Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 840 - 859)



  840. I will pass on to colleagues in a moment. So if you have a consultant who has a lengthy waiting list, and some have argued in front of this Committee that waiting lists may in some instances be constructed to create a demand for private medical consultations, if that consultant cannot see a patient and the GP says "you can pay to see the consultant privately and gain access to that consultant", that does not in any way undermine the treatment according to clinical need principle that you subscribe to?
  (Mr Fieldhouse) If a patient is referred to an NHS consultant, and I do not accept the point that waiting lists are manipulated in any way—

  841. We have certainly had people suggesting to the Committee that is the case.
  (Mr Fieldhouse) I have heard those suggestions. I have never seen any evidence that bears that out. Certainly we would not support such manipulation of waiting lists, if there was any evidence, for one moment.

  842. Why would I choose as an NHS patient to pay to go privately if I did not have to wait on a long waiting list? If there was not an NHS waiting list would people honestly choose to pay for private access to a consultant?
  (Mr Fieldhouse) It is our belief that if there was not an NHS waiting list then, yes, some patients would choose.

  843. I do not think they would in my part of the world.
  (Mr Fieldhouse) I think there is a lot of evidence that some patients would choose to go into the independent sector. Whether that be for personal convenience, for business convenience or for the ancillary comforts that may go with what the independent sector can provide or, indeed, for choosing and defining the person who actually renders their treatment, all of those are factors which make people use their own funds for that purpose.

John Austin

  844. That may be true around the margins but I think the point that the Chairman was trying to make was about the failure to separate properly the public and private provision. If I could just read something which was in an article on integrated health care in The House magazine, which may not be your regular reading material. It is an excellent article written by the Chairman. He said "Would we honestly tolerate teachers in state schools saying to parents `my class is full and I cannot teach your child, but if you pay me a fee I will ensure he or she receives proper tuition'. Would we allow teachers to build up class sizes and spend less time with their class in order to give private tuition to fee payers? We do not allow it in education, why should we allow it in the Health Service?"
  (Mr Fieldhouse) Effectively, and I cannot comment on the teaching profession, I am not aware that consultants are in some way, as you seem to be suggesting, saying to their patients in NHS clinics "I am sorry the waiting list is this long but pay me and you can come and see me privately". Effectively they may be referred privately but my experience in the private sector is that decision is almost universally made outside the NHS referral system and often normally before it, in other words a patient with PMI insurance who wishes to go down that pathway makes that decision in advance and follows an alternative pathway.

  Dr Naysmith: This has partly been covered already but I have people who come to see me in my surgery who tell me about this.

  Julia Drown: Me too.

Dr Naysmith

  845. That they have been seen by a consultant on a National Health Service referral and the consultant says "It will be six or nine months until this can be done under the National Health Service" but, and I know this is not supposed to happen, the suggestion is made to them if they are prepared to go private they can have their varicose veins done in three or four weeks' time. It happens so often, and all of my colleagues around the table will back me up, that I cannot see how it can possibly not be true.
  (Mr Fieldhouse) I accept what you say but we would not support such behaviour is all I can say.

  846. It happens all the time. You say you would not support that behaviour?
  (Mr Fieldhouse) I do not think it is appropriate for consultants to suggest to patients in an NHS consulting room that they should go down a private sector pathway. It is perfectly appropriate, because patients ask all the time, to ask what the waiting time is.

  847. So what would you do to try to discourage this happening, if anything?
  (Mr Fieldhouse) I think the guidance from all the professional associations is already there. This is an inappropriate way of conducting one's NHS practice and it certainly is not something we would foster as appropriate behaviour for a consultant.

Siobhain McDonagh

  848. I know anecdotal evidence obviously annoys you terribly but I am more than happy to give you names and addresses of people who have had that experience. It seems to me, not trying to cast the consultant in the money grabbing mould, for somebody who has got a serious condition, and I am thinking of a lady who has since passed away who was told she had a very serious heart condition and her husband claims she was told she was a ticking time bomb and told he could not do anything for her for a year, it was only a very short step for them to say "And if we want it privately, what is going to happen?" I do not believe there is anybody here who has not had that experience.
  (Mr Fieldhouse) If I may say to you, I think you are unfolding the circumstances in the different direction of a patient asking for information, whereas the suggestion has been there is a sales pitch from the consultant.

Dr Naysmith

  849. I was much more subtle than that.
  (Mr Fieldhouse) If the patient is asking for information then I think it would be very difficult and perhaps even inappropriate not to give that information because it may well be that they would seek that treatment not from you but from somewhere entirely different. If it is information given in the patient's best interests on a knowledge basis, and has been requested, then I cannot see that that is an inappropriate pathway. The reverse, as we dealt with earlier, of an attempt in some way to foster a private practice by volunteering certain information when a patient has not asked for it I think is inappropriate.
  (Mr Hassell) Firstly, Chairman, you were quite clear at the beginning about your own position and we know of your opposition to private health care.


  850. You know my position well.
  (Mr Hassell) I think I should try and balance for the record my position certainly and that is my understanding is the main thrust of this Committee's purpose is to examine the workings of the Concordat and I would like to place on record my congratulations to the Secretary of State, Alan Milburn, and the Government for having the vision to actually agree the Concordat and other Public-Private Partnerships. From my point of view I find it disappointing that you are addressing the issue of consultants' activities in the NHS rather than addressing the benefits to patients. If there are 70,000 patients, as you referred to Charles Auld a moment ago, surely it is important that there are 70,000-odd NHS patients who are benefiting from faster treatment?

  851. If I can come back to you on that. My concern is in the short-term I have constituents who have gone to private hospitals and are happy to have their operations done but certainly one or two have asked me questions as to why it is they have seen in the private hospital the same consultant they should have seen in the NHS but could not see them. We need to get to the bottom of this.
  (Mr Hassell) In a previous session Dr Taylor, who is not here this morning, referred to one of the consultants who for 18 months had not been able to undertake work in an NHS hospital but it was not his fault at all, that was due to the unavailability of theatre time or other issues. There are issues such as that, not just the issue of how a consultant spends his time but how the infrastructure is or is not supporting the consultant.

  Chairman: I want to come back on that specific question to Mr Auld because one of the concerns I have got in terms of Mr Auld's evidence is he refers to our Committee's visit in 1999 to Stockton Hall as part of our mental health inquiry, and we were grateful to your organisation for facilitating that, and I think it is a fair summary that in terms of our reaction to the quality of care it was a positive reaction, but in answer to your point, Mr Hassell, about my views on this, my particular concern is we are thinking particularly in the short-term motivated by waiting list targets and not thinking of the longer term effects on the Health Service. Stockton Hall is a good example. It is a psychiatric hospital based near York, not far from where I come from, and my colleagues, certainly Mr Austin who was present, will confirm that what concerned us in particular about that unit provided by a private company was it was virtually full of young black men from London who were being treated for serious psychiatric problems and why on earth should that unit be 200 miles away from where they came from. I think the feeling was, and we said this in our Committee, that by going to the private sector for a short-term answer to the difficulties, the long-term development of more appropriate facilities is retarded. I do not know if you want to comment as you were present, John?

John Austin

  852. That is true. We commented on the quality of care and we had no queries about that, but clearly it was inappropriate provision because of its location purely because there was spare capacity in the private sector and a failure to invest. If you go for this short-term expediency, and there is an argument for it, it then removes the resources that ought to be available to redress the problem that is there in the first place, which in this case was the non-provision of proper facilities in the London area.
  (Mr Auld) Could I respond, please? I think, first of all, just to address the issue of-short-termism of the solution, I would have to remind certain Members of the Committee that Partnerships in Care has been doing what it does now for about 20 years, so I think in answer to any fears that one might have in terms of the latest developments of the Concordat and the recent announcements and developments, one might be tempted to look at the way in which a similar form of partnership has been evolving over some two decades in the psychiatric rehabilitation field. I am very pleased that the Committee has endorsed the quality of the care and there is certainly no anxiety about that. We would share the previous expressed concern that the Committee had about location of treatment. In one sense this is in part to do with the nature of the conditions that have to be treated. As many of you would know, they are not very frequent as a percentage of the population. The consequence is that to have the right critical mass of a centre or a hospital to treat these conditions you tend not to have too many of these hospitals. That said, it is also fair to say that we, and we are on record as saying, have been trying very hard to improve the locational aspect of treatment. We were the first since the war to set up an inner city psychiatric hospital, Redford Lodge which is in Edmonton and that is a major catchment area in that part of the South-East. In the area of the treatment of women, many of whom have come out of the special hospitals, we now have hospitals up and down the country and are treating more of that category of patient than the Health Service is in terms of special beds. I accept that there is more that could be done in terms of improving the locational aspect. I agree with you that I think the quality is there. Importantly, we would say perhaps it is a model of the way that the acute sector will go. The important thing is that patients are being treated, patients who if we were not around I believe would not be being treated.
  (Ms Bryson) I would just like to agree with Mr Auld. The project that we did this time last year treated almost 1,000 patients in the private sector and the majority of these patients were patients who had been waiting a very long time on waiting lists, some very elderly patients waiting for cataract and hip operations that the NHS at that time could not deliver and they were very grateful and very pleased to have their treatment in the private sector. To pick up on a previous point, we did encounter difficulties with consultants and some blockages to transferring these patients into the private sector, to quote some of them, because it would affect their private list.


  853. Could you say that again, please?
  (Ms Bryson) It would affect their private list. Some were particularly obstructive with it and we had quite a lot of difficulty circumventing that. I think there is a cause for concern in terms of how one manages the consultants if one is going to use the private sector. Maybe there should be a debate as to who holds the NHS waiting list. I would argue it should not be the consultants because they should not be allowed to have that control over where and when patients are treated.

  854. You were saying there was some obstruction by NHS consultants about moving people from their waiting lists into the private sector because that would impact upon their private lists?
  (Ms Bryson) Yes.

  Chairman: A very interesting point.

Julia Drown

  855. Just following up on some of the points made. First of all, on the point Mr Auld was making about trying to make sure there is provision in the right place and picking up the Chairman's point on this. The Concordat does clearly say that capacity is going to be used in the private sector. This is really a question for Mr Hassell. Because the Concordat is in place is the independent sector expanding provision, or planning to expand provision, either in terms of building or in terms of recruiting more staff?
  (Mr Hassell) I can only answer from my perspective in representing members, I do not have detailed knowledge of their individual business plans. I am not aware of the sector having any massive expansion plans, or indeed any expansion plans, that were not in place prior to the Concordat being signed. I do not see that the Concordat actually is against the objectives that the Chairman wishes to achieve for the longer term because a major tenet of the Concordat is that there should be joint planning and that planning should involve the independent sector and the public sector. Therefore, I think by working towards we can move towards the strategic objectives that the Chairman was suggesting, which has to be beneficial for patients. We are talking about the use of scarce resources, which I think we all agree on although we may have a slightly different viewpoint on it. By working together I think we can make sure that patients benefit by siting establishments closer to the area of need and ensuring that it benefits all patients, whether they be NHS or independent sector funded patients.

  856. It is about using spare capacity that is already there?
  (Mr Hassell) There is capacity there and, indeed, as I think was mentioned on Tuesday when the Secretary of State made an announcement about a fast track surgical centre, there are plans for another 20 such centres over the next few years. I have no knowledge at all as to whether they will be within the NHS or in the private sector, but I think those sorts of initiatives, well planned, have to be beneficial to bring down the million-plus waiting list. I think that is where the central debate has to be, on the patient.

  857. We will come back to those issues later. Do you accept in terms of the general provision through the Concordat that your members, in so far as they help in dealing with the waiting list, might be dealing with a one-off problem and you will do better for a while but if the waiting list goes down there will not be the work so the work might not be there in future years and in that sense you are being used?
  (Mr Hassell) I do not think that is the case. The model you are thinking about there makes some static assumptions. I think demand will change over the years and expectations will continue to grow on the part of consumers. I suspect, and I have no knowledge of this, it is no more than a personal gut feel, that there will be quite sufficient demand to challenge both the NHS and the independent sector, that is why it is important we work together.

  858. Are you entering the deals only on the assumption that work will carry on?
  (Mr Hassell) I am not an operator so it is difficult for me to answer that. I suspect that my members, all of whom are committed health and social care professionals, will have taken a long look at the markets they are working in at the moment and I am sure they are motivated for the right reasons of ensuring patients have services where they need them.


  859. Mr Huntley has been sitting quietly with various expressions on his face. Do you have any thoughts on the general points we have covered from your perspective within the NHS?
  (Mr Huntley) Not on those specific issues because, as you are aware, Chairman, we are actually dealing with overseas hospitals.

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