Examination of Witnesses (Questions 220
- 239)
WEDNESDAY 8 NOVEMBER 2000
RT HON
ALAN MILBURN,
MR JOHN
HUTTON, AND
MR COLIN
REEVES CBE
Dr Brand
220. I think the figures given by the Secretary
of State are interesting because they mainly reflect expenditure
in the residential care and long-term nursing care sector rather
than the acute sector. When we asked officials last week what
assessment had been made of the extra shift in resources towards
the private sector as a result of the Concordat, they could not
give a figure. Have you thought of what sort of figure might be
involved or what sort of percentage of work?
(Mr Milburn) In the future you mean?
221. What are you aiming at in the Concordat?
(Mr Milburn) We do not have an aim in terms of the
percentage being spent in the private sector. Let me give you
the closest I can get to that because, frankly, that is a matter
of local discretion. I cannot decide, with the best will in the
world, although sometimes people accuse me of wanting to do this,
and believe me it is the last thing I want to do, I do not actually
want to run the health service in the Isle of Wight, that is—
222. I have not seen the Darlington Echo
so—
(Mr Milburn) It is the Northern Echo because
otherwise I will into trouble if we get the man with the newspaper
on us. I do not even run the health service in Darlington, let
alone the Isle of Wight. That is the responsibility respectively
for those in Darlington and in the Isle of Wight. They have got
to hammer out the arrangements as far as private sector provision
is concerned.
223. Surely you would have some concern if,
say, 30 per cent of NHS revenue goes into the private sector?
(Mr Milburn) Let me try to answer specifically the
question and then I will answer your follow-up question. If the
figures provided to us by the Independent Health Care Association
are right, and I guess they are right because those are the figures
that they have provided us with, we reckon that in the acute sector,
which is for the moment what we are concentrating on, there are
approximately 10,000 acute beds in the private sector hospitals.
If they are also right that their average occupancy is around
50-55 per cent, and if they are also right that in, for example,
January and February those occupancy figures fall even further
because by and large people opt not to go into hospital over Christmas,
New Year and so on and so forth, then arguably there are probably
around 5,000 acute beds that are currently unoccupied in private
sector hospitals that potentially, at least, are available for
NHS patients. That is the best answer I can give in terms of the
usage which potentially can be taken advantage of, but I would
just stress to you that is a matter that has to be hammered out
on the ground. As far as the percentage of NHS expenditure going
into the private sector is concerned, I do not have a figure for
that but I would be pretty amazed if we are talking about anything
other than the sort of marginal use of the private sector you
see now—4.8 per cent at the moment.
224. You are going to be monitoring that. Can
I follow up? We talked about the acute sector but of course the
main work is done in intermediate facilities, intermediate care,
and I very much welcome that is part of the national plan. Do
you have a concern that the private sector might not actually
be there to provide it? I am getting a lot of feed-back from nursing
home commissioners, let alone the providers of nursing home places,
that they are not going to survive until these contracts are going
to be in place.
(Mr Milburn) Perhaps I can bring in John in a moment
or two because, as I think members of the Committee are aware,
Mr Hutton had a meeting recently with some of the care home providers
to discuss precisely those issues and maybe he can run through
the figures for you. My understanding, from the best knowledge
we have, is that although it is true in some parts of the country
there has been a movement of providers out of the nursing home
sector—actually largely, I think, because of the escalation
in property prices in London and the South East and so on and
so forth and it has actually become a slightly more attractive
proposition to sell up rather than to continue in business—the
market analysts who deal with this and who provide advice to the
sector and advice to the public too, I suppose, Laing Buisson,
say that right now there is still over-capacity in the sector
rather than under-capacity.
225. But that does not help a health authority
or a trust which has lost a third of its potential private sector
capacity because people have gone out of business, and they cannot
deliver the guarantee of nursing home places as part of the winter
crisis planning.
(Mr Milburn) But this is a very important issue. I
think if we get terribly hung up about the definition of intermediate
care that is purely about the number of nursing home, or indeed
residential home, places which are available, frankly, we miss
the point. Intermediate care, which is what you are asking about,
spans a whole series of services. It is not even just about traditional
nursing home and residential care placements, it is about intensive
home care packages of support provided in people's homes. We know
from all the monitoring we have undertaken over recent months
and weeks that in fact social service authorities are buying enormous
quantities of intensive home care packages of support. I think
that is by and large the right thing to do and it is indeed what
this Committee has argued for in the past, that rather than fostering
dependence in the care system, we should be fostering independence
in the care system—
226. No one is arguing with that, Secretary
of State.
(Mr Milburn)—and allowing people to remain at
home rather than being institutionalised. There is more investment
in home care packages of support. Intermediate care also includes
the provision which is made available to prevent people from getting
into hospital in the first place and ensuring their more rapid
discharge from hospital when they are ready to leave hospital.
What I am saying to you is, when we assess preparations for this
winter, or indeed when we assess the state of health of the health
care system as a whole, we really must look beyond the traditional
definitions of institutionalised care, whether that be in a hospital
or in a care home setting. I believe if we do not do that actually
we will end up replicating many of the real fault lines we have
in the system today. You know as well as I do that, for example,
we have according to our National Beds Inquiry—the first
inquiry of its sort in 30 years—approximately 20 per cent
of elderly people who are needlessly today occupying an acute
hospital bed, not because they need it but because there is nowhere
else for them to go, and that is wrong. It is wrong from their
point of view because it means they are not getting appropriate
care, it is wrong from the hospital's point of view because they
cannot be using the beds for patients who really need it, and
at the end of the day it is probably wrong from the taxpayers'
point of view because keeping people in hospital is a pretty expensive
business.
227. I made that very point, Secretary of State,
in my first questioning on health expenditure three years ago,
but it does not do away with the fact that there are going to
be patients blocking acute hospital beds—it is a nasty term—because
the private sector at the moment does not have the confidence
that the fee levels currently paid for the majority of their business
which is through social services will allow them to remain open
so they can offer capacity to the National Health Service. The
National Health Service can be quite generous with their fees
but it is a marginal part of their activity, and they depend on
the security of realistic fees being paid. My own local authority
area is suffering from this, as are other providers. If, on the
Isle of Wight—and we pay very similar fees to the rest of
the country—people are finding it difficult to invest and
to have commercial confidence in providing these places, then
I really wonder how people operating in Surrey or Berkshire manage
to do this very work. I hope the other part of the Department,
the social services arm, is seriously looking at fee levels.
(Mr Milburn) I think John should come in.
(Mr Hutton) I think the Secretary of State has made
it very clear, Dr Brand, that when we are talking about the intermediate
care services we are not just talking about beds in nursing homes—
228. No, I accept that.
(Mr Hutton) I think that is a very important point.
The defining characteristics of intermediate care services include,
for example, hospital admission prevention work, home care support
and speeding up the rate of recovery from acute episodes of illness.
Some of those will clearly need to be provided for in-patient
facilities, some by the private sector, and that is very much
what we would like to see happen, but not all of them require
that type of service. On the point you made about shortages in
the nursing care sector, all the information we have at the moment
is that there is not a uniform national picture about the number
of bed losses in the nursing home sector, in fact there are some
parts of Britain, certainly some parts of England, last year which
recorded a slight increase in the number of nursing care home
beds. There is certainly evidence to suggest there are some regional
problems and overall there is no doubt in the UK overall there
has been a loss of some beds. We estimate around 8 to 9,000 beds
might have been lost last year, which is about 4 per cent of the
capacity in the sector as a whole. But I think it is very important
too that the Committee is aware from the evidence which was recently
made clear in the Performance Assessment Framework for Social
Services, for example, that that has been largely offset by a
substantial increase in the amount of support provided for people
in the home, both intensive packages of home care support and
more broadly based packages of home care support which would support
independent living at home. It is a complex situation, I would
agree. One of the things we will have to deal with is this whole
sector, which is a crucial partner in developing services in this
area and in making sure the NHS itself runs effectively and we
do not have the problems which have been identified. We do have
an issue to address and we are beginning to do that, as the Secretary
of State said a moment ago, by opening up a new dialogue with
the caring sector, all parts of the caring sector not just the
profits sector but the independent sector and the local authority
sector as well who all have contributions to make, to try and
get the stability and confidence back into the market which is
clearly necessary. We need to do that and we will be addressing
that in the next few months. It is probably wrong to say, Dr Brand,
that our ability to deliver the intermediate care packages we
identified in the NHS Plan, which are fundamental to the new vision
we have for how the Health Service works in the future, at this
stage will be compromised by the current market trends in the
private nursing home sector.
John Austin
229. I go back to elective treatment. You referred
to a lack of capacity in the NHS and spare capacity in the private
sector, in the two NHS Trusts which serve my area, the lack of
capacity is not an absence of operating theatre availability,
for instance, it is a lack of skilled nursing staff, doctors and
the other technical and care staff. So if that is the reason for
the under-capacity and you are going to tackle the waiting lists
by purchasing the capacity in the private sector, it clearly is
not going to be done with the nurses and doctors who are not available
in the NHS to carry out the work. I do not know what it is like
in other National Health Service Trusts, but in both of the NHS
Trusts in my area they are not under-spent on their budget at
the end of the year, so if money is now going to be spent on treating
patients in the private sector, it can only be found from taking
it away from the NHS.
(Mr Milburn) If that is the situation in Greenwich
then clearly there will not be a deal. That is a matter for the
people in Greenwich, it is not a matter for me. I cannot decide
that. I would be astonished if in Greenwich this winter, for example,
plans have not already been put in place—and it would be
an eminently sensible thing to do—to deal with the inevitable
pressures that arise during the winter months. They arise everywhere.
Despite what you read in the Daily Mail it is not just
a phenomenon in England, Scotland, Wales and Northern Ireland,
it happens the world over. If provision had not been made to move
the National Health Service in your area, Mr Austin, largely from
elective work to largely emergency work, the consequence of that
is some of the capacity that you say you are short of, doctors
and nurses—and I accept you are and I accept, incidentally,
the National Health Service as a whole suffers from that and we
are putting it right rather than sweeping it under the carpet
which perhaps has been the case in the past, we have been straight
about these things and said there is a problem and we have a way
of dealing with it and over time it will be put right—and
I would be very surprised if precisely that shortage of capacity
you describe from the doctors and nurses, particularly some of
the surgeons, is not actually displaced this winter as emergency
pressures come in. That is inevitably the nature of what happens
in the seasonal cycle in the National Health Service. Then there
is a choice for the National Health Service. I do not know whether
you are going to be under-spent or over-spent this year—
230. I do!
(Mr Milburn) As Colin quite rightly reminds me, we
are going to break even, and that is why he is the Director of
Finance and I am not! This year the National Health Service is
in a different situation, and actually it is difficult for Directors
of Finance to recognise that they need not hoard a lot of cash
now. That is perhaps what has happened in the past when the NHS
has been under-provided for, this year there is actually quite
a lot of money in the system. If there is money in the system
what I want to say to every part of the National Health Service
is if there is cash available and if the value for money arrangement
can be struck with the private sector and if there is capacity
which is available and you can assure yourself of good, high standards
for patients, then do that in order to get NHS patients better
and faster care.
231. Talking about the winter situation, I agree
whole-heartedly with the Minister of State when he says there
are people occupying beds inappropriately and that is the problem.
Why is it then that the number of geriatric beds in the NHS Trusts
is continuing to fall? The figures you produce in the Bed Availability
and Occupancy paper show that in the last seven years geriatric
beds in National Health Service Trust hospitals have gone down
by 5.4 per cent and in the past year by 2.9 per cent. Why are
beds still closing in the NHS?
(Mr Hutton) I am not sure I have precisely those figures
in front of me. I know we have submitted evidence to the Committee
about that. I think we are trying to address some historic trend
problems here in the NHS. The position we inherited was that there
was this argument and dogma, "You can just dispense with
these beds; bed numbers are not important", but we have moved
to a situation where we now recognise quite clearly that those
issues are important and we are trying to address that. As part
of the NHS Plan, for example, we have just been discussing around
intermediate care, we do envisage 5,000 extra intermediate care
beds coming into service. I think a very large number of those
clearly will be in the NHS.
232. Do you have a break-down of how many of
these intermediate care beds will be in the NHS?
(Mr Hutton) We will try and help the Committee with
that. At the moment I do not think I can be more specific than
the information I have given you. These are historic trend issues
and we are trying to address these and to reverse them and that
is what we have in mind.
(Mr Milburn) As far as geriatric beds are concerned,
I think you are looking at Table 4.13.1, which is the table I
have in front of me—
233. Table 4 on page 18 of the Bed Availability
and Occupancy paper.
(Mr Milburn) I think we are agreed about the fact
if not the table. Specifically on geriatric beds, and if I can
now I will make a more general point about general and acute beds,
yes, it is true they are continuing to fall but remember there
are different forms of provision which are coming on line. In
truth, geriatric provision is not what it always should have been
from the National Health Service. If the Committee is as concerned
as I think it is about standards of care and the quality of care
which is provided, particularly to older people in the National
Health Service, then frankly keeping people on long-stay geriatric
wards has not always been the most appropriate thing to do, and
many of us would have doubts about whether some of the provision
that is currently available is as appropriate as it should be,
and keeping people in hospital needlessly is not necessarily good
for their health. That is why, taking a broader view about the
form of provision and making sure we do genuinely get the right
number of beds of the right sort in the right place, is the right
thing to do in my view.
234. But that is the total figure for geriatric
beds, it does not address the issue of quality. Some may be good,
some may be bad.
(Mr Milburn) We can come back to you but I do not
think it is. I do not think, for example, it would in this category,
but maybe Colin can correct me if I am wrong, include the build
up of NHS intermediate care provision, and nor would it, as I
was indicating earlier to Dr Brand, account at all for social
services provision which is provided in the form of intensive
home care packages of support. Arguably, if we listen to what
older people are saying, as we should, what they most value about
the care they are provided with is the ability for them to retain
their independence. Older people are just like everybody else,
they want to remain independent rather than being dependent. So
I do not think, in truth, we should assume that the number of
geriatric beds in hospitals is the best yardstick against which
we can judge the quantum of either beds or services that are being
provided to older people in the National Health Service.
235. I accept the point there may be ways of
caring for people other than in beds in hospitals or private facilities,
but in terms of the headings I cannot see those intermediate care
beds in the NHS could be in any other category other than under
geriatric in that table, because they would not be under acute
or anything else.
(Mr Milburn) I have not got the answer to that but
perhaps I can check and send the Committee a note, if that is
helpful.
236. One other point I want to raise on the
question of elective surgery being carried out in the private
sector is that much has been made in the past by doctors of the
difficulties of split-site working. The other issue, of course,
is much of the care provided in NHS hospitals is provided by junior
doctors, and the Royal Colleges have taken a very strong line
on split-site working in terms of validation of qualifications.
One of the reasons why a hospital closed in my area was because
the Royal College would not accept the split-site working for
junior doctors was a reasonable way of training. How are you going
to address the issue of providing medical care in the private
sector? It is not just junior doctors but the whole question of
anaesthetist cover as well.
(Mr Milburn) I think that is a big issue, it is an
issue certainly in relation to the Concordat but it is a broader
issue too. As you know, when we put together the NHS Plan we did
a lot of work with several of the Royal Colleges—Surgeons,
Physicians, GPs and so on and so forth—and I have the greatest
respect for them but it does not always mean they are right. There
are very, very different views amongst the Royal Colleges, for
example, about the appropriate size of a population that should
be served by a district general hospital. The Royal College of
Surgeons say one thing, the Royal College of Physicians say quite
another thing, and there are different views too about split-site
working. My own view is this, I think two things have to happen.
First of all, I think that as the NHS Plan signalled, we will
want to enter into discussions with the Royal Colleges about better
ensuring in the future that the training needs of doctors are
better aligned with the service needs of patients and in particular
that the training tail is not wagging the service dog, and that
sometimes has happened in the past. But, secondly, we have to
get into some meaningful discussions to try to solve the big conundrum
which is that medicine is becoming ever more specialised, continually
more specialised, and indeed the way we train and educate our
doctors in many ways exemplifies that and it intensifies it so
we have more and more concentration of medical expertise potentially
in fewer and fewer hospitals, and at the same time, quite rightly,
we want to make more care available more closely to home for people.
In the end, I think the only way we will deal with these two issues
is by recognising that rather than the mountain having to come
to Mohammed, sometimes Mohammed will have to go to the mountain
and doctors will have to service several hospitals in their area.
That is what is happening in my own area in Darlington, the Darlington
and Bishop Auckland Hospitals are now within one Trust and increasingly
we expect the orthopaedic surgeons and others to cover both hospitals
and for good reasons, because they are serving two quite distinct
communities.
237. Whether that is desirable or not, at the
moment the accreditation and approval rests not with the Secretary
of State but with the Royal Colleges.
(Mr Milburn) That is why, as you will recall from
the NHS Plan, we talked about forming a new organisation, the
Medical Education Standards Board, precisely to deal with some
of these issues, to ensure we can better square up the service
needs of the Health Service with the needs of patients, particularly
to have good, high quality clinical care based as closely to home
as possible and the training needs of doctors. We want to have
specialised doctors providing high quality care but that cannot
be allowed to compromise the access to service provision which,
quite rightly, NHS patients want. If you remember, in the NHS
Plan we suggested the new Standards Board will look at these issues,
that the Royal Colleges will be represented on them but the Royal
Colleges will be working in conjunction with the National Health
Service rather than, as perhaps has appeared to be the case in
some places in the past—including by the sounds of it your
own—imposing requirements on the local National Health Service
which arguably have not always been in the best interests of the
local National Health Service.
(Mr Hutton) Could I add, Mr Chairman, before we move
on, that some of the wider issues that Mr Austin is referring
to in relation to the style and pattern of NHS services for old
people will be addressed in the National Service Framework for
Older People which we hope to publish before the end of the year.
I think the concerns you were raising earlier about the pattern
of acute based care centred around the number of geriatric beds
will be addressed as part of the new national standards which
we expect the National Service Framework to be addressing.
238. Could you confirm that might be on or around
14th December?
(Mr Hutton) Certainly we expect it to be published
before the end of the year, so that gives us a little more leeway,
it might give us until 31st December. We hope to publish it before
the end of the year.
(Mr Milburn) I have more information on the geriatric
beds, Chairman.
Chairman
239. Amazing!
(Mr Milburn) It is amazing, is it not?
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