Examination of Witness (Questions 300
- 312)
THURSDAY 22 JUNE 2000
RT HON
JOHN DENHAM
300. Can I take you to the international report
which came up? You heard the exchange earlier. One of the comments
about that was that there could not be fairness so long as we
maintain the present mixture of private and NHS work. There has
been a report of some talk in Whitehall that the Government may
be considering, amongst many of the options, the possibility of
buying out the consultants' right to work in the private sector.
Is there any truth in that rumour and what sort of financial calculations
do you put on it?
(Mr Denham) I would be the last one to
wish to substantiate the sort of rumours that are in the press.
The issues that are involved if you were to consider that sort
of thing are well-rehearsed, there are issues about equity and
issues of expense—equity in the sense that very few paediatricians
or psychogeriatricians have any private practice, they would probably
feel very happy if they were paid the same as it would cost to
buy out, say, the orthopaedic surgeons, but that is a big cost
for what you get at the moment. The other way round, it is quite
expensive to go for the very highly paid specialties. So there
are numbers of issues of that sort if you were to go down that
route, but I am not going to comment at all on the rumours you
said were in the press.
301. Could I raise a different but somewhat related
point? Since it has been asserted all along that consultants are
not off on the golf course and that they are working more than
the hours they are contracted to do in the NHS, and we have talked
about the other capacity problems which cause the waiting list
to grow, the Government has recently made some suggestion that
one way of tackling this perhaps in the short-term is a planned
use of spare capacity in the private sector. After our last session
when that was raised, the Secretary of State said it would be
renting space in the private sector and people would be treated
by NHS staff and personnel. If there is no spare capacity as far
as consultant surgeons and the rest are concerned, how would that
be a reality?
(Mr Denham) There will be times at the
moment when we have capacity problems, where, for example, an
individual NHS surgeon is not able to operate because of other
pressures on the system. There was clearly a situation in early
January this year, the first week in January, when significant
numbers of planned operations were cancelled because of winter
pressures—
302. But that was winter pressures on the medical
beds which spilled over. I can see an argument for using the spare
capacity to manage the winter pressures.
(Mr Denham) In those circumstances, it
is conceivable, for example, that you could have an NHS consultant
unable to operate because you do not at that time have the capacity
in the NHS, but an operating theatre which might be used by the
NHS consultant and the whole NHS team, or the NHS consultant with
a team supplied by the private sector, enables those operations
to be done in the private sector. That is an NHS patients, by
an NHS consultant, but in a building which is physically part
of the private sector hospital. It seems to me that in those sort
of circumstances that ensures the NHS patients get treated and
is a solution to a capacity problem that the NHS has if you cannot
provide the operating theatre space for the doctor to operate
in.
303. There will be no additional financial resources
available to the trusts or wherever to do that, therefore would
you not merely be taking more money away from the NHS and putting
it into the private sector?
(Mr Denham) You are paying a salary for
the consultant anyway—if the consultant cannot do a list
you are still paying their salary, they are not on piece work
although it sounded as though we were getting quite close to it
earlier in the discussions. It would actually enable them to be
operating in another setting. Of course, that does not mean that
that is the situation for a year and a day because there will
be costs to doing that, payment would have to be made and in looking
at the trusts' capital programme and future development and sensibly
making the best use of NHS resources you will say, "Do we
need extra operating theatre capacity?" The constraints can
sometimes be physical in terms of physical facilities like operating
theatres, sometimes it may be staffing—intensive care beds
and whatever. I think that making sensible use of those types
of facilities in the way I have described will mean that NHS patients
who would otherwise perhaps have their operation cancelled can
be done as NHS patients.
Chairman
304. I have listened carefully to your answer
to John Austin and what you are proposing in fact has happened
over many years. The NHS use the private sector in a number of
ways and we, as a Committee, have looked at this recently. One
of the worries I have, among many of the worries which I am sure
you are well aware of, is that the manner in which you are suggesting
use of the private sector implies it is a short-term fix effectively
until something happens in the NHS to expand the NHS ability to
treat these patients within the NHS, but the record actually proves
the opposite. The record we have seen—and mental health
is a good example which the Committee looked at quite recently—is
that where you do use the private sector because of lack of capacity
in the NHS that in a sense prevents the NHS resolving those issues
at a local level itself, and therefore you end up built into a
long-term usage of the private sector which effectively stops
you addressing the key issue at local level. The best example
that we have seen recently is the use of private psychiatric facilities
at the other end of the country for patients in London. In some
parts of London they have not needed to do that because they have
addressed the issue in their own areas, but others have preferred
to use the private sector and have not come up with their own
solutions which would have been far better integrated into their
own areas where people actually live as opposed to 200 miles away.
The worry I have about the concept you are suggesting is that
the track record so far is one where that sort of arrangement
avoids addressing the real issues in the National Health Service.
It is a short-term fix but you end up with a long-term arrangement
which does not resolve the difficulties you should be addressing
in the first place.
(Mr Denham) I think it is very difficult
to say to a patient who could be treated perhaps in the next 12,
18 or 24 months in the way that I have described, "Well,
we are not going to let you be treated, even though you could
be treated, because we have long-term worries that we cannot run
the NHS properly." That is my real worry. I think we have
made it very clear that the principles of value for money, best
use of NHS resources, do not change in trying to put the basis
of working with the private sector on a more formal basis. Those
principles must be right and they are ones we have always held
to, that we do not want money wasted which could be better used
in the NHS itself. But, equally, I think it does make sense to
recognise that if there are opportunities to make sure the patients
are treated which represents a good use of NHS staff time and
NHS resources, we should do that.
John Austin
305. I think this is an argument for another
time but I still do not understand the logic of that because the
trust does not have any extra money, it is fully committed to
its resources, it may be there is a shortage of care staff or
nursing staff or whatever but if there are no additional resources
and you take that money out of the NHS, even if you are treating
more people, there is then not the resource to provide a service
in the NHS.
(Mr Denham) What we have to recognise
is that as we build up the capacity of the NHS and tackle some
of the shortages of capacity then things will get better. In the
situation we are currently in when we have only begun that process,
although we have made some good progress, our current use of resources
is not always optimal. If you have a surgeon who cannot operate
because they cannot get into an operating theatre or because the
medical beds have been taken up with delayed discharges from hospital,
then you are not making the best use of the skills of that person.
That is why, whilst we are, yes, investing substantial amounts
of money in extra critical care beds, trying to address one part
of that problem, and making substantial investment in intermediate
care, trying to free up the medical beds, nonetheless the potential
is still there at this time for possibly the highly expensive
skills of individuals not to be used. If we could find a way of
using those and treating NHS patients, that seems to me to be
a reasonable thing to do.
Mr Amess
306. John Austin has said it is an argument to
have another time, I think this is entirely the right time and
place to have the argument. Listening to you very carefully, it
seems to me as if there has been a dramatic change in Government
policy. This is extraordinary! I would like to ask first of all
-and dressed up as it is, I cannot think all of your colleagues
will be enamoured with this change of policy, there has always
been this mix between the private and the national sector—why
and when did you as a Government minister decide to do a complete
about-turn and suddenly find that the arguments that people like
myself have always employed fit your circumstances now that you
are in terrible difficulty and you are not delivering on people's
expectations as far as the National Health Service is concerned?
(Mr Denham) The answer is, of course,
that you are trying to knock down a caricature of your own making.
It has been the case throughout the three years of this Government
that use has been made of private sector facilities to treat NHS
patients when the NHS has not had the capacity to do so. We have
not tried to ban that from happening. We have said, quite rightly,
we have to make the best use of NHS resources, which has been
happening. It does seem sensible to try to put the basis of that
co-operation on a more formal and regular and clear basis, so
that people can see what is going to work and what is not going
to work. That is what we are doing. If that removes a caricature
of the Government that you used to find convenient and which you
can no longer snipe at, that is not my problem.
307. No, not at all. I do not think this Government
does anything lightly, I think they deliberately wanted this to
be known, but much as you say this has always been done since
1997 I think it was ideologically something which the Government
did not countenance. Given that as far as I am concerned there
has definitely been a complete change of policy, and you have
said you are going to put it on a formal footing, how long is
this going to continue? Until the waiting lists come down? Until
the general public are satisfied that the Health Service is improving?
Is this an open door or is there a time limit on it?
(Mr Denham) There is not a time limit
on it. Circumstances will change over time, the nature of the
partnership you need with the private sector may well evolve over
time as the NHS builds up its capacity, but there is not an arbitrary
time limit on this. What we are trying to do is talk to the health
care providers on a national level about the best basis for a
partnership so it is clear to everybody how that is working.
308. I think this is very helpful and I am pleased
the Government has changed its view on this. You listened very
carefully to the two gentlemen giving evidence beforehand, do
you as a Government minister condemn those who have—and
you talk about a caricature—characterised these consultants
as being a lot of money-grabbing people going fishing (who the
hell wants to go fishing, I do not know, but anyway if it gives
them pleasure) and playing golf? It seems to me that they were
trying to cry out for help, that morale is so low amongst consultants
that they are fed up with being beaten over the head because they
are doing private work. Could not the Government help with this
and give a steer and say, "No, we think it is awful you are
being criticised, we quite understand there has to be a mix of
the two sectors"?
(Mr Denham) I hope that nothing I have
ever said has added to the caricature that is being portrayed
of consultants. The vast majority of consultants work extremely
long hours for the NHS, they work very hard for the NHS, they
are productive. But there are variations in productivity and performance
and in the way people do their service, so we need to have a contract
which can deal with the other in a properly managed system. I
think that is what the vast majority of consultants want. It is
also the case that clinically the great majority of doctors are
very good, but on a similar basis, as sadly we have seen rather
a lot of cases recently of high profile, there are areas of clinical
under-performance. That is why, in parallel with everything we
are doing on consultants' contracts about pay, we are introducing
the new systems of clinical governance and performance assessment
and support to deal with the minority who let down the rest.
309. A final point, Chairman, because I will
not bore everyone with it too much because I think we did this
a year ago at the Committee Stage of the Bill—we are reliving
it—I just wonder, now that the Minister has had time to
reflect on this, would he agree with me, considering the consultants'
contracts, that particularly in my area to have paid consultants
large sums of money to come in and work on a Saturday because
it then suited the Government's agenda to get the waiting list
down, was a little hypocritical given that the Government, when
it suited its own purposes, was more than happy for the consultants
to take the flak for not honouring appointments? It seems to me
as if the Government wanted it each and every way. Given that
money is so scarce, it seemed pretty hypocritical that they were
paid all this extra money.
(Mr Denham) That is clearly a matter
for each trust to judge. If a trust was satisfied—I hope
they would have had to be—that the consultants were in the
rest of the week entirely fulfilling their obligations and a reasonable,
good level of work in the NHS, if they wished to make the extra
payment, that is a discretion available to the trusts to do. It
is done for a variety of purposes. It is done on occasions to
increase the number of patients who are treated. It is sometimes
done because people take on additional responsibilities over and
above the ones they would normally exercise. That is a decision
which has to be taken at local level by trusts. What I hope is
that with a new contract in place, the system of appraisal and
job planning will actually give everybody a much better baseline
against which to judge when something should have been done within
duties anyway and when some extra reward is required.
Dr Stoate
310. You have already talked about the structural
difficulties in the NHS when I asked you about how long consultants
were able to operate for, and Mr Amess has been pressing you on
the policy of allowing the private sector to use its spare capacity
and consultants to work on Saturday mornings to clear the backlog,
but how much of the structural difficulties do you think are due
to the fact that the NHS has closed far too many beds over the
last 20 years and has not trained enough nurses over the last
20 years? I probably know the answer!
(Mr Denham) I am very glad you have asked
me that question! In the National Beds Inquiry we set up the first
inquiry into the number of beds the National Health Service needed
for a generation, and it shows that we need more beds particularly
in intermediate care, if we follow the strategy of care closer
to home, and we have begun the process of investing in developing
intermediate care provision this year. Of course, we are suffering
in nursing supply at the moment from the cut in the number of
nurses in training in the early part of the 1990s. We have increased
that but it will be a number of years yet—well, we will
never absolutely make up the losses, we would have another 15,000
trained nurses employed if that had not taken place, but we have
not. We have dramatically increased the number of training places
and the number of people who want to become nurses.
Mrs Gordon
311. To get back to accountability, Mr Machin
earlier on mentioned the Green Book, or in his case the not-so-Green
Book, and the need for it to be up-dated and that past Governments
have failed to do this. Is it one of the things that you are looking
at?
(Mr Denham) I think there is an understanding
between us that when you look at the contract as a whole, this
whole question of how you regulate or monitor or enforce within
the private sector, whatever private sector allowances may be
in the contract, needs to be looked at. I think the decisions
were taken a bit before my time in the Department but I think
the view of this administration was that it did not make sense
to try and deal with the Green Book as a separate issue outside
the context of the consultants' contract as a whole. We have been
keen to deal with the whole package of the consultants' contract
including the relationship with the private sector work rather
than just take the Green Book in isolation.
312. Can I just confirm that the contract that
will be negotiated is going to be a national contract with no
local variations?
(Mr Denham) Our aim is to have a national
contract. The extent of trust variation is something which has
to be looked at but our aim, as with Agenda For Change,
is that we are looking for a national contract but there may be
scope for local flexibility.
Chairman: Minister, thank you for your attendance.
We are very grateful for your help in this inquiry.
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