Examination of Witnesses (Questions 904
THURSDAY 6 DECEMBER 2001
904. Can I welcome our next set of witnesses.
Can I ask you briefly to introduce yourselves.
(Mr Roy) I am Donald Roy. I am Vice Chairman of the
Association of Community Health Councils for England and Wales.
You have had a written submission from us. My background otherwise
is that I have been the Chair of my local Community Health Council
in South West London for the last four and a half years and, also,
another relevant factor is that I have been a member of the External
Consultation Group on the Care Standards Act.
(Mr Catton) My name is Howard Catton
and I am a national officer with the Royal College of Nursing.
(Mr Campbell Davis) Good morning. My name is Trevor
Campbell Davis. I am here representing the NHS Confederation which
is the membership organisation for the vast majority of NHS trusts
and primary care trusts and health authorities in England, for
health authorities and local health groups in Wales and for trusts
and health boards in Scotland and health and social services boards
in Northern Ireland. So we take a view across the different parts
of the Kingdom. I am Chairman of the Acute Services Committee
of the Confederation in England and Wales and therefore have a
particular locus in the hospital sector. My present appointment
is as Chief Executive of a teaching and district general hospital
in North London, the Whittington. I have a background both in
the health service, in primary and community care as well as hospitals
but also have worked in the private sector for a significant part
of my career, albeit not in health care.
905. You were not on the radio on Friday evening,
(Mr Campbell Davis) I was indeed.
906. It was you.
(Mr Campbell Davis) It was me.
907. I could not get a word in edgeways.
(Mr Campbell Davis) I will try and do better today.
908. This is a question for Mr Roy. We have
been hearing this morning about the Concordat from the providers'
point of view. I just wondered, have you had many communications
from patients about what their view is of the Concordat?
(Mr Roy) Well, not directly from patients. Obviously
we have taken an interest in the Concordat and particularly wearing
my South West London hat, we have a very, very good understanding
with a lot of public sector players in the local health economy
and we have had quite a dialogue with them about how it has worked
out in practice. I think you will find in our evidence the experience,
certainly in South West London, was that not one single complaint
or near complaint emerged from the way it was done by St Georges
Health Care, indeed they got rather more letters of compliments
than they normally expect for the way it was run. I cannot speak
nationally, largely because there may be local CHCs who have had
complaints elsewhere in the country, but if they have, certainly
they have not, to my knowledge, notified the ACHCEW office. I
cannot be absolutely certain there has been no negative feedback
anywhere but certainly when we have asked about itwe asked
our member CHCs whether they had heard anythingnone of
them came back. They are usually pretty vociferous if there is
an issue coming in to us. Thus far I have to say provisionally
there has been no negative feedback that I know of.
909. Perhaps I could move on then to Mr Catton
and ask if, in your opinion or in your organisation's opinion,
the Concordat has had a beneficial impact on current operations?
Has it been a good thing?
(Mr Catton) It is early days but we are getting a
mixed picture. As far as elective care is concerned, we have had
reports back where it has improved access and it has improved
the speed of care for patients. What has been reported also is
that it is changing the nature of work for those nurses who are
left in the acute sector. Those patients in the acute centres
are more highly dependent and that brings with it its own pressures
and stress on the staff who are there. As far as the intermediate
care is concerned, again we have had some very positive reports,
particularly for elderly clients moved into settings where they
have much better rehabilitation, promotion of independence. Those
examples are areas where they seem to have a very clear service
agreement about what is going to be provided and how. The key
elements which nurses are telling us are in those service agreements
around clear standards for clinical governance and audit, clear
standards as far as staffing is concerned, what diagnostic services
are and are not included and arrangements for discharge planning.
A general point which I would makeand I highlight it in
our evidence and I know it is perhaps more in relation to PFI
but I do feel it applies across all of these arrangementswe
do have a concern that when negotiations and discussions are going
on with some of these arrangements there could be a lot of room
for improving that by including more clinical staff who are delivering
the service and who know what is going on.
910. One of the main reasons for introducing
it was to try and reduce waiting times and waiting lists. Would
it be your impression that has happened? What do you think its
effect has been on waiting times and waiting lists?
(Mr Catton) Clearly there has been a reduction in
waiting time for some patients but a key issue for us is nursing
capacity, it is the number of staff. You have had a debate this
morning about numbers and figures and I can give you our view
911. I think we have got quite a lot of information
and views on the National Health Service. We are looking now at
whether you feel there has been an effect on waiting lists and
waiting times in terms of the Concordat?
(Mr Catton) Yes, there has been an improvement but
in the longer term there are concerns about what the implications
will be for service planning, investment and staffing issues for
the NHS, for the public sector, in the longer term.
912. Good morning, Mr Campbell Davis, a beneficial
effect and an effect on waiting times, what are your views?
(Mr Campbell Davis) Beneficial, but modest thus far.
The relative size of the two sectors, the private sector is relatively
small. It is not contributing on any major scale to bringing waiting
lists down yet in our experience, but it is having some impact.
The sort of announcements which are being talked about at the
moment might increase that substantially, in part because the
amount of money that it has been suggested will go into the private
sector to buy case load will be quite different.
913. Is it not an expensive way of achieving
a reduction in the waiting lists? What is your view on that?
(Mr Campbell Davis) It may be more expensive, although
arguably not that much more expensive because if you look at the
costs to the health service of trying to fix and firefight all
of the problems that we have in a hospital like mine, which is
working at close to 100 per cent of capacity all of the time,
we spend much more money than I would choose in keeping all our
balls in the air. If we could take some of the pressure off that,
and allow my system to work at, say, 80 per cent of capacity rather
than 98 per cent, we might find we were much more cost effective
and beneficial to our patients. The word I want to stress to the
Committee this morning again and again is capacity. We need more
and we need it now, and I am less concerned about where it comes
from than I am about getting a better environment for patients,
which is not under so much pressure.
914. Can I pick up a point that Mr Catton made.
Naturally moving more of the elective work into the private sector
does put more stress on the NHS nurses because they have less
of the easier stuff to do. Has the RCN any figures of the loss
of NHS nurses (a) to the private sector and (b) to agencies just
because of this increased stress load? These are figures which
I think will be terribly important to get if they are possible.
(Mr Catton) I cannot give you figures directly in
relation to stress load and people moving. We believe that over
the last year seven per cent of nurses have left the NHS for non
NHS sector, 13 per cent in total change employers. Now the cumulative
effect, obviously that number will build but equally there is
a flow the other way. I would not say to you that I believe it
is an issue about poaching, it is an issue about the size of the
pool. When the plan was announced with the 20,000 nurses, we did
some work around what that actually meant to achieve that. If
you look at people who will be retiring and who will be leaving,
it was in excess of 100,000 nurses who would be required to hit
the target of 20,000 more nurses. The age profile in the non NHS
sector is older than in the NHS so the private and independent
sector may be under more pressure more quickly with an aging workforce.
I am not aware of any evidence at the moment to suggest there
is poaching, it is the size of the pool.
915. I was not really getting at that but seven
per cent was the figure you gave who have left the NHS.
(Mr Catton) Yes.
916. To go into nursing in other areas.
(Mr Catton) Into non NHS sectors, that is the private
sector, independent sector, charitable organisations, voluntary
or to be occupational health nurses directly for companies and
917. I would just like to pick up on the conversation
between Doug Naysmith and Mr Campbell Davis. You used the word
"modest" in terms of the benefits the Concordat achieved
in terms of bringing down waiting lists. The General Healthcare
Group evidence to us suggested that waiting lists were 70,000
lower than they would have been if we had not had the Concordat.
Would you recognise that figure and, if so, would you agree that
is slightly better than modest?
(Mr Campbell Davis) I could not comment on the specific
figure but my comment about it being modest was in the context
of the total number of operations which go through the health
service which, of course, is much greater than the waiting list
at any one time. I think it has potential for bringing the list
down considerably further. If the sort of plans which are being
developed at the moment are taken forward, using NHS management
and working closely in harness with the independent sector, I
do think the issue of how well we purchase and how well we control
the flow of NHS patients through the private sector will determine
the quality of the whole experience. Implicit in the discussion
is the risk that we recognise that we could end up, unless it
is carefully managed, with qualitatively a two tier system.
918. Am I right in thinking then the Confederation
would like to see more accelerated use of the Concordat?
(Mr Campbell Davis) If our objective nationally, and
we believe that it is and we support it, is to bring waiting lists
down as quickly as the Government wishes, then I think in the
short and medium term it could be very beneficial, yes.
919. If the Concordat route was not available
and had not happened, what do you think the impact on waiting
lists would be say three to four years hence? Would it be possible
to bring waiting lists as low as they possibly will be under the
Concordat if those operations were under the NHS?
(Mr Campbell Davis) I do not know whether you chose
your time frame of three to four years particularly for that period.
That is probably just on the horizon of when it might be possible
to develop NHS capacity to make a difference. We are putting a
lot of capacity into diagnostic and treatment centres which are
now beginning to open and being planned. My personal view is that
in five years' time we could have substantially more NHS capacity
which might bring the lists down quite quickly. In a shorter time
than that, I think not, on the scale that we need to get the lists
down as quickly as we would like.