Examination of Witnesses (Questions 40
- 59)
MONDAY 21 OCTOBER 2002
MR RICHARD
DOUGLAS, MR
ANDY MCKEON,
MR GILES
DENHAM, MS
MARGARET EDWARDS
AND MR
ANDREW FOSTER
40. Is it possible for the Committee to look
at the responses you receive at some point?
(Ms Edwards) I should think so.
41. In terms of the point raised earlier on,
I certainly had local consultants and managers saying to me that
they would have preferred to have been given the freedom to spend
this money within the NHS rather than commit it specifically to
the private sector. Was that a factor that was looked at within
your survey? Would they be able to respond to that point in some
way within the questionnaire?
(Ms Edwards) We did not specifically ask that question.
The guidance has always been that they should provide the best
value for money. The clear guidance we have given from the Department
is to get best value for money from the private sector, as I said
earlier, we need to stop some of the spot purchasing going on
at the end of the year and spread it. The additional funding put
out last year specifically for purchasing in the private sector
was at the end of the year and it was recognised because of that
there was likely to be some considerable pressure. There was already
pressure within the NHS on electives and each economy was asked
to look at the situation in their area and they took quite different
approaches. What we did get back from the survey showed that there
was quite a lot of diversity in approach.
42. Who suggested that a 50 per cent response
was not good enough to publish?
(Ms Edwards) That was done within the Department in
discussions with senior officials.
43. Have you got a minimum figure for returns
on the next one you are doing?
(Ms Edwards) We have not agreed. We have got a—
44. What would you reasonably expect? 65 per
cent? 60 per cent? Where are we?
(Mr Douglas) I would hope if we are collecting it
on the basis that we want this information ourselves that we would
get a significantly higher response than 50 per cent. I will assume
that we will get a response sufficient to publish.
45. Okay, but we are not sure what that figure
will be?
(Mr Douglas) No, but it will be big enough because
we will make sure.
Andy Burnham
46. To push you a little bit further on that,
are you surveying PCTs and trusts as part of this survey?
(Ms Edwards) We have been surveying all NHS chief
executives on a commissioning basis.
47. You indicated last year that costs came
out slightly above the NHS reference costs. Was that an average
cost?
(Ms Edwards) The NHS reference was an average cost.
48. You took an average of the price paid?
(Ms Edwards) That is right. If you take a cataract,
the average costs from the survey were slightly higher than the
average NHS cost for the cataract.
49. As part of our evidence, as I seem to remember,
there is a very, very wide variation indeed between some parts
of the country and others as to the cost being charged. Can you
give us an idea for any one procedure the range in cost that was
picked up by this survey?
(Ms Edwards) I do not have the range with me. The
ranges varied geographically and they varied as to time of year
and even within very tight localities there were significant variations,
but I do not have the actual range with me.
50. Just from memory, I seem to remember going
from thousands of pounds to hundreds of pounds for some of them,
big gaps in the costs.
(Ms Edwards) One of the difficulties we face is comparing
like with like and, for example, if you take a procedure like
a hip replacement, what is purchased in one area may include recuperation,
rehabilitation and physiotherapy but not in another area. We are
trying to refine that so we can compare like with like. Some of
the figures in the past have included basic work, diagnostics,
and others have not, etcetera.
51. I understand that but is there a concern
that given the volatility of the prices that the NHS has been
quoted that policies are a year on and yet we are nowhere clearer
on knowing what the true value for money is?
(Ms Edwards) One of the reasons for wanting to get
the survey right and share the information with the NHS is to
give the NHS benchmarks about what is reasonable to pay. By providing
the NHS with information about what is the standard price for
a cataract, we should reduce some of these variations by creating
those sort of benchmarks.
52. Is there any evidence in the absence of
that that some health bodies have stopped using them for the private
sector?
(Ms Edwards) I have got no evidence of that at all.
53. In your view is this variation mainly determined
by available capacity so that in parts of the country where private
sector capacity is more plentiful that is, crudely, where prices
tend to be lower, and it is parts of the country where it is not
in such great supply where prices are far higher?
(Ms Edwards) That is one of the major factors when
you are talking about providers being able to provide it at relatively
marginal rates or having to increase staff to cover the provision.
That is one of the reasons we have moved away from the idea of
a nationally negotiated contract to allow individual economies
to negotiate within the Concordat framework.
54. In the absence of a reliable survey, you
obviously nevertheless gleaned information from last year's patchy
survey which has given you some early thoughts. On the basis of
that, have you issued any interim guidance to PCTs or to trusts
about use of the private sector in, say, particular parts of the
country where the costs seem to be far higher than other parts
of the country?
(Ms Edwards) No, not on the back of anything to do
with the survey. As I say, we have given limited information on
the survey out to the NHS. What we have done is through a process
of capacity planning where we are asking each economy to identify
their capacity requirements for the next three years, we have
asked them as part of that to look at what is available in the
private sector and make sure they are making maximum and efficient
use of that within their capacity plans, so as part of separate
guidance we have been talking to them about making sure they use
all the available resources. As I mentioned earlier, within that,
in advance, we have given some clear advice that they would get
better value for money from the private sector if they entered
into medium-term deals rather than negotiating at the end of the
year.
Dr Taylor
55. Moving on to question 1.4.1, the question
was how much has the NHS spent on health care provided outside
the UK, to how many patients, and what treatments in each year.
I was rather disappointed to find from the answers below that
the quality of the information available on these is really very
poor. Point 5 says: "No precise information is available
on the types of treatment covered." Obviously in the one
trial that in the South East England has taken place at a £1.1
million cost with 190 patients, I understand, that is considerably
more than it would have been within the NHS reference costs. Is
that right? Have you any plans to improve the amount of information
available, because lots people are actually asking me under E112
when they are waiting for a long time for a cardiac coronary artery
bypass how they get it and when they can get it abroad? So it
is a fearfully important part to look at and you do not appear
to have that much information on it at the moment.
(Ms Edwards) I think we need to distinguish between
the patients who are treated under the more traditional arrangements
of E111 and E112 and the work that we are doing to purchase explicitly
services like cardiac surgery from abroad.
56. So that will not be E112?
(Ms Edwards) No, it is through a separate mechanism.
57. Do PCTs know about this?
(Ms Edwards) Yes. What we referred to as our first
pilot last year, which was a small-scale pilot where 190 patients
were treated through a separate mechanism, unlike with the E112
and E111 arrangements, we paid direct and entered into a planned
agreement using NHS funding.
58. Right, so what is the likely funding under
this special agreement for 2002-03?
(Ms Edwards) We do not have a figure at the present
time partly because we encouraged individual commissioners to
enter these agreements so we do not have the total. In terms of
patient numbers we are looking at very small thousands, 2,000
to 3,000 patients, which are the sorts of numbers we are anticipating
going abroad. In addition, there will be some cardiac surgery
patients. So not large numbers but significant in terms of the
patients treated because these tend to be orthopaedic and cardiac
patients.
59. If we have this questionnaire again next
year will you be able to tell us more about the 111s and the 112s?
(Ms Edwards) I do not know if we will be providing
any more detail. Certainly on the ones purchased through the health
agreement we will have all that sort of information in detail.
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