Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 200 - 219)



  200. I have read the details that you published on the Concordat, particularly referring to elective care, which is what you have been referring to in discussion over the last few minutes. You could end up with a Primary Care Trust commissioning care from a private health provider for a patient who has been waiting on an NHS waiting list to see an NHS consultant who also works in the private hospital where the commissioning could take place. So we could have NHS patients who are not able to see the local consultant directly being referred by their own GPs often, as we are aware, because that consultant has a healthy private practice and he is not available because he is working in the private sector, but instead of seeing them in the NHS they will see the same consultant in the private hospital on this contract, whether the commissioner is PCG or PCT, at a much higher cost surely?
  (Mr Milburn) That is why I say that there are two further important caveats. I said, first of all, that our preferred option is genuinely to take advantage of spare facilities. If operating theatres are not being used and if hospital beds are lying empty and we can use those for the benefit of NHS patients I think broadly that is a good thing to do. If people are waiting, with respect, for an NHS operation and are waiting in pain and discomfort, let alone needing critical care facilities, I think the last thing that they are concerned about is frankly where the treatment takes place, providing the care is for free.

  201. But one of the reasons they are waiting, Secretary of State, is because we have got consultants moonlighting in the private sector. You are giving a huge boost to that moonlighting by virtue of the answer you have just given me.
  (Mr Milburn) With respect, that is your word and not mine.

  202. I think it is your word as well.
  (Mr Milburn) Well, since the cameras are rolling and since we are in public session, that is your word and not mine. However, as you know we have a set of proposals around precisely that phenomenon. You call it moonlighting, I call it maximising the capacity of the National Health Service and ensuring that we get the maximum contribution from each and every consultant. So we have an answer to that particular question and I think there is a further very, very important set of caveats that everybody should be clear about. I think it is the right thing to do, to take advantage of private sector capacity for the benefit of NHS patients, but there are two important caveats. One is that we should get the best value for money for the taxpayer, and there is certainly no blank cheque here. My guess is that there will be tough negotiations between NHS Trusts, Primary Care Trusts, Primary Care Groups, health authorities and private sector providers and that is how it should be, because nobody would forgive us, least of all this Committee or the Public Accounts Committee, if we did not get a good deal for the taxpayer. The second caveat is that we have to be in a position where we ensure not just good value for money for the taxpayer but the highest standards of care for the patient.

  203. I have to say that in terms of the taxpayer, the answer that you have given me seems to indicate that in many respects we will be paying more for the use of the private sector than the use of the National Health Service, so that—
  (Mr Milburn) With respect, Chairman.

  204. Can I just finish the point? A number of people in the NHS have already come forward with their concerns over the way in which this Concordat will cost the public purse more than would have been the case had we used the National Health Service. That is a concern that certainly I have got looking at the detail of what you are proposing.
  (Mr Milburn) With respect, there are two answers to that. First of all, you do not know and I do not know what the deals are going to look like as they are hammered out on the ground. Secondly, it is not a question of making a choice. The National Health Service today, and we all know this from our own areas, is short of capacity. So patients are being asked to wait artificially long. We do not have enough beds, we do not have enough doctors, we do not have nurses, we do not have enough operating sessions. We are putting that right and the thing is moving in the right direction and over the next few years there will be more doctors, there will be more nurses, there will be more beds, more critical care facilities, and at the same time we have spare capacity going begging, lying idle, in the private sector. Personally I do not think that there should be a sort of ideological barrier to patients, National Health Service patients, getting treatment there.

  205. I think my concerns are practical and I have put some practical questions. You know my views on the private sector and I think I know your views on the private sector as well. My concerns are entirely practical. We have talked about the Health Service being short of doctors and nurses, and certainly the inquiries this Committee has done have shown exactly where the doctors and nurses go; they are trained by the NHS and they are recruited by the private sector. That is the reason why we cannot staff our beds, because we have not got the manpower, you are losing these people to the private sector. The concern I have got is that what you are doing will lead to even further numbers of people leaving the NHS and going into the private sector. I have got a number of colleagues who want to come in on this point but can I just finish with one quick question on quality. Currently in the private sector, as far as I can see, and we looked at the quality of the private sector and certainly this Committee across the board politically had serious concerns about quality issues in the private sector, they do not publish information on performance. Is that an issue that you are looking at? Is there some mechanism whereby you intend to introduce this? Certainly there have been many witnesses that we have met at this Committee who have raised very serious questions about the quality of the work that is currently undertaken in the private sector.
  (Mr Milburn) I understand those concerns and, as you know, there have been concerns raised in the House about the quality of private work, sometimes in both Houses, when things go wrong. There are some issues there. Certainly if we are treating NHS patients for free in independent sector hospitals then I have to have an assurance as Secretary of State that the standards of care are appropriate and as high as possible. There are two important changes that we are introducing. One we have already introduced is the Commission for Health Improvement. Remember that its remit, if you like, is the Independent Inspectorate for the National Health Service will follow NHS patients as they are treated in private sector hospitals. So the Commission will have a remit there and, of course, it will publish reports and data and so on and so forth following its inspection visits. The second important development is the National Care Standards Commission, which admittedly will not come on line until 2002 but it has a specific responsibility for, if you like, policing and inspecting the private sector, not just acute sector hospitals in the private sector but also residential and nursing homes and so on and so forth and, again, it will publish more and more data. Yes, I think this is a good question to raise and there are some corollaries. If essentially the taxpayer is paying for more care of NHS patients in private sector hospitals taking advantage of capacity that is not being used at the moment, then certainly the taxpayer and the public, as patients, have got to be assured that the standards of care are right. I think that will mean inevitably over time that in the private sector—hospitals we are talking about here but the same applies to residential and nursing homes too—there will have to be more and more openness and have to be more accountability about their performance standards. That seems to me to be a good thing and not a bad thing. It is always the same with this, the good guys have got nothing to lose, the only people who are worried about it are those who have got something to hide.

  Mr Burns: Secretary of State, I was listening very carefully to what you were saying and it seemed to me that you were being extremely logical and putting forward an extremely sensible suggestion.


  206. Notice where the support is coming from.
  (Mr Milburn) That is particularly helpful, Mr Burns, and I am extremely grateful for your support.

Mr Burns

  207. The other thing that I thought was interesting was one of the reasons you said why it was important to do this, with, of course, the crucial proviso that the health care is free at the point of delivery and always will be, was you mentioned that of course you should do this with spare capacity because most of our constituents are facing artificially long waiting times at the moment and it is silly not to use such spare capacity. I think that is absolutely right.
  (Mr Milburn) I think that is right. I think, with respect,—

  Mr Burns: No, no, stop there, do not spoil it. I have not finished my question.


  208. Let him finish his question, to be fair.
  (Mr Milburn) I will spoil it in a moment.

  Mr Burns: Given the logic, the sense, of all this, could you tell us why it has taken three and half years to do it given that the problems have not gone away and, in fact, in some ways, particularly on waiting lists, just on the numbers, the problems during part of that three and a half years have increased? The other thing I would like to know, because of course you were the Minister of State at the Department of Health for the first 18 months of this Government, is did you share these vigorous, logical, sensible views at the time in the Department of Health or did you feel rather constrained by your predecessor who I think would be more like our Chairman in his views on your Concordat.


  209. He is a Yorkshire man.
  (Mr Milburn) That is an extremely helpful set of questions. I have indicated that I think consistency is an important quality in politics and I hope I am always consistent. I will be consistent in a moment, if I can, by coming to quite a sharp differentiation between, with respect, the two parties' policies on these issues.

Mr Burns

  210. Parties?
  (Mr Milburn) The two parties' policies on these issues.

  211. I have not mentioned parties.
  (Mr Milburn) No, but I am going to mention them because it is one of the prerogatives of those questioned here that they are allowed to give their own answers.

  212. Right.
  (Mr Milburn) Let me just deal with the specific question about why it took three and a half years. What we had to do in 1997 when we got into office was stabilise the National Health Service. That was the right thing to do, it was the right priority. You remember when we got in, indeed I think you were a Minister, Mr Burns, in the Department of Health just prior to 1997, at that point the National Health Service was spiralling out of control. We had £500 million worth of debt in the National Health Service and in the last year of the previous government spending on revenue actually fell in real terms, the first time it had done that in many, many years indeed. Morale was plummeting and, of course, waiting lists were rising. Our first priority, quite rightly, was to get the National Health Service back under control.

  213. I do not quite remember it like that, but carry on.
  (Mr Milburn) I am happy to try to refresh your memory.

  214. From one side.
  (Mr Milburn) That was the right thing to do, to try to stabilise the Health Service. It is not true to say, incidentally, as the Chairman was indicating just a moment or two ago, that somehow or other the Concordat, or co-operation, with the private sector has just come out of the blue; it has not. In fact, I think the figures the Committee have been given indicate that over the last few years the proportion of NHS spending going into the private sector has increased. I do not have a problem with that providing it is getting a good deal for taxpayers and the right quality of care for patients. Where I think there is a world of difference, with respect, between what the Government is trying to do and what others would seek to do, and maybe you are one of them, I do not know, I think it is right and appropriate if there is spare capacity available in the private sector to use that for the benefit of NHS patients. I do not have a problem with that and I do not think that you do either.

  215. No.
  (Mr Milburn) Where I have a problem is in the expansion of the privately paid for health care sector because if that happens, if those who advocate that the answer to our health care systems problems in the UK are to expand the private health insurance market and thereby expand the number of patients for their care, if we accept, as I think we all do, that there is a constraint capacity problem for the National Health Service, in other words we have not got enough doctors and we have not got enough nurses, if that is the situation and people accept that then an expansion in the privately paid for health care sector can only be robbing Peter to pay Paul. It can only be to the detriment of NHS patients for a very, very simple reason, and that is that if there are not enough doctors and nurses working for the benefit of NHS patients, an expansion of the doctors and nurses providing care to the paid for private health care sector can only be to the detriment of the National Health Service. Those who advocate this policy need to look at it again, because far from being a relief for the National Health Service and a relieving of the burden on the NHS, it is actually the imposition of a burden on the National Health Service.

  216. What about the first 18 months as Minister of Health?
  (Mr Milburn) As I said to you, I have always been consistent in my views about this.

  217. I did not ask if you had been consistent, I assumed, because you told me, that you are. I asked if the Department of Health had a problem with the sort of sensible policy you are now—
  (Mr Milburn) No, and you can see that, with respect, in the figures. The figures demonstrate that in 1997, or 1998-99, the proportion of NHS spending going into the independent sector was around 4.8 per cent and that had increased from our first year in office. That would indicate that far from there being a problem, it was always recognised as a sensible, pragmatic solution to the immediate short-term capacity constraints that the National Health Service faces.

Dr Brand

  218. That is a fascinating answer but—
  (Mr Milburn) I cannot speak for anybody other than myself.

Mr Burns

  219. I did not think that your predecessor was on record in public taking that view. I know you are saying that you cannot take responsibility for him, and of course you cannot take responsibility for what your predecessor said or did, but you were part of the team with him and he was the leader of that team that probably set the public face of the way to move forward.
  (Mr Milburn) As I say, it is also one of the prerogatives of those coming here that they answer for themselves and not for others.

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