Oral evidence: Services to people with neurological conditions, HC 502

Oral evidence, 14 December 2015.

Witnesses

Dame Una O’Brien, Permanent Secretary, Department of Health, Simon Stevens, Chief Executive, NHS England, Professor Sir Bruce Keogh, National Medical Director, NHS England, Dr David Bateman, National Clinical Director for Adult Neurological Conditions, NHS England, gave evidence.

Chair

Good afternoon. This is our second panel—the people who are responsible for ensuring the delivery of neurological services in the UK. I will not repeat my preamble—I think all of you but Simon Stevens were in the room—but I am delighted to welcome our second panel. Sir Bruce Keogh, the National Medical Director for NHS England, is a reasonably regular visitor, although not as regular as some of your colleagues on the panel. Simon Stevens is the chief executive of NHS England; welcome back, Mr Stevens. Dame Una O’Brien is from the Department of Health. Dame Una, we have learned today that you will be moving on in April, so you will be losing your frequent flier points at the PAC, depending on where you go. We may see you again—we don’t know yet—in another role, but it’s up to you to tell us that in due course. We are delighted to welcome Dr David Bateman, who is the National Clinical Director for Adult Neurology Conditions for NHS England. We are really pleased to have you here, Dr Bateman; we were particularly keen to have you as a witness. I think you heard from the pre-panel that we have a lot of questions for you this afternoon. I need to declare again for the record that I have an interest, in that my brother, Dr Charles Hillier, is a consultant neurologist at Poole Hospital NHS Foundation Trust. I am going to hand straight over to Anne-Marie Trevelyan, who is leading our questioning.

Mrs Trevelyan

I am new here so I have been quite intrigued to discover, from looking at a progress report, that although some of the PAC’s recommendations following the 2011 NAO Report were rejected by the Department, you have moved ahead with some of them, which is good news—but not necessarily particularly good progress—on the specific issue of appointing a clinical lead for neurology, which was not supported by the Department at the time, and establishing local neurological networks. I am really pleased to welcome Dr David Bateman. It struck me just from reading the Report, not having followed earlier ones, that this was an obvious and important part of the process of improving neurological services for patients. May I start with you, Dr Bateman? How do you think the support for those suffering from motor neurone disease, MS, Parkinson’s and other less well known neurological conditions is improving and what support are you getting from NHS England to make that happen?

Dr David Bateman

I have been in post for only two years, so we have obviously had to do quite a lot of groundwork to begin the improvement. The clinical networks—or strategic clinical networks, as they were previously called—have been fundamental and I think they are critical for dealing with quite a lot of the problems that have bedevilled neurology services from the start, really, because patients do cross a lot of boundaries, from a neuroscience centre to a DGH to the community. For neurology services, clinical networks are probably the most fundamental and most important way of trying to establish care pathways for those patients across all these health boundaries. What I have been doing with the clinical networks is helping form them and helping to set them up. We have managed to appoint clinical leads in all the clinical networks now and their work programmes have been determined by my leadership and my priorities and the national agenda, and also, to some degree, by local priorities. Now they are really beginning to bear fruit. All the neurology clinical needs have got some very supportive, very hard-working clinical managers, and they are beginning to develop programmes that, as I say, are making a difference. Just to give some simple examples, in the Thames valley, there is a fantastic clinical network that has been looking at headache out-patient referrals and trying to think about how we can improve access for patients with chronic daily headaches of various kinds, how we can improve their care, and how we can try to transform the waiting times for patients—for neurology out-patients—by seeing if that kind of work can be done in another way. They have managed to think up a potential model with GPs with a special interest who are not new and they have been able to demonstrate that there is quite a lot of interest from GPs and quite a lot of uptake of that kind of model. They have been able to see patients earlier, have reduced the follow-up, have reduced the investigation rate and have improved the outcomes—so much so, that Oxfordshire CCG now wants to commission that kind of service. When you think that 20% of out-patient referrals to a consultant neurologist are probably for headache disorders, if they were all removed, we would have some opportunity both to shorten the waiting times and to see if we can actually begin to reconfigure what neurologists do to do other kinds of work. Another colleague is looking at headache in a slightly different way—at giving GPs protocols for diagnosing and managing headache and giving them access to scans. That is under way at the moment. They have also looked at data again to see how patients are being looked after in their particular group of CCGs in the clinical network so that they can actually begin to understand what is happening and who is getting treated where. Most of the clinical networks, in fact, have got programmes around headache in one way or another, so they are copying that kind of work, and that is being rolled out. Other clinical networks have begun to look at what we can do about the care of patients who are being seen in seizure clinics and in the acute emergency departments. That is fairly critical if you have epilepsy, because if you have a new epilepsy, you will probably be taken to the emergency department, and if you have existing epilepsy that is poorly controlled, you will go to the emergency department, so it is a critical part of the care pathway. We had two previous big audits called the national audit of seizure management in hospitals, which demonstrated that we were not doing well so quite a lot of the clinical networks have been looking at that pathway to see if they can put more resources into it, identify these patients and make arrangements to ensure that they are being seen. Only about 25% of new patients with epilepsy were actually being seen, so we wanted to see if we could significantly improve that. The other thing about these acute neurological conditions is that a lot of patients with acute headaches and seizures get admitted to hospital because of the difficulties for people in the emergency department knowing the cause and whether it is serious. If you look at the length of stay—this is where data are really helpful—it is 1.7 days for those patients, so they have a short stay until they are better and then they go home. It is not actually a very effective way of dealing with it. Looking at the data, it costs us £70 million a year to look after epilepsy emergency admissions of people who already have a diagnosis. We are thinking about ways in which we can significantly improve that care pathway. The clinical networks are also looking at those across the whole country. NHS England has very kindly taken up my cause, which was trying to improve community care of long-term neurological conditions. From my perspective as an adult neurologist of 25 years, once you get a neurological diagnosis, the less you see of hospitals and the more you are managed as a normal person looking after your own condition, the better. I am very concerned that patients do not get access to the right care at the right time and that we do not prevent the deterioration that has unfortunate consequences. With NHS England, we are looking at commissioning person-centred, co-ordinated care of patients with all neurological long-term conditions. That work has only just started but if it is successful, it could make a huge and critical difference.

Chair

Dr Bateman, we very much welcome your expertise but we have quite a lot to get through. That is fine for the first answer but all panel members need to keep answers a little bit shorter. Anne-Marie and I have a lot to get through.

Mrs Trevelyan

Thank you. Mr Stevens, we heard from the pre-panel—and I certainly found out in my research into this—that Dr Bateman is a bit of a hero in the neurological world. His arrival has been greatly welcomed. There is some talk of changing that. Can you confirm that you will not get rid of the national clinical director for neurology? He is obviously adding value.

Simon Stevens

Yes. I am sure Sir Bruce will want to come in there because these are his shock troops. The fact is that when NHS England was set up, as I understand it, a large number of appointments were made for a period that initially takes place until March next year. At that point, a review has been undertaken to consider how the role of the national clinical directors relates to the strategic clinical networks, the clinical senates and the clinical reference groups. There is quite a labyrinthine structure of clinical advice nationally, even before you get to the leadership that local CCGs are bringing to the party. Sir Bruce, rightly, is looking at that and may want to say a bit more.

Chair

Yes. Sir Bruce, are you reviewing it now or in March?

Sir Bruce Keogh

No, we are reviewing now with the intention of trying to have a slightly more coherent structure in March. The issue that we are trying to address is that we probably have more clinical leadership in the NHS now than we have ever had.

Chair

Anne-Marie Trevelyan’s point is about the clinical lead—Dr David Bateman’s position and the equivalent position.

Sir Bruce Keogh

I need to explain how we get there, sorry. We have CCGs, clinical reference groups that oversee specialised commissioning, and the strategic clinical networks, which you have heard about and are also clinically-led. We are also trying to encourage local leadership through the CCGs and the strategic clinical networks. We currently have 24 national clinical directors. We are trying to focus those on three areas: our corporate priorities; life course things such as maternity, children, and frailty and end-of-life care; and the big killers. At the moment, we do not see that neurology fits specifically into that, but what we do see is a groundswell of support among the strategic clinical networks and the leadership there for promoting the development of neurological services. In fact, David has explained that.

Chair

Sorry, I am not quite clear. Can you give us a hint where you are going with this? You talk about the need for this network. Does that mean individuals’ needs?

Sir Bruce Keogh

At the moment, a hint is that we are not intending to replace the national clinical director for neurology.

Mr Bacon

You say “at the moment”. There is a review going on. Are you saying that next March it might be something different?

Sir Bruce Keogh

Yes.

Mr Bacon

It might. So you might scrap the national clinical directors?

Sir Bruce Keogh

Yes.

Mr Bacon

And do what instead?

Chair

That is what I am not clear about. You have all these various structures. Which one would be the predominant structure?

Sir Bruce Keogh

The strategic clinical networks.

Mr Bacon

But will they have someone in charge of them?

Sir Bruce Keogh

Yes, they do.

Mr Bacon

Who is in charge of them at the moment?

Sir Bruce Keogh

Well, they have come together as a collaborative.

Chair

So all the different strategic clinical networks have come together?

Sir Bruce Keogh

Yes, they have. So we would see the leadership coming through that. We would also see a—

Mr Bacon

I didn’t ask you to describe the leadership; I asked who was in charge.

Sir Bruce Keogh

The collaborative will come together—

Mr Bacon

So there are lots of people in charge. The trouble is, we have found on this Committee in lots of different domains for many years that when lots of people are in charge, it turns out that no one is in charge. The great thing about national clinical directors is that there is a visible person in charge, the emblematic example being Sir Mike Richards, who did a brilliant job. We recommended that you introduce a national clinical director in this area. You refused our recommendation and then did it. It sounds like you are now threatening the future of the national clinical director, without saying clearly what you are going to do instead or who will be in charge.

Sir Bruce Keogh

As the person responsible for bringing in more clinical directors than we have ever had in the NHS, I am not aware of having refused a national clinical director for neurology.

Mr Bacon

You should read the Treasury minute in response to our previous report. We recommended the introduction of a national clinical director for neurology, and the recommendation was turned down by the Government—you obviously didn’t read the Treasury minute. What we are interested in is what you are going to do instead.

Sir Bruce Keogh

Our review is taking place and I will send you a note.

Chair

You talked about bringing everyone together as a collaborative. Does that mean across the different clinical areas?

Sir Bruce Keogh

Yes. Well, there will be a neurology collaborative. They will be specifically focused.

Mrs Trevelyan

This was raised by the pre-panel, and it struck me enormously in the Report: what there is not in neurology is any decent data. It is very, very difficult to get a handle on just how many people suffer from each disease, how it is monitored and how it links through. That was raised in the previous Report, and it would be helpful if you could explain why you have not developed a comprehensive dataset across neurology using, as was indicated, the patient’s unique NHS number, for instance, which tracks them in the many areas of the medical framework that they hit.

Simon Stevens

There is a programme to do exactly that; it’s called care.data. This Committee is very familiar with the troubled birth of that programme, but at the point that care.data comes into being, it will do precisely what you say: it will enable data linkage across settings and enable information for planning and for quality improvement purposes that, at the moment, requires a series of one-off, rather laborious and expensive efforts, which is not a sustainable way of generating good insight into not only these important neurological conditions but a range of other patterns of care as well. We have to get away from the idea that the only way in which we generate information to drive improvement is through these one-off, bespoke exercises. We have had an overly fragmented set of responsibilities between NHS England, the Health and Social Care Information Centre and Public Health England, which is the host body for neurology data and the equivalent cancer data. We have talked in this Committee about the issues with cancer data as well. One of the things we are doing across the NLBs—the national leadership bodies of the NHS—with the Department over the next several months is looking at how to streamline and harmonise that source of intelligence for the health system as a whole. We need to make sure that the benefits are felt for neurology, just as they will be for cancer and other conditions.

Dr David Bateman

I would really welcome and agree with that, but you need to have a Neurology Intelligence Network, because someone needs to understand the data and needs to know how to interpret it and what could be done about it. If you do not have those things, it is not going to mean very much. That is what the Neurology Intelligence Network is about. We had a neurology compendium of data—a big dump of data, the first ever—but it is slowly being turned into intelligence at the moment. Given the resources that we have had, I think we have done pretty well in terms of the kind of data that we have got. We would not want to repeat that one-off data dump. We want to be savvy about what data we get and why, and get some data on a regular basis so that we can see changes and some new data based on what we think is important, but I think if we do not have expertise and intelligence—

Chair

Sorry. I apologise for the funny noise and feedback. It is distracting. It is the ghost of Committee Room 15. Perhaps William Gladstone has risen from the grave.

Dr David Bateman

Can I just make one point? We have appointed a number of new analysts at the Neurology Intelligence Network. It has taken them a long time to understand the neurology framework and the neurology data.

Chair

You say “a long time”. How long?

Dr David Bateman

Well, I don’t know.

Chair

Months or years?

Dr David Bateman

Six months or so. Understanding the neurology domain and the playing field, how neurology services are organised and how to get the right sort of data—

Chair

The problem for us is that we have heard this before.

Dr David Bateman

I look after Michael Jackson, the senior analyst, because I live in Sunderland and he lives in Durham. We work very closely together, and that has been a very fruitful relationship. He has done some fantastic work.

Q63Mrs Trevelyan

Dame Una, perhaps you could expand for us how care.data is going to work and what its time frame is, realistically. I am new here, as I keep saying, but I am rapidly learning that anything to do with IT systems usually falls off a cliff. In the meantime, we have 4 million patients out there with neurological conditions who need looking after and better care, so it would really help if you could explain how it will work and what the time frames look like, so we have some idea of whether this is a realistic proposition in the short term.

Dame Una O'Brien

If I might say so, you are sitting next to one of the country’s experts on this entire matter. There is much that could be said about it. The crucial thing is that we have got to solve this problem generically. What I mean by that is that we have to solve it for all people with all conditions—this ability to link data—so that if you are sitting in a GP’s surgery or a CCG, you can see the totality of the patient population and who is building up risk. Just the other week I had a discussion about diabetes and trying to get people who are pre-diabetic. It is exactly the same issue. To your point about when this will be solved, as you know, the Secretary of State has asked Dame Fiona Caldicott to look independently at the fundamental issue of where the proper arrangement sits for people’s ability to opt out. She is now looking at all the matters related to that, and her report is due at the end of January or early February, I think. We have to get to a proper settled position about how the different elements of data law come together. It is not just health law that applies here; it is also the Data Protection Act. I think we have now understood at a very deep level, following findings from this Committee and the NAO and the work that we have been doing with the Department, what we need to do to solve it. We are determined to solve it, because one of the good outcomes from the spending review is that we now have investment in technology which will enable more effort to go into building the digital framework for this information to be properly exchanged. So I cannot give you precise dates as such, but what I can tell you is that the components are now in place, and we are very determined that we will deliver those changes in this Parliament.

Mrs Trevelyan

In this Parliament—that is, within the next four years. Patients who have motor neurone disease at the moment and have very little support are not going to see the benefit of that. Because you have not yet got it in place, what are we going to do in the near future to make sure that our neurologists out there on the ground have better data, so that they can better support and assess what they are doing to get the best for those patients?

Dame Una O'Brien

If anything, our problem is that we are awash with data, but it is not actually joining up. We have to find a once-and-for-all solution that can do this, legally and technologically. Hopefully, we will do it before 2020—that would be our ambition—but I stress the scale at which we are trying to address this. In respect of what is going on right at the moment—my colleagues in NHS England know more of the detail about this than I do—we have made very good progress on the summary care record at the level of the GP. I think this starts to open up the possibility of greater clarity about people having access to their own record—that is No. 1. Secondly, we might be able to leapfrog this confusion about care plans because, in the summary care record, we now have the ability to assemble the elements of a person’s individual plan. From the point of view of what people actually want—

Chair

When you say “we,” what do you mean?

Dame Una O'Brien

The system.

Chair

So the clinician on the ground can do that?

Dame Una O'Brien

Yes. What that actually means is that, for people with any long-term condition based in the community, you want to be able to see the elements of your plan and your care record. We already have same much nearer term progress on that than this ultimate data linkage, which has to happen and has to be done once and done legally.

Chair

I want to bring in the Comptroller and Auditor General now.

Sir Amyas Morse

Just to go back a little bit. One of the things that is clear is that information and the organisational maturity around it can be very difficult. It sounds that, in the case of neurological conditions, it is considerably worse than for any other conditions. We know that, unfortunately, the systems do not always develop in time; while we are waiting, what is going to be put in place to support people with this condition? At the very least, the paper says that supporting information is needed. Are you any further along on that?

Simon Stevens

Absolutely. Public Health England have not said that they will not continue with an information network for neurology; what they have said is that, given the overall need to generate efficiencies across their own running costs and those of the national leadership bodies as a whole, we have to answer the question of how we get more coherence between the value added that Dr Bateman rightly described as a kind of extra intelligence that comes from people who know the world of neurology and neurological conditions and the fantastic work that the patient groups do versus the grunt labour of assembling routine datasets to answer exam questions that should be generated automatically off the back of the administrative datasets at our disposal. It is about how we keep the value-added piece with a proper neurology focus while standardising and systematising the underlying routine analytical production. That is the question that we want to solve not just in the case of neurology but for other conditions, too, and I think we will get there.

Sir Amyas Morse

The only thing that is absolutely clear is that you are not going to have a clinical lead.

Simon Stevens

As far as the information is concerned, we want something that is at least as good as what we have, and over time is better. If you look at the much-heralded data that is being produced by the Neurology Intelligence Network, a lot of it is pretty exciting, but it is not that exciting. We ought to have at our fingertips the age and each standardised utilisation rates for different neurological conditions. We have some of this coming out of the Intelligence Network, and we have some of this coming out of the NHS atlas of variation, which is a separate but related product. We have the commissioning for value exercise, which is also being done through PHE and NHS England. We have the Right Care process. Frankly, we have too many different—

Chair

A smorgasbord.

Simon Stevens

Yes, and it is time to produce a fixed menu with some à la carte options that are genuine upgrades.

Chair

It sounds as though you have just written the recommendation for our Report.

Mrs Trevelyan

I am looking forward to this magical data world, but in the meantime we have to look after patients. There is one indicator that has been used but, as has been mentioned, it has stopped—the monitoring of epilepsy and patients who have been 12 months without a seizure. That was a really useful indicator, and it helped neurologists to do well, and it helped those patients. Are there other indicators that would be genuinely useful to help improve outcomes and care for sufferers? Why do we not have them?

Dr David Bateman

We are getting them. We have data on emergency admissions for existing long-term neurological conditions, so we know the rates of emergency admissions for epilepsy, for Parkinson’s disease, for motor neurone disease, and for multiple sclerosis. These are for conditions that are already known about, and we would hope to prevent those emergency conditions if we had better care pathways and better support. So we know that for epilepsy, for instance, we are spending £70 million a year on those admissions, which are a very poor utility.

Mrs Trevelyan

But you can tell the differences across England in terms of the better and less good care that is available.

Dr David Bateman

As Simon Stevens has said, if we use the commissioning for value, which I have been supporting enormously, hopefully they are going to produce some CCG neurology packs early next year on their outcomes and costs and various indicators for the emergency admissions for epilepsy and other long-term neurological conditions. They will have their out-patient activity and costs compared with the best and the worst in the country and with their peers. That will give a real opportunity for CCGs to look at their own care pathways and to begin to think how they can improve these care pathways. That will be of great importance, but critical to that is a message that the CCGs hopefully will get with those packages that this is a real opportunity; we can commission these care pathways on our local population base and we can try and improve them. That has been the major problem with neurology services. There has not been a lever and there has not been the data to enable that process to happen. We have had a problem with commissioning responsibilities that hopefully NHS England are involved in addressing.

Mrs Trevelyan

Sir Bruce, with that information, who will have oversight to look at this and make sure that if there is poor practice, the CCGs will be asked to improve what they do if they are not focusing on the neurological illnesses?

Sir Bruce Keogh

I think that there will be a variety of places where that sort of information will get some oxygen. The first is the strategic clinical networks. The second, which we have quite a lot of hope for, is in the programme called Right Care where we look at variation across CCGs in a number of different areas. We identify those that are performing well and less well. We develop specialised admission packs for them. We go in and help the CCGs that are not performing well. That programme is just starting. It is going to be put in place in other areas. It is all very promising. I think they are starting on neurology at the beginning of April.

Dr David Bateman

Yes, as I was saying, that is the commissioning for value packs that I am keen on and supportive of. I am optimistic that that is going to be of enormous help.

Chair

Can I just be clear, before Anne-Marie carries on, about where responsibility lies. Sir Bruce, when you talk about “we”, are you talking about the Department of Health?

Sir Bruce Keogh

No, NHS England.

Chair

So if we come back to this, Simon Stevens, it is you and your team that will be responsible for making sure there is more clarity and common practice across CCGs.

Simon Stevens

Yes.

Chair

We just like to know who is in charge. It is you; that is all I need to know.

Simon Stevens

I said that without moving my lips.

Mrs Trevelyan

This is most encouraging, but my cynicism is starting to kick in on a regular basis with all big new projects. One of the problems that has been highlighted not only by our pre-panel but by a variety of people in the profession is that there just are not enough neurologists to pick up the workload. Is there anything going on to encourage more young medical students to go into neurology across the piece, so that the CCG cannot say, “The nearest neurological centre is 50 miles away, so realistically we cannot access that for our patients”? What are you doing to improve that outcome so that you can support this excellent-sounding work?

Simon Stevens

The first thing to say is that, over the course of the past decade, there has been an increase of about 60% in the number of whole-time equivalent neurologists in the NHS. This is a growing specialty that has coincided with a substantial increase in the investment that the National Health Service has been making in those neurological conditions. It is up by over 4% in cash terms since 2006-07. The proportion of CCG spending on neurological conditions has gone up by a quarter over the past several years.

Chair

Sorry, when you say several years—

Simon Stevens

It is in the NAO Report. From 2009 to 2012-13, there was an increase of a quarter in the share of their spending on such conditions. Looking out over the next five years, the number of new neurologists that there will be is a function of those who are already in the training pipeline, given the length of time it takes to produce extra neurologists. The numbers have been going up by about 4% to 5% a year. Of course, like every specialty, people would like to have more, but we are hunting within a fixed pool of extra medical graduates and consultant trainees, so the realistic answer for this Committee is that we are unlikely to see an acceleration in the growth rate for neurologists over the next four or five years. That is an unfortunate fact, given the numbers in training and the funding available over the next five-year period.

Mrs Trevelyan

Am I right in thinking that there’s about to be a cliff edge drop-off of those nearing retirement in the sector?

Simon Stevens

I’m not sure about a cliff edge, but there was a big increase in the numbers at the time that stroke services were improved some years ago. Some of those folks are now coming up to retirement. In my opinion—I obviously defer to Bruce and David on this—neurology is a specialty in transition, and there are pushes and pulls in terms of localisation versus centralisation. The push to localisation is the obvious benefit of having more readily accessible out-patient services. The pull towards concentration is the benefit of co-locating acute neurology with stroke care and full seven-day services to deal with the quality effects that we can see showing up in in-patient services. What that means is that it is too simplistic to say that this is all just about distributing more neurologists and out-patients in every footprint where the health service operates. There is also a requirement for some of the extra neurologists we are producing to beef up the multidisciplinary teams in some of the acute in-patient settings. There is no straightforward answer or one size that fits all. Interesting new models of experimentation are under way—I mentioned the work that the Walton centre for neurology in the north-west is doing in Merseyside and Cheshire. It is one of our acute care vanguard programmes and is looking at trying to square that circle. I would say that the Association of British Neurologists and others have been innovative in thinking about some of this, including telemedicine outreach in some situations. Those are the kinds of contours of the debate we are having.

Mrs Trevelyan

That is very helpful. I would be interested to know whether Dr David Bateman has the same view on the numbers, because different messages have come through to me.

Dr David Bateman

In England, there are only 25 neuroscience centres. Clearly, they are not sufficient to provide an acute neurology and an acute stroke service for England as a whole, so there have got to be a number of other places that are designated as acute neuro centres, if you like, and have services for acute neurology conditions and acute stroke conditions. I have been trying to propose aligning neurology and stroke more closely, because 50% of people who are admitted with a suspected stroke have some other acute neurology condition. We need to get them to work together, but it is not sufficient for it to be done in centres. We need to increase the provision of acute neurology care in DGHs. That is fundamental. At the moment, we have a long-standing manpower problem. I have not had the time or the resources to solve it. The ABN has very kindly tried to achieve that, but, as it said, we need a significant increase in the number of neurologists. Recruitment in stroke is difficult now, but it is not into neurology, so I think that is a way of dealing with it. If we want seven-day services, which I fully support, and seven-day acute neurology services, we have got to go down to a provision model that is in between what Simon Stevens is saying and what we have currently got. We have got to try to reorganise things. We have got to work smartly and try to get other people to do some of the things that neurologists do. That is the whole point of the NHS England collaborative commissioning framework for long-term conditions. If we can get that work well done, then it can be done by other people in a much more effective way.

Mr Bacon

On this point about numbers, Dr Bateman, you said that you would ideally like 50%, which would give you roughly another 325 over the next five years, taking you up to 975. Mr Stevens says that you are going to get 5% growth, which would give you half of that: 162. Do you get the sense that this is being placed as a high priority by the NHS, or is it just part of the generality of growth in NHS spending?

Dr David Bateman

At the moment, the neurology numbers are determined by the numbers of training posts. They have not been increased. The ABN kindly went to Health Education England and tried to persuade them to increase the numbers by illustrating the additional work and problems that we have got coping with the workload as it currently is, and with the desire to improve services that, by comparison with Europe and a lot of the rest of the world, are relatively poor. We have not been successful in that regard.

Mr Bacon

What I do not understand, Mr Stevens, is that the answer you gave made it sound like, “Yes, well, there’ll be a few more neurologists,” but it doesn’t sound like there is any push for this, and Dr Paul Morrish said it was not even on the radar.

Simon Stevens

You say you don’t understand, but I am sure you actually do. This is a zero sum set of choices that Health Education England has to make when—

Mr Bacon

I don’t understand that at all. That was going to be my point. It makes it sound like there is fixed number—

Simon Stevens

There is. There is a fixed number of medical graduates coming out of British medical schools together with some international—

Mr Bacon

Therein lies the rub. It is not a fixed number. We were going to give you £8 billion extra in the comprehensive spending review, although I blinked and now it is £10 billion. So a lot more money is going into the NHS, and I know you have got lots of things that you could spend it on, but this is a relatively small amount of money compared with the totality of the extra you are getting, never mind the extra you could get through greater efficiency.

Simon Stevens

I would be delighted to run through the numbers with you either in this Committee or outside it and show you that that figure does not include provision for a huge increase in medical school education and specialist training in this country. If we were to be spending at the level of, say, France or Germany, then we would be able to afford the kinds of medical staffing ratios that those countries have. To underline this point, the reason this is a zero sum choice is, sitting in this Committee on prior occasions—no doubt we will do so in the future—we have talked about cancer services and the need to expand the number of radiotherapists and medical oncologists. We have talked about GP services, the relative underinvestment in GPs, with the growth rate in consultants having been three times faster than GPs.

Chair

We get the point—

Simon Stevens

This is actually a set of choices. We do want more neurology services and we do want more consultant neurologists, but to pretend that that is not a choice that has offsetting consequences for other areas that we also want to improve in the NHS would be an unfair proposition.

Chair

Following on from that, Simon Stevens and Dr David Bateman, both of you have talked about staffing issues. Dr Bateman, you talked about other professions coming into the teams. If not neurologists—we recognise that in the short term you cannot conjure them from nowhere, and even with a major overseas recruitment it would be quite challenging—what other professions could make a difference to the outcomes for people with long-term neurological conditions? Whereabouts should that be in the system—at primary care level or in acute hospitals?

Simon Stevens

Dr Bateman made a very important point earlier, which is that quite a large part of what a number of our neurologists are doing is looking after stroke conditions, but there are other specialities that are also involved in stroke care, so there is a discussion about what is the disciplinary mix there. He also made the point that quite a lot of the conditions that neurologists are dealing with in their out-patient clinics could potentially be managed by other medical disciplines. That is the conversation that the various parts of the country who are redesigning their neurology services are focusing on hard. And there is also the opportunity, frankly, to put more effort into new onset conditions when they arise so as to improve people’s outcomes subsequently and potentially reduce the burden on the neurology services downstream. A good example would be the variation in epilepsy rates and the proportion of people who are admitted for epilepsy care on an unplanned basis. One recommendation for dealing with that is that, for example, parts of the country might look at rapid-access first-seizure clinics, so that people get that care early on and are unlikely to need the same degree of ongoing follow-up support.

Chair

So it is the pathways as well as staff.

Simon Stevens

There are pathways and there is staffing. By the way, I would also make the point about the important role that specialist nurses play in the care of people with neurological conditions. It is not all doom and gloom.

Chair

Dr Bateman, do you have anything to add to that? Who did you have in mind?

Dr David Bateman

I agree. We need to make sure that neurologists don’t do the things that they don’t need to do, but that means that other people have to be available to do them. Specialist nurses have clearly made a fantastic difference to the management of many long-term neurology conditions. They do an enormous amount of work and save a lot of consultant neurology time. Provided that there are enough specialist nurses and they are tied to and integrated with a team that is working effectively and well in the community—NHS England is trying to scope a commissioning model to try to develop that service, of which I am fully supportive—I think that that will make a difference. To return to the point about neurologists, at the moment, according to data from the ABN, something like between 30% and 50% of new consultant neurology posts that are advertised are not being appointed because we just don’t have the neurology specialist trainees to fill them. We have a need, and trusts have determined that there is a need for this work to be done, but we cannot provide it.

Chair

I suppose this should be addressed to Simon Stevens: has there been any attempt to use overseas recruitment to fill these positions that Dr Bateman says cannot be filled?

Simon Stevens

Individual trusts have done that from time to time, but I do not have a figure to hand.

Chair

So there is no plan in NHS England to do that. For the record, I see Sir Bruce shaking his head. If there are vacancies that cannot be filled, for all that you have just explained to us the challenges and other options, those are still vacant posts.

Simon Stevens

It is something that potentially should be looked at. I don’t know whether this specialty is particularly amenable to that, but certainly in psychiatry, a number of European psychiatrists are providing fantastic care.

Chair

Just to be really clear: there has been no attempt.

Simon Stevens

Well, NHS England is not charged with and does not run an international recruitment programme. That is obviously for employers and for trusts.

Chair

But given that there is a gap, and given what we have just heard from Dr Bateman about posts that are not filled—

Simon Stevens

In principle, I am all in favour of international recruitment of high-quality candidates.

Chair

So there is no bar by NHS England to stop that happening.

Simon Stevens

No, far from it. In fact, as you know, we sought to ensure that there were not arbitrary restrictions on the NHS’s ability to recruit from outside the EU.

Chair

It is helpful to have that on record, given that we have heard quite a bit about key staff shortages. Dame Una, when we were discussing data earlier you said you could not give dates and wanted a “once and for all solution”. I suspect that that sent a bit of a chill down the spine of most Committee members, because once and for all big solutions do not have a great record in the NHS. You talked about getting a proper data solution before 2020. Why is it always going to be in the future? These problems and issues around data protection have been around for a long time. We have had a number of hearings recently—I think you are our most frequent visitor this term—and we keep hearing about data issues. Why is it still not solved? What is the sticking point that is preventing GPs from sharing data with other clinicians and generally getting this right? It is constantly a problem.

Dame Una O'Brien

Let me be clear that there is no bar to the sharing of data around the care of an individual patient. Nobody should have any worry that individual clinicians cannot see the data, because the person’s care is at stake. That is really important.

Chair

We get that; it is just the issue of the aggregated data.

Dame Una O'Brien

My view is that one of the reasons why it has been hard to solve this problem is that the pace at which the technology is moving, and what the technology enables us to do, open up new possibilities about what could be done with the data that precede when even the legislation was put together. You are now potentially able to put together vast amounts of healthcare data to, for example, drive a diagnostic model. That was never understood or known about when the original legislation was compiled around data protection. This is why it is complicated, because we have duties to protect the individual information, and we have a mounting number of possibilities of what could be done with that data.

Chair

I am not trying to cut you short, but I think we have got that point. What is the barrier? We are going to make recommendations, which we will make partly to you, but we can also make to other people. Is there a magic thing that could happen that would make this possible, or is it inertia in the system? That is the impression we get sometimes.

Dame Una O'Brien

It is certainly not inertia.

Chair

So what is the magic thing? What is the solution?

Dame Una O'Brien

It is understanding precisely how far we could amalgamate data for, let us say, commissioning purposes without changing the law as it stands, or whether significant major legislation will be required to do it. That is the question that we are working on currently in the Department of Health. The precise task that Dame Fiona Caldicott is now looking at is whether, within the existing legislative framework, we could have a simpler choice for patients, so beyond the sharing of data for their personal care, what is the level of permission they are prepared to give, and should that be an opt in or an opt out? The question really lies in how far we can do that within the existing legislation and to what extent the Government would need to bring forward something much more fundamental.

Chair

May I push you on that? You say you cannot give dates, but you have people—

Dame Una O'Brien

Dame Fiona’s report will be completed by the end of January. We will consider that report in the light of other analysis that is being undertaken. From my understanding, no group of Ministers is more determined to sort this out than the group that we have at the moment.

Chair

That is helpful, because it gives us at least the end of January as a starting point to think about. I just wanted to touch on the tariffs issue, and I think that is you, Simon Stevens. We heard from Dr Morrish about the “bizarre tariffs”, to use his phrase. He came up with this having just done an FOI inquiry, so it is out there that some hospitals are being paid £600 for a patient and some £200. Does that accord with your experience and, if so, what are you doing about it? It seems a bit crazy, frankly.

Simon Stevens

The split between specialised commissioning of neurology services and CCG commissioning of neurology services might have had a logic at its inception, but it has also created a fragmentation, particularly when it comes to out-patient services. That is the reason why we are making a change from next year such that all neurology out-patient services that arise from a referral from a GP are locally commissioned by CCGs, so that we have more holistic planning and commissioning back into the system for those neurology services. In terms of the particular pricing of individual tariff components, obviously there is a consultation that takes place annually on that. Monitor then takes account of the responses and will promulgate a set of prices for consultation under section 118 of the 2012 Act in due course, to go live for April. Those are continually improved upon—

Chair

So is the simple answer to my question is that the changes that you talk about will stop this variation?

Simon Stevens

No, the changes that I have talked about in terms of the holistic commissioning will make it easier to have a total view as to what out-patient services should look like for the people living in a given constituency or CCG. In terms of how individual parts of neurology services are priced, that is a responsibility for Monitor under the tariff and is subject to consultation, and they will set out what the plan is for 2016.

Chair

So why is it so out of kilter now? Why is it so different now?

Simon Stevens

Could you say a little more about how it is out of kilter?

Chair

Unless you disagree with what Dr Morrish said, in which case make it clear—

Simon Stevens

I think I would need to see a little more detail to give you a proper response, but I would be happy to have a look.

Chair

It seems that there is a variation—a very wide variation—in the amount a hospital gets for treating somebody with a neurological condition, which presumably, as you have hinted at, wraps in other things in some cases, but not in others. Was that news to you when Dr Morrish said it, or were you aware of this anyway? [Interruption.] Oh, forgive me; you were not in the room when Dr Morrish gave his evidence. I think I have explained what his evidence was, so is that news to you?

Simon Stevens

If it is a consequence of the fact that the status quo ante is that if you are referred to a neurology out-patient appointment at one of the 25 specialist centres by your GP, at the moment that is captured in the specialised commissioning programme. If you are referred by your GP to a neurology out-patient appointment in one of the non-specialised centres, that is funded by your local CCG. That is a kind of dichotomy that I don’t think makes a lot of sense. I don’t know whether dealing with it will create the opportunity also to look at how elements of neurology services are priced per the tariff, but I will be happy to have a look at Dr Morrish’s proposition in more detail.

Chair

Dr Bateman, you look like you have something to say on this.

Dr David Bateman

The tariffs vary quite considerably. I work in Sunderland and my neighbours are Newcastle and South Tees, and for exactly the same work, they charge 25% more. For the same volume of work, we could appoint two more neurologists, so it makes a big difference.

Simon Stevens

But Dr Bateman, doesn’t that exemplify the point I’m making, which is that South Tees and Newcastle are two of the 25 designated neurology specialist centres—

Dr David Bateman

Yes, exactly. But I’m talking about—

Chair

Sorry, one at a time, or we will get completely lost as to what is going on.

Simon Stevens

At the moment, an out-patient appointment in Sunderland is classified differently from an out-patient appointment at the RVI, the Freeman or James Cook, simply by virtue of the other things that are going on in their neurosciences service and not by virtue of the clinical content of the out-patient consultation. We will change that from April.

Chair

Does that accord with your experience, Dr Bateman?

Dr David Bateman

The majority of activity that is going on in South Tees and in Newcastle is common, general neurology conditions. There has been a major problem with the designation of specialised commissioning. I think people tend to see “specialised” and “specialist” as meaning the same thing. In particular, CCGs have tended to interpret that all neurology is commissioned by a specialised route, via NHS England, whereas in fact the majority of neurology is common neurology conditions such as epilepsy, multiple sclerosis and Parkinson’s disease. What goes on in a neuroscience centre that is specialised is epilepsy surgery assessments, Parkinson’s disease surgery assessments and specialised diagnosis of rare neuromuscular conditions. The majority of other work is common general neurology, but the commissioning framework has never caught up with the changes in how neurology services are developed.

Simon Stevens

Until April 2016—

Chair

Ah, it’s always in the future, but at least it’s in the future. We will grab hold of that.

Dr David Bateman

Can I just make another point about that? That will only catch up in regard to general practitioner referrals. A lot of out-patient neurology referrals are from other clinicians to whom people have been mistakenly referred, such as a rheumatologist, an orthopaedic surgeon or an ophthalmologist, and it will not deal with the very problems that my colleagues have discussed and that I am trying to solve, which are how we improve the care pathways for people with acute seizures who are being admitted to hospital and how we improve the care pathways for those with acute headaches who are being admitted to hospital—those kinds of things. It will not resolve those sorts of issues.

Chair

I have one more before I shall pass over to Dr John Pugh, and then there will perhaps be a few more questions at the end. One of the issues that came through quite a lot in the evidence—I guess, Dame Una and Simon Stevens, I refer this to you—is the lack of good join-up with social care for people with neurological conditions. A very high percentage of people with neurological conditions receive social care but, again, data is a problem, so we do not know the figures exactly. Dame Una, what is the Department of Health doing to try to improve that, because if it was done well, it could reduce the number of acute admissions?

Dame Una O'Brien

All I can do is to restate what I have talked to the Committee about before, which is that this problem has to be addressed generically and it has to be addressed in the following ways. First, we need—the Government are committed to this—greater integration of health and social care. That is absolutely fundamental. Secondly, we need more multispecialty teams working together in the community. Some of the examples of that we are now seeing through the vanguard projects are beginning to show that if you bring social care and healthcare people together early on, they can provide a better service. The third thing—particularly, but not exclusively, in the case of people with certain severe long-term neurological conditions—is that we need an opportunity for more people to have a personal health budget that they can combine with their social care budget, putting them in charge of organising their care and support in the way that they want. The Government will set out a very clear expectation on personal health budgets in the new mandate for NHS England. Those are three interventions that are important, because they apply across the board, and that is some of the centrality of what is important at the moment. We are embarking on a set of changes that should be of benefit to people with a range of different conditions, and we will make more progress if we do it at scale than if we try to do it specifically around each individual specialty.

Chair

This is all great, except that local authority social care budgets have been cut by at least 16% on average, depending on the local authority, over the past four or five years. There is less money available, and once again we are expecting social care to pick up these issues that could save the NHS money. Laura Brackwell wants to come in on this point to clarify a figure.

Laura Brackwell

You talked about personal health budgets and putting that in the mandate. At the moment, the mandate includes an objective for NHS England to ensure that everyone with a long-term condition is offered a personal care plan, yet we see that only 11% of people with neurological conditions have a personal care plan. I was interested to know why it would be different for personal health budgets when it did not seem to be working effectively for personal care plans.

Dame Una O'Brien

These are two completely different things. We can talk about the personal care plan—

Chair

But if we are talking about integrated care, they become the same thing, don’t they?

Dame Una O'Brien

Most people who are in receipt of social care, particularly if they are adults under 65, are being offered, or should be offered—we have made big progress on this—a personal social care budget if they are eligible for help. When people are eligible for healthcare services, we want, within certain confines—this has been carefully piloted—to be able to give them that source of money as well, so that they can organise care in the way they want. We have seen far too many examples of people having different carers turn up at different times of the day, with care built not around their lives, but the convenience of the provider. A combined budget enables someone to have more control over that. They are different things.

Laura Brackwell

I was interested in the mandate as a mechanism for holding NHS England to account to achieve something. What is the Department doing, given that NHS England is not meeting that objective around personal care plans?

Dame Una O'Brien

If we move on from personal health budgets to personal care plans, part of the issue is how we are measuring things, because I do not think we are getting information that is telling us about the totality of a person’s interaction with a general practitioner. We are asking the question in a very particular way with patients, and because they do not have a document called “personal care plan”, they think they do not have one. I think there is an issue there that we need to explore further, and we are looking at what should be a better range of questions in the GP survey, but I do accept—I think this came up in the earlier evidence—that there is a sort of cultural problem around what is a plan and when someone knows that they have one that we have to address. That is not just in neurological conditions, but in long-term conditions more generally.

Chair

I can hear that there may be some truth in there, but it is in danger of sounding like patients do not know what they are getting. Most patients would know if they had a care plan.

Dame Una O'Brien

They do know what they are getting, but they may not necessarily know that it is called a care plan. It may not be designated as that. In the NAO Report and the evidence that you quote from the Neurological Alliance, when people are asked about their care, there is a very big gap between the much higher proportion of people saying, “Yes, I am getting care and I am satisfied with my care”, and what people say about care plans. That leads me to think that there is a problem in how the question is structured in the survey.

Chair

I think we are possibly getting into surmise territory there. I will throw to Dr John Pugh, and then any other colleagues who want to can come in before we wrap up.

John Pugh

Is the NAO Report signed off with the agreement of the Department and NHS England? Do you both sign it off?

Simon Stevens

On the factual accuracy.

John Pugh

On accuracy, okay.

Simon Stevens

It also has some judgments that—

John Pugh

The general theme is that there is a problem with the fragmentary character of commissioning. It is regarded as “continued confusion” by the Neurological Alliance, and I do not think anything said here would dissuade us otherwise, but one of Dame Una’s remarks nearly made Mr Phillips and I fall off our seats. She suggested earlier that you are awash with data. I have read the Report fairly carefully. There may be confusion here, where you have perhaps confused patient data, which is mentioned in the care.data programme that Mr Stevens has spoken about—this gap that will be filled—with data about the commissioning process, which seem to be singularly lacking in some cases. I just draw your attention to paragraph 1.3, which says that “NHS England does not know how many people have a neurological condition”. Paragraph 2.7 says: “NHS England does not hold information centrally on how much funding is available for strategic clinical network activity for neurological conditions specifically.” When you turn the page, paragraph 2.8 says: “NHS England does not hold information on how many staff support the different networks.” As you press on, paragraph 2.24 says: “The Department and NHS England do not hold data on the content of joint strategic needs assessments”. Mr Stevens has put some emphasis on the holistic local commissioning, but you clearly are going to need data there. Paragraph 2.26 says: “NHS England does not hold information on the extent of joint commissioning of neurological services.” You are not exactly awash with data when it comes to the actual process of commissioning and delivering the service, which is what counts. We agree on that. Whose fault do you think that is? What can we do to rectify it?

Simon Stevens

That implies that you think it is wrong that we do not, and I am not sure that I would agree with that in each case.

John Pugh

You don’t think it is wrong?

Simon Stevens

No, I don’t. To say that we do not hold information locally on every joint strategic needs assessment when all that is out there on everybody’s website—what does it mean to say we do not hold it? It means we do not do a print-out of stuff that is on the internet and stick it in a filing cabinet somewhere. What does it mean to say that we do not have the share of time spent by people working on the strategic clinical network? It means we have not sent them an Excel spreadsheet and told them to do a time and motion study.

Chair

Mr Stevens, this is an agreed Report.

John Pugh

May I pursue that point? If you do have the data—if they are really not a problem for you and they are available—have you looked at them? It is illustrated in the document that what different areas do is very fragmentary. Have you looked at the data in a way that gives you assurance that the holistic local commissioning that you have identified as the way forward can be done and will be delivered effectively?

Simon Stevens

I think my predecessors did not agree with the recommendation that JSNA monitoring was, indeed, an appropriate route to bringing about integrated commissioning locally, so the fact that that is not being collated nationally would probably not be a surprise.

John Pugh

But if you are recommending that we do more of it, you have to have some view about how it is going at the moment, do you not?

Simon Stevens

Yes, but not through that mechanism. That mechanism was talked about at the time, three years ago, but it is not actually the principal route by which we are going to get person-centred care for people in this country. We are going to get that through stronger holistic primary care. We are going to get that through the kind of integrated care delivery that Dame Una was talking about. We are going to get that through the integrated personal commissioning of budgets coming together. We are going to get that through the sort of work that the vanguards are doing on the back of the “Five Year Forward View”. Frankly, we have moved on quite a long way from the idea that it is just about bulldog clips around local plans and the scrutiny thereof.

John Pugh

May I invite Sir Bruce to say something? You mentioned something called Right Care earlier on. Is that an attempt to get a grip on what is happening in the local commissioning picture?

Sir Bruce Keogh

Yes, it is—precisely. The whole aim of Right Care is to understand what commissioning for value is, which areas are doing it best and—

John Pugh

Is that separate from looking at the joint commissioning plans?

Sir Bruce Keogh

Yes. This is something that is run out of NHS England, with a view to improving the quality of commissioning at CCG level.

Simon Stevens

Basically, what we are trying to do is—we all know that there is huge practice pattern variation across the NHS, as there is across every healthcare system. We have had it in the Intelligence Network reports. We have had it in the Atlas of Variation and so on. We are trying to put together a single dashboard for each CCG that we can then use to support and hold them to account for driving change over the next five years. What’s more, we have got some pretty big pound note signs off the back of it that we need as part of the contribution to efficiency over the next five years. This is not just about improving quality; it is also about how we are going to create value to give us the headroom to absorb the extra patients we are going to need to treat, and demand. So this is moving from an amateur minority sport into the mainstream, and it is central to the task of effective commissioning in the NHS.

John Pugh

So joint commissioning aside, do I take that as a general rebuttal of the point that I have made that there is not enough information available on commissioning? Point 2.26 says: “NHS England does not hold information on the extent of joint commissioning of neurological services.” Is that not a problem? You are saying it is not.

Simon Stevens

I do not think that in its own right it is necessarily a problem, no.

John Pugh

Oh.

Dr David Bateman

Let me just help out on one thing. As Bruce was saying, we have only just now got enough information to fill commissioning for value packs with neurological data. Next year will be the first opportunity that we have had to deliver these to CCGs, to try to get them interested in and thinking about how much money is being spent on care for their particular CCG and how it compares with how things are being done. I think it there is a fantastic opportunity to improve that, if they are supported by the clinical networks, and the CCGs realise that their commissioning can make a big difference.

Chair

One of the big gaps for me—you talked earlier, and again just now, about getting CCGs to do a better job. Two questions arise from that for me. Why is it so patchy, and do you as the clinical lead have the power and influence to push change? I am not saying that all lies at your door, but you are the lead. You seem positive that you can achieve that, but how? Why is it so patchy, and how can—

Dr David Bateman

This is one of the ways—by using the clinical networks to meet the CCGs with the commissioning for value packs, and organising that work to go on all together. I think that needs a bit more mandate than I—

Chair

But the variation is so wide. I won’t repeat all the figures, but—

Dr David Bateman

Yes, it is huge. We have now got the data, and that can save an enormous amount of money, and at the same time improve care.

Chair

So basically, the argument to CCGs is, “If you do this, you will save money in the long term”?

Dr David Bateman

It is a win-win situation.

Chair

But actually, some of the problems with this are picked up by social care. Someone at the acute end, health-wise, is picked up, but if someone is living with a long-term condition and it is not going well, social services support will pick that up, so the cost can fall—part of it, anyway—elsewhere. Is that something that gets picked up?

Dr David Bateman

Of course, if your long-term condition is not being managed well, you are going to need more care and you will go into a home sooner. That is the whole point of why NHS England is scoping this new commissioning framework to provide better care in the community.

Chair

But isn’t the danger there that CCGs will not see any of the benefit of that? If I had a long-term neurological condition that was not well managed and I ended up in a care home funded by the local authority, the NHS would not have to worry about the cost of that. Dame Una, you are shaking your head.

Dame Una O'Brien

Absolutely not. I would say that if a person is in a care home as a result of poor care, that is not a success for the NHS.

Chair

Clearly, it is not a success—

Dame Una O'Brien

Furthermore, if we are looking at it purely from the point of view of cost, of course that person continues to be completely eligible for health care. I refute the idea behind your question that a CCG somehow has an incentive not to care for people.

Chair

I don’t mean it has a positive incentive. I do not mean for a moment that any clinician would willingly and knowingly not care for somebody, but the point is that the cost does not fall on the commissioners. We have talked often in this Committee about cost shunting. The cost of a problem is not always picked up by the organisation that could save the money to the system by investing up front. We have seen that there is a very wide variation in CCG commissioning of neurological services. Dr Bateman has talked about saving money and convincing CCGs partly because of the savings, but they do not actually reap the costs if they do not do it, so they will not see the savings quite as obviously as he suggests.

Dame Una O'Brien

This is precisely why we need the integration that I have described. It should be lose-lose for the CCG and social care if they do not come together. It needs to be win-win for the patient and the public that they work together.

Chair

Is that not one of the problems, though? We heard loud and clear from our first panel, in a lot of evidence and in the NAO Report that the Department and NHS England do not really know how many people have long-term neurological conditions in this country. There is no joining-up between those getting social care packages and those with neurological conditions, so it is very difficult to measure the impact of some of the things that you have been talking about, because you do not really know.

Simon Stevens

We know, obviously, how many cases of illness have been treated; we know how many unique patients are being treated on the back of that. We will have a much better picture of the pattern of care not just for neurological conditions, but for the totality of what we are doing when we have electronic health records embedded in hospitals that match the kind of data that are available from general practice and we can link the two. Until we have that, we can do the odd one-off survey, but we are not actually on a longitudinal basis going to have that kind of insight. That is why the investment in information and the analysis that goes off the back of it is not just a nice thing to have in its own right, but a foundational asset for improvement that we want to see.

Chair

So how can you plan intelligently in the meantime? We hear a lot about what is going to happen, but right here, right now, how can you convince us as a Committee and the people out there who have an interest in this that you are planning intelligently to make sure—

Simon Stevens

We are planning with the tools that we have. If we had a different set of tools available to us right now, we would be able to act differently, but—

Chair

You can be saving some of the £70 million—

Simon Stevens

If you talk to the CCGs in your areas and ask them the question: “Would you welcome another bespoke piece of information collection, a data survey, a form to fill in and the returns sent back to NHS England nationally to help you improve the quality of your commissioning of neurology services?” I think we can all predict the answer that they would give you.

Chair

Which means that we have got to make sure that data collection is easier—

Simon Stevens

Precisely, which therefore means that it has to be automatic, off the back of the—

Chair

I think you all know that it is likely, without pre-empting the Committee, that we will be making some recommendation around data in our report.

Simon Stevens

To will the end is to will the means, therefore by what mechanism and over what timescale? Otherwise it is just a—

Chair

Absolutely. All our recommendations, which you will be picking up, have timescales attached.

Simon Stevens

And price tags?

Chair

Well, we are thinking about that too. That is another idea for us—perhaps the NAO can take that. Seriously, we recognise that we need to make realistic recommendations, but, please, we keep hearing that things will get better on data, we keep hearing that it will happen, but it hasn’t yet. I have two quick points, because I am aware that time is marching on. According to the Report, 58% of people with neurological conditions experience problems or delays in accessing treatment. Perhaps, Dr David Bateman, you could give us a brief summary of why you think the figure is that high. Earlier, you or some of your colleagues touched on GPs. Again, is there a couple of easy things to do, or is it a very complicated picture?

Dr David Bateman

Obviously there are delays in out-patient appointments and there is unavailability of urgent clinics. If we could transfer more out-patient work into urgent clinics, we could move those appropriate patients forward and—

Chair

So it is down to the number of neurologists, partly?

Dr David Bateman

Partly, obviously. But there are ways of improving things with the numbers we have got. We have already talked at length about in-patient acute care. I think we have to look at ways of deciding which DGHs should be acute neurology and acute stroke centres, if you see what I mean, and place a neurologist there so that they can run urgent clinics for people with acute seizures and people with acute headaches, and prevent them from being admitted. We have been able to show that, just by running an urgent clinic where the A&E people can get somebody seen within a week in our hospital in Sunderland, we have reduced the number of admissions for acute headache by 60%[7]. Those sorts of things can make a big difference.

Chair

That is very helpful. Dame Una, when the Neurological Alliance did its survey, it showed that the services for commissioning neurological support or treating people with neurological conditions are often not very joined up. In our last report—we touched on this briefly earlier—we made a recommendation on joint commissioning to try and improve that position. You didn’t accept that recommendation. I wonder whether you could explain why not, because we are very keen that our recommendations are realistic and taken up by the Department. It might help us in our next report.

Dame Una O'Brien

Just as a general reflection, it is very interesting to come back and recall the time when we were at the last hearing, when you made the recommendation, because actually the legislation had not yet been passed and an awful lot has happened in that time. The legislation has gone through Parliament, it was amended and then we had the whole period of implementation, and now we have had NHS England, including more than a year under Simon Stevens’s leadership, driving forward the commissioning improvement agenda. So it is a challenge when crafting these recommendations that they find a fixed point that we can link back to in years to come, because actually, now I can see that some of the expectations—the way we were thinking about the JSNAs at the time—have been superseded by the commissioning development work of NHS England, and the role we now see for clinical commissioning groups.

Chair

In summary, that is quite a long answer to the question of why didn’t you accept our previous recommendation.

Dame Una O'Brien

I honestly think that we never saw JSNAs as being that detailed, condition-specific, nor mandating that from the centre. The whole point of the JSNA was that it should be for the local commissioning organisation, involving all the different patient groups and other perspectives in a locality, to come together and set their local priorities; so the national priorities are set once through the mandate and local priorities are set through each JSNA. It would have been a sort of contradiction to then require things to go into what was effectively a local priority setting.

Q127Chair

We have heard quite clearly from Dr Bateman and from the previous panel that there are some good things that we—or the profession, those expert in this area—know work. They know that they deliver patients improved quality of life. There is a tension, we know, between local commissioning; but when the Department knows something works, or NHS England does, how do you make sure that that really gets out there so that all local providers are doing a good job?

Simon Stevens

It is a combination of things, isn’t it? First, we have NICE guidelines and other advice standards for the service. Secondly, we have a CQC process. Thirdly, we have the new Right Care scrutiny process that Bruce has described. Fourthly, as the Secretary of State has set out, we will be publishing a new CCG scorecard with a balanced assessment of how well they are doing, and ranking them on it.

Chair

When they are not doing well, what do you do? That is the key thing.

Simon Stevens

We will have a special measures intervention regime, in the same way that applies to providers. That is being set out by Jeremy Hunt.

Chair

David Bateman, will that give strength to your hand or, if you aren’t there in March, the hand of whatever body or individual succeeds you?

Dr David Bateman

I think those things are obviously going to be very helpful. The most helpful thing will be CCGs, which really hold the key—and if they have more information and more understanding of how their role and their commissioning for their particular population can make that difference—and I think that changes are taking place in the commissioning process to help support that and help improve it. So I think we have got to try to integrate all these things—commissioning for value, clinical networks, the neurologists on the ground. We have got to get them working with the CCGs to try to work out together how we can improve these pathways.

Chair

I think we have covered quite a lot of ground. There is probably more that we could cover on an issue that is as important to so many people as this. I think it is just worth going back to that figure that you gave us earlier, Dr David Bateman, about the £70 a million year it costs for emergency admissions for epilepsy alone, and reflecting on the point made in the Report that 10% of neurological patients are readmitted as an emergency within 30 days of discharge. There is a very big cost to the taxpayer of getting this wrong, let alone the cost to people’s lives. I don’t think I need to tell you that.

Simon Stevens

No. By way of context it is also worth pointing out, of course, that that emergency readmission rate for neurological conditions is lower than it is for other conditions, and, indeed, the rate of increase in emergency admissions for neurological conditions has been growing at a far slower pace in recent years than it did four, five or six years ago, and, indeed, at a slower rate than other conditions overall. So the neurologists and their colleagues the GPs are doing quite well on those measures.

Chair

That is very helpful, to have that on the record. Thank you, Simon Stevens.

Dr David Bateman

Individually that is not the case. If you look at epilepsy, for instance, the figures suggest that 30% of the patients are being readmitted more than five times. So we may be doing well overall, but I think there are these particular examples where we could do so much better. We know how to do better and we have got evidence that if a neurologist sees these patients more quickly we do a lot better and the patients do better.

Chair

Dr Bateman, I may be putting you in an awkward position by asking you this final question, but there has been talk—we have heard a lot—about the removal of the clinical leads. We heard Sir Bruce Keogh being quite up front about the fact that there is a review, and there is a definite question mark over not your personal position—I am not personalising it—but the role that you occupy. Do you think that you have been able to make a difference, and what do you think the risks are of losing that very personal, accountable—I am assuming you feel personally accountable for some of this—clinical lead role that you occupy?

Dr David Bateman

I think the role is crucial and critical. I am in no doubt about that, because I have been able to facilitate and help support so many things in terms of both the clinical networks and the Neurology Intelligence Network and to try to resolve the commissioning difficulties. Unless you have somebody with broad general neurology experience who has been passionate about improving neurology services for their lifetime as a neurologist, with the connections and understanding, I don’t think you are going to see the opportunities or be able to lead them.

Chair

Sir Bruce indicated that it might be replaced by—I don’t want to over-paraphrase—some form of committee or alliance, rather than an individual.

Sir Bruce Keogh

We are still thinking that through.

Chair

Well it was worth getting that on the record so that Dr Bateman—

Mr Bacon

You possibly might get it right.

Sir Bruce Keogh

We will.

Simon Stevens

I think it is worth saying that the difficult task that Bruce has been set is that he is having to do this in the context of a substantial cut in the resourcing available—the running costs. He has been asked, as has everybody across NHS England, to slim down our operations yet further. That is part of the reason why he has to do what he has to do.

Chair

I think you are hearing what our concern is. I just want to ask Dr Bateman a final question. There is a difference in accountability if there is a group of people as opposed to just one named person. Do you feel personally accountable for the problems and improvements in dealing with neurological services because your name is at the top of the headed paper?

Simon Stevens

Think carefully about how you answer that question. [Laughter.]

Dr David Bateman

I am perfectly happy to be accountable and responsible within the resources that I have available and within the time available.

Chair

Three days a week.

Dr David Bateman

Two, but I have spent far more time than two days a week. It would be extremely difficult actually to get that kind of commitment from various other people, given that they are all very busy, and to know who would be the best person to get it from.

Chair

I said that that was going to be the final question, but given that you have just heard that, Sir Bruce, if you did go for a different structure, who would be the named accountable person? Would you plan that, or would it be you and Simon Stevens?

Sir Bruce Keogh

Ultimately, it would end up with me and Simon Stevens.

Chair

You are very eminent, Sir Bruce, but you are not a neurologist—although I don’t whether you maybe did some neurology at some point—so who would be the eminent neurologist who would ultimately have their name at the top of the headed paper and be responsible?

Sir Bruce Keogh

I think we’d need to sort that out with the strategic bodies. You are pressing me for an answer that requires serious deliberation and cannot be given fast.

Chair

And we are glad that you are deliberating. It is just important to get these things out.

Mr Bacon

What is extraordinary is that if you were looking for new models where running costs were lower, you would go for a model where you had somebody who was doing one job and doing another job two days a week, which is what you’ve got. This is one of the areas where things appear to be working quite well. I mentioned the case of Sir Mike Richards earlier, only because he was the most outstandingly successful example we have seen so far in this Committee of a national clinical director. You preside over an organisation that even now, despite the fact that it is getting more money—can you remind us what the NHS budget in England is now?

Simon Stevens

NHS England is—the running costs—

Mr Bacon

I understand the running costs are separate—

Simon Stevens

That’s what these costs are.

Mr Bacon

What is the total budget of the NHS in England?

Simon Stevens

For NHS England to deliver the mandate, call it £101 billion, but obviously the vast bulk of that is distributed to local health services to treat patients.

Mr Bacon

Yes. A great deal of it does get squandered, though. We know this because we see it routinely.

Simon Stevens

That will obviously be the subject of a further discussion. I think the National Health Service is probably the best value health system in the world.

Chair

That is what we are here for as a Committee—to make sure that there is value for money for the taxpayer and effective services for the patients. Hopefully we have teased some of that out, and we will be issuing our report at some point in the new year. Our transcript will be available, uncorrected, on the website in the next couple of days, so if you have any thoughts about anything you have said, do have a look at that. I thank our panel very much for coming and particularly Dr Bateman for travelling from Sunderland to be with us today. Thank you very much indeed for attending our hearing. Oral evidence: Services to people with neurological conditions, HC 502 43 [1] Figures clarified by witness after session [2] Figure clarified by witness after session [3] Figure clarified by witness after session [4] Figures clarified by witness after session [5] Subsequent written clarification by witness: “The RCP Annual census 2013/14 indicates that the number of consultant neurologists in the UK is as follows: England – 640, NI – 16, Scotland – 75, Wales – 25, Total - 756 (cf 716 in 2012/13). It notes that the apparent increase of 5.6% since 2012/13 will be offset by those new posts with a significant number of PAs devoted to stroke services.” [6] Figure clarified by witness after session [7] Figure clarified by witness following session.