Examination of Witnesses (Questions 200
- 219)
THURSDAY 22 JUNE 2000
DR PETER
HAWKER AND
MR DEREK
MACHIN
Chairman
200. Below the belt that.
(Mr Machin) Can we have your contract?
Mr Burns: We do not have one.
Mrs Gordon
201. What we do have is a Register of Members'
Interests so that outside our contract with our constituents we
have to register interests. Is there an equivalent with consultants,
that they have to register what work they do outside the NHS?
(Dr Hawker) It depends. Obviously in private medical
practice it is pretty clear it is going on because people know
the local situation. There are rules and regulations on probity,
for example, of people who may be responsible for commissioning
expensive equipment. We are bound by the same rules that anyone
is that if you have a connection with a company you have to declare
it.
(Mr Machin) Yes, that is certainly the case. I would
not say all hospitals but I think most hospitals would have a
register of interests. Certainly one would wish to have on that
register such things as hospitality, significant hospitality,
that one had received from drug companies and equipment companies
in order that there could not be any charge that you were influenced
by such hospitality. If you are involved with a commercial organisation,
for instance, owning a company which is a supplier to a hospital,
clearly that is the sort of interest which should be registered.
When you get to the question of private practice, that is really
more implicit than explicit in so far as it is assumed that somebody
who is a maximum part-time consultant will be doing private practice.
I had an interesting example myself a few years ago when the fundholding
system was in. I was approached to do some fundholding work for
a particular practice. Now that I regarded as something which
potentially was cutting across the interest of the trust, so I
did go and talk to the chief executive about it in order that
there be no question that what I was doing was in any way detrimental
to the activity of the trust. He accepted that it was not, in
fact he actually said he did not think he had a right to interfere
anyway but the fact was we agreed a method of working and that
was cleared by me with the chief executive so there could not
be any accusations at a later date that one was doing something
contrary to the interest of my own trust.
(Dr Hawker) It was not uncommon at the time of fundholding
when some general practices were employing, if you like, consultants
to go and run clinics rather than send them to the hospital. Again,
from personal experience and contacts around the country, it was
not uncommon for the consultants to go and discuss this because
we could see the effect it could have on our departments if the
money was not coming into the hospital under that system.
202. Again, it is an individual thing, you are
going back to the trust and integrity thing. You did that, but
would all consultants do that? Should it be formalised so that
they know what they have to declare and what not?
(Mr Machin) I would be very happy to have more formal
arrangements because I see them as a protection. When I see things
going wrong, they are usually going wrong because of different
interpretations of the rules, or the lack of rules, a differing
interpretation by the different parties. I think if everybody
knows what they are supposed to do, it is a great protection for
both sides. We would not have a problem in introducing appropriate
rules, guidance, whatever you like to call it.
203. Finally, can I ask you, again in your evidence
you argue in favour of the principle of "positive accountability"
rather than "artificial limitations on activities outside
the contract". Given that the current system of accountability
obviously is not really working and is not effective at the moment,
are you not really just arguing for the continuation of the present
system?
(Dr Hawker) Absolutely the contrary. We want to see
change and I think we are at one with our departmental colleagues
on this. We want to see change. I think one of the fundamental
and most important things coming in at long last in the Health
Service will be proper annual appraisal. We are not too far off
being in a position to sign it off and get it moved forward. If
that is done properly then you do have a very big risk in a contractual
binding system—I look at it the other way round—and
I can then hold my managerial colleagues to account for providing
the resources that I need to provide the service that they have
agreed to provide. My managerial colleagues can then hold me to
account for what I have agreed to do and what I have contracted
to do. I think with that approach then you do not have to look
outside what people are doing when they are on their own time.
Dr Stoate: I would like to start by declaring
an interest, I am a member of the British Medical Association,
although because I am not a specialist or a consultant I do not
think there is a conflict of interest to worry us at the moment.
Chairman: Are you going to mention your private
practice?
Dr Stoate
204. What is that. What I want to concentrate
on actually is the consultants' working hours within their contract.
The BMA's memorandum states—and it has been confirmed by
the Audit Commission—that fixed clinics, as opposed to the
other clinics, are expected to account for between five and seven
sessions out of the notional 11 sessions on a full working week
which a consultant must fulfil except if by agreement or emergency.
Yet, the Audit Commission in evidence to us last week said that
there was very wide variation in the number of fixed commitments
which could not be rationally explained by workload differences
such as being on-call. Additionally, it found that only 68 per
cent of consultants were attending over 90 per cent of their fixed
commitments, after adjusting for sick leave, study leave and so
on. In other words only two thirds of consultants were sticking
to the notional sessions they were supposed to work. My main concern
is that there are very wide variations in the number of fixed
sessions. Although the Department says five to seven, the Audit
Commission says five to seven, you say five to seven, the evidence
last week was that some were only actually having two fixed sessions
per week. How can you explain such wide variations in the consultant
contracts across the country?
(Dr Hawker) A number of factors. One is according
to specialty. For example, the fixed commitment as defined is
where you are committing other resources, theatre sessions is
a classic example. Now many accident and emergency surgeons are
in their departments during the day but they are not counted as
fixed sessions because they are not formally operating. They may
have two operating lists. Another factor will be that some people
actually do allocate a moderately reasonable quota of sessions
for emergency and on-call work. When you look at the figures,
the average is one or two for being on-call. That bears absolutely
no relationship to anything, frequency of rota or how hard people
are working outside. There is another area there. There may be
particular circumstances, surgery, Derek can answer that, availability
of theatre time and outpatient time. In psychiatry, care of the
elderly for example, small numbers of fixed sessions are needed
because a lot of the work is working one to one with patients
on rehabilitation. A number of people have emergency specialties
where you know you have to be regularly dealing with patients
out of regular hours, where you may be doing a lot of consultant
work for your colleagues within a hospital. Certain medical specialties
for example will have higher calls for consultation, dealing with
patients in hospital, than other specialties. While we need to
look very carefully at the individual, the idea is to give a band
where we can look at exceptions and then find out why they are
exceptions and often there are reasons. I accept there may well
be occasions where there are no very good reasons and it is just
not very good job planning and not very good contract management.
205. I accept what you have said, and obviously
some of the factors you have mentioned are perfectly reasonable
matters. The Audit Commission says that the wider variations cannot
be rationally explained, that is what they are saying. They told
us last week that literally only two sessions in some cases are
actually fixed sessions. How is the trust to know whether it is
getting a good deal from the consultant when only two sessions
or possibly three sessions are actually fixed? How can they know
what the consultants do with the other sessions? You might be
right in that the vast majority of your members are acting totally
honourably but how is the trust to know that?
(Dr Hawker) They should be utilising—I accept
that maybe they are not—the mechanisms that are there. If
they are not then what we will be doing over the forthcoming weeks
and months with the Department is making sure those mechanisms
are in place and are used. We have had experience of this where
we have tried to get proper job planning reviews in hospitals
and have failed. It has not been because the consultants do not
want them, it is because either the staff are not available or
it has not been a priority within that unit. I think that is wrong,
it should be. It should be top priority in that unit, not just
so that the NHS and the patients know they are getting a good
deal but so that the people I represent know that they are protected
against unjust allegations and also, as far as my organisation
is concerned, where people are not fulfilling their contract we
do not get sucked in to supporting them for lack of evidence when
in fact they should be being dealt with under the mechanisms that
should be present.
206. Clearly the evidence we got from the Audit
Commission last week was that only two thirds of consultants were
attending even 90 per cent of their fixed sessions. Clearly the
current system is not working. Do you accept, therefore, that
there should continue to be fixed and variable sessions or would
you like to see an end to that and a totally different type of
arrangement put into place?
(Dr Hawker) We are moving on almost to conducting
the negotiations on consultant contracts.
207. In principle rather than in detail. In
principle to see if it is reasonable to have fixed sessions and
variable sessions if, firstly, they are so difficult to police,
secondly, they are such wide variations and, thirdly, it is very
difficult to know what is going on.
(Dr Hawker) Put it this way, we are more than happy—I
will speak for Derek but I will let him answer, he is the negotiator,
I am just the chairman—to look at any proposals that come
forward. The fundamental aim is, one, I suppose from our side,
is it going to advance our cause. I do not necessarily mean financially,
I mean the cause and reputation and so on. What are the effects
it will have on the service because, again, we are trained to
think through the consequences of action so something which might
seem a good idea when you start looking at those policies may
not be. I do not think we have any fundamental block on looking
at any constructive proposal but Derek runs the negotiations.
208. Mr Machin?
(Mr Machin) Yes. I would echo what Peter has said.
We have a very open mind on the consultants' contracts. Fixed
sessions were brought in, as I understand it, really at the behest
of the Department of Health rather than at the behest of the profession.
To comment a little further on your question of the variation
in the number of sessions. Peter has alluded to the accident and
emergency department, the other area that I am aware of which
causes great difficulty in fixed sessions is pathology. The idea
of fixed sessions is to utilise the other members of staff and
equipment and facilities which are necessary at a certain time
and those of us who operate, clearly in the operating theatres
there is a whole team standing by, outpatients are going to have
a whole team standing by, on the other hand, if you are looking
at slides it does not matter too much to other people when you
do it. It can be juggled around, for instance, doing post-mortems.
The pathologist might carry out two or three post-mortems and
then look at the histology. On another day, when there were no
post-mortems to do, he would start earlier with the histology.
It does not fit very comfortably into all specialties. I think
that is one area. The other area is I have to say I do find it
very irritating when people produce reports and they leave huge
lacunae in them. They say "66 per cent blur" and they
do not say what happens. The answer is "Why do you not follow
through and see what is happening at those particular times"
because, as one who is utterly cynical about any statistics produced
from the Health Service, I would be very suspicious that in actual
fact most people are off doing some management meeting. Because
that is the commonest reason why people are not doing their fixed
session in my experience because they are at a management meeting.
The trouble is it depends from whom the data is collected. If
it was collected from the outpatient clerk or theatre clerk they
would not necessarily know where the consultant was, all they
would know was the guy was not there at that particular time.
I view it with some suspicion. I would like to follow through
on this because I do not believe it is anything like as bad as
that.
209. It is not Health Service statistics, it
is Audit Commission statistics which we will have to hope are
slightly more robust. I take the point you are making.
(Mr Machin) They will have got their
data from the Health Service and that is the point, how they got
it.
210. Let us move on. Professor Light's evidence
to us is that many surgeons are operating far too few sessions
a week. He felt that if all services were able to offer four operating
sessions per week as standard he says waiting lists would plummet,
they would go down from months to weeks in many cases. Do you
accept that?
(Mr Machin) I think that Professor Light
has got a very odd view of how the Health Service works quite
honestly. If we were to increase the number of sessions of operative
work then we would need to have more operating theatres, more
anaesthetists, more theatre staff, we would need more pathologists
to deal with the pathology that comes out of the operations and
we would need more beds to accommodate the patients. I am quite
bitter about this one because I am at the moment trying to organise
the appointment of a third urologist at Aintree and I have been
trying to get this job up and running for about the last four
or five years. What I find is that at the moment there is no spare
operating space, fortunately we are having two new theatres built
but at the moment there is no spare space and there is no useful
or useable space in the out-patient departments that fits in with
the rest of the schedule. I am faced with a monumental task of
trying to persuade other colleagues to shift sessions around so
we can produce a meaningful job. Furthermore I then find that
about one of my operating sessions in five is cancelled due to
a lack of anaesthetists. Yes, our throughput is not up at target
levels but there are very good reasons for it. Now the problem
is if you just willy nilly are to increase sessions without dealing
with the infrastructure behind it, it will probably have no effect
whatsoever because at the moment most hospitals are working pretty
much to capacity taking into account the availability of beds
and the availability of support staff.
211. What you are saying is in your opinion the
rate limiting factor in the NHS is not the number of sessions
the consultants is doing but the total infrastructure of the system
which prevents you from working at capacity, is that fair?
(Mr Machin) I think there are a series
of rate limiting factors and they will vary from hospital to hospital.
In some instances it could be the number of sessions that the
consultant is doing but you must remember that people tend to
focus on surgical activities of consultant surgeons but please
remember that consultant surgeons have a lot of other things to
do apart from operating. This tends to be overlooked. It tends
to be assumed that if you are not operating you are not working
and that is really very, very far from the truth.
(Dr Hawker) I think we can support our surgical colleagues
on this. We are back to the question that surgeons are now increasingly
not on-call but providing the emergency operations. They have
got their teaching function, they have outpatients, it is quite
nice to go round and see the patients before and after operations
and provide the care. Increasingly, I am finding this, they are
spending more time because patients, quite rightly and correctly,
are not prepared to be seen or spoken to by other doctors, they
want to see the consultant surgeon. Four operating sessions a
weeks, other things might have to be looked at, might have to
be shed. It is not as straight forward as that.
212. Just to pick up your point about clinical
statistics from the NHS. Many of the surveys that we do see about
consultants' hours, of course, are self-report surveys from consultants
themselves. If you do not trust any Health Service statistics,
can you rely on those?
(Mr Machin) I am sceptical about all
statistics. The reason why I am reasonably confident about the
surveys that have gone into the Review Body report is that they
are not a single point on the graph, they follow earlier reports
and they demonstrate a trend and it is the trend which is as important
as the individual numbers. The figures that have been produced
are certainly consistent with my observation of my colleagues
who, by and large, are feeling pretty bloody stressed at the moment
and a lot of it is down to the amount of work they are having
to do and the pressure they are being put under. The criticism
that is going in the direction of consultants is utterly and totally
demoralising consultants at the moment.
213. If people are that stressed and overworked
and all the rest of it, do you think it is reasonable that they
should be doing so much private work on top of all that?
(Mr Machin) I think some of them regard
the private sector as a haven of peace quite honestly.
Mr Hesford
214. A haven of piecework?
(Mr Machin) Yes.
(Dr Hawker) 15-love.
(Mr Machin) There is a considerable difference, very
often, in the pressure of work in the private sector. Things are
much more leisurely than they are in the Health Service. A lot
of people find it quite attractive to practise medicine as they
would like to practise it, with rather more time to talk to patients
in the consultation rooms, and rather less pressure in the operating
theatres.
Chairman
215. Why do they not leave the Health Service
completely? Is it not a fact they need the Health Service to continue
their private practice?
(Mr Machin) That applies to some people
in some places but by no means to everybody in all places. Believe
it or believe it not, the vast majority of consultants have a
great feeling for the Health Service that they have problems with
the Health Service, and the Health Service produces all sorts
of problems for them, but they do feel an obligation to the population
to provide a service for them and, by and large, they do exactly
that, and a damn good service.
Mr Gunnell
216. Coming on to something a little bit more
specific about the private work consultants do. Would you accept
that consultants' private work is a factor which leads to NHS
patients waiting longer than they would otherwise do? If you think
that is so, is that fair?
(Mr Machin) I do not think it is a factor.
Chairman
217. Would you accept that some of your members
do?
(Mr Machin) I do not believe there is
any strong evidence about that. It is easy to make that sort of
accusation but actually proving it is very difficult. Correlating
lengths of waiting lists with the amount of private practice in
certain specialties is probably not statistically valid. You are
looking at something which has happened and you are then deriving
a cause from the effect. You could look at my practice where I
have a huge waiting list and I do not have a huge private practice.
The amount of private practice is dependent much more on the geography
than anything else. The rate of insurance of patients throughout
the country varies enormously. In somewhere like Liverpool it
will be down around four or five per cent, a bit higher on Wirral,
go down to Colchester and it is probably up in the high 20s.
218. That is not geography, that is social circumstances.
That is the economic position of people, not everybody can pay
surely.
(Mr Machin) Yes, to some extent—
219. That makes the first point that I made stand
up. People can buy their way in and access medical care on the
basis of the ability to pay. You have just given that evidence
in terms of the geography you have described.
(Dr Hawker) The causal link between waiting
lists and private practice has not been held up by evidence. One,
I have no doubt, can argue that there may be individuals who may
be behaving unethically or inappropriately but there is no clear
evidence. I come back to John Yates, who everyone knows has not
been the favourite in BMA House from some of the reports he has
produced, but even he, on recent statements, has said he cannot
provide concrete evidence which shows this. What we have got to
do, and this is where we are dealing within the contract negotiations,
is to say can we deal with this in a sensible way? Can we get,
with the Department, a definition of what we are expected to do?
What the State, what the National Health Service we work in and
support, what it expects of us, to ensure that we do it. I actually
think that if they do that we will be able to prove that practically
whatever they ask within reason we will deliver plus. That is
the key. That should deal with the problem. What we then come
back to is whether or not there should be in a democratic country
the existence of private medical practice alongside the State
Health Service. That is not a decision that I make, that is a
decision that the Government and Parliament will make.
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