Examination of Witnesses (Questions 100
- 119)
THURSDAY 2 NOVEMBER 2000
MR COLIN
REEVES CBE, MR
BILL MCCARTHY,
MR DAVID
WALDEN, MR
HUGH TAYLOR
CB AND MR
PETER COATES
100. And, presumably, once you had had your
first operation you would then have to wait for your second, right?
(Mr McCarthy) That is correct, yes.
101. Why then, nowadays, for the in-patient
hospital waiting list, is that activity considered to be one wait,
so when you have had the first operation and you are waiting for
the second you are off the waiting list?
(Mr McCarthy) I shall check what I said about episodes.
I think I was using loose language there. From the patient's perspective,
it seems to me, it would be one piece of care, but "episode"
has a technical meaning which is apart from common sense, always.
(Mr Reeves) That is absolutely right. I think, statistically,
it is two operations and it is also two episodes of care.
102. Right; but the point that Mr McCarthy has
just very kindly made is that most people, in the real world,
think they are waiting for an operation and they need two, which
then, if one were cynical, which I am not, some people would argue
that they think that the Government is artificially bringing down
the waiting list by considering the two operations to be an episode
of treatment, and one. And I know you cannot answer, so I will
not ask you to, but I will ask you to answer this. If you, at
the same time, had to have a cataract operation and a knee replacement
operation, and for clinical reasons they decided that you could
not have both on the same day but there had to be a wait, would
that be an episode of treatment so you would come off the waiting
list after you had had your cataract but before you had had your
knee replacement, or would that be considered as two different
operations, not an episode, so you would still be on a waiting
list?
(Mr McCarthy) I think that is two different operations
with different, I hope, consultants.
103. I hope so, for your sake.
(Mr Reeves) And, therefore, two episodes of care.
Dr Brand
104. It tended to happen the other way round,
actually, where you could get lots of patients' finished episodes,
consultant episodes, in on one patient by just getting a few guys
together on the same afternoon. We were talking about waiting
times, which clearly needs capacity, and now we have the concordat
obviously we need to explore what sort of contribution the private
sector will make. Can I ask what the expected expenditure by the
NHS in the private sector is likely to be?
(Mr McCarthy) I do not have a forecast of what that
expenditure is likely to be. I think, in the papers we provided
in response to your questions, we set out from accounts, in Table
1.4.1, our latest information from 1998-99 on what spending is
at the moment, and that is £1.25 billion, 4.8 per cent, of
total NHS spending. I do not have a forecast of where that will
go.
105. But we have just had a concordat signed,
which presumably is not a blank cheque, so there must have been
some figure in the Secretary of State's mind as to how much NHS
resource was going to pass over to the private sector?
(Mr McCarthy) I do not have any figure.
106. We will ask him next week.
(Mr McCarthy) I think the way that the concordat is
set out is that where the quality of services is judged to be
adequate, where this represents cost-effective value for money
for the NHS, and where it makes operational sense for the NHS,
then they should be free to use private sector facilities. There
is not, in that concordat, any target spending in the future on
the private sector.
107. Not even an estimation; but I think we
will have to take that up with the Secretary of State, if you
do not have it. How is that treatment cost going to be negotiated;
is it for local determination?
(Mr McCarthy) That is for local determination.
108. If they fail to deliver, is it going to
be a cost per case contract, no matter what?
(Mr McCarthy) I think that is up for local managers
and clinicians to decide, on the basis of what is appropriate.
It may, in some cases, be cost per case, it may be, in other cases,
hire of facilities, where the consultants are still working as
part of their NHS contract and we are simply using the private
sector for extra operating space and some recovery facilities.
I think it needs to be for local managers to decide what is cost-effective
and appropriate in their circumstances and then to agree what
is reasonable with the private sector. If it is not reasonable,
if it is not cost-effective, then local managers will not do it.
109. But given sort of national benchmarking
on everything now, are there going to be indicative prices that
are reasonable, or is it going to be based on the cost that the
local trust would have to meet for in-house procedures? Then,
of course, you have got the extra argument about the private sector
creaming off the easy bits, usually, and leaving the more complex
bits to the NHS. So that skews it. I would have thought there
would be a national indicative figure above which one should not
stray?
(Mr McCarthy) On the other hand, I think those very
factors that you pointed out, about the case mix of the people
being transferred, probably points to the need for local managers
to understand precisely the patients who have been transferred,
and to have a good feel, in those specific circumstances, whether
the price, whether it is just for facilities, whether it is for
the whole operation, whether that represents value for money locally.
110. I hope you are going to give them slightly
more support than what appears from your reply at the moment;
even the insurance companies have fairly good indicators of what
they would be prepared to pay and what they would not be prepared
to pay?
(Mr McCarthy) We probably will have information available.
(Mr Reeves) And you could come back and reinforce
what Mr McCarthy said, in a sense. The concordat was signed very
recently, it is intended as a national framework. I think he made
it very clear, in terms of the concordat itself, that the actual
individual agreements will be determined at local level. And,
I think, if you go back to the new NHS and when we started thinking
about long-term service agreements, again, the intention was that
contracts would be determined and signed at local level. Now it
could well be, through the passage of time, that there is guidance
from the centre to suggest limits, or some broad indication about
how those contracts should be formed, but at the moment I do not
think you can put too much individual detail to what is a broad
conceptual document.
Chairman
111. Can you tell us how long this concordat
is going to run for?
(Mr Reeves) There is no timescale at this stage.
112. So we are into this indefinitely then?
(Mr Reeves) It is open-ended, yes.
113. It is not a quick fix, it is a long-term
arrangement, this?
(Mr Reeves) I am sure it is seen as potentially a
long-term arrangement.
114. Can I raise a practical question, and I
noticed in the Statement by the Secretary of State he made clear
that it may well be that private sector staff, particularly nursing
staff, could be used within this arrangement. I know, Mr Taylor,
you are concerned with human resources, and we had you here before
when we looked at staffing levels, and, as you will recall, we
found very significant evidence that one of the main causes of
staff leaving the National Health Service was to move into the
private sector, and if you stimulate the private sector you reduce
the number of staff in the NHS. Does that not cause you something
of a problem, that we may here be creating a further movement
away from the NHS into the private sector by stimulating the private
sector through this concordat?
(Mr Taylor) I think there has always been and will
continue to be a two-way flow between the NHS and the private
sector. Our assumption is that a central thrust of the concordat
is about using capacity in the private sector which would not
otherwise be used. We think there is scope both in terms of beds
and staffing capacity to take on extra workload. So, at the moment,
our planning assumption is not that the publication of the concordat
and the immediate plans to use independent sector capacity will
have any immediate impact on NHS staffing. But one of the important
elements of the concordat is a recognition that we need to do
joint planning between the independent sector and the NHS on workforce
issues, that we have to look at the health workforce as a whole.
I think that is something we have not done terribly well always
in the past, and one of our clear intentions is that we should,
through local workforce planning confederations, get a better
perspective, better handle, on the total workforce needs in both
the independent sector and the NHS sector.
115. Let me put to you another concern I have
got. One assumes that when a local purchaser determines where
to buy from within the private sector they may well use their
nearest private hospital. Mr McCarthy, you are now privileged
to be up in West Yorkshire, so you will know that one of the major
private providers in your area, and mine, is Methley Park. Significant
numbers of the consultants in my local NHS hospital work also
in private practice at Methley Park. So it is an assumption I
would make that Methley Park would be used, if anything is used,
as part of the local concordat arrangements in my area. But if
I were a full-time NHS consultant, concentrating solely on my
NHS work, I am not sure how I would feel about the position that
we are into now, where we are shunting more and more work into
the hands of the consultants who are working at somewhere like
Methley Park. I do not think that necessarily will help return
people who are committed to the Health Service in a way I would
want to see them returned; particularly, as you are well aware,
we received evidence in the inquiry that we did not long ago,
looking at the issue of regulation of private medical care, about
the question of the artificial construction of waiting lists to
create a demand for private practice. I think we have got into
a situation here that we have not fully thought through, and I
can see a great deal of resentment between consultants, certainly
those who were not involved in private practice, at the way those
who, in a way, have not supported the initiative to reduce waiting
lists in the way that many, and I am not saying all those involved
in private practice have taken this course of action, I can see
a great deal of resentment occurring here at local level. Would
you agree that there could be problems of that nature?
(Mr Taylor) I think one of the elements of this which
we need to take into account is that one of the potential facilities
we are suggesting that local organisations need to look at is
the scope for permitting consultants who are working in the NHS
to do some of this work in using private sector facilities under
their NHS contract, because, I agree,—
116. There are some who would not want to be
seen dead in private hospitals, quite frankly.
(Mr Taylor) I understand that.
117. Which is why they are wholly committed
to the National Health Service.
(Mr Taylor) The distinction here is between somebody
doing work for their employer, for the NHS, under contract, using
facilities which are private sector facilities; so what we are
not positing is a completely stark divide between, on the one
hand, people doing NHS work in NHS hospitals and consultants working
in the private sector doing all the work under private sector
arrangements which is carried out at that particular location.
There seems to us to be scope, and probably increasing scope,
for consultants doing work using operating facilities and others
in private and independent facilities under their NHS contract.
118. And I think one other area, again, of practical
concern is, certainly, when we looked at the private sector, I
think the Committee as a whole was extremely concerned about the
quality of provision in certain aspects of the private sector.
Is not that an area that you yourselves are worried about? I certainly
recall, I think the Government has taken steps in this respect,
but we did not get a particularly positive impression of the overall
quality in certain parts of the private sector in the inquiry
that we undertook.
(Mr Taylor) I do not think I can go further than saying
that, in making any arrangement using NHS money to deliver care
free at the point of delivery, using the facilities of a private
sector, independent sector, provider, it would obviously be an
obligation on the contractor to ensure quality of service in all
respects. In other words, an obligation on the local NHS provider,
to ensure that they were making a contract or an agreement with
someone who was going to provide quality services; it is all part
of NHS provision.
John Austin
119. I was just going to comment on that. I
have a relative who works in the private nursing care sector and
I have raised this issue about salaries, pensions, conditions
of work, no access to pension; she has been working there since
April, she is now the longest-serving member of staff in the unit,
no pay for bank holidays, no extra pay for anti-social hours,
weekend working, or anything else. What is the NHS going to do
to ensure that those staff in the private institutions engaged
in NHS care are treated equitably with staff in the NHS?
(Mr Taylor) I do not think, as a result of this concordat,
there is any proposal to change the nature of the contractual
relationship in that respect.
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