Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 220 - 239)



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.


  239. Amazing!
  (Mr Milburn) It is amazing, is it not?

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