Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 860 - 879)



  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—


  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.


  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.


  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.


  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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