Examination of Witnesses (Questions 1
- 19)
THURSDAY 9 MARCH 2006
MR KEN
ANDERSON AND
MR BOB
RICKETTS
Q1 Chairman: Good morning, gentlemen.
I wonder if I could ask you to introduce yourselves for the sake
of the record and to tell us what area of expertise you bring
to us this morning.
Mr Anderson: Good morning. I am
Ken Anderson. I am the Commercial Director of the Department of
Health.
Mr Ricketts: I am Bob Ricketts.
I am with the Department of Health and I lead on policy for commissioning
and choice.
Q2 Chairman: Thank you very much
for coming along. This is our first sitting on our inquiry into
the ISTCs. I wonder if you could start by telling the Committee
how many ISTCs and National Health Service Treatment Centres there
are at the moment or under development.
Mr Ricketts: There are 20 open
ISTCs. My recollection is that there are approximately 45-50 NHS
Treatment Centres depending on how you categorise them, but I
would need to check that figure and come back to you.
Mr Anderson: I would defer to
Bob on the NHS, which is not my area of expertise, but we do have
20 ISTCs with another 10 to follow.
Q3 Chairman: What are the objectives
of the ISTC programmes, and how much importance do you give to
the objectives? Initially the three objectives of the programme
were to increase capacity, offer patients a choice of venues for
treatment and to stimulate innovation. Then we also had the introduction
of this word contestability which came into the frame as well.
What are the objectives? Does that cover all of them?
Mr Anderson: It covers a number
of them. Probably the main objective at the time was for capacity.
The process that we went through was one where we would go out
to the local NHS through the strategic health authorities and
ask them what capacity gaps they had and what they could not accomplish
or provide themselves either efficiently or at all. The primary
objective was the capacity issue. There were other goals that
we hoped to accomplish through the ISTC programme.
Q4 Chairman: It was the capacity
issue which seemed to be the obvious one that went round in the
public domain at the time. Was that because NHS Treatment Centres
were not capable of filling up the capacity?
Mr Anderson: The SHAs in conjunction
with the PCTs did an assessment of the capacity needs of the area
and, more importantly, they determined whether or not they could
fulfil those capacity needs. We received a series of submissions
to the Department on the back of that and that was fairly comprehensive
work that outlined in detail what the needs were in the local
area. That is how we were informed at the departmental level of
what the needs were, particularly around capacity.
Q5 Chairman: Was the location of
the first phase to do with where the capacity was needed as it
were? There is one just south of my own constituency which covers
North Trent and South Yorkshire. Was that because of the need
for orthopaedic surgery in that particular area?
Mr Anderson: That is exactly right.
We were informed by your local health economy that they needed
orthopaedic capacity in the case of Trent and therefore we procured
that capacity for them.
Q6 Chairman: That was a response
to the waiting times and the waiting lists.
Mr Anderson: That is correct.
I cannot speak for Trent itself. There was probably a variety
of issues that came up in the local economy that we are not aware
of at our level that they would have put into the pot to come
up with the answer that they ultimately gave us from the standpoint
of their needs.
Q7 Chairman: You will be very familiar
with the fact that some parts of the National Health Service felt
that the location of these could destabilise local hospitals.
Is that something that you took into account when the first phases
were located?
Mr Anderson: Again, the capacity
planning was done at a local economy level. It was not for us
to try to determine at our level. We would not have had the capability
because we do not have the granularity of data to go out and make
those decisions for a local health economy.
Mr Ricketts: It is worthwhile
adding, Chairman, since I was leading on the capacity planning,
that those discussions were very detailed with the health authorities
and PCTs. Back in 2002 there was a very real risk of not delivering
the six month waiting time target and certainly, looking at all
the projections of capacity for the NHS, there was a clear need
to rapidly expand the NHS Treatment Centre programme and to bring
in additional independent sector capacity not just to help hit
the six month target but also because in some places the non-elective
targets and priorities were under pressure. A secondary aim of
the programme was to take some of the pressure off so that some
trusts could then reconfigure and have more physical space to
handle some of their emergency pressures because at the time,
as you will remember, waiting time issues and also emergency admissions
were very high priorities. We were trying to address several issues
when we were looking at whether we needed this amount of capacity
in a given health system.
Q8 Chairman: Issues like choice came
along at a later stage as far as the Department is concerned.
Mr Ricketts: Strictly speaking,
no. Choice was at a very early stage of development. When Alan
Milburn announced the first wave of the procurement in December
2002 he put the emphasis on cutting waiting times, but he also
referred to an objective which was to increase patient choice
clearly with a view that in three years' time we would have to
offer choice. We were running with two objectives then, the primary
one being capacity, which was to hit the six month target and
to ease some of the pressure on A&E and the non-elective work.
Q9 Dr Stoate: I understand why the
objective was to improve capacity, particularly in areas where
there was a shortage and you needed government targets to get
the times down. Did you make any assessment at the time of whether
increasing that capacity or bringing new capacity into the system
would have any effect on existing NHS hospitals?
Mr Ricketts: We asked health authorities
and PCTs to consider whether there was likely to be an impact.
If we are talking there about Wave 1, which was the procurement
launched in December 2002, particularly when taking into account
the amount of elective work being done by the NHS, the overall
size of that was really too small certainly nationally and in
most health areas to have an impact. In terms of the ISTCs that
are open now, they are doing 60,000 Finished Consultant Episodes
(FCEs) a year this year and the total the NHS is doing is 5.6
million. Potentially if we had got the case mix wrong one could
have had an impact at specialty level in an economy. We had one
example of that in Southampton where we had to adjust the case
mix and likewise in terms of cataracts, but the volumes of additional
capacity we brought in from the independent sector were unlikely
to destabilise local economies.
Q10 Dr Stoate: Certainly they would
not destabilise the economy as a whole. You did not do any specific
research on whether there were locally specialty difficulties,
did you?
Mr Ricketts: Where concerns were
raised, we went back and challenged SHAs and PCTs on whether these
figures looked right and that led, for example, in the case of
Oxfordshire, to a reduction in the activity requirements. We offered
to move some of that capacity, because it is a mobile service,
to those places which had got their numbers wrong in the sense
of a shortfall. We were actually aware of that, but we did take
the view that for the first wave, because everybody needed the
capacity to get to six months, it was very unlikely that it would
tip any service over. Where concerns were raised, we followed
those up and we reduced the level of activity in the case of cataracts.
Q11 Dr Stoate: What you are saying
is that, so far as you are aware, there has been no destabilisation
or undermining of local hospitals because of these centres, is
it not?
Mr Ricketts: Very much so. They
are doing only 60,000 FCEs this year and next year it is going
to be 117,000, but the NHS will do nearly 6 million. It is difficult
to see how it can have a serious destabilising effect. I think
the bigger issue which has been raised by the service is the impact
on training, which is something where we recognise that if you
are moving out many of the frequent but simpler procedures that
junior medical staff train on then that is one of the areas where
we do need to avoid inadvertently destabilising training networks.
I think that feels like the bigger risk rather than causing a
service to fail, which is why we have been in discussions with
the Royal Colleges around how we manage the training element of
ISTCs.
Q12 Dr Taylor: Could you explain
additionality to us? Why was it such a crucial part of the ISTC
programme?
Mr Ricketts: At the time when
we launched the procurement we were very concerned about having
sufficient capacity, not just physical but also workforce, to
hit the six month target. There was a concern amongst ministers
and the professions that there was the risk that the independent
sector providers might "poach" staff from the NHS and
we might end up moving workforce shortages. Therefore, we agreed
with ministers to take a very strict view of additionality, which
was that no independent sector provider could employ anybody who
had worked for an NHS secondary care organisation in the last
six months. We have relaxed that rule for the current wave of
procurement because the workforce situation has improved, but
at the time we all thought the prudent thing to do was to have
some very strict rules around basically forcing independent sector
providers, unless it was a joint venture, to obtain their staff
from a non-NHS source because of the need to protect NHS services.
Mr Anderson: Even more important
than that was the need to bring in extra resource to do the surgeries.
As a country we did not have at our disposal the number of nurses
and doctors that we needed to perform procedures and to bring
the waiting lists down. It was a very specific part of policy
that looked at ensuring bringing in that extra capacity both in
terms of buildings, people and clinicians.
Q13 Dr Taylor: You are saying that
it is being relaxed with the second wave.
Mr Ricketts: It has been relaxed
for the second wave for those groups of staff where there are
no longer significant forecast shortages. Where we know we are
going to have some shortages potentially and we do not have a
surplus of staff, like radiology, radiography and some of the
more specialist nurses, then we have said that we intend to maintain
additionality for Wave 2. We have been in six or seven months
of negotiations and discussions with the key trade unions and
the staff associations around what should be the list of those
staff groups to whom additionality should still apply.
Mr Anderson: We also see additionality
and the need to relax it as a way to start to integrate these
facilities into the local health economy and so a relaxation of
the additionality requirement will allow that to occur. We have
had quite a bit of commentary from the Royal Colleges and others
saying that that is not being allowed to occur because of the
additionality issue. So we have taken that into consideration
and, through ministers, we have decided to change that.
Q14 Dr Taylor: To me that is one
of the most important bits because at the moment there is a divorce
between the ISTCs and the local NHS economy. In places where there
are, for example, NHS orthopaedic surgeons who could take on some
extra work, could that now be allowed?
Mr Anderson: It could be. It would
be looked at on a specific basis depending on the area but based
on the things that Bob has just mentioned and whether or not there
is a shortage or a deficiency because we do not want to move staff
out of the NHS into an Independent Sector Treatment Centre and
remove a resource that is needed in the NHS.
Q15 Dr Taylor: Unless you could be
sure it was not taking away from that capability within the NHS.
Mr Anderson: That is correct.
Mr Ricketts: What we have done
is introduce something called non-contracted hours so that particularly
medical staff, who are maybe not using the non-contracted hours
and who are not being used to the benefit of the NHS could work
for a private insurer or to do something else, who are subject
to strict controls around safe working, could then work in an
Independent Sector Treatment Centre. That is something that we
have had strong support from the medical profession for in terms
of being slightly more flexible and allowing people to use their
spare resources as long as it does not prejudice NHS care and
it does not lead to somebody working too many hours.
Q16 Anne Milton: How do complaints
about ISTCs compare with the NHS as a whole?
Mr Anderson: Currently we track
through our Key Performance Indicators (KPIs) serious untoward
incidents. Serious untoward incidents—and you have to understand,
to date we have done 49,000 elective procedures—are of the
order of one quarter of 1%. I do not know how that compares to
the NHS because in many cases they do not collect that data so
a comparison is not possible.
Q17 Anne Milton: What is a serious
untoward event?
Mr Anderson: I could not define
that for you appropriately. I could come back to you in writing
on that.[1]
Q18 Anne Milton: A serious untoward
event presumably is an event that everybody knows has occurred.
I was actually asking about complaints.
Mr Anderson: I do not have that
figure in front of me. Again, I could write to you and give that
to you.[2]
I do know that the satisfaction rates in the ISTC run at 97% in
comparison to 91% in the NHS.
Q19 Anne Milton: What outcomes are
measured, quality of life and morbidity et cetera?
Mr Anderson: That is a fair question.
First of all, I am not a clinician so I cannot go into the detail,
but what I can tell you is that we have a set of 26 Key Performance
Indicators that are contained in the contractual relationship
with the providers and they are clinical performance referrals
and the contractual obligations just generally of the provider.
Again, if you wanted specific detail on that, I could have somebody
from the DCMO's office write to you about that as it is outside
my area of expertise. We do collect them on a monthly basis; they
are monitored. The quality assurance process is basically a mirror
of the NHS quality assurance process. Patients are NHS patients
when they are in the ISTCs and they have all of the same rights
and capabilities of complaint as an NHS patient does. I do not
have those figures in front of me from a complaint standpoint,
but we can get back to you on that.
1 Ev 111 Volume III Back
2
Ev 112 Volume III Back
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