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

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

NHS NEXT STAGE REVIEW

Thursday 17 July 2008

PROFESSOR LORD DARZI OF DENHAM KBE, MR DAVID NICHOLSON

and DR JONATHAN SHEFFIELD

Evidence heard in Public Questions 130 - 289

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the Health Committee

on Thursday 17 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 Lord Darzi of Denham KBE, a Member of the House of Lords, Parliamentary Under Secretary of State, Department of Health, Mr David Nicholson CBE, Chief Executive, NHS, and Dr Jonathan Sheffield, Medical Director, NHS South West, gave evidence.

Q130 Chairman: Good morning, gentlemen. Could I welcome you to our second evidence session of our inquiry into the NHS Next Stage Review. I wonder if, for the record, you could introduce yourselves and the position that you hold?

Professor Lord Darzi of Denham: Ara Darzi, I am the Parliamentary Under Secretary for Health.

Mr Nicholson: David Nicholson, NHS Chief Executive.

Dr Sheffield: Jonathan Sheffield, Medical Director of University Hospitals Bristol Foundation Trust and lead for the Clinical Need South West Review.

Q131 Chairman: Once again, thank you very much for coming along. I have a few questions by way of introductory remarks in relation to this session. The review really provides very little detail in terms of the cost that it is going to have. Could you tell us why?

Professor Lord Darzi of Denham: Firstly, to start off with, as I made it clear in the interim report, this review is all about service transformation. Let us remind ourselves, with the CSR settlement back in October last year with the 4% increase, in real terms we will be spending somewhere in the region of £110 billion by 2010/2011. This review is all about the transformation of the service and how could we get better quality care out of the investment we are making. As far as cost goes, it is costed within the system and, at the same time, also some of the proposals in the enabling report are costed as part of that package.

Q132 Chairman: There have been detailed economic reviews of these. When you say it is within the package, we have got general inflation running at higher than 4% now and the economic outlook does not look great at this particular time. Are you sure that it is sustainable within this three-year term?

Professor Lord Darzi of Denham: Health inflation always has been higher than consumer inflation. I think that has been historical and we have all known that. Just compare ourselves where we were eight years ago. We have doubled the budget and we are keeping up with a number of European countries when it comes to expenditure. We are in good shape; we have a surplus. I think we have done reasonably well, if we look at the CSR settlement of 4%, in contrast to other public sector bodies, and I think we should live within the context of the funding that we have.

Q133 Chairman: You probably heard that last week some of our witnesses were quite critical of the lack of detail in terms of implementation of the Next Stage Review. Given the history of implementation within the National Health Service for the last 60 years and one week, are you happy that it will be implemented or do you think that what we are listening to here is warm words of good intent but that the likelihood of it being implemented is not very strong?

Professor Lord Darzi of Denham: I think the process in itself is very different in relation to the Next Stage Review. If we look at the contents of the review, we have the ten regional reports, and I had the privilege of attending the launches of the ten regional reports, and what is different about them, which is very unique (and I certainly learned something from it myself and I think the Department of Health also learned something from that exercise), is the tremendous amount of ownership in the review and the content of the local reviews and the pride in relation to what they have done. Let us not forget, there is fairly detailed implementation planning in every regional report and how they are going to make these changes happen based on the eight pathways. At the same time we will be holding the PCTs accountable in coming up and translating the regional report into strategic plans, which will be published in the spring of next year. At the same time we also have the enabling document that I published on 30 June with some of the enabling policies. These will be implemented and there will be an implementation board within the department. It is very important to realise that that implementation board is going to work very closely with the regional reports in making sure that some of the national policies are implemented. I think, if you also look at the two other documents that we published on the day, we have published the Next Stage Review: High Quality Care for All, but we also published Workforce Planning, an indication document in itself, which also has an implementation plan, and, similarly, the Primary Care and Community Strategy, which was published the Thursday after that report, also has an implementation plan. I am sympathetic to your concerns when it comes to implementation, but I think we have a completely new process here and we should never forget that a significant chunk of this report is about local implementation and clinicians and non-clinicians at a local level who have taken the ownership of making this happen.

Chairman: We are going to move on to one or two of those areas now, starting with quality.

Q134 Dr Stoate: Thank you, Chairman. I would like to congratulate you, first of all, Lord Darzi, on what is an excellent report and I think has been widely received as an excellent report, so I would like to congratulate you and your team on a splendid effort. However, you will appreciate it is our job to pick this to pieces and to look at some of the detail, which is always challenging. I would like to start with questions on quality. You suggest throughout your report that quality is at the forefront, and that is to be welcomed. However, we are all aware that there are unacceptable variations in quality, particularly amongst clinicians and other groups within the Health Service, which has been present probably for ever, and certainly most recently reports have been written pointing this out. What have you done and what can you do to address the really thorny problem of variations in quality?

Professor Lord Darzi of Denham: I agree, there are variations in quality, and I think we need to also put into context that throughout this year, which has been a fascinating year for me, all the business and where you go across the country, you will also come across some centres of excellence, you will come across services that you will find very hard to find even in Europe and across the Atlantic as far as the quality of care they provide. There is a uniformity issue, and think that has been acknowledged in the ten regional reports. What is interesting about this, I think one of the clinicians described it as a movement per se, for the first time that I could remember clinicians at a local level challenging themselves in the care they are providing and trying to see through the evidence base how could they transform services at a local level, and that is why I believe, if you look at the local and regional reports, there is a tremendous amount of aspiration and ambition. In some of them the ambition far exceeds anything I thought of back in October when I was in front of you. The eight pathways also provided a process through which we got clinicians and non-clinicians from all sorts of different backgrounds for the first time in some parts of the country, probably in the areas that you are referring to, sitting around a table and really challenging themselves: how do they break some of the boundaries that exist between primary and secondary care? How do they really break down the boundaries between health and social care? How do they even break down the professional boundaries that exist between our nursing colleagues, pharmacists and medical communities? Their aspiration, purely by breaking these boundaries, is to improve the quality of care at a local level, but I think whenever we say this we should also remember (and I say this as someone who has been working in the Health Service for the last 18 years), if you look at any of the quality parameters that we currently measure, I think we need to measure more, and I am sure I will come to that point. We have seen tremendous improvements when it come to outcomes of care. Within the last even five years, just look at the management of coronary heart disease. In the days of the NHS Plan I remember people thumping the table and saying, "We need more cardio-thoracic surgeons." Within a year of that emergency angioplasty came in. Within 18 months of that, this country led one of the biggest trials in the use of statins and, following that, you voted for a smoking ban. All of these changes have had a tremendous impact on mortality rates, for example, in myocardial infarcts a 42% reduction. Okay, we had to catch up a lot, but a 42% reduction is the most steep reduction that we have seen in any other country that measures these quality outcomes.

Q135 Dr Stoate: That has been welcome, and you have quite rightly pointed out the huge increase in quality across the piece, which is undeniable, and we are, as you say, amongst the best in the world now in many areas of medicine. The difficulty I have got is the variations; not the overall quality, which is undoubtedly going up, but the variations. We heard last week from witnesses who said that they had seen people practising, not even best practice, not even NICE guidelines, nowhere near the level they should be practising at, and yet, nevertheless, carrying on providing that service apparently unchecked. So I am not worried about the overall quality, which I think is good, and I am worried about the variations in quality, which I do not think is good.

Professor Lord Darzi of Denham: I agree with that, and that is the whole purpose of the report. At a local level to look at the eight pathways and challenge clinicians for the first time, "What is the evidence base in transforming your services?" I agree with that. There is got to be a huge cultural change in making that happen. That is why one of the outlooks in the report, something we should all be very proud of in this country, which has been copied elsewhere, is the creation of NICE post the NHS Plan. The National Institute of Clinical Excellence is now recognised internationally. I think what you are saying, and I could not agree more with you, is how do we get all these guidelines and standards out there down to the front-line and really implementing evidence-based care? I think we have identified the process, which is the eight different pathways, and these 2000 clinicians have truly engaged in this process. I think we need to help them next, because the story should not end. I think we need to keep the spirit of the review. These people, who have charted the paths of the best models of care based on the latest evidence, should actually start getting more engaged now in commissioning these services. I think that is a very strong point. The second, which is in the report, and I do not yet believe we have really appreciated its magnitude, is the transparency in the system: clinicians being accountable to the quality of care but also publicly reporting that and using that information, which I believe as a clinician too. To be fair, a lot of clinicians in these centres that there is high quality care, these organisations not just use the information to empower patients but they also use that information to improve the system.

Q136 Dr Stoate: A final point about quality of accounts. Do you think it is realistic to assume that the quality of accounts will ever be given the same status as financial accounts? Can you see a position, for example, where a trust that would do well on quality of accounts would get away with not doing so well on its financial accounts?

Professor Lord Darzi of Denham: I think they will take it seriously. I have no doubt it is in one area of provision of any service in which quality matters most. It matters to the patients who are using the service and, secondly, it matters a lot to those delivering the service. Something which people sometimes underestimate is the pride as a clinician, whether you happen to be a nurse, whether you happen to be a doctor, whether you happen to be a pharmacist, whatever, in the quality of the service they provide. So I think the boards will be held accountable to that, and I think we will make sure that happens. I think the question you are raising about quality and finances is an interesting one. If you really look at the facts and the evidence - and I came across this when I was looking at the Healthcare Commission information - those who are providing the best quality care also are the most financially stable organisations, and there is an interesting correlation there. If you look at the top ten from that, you will come to that conclusion. Any good organisation has to live within the means of its finances and also provide the best quality care. Health economists call efficiency all about that. Efficiency is to provide the best quality care within the financial means that are available to you. That takes time. If you read the report, we are shifting that into what we call service lines and really making clinicians, not just accountable to the quality, but clinicians also need to transform from being commentators on the resources to actually being also in charge of those resources. I think if you combine those two together, you will come up with a fairly powerful lever really looking at finances and quality

Mr Nicholson: Can I add to that? Each chief executive in the NHS is an accountable officer, and we send that out to them. The change we have introduced there is that their accounting responsibilities used to be entirely financial. We have now made them both financial and quality of care. So chief executives are accountable as far as quality of care as well, which I think will bring it much closer into the centrality of the way we manage things in the NHS. The second issue is in relation to the quality of the accountants themselves, which, of course, will be overseen by the Care Quality Commission, the regulator, and the regulator will obviously want to look and satisfy themselves that they are doing what they said they would do.

Q137 Dr Naysmith: Good morning, Lord Darzi. I want to stick with this variation in quality of care that Howard has been on just now. One of the methods that you recognise or suggest should be used to address variations of quality is the use of mortality results from hospitals. Of course, we all know that the data about mortality rates in hospitals can be misinterpreted and misused and can sometimes be misleading. On their own, they can be misleading. So how do you intend to ensure that the data are used properly to assess quality?

Professor Lord Darzi of Denham: Sure. I think you raise a good point about mortality figures. That is the data that is available now. I personally believe that it is probably one of the crudest, bluntest instruments that you can use. It is also an end point, and I think really in modern medicine measuring mortality rates is irrelevant. I think really when you are talking about quality of care, it is not irrelevant, it has relevance in certain conditions - coronary artery disease, for example, if you are having cardiac surgery, if you are having cancer surgery - but let us not forget, in modern medicine a large number of procedures have no mortality rate.

Q138 Dr Naysmith: Why are you recommending this method of assessing quality?

Professor Lord Darzi of Denham: What I am recommending there is measures or metrics that will measure safety, measure effectiveness (and I will come back to that point) and also patient experience. Safety measures as we know them: we do measure healthcare acquired infections, being a good examples of that. Untoward incidents: we have the National Patient Safety Agency that measure that. I think the main crux of the report is to look at the effectiveness side, and within that effective side it is not a new thing for clinicians to measure outcomes. You are right, within outcomes the mortality rate was one way of measuring it, but I believe there are other outcome measures and there are a large number of national databases that professional bodies have been involved in for many years in which I think probably, if you are critical, you could say that clinicians have not been as compliant in really entering that information. For the next decade, what I have said in the report, which is the component of quality measure which is important, is also the personalisation of care, which is one of the principles: in other words starting to measure patient-related measures.

Q139 Dr Naysmith: We will come to that later on, but sticking with the mortality tables at the moment, would it not be essential to cover both those clinicians, mostly orthopaedic surgeons, who operate both in the private sector and in the public sector? Should not their datasets be combined so that people can know what they are like in both sectors?

Professor Lord Darzi of Denham: You are talking about purely mortality rates.

Q140 Dr Naysmith: Purely mortality rates, yes.

Professor Lord Darzi of Denham: We have those mortality rates. That is available; it is in-house. All that information is available and we actually published it in NHS Choices recently.

Q141 Dr Naysmith: You published what these people do in their private work. That is what I am asking.

Professor Lord Darzi of Denham: Within the context of the new regulator which is CQC, one of the principles of the creation of the CQC is not just the integration of health and social care but to look at the whole healthcare provision, whether that happens in the private sector or in the NHS.

Q142 Dr Naysmith: These figures are published alongside the National Heath Service figures?

Professor Lord Darzi of Denham: The Choices website that we published recently, that NHS data.

Q143 Dr Naysmith: Whether you are using mortality tables or not, what measures should be used against poor clinical practitioners who are identified as delivering poor quality work?

Professor Lord Darzi of Denham: Maybe Jonathan might come in in a minute, but if I could take you back to the Care Quality Commission - it is quite fresh in my mind because I have to take it through the Lords after you have taken it through the House of Commons - there are two reforms when it comes to reforming the accountability of clinicians in the Health Service. One of them is the reforming of the GMC, the creation of the Independent Adjudicator, which has been warmly received by the GMC (General Medical Council), and the second one is the change of the burden of proof from criminal to civil. So we have the mechanisms now in place to tackle issues of clinical competences, and so on and so forth.

Q144 Dr Naysmith: Traditionally, it has taken a very long time to investigate and decide what is going to happen to a clinician who gets into trouble with his or her trust, sometimes years, and you suspend well prepared and well educated and expensive consultants for years.

Professor Lord Darzi of Denham: I agree, and you have made the case, and that is exactly the case which was made in reforming the General Medical Council, and a lot of it was based on the recommendations of this committee and others in how we reform the General Medical Council to meet some of the challenges which are facing us.

Dr Sheffield: As a medical director, that is the meat of my job in a large part.

Q145 Dr Naysmith: I can remember some of the United Bristol Hospitals Trust myself, but it was before you were there, I suspect.

Dr Sheffield: Absolutely, yes. Mortality to me is a useful indicator, but it is not the ultimate indicator. Certainly we monitor mortality throughout our organisation as a way of being assured that we have got good services, and one of the things that I found fascinating in the recovery of our particular organisation was that, as our efficiencies improved, as our reference costs have dropped from being 17 points above the national average down to below the national average, we have seen an improvement in our hospital standardised mortality ratio and it is almost a parallel line. We have gone from average hospital standardised mortality ratios down to some of the best mortality figures in the country, so there is a definite link between running efficient services and improving outcomes, but we also look at a whole range of other outcomes and certainly in very specialist areas we are very keen to develop those even further, because I need that information as a medical director. A lot of our processes around management of alleged or assumed poorly performing consultants has to be an iterative process anyway where, first of all, you have to look into the evidence in detail, and a lot of that is carried out internally, and quite frequently it is an educational process and a change in practice that is dealt with within the organisation rather than the ultimate sanction of going to the GMC. I think certainly acute hospital trusts now are much better at managing these problems internally and making sure that we get consistency of quality from our consultants.

Q146 Dr Naysmith: Should not the medical colleges have taken more interest in this in the past. They are signed up now, I assume?

Professor Lord Darzi of Denham: My views on this: everyone's business should be quality. It is not the medical colleges, it is the Department of Health, it is me working as a clinician, him working as a chief executive and, ultimately, it should be the business of anyone who comes to work, whether you happen to be a clinician or a non-clinician. I think the creation of the quality board is to bring all these stakeholders in, whether that happens to be NICE, whether that happens to be the regulator. Really it is defining what standards of quality are and at the same time, if you see through Chapter 4 in the report, the report is all about measuring.

Q147 Dr Naysmith: The point about all of this is that there have been reports over the last 20 years all saying we want to get quality in. We still have not got it. What makes you think that you are going to get it?

Professor Lord Darzi of Denham: I think we have done a lot actually; I really think we have done a lot. Look at the NHS Plan in the year 2000. Did we have any? We had no regulator, remember. We had no such thing called NICE setting standards. We had nothing called National Service Frameworks. To take the example of reducing the mortality rate of coronary heart disease, that was based on the National Service Framework. We had no clinical governance. Your clinical governance was a couple of clinicians coming in and doing their audit meetings. So a huge amount has been achieved in the last eight years, and we have also brought measures, you are right in saying, these measures that I referred to earlier. Quality has three aspects to it: it has the structure, it has the process and it has outcomes. The structure we fixed. If you look at the data we had back then - use me as an example - in 1994, when I was appointed, I was the only colorectal surgeon in my unit. Now, as I say in my report, there are four colorectal surgeons, one nurse consultant, two nurse specialists and two stoma nurses. We have fixed the structure - in other words the ratio of doctors and nurses to the number of patients we are treating. We have also dealt with processes - waiting times. It was a free-for-all back in 1994. You went in in 18 months or more. Intermittently you had to check your waiting list to see how many patients had dropped out from the waiting list. We now have a process metrics which says in 18 weeks that is the treatment plan that you should have. I think what we have missed out on is the qualitative outcome based patient-related metrics, and that is what this report is all about, because through that is the process in which you engage clinicians in measuring, as Jonathan said, not just death rates but actually qualitative metrics which have two purposes, as I said earlier, empowering the patient but, more importantly, I believe, system improvement, service improvement.

Q148 Dr Naysmith: I think what I was really trying to get at is the mechanisms you are going to use. Once you have assessed quality and discovered there is a clinician who is not coming up to scratch, is it going to be easier to dispense with his or her services? That is what I was really leading to. You are telling me that it is, that you have got the tools that you need to do that.

Professor Lord Darzi of Denham: Firstly, I think it needs to be beyond the clinician. We really need to challenge ourselves in measuring quality based key performance, and that is why patient-related measures are more significant: because they measure the whole of the journey. I could do a very good operation on a Friday evening. On the Saturday morning I could go and see the patient.

Q149 Dr Naysmith: I think some of these things will be explored.

Professor Lord Darzi of Denham: If the painkiller, if the analgesia ran out the night before, that patient would only remember the amount of pain they were in for three hours, they will not remember the procedure, so we need to find metrics in which to measure the whole of the team working. The answer to your question - if there is a problem in our team performance - you are absolutely right, there is a local governance and accountability structure in making sure that that is dealt with.

Q150 Mr Bone: I think patients will be very surprised to learn that under your NHS whether they live or die is not the number one priority. My father went into an old TB hospital for a heart by-pass - certainly not the quality you would like to have seen but it saved his life. I think that is a little bit more important than your overall measure of quality. Surely mortality is the number one aim not a new relevance?

Professor Lord Darzi of Denham: You are right, mortality is a very important figure, but what I said is it is a blunt tool, it is an end point. It is valid in patients having coronary heart disease, but let us not forget in a large amount of care we provide in the NHS mortality is not a factor. We need to find other metrics in which we measure the quality of care we are providing. I could not agree more with you. In coronary heart disease the mortality figures are there. In actual fact we have achieved a lot over the last eight years by making that information openly available, and we have seen similar changes---. I remember in New York, New York City published all their cardiac mortality, and you will see improvements, but there is a large amount of, not just procedures, care delivered out there which we need to find the right metrics or measures in which we improve the quality of that care.

Q151 Chairman: Could I go back to the issue of data collection and sharing. In relation to activity data and mortality data, I am advised that Healthy Choices actually collects NHS data only and that the private sector contract with Dr Foster to collect their data but these are not integrated. Is that right or not?

Mr Nicholson: In the information that is produced for Healthy Choices, and all the rest of it, the data is for those patients who are treated as part of the NHS, some of which can be treated in the private sector. So that is that bit of data. The second bit of data is the data that is produced by private hospitals for private patients, not to do with the NHS, and that is not part of that data, but, of course, when we introduce quality accounts every hospital will have to produce a quality account, whether it is public or private sector, and the regulator will insist that they produce that information.

Q152 Chairman: So that will be the change?

Mr Nicholson: Yes.

Chairman: While we are on this subject, I ought to mention that we have actually just agreed terms of reference for an inquiry into patient safety. We will be publishing the terms of reference within the next week and we will be starting the inquiry in the autumn. I just thought I perhaps ought to put that on the record, given we are in public session. Could I now move on to Richard.

Q153 Dr Taylor: Good morning. Before I move on to my next bit, one point about quality. You have mentioned the various innovations and the ways of measuring. One thing we have lost that to me was absolutely vital is the inspections for accreditation by the Royal Colleges of every unit in the country. Would you comment on the value of those and whether there is any likelihood of that being brought back, because, as you know yourself, Ara, you can judge the quality of care by looking at a patient's notes and seeing whether there was a record of when they last spoke to the family or the details?

Professor Lord Darzi of Denham: Sure. The answer to that I will say in what I have captured by being around for the last 12 months and doing the visits. They had a purpose in those days. These were the days that we did not measure anything. A couple of people from the colleges walked in, looked around: "What are you doing? How many junior doctors do you have? What are your rotas?", and a decision was made. We really need to move on. The Care Quality Commission now has registration very much enshrined in law. Every provider needs to have a registration. I also believe, and I have had numerous discussions with the colleges, that we need to have a system. The last thing we want is another cohort. Look at the colleges. Are we going to invite 18 different colleges to visit a single organisation throughout the year: one day we are going to have the surgeons, one day we are going to have the physicians, one day we are going to have the A&E? We need to find ways in which we can collect the measures of quality and the colleges may use that for accreditation purposes. I think the colleges have a very important role to play if there are issues of quality rather than just wandering in purely for accreditation purposes. We need an intelligent accreditation, if there is such a thing.

Q154 Dr Taylor: I am going to move on to patient reported outcome measures, which have got to be in place by 2009. We were told last week that this was really very ambitious. Professor Mays said it is very much a nascent industry and, of course, it has largely been applied in surgery, and then they went on to question, really, "Who is going to administer this system. 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." That was Professor Mays. Can you give us any idea of the detail of how these outcome measures are going to be recorded, coordinated, used?

Professor Lord Darzi of Denham: If I could go back, there are clinical outcome measures and, as I said, a large number of clinical teams across the country contribute to national databases and national audits in relation to that. I think what we want to do through this report is increase the compliance in entering data. The patient reported outcome measures (PROMS) that you are referring to, I think the best investment we have made was actually in this report. I do not know if you have come across this report. It is good reading actually. It has come from the London School of Hygiene and Tropical Medicine, and that was done jointly with the Royal College of Surgeons. You are right, it started with a number of elective procedures, and what we will be introducing is the findings of these reports, which are the four PROMS. If I am correct, I think they are hips and knees, varicose veins and hernia procedures. The answer to that is that the data collection has to be done by the provider, but the capture of the data, some of the recommendations here are to have that externally collected. From the first couple of agencies there is a reasonable summary of what they have learnt through this exercise. So they have a validated tool, which is PROMS, which means patients' views about their health before and after an intervention, but they have also added to that a quality of life questionnaire which has been validated too. I think we have the validated tool to implement that from April 2009, but we need to challenge ourselves to expand that in other areas, because surgery is not just what the Health Service provides, you are absolutely right, and there are other tools. There is the PASOS tool, which is patient experience of chronic illness care, which is developed in the US. Again a large number of patients have been through the validated tool. What this will do is really ignite the interest in starting to introduce these tools and measures into the system.

Q155 Dr Taylor: You do not think we are trying to go too fast at this. Previous things like the dental contract, Modernising Medical Careers, are things that are seen to have been rushed into.

Professor Lord Darzi of Denham: Yes.

Q156 Dr Taylor: Do you think we have got time to develop this?

Professor Lord Darzi of Denham: I think it is a gradual introduction, but, on the other hand, it is very different than the two examples you gave. This is what excites clinicians, and there is nothing new about this. This is what clinicians did before; this is what clinicians continue to do. I take your point, a gentle introduction to the service, not only that is important, but I think we need to do this in partnership with the service. So the next challenge we have between now and April, through the clinical working groups, the providers and others, is really to engage in this process. In 2009 it will be the four PROMS which I referred to earlier.

Mr Nicholson: Can I add a general point? I think the thing about this report which makes it different to ones that I have seen produced in the past is that there are quite a lot of gradual introductions of things. That is why we are going for four conditions on PROMS, not everything, because we do need to learn and test as we go along. That is something, I think, we have learnt to our cost in the past.

Q157 Dr Taylor: That is very encouraging, that you have learnt that the "big bang" approach does not always work?

Mr Nicholson: That is true.

Professor Lord Darzi of Denham: Can I bring in Jonathan as well.

Dr Sheffield: From the point of view of where we are at the shop floor level, there is a great hunger, particularly on the clinical pathway groups, that we get these results, that we understand how good our services are, and we are desperate to get these measures in because we want to see what our outcomes are. It is very difficult in some circumstances of healthcare to get that feedback. If you are a consultant in a big hospital, you might only see the patient once or twice a year and never see them again, so how do you get your feedback about the quality of care? So the use of clinical dashboards is something that will be welcomed at the grassroots level.

Q158 Dr Taylor: Finally, have outcome data been linked to Payment by Results anywhere yet?

Professor Lord Darzi of Denham: Yes, there is the evidence for that as well. There is two pieces of information on that. Firstly, the American healthcare systems have been using the Pay for Performance as an example, and Pay for Performance, if that pay is to clinicians, I think the evidence base is not there to support that it will improve quality. In actual fact, there might even be perverse incentives in there, but if you are paying a bonus on quality to organisations or teams, then certainly there is the evidence base. Probably the last one was the publication of the New England Journal of Medicine, which looked at a properly designed randomised study in which bonus quality payments did have an impact on quality improvement, but, interestingly enough, not on those who provided high quality care, because they continued to provide what they do, but mostly around those are nearer to the baseline and really shifting them up to where they need to be.

Q159 Jim Dowd: Richard has moved seamlessly into the area that I was going to look at and, in fact, stole one of my questions, but I will speak to him later about that! The issue of data collection, the accuracy of it, obviously is a benefit in itself for the NHS to know where it is effective where it needs improvement, but if you are now linking it to Pay by Performance it adds a completely different dimension to the importance of the accuracy of that information. Is the experience in Pay by Performance, whether in the US or the UK, where it is being practised, that it is a sufficiently refined tool, that there is evidence that penalising poor behaviour drives up quality and rewarding better performance has a beneficial effect on patient outcomes?

Professor Lord Darzi of Denham: We are not penalising those who are poor. We are actually putting a positive incentive in the system and rewarding the quality of care. The publication I was referring to is this Public Reporting and Pay for Performance in hospital quality improvement, which is the relevant document which I referred to published earlier. There is plenty of evidence. If you do it at an organisational level, yes, there will be quality improvements. I think you are right in suggesting, as I said earlier, if you are paying individual clinicians, then you will see some of the perverse incentives. For example, you will get fragmentation of care between clinicians competing for that. That in itself is poor. There is some evidence to suggest in the US that you may actually increase your volume, not necessarily the evidence base - in other words throughput or procedures which may not actually have the evidence base in supporting them - but at an organisational level, rewarding for quality, there is the evidence base there and I am fairly convinced that will have---. You are right, I think, back to Dr Taylor's point: how do you implement that and how do you link that too is the area that we need to put more thought and more depth into.

Q160 Jim Dowd: You say we are not penalising anybody for poor performance, but did the department not introduce a series of fines for trusts where their c.diff rates were at wide variance to the expectation just last year?

Professor Lord Darzi of Denham: That is proposed on safety issues, and I could not agree more. The Bill has gone through Parliament. The CQC will have enforcement powers in making sure, if there are issues of safety---. If I could take you back to last October, most of the discussions on the debate last October, in this committee, were about safety related to healthcare acquired infections, and we have to make sure that that is a given. Safety has to be a given in every healthcare provider. I have absolutely no problem in penalties associated with minimum safety standards in organisations, and I think we should all support it. I think what we are trying to do is to really reward quality of care based on the patient experience and also the outcomes, and that is a completely different phenomena of what we are really talking about when it comes to safety.

Q161 Jim Dowd: One of the issues we looked at in the new dental contract was the fear that as you provide incentives, whatever you care to call it, Pay for Performance, you actually skew the activities of the practitioners and they actually then start to do those things which are the most profitable for them and avoid those which are more expensive, and the issue of unnecessary procedures then arises. How do you guard against that?

Professor Lord Darzi of Denham: You are right, and that is the case I am making. The bonus that we are introducing is not for individual clinicians, it is actually for the team and the whole provider side of things, rather than individual clinicians. I think what you point out, which is something I have learnt talking about the science of incentives, it is no different than if you discover a new drug: any new drug has a therapeutic component, but, I tell you, it has a side-effect and you need to make sure that you manage the side-effect of that. That is why we strongly believe that we are not really putting this incentive purely on an individual clinician's pay but actually making it as a team and, more importantly, if we can challenge ourselves further to make it across a pathway.

Q162 Jim Dowd: What about the danger, I suppose, of incentivisation, where an area that has been incentivised attracts a disproportionate amount of attention and activity and an area which has not been is neglected?

Professor Lord Darzi of Denham: The whole purpose here is to introduce incentives across the whole system. We are linking into the tariff, as you correctly pointed out, the PBR. The other thing which we need to make clear here, if you do not receive the bonus - it is about 2.7% in the uplift of the tariff - that is irrelevant in organisations providing large throughputs of cases, but it is a very small component of the tariff uplift is what I am suggesting. It is not actually replacing the tariff by one single quality bonus.

Q163 Mr Bone: I would like to ask about the cost of patient outcomes and measuring it, but just following on from what you said at the end there, I can understand incentives and payments in a private system, but I cannot see how it is going to work in a state system because the state provides all the funding anyway. How do you square that circle?

Professor Lord Darzi of Denham: The state provides care, you are absolutely right, but we are incentivising public service providers in improving the quality of care. As I said, it is a 2.7% bonus payment for these organisations who are providing - I go back to Dr Stoate's comment - the highest quality of care, who are also measuring the experience of the patients going through, and I cannot see a difference. I think what you are referring to in the public sector, which is a fee for service where an individual clinician would be paid, is completely different and I could not agree more. We are introducing this within the context of a service outcome.

Q164 Mr Bone: Going on to the cost, we have heard some wide variations of the cost of measuring patient outcomes. One of the issues was just a questionnaire and the cost of inputting it, someone was saying, from £2.50 to £10.00, which does not sound a lot but if you multiply it by every patient it becomes quite a lot of money. What estimate have you made of the cost of measuring patient outcomes through PROMS and other measures?

Professor Lord Darzi of Denham: This paper says it is £6.50 and this was a trial, if you wish to call it that, and it was an added work to the NHS' work at the time. The costing was £6.50. I think, if you ask the private sector - and I did ask one or two of the private providers who do measure or have introduced PROMS into their system - it costs them about £2.50, as you pointed out earlier. It is one of these where scale will have a significant impact, I think. Let us not forget, there are automated ways of capturing this information, and I have no doubt in a large-scale automated way we will reduce the cost of that, but people do get hung up about cost. I remember when we first started, the cost of the review: was that money worthwhile? At the end of the day, if you are measuring something in which you are going to improve the quality of care, that is completely a trivial matter. If you do not listen to what the user of the service thinks of the services that you have just provided - that is number one - number two, if this is going to drive quality based and more effective treatments (and let us not forget, more effective treatment is cheaper ultimately), if we really could get a lot of the guidelines, a lot of the evidence-based interventions really implemented through this process of measuring it, I think at the end of the day we will save more money than actually treating some of the morbidities associated with care.

Q165 Mr Bone: I could not agree more, measuring the patient outcomes and improving quality. We have slipped in the European league down to 17 out of 27 and most of the countries below us are poor Eastern European countries, so we have got a long way to go and this must be the right way, but with these forms, I can see problems with my constituents, because I have a lot of Asians whose English is not particularly good. Most people, I guess, going through the system are elderly. Certainly in my father's case, he had slight Alzheimer's and had great difficulty in filling in these forms. How are you going to ensure that you get a really proper response to it so you have got the whole set rather than just all the middle-aged people who are filling them in quite easily?

Professor Lord Darzi of Denham: I agree with you, and in actual fact you probably could say they are the ones you need to measure because they are the ones who do not usually tell you and probably have not had---. Again, interestingly enough, if you look at the London School of Hygiene Report, there is another group actually. The drop out rates were quite high in patients with cataracts, who could not see the form, and you could see that difficulty too, and their suggestion here, and I agree, it is reasonable, is to get an interviewer, to get someone proactively going out to that subgroup of patients and managing them. There are ways in which we need to manage that and we need to really look at to that group of patients in doing that.

Q166 Mr Bone: Because it would not be satisfactory just having the articulate people filling them in.

Professor Lord Darzi of Denham: We do not want a system which goes out and asks the patients with a smile on their face, we need to make sure that we capture it properly.

Q167 Charlotte Atkins: Moving on to the GPs Quality Outcomes Framework, the review proposes a new strategy for developing and reviewing the QOF indicators?

Professor Lord Darzi of Denham: Yes.

Q168 Charlotte Atkins: What evidence-based interventions would incentivise improvements in prevention?

Professor Lord Darzi of Denham: The answer to that is, firstly, it has to be evidence based. Are we referring to the changes based on prevention and well-being? In that specific area, we need to identify the evidence base. That is why we have asked NICE (National Institute of Clinical Excellence) to do that as an independent body, and I have made the comment about where I believe NICE is, and NICE will be doing that, and I think patients will do that, obviously, in conjunction with the some of the professional bodies in making that happen. We have not done that exercise yet. There is some data. We asked Health England, if I am correct, which is a group that brings a number of stakeholders together, which includes the Academy of the Medical Colleges, the London School of Economics and others, who have been looking at this for about a year or so, and in their submissions to us they shared with us some of the evidence base in the US. I think, whatever you do in that area, you need to base it on two important parameters. Firstly, the clinical prevention of disease burden and, secondly, it has to be cost-effective, and aspirin chemoprophylaxis is one good example which both reduces the disease burden but also is cost-effective. That is where the expertise of NICE comes in. I can tell you, that is not something the Department of Health can be doing.

Q169 Charlotte Atkins: Having said that, a decision has been made, for example, for osteoporosis not to be in the QOF and there is no consistency, over the country as a whole, to pick up, for instance, on early fractures and follow those up to ensure that those people are then screened for something as simple as osteoporosis, which is very extensive among more elderly people, and try to eliminate the devastating impact, for instance, of hip fractures which can, of course, lead to death.

Professor Lord Darzi of Denham: I could not agree more with you. That is why QOF and the QOF points were never done in the most transparent evidence based way, they were done between a university and the colleges, and that is why we are getting an independent, NICE being the champion of evidence based, and really scoring the evidence base based on the---. Osteoporosis might be one of them. Ultimately what happens once NICE makes those recommendations is for the NHS employer, if I am correct, to actually negotiate that with the primary care community in deciding on the QOF points.

Q170 Charlotte Atkins: It demonstrates a huge variation in practice over the country. For instance, in the south-west I believe that quite a lot of good work is done on both falls and osteoporosis, but it is very, very patchy. In Glasgow there is a lot of good work going on, but it depends really on a postcode lottery here as to whether you are going to get sufficient follow-up and preventative measures to ensure that bone fractures do not become both disabling but also the basis for an early death.

Dr Sheffield: It was a source of discussion in our acute care group when we were discussing trauma, and we were absolutely clear that one of the measures that we would want to see was the assessment of any person with a fracture over 50, whether or not they had osteoporosis, so we could put in prevention from having further fractures. The ability to transfer that to the next stage, to primary care, would be fantastic from the orthopaedic surgeon's point of view, because we recognise that that has to be something that we do routinely in the prevention of many of the fractures as they have come into the acute sector. So we were very signed up, and I am sure clinicians would be very signed up to putting that type of measure into any form of assessment both of primary care and secondary care.

Q171 Charlotte Atkins: It is a matter of co-ordination between primary and secondary care, and it does not happen, does it?

Dr Sheffield: I think that is something we have to work on. One of the things that was really clear to us as a clinical group - because we had GPs on our acute care group as well - was that we have in recent years not had such good links across sectors, and we believe that actually the clinical forum is the ideal place to have these discussions and to be able to deliver the improvements by introducing our own standards.

Professor Lord Darzi of Denham: You are making absolutely the right point there, but what you are trying to do is to find the evidence base. What are the areas which have the greatest impact on the health of the nation when you are talking about prevention and well-being, and there is a systematic way of doing that. If you look at the US data, as I said earlier, osteoporosis, the first will be aspirin chemoprophylaxis, childhood immunisation will be the next one. That scores ten and osteoporosis scores about four or five. I am not suggesting that that is less relevant, but what is the evidence based on having the biggest impact on the health of the nation? That is the process that this report has introduced in getting NICE not just to do the appraisal of the evidence, but also to do the weighting of the evidence base. Following that exercise, you are right, we need to make sure that these become minimum in the QOF points and making sure that it is throughout the service, whatever we decide are the priority areas in which we are going to look at prevention and well-being.

Q172 Charlotte Atkins: Once these preventative measures have been introduced into the QOF, should other QOF measures be dropped, or is this in addition to the existing QOF incentives and measures?

Professor Lord Darzi of Denham: That is a decision that has to be made between, as I said, NHS Employers and whoever negotiates on behalf of the profession. I suspect it is the BMA.

Q173 Charlotte Atkins: But are you concerned that unless it is in the QOF, doctors are not incentivised, whatever people say, to actually carry out the appropriate checks?

Professor Lord Darzi of Denham: I agree. We have made a commitment there. It will be part of QOF. I cannot believe it is going to be extra points in QOF. It is going to be looking at the whole QOF globally and deciding with our primary care colleagues. We feel strongly in the report we have made the case for that. We need to move into prioritising our well-being and prevention over the next decade and that is where we see it and, ultimately, the negotiation with our primary care colleagues will be done between the employers.

Q174 Charlotte Atkins: What about PROMS. Should they be in the QOF as well?

Professor Lord Darzi of Denham: PROMS?

Q175 Charlotte Atkins: Yes?

Professor Lord Darzi of Denham: Well, that depends if you happen to believe, and I happen to believe this, and we published three years ago the White Paper Our Health, Our Care, Our Say. We made a very strong case and the evidence base was there to support the shift of a lot of care near to the patient's home and, ultimately, it is the primary community setting that is going to be delivering those, and if these include interventions in the way which patients experience matters, the answer is, yes.

Q176 Charlotte Atkins: The BMA tells us that they have a very high satisfaction percentage in term of patients, but it is very clear, I think, to any MP that there are individual GPs where there are issues that patients raise about access, about being able to book appointments and about the general experience they get within the surgery. Are you therefore committed to having PROMS in the QOF?

Professor Lord Darzi of Denham: PROMS is one way. We do patient satisfaction surveys, and we have just published the one on this year. If you look at that data, there is actually very high satisfaction in primary care, and we have to acknowledge that - that is very good - but you are right also in suggesting that there are issues relating to access. In actual fact, I think the satisfaction with access has dropped in comparison to last year, and we are addressing that, as you also know, within the interim report, which I spent a good deal of time discussing with you last time, in the new investment in primary community services, in enhancing access, in the creation of the so-called health centres.

Q177 Dr Naysmith: Can we move to the area of personalisation of medical services and patient choice, and can I ask you to begin with a slightly philosophical question. Do you consider choice to be an intrinsically good thing, or is there evidence to suggest that choice improves clinical quality and effective outcomes?

Professor Lord Darzi of Denham: I could speak as a clinician and as a patient. The answer to that is absolutely, yes. Choice is the most powerful lever that a patient has, and I will say that for a number of reasons. Firstly, I think choice is only meaningful if that choice is informed. We introduced choice three or four years ago, which you very adequately supported at the time. Choice in those days had a slightly different meaning. Patients were exercising choice of which provider they went to to get the quickest treatment. That has gone. Everyone now is providing care within 18 weeks. So choice needs to move on. I feel as a clinician that choice needs to be based on the informed information on the quality of care that I will be receiving. I have had a fascinating year here, I can tell you.

Q178 Dr Naysmith: You believe it from your own experience?

Professor Lord Darzi of Denham: No, patients as well.

Q179 Dr Naysmith: Is there evidence?

Professor Lord Darzi of Denham: Yes, there is evidence that those patients who exercise choice of healthcare are actually more in charge of their health, and there is the evidence of the British---

Q180 Dr Naysmith: But does it produce better outcomes for the patient as opposed to not having choice?

Professor Lord Darzi of Denham: It certainly is one of the most important levers in improving the quality of care from a provider perspective, and certainly those patients who exercise choice, as I said earlier, feel more engaged, more empowered to have control of their health, but that is only relevant if you are actually exercising---

Q181 Dr Naysmith: You have still not answered my question. Is there evidence to suggest that this improves clinical outcomes?

Professor Lord Darzi of Denham: Yes.

Q182 Dr Naysmith: There is?

Professor Lord Darzi of Denham: Yes. If it is informed choice.

Q183 Dr Naysmith: What is the source of the evidence? How can you say that it is evidence-based? Where is the evidence-base?

Professor Lord Darzi of Denham: A lot of evidence from the US will suggest that patients exercising choice---. To be fair, I think we should also put this in context. I will come back to that point about what choice means in different healthcare systems. Exercising informed choice does drive the competition between the providers in creating and providing a higher quality care.

Q184 Dr Naysmith: So it is more cost-effective as well?

Professor Lord Darzi of Denham: The cost-effectiveness element of it, I would not like to be quoted as having the evidence based on the cost-effectiveness of it, but certainly it drives up the quality of care. What is interesting about choice, following this report and certainly legislating for choice, is I cannot believe there is a single healthcare provider or an insurance scheme in the world that actually gives its patients free choice. That is a very unique and extremely powerful thing that the NHS has. I can also tell you that if you are privately insured in this country, you will not have the same choices as you have as an NHS patient, but we need to get over that health literacy of what choice means and move that on into informed choice.

Q185 Dr Naysmith: Yet you have stated that choice does not mean the right to choose a particular GP or a particular consultant. How meaningful is it if that is the case?

Professor Lord Darzi of Denham: We have moved on from a single provider: the idea that you are going to come and see me individually. I made a reference to the team I work in. The idea that you are going to come and see Mr Darzi at St Mary's or the Royal Marsden Hospital are well over. We work as part of a team. I have four colleagues. We all provide the same quality of care. It is a team effort, and I think the leadership of that team will ensure that the quality of care across the team is exactly the same, and that is the culture we are moving into, and I am sure you will come into and reinforce what happens in Bristol.

Q186 Dr Naysmith: Before you answer that, it has been the practice for a very long time that you are sent by your GP to see a particular consultant and you turn up and you are seen by a more junior member of the team. That never used to bother anybody on the providers side, but people used to think, "Why am I not seeing the proper doctor that I was sent to?" You are saying it is going to be even more like that in the future. It is a team. You will not be referred to a consultant; you will be referred to a team?

Professor Lord Darzi of Denham: Yes, I am saying you will be referred to a team who are providing that service - individual consultants providing a service. There might be a specific reason why the GP may wish to see that individual within the team of four, for example. I may have an interest in doing specific, if I could use the example, ultra low rectal cancers, and within that team we know that I will do those. That is really what is happening across the country. If you go to any of the clinical teams, whether you happen to visit---

Q187 Dr Naysmith: That is why you are saying that patients should not have the right to choose a particular GP or a particular consultant, because it is now a team effort.

Professor Lord Darzi of Denham: It is a team effort. The GP may have further information based on the team and the sub-specialisation interest of that team in managing that care. We really need to capture this. The days of one single individual with his or her houseman running a service are over. We are talking about multi-disciplinary teams. You cannot run a service now if you do not have the competencies when it comes to your specialist nurses, it comes to your dedicated out-patient facilities.

Q188 Dr Naysmith: In many parts of the world you can just choose to go and see a consultant of your choice, and you see the person whose door you knock on and you can appoint them.

Professor Lord Darzi of Denham: Within that team you will still have the preference of an individual treating you. We are not going to put blocks on that. Within that team you may choose to have your treatment by an individual. Ultimately, you are talking about the operative procedure here, or you are talking about out-patients, but care is no longer just that, care is across the board.

Q189 Dr Naysmith: I have got another question to ask you, but I would like to hear what Dr Sheffield has to say about Bristol particularly.

Dr Sheffield: In Bristol in particular you could say that some consultants would still like to have that individual referral, but the truth is that it is impossible for GPs to know the individual special interests of every single consultant, and so referral to a team is a much better methodology and then triaging the letters to make sure that they go to an appropriate specialist in that area, because the sub-specialisation that is going on within all our major areas of care within our organisation are meaning that it is very frustrating for patients to turn up to see one consultant who does not deal with that condition any more. The fact that you can actually refer to a team and then the team decides who is the most appropriate person helps enormously. We are moving much more towards team discussions also about what the appropriate treatment for that patient is. So, no matter by what route you are referred into the hospital, there is often a team discussion between consultants of various specialties about what the best method of treatment for the patient is. It is an old-fashioned model of working just on a one-to-one basis with consultants when we know that if you have a major operation it is not just the quality of the surgeon, it is about the quality of the anaesthetic, the quality of the nursing care, both pre-operatively and post-operatively, and the quality of the aftercare in the community that is important towards the final outcome for the patient. So it is very difficult to justify a single person to person referral.

Q190 Dr Naysmith: Can I move on to another question? To what extent should we be prepared to live with the risks that are inherent in individuals being given greater choice and control over their care? For instance, does this mean they will be allowed to make inappropriate or non-evidence based choices within budgets? That, of course, would be a waste of NHS resources. How would we control that?

Professor Lord Darzi of Denham: You are talking about personalised budgets?

Q191 Dr Naysmith: Once you give personalised budgets to people and they are in control of their own care.

Professor Lord Darzi of Denham: Absolutely. That is one of the outputs of the report. That is back to Dr Taylor's point. That is one of the areas in which we have got to pilot these. This is not a national roll-out. You are right in raising issues about the type of treatments and who is going to support the patient making those decisions.

Q192 Dr Naysmith: Will there be different pilots, different models tried out?

Professor Lord Darzi of Denham: Yes. There are three different models. One of them is the notional budgets where patients know what the cost of their treatment is, the second one will be a hard budget. I think the evidence base, certainly if you look at the US literature, will suggest a single commissioner, in other words a clinician or a nurse, who will help you with that budget, but we are also suggesting we might try the cash payments with that. I think what we need to do is, firstly, we need to decide what areas, what conditions we need to pilot these in, and we need to do this with the voluntary sector. There has been a tremendous amount of lobbying for this in support when it comes to the Long-term Conditions Alliance, Diabetes UK, the Neurological Alliance. Once we really decide with them what conditions are there, we really need to support that with the evidence base to ensure that issues of the nature that you refer to are not---

Q193 Dr Naysmith: Will you give an undertaking now, and probably Mr Nicholson needs to be involved in this as well, that you will not roll this out without evaluating the pilots properly and making sure that they work?

Mr Nicholson: It is absolutely written into the Next Stage Review, and that is exactly what we are going to do. We are going to evaluate them and see what works and see what they say. Absolutely.

Q194 Dr Naysmith: It is interesting that you mention the Diabetes Society because they are quite concerned. While welcoming what you have just said, they want to be sure that somebody who does not want to take part in this sort of scheme, who just wants to be treated in the slightly old-fashioned way of taking their advice about clinicians, is still going to be allowed to do that?

Professor Lord Darzi of Denham: Absolutely.

Q195 Dr Naysmith: We can reassure them on that.

Professor Lord Darzi of Denham: Absolutely. This is not an opt-out scheme.

Q196 Mr Scott: Lord Darzi, why have you insisted on one GP-led health centre for each primary care trust irrespective of patient need? Would it have been better to let each primary care trust decide whether or not they wanted a GP-led health centre?

Professor Lord Darzi of Denham: I announced that in October, rather than this report of the 150 health centres, and I remember debating this with you on 24 October when I last met the committee. This is additional new investment that the Government is making in really building up the quality in primary and community services. This is additional to the services. The question you are asking is how do you distribute that. We have 152 PCTs. They are our commissioning routes. This is how allocations are made, and that is how we have allocated the funding, but what happens with these health centres, the type of services they provide, has to be a local decision, as you correctly pointed out.

Q197 Mr Scott: So you do not think it would be more cost-effective to use the 250 million on under-doctored areas of social deprivation?

Professor Lord Darzi of Denham: We are. Out of the 250, if I could just come back to you, there is 100 million - you are absolutely right - in areas of not just social deprivation, in areas where we know we have a huge disease burden that we really have to tackle, and I think I showed the evidence base in October, the correlation between the number of general practice colleagues and the disease burden but also the QOF points, the QOF scores, and the 100 million is to invest in new primary care services, not health centres, primary care services, in these specific areas. That leaves you with the 150 million, which as you correctly point out, is the health centre money. So we are tackling both issues of access and additionality in addition to really meeting some of the needs at a local level when it comes to inequalities of health and healthcare.

Q198 Mr Scott: You scaled down from the original proposals the GP-led led health centres. For example, there is no mention of a review of treating acute services in these proposed centres?

Professor Lord Darzi of Denham: That is a local decision, Sir. The one thing we said about the health centres, and that was based on the improving access needs, which Ms Atkins referred to earlier, where we wanted to have centres that are open eight until eight seven days a week, and that is what we have tagged the funding with to the 150 health centres, but the provision of other types of services is based on the local needs, local decisions, actually based on the local reviews.

Q199 Mr Scott: Can I press you on that. That would mean that if locally they felt that the district general hospital was the best way of treating those needs,. there would be no change to that whatsoever?

Professor Lord Darzi of Denham: Absolutely. Urgent care provision is a local decision. It is based on the eight pathways and what they wish to provide to meet their urgent care needs.

Dr Sheffield: There was a source of big discussion in the south-west and we were particularly keen, and we did not want to undermine the district general hospitals, but there is an issue in the A&E departments out of hours with a lot of patients coming that were really probably better treated within the primary care sector. If we give the example of mental health, an awful lot of patients come to A&E because there is a lack of access to mental health services out of hours. The provision of these health centres, if the local PCTs decided that they wanted to provide liaison psychiatrist services within those health centres, they would be absolutely welcomed by the acute hospitals because it would provide a much better service for those patients and would reduce the burden on the accident and emergency departments. We had a discussion saying that there is no reason why these urgent care centres should not be absolutely adjacent to the A&E departments. It was just a way of filtering patients to a more appropriate environment than the rough and tumble of an A&E department when it is very busy with major accidents.

Q200 Mr Scott: So you would see it as complementing rather than replacing?

Dr Sheffield: Absolutely.

Q201 Sandra Gidley: Could I just pick up on this £150 million and the health centre in every PCT. I fully support the aim that they go in under-doctored areas; how many actually have?

Professor Lord Darzi of Denham: Since we made the announcement?

Q202 Sandra Gidley: How many PCTs have actually placed a GP-led health centre in the most under-doctored areas?

Professor Lord Darzi of Denham: Again if I could separate the two, the £100 million was for new primary care provision in the under-doctored areas, and that is exactly what we are procuring for. The health centres are for the PCT to decide where they are located geographically. The health centres are not part of the investment in the under-doctored areas. The £100 million is; the £150 million is different.

Q203 Sandra Gidley: Given that the problem has been acknowledged, do you think it is the right way to spend £150 million in that case, because for example Hampshire is a very large PCT and Basingstoke, which is at the centre of Hampshire but nobody from about half an hour distant will go to it, is not under-doctored, so I cannot quite see the point. There are other areas where they could probably benefit from two good GP led-health centres where there are real health needs and real under provision. You are talking about under provision being linked with poor health outcomes.

Professor Lord Darzi of Denham: The geographical location of that is still decided by the local PCT.

Q204 Sandra Gidley: You keep going back to this word 'local' but no local people have made a decision in this. It is just a few bosses sitting in an office in Winchester deciding what happens to the whole of Hampshire for example, replicated around the country. Is it not token localism?

Professor Lord Darzi of Denham: Every PCT, and there are numerous examples of PCTs across the country, have engaged with the local population in deciding that and have also engaged with primary care colleagues in making decisions about that. In some areas, you are right, there have been some challenges, and that needs to be done in a more open and transparent way. The motive of this is to increase the capacity of primary community services, to provide more choice for patients, to improve access but at the same time to tackle some of the inequalities in healthcare.

Q205 Sandra Gidley: Okay, we will see. Just before we move on, the BMA seem to have a problem in differentiating between a poly-clinic and a GP-led health centre. Can you tell us the difference for the record?

Professor Lord Darzi of Denham: Yes. Poly-clinics was a description of a differentiated health centre for London. That is where poly-clinics are all about and that was in the London report. I made the case for these at the last meeting on the 24th which is in your publication. They are very different, they are providing a wider range of services and that includes integration with some services in social care and it also includes some degree of vertical integration. That is one point I would like to make for the record. The second point I would like to make for the record is that the London report was the first report to describe what we call a federated or a networked model of poly-clinics. In other words, a number of GPs remaining in their same practices and working jointly will have access to a centre which provides them with out-of-hour services such as urgent care provision, mental health services, diagnostics, and others, so that is a London solution. Interesting, if you look at the nine other reports, they have other solutions. Let us not forget, if I could make the case for London, the challenges for London's primary care are very, very different from the rest of the country and also it has been historical. When I was asked to do the London review, the first thing I did was read all the reviews which were done by people before me and the same old story comes up time and again in primary care: we need to make investment, we need change. This was what Londoners chose to have. This is what clinicians in London, including primary care colleagues in London, wanted to see happen. The BMA may have interpreted that in different ways but back in July when it was published they were supportive of it. For all sorts of other reasons I think there is a confusion or there is a confusion being created between poly-clinics in London and these health centre elsewhere.

Q206 Sandra Gidley: Thank you for that, that is clear, and hopefully the BMA will be taking note. There have been some suggestions that the real purpose behind the drive towards GP-led health centres is to provide more independent sector provision. What evidence is there that this sort of mixed economy of primary care provision will be more efficient than what is currently available in the NHS?

Professor Lord Darzi of Denham: Firstly the purpose of this is not to introduce the private sector. The purpose of this is improving access and enhancing the quality of care in primary community services. I think it is very important that we all realise that. It is also worthwhile to make the point within context and say that GP colleagues run independent businesses. Let us not forget that; and they are independent businesses. What I want to see out of this and what the Government wants to see out of this is the best healthcare provision at the best value, and many GP colleagues across the country are coming together and putting in very strong bids for these, I understand, as is social enterprise, as is the private sector. Ultimately what we want to do is to provide the best healthcare and the best value to the taxpayer and the patients who use the services.

Q207 Sandra Gidley: The report does not cost anything though so how can we actually know whether this additional provision is providing value for money? Would it not have been better to pilot it?

Professor Lord Darzi of Denham: Piloting primary care centres? We have had them since 1948. Actually I have brought it with me.

Q208 Sandra Gidley: I have seen that.

Professor Lord Darzi of Denham: If I could just read to you.

Q209 Sandra Gidley: They have waxed and waned.

Professor Lord Darzi of Denham: Firstly on the first page here it says "choose your doctor now". This was on 5 July 1948 and the last paragraph says "special premises known as health centres may later be opened in your district. Doctors may be accommodated there to provide you a wide range of services ..." and you might be interested in this "... including dentistry and other services on the spot". I promise you I did not invent this.

Q210 Sandra Gidley: They say there is nothing new but is not the difference that then you chose your doctor and you could choose to do that and now I understand that you do not have to register with these new GP-led health centres. That is the bit that is untried and untested and for which we do not have the economic case.

Professor Lord Darzi of Denham: I will make two points on that. You are right, these health centres will provide services to those who are registered and also to people just walking in and out, a walk-in service. We felt that was important because some patients are very gratified by the services they are receiving from their GP practices and they want to stay there - and that doctor/patient relationship is a very important one - but at the same time, for all sorts of personal reasons, they may only have the ability to go to care out of hours or at the weekend, and they will have access to these health centres. That is one and the second one is this also builds new capacity because, you are right, in areas in which a patient may not be a happy with the service, they will have the choice of moving on into another practice. We are doing that also through reforms in the system itself. Patients will be allowed to register where they choose to register.

Q211 Sandra Gidley: How do you respond to my local GPs who despite being some distance away from the new centre feel that the new GP-led health centre will destabilise the local health economy, they cannot see how the income streams are going to work without patients registering and feel that ultimately in a couple of years' time people will be made to make a decision to register with one of these centres. Are their fears unfounded?

Professor Lord Darzi of Denham: A large number of general practice in this country provides excellence in healthcare, let us not forget that, and those have absolutely no fear. It is an interesting story because it came round at the same time as the independent sector treatment centre programme was created, and I happened to be the adviser to your Committee in those days, and there were exactly concerns that it was going to affect the business of my hospital or the hospital next door. That has not happened. We need new capacity in primary care and we need to be proactive. I would like to see the NHS in the next year proactive in meeting its challenges. Historically we have always been reactive. The NHS Plan was reactive because the NHS was falling apart. Let us look at the challenges facing us such as the changes in lifestyle diseases. Did we predict ten years ago we are going to have an obesity epidemic, no, ageing population, all of all are living five hours longer a day ---

Q212 Sandra Gidley: It seems like it!

Professor Lord Darzi of Denham: Long-term conditions - one of the successes of the NHS is to convert an acute illness into chronic illness. You need to ask you question: in 2008 are we ready in our primary community services to meet those challenges? That is why we are investing proactively there. I truly believe that is important and I also believe that if you are going to have the biggest impact on the health of the nation, you are not going to have it in the hospitals I work in; it has to be in primary community services, so that is where we are coming from and we need to work in partnership with the professional bodies and the BMA in trying to address these challenges for the future, so this is not a threat; this is an opportunity.

Q213 Sandra Gidley: Okay, moving away from GPs we have had 90 walk-in centres introduced over the past few years which in many areas have been well-used. Is it not confusing for patients to have walk-in centres in one place and a GP-led health centre where they can go or does this mean that we might see the end of walk-in centres because they have not quite achieved what they were intended to?

Professor Lord Darzi of Denham: I do not think so. Firstly, you have acknowledged that walk-in centres have been a success and I agree with that. I was not sure when they first came out but there is a huge amount of satisfaction in there. Essentially what you are saying, and I agree with you, is one size fits all does not exist any more, and what we need to do is to give the choices to the patients depending on their circumstances, their own needs, where they wish to go to, but ultimately what is important - back to 1948 - is everyone will have a registered doctor. That should never be eroded. If you have extra services on top of that, why not?

Q214 Sandra Gidley: This may be a difficult one to answer but if GP-led health centres prove to be as successful as you hope, where do we go next? Will there be more money for more in the future?

Professor Lord Darzi of Denham: I have no doubt that in years to come we will need to look at resources in primary community services. PCTs have allocations on a yearly basis. Primary care colleagues have always been engaged in changing and improving services but that is a local decision. We have made this investment and we have no intention of further investments within the next three years in relation to that, but that is a local decision as to what primary care colleagues wish to do. We are increasing capacity and I think we need to work with them in really getting us ready for some of the challenges that I have referred to already.

Chairman: We are now moving on to speeding up the NICE process. I wonder if we could speed up our process as well. We are one and a half hours in now and we have still some time to go on questions. Richard?

Q215 Dr Taylor: To me this is really one of the most important bits of the whole report - speeding up NICE. Some commentators have told us that NICE is doing extremely well out of the Darzi review and, I believe, having its budget tripled to £90 million per annum. This is absolutely excellent if it really does make the NICE process quicker because if we could get NICE results within a very few weeks of drugs becoming available, then this would solve all sorts of problems. Do you think even with the extra money NICE will be able to do this? Will they have the technical expertise in their staff?

Professor Lord Darzi of Denham: Absolutely, but firstly again I have acknowledged the role of NICE and if you look at the report it is all about rewarding excellence and quality and NICE is one of these organisations that really has taken off, if you look at the last eight years where we are in relation to appraisals compared to Europe and the US, the US health system is creating a NICE. The answer to that question is, yes, I have had meetings with both with Chief Executive and the Chairman of NICE and they feel with the extra resources they have that will expedite the approval of drugs. However, it is not just the money. We also need to build into the system the intelligence, working in partnership with industry and others, as to what is in their pipeline before it even comes out and the evidence base needs to build in partnership with NICE and then really get that through NICE. I do not think we will meet your aspiration of a few weeks because let us not forget that every decision NICE comes up with has to have a public consultation because that is part of their process and their appraisal and that will be maintained. I think we will be down to three to six months ideally whereas now it is about 18 months. I am delighted that you like the proposal.

Q216 Dr Taylor: But we are getting away from the delays in referral to NICE?

Professor Lord Darzi of Denham: Yes, absolutely, that is what I am saying. Even before the drug comes out we need to capture that intelligence.

Q217 Dr Taylor: Right. In the recent NICE report we did we tried to get them to clarify the difference between technology appraisals and guidelines, one being mandatory and the other not, by actually changing the title. I am going to stray onto the NHS Constitution for a moment (although we are coming back to that later) and I think we are told: "The NHS Constitution will enshrine in law a universal right to approve treatments if they are clinically appropriate for individual patients." Does that mean those that have a technology appraisal behind them?

Mr Nicholson: That is correct, yes.

Q218 Dr Taylor: Do you not agree with us that it would be rather useful to get NICE to change the titles because guidance includes technology and technology appraisals as well as the public health things and nobody realises what is a technology appraisal which is mandatory and what is a guideline which is not.

Professor Lord Darzi of Denham: I am more than happy to talk to them about language; no problem.

Q219 Dr Taylor: Thank you. Another thing that came out of our first NICE report was that local decision-making is really sometimes at odds with the central directive. I always remember across the river at St Thomas' implantable defibrillators became a 'must' they had to do' and they would much rather have had more nurses in A&E than these implantable defibrillators, so is there always going to be a conflict between this sort of local decision-making and the centrally issued directives of the technology appraisals?

Professor Lord Darzi of Denham: I will tell you this as a clinician - if that is the guidance that is the best evidence in management of a condition. All clinical colleagues will aspire to deliver that, that is the way it is, however we also need to exercise our professional judgment and our clinical competence. You do not fit patients to technologies; you actually try to fit technology to the patient and that is where local professional judgment comes in. The whole report is about clinicians exercising their professional judgment in this new framework that I am describing.

Q220 Dr Taylor: And if we get NICE working quickly would this in your opinion be an answer to the top-up fees conundrum?

Professor Lord Darzi of Denham: That is a completely different debate. I think it will have a tremendous impact on it because we are expediting drugs. Herceptin will be the one that comes to memory. If we had a much more pro-expedited process in getting the drugs through, yes, it will have a major impact.

Q221 Mr Bone: If you go back to Wanless and the interim report we had a very useful little table which said take-up of drugs and diffusion and it said USA: take-up, rapid, diffusion, rapid; France: take-up, late, diffusion, rapid, but when it got to the UK it had UK: take-up, late, diffusion, late, so are your proposals going to bring us closer to the US standards of rapid take-up and rapid diffusion?

Professor Lord Darzi of Denham: The answer is yes because we are expediting the process of approval, but at the same time those ten reports are looking at the evidence base, the pull effect in really getting that option through, and the report also described what I described as the pioneering NHS. I think I referred to being much more proactive in resources. We also need to be proactive in the up-take of new technology. One thing about healthcare - and I gave you the cardiac example earlier of angioplasty, statins and smoking - is that things happen at a tremendous speed. We need an NHS that is exploiting these technologies to the advantage of their patients and that does not mean it is always more expensive because in the nature of these things, they are much more cost-effective and I think that exercise of the ten regional reports has really highlighted the appetite for taking the latest guidance from here and making it happen locally, and getting a reward for it.

Q222 Jim Dowd: Can I look at issues around leadership and the workforce. Being an NHS manager has never been easy. Probably today it is even more difficult than ever, particularly given the tabloid view of NHS managers being parasites on all the decent clinicians who are trying to deliver the service. You have sitting next to you in Dr Sheffield an ideal example of somebody who has made the transition from clinician to manager. How do you intend to realise your proposals to make this far more the norm than it is at the moment?

Professor Lord Darzi of Denham: Firstly let me just say the aspiration of the top manager in the NHS is to have more clinicians working in there and what I am doing is meeting his aspirations in the report. I am sure David will come in because he led this piece of work. If I could just describe one bit of the report which really has engaged the profession. Clinicians, whether you are a nurse, a healthcare professional or pharmacist, you are not just a practitioner; you are a partner; you also are a leader, and we need to bring more of that into the provision of the service lines whatever that happens to be. For that both clinicians and non-clinicians need both management and leadership skills and the report is all about building up that structure and that resource in making more and seeing more people like Jonathan really leading services because - and I made that point earlier - you can really bring in and converge the quality of care with the use of resources and doing that in partnership with management.

Q223 Jim Dowd: Would that extend to the non-execs as well?

Professor Lord Darzi of Denham: In the development of their skills?

Q224 Jim Dowd: Yes.

Professor Lord Darzi of Denham: Absolutely. There is a major scheme - and maybe David will comment - on forward development.

Mr Nicholson: As the chief parasite in the NHS I can say that! This is such an important issue for us. It seems to me it is the issue that got missed out when three or four years ago people talked about reforming the NHS, they talked about the technical aspects of reform, payment by results and all that sort of stuff, but the real issue is leadership, and it seems we are quite unusual as a health system in this country of having relatively few clinicians in the most senior posts and I think it shows in terms of the focus of our work. There is a short-term set of issues that we can deal with but there are also some long-term ones, and I think the report addresses both. The long-term ones are all about building in management training expertise and understanding at under-graduate level for doctors in particular and nurses and other clinicians and to bring that right the way through their training so there is a whole series of things for us to do in there. Then at the top level there is identifying clinicians particularly at the moment and our aspirations are that within three years on every shortlist for a chief executive job in the country there will be at least one appointable clinician who will be available for appointment. To do that we are doing a lot of work across both the regions and nationally to get people ready for doing so because although most doctors do provide leadership and most doctors do believe that they are the best managers money can buy, sometimes they need a bit of education, training and support to get them into the position where they can actually deliver.

Q225 Jim Dowd: Are those the only attributes that need to be nurtured to improve the quality of the NHS product or are there others?

Mr Nicholson: No, there are all the rest in the report but leadership is a crucial part of it that we need to invest in to make it happen.

Q226 Jim Dowd: It is the leadership rather than the performance. There is nothing missing per se, it is just we need more skills amongst the leadership and we need them to be spread more widely?

Mr Nicholson: We need to do that. We need to bring people from outside of the NHS as well. There is a whole pool of people with expertise in local government, the voluntary sector and the private sector that we can bring into the NHS, and we are developing processes to enable us to do that. The issue for me in leadership terms what I want to get to is a place as what I would describe as being spoilt for choice. When we get to the most senior jobs instead of just having one person who we can appoint and that is all, we should have a choice, and that is what we want to do.

Dr Sheffield: As someone who has been at that interface I would say that it is very easy as a clinician to criticise the general manages but they go into the NHS with the same values as clinicians: they want to help patients. It is quite insulting sometimes the language that we use as clinicians towards general managers. They just have a job to do that is about managing the total healthcare system. Where it works best is where there are strong leaders both in general management and clinically and where they work really well together as teams. There is a huge issue about how we all work better as teams at all levels within our organisations.

Professor Lord Darzi of Denham: Leadership is a loose term that has been used before. What is leadership? You have to have a purpose; what are you creating the leadership capacity for? You will see across the report this is leadership for quality. Whether you are a clinician or a non-clinician you are here to provide quality care based on the resources that are available to you, based on the evidence base and based on the vision that you put together.

Q227 Jim Dowd: You proposed identifying and mentoring the top 250 managers in the NHS to spearhead this improved approach. 250 out of 1.2 million people who work to the NHS does not seem a very significant number.

Mr Nicholson: This is just the national effort. Every region now has a whole set of programmes there to deliver support, health education and leadership at the regional level and the local level. That has already started and there is not a region in the country now that does have all that, so we are tackling a huge number of people. We identified the top 50 organisations in the country, either the biggest or most complex organisations, because what we believe is first of all we need to improve the quality of leadership in those organisations and we can all get better and we need to invest to make that happen. Also we need to make sure that we have enough people coming through the system to populate those jobs in the future. The market simply will not deliver the people that we want; we have to nurture and support them through the system. We are focusing on that nationally but there is a massive programme going on regionally and locally.

Q228 Jim Dowd: I will not ask you if there is a parallel programme to turn managers into clinicians. How difficult can it be?

Mr Nicholson: It is a good point.

Q229 Stephen Hesford: In terms of accountability, the review talks about increased local decision-making which we would all support but there is a potential concern that the chosen bodies, the SHAs, are said to be large and impersonal and also potentially lack expertise, so if those criticisms at all are fair, is accountability going to be what we want it to be?

Professor Lord Darzi of Denham: I think we need accountability across the system. The report describes accountability across the system. Firstly let me start with the process. These were ten regional reports actually working with clinicians, in Bristol or wherever, regional and granular to PCTs and providers in capturing clinicians across the system in health and social care and bringing them together and creating these visions. Next, you are right, we need to transfer that into what I would I described earlier as the PCT strategic reports because we need to get down to the system because the SHAs are too high up, you are right, and we need to get that even lower than that. I think accountability will be in that system. How do we get the clinicians who designed the eight pathways now to be involved at a commissioning level to commission these pathways? Let us not forget that one of the most powerful processes we have all gone through in these reviews is that each of the pathways, each of the local visions have engaged locally with the public and patients. If I am correct, the figures are near enough 60,000 people who have been involved across the country in contributing to this report somehow or another. You are right, accountability has to be local, I believe probably at the level of PCTs and good PCTs will push that even further to the providers.

Dr Sheffield: As a clinical group we were very clear at the end of the process of writing our report that we wanted the PCTs to own the document. All the clinical pathway groups that we have put together are really very keen to be involved in that process so we have been going out to the individual PCT groups and explaining the reasoning behind our report and why we think these targets are so important, so we were really keen that the PCTs owned it and the PCTs would manage the implementation of our report and that we also would offer ourselves available for advice as to the reason why we came to that. We have worked very hard on making sure it is a document that is owned throughout the South West rather than in Taunton in the SHA headquarters. We felt very much that we had come from all points of the South West into groups to deliver the report and we also feel now we have a responsibility to take it back out into the communities throughout the South West to deliver it. I am quite sure that is the process that is going on up and down the country at the moment.

Q230 Stephen Hesford: Is there guidance to PCTs which tells them that they can have this ownership and should have this ownership as opposed to they might have it if they want it?

Mr Nicholson: The process that we are working through with PCTs at the moment is that by the end of this year they are to put forward their strategies for the next three years of healthcare development in their PCTs, informed by the kind of work that Jonathan has just talked about, and to produce a proper operational plan next year. It is entirely a matter for them to take account of the national and regional work to take it forward and that is their responsibility as PCTs.

Q231 Stephen Hesford: Will a chief exec of a PCT be performance managed on this to make sure that this is driven through?

Mr Nicholson: What we expect PCTs to do is to set out the direction of healthcare in their locality, to set out what targets they want to set locally, what ambitions they have for driving things locally and then we would expect the SHA to ensure that the PCTs deliver what they said they were going to deliver.

Q232 Dr Stoate: I would just like to follow up on something Stephen said. What happens if there is a difference of opinion between the PCT and the SHA about what should be delivered locally. Who actually wins if the PCT's aspirations and the SHA's aspirations do not fall into line? What happens?

Mr Nicholson: It is quite difficult to work out under what circumstances that might happen given that in most of the country, and I am sure it is the same in the South West, and in London in fact, PCTs recognised and accepted Healthcare for London as the direction forward. It would be quite difficult in those circumstances for a PCT to then say that they supported Healthcare for London and then to do something completely different.

Q233 Dr Stoate: If there are 32 PCTs in London what if one of them had said, "We do not want a poly-clinic thanks very much, we are doing very nicely as we are," what would have happened then?

Mr Nicholson: If they had accepted Healthcare for London ---

Q234 Dr Stoate: What if they did not? What if they said, "We are not having anything to do with it"? I am trying to make a hypothetical point but it is a real point because if for example a PCT had been vehemently opposed to poly-clinics, and said, "We are perfectly happy with the situation we have got, we do not want anything to do with it, we are not signing up for this document," what would have happened then?

Mr Nicholson: If they had not signed up for Healthcare for London? They would have had to have gone through the process of modifying Healthcare for London in those circumstances because they needed to get everyone to sign up to it. That was the whole point of the process that they went through.

Q235 Dr Stoate: I am slightly concerned and all I want to try and tease out is which takes precedence if there genuinely is a deadlock. Is it the SHA that gets its way or would it be the PCT that gets its way?

Mr Nicholson: At the end of the day it depends on the scale of it. If for example a PCT decided it did not want to implement 18 weeks, the PCT absolutely would not get way its way. It is a national thing that we expect to be driven through the system and that was the case. If they wanted to put a health centre or a clinic in a place which was slightly at variance with the national model, it would depend on the variance of the judgment between the SHA and the PCT and what was sensible; it would be a dialogue.

Professor Lord Darzi of Denham: Ultimately it is the evidence that would win. PCTs are the commissioners who are sitting there providing services on behalf of the local populations that they are serving and it is the evidence base that is important. That is the evidence base when it comes to what clinicians have done and that is why we believe that the clinicians should be engaged in making these things happen.

Q236 Dr Stoate: That is fine. I want to come on to commissioning. We had some trouble with this last week. What is World Class Commissioning and if we saw it how would we know?

Professor Lord Darzi of Denham: I think you will see it when you see world-class quality of care, you see the end product. It is the means of achieving that end product, so that is what I see World Class Commissioning leading to - a first-class service - which is commissioning based on evidence and commissioning based on the needs of local populations. As you know, the Department published that organisational development tool last year with a number of competences, ten or 11 competences, and they are mostly process-related but I think we also need to hold the PCTs accountable to the health outcomes of the populations and that is where the evidence base comes in.

Mr Nicholson: We have defined it through the 11 competences. I do not want to bore you with all of them, but they are quite clear about what World Class Commissioning will look like. We will then measure the PCTs' performance against all of those 11. You will be able to see where your PCT stands on each of those 11. You will be able to make your judgement and you will be able to see where they are making progress and where they are not.

Q237 Dr Stoate: That is fair enough. Obviously I appreciate we are right at the beginning of this process and last week we were told that we are in the foothills of World Class Commissioning which sounds like a rather nice place to be. When will we see the benefits of this programme?

Professor Lord Darzi of Denham: When PCTs commission the type of services that are evidence-based which are improving the health of the populations that they are ---

Q238 Dr Stoate: When will we get some noticeable, tangible improvements? When will we start to see these results?

Professor Lord Darzi of Denham: Firstly let us acknowledge that PCTs are about 18 months/two years old, where they are at the moment, and some of them have matured significantly but some of them also need some support and some help in building up some of their competences. The Department is involved proactively in helping them through that by whichever means are required in raising those competences to the level that we have described in our framework.

Q239 Dr Stoate: So it is an on-going process but you expect to see some results reasonably soon?

Mr Nicholson: We would expect to see results this year.

Q240 Dr Stoate: That is fair enough, thank you.

Professor Lord Darzi of Denham: And we will be publishing their performance as well. We are back to quality counts. They will be publishing their competences and where they score.

Q241 Sandra Gidley: In our recent inquiry into dental services that we did, a number of problems with commissioning were highlighted and World Class Commissioning actually requires the transformation of PCTs from acting as payment agents to hand out the money to being more analytically based and a bit more hard-nosed when they are commissioning. I think some PCTs have struggled with having the right staff to do this. Where are they going to come from?

Mr Nicholson: If you look across the country as a whole I think the skills that PCT staff have are improving. The investment that we are making in leadership and management development will improve the quality of the people that we have got. That is the first thing. The second thing is that we are investing in independent and private sector and voluntary sector organisations of people to help us do this through the FESC process. In every region of the country now there are PCTs that are bringing in that expertise, whether it be through companies like Humana or organisations like the Terrence Higgins Trust, we are seeing a significant change in the nature of commissioning through that investment. The third area is that we are seeing increasing pooling of expertise between PCTs. That can be shown at its most obvious in the West Midlands where you have a West Midlands-wide agency which supports PCTs with analytical and procurement support, or by the plans that are being developed in London. You are seeing across the country that sort of pooling going on.

Q242 Sandra Gidley: Is it good enough yet?

Mr Nicholson: I think we are on a journey. I do not know whether we are in the foothills because I think some people are really quite near the top already. We have a lot to do to make it move from islands of excellence to one where most parts of the country are in this place, but we have now got a mechanism and we have clearly identified what success looks like, and we are going to measure PCTs as they go through.

Q243 Sandra Gidley: Do you accept that some of the problems with commissioning are down to the lack of competition on the supply side?

Mr Nicholson: The supply side?

Q244 Sandra Gidley: Well, there have been rumours that GPs have been quite keen to commission for themselves and there have been some correlations pointed out between GPs with a special interest and what special services are commissioned, strangely, for example.

Mr Nicholson: This is all new territory for us in terms of a PCT being responsible in some way for managing the various elements of a healthcare system rather than managing particular functions. We are learning from that. There is no doubt that there are some parts of the country where there is not enough supply-side commissioning to improve the standards and give patients choice in the way that we want and that is part of the responsibilities of PCTs. In fact, it is one of the competences within World Class Commissioning to be able to demonstrate where there is supply side competition, is it effective, and where there is not, what you will do as a PCT to inject more competition into it.

Q245 Sandra Gidley: My next question was going to be what is being done to create greater competition on the supply side. Is the answer that it is a competency or am I getting that wrong?

Mr Nicholson: The first thing is that competition is a means to an end, it is not an end in itself, and you have to analyse your market or your system to work out what the nature of the competition is that you want and how you want to make it work and that is a competency of PCTs to be able to identify that in order to make the local decisions that they need to do and to either create competition or create level playing fields where they need to take things forward. It seems to me that is the direction that we are going in and we are really at the beginning of all of that.

Q246 Sandra Gidley: Will this ultimately mean greater use of the private sector?

Mr Nicholson: It will certainly mean different models of service and different models of care. I do not know whether it will mean more private sector; it depends very much on how the private sector responds to the kind of challenges that they make. We will certainly make the process more transparent and open and will give more and different providers the opportunities to come into the system and provide services. Whether or not it will be successful will be a matter for local determination.

Q247 Sandra Gidley: It all seems a bit vague to me, I am afraid.

Mr Nicholson: It is not that vague. It seems fairly straightforward. If you have got a part of your system where there is no choice and no competition whether it be in pharmacy or whether it be in dental or whether it be in general practice and you believe as a PCT that your analysis shows that competition and an alternative supplier would improve quality and improve choice, then you make investments to make that happen. That is straightforward to me.

Q248 Sandra Gidley: I think, as we have heard, we are in the foothills so we will probably be re-visiting this when we have climbed a little higher. Last question: how do you expect PCTs to counter the incentives that payment by results give to acute trusts to increase their activity?

Mr Nicholson: It is a double-edged sword really because the incentives work the other way as well of course. Payment by results is a fantastic incentive by PCTs not to refer inappropriately patients to the secondary care sector and so the incentive works both ways. One of the things that we need to do when we set the tariff, the contract and the rules, which is part of a national responsibility, is make sure we get the right balance in that. I think people would say that the new contract that we established this year shifts the balance significantly to commissioners, and we think that is the right place for it to be at this present moment in development.

Professor Lord Darzi of Denham: Adding to that also, going out and reaching a local population and looking at the health outcomes and needs and that is what I said, if we are really going to be proactive we need to look at prevention and well-being. PCTs need to proactively go out and make that happen.

Q249 Sandra Gidley: But CQC is not going to be looking at that aspect of things, is it, it is going to be looking at the whole picture?

Professor Lord Darzi of Denham: CQC will be looking at the quality of commissioning but their performance management will be by the SHA.

Q250 Sandra Gidley: It will not be looking at health and well-being; it might be looking at health outcomes but it does not really have a remit to look at the more public health aspects.

Professor Lord Darzi of Denham: We will have that in the operational framework.

Sandra Gidley: That is reassuring.

Q251 Dr Stoate: In your report you write that you are going to give stronger support to practice-based commissioning, which I think is probably quite a sensible idea. The problem is how exactly are you going to strengthen practice-based commissioning because at the moment many GPs that I meet are fairly confused about what it means in terms of workload and even how to go about the process.

Professor Lord Darzi of Denham: What I have heard talking to primary care colleagues is that in some areas it has worked and in a lot of areas it has not really taken off. You are absolutely right, most of that is based on, "Give us more freedom; give us the tools; give us the information. How can you commission if you do not have the information? Give us the infrastructure," and some have said, "Give us the competences." We work with FESC for example in bringing that into practice-based commissioning. I think there is the appetite there in some areas and I think the incentives are now aligned and that is what we are saying in relation to the report. And I think if we can really engage them with the regional reviews here, a lot of GP-led PBC groups contributed to the different pathways across the country. I think that is one way of giving them more freedom to get on and do what they need to do.

Q252 Dr Stoate: I am sure that is true but GPs often lack the knowledge, as you say, and the information and the necessary skills to make it happen and some PCTs, frankly, have not been as helpful as they might in this area so what can you do to try and drive this process further because in many areas - and I speak to a lot of GPs and I am sure you do - it does seem to have stalled in that no-one quite knows where to move on to?

Professor Lord Darzi of Denham: It depends why it has stalled and what you are saying to me is some GPs want to get on and just provide care; they are not interested in the commissioning element of it.

Q253 Dr Stoate: That is a slightly different area. The King's Fund has told us that many GPs simply do not want to get involved in this, they would rather provide clinical care than commissioning, and that is reasonable, but even in areas where GPs want to get involved in commissioning, certainly in evidence I have had personally from people I have spoken to, that it is just not happening either because of lack of knowledge, the PCT has not been supportive, the PCT has lacked the necessary skills itself, they have not been able to take the decision necessary, and it is all taking a lot longer than it should. What can you do to try and kick-start it?

Professor Lord Darzi of Denham: Through the primary community care strategy. There are very clear proposals on how we develop practice-based commissioning in these areas in which, as I said, most of that is based on either bringing competences from outside, building them the infrastructure, giving them the right tools and making that happen and putting the right incentives in attracting primary care. One of the proposals, as you probably know, is the integrated care organisations which there is a huge amount of appetite for because that combines both some of the commission aspect and the provider aspect based on certain rules.

Q254 Dr Stoate: Although GPs might invest, they might employ people, they might set the systems up, what they are slightly concerned about is if the goalposts move in a year or two's time and the priorities change. It might be very difficult for them to then change what they have already set up simply because they have invested so much in it. Is there something you can do to try and make sure that is not a problem?

Professor Lord Darzi of Denham: We made that commitment back in July. We said there is no structural change and we did not make any structural change and we nee