Examination of Witnesses (Questions 600
THURSDAY 22 NOVEMBER 2001
600. You do not really have a preference. You
will offer either/or.
(Dr Prudo-Chlebosz) Yes.
601. What do you think about what you have just
heard, Mr Spiller?
(Mr Spiller) It is inappropriate if they are individual
contracts for both to be on offer because this will create huge
problems. If we were looking at this in a year's time, we would
have a different attitude to it, and so would the private sector.
I come back to agenda for change. Huge changes are taking place
both in pay levels and in the way in which pay is determined.
Some of the advantages which are perceived at the moment in the
private sector will disappear because we believe the NHS arrangements
which will come through agenda for change will be so much better
than they are at the moment. We have been working for this very
result for many years and we are pleased to see it on its way.
One other thing I really need to say is that terms and conditions
of employment are not necessarily the major issue that even we
are concerned with. One way or another we know that the employer
will have to pay sufficient to recruit and retain. That is a given.
What we are more concerned with is the long-term viability of
this process, particularly if the employer changes, as could happen
for example with Ealing; having gone from the NHS to TDL, it could
now go to Quest and that is a big concern. We are having this
continual change of employer and although TUPE is there, it can
create enormous difficulties when you are taking people in from
different areas, some coming from the NHS, some coming from another
private provider. We had this experience in the private sector
with contracting where it creates huge anomalies, where people
can stay on their previous terms and conditions of appointment
and be working alongside somebody on different terms of employment.
You can have three separate terms and conditions of employment.
A computer company we deal with has 42 different sets of terms
and conditions of employment as a result of TUPE which it has
to operate within the same company; an almost impossible task.
Our preference is that there should be retention within the NHS.
We believe there is an important case to be made for introducing
additional management into the NHS, there is a shortage of good
management at the moment. The private sector may well be able
to provide this and they may well be able to provide other elements
and new ideas which are perhaps not in the NHS at the moment.
We believe there are ways of doing this without changing the status
or position of staff.
602. Would you therefore see a viable model
for the pathology service being the facilities, laboratories,
capital equipment provided through the PFI route, staff employed
by the NHS? Would that enable you to get the money into the modernisation
of the bricks and mortar? Would that be your preferred model?
(Mr Spiller) We take a pragmatic view on whether the
private sector should be involved in those circumstances. If it
delivers a better service to the patient at a better price, then
we have no objection to that happening. The proposal you have
put forward, the model you have put forward, is one we could certainly
live with and where we could see some advantages.
603. Does Ms Wannell's evidence not suggest
that when the staff are also employed by the private sector, the
quality is improved as well? Thinking about the service to patients
and not just about the conditions of the staff, is there not some
evidence that that has introduced quality gains?
(Mr Spiller) No. No, the evidence on improved quality
gains comes largely from the investment which is going in. Pathology
has been starved of investment over the years and what we see
now is the private sector coming along and putting investment
in and that is why there is a big improvement in quality. It is
not down necessarily to the way in which people work or their
capabilities. One has to say as far as the private sector is concerned
that where it previously existed, it has existed either because
the private health sector was using it or the pharmaceutical companies
and they had to have high standards.
604. Has the introduction of a contract focused
attention on performance in a way that there was no direct lever
on performance under the old system? Would you accept that?
(Mr Spiller) No, I do not think so. One of the areas
of difficulty we find in contracts is that the transaction costs
can be quite significant on occasions. One of the costs we are
finding with private sector, or fears of our members have been
expressed in this way, is double testing. Where a test comes out
as not truly abnormal, but on the other hand not quite right as
well, in a NHS laboratory this will always be investigated further
at the initiative of the scientist who is dealing with it. The
worry we have is that where there is a contractual arrangement
which is trying to drive down the number of tests done, albeit
that is what is required clinically, these opportunities are not
there. They are much more cost conscious. That may be a good thing
and it may be that one should get authority for those additional
tasks but that happens at the moment and one can give a GP an
answer which he was not expecting because you have done something
extra which he did not ask for.
605. West Middlesex seem to suggest they have
solved this by having it clinician-led. Would you not accept that
that always works?
(Mr Spiller) It is always clinician-led in that sense.
What we are trying to do is break away from it having to be clinician-led.
606. What they are suggesting is that no-one
would stop doing something because of a cost pressure. If it deserved
further investigation they would do that.
(Mr Spiller) No, no. I do not think that is necessarily
607. I should like to come back to an expression
you used a few moments ago about a shortage of management in the
Health Service. Did you mean there are just too few managers or
high vacancy levels or there is not enough management skill within
the NHS? What did you actually mean by that?
(Mr Spiller) That was a mistake of my own making because
we represent managers as well in many areas. There are several
features. The first is that the management structure in the NHS
leaves a lot to be desired; we and indeed the DoH have found the
independence of trusts has been a major problem. Secondly, the
management style has been governed for the best part of 20 years
by managers trying very hard to drive costs down and sometimes
reduce resources and it takes time to change that management style
around. Thirdly, there is simply a shortage in numbers of management
and fourthly, there is something left to be desired among a lot
of NHS managers as to levels of competence. In all respects I
can see that there will be areas of the private sector which could
help with that, certainly in terms of it lifting the number of
good managers within the NHS. There is no question that we are
short of good managers in the NHS and that is not in itself denigrating
existing managers, it is simply that we are asking too much at
the moment of managers to deal with the move to PCTs, where there
is hardly any HR component.
608. I am still not clear whether you are emphasising
better managers or more managers.
(Mr Spiller) More managers.
609. More and better managers.
(Mr Spiller) More managers; one would hope obviously
that they would be better.
610. Earlier you were suggesting that in terms
of improving the career prospects of your members, particularly
technical staff in the service, there was an indication that things
were getting a little bit blurred between the clinical pathologists
and staff in that your members were beginning to take more decisions
than perhaps they used to. I think that is an excellent idea and
it reflects things which are happening elsewhere in the National
Health Service: radiology and radiographers for instance are becoming
a bit blurred and some of the things doctors used to do which
nurses are now being entitled to do by legislation. I just want
to know whether you think that is going to happen more. Then I
am going to ask Professor Lilleyman what he thinks about that.
It is a very interesting area. Do you think it is likely to carry
on expanding, particularly in the light of what else we have been
hearing this morning about separating off technicians in the service
from the actual hospitals and a central organisation which might
be a long way away from where the clinical decisions are made?
(Mr Spiller) It is a trend which is developing for
very positive reasons, partly driven by the shortage of consultants
and looking at ways of trying to enable the decisions to be made
which consultants would otherwise be doing. An example of this
is that one of the sections of our union, the medical practitioners'
union, has recently proposed that the new surgical diagnostic
units which are being proposed should be run by nurses and operated
by nurses rather than doctors, that many of the features of those
could be done by well-trained nurses rather than necessarily using
doctors to do that. Some very fundamental changes are being proposed.
Intermediate level of professions is something which is seen as
being much more desirable now, much more possible, It happens
in many other places in the world. We have very clear professional
lines of accountability in the Health Service in Britain. That
is going to become blurred as there is going to be much more work
across professions and across departments.
611. You certainly see this as a positive move
for the people you represent.
(Mr Spiller) Most definitely. Even though some of
our members' work will be given to people who might be seen as
being lower skilled than they are, we see this as a positive move
both to reduce the shortages which exist, but also to be more
positive, to give people a higher level of skills and better commitment
to the work they are doing.
612. Professor Lilleyman, far be it for me to
suggest that your College is equivalent to a trade union, but
what do your members feel about this kind of thing?
(Professor Lilleyman) May I first of all point out
that 20 per cent of our members are not doctors and we are unique
as a medical Royal College in that regard. It is something we
are actually rather proud of and that constituency is increasing.
That in itself is a testament to the fact that we have no difficulty
whatsoever embracing the skills of our scientific colleagues.
I should point out something which has not actually arisen this
morning so far and that is that there are three professional tribes
in NHS pathology, not just two as we have been talking about.
We have the medical practitioners, we have clinical scientists,
who are separately regulated under the Council for the Professions
Supplementary to Medicine and we have the MLSOs. The fuzziness,
the blurring of the boundaries is not just going to occur between
the scientists and doctors, it is also going to occur between
two different types of scientists. Witness to this fact of course
is that those two tribes are already merged into one in the independent
sector. They do not exist as two separate tribes outside the NHS.
I and most of the members and fellows of the College would have
no difficulty at all embracing flexible working in all its aspects
in the delivery of pathology services. We see this as not only
essential due to workforce problems but highly desirable from
a professional point of view.
613. Are you encouraging it?
(Professor Lilleyman) Yes.
614. Karen Ward, how do you see this when what
you want really in the setup you are proposing is to have a much
more factory scale thing where you get through more and more tests
in as short as possible time, in some cases away from the clinical
setting? How do you see this fitting in with your plans?
(Ms Ward) Everyone has this fear of the factory laboratory
and most people seem to focus on that as the big issue for them.
615. Reassure us.
(Ms Ward) Our approach is that the configuration of
a laboratory, where it is, how big it is, what tests are done
there, is really the last decision which is made. We always start
from the premise that you design a service based on the needs
of the users of that service. If the clinicians of an acute trust
have a particular profile, they have oncology clinics, they may
have rheumatology clinics, then the service is designed to support
that clinical activity. Once you have done that with all of the
users of the service, designing the laboratory to support that
activity is a relatively easy step. It is not a decision we as
a company would make on our own. We feel one of the problems with
the current procurement process, for example, is that it keeps
people apart for too long a time. You really need to involve the
professional groups at a much earlier stage. They are the ones
who are going to have a big impact on how services can best be
delivered. What we see as a partnership is bringing together the
strengths of the two parties. It is not a question of a company
like ourselves coming in and saying this is how it is going to
be folks, like it or lump it. It is a question of working in partnership
as we do with the consultants at the West Middlesex and the staff
of the West Middlesex and many of our staff are key people in
determining changes to service provision. As far as we are concerned,
they all have a contribution to make. There is no one particular
organisation which holds sway over any other, it is a true partnership.
Gail Wannell was talking earlier about looking at how services
are best used. It is not in our interest for the use of the service
to go through the roof, because if the trust cannot afford to
pay for that, then that is not in their interest or in our interest.
What we are aiming for is appropriate use of the service, use
of the service based on best practice, based on testing protocols
so that there are clear paths through to audit, so you can see
that what you are doing in a laboratory is providing benefit to
the doctors and to the patients who are using it. Roger's comments
earlier on about the staff being concerned about not being able
to do additional work on samples is certainly something our staff
would find a complete anathema.
616. What would they do if they came across
such a situation?
(Ms Ward) Exactly what they did before the partnership
617. Which is?
(Ms Ward) If a specimen needs further tests then that
would be done. It is based on clinical need and they are as responsible
people as you would find anywhere. They are very highly trained,
very highly skilled and in their view, they are looking after
the patient just as much as anyone else is. We would expect them
to do that. Our response would be that if someone did not perform
an additional test because they were concerned about being allowed
to do it under the contract, that would be the wrong approach
as far as we were concerned.
618. Do you lose money as a company when they
do that further testing?
(Ms Ward) I am not sure I can answer that question
because the service is designed to produce outcomes. What we are
looking at here is delivering a service, we are not delivering
a certain number of washers. What we are trying to do is provide
effective management of a particular patient to the trust. If
we were to say, for example, that we do not do that test and we
have to wait for it to be requested by the doctor, that patient
would stay in hospital longer. What we are saying is that no,
we are there to provide a service, we are there to provide effective
services to the trust. Anything that helps the trust treat that
patient better and the doctors treat that patient better is a
good thing for both of us.
619. I want to give Dr Prudo a chance to say
what he thinks about this.
(Dr Prudo-Chlebosz) In addition to what has been said,
modern technology is driving much of this. When we went to Ealing,
most of the pathology reports were signed off by a consultant
pathologist. We introduced rules-based reporting which is that
the consultant sets up a set of rules and these are incorporated
in a software programme and you only sign off exceptions.