Examination of Witnesses (Questions 20
- 39)
WEDNESDAY 24 OCTOBER 2001
THE RT
HON ALAN
MILBURN, MP, MR
ANDY MCKEON,
MR PETER
COATES AND
MR NICHOLAS
MACPHERSON
Sandra Gidley
20. We have just had the announcement of this
year's jam jar of money to solve the problem, big though it may
be. You have admitted that you would like to see a long term solution
to this but it is not quite as easy as everybody is making out
because the problem that is being highlighted locally with the
independent, private hospitals is that they want to deal with
their private patients first, the ones who fund them. They do
not feel inclined to commit, because they do not have the capacity,
to taking more NHS patients. They are quite happy to take the
patients short term when they have the capacity but there is a
gradual creeping and a pressure being put on these hospitals so
that more and more cases are taken. This is having an effect on
people who pay for their private health care. Bizarrely, people
in the private sector are now waiting three months for certain
hospitals and certain consultants. I have had people ringing up
and saying, "I am paying twice and I am still not being seen
quickly." Do you feel that it is fair that patients should
pay twice and still have to wait because the private hospitals
are full of NHS patients?
(Mr Milburn) I do not believe that private sector
hospitals are full of privately paid for patients. In fact, I
know that is not the case. We are running at 89 per cent occupancy
now in the NHS. BUPA and other private sector providers are running
probably at 55 or 60 per cent occupancy, based on private sector
customers paying. They have 30 per cent occupancy free. There
is a very simple choice. We can say we do not like the private
sector and we are not going to do business with the private sector.
There are all sorts of difficulties in getting into bed with the
private sector. Or, we can do the sensible and mature thing which
is to take advantage of that spare private sector capacity for
the benefit of NHS patients. That is what we are going to do.
Indeed, we have been in discussions through Andy and other officials
over the course of the last few months with the major private
sector players who indicate three things to us. One, that business
is increasing as a result of the Concordat with the National Health
Service. Indeed, BUPA tell us that the number of NHS patients
has increased three-fold in their hospitals. Secondly, they still
have spare capacity available. Thirdly, they tell us that they
can accommodate a doubling in the number of NHS patients coming
through their doors. At a time when my biggest problem is not
the shortage of cash - although more cash would always be helpful—
Julia Drown
21. Especially in Swindon.
(Mr Milburn) The biggest problem is the shortage of
capacity. I would be foolish to say to BUPA, CHG or BMI, "We
do not want your capacity because somehow it is contaminated goods."
What I am interested in is getting the best benefit for the NHS
patients. That is what I am going to do. If that causes a problem
for our private sector partners, that is a problem they have to
conjure with because the result of us doing more business with
them is that they get more money.
Sandra Gidley
22. We are talking Hampshire here so perhaps
you should get out a bit more. One of the other problems is, with
the constant reorganisations in the Health Service, how do we
know that there is going to be enough long term stability so that
we can forward plan, because there is another initiative nearly
every week coming out of the Health Department. There were 25
during the consultation document's release during the recess.
Are we going to have a period of stability?
(Mr Milburn) I am sorry that we are doing too much.
23. It might be better to concentrate on doing
fewer things well.
(Mr Milburn) We will try not to do so much in the
future. If that is what you would like us to do in Hampshire I
am quite happy to oblige and I am sure the people of Swindon will
be absolutely delighted. We have a long term plan. It is called
the NHS plan. It is a plan for ten years and that is what we are
going to implement. There are various aspects to the NHS plan.
I do not know whether you have had a chance to read it. If you
have not, I will gladly send you a copy of that and you can see
the range of things that we are trying to do. What we are trying
to do is change the NHS in all respects. What frustrates me about
the debate on NHS reform is that although what we are talking
about today is really important because it does provide more capacity
in the system and means more care for NHS patients, sometimes
reform in the NHS is characterised purely as the NHS developing
a new relationship with the private sector. It is one part of
the reform programme but it is by no means the whole of the reform
programme. What we have to do is breakdown the demarcations between
the staff, as we were discussing at last week's hearing, ensuring
that the relationship within the public sector between health
and social services improves; making sure we make the optimum
use of the skills within the National Health Service, the extra
IT that we need to get into the National Health Service. These
are at least as important as the work that we are now doing with
the private sector. My own view about this is that we would be
incredibly foolish to turn our backs on spare capacity where it
exists and where it can bring benefit to NHS patients.
24. I admit there is capacity but it is not
always long term and it is not all around the country so different
solutions need to be prepared for different parts of the country.
You have just mentioned breaking down demarcations between staff.
If more NHS staff are attracted to the private sector because
of the increase in the Concordat, would you say that was a triumph
or a disaster for government policy?
(Mr Milburn) The crucial thing is what happens to
the NHS patient and whether they get care provided for free, according
to need, not ability to pay. What is happening in the NHS today
is that there is an increasing range of providers in play. The
dominant provision is still through mainstream NHS hospitals but
what we are also seeing, as we develop the Concordat, is growth
in NHS treatment taking place in the private sector hospitals.
As far as the staff issues are concerned, if we were to see the
seepage out of NHS staff, particularly some of the skilled staff
where we have really big shortages, into organisations that were
not providing care for NHS patients, that would be a concern.
What we are talking about here, remember, under the Concordat
is precisely making more care, more treatment, more operations
available to NHS patients.
John Austin
25. You refer to the question of capacity and
the Chair referred to consultants and consultant time. You talked
about beds not being available. We all know that in the past beds
have been cut dramatically, particularly acute beds. It is not
the physical capacity that has disappeared; it is the staffing
for those beds that has disappeared. When we talk about a shortage
of capacity, it is because there are not enough nurses or whatever
in the NHS hospitals. There is not some magical, additional pool
of people. There is one pool of nurses. Some work in the private
sector and some work in the NHS. Are we not just continuing to
compound the problems of the NHS hospital and its ability to retain
nursing staff?
(Mr Milburn) No, I do not think we are and I would
be concerned if that was happening, since we have had such an
enormous effort in getting nurses back into the National Health
Service, an effort incidentally which has paid dividends. We have
a lot more nurses coming through all the time. It would be a concern
to me, as I think I said last week, if we were getting nurses
in through the front door and then found, through whatever means,
they were leaving by the back door. There are two points to this.
First, I do not think it is true that the only problem in terms
of capacity that we have is just staff capacity. I was not saying
that the only problem was theatres, beds or IT facilities. In
Kent right now we have capacity constraints and NHS doctors and
nurses who walk down the road to a private sector hospital and
operate on NHS patients in their NHS time. Why do they do that?
They do that because their hospital is full. Maybe over time we
can put that right but do not let us pretend that somehow or other
the capacity constraints that the NHS faces today, the shortages
that we face—and we all know the reasons for that: lack
of investment over 20 or more years - are just capacity constraints
and shortages. They are about staff. They are about infrastructure
too. You only have to walk into most local hospitals - Greenwich
Hospital would be a good example - to see precisely what the result
of under investment has been. Frankly, shoddy buildings, dilapidated
equipment, equipment that breaks down all the time and a shortage
of capacity. The first point is it is not purely about staff constraints;
it is also about real hardware constraints - i.e., around operating
theatres and beds.
26. Greenwich Hospital has closed and the new
Queen Elizabeth PFI Hospital is open: state of the art, absolutely
superb facilities there.
(Mr Milburn) That last one was terrible though, was
it not?
27. You have a private sector hospital with
spare physical capacity. A private sector hospital is running
for profit. It is not going to staff that extra capacity if it
has not filled it with private patients. Therefore, if you then
give it an incentive to take NHS patients, it will recruit the
staff in to cope with that number of patients. The only pool it
can poach them from is from the NHS.
(Mr Milburn) I do not think necessarily think that
is right. I am not sure on what terms BUPA employ people but it
is certainly true you could make quite a convincing case that
BUPA does not employ a huge number of doctors. It has some medical
officers in its hospitals but by and large it relies upon NHS
consultants and so on. The same is not true of nursing staff.
The private sector is quite a big employer of nursing staff. I
cannot remember what the numbers are now but they do have their
own staff on their books, so to speak. The question is whether
or not from the private sector point of view and, more importantly,
from my point of view we are making optimum use of the resource
that is available. It is like the hardware. If the hardware is
lying idle in a private sector hospital - i.e., the bed, the operating
theatre, the critical care facility - equally if there is software
- i.e., the nurse - lying idle, not being used to maximum efficiency,
that is a resource that is being wasted. What we are trying to
do is to maximise the capacity all round.
Chairman
28. You said a moment ago that the problem was
not so much resourcing, although obviously more resources would
be welcome, but capacity. You will recall when the Prime Minister
announced the NHS national plan I had a slight difference of agreement
with him on emphasis rather than anything, in principle, over
the use of the private sector. I suggested, if we need that capacity,
although the private sector in many respects is having difficulties
in some areas, why do we not simply buy that capacity and take
over those hospitals. He said that was not possible but I recall
over the recess period we did do that. Why do we not do it more
often?
(Mr Milburn) The London Heart Hospital, which is the
hospital you refer to, I bought for £25 million and we got
a really good deal because it was an asset that was worth £35
million—state of the art, fantastic. What is more, we also
bought the staff, the nurses, the doctors and the back-up staff
too. They came over to the NHS. That was a hospital that had run
into trouble for reasons that we need not go into here. I acquired
that asset because I thought it would bring benefit to NHS patients,
including being able to do more heart operations on the NHS which
we really need to do a lot more of and a lot more quickly. There
are private sector hospitals that are running now on very low
levels of occupancy. What we are looking at is whether or not
we can more effectively not just contract with a private sector
hospital running at low levels of occupancy; but effectively buy
up for a period of a number of years that total capacity and monopolise
it for the benefit of NHS patients. If you ask me about whether,
if another London Heart Hospital came along with that standard
of care in the right place, in London where we know we have particular
capacity constraints that colleagues will recognise, if there
were something similar to that, I would potentially be interested
in making a further purchase, potentially I would. I stress again
that it would be one of a number of relationships that we need
to build with the private sector. I outlined some of them in answer
to Mr Burns's earlier questions.
Dr Richard Taylor
29. Secretary of State, I have no objection
to using the private sector in the short term as an expedient
to help out but I would like to explore some of the objections
to using it in a much wider form in the long term that have been
mentioned already. What we want are actual facts. The private
sector will cream off the easiest, least stressful bits from the
NHS because it does not do much in the way of emergency care which
is the sort of thing that is unpredictable and most stressful.
Therefore, I am quite sure nurses are leaving. Why we have shortage
of capacity with theatres in Worcestershire is that theatres are
sitting unused in the NHS because the nurses have left. What we
need to know is the facts. What have nurses who have left the
NHS left to go and do? Have they left nursing altogether? Have
they gone to the private sector? Have they just moved out of the
hospital service into the community service? The only way you
can answer the worries about the long term loss of nurses to the
NHS is if you produce the facts to show that they are not being
lost.
(Mr Milburn) I am happy to share what data we have
on that. There is one fact I can share with you and that is the
number of nurses is rising, not falling. With respect, I am sure
you were not saying that they were falling but your remarks could
have given that impression. The number of nurses is rising quite
steeply. What is more, the number of nurses coming through the
pipeline is set to produce even more increases than we have seen
in recent years in the years to come. For example, you know as
well as I do that the number of applications for nurse diplomas
and nurse degrees is up massively. They are going to produce a
cohort of future nurses on a scale that we have not seen in this
country maybe since the NHS was formed. You ask me where nurses
are going to when they leave. My understanding from the figures,
as I remember them, such as we have them - I am very happy to
let the Committee have what we have access to - is by and large
when nurses leave they leave for the obvious reasons. Most nurses
still today are women. They go off and have a family. Our problem
is that historically we have not been too good at getting them
back. We need to get better at that and that is why we are exploring
how we provide child care and all of these things. Is there a
big seepage from the NHS into the private sector? As I remember
it, no, there is not, but I am happy to share the data with you.
30. I was not expecting an off the cuff answer
in all detail. What I am asking for is a future survey over the
next few months to see exactly where the nurses are going. You
say there are more nurses. We certainly do not notice it in Worcestershire
with empty theatres that cannot be staffed.
(Mr Milburn) With respect, that is not such an intellectually
robust case.
31. It is a fact.
(Mr Milburn) I do not dispute that. There are empty
theatres all over the place. There are too many people on the
NHS waiting lists, waiting too long for treatment but do not fall
into this fallacy that unless you solve every problem you have
not solved any problem. The truth is there are more nurses and
there are more nurses coming through. I am sorry you do not feel
you see them in Worcestershire, but I will look into how many
nurses are employed in Worcestershire and I bet it shows an increase.
32. I have surgeons approaching me who have
not done routine prostate operations for 14 months because the
theatres that they would do them in cannot be staffed. The one
way you will help is by putting money in and at least they will
be able to do some of these in the private sector as a short term
expedient, which is excellent. I do not know what to say to this
chap who has not been able, because of shortage of nurses to staff
theatres, to do a routine prostate for 14 months. I have constituents
writing to me who are getting up 15 times a night and they cannot
be operated on.
(Mr Milburn) I understand that. As I said right at
the outset of my remarks, the biggest problem we have today is
shortage of capacity in the NHS. If I could click my fingers and
conjure magically out of thin air more trained nurses for Worcestershire
today, I would do it for you. You know I cannot and I know I cannot,
so what we have to do is grow them or bring them back. We have
brought, in the last 18 months alone - it might be the last two
years - a further 9,000 nurses back who left the NHS and have
now returned. Why has that happened? Because we have made nursing
more attractive by giving them better pay, by improving child
care, improving flexibility and accepting a very simple fact:
that they are in the key positions. As I said last week, there
is a labour market shortage. The people who pull the strings are
not the employers; it is the employees. What we have to get much
smarter at in Worcestershire and elsewhere is making sure that
we can attract people back on terms that are agreeable to them.
That means some changes around the very way we employ people,
in my view.
33. May we have the figures?
(Mr Milburn) Absolutely.
Jim Dowd
34. The whole question of private sector involvement,
whether through the Concordat or elsewhere, must be the best possible
service to the public and the best possible value for taxpayers'
money. Any device we can use to achieve those twin objectives
is useful, whether it is the opportunist acquisition of the London
Heart Hospital or a more sustained approach. I do not have the
difficulty that other Members of the Committee seem to have in
grasping that. You mentioned today and last week the capacity
in the NHS sector health care - on an earlier figure, you gave
us about 98.5 per cent - is about 90 per cent. You said you would
like to see it lower. You said that last week as well. That troubles
me because the acute sector in particular is astonishingly expensive.
There is a huge investment of taxpayers' money tied up in that.
I accept we cannot run them at 100 per cent because of pressures
on staff and individuals, but the second of my twin objectives,
getting the best possible value for public money, means we have
to use them as effectively as possible. In your view, if 89 or
90 per cent is too high, although that already implies ten per
cent slack in the system, what kind of target would you be looking
at?
(Mr Milburn) That is a very good question. We have
commissioned research from York University which the Committee
can see, which indicates that if you get occupancy rates in excess
of 82 per cent you start getting a higher level of cancelled operations
taking place at the last minute, which is hugely frustrating,
not just for the patients but for the members of staff as well.
Staff do not like having to ring up the patient on the morning
of the operation to say it is cancelled. Occupancy levels give
you higher levels of long waits in accident and emergency departments
because the whole system gets log jammed. The beds are too full
partially because we cannot get a lot of old people out of the
hospital and back home for the reasons we discussed last week.
The consequence is not only felt at the exit end of the hospital;
it is also felt at the entry end, where people cannot get out
of accident and emergency or out of the medical admissions unit
onto the acute ward because the beds are too full. What we have
been looking at very closely is what we can then do to get occupancy
levels down from around 89 or 90 per cent at the moment across
the NHS. In some of the areas where we have the biggest problems
they are higher still. We want them down towards levels of 82
per cent and some of the things we will be saying tomorrow will
be around the progress that we can make towards that. That is
really where we need to get to. It will take some time to get
there. I know that sounds as though, on the face of it, somehow
or other we are making the hospital sector less efficient. That
is not quite true. The problem is that it becomes less efficient
the more you get above 82 per cent. 89 per cent makes it inefficient
because you have all these patients stacked up either in the acute
wards or alternatively in the A&E department. That is partially
a consequence of getting the relationships right in the hospital
between the A&E department and the acute wards further through
the system and then the wards and what happens in terms of discharging
arrangements.
John Austin
35. You will remember this Committee in the
last Parliament looked at regulation in the private sector and
I think your predecessor felt that regulation of the private sector
was not the responsibility of the NHS. We felt it was the responsibility
of the Department of Health. Given that you want to build this
partnership, will you reassess the advantages of bringing the
private sector within the same regulatory framework as the NHS?
(Mr Milburn) We have to look at those issues. We have
a mechanism with the Commission for Health Improvement inspecting
NHS hospitals and the National Care Standards Commission effectively
regulating the private and voluntary sector, including residential
and nursing homes in so-called social care. The Commission for
Health Improvement, as you remember, when we put this through
the Health and Social Care Act, and the National Care Standards
Commission are empowered to work together jointly, calling staff
backwards and forwards and effectively subcontract some of their
operations, one to the other. That is something we want to see
developing. We want to see how it works. Remember, the National
Care Standards Commission is not yet in being and will not be
until April next year. There is an important caveat. The Commission
for Health Improvement can follow the NHS patient. If the NHS
patient is treated in an NHS hospital, the Commission for Health
Improvement will obviously go to the hospital and do its periodic
assessments. However, if the NHS patient is treated in a private
sector hospital under the Concordat, for example, the Commission
for Health Improvement can still follow that NHS patient. In a
sense, we already have the makings of what I think the Committee
were concerned about, which is to have one means of regulation
for the care system. What I would want to see is whether or not
those relationships and organisations that we have put in place
really are delivering the goods both to the patient but also,
importantly, for the service provider because I do want to avoid
a situation where we have over-inspection and it becomes overly
bureaucratic and so time consuming, particularly for clinicians
providing information and having endlessly to talk to different
visiting groups and inspectors so that they cannot get on with
the job and what they are paid for which is to treat patients.
The answer to the question is what we need to do is make sure
that we have a means of ensuring that regulation is coherent.
I think we probably have the means to do that. I want to see how
it works. If I am not convinced that it is working properly, we
will need to revisit it.
36. The time frame.
(Mr Milburn) The National Care Standards Commission
comes into operation in April. The Commission for Health Improvement
and the NCSC have already had the appropriate discussions about
how they can pool resources, and so on and so forth. I think we
want to give it a year and see how it is operating. I will be
quite happy, it is in the Committee's interest, to report back,
if you want me back. I can send you a note about what our assessment
is. If I am not convinced it is working we will need to revisit
it.
Julia Drown
37. I would like to explore the areas in which
private sector involvement might be appropriate in the National
Health Service and where it might not. You said in speeches that
areas like pathology and the diagnosis of treatment are right
for further private sector involvement. You also mentioned things
like private sector management, stand-alone surgery units and
IT systems, in those areas why can the National Health Service
not improve its performance? What, in particular, are the obstacles
that face the National Health Service?
(Mr Milburn) It can and I hope it is. If you take
somewhere like pathology or radiology, which in many ways are
the forgotten clinical services in the National Health Service.
I do it as well, we talk about doctors and nurses, you do not
talk about pathologists or radiologists or therapists, and so
on and so forth. The truth is the doctors and nurses would not
be able to do their jobs without their back up. It is worth remembering
that six in ten people who come into hospital now will require
some sort of diagnostic test. Unless we have decent up to date
pathology labs and radiology services then we are going to encounter
enormous problems in getting the waiting times down for treatment.
I think you are aware, as I am very painfully, these so-called
back office clinical services have suffered even more neglect
than the front of house clinical services. You only have to walk
around most pathology labs to see that is the case, equipment
is pretty outdated, the staff, by and large, have an older age
profile than many people who work in the National Health Service
and the rates of pay have been pretty appalling for people. We
have begun to make a difference around that. Last year, or earlier
this year, we increased the rates of pay for pathology staff quite
markedly, which is a very, very important signal and a first start
for those staff. They are scientists, they are technicians and
we should treat them as such, they are not second rate citizens.
We are beginning to make a difference there. There is money going
in. As you are aware after the last Spending Review we established
what we called the Pathology Modernisation Programme which has
spent so far £20 million on 35 projects across the country
trying to modernise the equipment, trying to make sure it is up
to date, trying to make sure that if the National Health Service
front of house is operating 24 hours a day one of the big problems
we have is in A&E, the A&E department is obviously there
24 hours a day but the radiology services might only be there
from 9 am to 5 pm, then you wonder why people are stuck on trolleys
or occupying a bed needlessly just waiting for a test.
38. Insofar as there are barriers and people
were not paid well enough in the National Health Service, that
barrier is going down. Indeed, there is an issue there that partly
in these areas it is going against one of the principles that
you suggest in your paper that is important, that you would not
want to bring in private sector involvement if it would involve
having to recruit staff in areas where there was a shortage of
staff, which is the case in pathology and parts of radiology.
Why do you think this particular area is right?
(Mr Milburn) Essentially we have two big problems,
one, we have a shortage of staff capacity. Radiology, for example,
that is our primary worry, although we are well behind on the
provision of CT scanners and MRI scanners compared to other countries
in Europe we are putting that right. There is a huge investment
going in through mainstream capital and also through the new Opportunities
Fund and that is going to really make a difference, particularly
around cancer, and so on and so forth. The second problem is round
the shortages of capacity in relation to equipment and infrastructure,
there the private sector can play a role. The third area is an
important one, at the moment the private pathology services in
this country are a very small element of the National Health Service
in this country. Private pathology accounts for between five per
cent and seven per cent of overall National Health Service pathology
capacity. What we do know is that in the private sector there
is spare capacity in pathology. What we need to do is to discuss
with private sector providers of pathology services whether there
is not a means of garnering that investment, their resource, their
spare capacity for the benefit of National Health Service patients.
39. Is that in consultant time, equipment or
technician time?
(Mr Milburn) At the moment this is service capacity,
it is not just that they are better equipped and more modern but
the services that they have could take more National Health Service
custom. What we are doing—this might be useful, I am not
sure we mentioned this in the memorandum or not, if we did not
forgive me, we have this Pathology Modernisation programme underway,
which is largely being focussed on very small-scale projects until
now—in this financial year is contemplating spending a further
£8 million on four large scale pathology modernisation programmes
dotted around the country. It is entirely possible that one of
those will be a PPP with the private sector.
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