was a prestige advantage in doing that. We do not know what the effect was on the things which were not being incentivised. In other words, did all the effort that was put into improving the pathway for myocardial infarct mean that the chronic obstructive airways disease, which was not part of the incentive scheme, suffered from that. There is no evidence on that, but obviously it would be a danger. I think the Department of Health have discovered incentives in the last few years, and it has come almost to the point where they believe it is the only answer. I think it has to be part of the package, and if you only rely on these incentives to drive up quality you will be disappointed. There was enough evidence to make it worth trying these out and piloting them. There is probably not yet enough evidence to adopt them. There are some hazards, particularly around the patient experience based payment, and these are methodological problems rather than issues of principle.

Q90 Dr Stoate: That is the point. There are a lot of unknowns here. The document says, "From no later than 2010, payments will reward outcomes under the scheme." Do we know they will be sufficiently robust by then? Will we be relying on them? Will they measure the right things?

Mr Edwards: There is an ordered dilemma here, because unless you start collecting the data and making it feel real people will not bother doing the data collection properly. There is plenty of data collected in the NHS which we know is slightly ropey, because people suspect - in fact probably quite rightly - that quite a bit of it is not ever used so why bother collecting it. The dilemma for policymakers is how to make this feel real. One of the other proposals is to move from a payment based that is based on averages to one based on best practice. I think that has some real logic to it. At the moment the tariff price paid in the NHS is based on the average practice. The average includes everything from the excellent to the potentially dangerous, I suspect, and setting a tariff that says "This is the quality that NICE says the best looks like" is quite a useful way of sending a signal that what you do clinically really matters in terms of the success of your organisation.

Mr Dickson: In answer to your question about 2010, I think it will be a huge challenge, not least because they are only starting to collect PROMs from 2009. Obviously it takes a full year and then it takes time to get the data together, like everything else in this, so I think they have set themselves a very challenging target there.

Mr Edwards: BUPA already use PROMs, of course, quite successfully.

Mr Dickson: It is for the NHS to get themselves geared up in order to do that, but it will take time.

Q91 Dr Stoate: How much will it cost to c