Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 940 - 959)



  940. Mr Roy?
  (Mr Roy) Could I make a couple of points. First of all, I think we have to make it clear that from a strategic planning point of view the NHS has power over what it provides to a quite different degree from what it contracts for. Essentially if a private provider were to choose to take the strategic decision to withdraw or to substantially vary its service, it is not clear what powers anybody would have to do anything about that. This is in fact worse than, for example, arguments about PFI because most PFI contracts at least have a step in clause. If you are talking about buying private capacity, there is nothing to stop the owner of private capacity at one stage deciding that for various reasons they do not wish to continue to provide it. Within the NHS there is quite a strong process, which I hope will continue whether or not CHCs are still around to enforce it, for discussing whether there should be changes in capacity and in provision. This process, if it is used properly, can do quite a lot in terms of providing good strategic planning and keeping things on course. I cannot see how such a process could be made to apply to a private provider. It might not matter if the private sector remains marginal but if for various reasons it ceases to be marginal then the status of that capacity and access to it would become quite a serious matter.

  941. What is your definition of "marginal"?
  (Mr Roy) Well, I think the current ten per cent or less in terms of beds is probably something that is pretty marginal. There could be local situations, I do not know of any myself, if, say, something like 30 per cent or 40 per cent of your local health economy acute bed capacity was in the private sector and was, therefore, a rather different basis from the NHS in terms of ability to change it, then I think that would cease to be marginal, certainly.

  942. Generally then, what do any of you see as the practical limitations of the involvement in the private sector?
  (Mr Roy) I would see it as being a useful adjunct. I tend to see it as the oil on the wheels, the thing which makes the system work a little bit better, the thing which can be brought in, occasionally used to buy you time to adjust capacity in the public system. That would be my way of looking at it. Also, possibly, occasionally useful in terms of getting good innovations. I think one should not neglect the ability of clinicians, managers and others in the NHS to produce sensible innovations as well.
  (Mr Catton) There is no large scale private district general hospital. There is not the expertise or the experience there, that would not seem to be appropriate. I think there is an issue around being clear on charging. Creeping charges, whether they be for TVs and radios and then whether it be laundry and food and clinical services, there should not be any charging for clinical services, but are we clear on what clinical services are and the risk, therefore, about whether top ups could be offered. There would be a basic or core service and then there would be a fee or charge and a top up. I think those issues need clearly defining.

  943. It is just the area of what is called simple surgery we are talking about, we are not talking about acute, significant involvement in acute care. We are talking about simple surgery, simple procedures, not talking about emergency procedures?
  (Mr Catton) Yes.

  944. Does it matter from the taxpayer's point of view, the patient's point of view, who provides these things?
  (Mr Roy) I think it can do. There is the other issue which I do not think has been raised so far which is the issue of protection, complaints processes, etc, if something goes wrong. With the best will in the world things will go wrong. One of the things we at the Association have been very keen to do is to try to ensure that whether it is us or some kind of successor along the lines that may emerge from the Committee down the corridor, their remit should extend into the private sector so that you do not have a situation where there is a two tier level of protection. In fact, that is one of the things we have pushed for in terms of the implementation of the Care Standards Act. We have specifically in the consultation of the Care Standards Act requested that in addition to frequency of inspection of independent hospitals being maintained at current levels rather than reduced, as is currently proposed, there should also be a procedure that in fact the CHC on an interim basis and in the event of us being replaced by some other suitable organisation, that organisation should be given visiting rights.
  (Mr Catton) In terms of does it matter, if there are clear systems there to ensure quality, that services are being provided on the basis of need, that it is transparent how those decisions about who is going to provide it so that you can hold people to account, if it is not in the public interest, it is not providing wider goals of social responsibility and social equity, if those sorts of systems around accountability and equality, involvement and transparency are in place, then it may not but the concern is at the moment those are woolly, not clear.

  Jim Dowd: Those are the responsibilities of the strategic authority and the commission. They are the ones who will impose the quality standards.

John Austin

  945. Could I come back to the patient, patient representation and influence in the NHS. Even if we get the structures right, is it not inevitable that the complexity of the mixed economy will make it more difficult for patients to have an influence on the NHS?
  (Mr Roy) I think initially that is true. However, if you have a structure which is based on flexible and adaptable organisations, and ones which are not so closely related to particular trusts and are more related to the actual patient journey—because patients quite often, even without leaving the NHS may travel across several trusts—if you have that kind of structure, if you have proper resourcing so that the ability to go into the private sector which would involve obviously more people doing visits etc, is properly resourced then I think that could be managed. Obviously it is a bit more complex but, to be honest with you, even the existing NHS with the number of different trusts interacting with one another is pretty complex and it is going to get more complex, in my view, in terms of the patient pathway because of the other sensible development of things like clinical networks and greater degrees of specialisation between acute hospitals.

  Chairman: If I could just come in. You talk about a patient journeying across several trusts, across several countries we have heard this morning, I am interested in what your thoughts are. We are trying to look at models and if we replace CHCs what those models will be.

  Siobhain McDonagh: I want to be on the CHC which goes to Spain.


  946. How do we take account of the fact patients will be travelling far and wide?
  (Mr Roy) I think there are ways of doing it. I should say I am speaking personally because we have not yet formally considered this even among the honorary officers of ACHCEW. My view would be that just as between CHCs at the moment we quite often have what are known as host arrangements, that is if there is a patient coming from one particular geographical area who is being treated in a trust somewhere else we will have conventions as to who deals with their problems, who does the visiting and so on. For example, I am Wandsworth CHC, I occasionally visit Barnes Hospital which is strictly the responsibility of Richmond and Twickenham. If we go to Barnes Hospital we make sure there is one observer from Richmond and Twickenham CHC with us and that works perfectly satisfactorily. If we are talking about long distance stuff, I think we probably need to go from a host to a pooling arrangement where you might have a situation where you might accredit a CHC or successor organisation to be of a standard where it is appropriate for them to be sent on to visit overseas.

  Chairman: I think perhaps I have taken you down a questionable direction in terms of our specific inquiry. Richard, do you want to come in here?

Dr Taylor

  947. I want to go back to charges and costs because those have only been just very briefly mentioned and really to Mr Campbell Davis. As I see it there are really two ways that consultants can do NHS work in the private sector. Firstly, if a list of their's is cancelled in advance then that list can perhaps be reinstated in the private sector so they are doing NHS work in their NHS time in the private sector, that is one scenario. The other is obviously if extra sessions are put on in the private sector, which is not in their NHS time. Are there actual agreed arrangements for paying consultants for those two different types of work because I am retired, I no longer have an interest in this at all?
  (Mr Campbell Davis) Yes, those are the two methods by which they can do it.

  948. Yes.
  (Mr Campbell Davis) There are arrangements made by individual trusts with individual consultants about how they would pay for that. As you know, the consultant contract is under discussion nationally and I imagine those negotiations may take some aspects of this into account. As things stand I believe the arrangements tend to be local and tend to be with the doctors working in a particular hospital.

  949. So there is not an agreement yet that if they are doing NHS work in NHS time in a private hospital they do not get paid extra?
  (Mr Campbell Davis) They certainly do not in the trusts I have been associated with.

  950. They do not?
  (Mr Campbell Davis) They do not. It may be that particular hospitals have made that arrangement if it facilitates getting that workload carried out elsewhere.

  951. So there is no rule either way on that?
  (Mr Campbell Davis) I am not aware of one.

  952. I believe in my own part of the country if they are doing extra lists in their own time they get paid something like half the ordinary private sector rates, is that natural?
  (Mr Campbell Davis) Again, it is determined by the individual hospital. In the case of my own hospital we have such an arrangement and we pay at a higher rate but nothing like as high as they would be paid if they were working for the private sector.

Andy Burnham

  953. Just a quick question to conclude. You mentioned before to Dr Taylor seven per cent of nurses were leaving the profession a year. How many of your members now are non NHS, do you have that figure?
  (Mr Catton) Yes. 25 per cent of our membership work in the non NHS sector but I think it is important to mention that can be in a range of settings, for example in industry, it can be independent care homes, private, charitable.

  954. Might you be able to write to us and say how the balances have changed over the years, the pie chart, as it were? Presumably it is increasing year by year at the moment, I would have thought.
  (Mr Catton) Certainly I will look at that and try and find you some more information. The other interesting figure from our membership is people who are leaving the profession, so this is based on our membership records, and the people who leave the RCN give us the reason they are leaving because they are leaving the profession and last year that was at 20 per cent.

  955. Just on this issue of mixed economy of health, what do you see the problem for your membership of working within that environment is?
  (Mr Catton) The complexity issue which was raised a minute ago, I think, yes, systems and structures could be more complex but so is the whole nature of health: more information from e-mail, treatment options and all the rest of it. I think there is a much bigger issue there about what the future health care worker will do and some of that may well be around the guider and the interpreter, more accompanying the patient through their journey because of this massive information and different structures. I have talked about the difficulty with fragmentation and commissioning and equality. There are some key workforce issues that if there is a mixed economy, if people are moving between sectors will their continuity of employment be protected? Pensions is a big issue. There is a difficulty in recruiting from the private and independent sector. Similarly, opportunities for career development and promotion, whether those are balanced across the sectors.

  956. Equally, in terms of the pure self-interest of your members, presumably it is a much better environment to be because they have much more power and they have much more choice open to them. I am thinking specifically of agency nurses who have gone over to an agency and then there are nursing homes particularly where they have gone back to the same nursing home at a much higher rate and then they have been taken back on to the nursing home staff at a higher rate than they were before.
  (Mr Catton) Higher pay rate?

  957. Yes. So in terms of the interest of your members it might refer to the mixed economy because there is more chance of —
  (Mr Catton) Nurses have always moved between the different sectors, and that may have increased in recent years but that has always been the case. The private independent sector employers will often say to us that they have a problem with people not staying with them because promotional and career development opportunities are back in the NHS. Also, they have a problem in recruiting around the pension issue as well, that mixed career path, and moving in different areas has always been a feature.

  958. We have heard a lot recently about the amount that trusts are paying for agency staff. Do you expect in the next few years to see a migration back from agencies to the NHS but also staff coming back being at significantly higher levels of pay given that might save money for the NHS long term?
  (Mr Catton) The difficulty is that in our experience the NHS has been reluctant to pay overtime rates. If they needed extra staff to cover a shift they may have offered time back or they may have offered it at plain time rates but they were very reluctant to pay the nationally agreed weekly overtime rate to do that work. There were real difficulties for nursing staff because they ultimately felt as though there was pressure put on them to cover a colleague who had gone. Then they went and did agency work. If the appropriate rates were paid the NHS nurses would do it. There is also the issue of continuity as well, they have got the same staff looking after them rather than this mix of agency.

  959. Do you think it is a fair criticism that trusts have been too short sighted? They have not foreseen what would happen by being perhaps too rigid? Nursing staff have gone over to the agencies and the NHS is paying out a lot more now because of that.
  (Mr Campbell Davis) It is changing. Certainly it happened in the past but, of course, it is a consequence of trusts being as short of money over many years as they have been and trying to do everything all at once which means that you squeeze everywhere you can. When you look at your overtime bills and your agency bills and those you pay the bank nurses working within the hospital, in the case of some of the London trusts it is six or eight million pounds a year. So the advent of NHS professionals, which is the NHS as a managerial way reacting to that and saying "Let us bring this in-house. Let us stop feeding this into the private sector to this degree" I think will transform it over the next couple of years.

  Julia Drown: The Committee did not want to let the NHS Confederation go without picking up some of the points you make about the PFI in your evidence. You may want to respond to some of this in writing. Four brief things from it. First of all, you talked about the need to have flexibility in PFI schemes. You suggest that the private sector is prepared to absorb, contractors may not be willing to take on any flexibility considerations for long term future. Also, again on risk transfer, you said in 5.2.1 of your evidence how some of the transfer of risk has not been particularly valid. I would like to hear more about that. We were also quite interested in your work on the future hospital network which showed best practice of future hospital developments, and we would be interested in your thoughts and what has come out of that so far? Finally, we have been interested in how the PFI could be made to be accountable and more obvious to the public? In your view, do you think it would be possible on a sheet of A4 to be able to quite easily explain to the public the difference in cost between the PFI option and the public sector comparator?

  Chairman: That is some question at five to one, Julia!

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