Examination of Witnesses (Questions 140
- 155)
THURSDAY 15 JUNE 2000
MR HUGH
TAYLOR AND
MR STEVE
BARNETT
140. I accept that, but the point I am trying
to make is not that they do not give value to the NHS, I am not
making that point, the point I am making is if they have a contract
with the NHS for five and a half days, how do they then manage
to fit in more than two sessions a week of private work while
still working five and a half days for the NHS? I do not see how
that works in practice.
(Mr Taylor) If at local level that is an issue, if
the manager does not think they are getting the work out of the
consultant and they are aware that the consultant is doing that
amount of private practice, then of course it is an issue for
the employer to sort out with the individual concerned if it is
impacting on their NHS work.
141. If, for example, a teacher were contracted
to work five days a week in a school and was found to be doing
three sessions a week in another school down the road, somebody
would say "hang on a minute, you were meant to be in the
classroom that day". I am still slightly confused. I can
understand the maximum part-time contract because that is easy
to understand, but a full-time contract of 11 sessions a week
pretty much rules out you doing anything else during that week,
in fact including Saturday morning. Is an 11 session contract
actually an 11 session contract or is it something else?
(Mr Taylor) I think that part of the confusion here
is about the apparent rigidity of the formula used which is this
notional sessional idea which adds up to a certain number of hours
per week and the fact in practice, because they are professionals
and because of their motivation, many doctors work outside the
hours and more days per week than a conditioned hours approach
would suggest. In practice they have a lot of flexibility about
when they work and where. Our concern would be if that flexibility
gives rise to impediments to NHS work. If the doctor is not available
to work in the NHS when the manager wants them there to work then
clearly that is something which is not satisfactory.
Mr Gunnell
142. When you gave us the figures for people
on different types of contracts you said that was divided up according
to speciality.
(Mr Taylor) Yes.
143. I would have thought it would be helpful
if you could let the Committee have that divided up according
to speciality.
(Mr Taylor) Yes.
144. But in particular I was wondering what
the figures were for orthopaedics because we gather that is the
area where there is highest demand.
(Mr Taylor) I have not got the figure here for orthopaedics.
The figures for surgery overall are 46 per cent on full-time contracts,
43 per cent on maximum part-time contracts and 11 per cent on
other. That is lower than the average for the NHS as a whole,
which is perhaps what one might expect.
Chairman
145. Before we conclude, I am conscious we have
not included Mr Barnett at all. I will throw you an awkward one
to make you feel at home. You may or may not have been in the
session when I raised the case quoted by Professor Yates in his
evidence. I assume you have probably seen the evidence put to
the Committee of the case of Keith, so you know the circumstances
of this particular patient. What I wondered was—and you
have been included in the negotiations on the contract—does
the principle of equity play any part in these negotiations?
(Mr Barnett) In terms of access for?
146. In terms of the fact that since the NHS
came in we have not had the equity, where you have situations
like with the patient we talked about here where this individual
is faced with a lengthy wait or paying. Some people clearly can
pay, but some cannot, and where many constituents can, there are
a lot more that cannot. Therefore, it seems that despite what
we have said in the 50 years of the success of the NHS we have
never achieved the basic central principle of equity that we boast
of as being the greatest achievement of the National Health Service,
because it is not there. If you have got money you can get in
quicker for access in cases such as Keith. Are we actually addressing
this issue of equity, basic fairness, and the fact that people
should have a right to receive treatment on the basis of their
need when clearly they do not? Does this play a part in the dialogue
we are having with the consultants at the present time?
(Mr Barnett) At the present time we have not had dialogue
around those issues. We have concentrated on negotiating around
the appraisal systems and job planning review, and much greater
emphasis on employer driven management processes, so that, for
example, in the job planning review there will be greater concentration
on patient contact and patient outputs and less concentration
on just allocating blocks of time within which a consultant determines
areas of activity. I would think that out of that management process
around appraisal and the planning review there will be greater
employer input around local service-based goals and objectives
and targets. To date we have not talked specifically on issues
of equity and access to patients.
147. Is there a possibility that you might be
doing?
(Mr Barnett) I think we have set ourselves a stiff
target to agree certain things by the end of July. Beyond that
there is a broader aspect to the contract and I would have thought
that as part of those discussions that issue is bound to be played
in.
(Mr Taylor) Ministers have raised the whole question,
which is addressing whether the work done by doctors in the private
sector raises issues of perverse incentives and so on, so that
is a debate under consideration. We have a specific remit for
the present stage of the consultant contract negotiation, which
is the one that Steve Barnett has just described.
148. Can I quote from Professor Light's solution
on the issue of waiting lists where he tells us that the consultants'
control of waiting lists is "a blatant conflict of interest,
an invitation for mischief". Would you agree with that?
(Mr Taylor) We said in the memorandum that we gave
to you that evidence is hard to find.
149. He seems to have found quite a bit. It
seems that the Department does not find the evidence that certainly
a number of our other witnesses appear to be able to get quite
easily.
(Mr Taylor) The evidence which he has given, and Professor
Yates and others, all point to significant variations in consultant
performance and they raise questions about the relationship between
private practice and NHS work, as ministers have said in recent
weeks, but I do not think there is a causal relationship established
between the fact that someone works in the private sector and
the length of hospital waiting lists. I am not aware that it has
been firmly established.
John Austin
150. If there is a perverse incentive, given
that half the beds in the private sector are unoccupied, would
not a decision by the NHS to solve its waiting list problems by
purchasing care in the private sector add to that perverse incentive?
(Mr Taylor) Are you referring to the statement that
was made this morning?
151. Yes.
(Mr Taylor) I think the particular issue there is—this
is not a universal thing—there may be times when, during
the winter periods when the NHS is under pressure of hospital
beds because of a large acute intake—
152. These are largely medical beds?
(Mr Taylor) Exactly.—when it is possible that
we could utilise the time of expert staff like surgeons and others.
153. That is not a waiting list issue, is it?
(Mr Taylor) It is, because one of the consequences
sometimes of the pressure of winter and the acute medical intake
is that there are not beds available to admit people for elective
surgery, which, therefore, contributes to waiting.
Chairman
154. In our experience it is not a matter of
beds, it is a matter of staff for beds. I would be interested
in your thoughts on—if there is discussions going on about
the use of private sector—where the experienced personnel,
the trained personnel in the private sector will come to service
the beds that we use in the private sector. We have looked in
some detail at the private sector and we have looked in some detail
at the staffing difficulties of the NHS—I believe you were
a witness before, Mr Taylor—and the picture we get quite
clearly is that if you expand the private sector those staff come
directly from the National Health Service. Are you happy about
this idea of using the private sector? Have you looked at the
impact that that may well have on the staffing difficulties in
the NHS?
(Mr Taylor) I think what ministers have indicated
is a wish to explore this as an avenue. Obviously, one of the
things that we would need to explore is whether it would create
perverse effects within our own system, including staffing and
other issues. I think what they are saying is that certainly this
is an issue which merits exploration.
155. Do you accept there is evidence that the
recruitment into the private hospital sector or the private nursing
home sector arises frequently directly from people who work in
the NHS and if you expand that sector, use that sector and if
you service those unoccupied beds in the private sector you automatically
remove staff from the NHS?
(Mr Taylor) There is movement between the two sectors.
The key to that in the long-term obviously is to recruit more
staff overall and to hang on to staff better than we do at the
moment. There is some evidence that we are beginning to do that
rather better, but clearly there is competition between the NHS
and other sectors for the employment of key staff.
Chairman: Do you have anything further to add?
I thank you for coming along this morning. You indicated that
you could give us some written evidence on certain points and
we appreciate that. Thank you very much.
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