Examination of Witness (Questions 280
- 299)
THURSDAY 22 JUNE 2000
RT HON
JOHN DENHAM
280. I can see why from the Government's point
of view and from the NHS's point of view and the patient's point
of view that is an extremely good answer but I can also see why
Dr Hawker's colleagues might throw their hands up in horror when
you mention productivity. How are you reasonably going to measure
productivity? Is it a fair measure of a consultant's effectiveness?
(Mr Denham) Provided you take all of
the issues into account. One of the difficulties is that the data
that is currently available is often quite crude and will not
easily distinguish between the case mix for the individual surgeon
and the other constraints, like other capacity problems in the
Health Service, for example winter pressures. One of the reasons
we are putting such a big investment into critical care beds is
that we have had periods in the past where elective surgery cannot
be carried out because of other pressures coming into the system.
If you are not careful that can waste the time of the consultant
and also feed through into the productivity figures. In principle,
if you have got good quality data you have got at least a starting
point for the appraisal process, to say "this is the average,
this is where you are against a benchmark, let us go through why
that might be". I do not think it becomes a conclusive issue,
I do not think you do it on the basis of "you saw 50 patients,
you saw 60, so the person who saw 60 must be a better doctor".
None of us would want to work in that sort of environment. You
need good quality data so you can see how somebody is comparing
against the average.
281. The problem is although it is good in principle,
and I entirely accept the point you are making, in practice all
these things are dogged by soft factors. We have found the same
thing with teachers. They find appraisals extremely threatening
and difficult because they say you cannot measure a teacher's
performance by looking at exam results or the number of kids who
turn up in the mornings because it is just too crude. For the
many reasons you have mentioned yourself that are these so-called
soft factors, case mix, winter pressures and all these things,
surely it becomes either so woolly as to be meaningless or so
rigid as to be impossible to comply with?
(Mr Denham) I do not think that is true.
You can get firm enough data to be a starting point for discussion.
It cannot necessarily close the discussion but it is the starting
point for discussion. The alternative, after all, is just to say
"we are not going to look at these issues at all" and
assume that what is happening must be okay. I think that leads
you back to the sort of evidence that was quoted this morning
from the Audit Commission or other individual studies which show
wide and apparently inexplicable variations in productivity and
performance. Let us not forget that productivity is one issue
that we would want to look at in appraisal. There is the whole
question of clinical quality appraisal, it is also the forum in
which a great deal of clinical governance and the gathering of
evidence for revalidation will take place. These are settings
in which you can look at a consultant's performance in the round,
not just in terms of pure measures of numbers of people seen.
282. It might be fair to say that the reason
why the consultant contract is substantially unchanged over the
last 50 years is because government after government have had
these ideas and they have fallen foul of reality and it is actually
extremely difficult. Can you honestly say at the moment that you
are able, and you are on course, to make the changes that previous
governments have not been able to achieve?
(Mr Denham) Yes, I think we are. There
are some difficult problems in this because this is a professional
contract. We know that the vast majority of consultants work very
long hours indeed and none of us on either side of the discussion
want to trigger a clock watching mentality which dramatically
reduces the amount of time that people put into the NHS and simply
say "right, time is up, I am going home". That is not
the way professionally consultants want to work and it is certainly
not the way the NHS needs them to work. But, having said that,
I am confident that the key elements of appraisal as a formal
contractual requirement, of job planning as a formal contractual
requirement, of an employer based process in which the employer
is able, obviously after negotiation and discussion, to determine
when fixed commitments take place, will be there because those
heads of agreements are already in the published document that
we produced with the BMA at the end of last year.
283. You will have heard me ask Dr Hawker beforehand
how he could justify the variation in the number of fixed sessions.
Do you think it is justified to have such a variation in the number
of fixed sessions or would you like to see a much tighter number
of fixed sessions in the contract for consultants?
(Mr Denham) One of the things we have
got to do in the contract is find the best way of describing the
consultant's working week. There are some dangers in saying it
is a thirty-eight and a half hour week because then what happens
to the rest of the time we put in? We need a grip on fixed time,
we need a grip on what is happening the rest of the time, but
we do not want to undercut the commitment that consultants make
at the moment. That is a key part of negotiations, how exactly
you express that, and I would rather not take that any further
at the moment. The second thing is what worries me more than the
statistics about the wide variations in sessions is the fear that
if people are currently under-performing no-one is addressing
that in the system. That is data, if you like, that is coming
out from the individual trust. My worry would be if nobody in
the trust was aware that a person was apparently doing much less
than their colleagues and still less nobody had sat down with
them and discussed why it was happening. That is why I keep coming
back to these twin principles of job planning and appraisal, because
it is at that point, at the point of the individual who is the
subject of those surveys, that the manager can sit down and say
"why is your way of doing your job so different from that
of your colleagues?" and can address the situation.
284. Dr Hawker and Mr Machin both felt that the
reason why some surgeons were able to do as many sessions as they
liked was not because of anything to do with them but because
of the infrastructure set-up, availability of theatres, availability
of outpatients, availability of nurses, etc. Is that a fair argument
and what do you think about that?
(Mr Denham) It must have been a factor
because we would not be putting the big investment into critical
care beds that we are, or big investment into intermediate care
to tackle bed blocking, if we did not think there was a problem
with bottlenecks in the system, capacity problems in the system,
which affect a lot of things that hospitals do and amongst those
things is access to elective surgery. Yes, there are capacity
constraints in the system and one of the reasons we wanted and
needed the extra investment the NHS is now getting was that gives
us the ability to deal with those capacity problems.
Mrs Gordon
285. On accountability, obviously this is one
of the things that has come out, that there does need to be more
accountability, and it is very good to have the appraisals and
job plans going across nationwide, but can I just ask on that,
who will administer this? How will it work? There is a problem
with resources to make it work and workload. Quite often you put
a system into place and people say "oh, no, something else
we have got to do". How will it actually work on the ground?
(Mr Denham) Some of these details have
got to be worked through in the negotiations. I think the evidence
that we have picked up from those hospitals that have, as a local
initiative, initiated effective appraisal is that almost always
the time you invest in doing something pays dividends the rest
of the year because you are sitting down formally and sorting
out problems and identifying issues. We need to do two things.
There clearly needs to be a very strong clinical input into the
appraisal system because a lot of the issues under discussion,
including part of the issue of how people organise their services,
address clinical issues. We also need to make sure that there
is a line of accountability that goes right up to the chief executive
of the trust so the chief executive is able to have an overview
of the work of the whole of the consultant body and be sure that
everything is working as effectively as possible. Details of how
we get those elements together have still got to be worked through
in negotiations.
286. Have you any idea when it is likely to begin,
to be implemented?
(Mr Denham) Negotiations are under way
at the moment. As I think Mr Machin said earlier, we have spent
a long time trying to work out a system of intensity payments
which are distributing part of the money which the DDRB recommended
last year. Most of the formal negotiation time has been spent
on those. Inevitably in the nature of things a certain amount
of informal discussion takes place around the margins of that,
so the issues of job planning and appraisal and so on are not
new ground entirely. We would like to be in a position to report
to the DDRB, the review body, in their next round in the autumn
that we have wrapped this up, we have made progress to wrap up
this contract on these key issues. That is a challenging timetable
but I think ourselves and the BMA will do everything possible
to meet that sort of timetable.
Mr Gunnell
287. Professor Yates described the contract which
exists for the consultants at the moment as one which allows highly
talented staff "to go and work for the opposition—not
just out of hours, but during the normal working week". Would
you say that is true of the present consultants' contracts? Can
you allow such an arrangement to continue? Do you think it is
in the best interests of the NHS?
(Mr Denham) It is an odd situation, I
accept, and the contract arguably does allow people to go off
within their contracted hours if you look at the contract as a
purely thirty-eight and a half hour week contract. In the context
of overwhelming evidence, which everyone broadly accepts, the
vast majority of consultants are working far longer hours than
that and the contract is not seen as one that is strictly tied
to a certain number of hours a week. I am not sure the issue is
as relevant as it would be in a strict nine to five Monday to
Friday job. At a time when we are trying to get the whole of the
Health Service to move as far as we can away from the idea that
the NHS is a nine to five Monday to Friday organisation rather
than a seven day a week organisation with quite extensive hours
of operation, in those circumstances it is a helpful concept.
What I do think is important is that the appraisal and job planning
system is able to be quite clear about when, where and how consultants
are delivering their NHS duties. There are clearly some circumstances
in which the timing of private work could be disruptive to NHS
activity and we need to be able to deal with that. There are other
circumstances in which it could be taking place within what we
traditionally see as the normal working week where that is not
actually a problem.
288. Do you think that the amount of private
work which may be undertaken is best controlled by stipulating
the maximum number of hours or is it best controlled by stipulating
the maximum amount of money in terms of a percentage of the NHS
work?
(Mr Denham) I think it is probably addressed
by making sure that we have got a system that gives effective
oversight of the time that people are giving to the NHS. That
is where I start from in looking at this issue. People are contracted
to work for the NHS, they are by and large working very hard,
productivity is higher than in most other European countries,
we have got less doctors per head, and we are trying to address
that problem over time. What we need to do is to look at the effective
use of the time that people are giving to the NHS and make sure
that is being handled properly through appraisal and job planning
and, through that, to tackle the variations which do exist in
the way people perform.
289. So you would not actually want to specify
either a maximum number of hours, nor would you want to specify
the ten per cent rule where you would want to make sure that the
necessary time was given to the NHS?
(Mr Denham) There is a ten per cent rule.
I am sure that in the negotiations with the BMA we will want to
look at the way in which private practice is handled in the contract
and the way in which it is regulated.
290. Yes.
(Mr Denham) But I would not like to go
further than that today.
291. What effect do you think that private work
does have on NHS patients' waiting times?
(Mr Denham) I have not yet seen evidence
that suggests, or proves rather, that, if you like, blatant lengthening
of waiting lists in the NHS takes place in order to generate greater
opportunities for private work. There are statistical correlations
but the cause and effect issue is not proven. Where we need to
look at the system carefully is whether we have got all the rewards
in the right way that encourage people to give more of their time,
or most of their time, and effort to the NHS rather than to the
development of private practice. That is obviously an issue in
looking at how we allocate the intensity awards. It is the reason
why we agreed an initial change in the discretionary awards this
year to give greater emphasis to NHS service. We need to look
further at the whole structure of rewards from intensity payments
to discretionary payments to distinction awards to make sure that
things line up and, where people feel they have a choice between
putting greater effort into the NHS or developing private practice,
things are clearly incentivising the biggest contribution to the
NHS.
292. You heard what took place in our discussion
with the BMA representatives. Are you optimistic that you will
be able to come to a contractual agreement with them which will
enable you to have a system in which the NHS gets full value for
money and in which you have that degree of flexibility which is
necessary and that degree of, in a sense, rigidity which is necessary
from the NHS point of view and one in which you can get value
for money?
(Mr Denham) Yes, I do believe it. We
are not there yet but I do believe it can be achieved. I would
stress that any contract needs to be managed, so in addition to
agreeing, if you like, the legal document with the BMA we will
need to make sure that at trust level the structures and the capacity
are in place to manage the contract effectively because if we
look back over the past however many years we can see there are
wide variations over job planning, over appraisal and so on at
local levels. We will need to manage it effectively.
Chairman
293. Can I come back to a point I raised in the
earlier session about Professor Light's assertions in relation
to the waiting lists and private practice where he alleged that
the consultants' control of waiting lists is "a blatant conflict
of interest, an invitation for mischief". He puts forward
some very strong ideas about what he terms as dubious practices
in which consultants sometimes engage to increase private work.
Do you accept that there are some concerns in this area? Are you
looking at this issue of control of waiting lists by consultants,
particularly consultants who have got their own private practice?
That is going back to the first point I raised with you earlier
on.
(Mr Denham) Certainly there are a number
of trusts up and down the country which in key specialities have
actually agreed to move away from consultant specific waiting
lists and from consultant specific referrals and that has often
developed, not exclusively, where people have developed booked
admissions programmes.
294. So you believe that is a way of getting
round this potential conflict?
(Mr Denham) I think that is a very good
practice. There are some sensitive issues because if you have
a team of surgeons with greater and greater specialism it will
not always be appropriate to refer, as it were, to the general
body or to the person with the shortest waiting list. That is
an issue for GPs who are doing referrals as well as consultants.
I saw a system in Lewisham the other day, for example, the direct
booking system, which will enable GPs either to refer to any named
consultant or to the consultant group as a whole. I think in broad
terms we would encourage those types of development because they
do avoid the situation which I certainly see in some parts of
the country with patients stacking up at the end of somebody with
a very long list for what is actually a very routine procedure
and others with much shorter waiting lists. So it is not just
on the question of interaction between private practice and the
NHS, it is often a more efficient use of consultants' time.
295. So in practice there are some areas where
we see a difference of approach being taken which you would encourage?
(Mr Denham) Yes.
296. Would that be part of your discussions with
the BMA at the moment?
(Mr Denham) They are not part of the
contract negotiations at the moment, they are very much part of
the wider discussions about modernisation and how we push forward
best practice in the NHS.
297. This might be something which is in the
announcements next month?
(Mr Denham) We will have to wait and
see what is in the announcement!
Mr Burns
298. Good try!
(Mr Denham) You lulled me into a sense
of false security!
John Austin
299. In essence, you are actually saying there
is some merit in Professor Light's proposal for booking and assignment?
(Mr Denham) I think there are many merits
in that sort of approach, not necessarily, to be honest, to address
the issue which has been the main issue in front of the Committee
today about abuse through private practice, but where there are
systems of that sort running it can simply mean far less inequity
in the waiting list for different surgeons and the best use of
time of doctors, and where there has been agreement that is the
best way to do it, it can bring significant improvements.
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