Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 700 - 719)



  700. One of the issues I raised with the Secretary of State when he came at the start of this inquiry was evidence which I personally received that patients waiting to see particular consultants on NHS waiting lists are told under the concordat they will be seen instead within the private sector; go to a private hospital and see exactly the same consultant in their private time in a private hospital. Is that something which is happening in any widespread way or is it just an odd example I have in my area which is not replicated elsewhere?
  (Dr Fradd) We are not inundated with correspondence on that and certainly in my personal experience as a GP, I have not experienced it. I am sure there are cases around the country but there is pressure on the NHS to deliver the service so that they do not lose the resources to the private sector. In a way that may be a positive incentive to make sure that the system delivers well.

  701. Nobody would really write to you to complain about that situation, so it may not be an issue drawn to your attention.
  (Dr Fradd) It may not be an issue.

  702. Would you share my concern if that were happening to any great degree?
  (Dr Fradd) Yes, I would.

Dr Naysmith

  703. In what area do you practice when you are practising as a general practitioner?
  (Dr Fradd) I practice in inner city Nottingham, a very deprived area, one of the old city challenge areas.


  704. Do you have any thoughts on these general points from your perspective in the Alliance?
  (Dr Dixon) Yes, there is a capacity problem in the NHS, both in terms of resources and manning, as we all know. Private capacity does potentially offer something; potentially certainly in the short term in terms of lopping off some of the long waits and work that is required. We also need to look at the short term and the long term. We need to look at the way in which short-term solutions might impact upon more important developments within the NHS capacity which we need to be working on. Not a great deal of it is going on at the moment because PCTs and PCGs are such new organisations. The importance for this Committee is to look at how, particularly in primary care, we are going to go about it. I see that as the purpose of today.

  705. One of the areas which has been drawn to my attention and the Committee had some evidence on in a previous inquiry was the correlation occasionally between lengthy waiting lists and the private practice of the consultants concerned. I am making no suggestions other than to report some interesting correlation. In terms of logic, it does not seem to me to make a great deal of sense to be sending people to see these consultants in the private sector without addressing why we have these long waiting lists in the first place. Do you see that there is some degree of inconsistency between on the one hand attempts under the consultants' contracts to retain people for the first seven years to work wholly in the NHS and at the same time putting additional work into the private sector?
  (Dr Dixon) There is the conflict of interest you relate to. What we need to do is to try to reduce that conflict of interest and incentivise consultants and all practitioners working within NHS to take some responsibility, particularly for waiting within the NHS. At the moment the conflict actually splits them in two. There are ways of doing that and what evidence suggests is that those trusts, for instance, which have the best waiting lists, are those where they have most involved the clinicians in the initiatives they have done. It is a question of making sure that the team is working for the NHS and is not split between its private and its public responsibilities.

  706. Dr Stanton, you cannot answer for your BMA consultant colleagues, but you may have your own opinion on this area. Do you have any thoughts on that point?
  (Dr Stanton) I am also Secretary of the London Group of local medical committees, so have a number of established primary care trusts on my patch and also most of the London hospitals. Certainly the overwhelming difficulty for those primary care trusts in London, which have already been established is simply trying to juggle their budgets essentially to keep their NHS hospital services going. There is no spare capacity or particular wish to be diverting money into the private sector. My impression is that it is not really the work pattern of consultants which leads to the block, it is actually the lack of resources within NHS hospitals which leads to these problems, lack of operating time and nursing staff where there is a crucial shortage. It is a huge problem.

  707. It is nothing to do with the fact that some of them spend rather a lot of time in the private sector.
  (Dr Stanton) That has always been the case in some parts.

  708. Does it always have to be the case?
  (Dr Stanton) I am sure not.

Jim Dowd

  709. What you seem to imply, Dr Fradd, is that the spending patterns that the PCTs have inherited are historic and that there is no room to change them.
  (Dr Fradd) It is remarkably difficult to shift money about which is going to have a negative effect. Trying to close the most expensive parts of the service, neo-natal intensive care and intensive care beds, because that would have enormous implications in lower tech care, is very difficult and there is always going to be a demand. We would share the desire that there should always be the facilities for such care. They take precedence over dealing with what may be perceived as much less exciting care of a routine nature. So repairing a hernia does not have the same attraction for publicity as doing coronary artery grafts or major work like that. The reality is of course that it is just as devastating for the individual doing manual work as there is no way you can work if you have a hernia. The problem is that the resources are fully committed historically, as you put it, and there is almost no freedom of manoeuvre to do anything because there is no—

  710. Surely part of the role of the PCTs was to unblock that historical pattern.
  (Dr Fradd) Of course, but you cannot actually look at the problem—

  711. Yes, I understand that. We can always do more with more money. There will never be an infinite amount of money. There will always be a limitation.
  (Dr Fradd) I totally agree.

  712. But surely the PCT's responsibility is primarily the service it provides to its local community, local citizens, rather than a kind of secondary involvement in the infrastructure of the acute sector.
  (Dr Fradd) I am sorry, I stand by what I say. You can delegate responsibility, but if you do not delegate the power to do anything about it, then it is pretty useless. We have had amazing commitments from this Government to the NHS. We had £1 billion only this week. What we need to do is to make sure that extra resources do not get earmarked before we have the opportunity to make those developments. There is the most enormous potential for development within primary care in particular, but we have to have the spare capacity. Nobody is going to allow me as a member of a primary care trust to start closing hospital beds with long waiting lists because I want to start getting something off the ground in primary care which would probably have a run-in period of several months if not years.

  713. That is not a decision for you at the PCT about beds at the local acute ward.
  (Dr Fradd) Of course it is in terms of the funding.

  714. It is in the way it knocks on but your task is getting best value for public money and best service to the patients and that is where your priority should be.
  (Dr Fradd) The way my colleagues see it is that we have to maintain the historic standard and it has to be done out of private money.

  715. You rendered the question I was going to ask quite redundant. I was going to ask whether you were happy to see a mix of commissioning from PCTs—
  (Dr Fradd) Of course but given the resources.

  716. If you say that all you have done is inherited what has gone before then actually what you are saying is that there is something you can do about it.
  (Dr Fradd) To a large extent I am saying that. Without the necessary resources we do want to do that, we do want to get into the driving seat. But you would be the first person, if a maternity unit were closed locally to say your constituents were not happy with that. To a certain extent we have to recognise the nature of the NHS is such that it takes an awful long time to move it. The public rightly demand that they at least have a certain level of service and if in trying to improve that service you are not given the seed money to get that off the ground, then I do not see how you move it forward.
  (Dr Dixon) This is an evolutionary process. Unified budgets are very new and the management infrastructure and primary care trusts are fairly undeveloped at present. The priorities over the last year or two have been mainly secondary care and 80 per cent of primary care trusts have been asked in-year to help towards secondary care overspends. That is the reality of the pressures on the system at the moment. You are dead right. In the future, the unified budget will be there to be used flexibly. I am also the commissioning chair of three PCTs. At the moment I find much of my work is simply following the NHS, following many of the central directions and much of the secondary care agenda and that does not give much room for manoeuvre. For the future, yes, as a commissioning chair I see myself looking at options quite seriously. When I find myself blocked by services in the public sector in the way that can happen sometimes because of the disparate interest between private and public, then there will be chances where we might start looking at commissioning services elsewhere. It is a stage of evolution. That is next year and the year after and it does depend also on capacity in the NHS and also the amount of money at my disposal for doing that.

  717. It seems a curious formulation that you need more money in order to spend the money you have better, although I do accept there is a degree—
  (Dr Dixon) It is about closing ward.

  718. In the BMA memorandum to the Committee you said that GPs are well placed to deliver an improvement to services and introduce innovative ways of working. Can you expand on that, given the constraints you have now said they are working under in PCTs?
  (Dr Fradd) Yes. Again it depends on capacity and that does tie in with what you are pushing at which is the possibility of new ways of working. We have suffered under three reorganisations in my working lifetime which have thrown up enormous burdens just in adapting to the organisational structure of the NHS. We are now in the middle of probably the most major one I have ever seen with the move to strategic health authorities. That actually consumes quite a lot of medical time and other people's time which necessarily takes away from innovative working at the coal face. Having said that, we have made some very radical changes. If you look at diabetic care, ten years ago that was a hospital-based care package. That is now almost entirely based in general practice and certainly the upper end of the profession would like to see it all managed within general practice. There are the potentials for things like intermediate care for specialist services, but only if we can look at new ways of working in some of those areas of care which do not really require the service of the general practitioner. Let me give you one example: a minor self-limiting illness, particularly at this time of year, upper respiratory tract infection. That is not a problem to take to a doctor. It is something to be taken to the pharmacist. Unfortunately the Crown report is very nearly two years' old now to empower pharmacists to prescribe. You will not unlock that problem at my inner city practice for patients who get free prescriptions by moving them to the pharmacist if the consequence is that they have to pay for those drugs, albeit relatively small costs and even in NHS terms. There are things which we need to do to empower my colleagues to shift the work. I think we are at a very exciting time. We are currently locked into negotiations with the NHS Confederation on the new contract. We certainly have a very similar view of the problems and these keys which need to be turned on both sides in order to move it forward. My fear is that we shall not be allowed to reach a conclusion in those negotiations and then see them implemented, that we shall see ministerial interference in the outcome of those negotiations. I am not saying that Ministers do not have a right, but they are going to be included in feedback on those negotiations as they go through. We do have a brave new world which is possible but it will demand some regulatory change such as pharmacy prescribing, it will mean that we have to be allowed to reorganise the way services are delivered at the level of the practice and PCT.


  719. I was very interested in the point you made about the use of pharmacists. Unfortunately our pharmacist is on another committee this morning because she could probably take this point further. You implied that in a week when we have had the very important reports which have informed debate about general taxation resource in the NHS we need to look perhaps at how we use access to GPs. The implication was that because we have a financial incentive for a patient to see you on the basis of getting a free prescription, that results perhaps in more cost to the NHS than looking at unravelling the prescriptions to enable people to go straight to the pharmacist; it is a cost issue. Have you researched this in any way in detail to look at what this cost implication might be? You are implying to me that there ought to be a shift in policy to make more effective use of pharmacists, reduce the burden upon GPs and that that may well be an area which reduces the costs to the NHS in the longer term. We were talking this morning in the press about how many billions we need. A lot of us round this table think we can spend existing money far more effectively and I am sure you would agree with that.
  (Dr Fradd) I certainly would agree with that. Some very good pilot studies have been done, one in Newcastle which I am very happy to let the Committee have the details of, where they have earmarked funds through the health authority for pharmacists to be able to prescribe under patient group directives. The trouble with that is that you have to be very specific about the range of activity which is going to be allowed, whereas I believe that pharmacists, where they are dealing with over-the-counter drugs are already in effect prescribing to those people who can afford to buy those drugs. So what is the difference in giving them a Government piece of paper which gives them eligibility for those drugs for free? The costings on that are extremely competitive on that Newcastle project. They demonstrated that, even though they paid an incentive to the pharmacist to participate and we do have to remember that we must resource the colleagues who are taking on this work. It is no good expecting people to take on more work and more responsibility without giving them some reward for that and making sure they have the money for infrastructure like private rooms within a pharmacy to deal with personal problems. In terms of resourcing, coming back to your question, the pilots which are out there demonstrate very good value for money and not least the opportunity cost because the thing we are shortest of is people with skills, nurses, doctors. Therefore if we can free up time from them, we can get much more out of the system. We need to have a move to the right where we move the less complicated work down to people with less experience, fewer skills. My colleagues and I can then move to higher added work.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2002
Prepared 15 May 2002