Examination of Witnesses (Questions 240
- 259)
WEDNESDAY 8 NOVEMBER 2000
RT HON
ALAN MILBURN,
MR JOHN
HUTTON, AND
MR COLIN
REEVES CBE
John Austin
240. Could I also say that according to the
document I have in front of me, the number of households receiving
home helps, meals-on-wheels, or attending day care, is also falling.
(Mr Hutton) Can I just correct that because I think
the data you might well be using is the data we provided to the
Committee and it only goes up to 1998. In the Performance Assessment
Framework I am glad to say the data is more up-to-date than that,
and I think for the first time we can say that trend has been
reversed.
(Mr Milburn) I am told, though I may stand corrected,
that geriatric beds are actually counted in the general and acute
bed category.
241. The intermediate care beds?
(Mr Milburn) No. The intermediate care beds I think
are a quite separate category although I will try to clarify that
later.
242. Not in this table?
(Mr Milburn) Not in this table.
243. The headings include acute, geriatric,
general medical, mental illness, learning disability—
(Mr Milburn) Geriatric beds are a sub-set of general
and acute beds, and it is true to say that overall the number
of general and acute beds fell in the last year for which we published
figures, which I think was up to 1998-99. The number of acute
beds fell by approximately 500. My own view is that that is probably
a bottoming-out of the long-run trend because the number of acute
beds has actually been falling on average by around 2,700 every
year and, as you know, in the NHS Plan we made it pretty clear
that over the course of the next few years we need to see an expansion
in the number of general and acute beds, because with occupancy
levels running pretty high in hospitals already, leaving aside
the fact we want to be doing more waiting times work, getting
waiting times down, ensuring there are more operations carried
out rather than fewer, that would seem to me to call for an increase
and expansion rather than a decrease. I do not know whether that
in part answers your question or not but that statistically, I
am told, is the right answer.
Mrs Gordon
244. I wonder if you could clarify the situation
on critical care. I am not sure what medical conditions you are
talking about. In the Concordat you talk about the transfer of
patients between NHS, private and voluntary health care providers.
How will you ensure the standards of care are maintained during
transfer? Following on Mr Austin's point about more than one site
for treatment, what is the critical care? Who are you treating
and how will you ensure those standards are maintained? I have
other questions but I will leave it at that for now.
(Mr Milburn) We make it pretty clear to the NHS, because
it is good clinical practice in any case and most people would
want to do this if they humanly can, that the number of transfers
should be kept to an absolute minimum particularly for critically
ill patients. That is self-evident. Clearly it is not a good thing
to have to move a critically ill patient between hospitals. So
where possible we have to minimise the transfers but that, in
turn, is dependent upon the extent of critical care provision.
This year, because we have spent an extra £150 million on
expanding critical care services, and also changing the way in
which they are provided in hospitals, there will be very many
more critical care beds in hospitals this winter than there were
last winter. There will be probably over 300 more critical care
beds available in NHS hospitals this winter than there were last
winter, precisely because of the investment we have made. However,
we do know that in addition the private sector has a number of
critical care facilities. Critical care is usually divided into
two categories, as you know; high dependency and intensive care.
My understanding is, although I do not have the figures in front
of me, that most of the critical care beds which are available
in private sector hospitals, unlike in NHS hospitals, tends to
fall into the former category, ie high dependency care rather
than critical care. But you could envisage, for example, an NHS
patient who has a major operation, a heart by-pass or whatever,
in a private sector hospital, could then take advantage of critical
care facilities in the same private sector hospital, so it would
be that sort of arrangement which would pertain in the Concordat.
245. I understood last week when we were talking
to the officials that there would be actually a differentiation
between NHS patients in private sector facilities and the private
patients there, that there would in fact be a basic package for
NHS patients, not in medical treatment but in the whole care that
they got. I was a bit worried about this differentiation. Given
that the private health care has to make a profit, I was worried
that the NHS patients are going to be given the hard sell to buy
the frills, if you like, which were not put in the package. The
other thing was, you talk about winter pressures, is the Concordat
just for winter pressures and for the bad times of the year, or
is it for all time?
(Mr Milburn) On these two separate points, I very
much hope that no NHS patient is pressurised to do anything they
do not want to do, and certainly that is not the intention. As
far as different levels of care are concerned between an NHS patient
and a private patient paying for their care, clearly that is a
matter which has to be sorted out between the NHS Trusts, the
Primary Care Trusts and the independent sector/private sector
provider. On the question of winter pressures and whether or not
the Concordat is only about winter, I have absolutely no doubt
whatsoever that the Concordat will be beneficial during the course
of the winter precisely because of the extra demand pressures
which inevitably flow into any health care system in the depths
of winter with more `flu, more respiratory illness, probably more
road traffic accidents, more slips and falls and breakages and
so on and so forth. If there is capacity there during the winter,
we should be seeking to take advantage of it, and the message
which is being sent out into the National Health Service is that
it will be for the local health service to determine how best
to take advantage of the framework that we have established under
the Concordat. But, no, it is not just for the winter because
right now, as I indicated in my first answer to the Chairman,
we simply do not have enough capacity in the National Health Service
to do what we want to do. Sure, we will grow that capacity over
time, and certainly by 2004-05 the situation in the National Health
Service will look very different from the situation today, there
will be an increase in the number of general and acute beds, we
will have 2,000 more, there will be an increase of 7,500 consultants,
we will have 2,000 more GPs and 20,000 more nurses, so the situation
will look very, very different then. Right now, those nurses and
doctors by and large are in the training pipeline. Obviously we
have to recruit some from abroad and try to bring back some who
have left and retain people, but they are not on-stream at the
moment, and that causes a short-term capacity problem for us.
This is one means by which we can plug it, just as I announced
yesterday in the agreement with the Spanish Government that one
of the ways we can in the short-term plug the capacity gap we
have in the number of nurses available to the National Health
Service will be to do some recruitment from abroad, providing
of course that the standards of care and the English language
qualifications are right.
246. Given that the private health sector is
working at 50 per cent capacity—I am not going to imply
nurses and doctors are standing round doing nothing, obviously
they are not but they have that capacity there—do you ever
think to try and recruit them back into the NHS?
(Mr Milburn) We have been pretty aggressive in our
recruitment of nurses, as you are probably aware, and indeed we
have offered enhancements to try and attract people back into
the NHS, not least pension enhancements and so on and so forth.
I have no doubt there will be some—I cannot quantify the
numbers but I would guess—nurses who have come to work in
the National Health Service who used to work in the private acute
sector or indeed the private nursing home sector. That is probably
true but I do not have numbers on that, I am afraid.
Chairman
247. We have spent over an hour on the Concordat
and I know Mr Burns wants to move on to long-term care but before
we move off this, so I fully understand the Government's position,
can I ask you this? When we looked at the issue of consultants'
contracts, we did clearly get some anecdotal evidence suggesting
the creation of waiting lists to produce a demand for private
practice and that you were aware of that. I got the impression
that you were concerned in the discussions on the consultants'
contracts to attempt to draw into the NHS consultants who spend
much of their time in the private sector. Does that remain the
Government's position?
(Mr Milburn) Yes. We set out in the NHS Plan precisely
what we intend to do which is—
248. So you remain committed to try and draw
NHS consultants who are part-time currently in the NHS into, wherever
possible, full-time positions?
(Mr Milburn) There is a differentiation, I think,
and I think there has to be, given the fact we have some existing
consultants and they are employed on a particular set of terms
and conditions, between existing consultants and newly qualified
consultants.
249. I appreciate that. I am looking at existing
consultants. I appreciate the answer you gave earlier about the
first seven years.
(Mr Milburn) Let me finish the point then. Although
we want to introduce this policy for newly qualified consultants,
and that is the Government's intention—and clearly there
has to be a negotiation but unless we intend to do it we would
not have said we were going to do it in the NHS Plan—there
will be discussions going on with the British Medical Association
and with other organisations. But I think what will happen as
a consequence of doing this and actually making it more attractive
for people financially to work in the National Health Service,
because this will not come for nothing from the Government's point
of view, from the taxpayers' point of view, if essentially we
are saying to newly qualified consultants—and I will come
to existing consultants because I think this will have a knock-on
effect—"We want your labour exclusively for the National
Health Service for up to seven years and you cannot go and work
in the private sector", it seems to me perfectly reasonable
that we should offer those newly qualified consultants some more
money, and that is what we will have to discuss. There are various
other things we will need to do, we will need to reform the discretionary
point and distinction award system to provide a bigger pool of
resources available to reward those consultants who are committing
most to the National Health Service. What I think that will do
is not just have an impact on newly qualified consultants, I think
that will have an impact on existing consultants in a positive
and beneficial way, because it will begin to turn on its head
the way that for 50 years the National Health Service has operated
in relation to its consultants which is this, that the only way
you as an NHS consultant get on and do well and get more prosperity
is by working in the private sector. We, the National Health Service,
in the way it was established and the way it has operated for
50 years, have actually provided a positive incentive for NHS
consultants to go and work in the private sector. That is a choice
that the National Health Service made then and we are making a
rather different choice now, which is to say, that we want your
exclusive labour, certainly as newly qualified consultants, but
we want to provide some of the right incentives to you to come
and work in the NHS. For example, as far as these distinction
awards are concerned, which are very important enhancements to
a consultant's pay, worth up to £60,000 a year for those
at the top of the distinction award ladder, it seems self-evident
to me that the people that we should really be rewarding for NHS
endeavour, as NHS consultants, through the distinction award and
discretionary points system, are those who are committed most
to the NHS and doing most for NHS patients. So the answer to your
question is, yes, we want to have more NHS consultants and, yes,
we want to get more NHS work from consultants, and by doing what
we are doing, or proposing to do with newly qualified consultants,
I think we will begin to turn the incentive structure round so
that it becomes more worthwhile for people to commit more full-time
labour to the NHS. Now that, just as a caveat, does not decry,
for a moment, the fact that NHS consultants are overwhelmingly
working extremely hard for the NHS. They are. You only have to
go into every hospital and you will see that people are working
under pressure. They are working pretty much flat out. That goes
for the doctors, the nurses, the other staff too. But certainly
I think here that there is a big deal on offer. If we are going
to expand the number of consultants in the way that we are, in
a historic rise in the number of NHS consultants—30 per
cent over the course of the next few years—that will get
us more labour. What I also want to do is to maximise the contribution
that each and every one of those consultants make to the NHS.
250. I remain baffled as to how the Concordat
takes us in that direction. It appears to me that quite clearly
you are shifting work into the private sector and the private
sector is being awarded for those doctors, (to use the term moonlighting),
to gain more work in the private sector, will do more work there,
and will spend less time in the NHS.
(Mr Milburn) With respect, Chairman, I answered, that
question earlier. I think I answered it twice. You might not be
convinced but that is a matter for you and not for me.
251. Well, I am absolutely baffled as to how
this is consistent.
(Mr Milburn) I think it is entirely consistent because,
as I indicated at the outset, our preferred option is very straightforward
in relation to the Concordat. That is, to use private sector facilities,
operating theatres, hospital beds, critical care facilities, when
they are available.
252. And staff.
(Mr Milburn) And to use NHS consultants in NHS time
to provide care for NHS patients.
253. You did indicate to me that it could be
an NHS consultant who was working in their private time treating
NHS patients. That was what I could not understand how that could
benefit. That was the answer you gave me.
(Mr Milburn) No, no, I gave you two answers which
were entirely consistent.
254. It is not consistent with what you said
because clearly you said to me that we could have a referral.
I asked you about elective care where a purchaser, a PCT, purchased
from a private contract, with a private hospital, care for a particular
patient, who may be on the NHS waiting list. That patient would
be treated by a NHS consultant working in the private sector.
You gave me that answer. You are nodding. Is that correct?
(Mr Milburn) Can I be absolutely clear—
255. I am asking you, is it correct? Is my understanding
correct?
(Mr Milburn) Let me give you the answer since you
have asked the question now on three or four occasions. I will
give you one answer.
256. Is it correct, that is the important point.
(Mr Milburn) The important thing is this. In the Concordat
what we set out are a number of options as to how the NHS and
its staff can be deployed for the benefit of the NHS patients
in the private sector. As I indicated earlier, no, I would not
rule out the National Health Service purchasing care from private
sector hospitals and using NHS consultants who are working in
their own time in the private sector. I would not rule that out.
My preferred option—and I have said this now and I guess
that you are getting bored with it—
Dr Brand
257. With all due respect, Chairman, I think
the rest of the Committee has now heard the question three times
and the answer almost four times.
(Mr Milburn) Well, I will give it for a fifth time
and maybe I will convince the Chairman. (It is worth trying, I
do not give him up as a lost cause!) My preferred option, as I
have stressed throughout, is to use private sector facilities,
critical care beds, operating theatres, hospital beds, using NHS
staff specifically, NHS consultants working in their NHS time,
to provide care for free for NHS patients. That is precisely what
happens in many trusts around the country. It happens in the Medway
Trust. What we do there—nothing to do with me, it is the
local management who negotiate that with the BUPA hospital—they
have persuaded, cajoled or encouraged NHS orthopaedic surgeons
to work in NHS time, on NHS patients, providing operations for
them in private sector facilities. That is my preferred option.
That is the right thing to do. I think that should help to solve
your sense of bafflement.
Chairman: Okay. It has been an interesting exchange.
Mr Burns
258. May I move on to long-term care because
this is something we did discuss with your officials last week.
I wonder if you could define nursing care and personal care.
(Mr Hutton) It might be helpful if I try to answer
those questions for you. We set out very clearly in our response
to the Royal Commission on long-term care in the NHS Plan the
actions we intended to take to end what I think most people would
accept has been an anomaly and a perversity of funding arrangements
long-term care. If you were at home or in a residential care home,
nursing care would be met by the NHS. If you went into a nursing
home, you were means-tested and therefore faced a charge yourself.
We are going to correct that anomaly.
259. I am sorry, that was not what I actually
asked. I asked if you could define what nursing care and personal
care was.
(Mr Hutton) I will do that for you. However, I want
to make it clear that we will need to legislate to do this. We
hope to do that as soon as we can. I set out too in the NHS Plan
what we intended to cover by our definition of free NHS nursing
care. We defined it very clearly and precisely in the Plan to
cover the time spent by a registered nurse either providing, delegating
or supervising care for residents in a nursing care home. That
is our definition of nursing care. It is a more gentle step certainly
than we find in the Minority Report of the Royal Commission. Certainly
it is broadly along the same lines as the Royal Commission Majority
Report when they talk about time spent by a qualified nurse. We
are not intending to define personal care.
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