Examination of Witnesses (Questions 100
- 119)
THURSDAY 15 JUNE 2000
MR HUGH
TAYLOR AND
MR STEVE
BARNETT
100. Duck that one. It is an unfair question
and I apologise. What are the reasons why we are still having
to go round the houses when at the end of the day my constituents
and constituents of my colleagues face this dilemma that if they
cannot get access through the NHS they can see that certain people
can queue jump by paying? It is profoundly wrong, surely. What
are we doing about it?
(Mr Taylor) I think we have to separate out different
issues here. We have to start with the fact that all the evidence
we have suggests that on average doctors in the NHS work substantial
and long hours. The evidence which was given to the Doctors and
Dentists Review Body last year, based on a well-founded piece
of research, suggested that on average full-time consultants were
working just over 51 hours a week and maximum part-time consultants
over 48 hours. We are not talking about people taken as a whole
who are not spending substantial amounts of time working for the
NHS, the great majority of them are. There are significant variations
within that overall figure and that is one of the things we recognise
needs exploring. We think there are issues still, and that is
why we are in the consultants' contract negotiations now, about
the effective management and the commitment that those doctors
make to the NHS. That, despite the fact that, as you rightly point
out, there have been concerted attempts in the past to establish
job plans and so on. There is evidence that still not all consultants
have job plans and they are not necessarily managed effectively.
That is why we and the BMA together recognise the need to change
that.
101. It is not just about hours. I will certainly
accept that many doctors work extremely long hours. One of the
worries I have got about this whole area is I have come across
cases where people in private hospitals are being wakened to see
their doctor before five o'clock in the morning who is then back
again at eight o'clock at night and who has done sessions in the
NHS. It is not the number of hours, it is what they are doing
in those hours and whether, in fact, they are treating people
in accordance with the actual clinical needs of those people.
With respect to the current situation the worry is that so often
their time is being spent on less serious cases in the private
sector as opposed to the more serious cases in the NHS.
(Mr Taylor) We have a situation, and it varies between
consultants and therefore specialties, where around 60 to 70 per
cent of consultants' time is spent, according to the research,
on clinical duties. One of the features of the research that was
carried out by the DDRB demonstrated compared with the previous
survey done in 1989 the amount of time spent on clinical duties
had actually declined slightly over that period and the time spent
on other duties, including training, management and some other
issues, had gone up. So the overall number of hours doctors were
working had gone up. There is an issue about the time spent on
clinical activities. There is an issue too about the requirement,
as we see it, that the NHS should have, as it were, the first
call on the time and availability of doctors working in the NHS.
There are a number of ways in which we feel we need to approach
that. First, we think it is important that there should be better
rewards in the system for doctors who are committing themselves
to NHS service duties. That is why we have agreed with the BMA
that we should extend the amount of money that is available for
discretionary awards in the system and at the same time change
the criteria for those awards to put greater emphasis on the performance
of service commitments. So there is greater leverage for NHS managers
in terms of incentivising performance. Following the recommendation
of the DDRB we are also negotiating with them a system of intensity
payments to reward those doctors who are, in fact, working hardest
and longest in pursuit of NHS duties. We think there are changes
that can be made to the incentive structure to support the kinds
of concerns that have been highlighted. The other issue is a straightforward
management issue which is about making sure that there is an effective
managerial relationship between the employer and the consultant.
I think both sides recognise that needs to be underpinned by an
appraisal system. In other words, the job planning system needs
to be underpinned by an appraisal system which enables the employer
to work with the consultant to assess their job plan and performance,
to work with them on improvement as necessary and also to get
into the whole question of the management of their team and an
evidence based approach to productivity and performance. I think
we would be the first to acknowledge, based on discussions we
have had with NHS managers, that the implementation of that kind
of approach is still patchy across the NHS.
John Austin
102. Could I ask you if you know what proportion
of consultants are employed on a full-time, maximum part-time
contract?
(Mr Taylor) Yes, we do. According to the last census
figures 58 per cent of consultants are on whole-time contracts,
25 per cent on maximum part-time, 11 per cent on part-time and
6 per cent are on honorary contracts, that is people who are effectively
employed by a university or other employer and who are associated
with a particular hospital for clinical duties. We have a break
down of those figures by speciality as well because there are
obviously variations in the proportions by speciality.
103. How is it determined which contract a consultant
is on, who determines it?
(Mr Taylor) The local employer determines it. In practice
the normal way this would happen would be that a consultant would
be employed on a full-time contract but the employer, as you know,
can monitor and require audited evidence of the amount of money
that the individual is earning in the private sector. As soon
as that exceeds the ten per cent rule then the consultant is automatically
put on to a maximum part-time contract.
104. We have heard about the ten per cent rule
with regard to full-time consultants. It was suggested by earlier
witnesses that really is a fiction, it is not really policed in
any way. What would your comment be on that?
(Mr Taylor) The first thing is the fact that 25 per
cent, a quarter, of doctors are on maximum part-time contracts
is an indicator in itself that the ten per cent rule is being
enforced at least to that extent. We do not have information centrally
that enables us to make a clear judgment about whether every single
consultant who is on a full-time contract is keeping to the ten
per cent rule, it is a matter for local employers to enforce.
I think there has been historical data to suggest that might not
always be the case, but I do not have up to date information on
that centrally.
Mr Gunnell
105. It was suggested to us that there was only
one case where the trust had really taken this up. The example
cited was an instance in Southampton, one example where there
was evidence or it could clearly be said it had been followed
up.
(Mr Taylor) I do not know enough about the specific
incident. If you mean that is an incident where there has been
a row about it, that is another factor. One has to bear in mind
that quite often the knowledge about the private sector practices
of individuals will be pretty well known to people in the trust.
These things are not really done in a corner. I do not think that
kind of anecdotal evidence necessarily in itself is an indicator.
I am not sitting here saying that there is rigid enforcement of
the ten per cent rule across the NHS. This is one of the issues
that the BMA has raised with us in the context of these negotiations,
it is one of the things we will be exploring.
John Austin
106. Can I pursue this. One of the issues that
arose earlier was this issue of perverse incentives and whether
there is an impact upon waiting lists. The Chairman referred to
Nick Timmins' article in the Financial Times. He was saying
that there is little hard evidence that long waits are tied to
consultants' private practice but that is because NHS managers
have no rights to know how much private practice their consultants
are doing. Would you agree that there is not the evidence on the
ground so that we know what is happening?
(Mr Taylor) It is open to local managers to call for
audited accounts. I do not think that in itself is a persuasive
answer. The fact is that in many cases the trust manager, the
chief executive, will know that the individuals concerned are
fulfilling their obligations to the NHS in terms of their contract.
Under those circumstances the issue is whether the ten per cent
rule needs to be enforced because there is a breach of it and
it is up to them whether they enforce it. I do think we have to
keep on emphasising that although there are significant variations
across the country between individuals and specialities, the overall
picture, and this emerges when we talk to chief executives about
this, is not of a workforce that is to any large extent shirking
its NHS responsibilities but keeping to those responsibilities
and supplementing them with private practice in some cases. Clearly
where a trust is having difficulty with an individual you would
expect it to be looking very rigorously at a range of factors,
including the amount of private practice.
107. There has been some suggestion that consideration
might be given to buying consultant surgeons out as far as their
private practice is concerned. What consideration has been given
to that in the corridors of power? How much have you anticipated
that will cost?
(Mr Taylor) I think I had better answer that question
by saying at the moment there is a ministerially inspired debate
about all these issues in the context of developing a national
plan. A lot of ideas have been generated and a lot of proposals,
some of them have been debated in the columns of the national
newspapers. It is not for me to say what view Ministers will in
the end take of all that. The difficulties of that kind of approach
have also been very, very well brought out in some of the correspondence.
You have to ask yourself what is the gain you will get from pursuing
that route and that raises some quite difficult questions.
Dr Stoate
108. I said earlier on I was rather confused.
I thought I knew the health service quite well and I have found
out that I do not, in fact, certainly in this area. I am even
more confused because the answers you have given are totally in
conflict with the answers we had from our earlier witnesses. You
have told us that 25 per cent of consultants have maximum part-time
contracts and yet Professor Yates told us that 80 per cent have
maximum part-time contracts. Not only that, but the Consumers'
Association told us that in their survey over 50 per cent of consultants
did more than two sessions a week in the private sector. That
cannot possibly be if 50 per cent of them have got whole-time
contracts. Something very odd is happening. Your answers and their
answers are completely at odds.
(Mr Taylor) All I can go on is the official data which
is published by the Department of Health which is based on the
annual census of doctors and reinforced in terms of proportions
of doctors between the different contracts by the research which
MORI did for the DDRB last year. They produced slightly figures
but that was based on a sample survey. They are not so different.
I think they had 55 per cent on whole-time and slightly more on
maximum part-time but that was based on a sample survey. I think
the proportions I have given you are almost certainly right.
109. This is even stranger then because you
say you are relying on official published figures.
(Mr Taylor) And on independently carried out research.
110. And yet we are being told that often figures
are not collected because trusts have their own contractual arrangements
and they can vary the contracts as much as they like. If you are
right that well over half of consultants have got whole-time contracts
and well over half of consultants are doing two sessions or more
than two sessions a week in the private sector, the two cannot
possibly be right unless someone somewhere is fiddling something.
(Mr Taylor) The fact that you are on a full-time contract
does not debar you from doing private sector work. What it does
in terms of the contract is debar you while you are on a full-time
contract in principle from earning more than ten per cent of your
salary.
111. And yet we are told that is not true. Professor
Yates told us that may have been true once but since the advent
of trusts ten years ago now that is not the case and he quoted
two trusts to us and gave us the names of those two trusts where
it certainly was not the case, although he was not sure that was
the whole picture. What you are saying is the official figures
say one thing and what Professor Yates is saying is those official
figures do not mean a thing because trusts are doing something
totally different. Where do we go from here? We do not seem to
be able to get any concordance on what the real issues are.
(Mr Taylor) I do not think we are necessarily saying
different things. What I have said is that we do not have central
information on the enforcement of the ten per cent rule in trusts.
What we have information on, and I just want to emphasise this
is not just our statistics but is corroborated by an independent
survey done for the Independent Pay Review Body. We know what
proportion of consultants are on the particular forms of contracts
and, therefore. what that means in terms of pay, and we know from
research that has been carried out what on average the hours worked
by consultants in the NHS are and what the variations are around
that mean, which are pretty considerable. We also know from talking
to chief executives in the NHS, which I do all the time—we
have a reference group supporting us in the consultants' contract
negotiations—that their view is many of their consultants
are working extremely hard on behalf of the NHS and putting in
extremely long hours and some of them also supplement their salaries
with work in the private sector.
112. I have no problem with that because I have
known consultants for very many years working in the NHS and I
know that the vast majority of them do an extremely honourable
and decent job and I am not for a moment suggesting that the bulk
of consultants are somehow fiddling the information but what I
am saying is these wide variations in fixed sessions really do
seem to be an enormous problem. We heard that the number of fixed
sessions can be two or it can be eight. We have also heard that
the so-called non-fixed sessions can be pretty much anything they
like. If somebody is able to have a full-time contract with the
NHS and still be able to carry out more than two sessions a week
in the private sector, which is certainly the mixture of evidence
we have got today, those so-called unfixed sessions must actually
be being interpreted fairly widely by a number of people. All
I am saying is, is it not the case that we simply do not know
what is going on because your survey says one thing and the Consumers'
Association says something that does not fit. If I was an outside
observer and I was listening to your evidence I would be reasonably
complacent that things were going very well but if I was listening
to the Consumers' Association and Professor Yates I would not
be at all complacent.
(Mr Taylor) I certainly would not want to give the
impression that we are complacent. I started off by saying the
reason we are in consultation and negotiation with the BMA at
the moment is because we do not think that elements of this system
are working as effectively as they should be. In particular, we
are not satisfied that managers across the NHS, employers across
the NHS, have got a sufficient hold, if you like, on the availability
and time and performance of their consultants. We think that system
needs to be improved. That is about effective management. I think
it is important to stress in this that although this is a negotiation
and there will be strong differences, I think the BMA also recognise
that the current position on the contract, which is confusing,
which does not give clarity to the public or in many ways to the
staff themselves, is unsatisfactory and needs to be resolved.
None of us is complacent about the situation as it is now. If
I could just add to that, the research that Professor Yates and
others have done has been extremely powerful in pointing up concerns
to us about variations in performance, about take-up of theatre
time and take-up of specialist consultant time and is integral
really to the work we are taking forward on attempts to reduce
waiting times in the NHS, for example. So complacency is not at
all a word that I would seek to use. I do not have any basis for
saying that the number of maximum part-time contracts is 80 per
cent. It may be that some evidence suggests 80 per cent of consultants
do some private practice work but that is a different matter.
113. Certainly the two figures, as you will
agree, significantly conflict. I want to ask a slightly unfair
question. Do you think that at any level in the NHS there is any
sort of collusion to either confuse the figures or somehow cover
up things that are going on? We have all seen in the press the
high profile cases where perhaps things have not been policed
as well as they have been. Do you think there is any evidence
that perhaps things are being washed over or a blind eye is being
turned or perhaps nobody is taking much notice?
(Mr Taylor) I am not aware of any information on that.
What I do think is the case is we need better managerial systems
to provide more effective management of time and performance,
that is true for doctors and it is true across the NHS.
114. Do you think that employers in trusts ought
to be required to keep much more detailed information on exactly
what consultants are doing both in and outside the NHS, or do
you think that would be overly intrusive?
(Mr Taylor) We do have a certain amount of information
at national level, if that is what—
115. I meant at local level.
(Mr Taylor) At local level I think it is entirely
proper for managers in a trust to have the kind of relationship
with consultants which means that they work very closely together
on their availability and on commitments because that is absolutely
necessary to making the NHS work efficiently.
116. Why do you think all the evidence seems
to be that most trusts are not doing that? Is there any reason
why they are not doing it because it ought to be relatively straightforward?
You are saying it is desirable but why is it not happening?
(Mr Taylor) I think the answer is in some cases it
is happening but not in enough. I think the reasons for that are
partly historical. We are talking about a move to a more managed
culture than has been the case in the past with increasing pressure
on the NHS in terms of demands upon its services in an environment
where overall in the NHS productivity and activity has risen dramatically.
That puts a new premium on really managing closely all the different
factors which go to making an effective service for patients,
including the availability of all resources, including human resources,
which go towards that end.
Mr Gunnell
117. Were you present at the end of the previous
hearing?
(Mr Taylor) I am afraid I was not actually because
I could not get a seat.
118. There was a suggestion that we really lack
data on a lot of things in connection with this whole field and
what was suggested was the NHS nationally ought to make sure that
they collect every patient's record, both from the public and
private sector, and they have on those records not only the operation
that the person has had but the name of the person who conducted
the operation so that it is possible to work out from that, in
a sense, more data about the way most consultants are spending
their time. Do you plan any systematic collection of data of that
sort?
(Mr Taylor) We have a certain amount of data at national
level already about Hospital Episode Statistics which give us
a certain amount of national information about productivity. That
is broken down by individual consultant. There are issues about
confidentiality, about reliability, about applicability of some
of that information. In response to the Government's commitment
to improve quality of performance across the NHS we are developing
data sets associated with clinical outcomes, clinical indicators,
which gives information on a hospital by hospital basis which
will be useful, certainly useful for hospitals in measuring their
performance against that of other hospitals. In some areas there
are more specific clinical data sets which do enable individual
clinicians to compare their performance against that of other
doctors. Those data sets are available. I think the question here
is most of them are used, particularly the latter ones I have
been talking about, to support improved quality, to enable clinicians
to build an evidence base for their own performance. There is
a question about how information which is collected in that way
can be made relevant to benchmarking performance for the managerial
purposes we are talking about. Undoubtedly that is something which
Ministers would want us to explore.
Chairman
119. I thought you were actually present during
the previous session, I apologise. I thought you had heard some
of the earlier questions. One of the questions I put to the previous
witnesses, following along similar lines to what John Gunnell
was just asking, was whether any exercise had been undertaken
in respect of evaluating the operating lists, the use of individual
theatres where they are used for private patients and NHS patients,
the same NHS theatres by the same consultants who work part-time
in the NHS and part-time in the private sector. I asked the previous
witnesses whether any work has been done on evaluating the clinical
needs of those patients in each sector and comparing their needs
bearing in mind they are being funded through the same consultant
in the same operating theatre. Has that not been looked at at
all?
(Mr Taylor) The honest answer to your question is
I do not know but I can get back to you.
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