Examination of Witnesses (Questions 920
- 939)
THURSDAY 6 DECEMBER 2001
MR DONALD
ROY, MR
HOWARD CATTON
AND MR
TREVOR CAMPBELL
DAVIS
920. The Concordat will help as a mechanism.
(Mr Campbell Davis) Yes, I believe so.
921. It will clear out waiting lists and put
more capacity into the NHS as well.
(Mr Campbell Davis) I think so.
922. Okay. Can I just ask all three of you as
well, let us say this figure of 70,000, just for the purposes
of our discussion, would I be right to think that they would be
disproportionately drawn from certain parts of the country where
access to private sector facilities is greater for possibly centres
of population and, if that is the case, is there a danger that
it might increase distortions within the NHS? For instance, people
in the area I represent, Leigh, there is no chance of going abroad,
they are no private sector facilities around, is there a danger
the Concordat would accentuate distortions which already exist
in the waiting lists across the country?
(Mr Roy) I think it could create some new distortions.
From our point of view, we are a bit cautious about accelerating
the process because the good pilot schemes which have taken place
have involved a fairly strong element of management and control
by the NHS, particularly by experienced NHS acute trusts. If we
have an accelerated programme, and if the accelerated programme
is run through primary care trusts, which are not exactly mature
organisations compared with the acute trusts, then I think there
is a risk we could get another kind of two tier which is that
there would be some uses of the Concordat which would be still
maintaining the rather high standards of safety and satisfaction
that have been managed so far but there is a considerable risk
that particularly if we are dealing with inexperienced commissioners
and a lot of money is being thrown around rather quickly, we could
end up with some patients finding themselves not encountering
the same kind of standards and back up as the good end of the
private sector and NHS in general in fact offer. So, I think there
is a potential problem there. I think ironically in the areas
where private capacity is around, the tiering system if we are
not careful could go the other way. We could get people, not everybody,
going into every private sector hospital but we could get instances
of people going into hospitals where the care was actually substandard
and through nobody's fault, because of speed, because of inexperience
etc, we could start creating a two tier system of quite a different
kind.
923. Could I ask Mr Catton, is it true, do you
think, that waiting lists are coming down much more quickly in
certain parts of the country than others?
(Mr Catton) I think there is a risk and if you look
at recent developments around London and the South East and the
targets to address waiting lists there, the issue for us is that
is then coupled with those areas which have also particular problems
around shortage of nursing staff. The potential to bring waiting
lists down quickly will expose and highlight the difficulties
in the staffing capacity.
924. Taking the point Mr Campbell Davis raised,
it is a short term expedient, it might make the working environment
for nurses and doctors much better in the future by reforming
the workload and cutting through the blockage in the system. Do
you agree there might be long term benefits?
(Mr Catton) We do not have any difficulty with the
pragmatic short term approach to dealing with these issues. The
difficulty for us, as our new General Secretary constantly keeps
saying, is what is the end game. We do not know where the long
term policy is going and that is causing some anxiety amongst
our members as well who are concerned if it is a longer term arrangement
"what will happen to my employment status?" What about
investment and development decisions that the public sector is
making? Will those be changed or altered in some way? I do not
have a difficulty with the short term but I think it would be
incredibly helpful to have greater clarity about where the policy
is going in the long term.
Chairman
925. Can I ask, I do not know if our witnesses
were present for the earlier exchanges where I asked the question
of our colleagues and friends from the private sector as to the
proportion of doctors working within the private sector in terms
of how many worked in the NHS also. I think the figure was given
at least 90 per cent of those doctors working within the private
sector also worked in the NHS. In a sense, turning around Andy's
question about the 70,000 benefiting from the Concordat who are
going into the private sector, I asked this question—and
I put it to you—what the impact on waiting lists will be
if those 90 per cent actually work wholly in the NHS? Mr Campbell
Davis, how do you feel about that?
(Mr Campbell Davis) If it was possible and done quickly
enough, I would very much welcome it. The reality is that most
public sector hospitals at the moment working close to capacity
have limiting constraints which are not just the availability
of medical staff, they are certainly to do with medical and nursing
staff being available in sufficient numbers, but they are also
to do with physical constraints, the numbers of beds in the hospital,
the number of operating theatres we can run and all of those infrastructure
things. So often in many hospitals we are in a position of having
to ask our surgeons not to operate, not because they are not available
but for other reasons. Having said that, when I mentioned capacity
earlier, the biggest capacity constraint is in staff supply, both
medical and nursing, and until we can get to the point where we
have substantially greater numbers of doctors, the end point is
not reachable, and that is six to 13 years out, depending on how
long it takes to train a specialist. As well as capacity the other
word I would leave you with is pace. We are trying at the moment,
in our view, to fix—if that is the right word—the
NHS 53 years on, but you cannot fix it in one or five, arguably
even in ten years; it is a ten to 20 year journey. We and our
members welcome all the help we can get from all the sectors all
of the time to help us on that journey. We do have a very clear
view of the end point as a National Health Service ten or 20 years
out. It will be different undoubtedly, it will be modernised but
we need to use all these tools and most of all we need more doctors,
more nurses and indeed, dare I say, Chairman, more managers because
coming from a private sector background, one of the greatest contrasts
is qualitatively and quantitatively—and I think most of
my colleagues managerially in the health service would accept
this—in management. We do not have the tradition over decades
of building up the management cadre that is able to deal well
enough with the complexity of some of the issues. I have to say
working in the health service is much more complex than working
in many private sector environments.
926. This comment Mr Catton made about the end
game. There are one or two people in this Committee worried about
what the end game might be and where we are at with the basic
principle which has served the NHS well, in my view, since 1948.
Would you accept the concern—taking on the point about capacity—that
if you have the personnel in it will make a difference but capacity
is an issue as well? One of the problems we have got in relation
to capacity in terms of Concordat is if we use the private sector
capacity it requires the development of NHS capacity. Do you see
that as a problem?
(Mr Campbell Davis) It is a risk certainly, Chairman,
and I think we have to manage it. I think it is manageable and
I think the relative scale of the two sectors gives us some control.
I have to say that in terms of using public money to purchase
health care, we are if not a monopoly purchaser a very substantial
one and we should use that strength—and it is a great strength—wisely
and make sure that we get the development and investment in training
and resources in the way we need for the health service. I do
not see it as being an unmanageable threat.
927. I do not know whether your trust has had
any involvement with the hospital that was acquired in London
over the summer period from the private sector. Is that a step
you would welcome? Do you see that as being more sensible than
effectively renting capacity?
(Mr Campbell Davis) I am aware of it. It is not far
from my trust. I think it is one relatively modest but helpful
building block in a very large structure. I do not see that as
a generalisation as the way forward. I think simply buying hospitals
around the country will not of itself solve these problems but
there will be occasions, and that might be one, where it helps.
928. Can I just put to other witnesses the question
of whether you see the Concordat with the private sector perhaps
retarding, setting back more radical solutions in respect of the
relationship between the NHS and the private sector which perhaps
would be more helpful than some short term fix, so to speak, based
on trying to achieve waiting list targets?
(Mr Roy) I think the Concordat covers a multitude
of things. I will take one extreme case where the Concordat is
the obvious and sensible thing to have gone with. This was an
instant with another one of my local trusts where they were trying
to meet their waiting list target and the consultant in question
I think had a family bereavement. The result was that they were
going to miss their target in terms of outpatient waiting times.
So what do they do? It would not have been sensible to have kept
the public sector capacity in place simply to deal with that situation.
They did find that there was a local private sector hospital which
had somebody of the appropriate status and standards who they
could use on a temporary basis and they sent patients there for
two to three weeks. That is absolutely fine.
929. But is it? Can I just put to you, the point
I was making about 90 per cent being involved in the NHS is absolutely
fine for people you are talking about there but what about the
other people on the NHS waiting lists of that particular doctor
who could not be treated because of their involvement in the private
sector?
(Mr Roy) I do not know whether the person at the hospital
—
930. You understand the point. We need a wider
view rather than a narrow view.
(Mr Roy) I am taking that as the extreme case which,
from my point of view, was relatively uncomplicated. It becomes
much more complicated if you have a hospital which has to decide
whether it is going to spend time working up business cases for
new capacity, and even small bits of capacity, the odd ward, half
a ward, a couple more nurses, a consultant takes a monumental
amount of time to get through the system. What worries me a little
is that the Concordat could produce a situation where because
it is too much hassle internally to try to expand provision in
the public sector, and particularly if the money is dribbling
out at very short notice and has to be spent quite quickly, the
temptation will be over time to respond by buying in and buying
in even when on any normal assessment on a level playing field
basis it might have been more sensible and more cost effective
to have expanded the public sector provision in the first place.
I think that is a real risk and I think the answer, I am afraid,
is not going to be in terms of relations with the private sector
but to reform procedures within the Department of Health which
I think is probably the Committee's job rather than mine.
931. We welcome your advice on that process.
Mr Catton?
(Mr Catton) I would agree with many of Mr Campbell
Davis's points about the issue of capacity, it is not just down
to the doc's (as in doctors), it is others as well. In our evidence
we gave the example of Kington and Ledbury hospitals, small community
hospitals which are going to be reprovided under, and I am still
not sure whether it is a PPP or whether it is a Concordat arrangement.
The Department's response to how that decision was arrived at
and was planned is included in the evidence. What is clear is
there are clinical staff who are being moved as part of a Concordat
or PPP type arrangement. That process will not be happening under
PFI but it will be happening under these sorts of arrangements
but there is not the clear process that you go through with PFI
that you would go through with a Concordat or a PPP which I know
comes back to where is it going but in many ways it seems much
more muddy to us about how you make value for money decisions,
where accountability lines are, staff are moving under these arrangements.
John Austin
932. I think part of the question has been answered
to the Chair. Mr Campbell Davis was saying perhaps in the short
term it is better to spend some of the money in the private sector
to enable the NHS to cope with the pressures and get on an even
keel. This is a long term issue. At the moment we have an NHS
with clinician PCTs and acute trust providers and you represent
both.
(Mr Campbell Davis) Yes.
933. Increasingly those trusts have been facing
private sector alternatives. Is there not a dilemma there for
your organisation and the NHS which seems to be a cohesive whole
towards the goal?
(Mr Campbell Davis) I guess it depends a little what
happens to demand in the service. One of our primary objectives
at the moment, whether it is in primary or secondary care, is
to get to a level of activity that is not always pushing against
the buffers. If we achieve that over the next five or ten years,
if we build more NHS capacity and use the private sector, then
there will be a question of whether or not the private sector
are always operating at the margins to provide that headroom or
whether they are more centre stage, providing a larger part of
it. I accept the latter is at least a possibility. If, as one
of your earlier witnesses suggested, demand is almost insatiable
and continues to rise, maybe the total quantum goes up at such
a pace that the only way we can keep patient provision at the
level we would like, which is what it is about, is to have a plurality
of provision. I am not sure whether we will reach a point where
if my hospital is operating at, say, 80 per cent capacity, with
a balance between emergency and elective work, whether then having
a limited amount of private sector capacity around is the enabler
that allows us to stay there or whether they become voracious,
eat into it and suddenly I find I am working with a half empty
hospital.
934. We are not talking about using the private
sector's spare capacity at the moment and building up the NHS
capacity, we are talking about a mixed economy which is planned
which will mean an expanding private independent sector as well
funded by the public?
(Mr Campbell Davis) Yes. I think within the health
service at the moment we are talking more about the former but,
of course, the private sector will make its own judgments and
presumably take its own risks and if it chooses to, I guess, will
compete for further capacity later. I am not sure I view that
as too great a risk to the health service. I think that could
keep us on our mettle, and in terms of the quality of the patient
care that we give I welcome other exemplars outside my hospital
showing better ways of doing it, if indeed they exist. I know
what we need to do internally to make things better but I do not
believe we have the sole wisdom on how to do it.
935. You referred earlier on to your historic
status as monopoly provider of the publicly funded and publicly
provided service. I do not know whether your Confederation has
given consideration to a concern which has been expressed fairly
widely, certainly expressed in evidence to us from one of our
witnesses, that so far the public sector and public services have
been out of reach of the tentacles of the World Trade Organisation
but once we move into a mixed economy of provision, even though
public funded, there is an argument that it comes then within
the remit of the WTO and, therefore, the whole thing has to be
opened up to competition and competitive arrangements. Has the
NHS Confederation taken any advice on that?
(Mr Campbell Davis) Not that I am aware of, Mr Austin,
I confess I missed the point earlier so I am not sure I am able
to guide you on it.
936. It was not earlier today, it was in evidence
from Allyson Pollock when she gave evidence.
(Mr Campbell Davis) I see.
937. It has been suggested that once you move
into an area where it is not a monopoly public division but it
is part private, part public, this is open to the regulations
of the World Trade Organisation and, therefore, all this provision
has to be opened up to private competition?
(Mr Campbell Davis) I have not heard it explored but
I will ask my colleagues and perhaps we might like to write to
you, Chairman, on the subject.
Chairman: That is helpful.
Jim Dowd
938. Just following on from what John was saying,
the move towards long term contracts, mutualising whether it is
spare capacity or whether it is just capacity of the private sector
must impact at some stage on the whole question of strategic planning
within the health service. Perhaps I can start with Mr Campbell
Davis. How do you see that unfolding and will it reach a point,
for example, where the provision in the private sector will be
taken as permanent and the provision then not funded in the NHS
provided contractual relations exist to utilise that?
(Mr Campbell Davis) Two points, Chairman, in response.
Firstly, I think our members are concerned that we quickly move
to an NHS structure that allows good strategic planning. We are
extremely aware that at the moment many NHS structures are in
flux, they are in change, health authorities to strategic health
authorities, primary care groups to primary care trusts. It is
relatively difficult at present to get clarity of strategy in
local sectors, if not nationally. It may not be an issue at departmental
level. That will be clarified by next April when we have strategic
health authorities and I would hope that they, working with the
primary care trusts, could begin to do some of the planning which
you imply. Secondly, in terms of private sector capacity soon
becoming permanent, there are, of course, already many examples
of that in mental health provision, in social care provision,
in rehabilitation and in others, so I would not suggest that will
be happening for the first time. I imagine the answer is if it
is appropriate and if it fits and if it works well for the patient,
they might wish to make that judgment.
939. Mr Catton?
(Mr Catton) I would agree with the issue around mental
health. It may well be in the longer term, a lot of those services
being provided in the private sector, your strategic longer term
plan is they should stay there and be developed there. I think
the question you raise is exactly the question which is in a lot
of nurses' minds at the moment and the concern is around the separation
of commissioning and provision. I have already said nurses believe
they can play a much greater role in commissioning what a service
is so that it gives the flexibility and scope that you are providing,
when people get sick or their conditions change, you may have
to change treatment, you may need to change the staffing arrangement.
The concern is that the separation of commissioning and provision,
if it is not done in the right way and the nurses are not involved
there, it could be inflexible and there could be quality issues
and problems which arise.
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