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Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 920 - 939)



  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.


  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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