Examination of Witnesses (Questions 860
- 879)
THURSDAY 6 DECEMBER 2001
MR PETER
HUNTLEY, MR
JOHN FIELDHOUSE,
MR CHARLES
AULD, MR
BARRY HASSELL
AND MS
KAREN BRYSON
860. We are going to come on to that point specifically
in a moment or two, it was the general issue.
(Mr Huntley) I think the general issue is we must
identify, in the same way Ms Bryson is having problems with the
consultants, that sometimes for good reasons consultants do not
wish patients to go overseas. They are being quite obstructive
in assisting us in being able to do that. There are some very
good reasons for it. They are not sure of the quality yet and
that is one issue we will have to look at. They appear not to
have any objections to them moving into the private sector in
the UK though.
John Austin
861. I think Mr Hassell has partly answered
the question I was going to put. Mr Hassell has generally welcomed
the Secretary of State's decision to justify purchasing from the
private sector in order to address the current shortages. Obviously
we can all see the benefits to the individual waiting for a cataract,
a hip, a knee or varicose veins or whatever, but in response to
Julia Drown you said it was on the basis of using your spare capacity.
Can you quantify what that spare capacity is within the private
sector and if it is spare capacity will it be charged to the NHS
at marginal cost?
(Mr Hassell) With respect, I do not think I actually
said it was specifically using spare capacity, I think Julia Drown
suggested that. Obviously there is extra capacity which is being
used. One of the misnomers that is quoted frequently is the low
occupancy of the independent sector. That is a mistake in that
the bed counts traditionally take place at midnight and what has
happened over the years is there has been a shift from inpatient
treatment in the independent sector to a tremendous growth in
day case work. That is why we move away from just talking about
bed numbers because it is not necessarily the right currency to
talk about. What I think is important is identifying the needs
in a particular area and where Commissioners are able to identify
those needs they talk to the independent sector about how the
independent sector may be able to help them with those particular
needs and demands, not just looking narrowly at capacity. The
second part of your question related to costs in some way.
862. If it was spare capacity whether it would
be at marginal cost?
(Mr Hassell) Again, they are issues to be negotiated
locally. The issue of management accounting costing is quite a
complex area. Some people may charge on the margin, others may
not, they really are issues to be negotiated between the local
NHS Commissioner and the independent sector, not for me to lay
down a rule.
863. If you were not agreeing with Julia Drown
that it was just spare capacity you were talking about, if we
go back to the point the Chairman made earlier, let us leave consultants
out of it, you were saying it is not just whether consultants
are available but it is the lack of resources, whether it is theatre
time, the technicians, nurses or whatever, and there is only one
pot of money and one pool of resources and staffing. If we do
expand the work within the private sector for treating NHS patients
then surely that is going to exacerbate the problem of lack of
staffing within NHS hospitals?
(Mr Auld) Perhaps I could answer that. If I may, I
would not quite start from there. You may be right in saying it
exacerbates a problem in the NHS but our view, unsurprisingly,
is as long as patients are being treated, NHS patients are being
treated, free at the point of delivery according to need, that
is the thing that counts. At the end of the day there have been
questions about supply and demand and whether or not we as a private
sector would be used and then cast aside once we had eaten up
the 270,000-odd people who are on the waiting list. There is a
universal law at work here, I would suggest, which is the law
of supply and demand, and one of the immutable ones in health
care, which I would suggest has been one of the key questions
we and our forebears have been wrestling with, is in health care
demand always seems to be in excess of supply regardless of what
that supply level is, even if it is at an economic supply level
of the sort you have got in America. It certainly has been a fear
that I have expressed quite publicly about being used and then
cast aside in relation to plans, which we have included in the
submission, to build at our risk a Diagnostic and Treatment Centre
specifically for the treatment of NHS patients, built, staffed
and managed at our cost and at our risk. If I have one concern
in doing what is no more or less, as you will recall, Chairman,
the model that has been used on the psychiatric side of the business,
it would be that political or ideological concerns, regardless
of quality, price, value, could actually put that investment at
risk. If these risks diminish, and I would suggest they are diminishing
well and I support what Mr Hassell has been saying in applauding
the way in which Mr Milburn is moving and at the speed at which
he is moving at the moment as well, which is laudable, then—
Chairman
864. I will pass on to him your good wishes.
(Mr Auld) Thank you. That is going a long way towards
alleviating my concern as regards making that sort of investment.
Julia Drown
865. You mention there the issue of risk and
it seems to me that both of you have avoided taking responsibility
for the risk that maybe the waiting list will be one-off work
and then you will not have the work in the future. My concern
is that you are not really prepared to take on the risk.
(Mr Auld) Forgive me, we are. I have said we will
do that. What I have said is if we are talking here about the
straight forward prosecution of a task of treating NHS patients
according to demand, as long as we organise our business well
on quality, on price and on value to the NHS Commission and to
the taxpayer in general then I will take that risk and hopefully
I will do that right, and if I do I would expect to be able to
see a political prospect where that move would be encouraged,
I would be encouraged to do more of that, and I would certainly
be happy to bring forward investment of that nature.
866. Fine. You were saying it does not matter
where the patients are treated but say you decide to pay nurses
ten per cent more than the NHS is paying and you take the nurses
out of the local NHS health system, the patients still get treated
but less patients will get treated in any one particular pot of
money because you have ended up creating competition for a scarce
staff resource with the end result that nurses get better paid,
which we would all celebrate, but less patients get treated.
(Mr Auld) There are two things there. I do not think
you were quite edging this way, but just in case you were, we
do not pay premiums in the independent sector for nurses, and
that evidence is there. We pay slightly differently but we basically
pay the same rates.
867. You could if you saw that was the way in
which to deliver a particular contract.
(Mr Auld) I think the point I am making is first of
all we do not and, secondly, I would also make the point apropos
what you were saying about less patients being treated, there
is some evidence to suggest, notably evidence published by Ms
Bryson recently in Health Service Journal, which I saw
Mr Amess had a copy of, which is indicating that in a smaller
focused unit, like a Diagnostic and Treatment Centre, regardless
of independent or NHS sector owned, the focus of the process of
moving through acute elective procedures will actually produce
a larger number of patients treated. There is at least some circumstantial
evidence on that and it may well be Mr Fieldhouse could confirm
that sort of environment is conducive to greater productivity.
Chairman
868. Could I bring Ms Bryson in and then Mr
Fieldhouse.
(Ms Bryson) I just want to make the comment that if
we are talking about developing a partnership with the private
sector that has to also include the workforce. I know that within
Cancer in Sussex we are working quite closely with the private
and voluntary sectors as well. I think maybe we cannot progress
further down the private partnership unless we take that side
into account as well because we will end up with significant problems
in the future. On the point about the private sector and attracting
nursing staff, I have had quite detailed discussions with our
local private providers and they did not see it as being an area
of conflict. They do not pay more than the local NHS but what
they do offer in some ways is more flexibility in terms of working
hours and a better working environment for the nursing staff and
that, they think, is why potentially nurses are attracted into
the private sector. If we can replicate that type of environment
within the NHS and have a balance and learn from the private sector
in terms of how to run the NHS and certainly work in partnership
in terms of offering facilities and capacity and treatment then
that must be a win-win for both sides in this.
(Mr Fieldhouse) I think there are two issues in relation
to consultants that have been raised in the debate and remain
unanswered. One is about consultant co-operation under the terms
of the current Concordat and the other is about consultants' concerns
about patients moving overseas for treatment. If I deal with the
first one and what my colleague at the other end of the table
mentioned earlier. I am well aware that we now have two administrations
which have used the Waiting List Initiatives as a means and a
method of targeting the numbers of people on waiting lists. I
think there is among many consultants, and that may reflect on
the concerns or obstruction that was suggested, a feeling that
the time has come, and indeed many of us felt it should have been
there originally, to invest, as you indicated, Chairman, in the
NHS and the manpower and facilities in the NHS should be there
to deal with these patients rather than constant, repetitive attempts
to deal with waiting lists when they are getting out of control
which seems a never ending circle. I see that as a concern of
consultants in the first instance and a way of expressing that
concern. In terms of their co-operation under the Concordat, I
think the evidence is they have co-operated. Consultants across
the country have been operating on Saturdays, Sundays, moving
themselves into independent sector hospitals under their NHS contracts,
or if it is not within their NHS contracts undertaking the work
on the sorts of schemes the independent sector have produced.
I think they have contributed enormously to this Government's
wish to get the waiting lists down. On the latter point, if I
may continue on to that,—
Chairman: Can we come back to that later on,
I want to move on to that issue in a moment or two.
John Austin
869. I think Karen Bryson, in my view, is absolutely
right, that from personal experience many of the nurses I know
who work in the private sector do say it is because it offers
flexibility of working hours and working arrangements, which for
some reason the NHS in most places seems incapable of doing and
I think the NHS has got to get its act together in that respect.
The issue again is Mr Auld has been perfectly frank, he is prepared
to do speculative build because he thinks the business will be
there, and thank you for your directness and honesty in that.
My real concern is about this area where there is this limitation
in terms of availability of staff and if we go down this road,
not just as an immediate method of reducing waiting times, which
will be to the patient's benefit, there is not going to be a reduction
in the pressure on our district general hospitals who will still
have the same throughput but this will be addressing people who
have not yet got to hospital because they are on a waiting list
or a waiting list for a waiting list. What will happen in my view
is as you expand the provision in the private sector there will
be a further leaching out of staff from the NHS making the working
conditions in our NHS hospitals worse and more pressurised than
at present and you will begin a spiral. Is that not a realistic
viewpoint?
(Mr Hassell) Firstly, can I reinforce what Karen has
said about the Workforce Confederations. There are 24 Workforce
Confederations in England and the independent sector has representation
on all of them. We agree with you that working together in the
development and planning for workforce issues is vital and we
look forward to taking a very active part in the development of
the Confederations, which again has a benefit from the Concordat,
that was again one of the aims set out in the Concordat. As a
general comment about the issue of nurse retention in the NHS,
you will remember the Secretary of State made it absolutely clear
that the independent sector is not the major problem regarding
the loss of nurses from the NHS but the NHS itself and the need
to improve its ability as an employer and to retain staff. Indeed,
Chairman, I am sure you will remember your own report in February
1999 which clearly addressed some of the shortcomings within the
NHS.
John Austin
870. Can I ask you where you got your figures
from that you gave us in your evidence that 90 per cent of nurses
leaving the NHS leave the profession altogether?
(Mr Hassell) I believe that was from an RCN report
of about four years ago which I think they have updated in this
last year. I think there is a number now which is somewhere in
the region of seven per cent, but it is still a small figure.
An issue which always puzzles me is as to why it is there is always
a suggestion that the state actually owns the nursing staff. Surely
it is entirely up to the nursing staff to make their own decisions
about their career progression. I would think that over a period
of years we will see quite a healthy movement of staff to and
from the NHS and to and from the independent sector. That has
to be good for the provision of health care as people build up
experience and take on responsibility at different stages of their
career progression.
871. Do you think there should be a training
levy then on the private sector?
(Mr Hassell) The independent sector does already participate
in training. Last year we had about 2,000 clinical placements
from the training system into the independent sector and we are
working to take more. Many of our members have post-qualification
EMB courses they run so we do contribute in many ways. To finish
on the point, I think some of the questions have related around,
on the one hand, whether independent sector activity destabilises
the NHS and, on the other hand, the issue of risk. I think we
have to bring it into perspective. There are just over 10,000
independent acute hospital beds in this country compared with
almost 300,000 beds in the NHS, which comprises acute beds, mental
health beds, beds for elderly people, etc. In undertaking the
Concordat waiting list work that we have been talking about, that
volume of work is enough to benefit 70,000 or more people, whatever
the numbers happen to be, but it really is not enough to destabilise
or threaten the NHS in any way at all. It does make a significant
contribution to those individuals.
Chairman
872. Ms Bryson, you wanted to come in. I am
sorry to interrupt but we are tight on time and we have some other
questions.
(Ms Bryson) Yes, within East Surrey certainly and
the local authorities around us we would be very concerned about
speculative build. What we are looking for in the partnership
is we know where our pressure points are within the NHS on the
local waiting lists, we know where we do not have enough capacity
and why we do not have that capacity, and what we will be looking
for is very much to partnership with the private sector and to
work closely with them in terms of what they can provide for us
because we cannot actually meet the demand coming through our
systems and looking at some time into the future and saying "we
know we are going to get some work or capacity issues in the future"
and maybe working with the private sector in terms of trying to
cover that gap. A good example would be in endoscopy where we
know we have an extensive waiting list and we do not have enough
capacity. That is something that directly affects patients, not
just within general surgery but also within the cancer services
and a whole range, so we are looking for a partnership and certainly
not speculative build.
John Austin
873. I do not want to underrate the severity
of the conditions you treat but since the phrase was used by FIPO
in their evidence I will refer to "simple surgery",
which is perhaps the bread and butter of the private sector at
the present time. Mr Fieldhouse, in your evidence you suggested
that if there is an expansion of the role of the private sector
then there may be an increased need for junior doctor cover and
this in itself poses some problems and there may be some difficulties
in the Royal Colleges with training and career opportunities.
Would you like to say a bit more about that?
(Mr Fieldhouse) Yes. There is a reference to that
in terms of the fact that we are concerned under the Concordat
that the logistics of quality care delivery should be sorted.
It is about producing the detail when patients are moved as workloads
from the NHS into the independent sector under the Concordat arrangements
with all of the things that need to be done in detail in terms
of the follow-up, the assessment, the transport parameters, the
handling of complications that may occur in the future. All of
those areas need to be concerned and considered in detail and
they often vary depending upon the local arrangements, particularly
in specialist areas that can extend into junior staff cover. Independent
hospitals do have resident medical officers but if you get into
particularly highly specialised areas of surgery there is sometimes
the need for not just the consultant but the team to be involved
on the independent sector site facility and the arrangements for
that need to be thought through in advance.
874. So you would advise us to talk to the Royal
Colleges?
(Mr Fieldhouse) I think the Royal Colleges' concern
is if this became a major area, at the moment junior staff are
trained essentially within the NHS environment and, indeed, things
such as their insurance cover have to be thought about if they
work outside. At the moment I do not think there is any evidence
that I am aware of that this is a detriment to junior staff training
at the present level of activity. If the future of the NHS changed
markedly in terms of the plurality of facilities that deliver
health care in this country, and we are thinking many years down
the line perhaps, then patently we would have to think of the
locations where junior staff were trained and the facilities in
which they were trained, and that would perhaps then move the
medical arena of training into the concerns we have already heard
about in terms of nursing where it is already happening.
Jim Dowd
875. Ms Bryson, when you undertook the local
initiative it was about the impact on the private lists of consultants
that was the problem, but you did not actually expand on that.
What did you feel that the problem was? Was it that they were
losing business that they might have got had the initiative not
taken place? Was it that they were doing the same procedure but
for a lower fee than might otherwise have been the case? What
was your estimation of the obstruction?
(Ms Bryson) I should say that the consultants that
we used for our project on the whole were not our local consultants.
We commissioned the service with the private sector and that included
a full package of care which included the consultant and anaesthetist
cover, so we would not contract directly with consultants. The
majority of the consultants used came from outside the patch.
There was concern from the consultants, yes, not very many, one
or two, that if we took patients off their waiting lists it would
have an impact.
876. What was the impact? Was it the fact that
they would not treat them?
(Ms Bryson) It was a combination that they would not
be treating their patients in the private sector and that they
did not like and, secondly, yes, it would have an impact on their
private work.
Chairman
877. Mr Fieldhouse, do you want to come in?
(Mr Fieldhouse) I do not think the phrase "in
the private sector" is the important bit, it is that they
would not be treating the patients. I have seen other instances
happening where managers transfer patients that consultants have
already seen, assessed and designated a treatment plan for. That
patient is then taken out of the hands of that consultant who
thinks he has a responsibility for that patient's care to be delivered
in the NHS and it is taken to another person of whom, as was indicated,
he may know nothing, have no control over and not know whether
his treatment plan will be followed. I think that is the problem
when patients are pushed around like this, whereas their GP has
sent them to one individual presumably because the GP believes
that one individual has the expertise to render the appropriate
care for that patient.
Jim Dowd
878. Patients are not serfs, they do not belong
to consultants, surely it is a question of taking them to wherever
they will get the appropriate treatment.
(Mr Fieldhouse) So long as the patient is part of
that contract and fully informed as to what the effects of the
move are because they went to the first consultant on their GP's
advice believing that was the right place to be and they are now
being moved for the purpose of an initiative to a completely different
clinician to deliver that care. If they have been involved and
accepted that move and are fully aware of the potential effects
of that move, that is fine.
(Ms Bryson) The majority of patients that we treated
in the private sector were very elderly patients, a long time
on waiting lists, who had last seen their consultant almost 15
months ago at a single outpatients and that does not constitute
a detailed understanding and package of care.
879. I think this is a bit of consultant proprietorialism,
they believe that patients belong to them. How many patients to
your knowledge objected to being moved?
(Ms Bryson) We had very few patients who did not want
to have their treatment in the private sector. They were given
the option to stay with their NHS consultant should they wish
to do that. The majority of patients who were treated in the private
sector were very happy to have that treatment. I visited one of
the private hospitals where patients were having their cataract
operations, many of whom had been waiting on the list for 15 or
16 months, I spoke to each one of them and they were all very
happy to have their treatment, had been waiting a very long time,
it had an impact on their daily quality of life, and they were
not concerned that it was not their NHS consultant in their local
NHS Trust who was treating them.
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