Examination of Witnesses (Questions 220
- 239)
THURSDAY 22 JUNE 2000
DR PETER
HAWKER AND
MR DEREK
MACHIN
Mr Gunnell
220. What you are saying, first on Professor
Yates, the statement he made to us, last week, is contentious.
He says "... it is incontrovertible that private patients
are treated more quickly than NHS patients... There is also some
evidence which suggests that not only do the rich get treated
earlier, but also more often". When he says that evidence
is incontrovertible would you say it is?
(Dr Hawker) That is not linking the existence
of private practice with the length of NHS waiting lists. What
it is saying is very clear, that there are fewer people seeking
private medicine, which is incontrovertible, if you have fewer
people coming through a system. When we have worked with the Government
over the next five years and used the extra funds coming in and
we have the extra resources, you will see waiting lists come down
because we will have more people to see the patients so that it
is patients per doctor, that is the key. At the moment this country
does not have enough doctors to deal with the patient population.
Chairman
221. Could we extend the point just to reinforce
the point you are making. Do you then dispute the Audit Commission's
comment that the results of the work they did show that 25 per
cent of consultants who do most private work carry out less NHS
work than their colleagues? That surely has a bearing on the waiting
list?
(Dr Hawker) It has an influence on waiting
lists but it is wrong on one condition, and one condition only,
that 25 per cent are not fulfilling their National Health Service
commitments. I have no doubt that if you take people who are working
45/50 hours a week for the National Health Service, they are able
to spend less time in private medical practice than somebody working
40/45 hours for the National Health Service. Both groups of doctors
are more than fulfilling their commitment to the National Health
Service. Where I think you have a perfectly valid and perfectly
acceptable point, and one that I would agree with, is if somebody
is not doing what they are expected to and what they are contracted
to and it is having a deleterious effect on the National Health
Service, then that is actionable. If there is a systematic abuse
of that, we have to track it down and name it and deal with it.
I do not think there is a systematic abuse and I think that Audit
Commission information, what they do not do, they do not look
at what hours those doctors are spending.
222. The figures are wrong?
(Dr Hawker) No, the figures are absolutely
correct. They have found the percentage of people who do more
private work do slightly less NHS work than somebody who does
less private work.
223. Significantly less?
(Dr Hawker) What I am saying is are those
doctors fulfilling their National Health Service contracts? If
those doctors are fulfilling their National Health Service contracts
and over, then there is nothing wrong with what they are doing.
It is when they are not fulfilling their contract that it becomes
a matter of contract law and disciplinary procedure.
Mr Gunnell
224. You are clearly in favour of much tighter
contracts than there are at the present time?
(Dr Hawker) Yes, we have been looking
for much tighter contracts for a number of years.
225. I get the impression from what you said
earlier that would imply you would want to have the ten per cent
rule in the contract and you would want the ten per cent rule
to be reinforced?
(Dr Hawker) No, what I want is a contract
which spells out what I have to do to fulfil my contract. I then
want to be held to it.
226. I see.
(Dr Hawker) I do not want to have systems
which are unworkable. It is easy to find out what I am doing,
it should be easy with appraisal and a proper contract review
to make sure I fulfil my contract. What I do outside that contract
should be a matter for me and my conscience.
227. How much time do you think consultants should
be allowed to take off to do private work?
(Dr Hawker) Consultants do not take any
time off to do private work. They do private work in their time
when they have fulfilled their contract.
228. On the evidence we have there seems to be
a slightly more relaxed attitude to that in that in 1990 Sir Duncan
Nicol asked how many half days it would be unreasonable for consultants
to take off for private work and he thought that it would not
be reasonable to take more than one half day a week. The Consumers'
Association asked the same question of Sir Alan Langlands and
he said that "the nature of such contracts is a matter between
the individual consultant and the employer." That implies
a less rigid attitude to the one half day a week.
(Dr Hawker) This concept of taking time
off expresses a fundamental misunderstanding of the nature of
the contract. We do not get leave of absence to go and do private
practice. What I have is a contract which spells out how much
work I should do, certain sessions where I ought to be unless
I have permission, and I have permission to be here today, I assure
you, what the allocation for being on call is. Once that is fulfilled,
it is not taking time off, it is using the time that is mine or
my colleagues. What I am saying is that what we want, I would
agree with you entirely, is much clearer demarcation of what the
contract requires, what the hospital is employing us to do. Once
we have done that and we have put in the mechanisms to police
it, it is not a matter of taking time off, it is what the doctor
is doing with their spare time. One might encourage people to
spend a little bit more time with their families, but if for their
personal circumstances they wish to go fishing for the day and
not spend time with their family, or spend the morning in a private
hospital and do other things, that is as long as it is in their
time, not the time they are employed by the hospital.
229. What you want is stricter control mechanisms
in terms of the contract? You want the contract to specify very
rigidly what is expected of the consultant?
(Dr Hawker) Again thinking through the
consequences, with too rigid control, there could be a distortion
of how medical practice works. Dr Stoate will know you cannot
rely on patients coming in acutely ill between nine and five Monday
to Friday which is why we have to have flexibility. You cannot
rely on the time when somebody in hospital has a complication
or a problem, we have to have that flexibility. There is a balance.
One way of doing it, a chief executive I used to know suggested
"What I want you chaps to do is to sign up, nine to five
Monday to Friday. There are your ten sessions". He was rather
taken aback when I got a draft contract on those terms typed out
and I said "That is fine, now what are you going to do about
the other 128 hours a week?". This has been the problem.
I happen to think that the professional attitude to providing
care way beyond anything which you should be strictly nailed down
to is the right way. Another view among many colleagues increasingly
is that because we have done this in the past, and there have
been accusations that we have been short changing the National
Health Service, well let us time every minute that the Service
buys and then when we finish that is what we have done. Now I
think somewhere between the two is a balance which retains all
the benefits that the Health Service want, better policing, if
you like to use those words, better care and better quality without
losing the professionalism that most of us still happen to believe
in. That is where the negotiation has to concentrate on getting
that balance. What I would not want to do is to tie things down
too tightly to protect doctors against unreasonable accusations
and cost the National Health Service a lot of high quality people
and a lot of high quality time.
230. In the discussions which you are going to
have with the Department of Health very shortly that will be the
sort of contractual mechanism you will seek to put in place?
(Mr Machin) Yes, very much the case.
We want a contract which is fair to all parties, patients, doctors,
management, Government. We do not think the current contract is
particularly fair. You are anxious about under-compliance, my
colleagues press me because they feel they are being unduly screwed
down by the current contracts. They are having to do very long
hours of work for which they do not feel they are properly remunerated.
Somewhere along the line we have to reach a balance on this. As
Peter has indicated, one can go too far in the direction of, if
you like, paying hour for hour and actually contracting on a very
tight basis. Equally well at the moment the current contract seems
to some of us to be the worst of all worlds because the vast majority
of contracts way over achieve on their contract and yet the profession
is constantly under criticism for alleged breaches of contract.
We have what for many of us is an appalling paradox, the way in
which the profession views its compliance is totally different
from the way other people look at it.
231. You will be seeking in your discussions
with the Department of Health—and the Minister is here listening
to you before he meets with us—a contract which gives you,
in a sense, the appropriate level of flexibility but which delivers
for the Health Service what they want from consultants?
(Mr Machin) Yes, I think that is a fair
comment.
232. One in which patients in the Health Service
get the benefit for consultants' working time?
(Mr Machin) Absolutely.
Mr Hesford
233. What would be the minimum hours then per
week if you want to tie this thing down that would be acceptable
in your contract and then you can go off fishing?
(Dr Hawker) Minimum hours, again I do
not know what the Department have. As far as I am concerned minimum
hours, we cannot do anything less than about 60/70 at the moment
which would give me a major advantage and cut back a little bit.
234. This is a serious question. From your point
of view what would be the acceptable minimum?
(Dr Hawker) I think there are two points.
235. However you spread it over the week what
would be the acceptable minimum?
(Dr Hawker) There are two areas. One
is you will have to have a part-time option for equal opportunities
legislation and a whole host of reasons people wish to work part-time.
We have evidence that some people wish to work or be able to work
two or three sessions a week, that is what ten or 11 hours, others
on part-time contracts will work eight or nine sessions a week,
again for personal circumstances, which is 27/28 hours. There
is nothing wrong with that. You might say "Well, that is
the minimum" if you like. I think to maintain clinical practice
I suspect someone would have to put in a good two sessions of
clinical work a week or maybe three to maintain their expertise
and their quality. There may be a minimum on the quality of care
but I do not think there is a minimum on what we can offer to
people or what people may wish to take up. If you adjust the payment
so that there is a reasonable unit payment then what we are looking
at is what is a maximum that one should be expecting from people.
Then we have the difficulty of how do you take into account the
emergency on-call because if you put in an hour for an hour, on
doctors in many hospitals doing one in four by Tuesday evening
the European Directive 48 hour maximum working week comes in and
that doctor has fulfilled everything that English law now says
that they have to do, 48 hours work. I think to come up with a
simplistic figure of what is the basis of the contract, I do not
think it is possible. I am not too sure quite honestly even if
I did that with John, Colin and the entire team sitting over there
I would let them know what I am prepared to settle for in contract
negotiations.
236. We are not negotiating, we are seeking simple
adult evidence.
(Dr Hawker) I have given the evidence.
I think there is a minimum time that one has to work with patients
to maintain quality. One could argue that might be two sessions,
three sessions a week. So if you are asking what is the minimum
a doctor should be contracting for the National Health Service
I would say probably between eight and ten hours.
Chairman
237. Can I come back to the issue of the relationship
with waiting lists and the waiting list question, the alleged
perverse incentives which have been widely discussed. Mr Machin,
a few moments ago you said that Professor Donald Light who has
written to the Committee—and you will be aware of the detailed
articles published in the BMJ on the issue of contract -you said
he has an odd view of how the Health Service works, that is paraphrasing
what you said a few moments ago. I suspect he would say you were
defending the indefensible in respect of the impact of the current
contract on patients and on waiting lists. In his evidence to
us he suggests that consultants' control of waiting lists is "...
a blatant conflict of interest, an invitation for mischief".
I wonder how you feel this conflict might be resolved and how
do you respond to Professor Light's assertion that consultants
engage in dubious practices in order to increase private work?
Is he completely out on a limb on this or has he got some merit
in what he is saying?
(Mr Machin) People are making allegations
that there is some sort of manipulation of waiting lists in order
to direct people into the private sector. I think that is capable
of being investigated.
238. Can I just butt in about allegations. If
you had a private practice and if I was waiting to see you and
you told me that I would have nine months to wait for a particular
problem—and I do not know the detail of what you do—but
if I was to cross your palm with silver I would be in to see you
next week and in for treatment the week after, is that not wrong?
(Mr Machin) I would not say that to you.
239. I am not saying you would but some consultants
would.
(Mr Machin) I am very uncomfortable about
anybody raising the subject of private medicine in a Health Service
clinic. I would never do it, occasionally patients ask. It is
fine I will answer their question but I would never raise the
subject to a patient and suggest that were they to opt to go privately
then I could do something for them quicker.
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