Examination of Witnesses (Questions 20
- 39)
THURSDAY 9 MARCH 2006
MR KEN
ANDERSON AND
MR BOB
RICKETTS
Q20 Anne Milton: And if you could
also let us know what a serious untoward incident is.
Mr Anderson: We will define that
for you.
Q21 Anne Milton: It has to be said
that theatres in the NHS throughout the night lie dormant. On
the basis that you were attracting medical and nursing staff from
elsewhere because of additionality, would it have been possible
not to have started the ISTCs and to use the theatres overnight
and to bring in staff from elsewhere if there was not capacity
in the medical and nursing staff?
Mr Anderson: In some cases we
did that. Depending on the contract and the availability and capability
within the local economy, we did use existing NHS facilities.
There is a difference between currently elective surgical throughput
and it basically relates to keyhole surgery and whether or not
those facilities are up to doing it because it is a completely
different type of surgical event. What we were trying to do, along
with the all the other things we mentioned at the beginning, was
to bring in innovation as well, new working techniques, so that
we could increase throughput and, more importantly, quality for
the patient and a lot of times that entailed that we had to go
out and build fit for purpose facilities.
Q22 Anne Milton: Will you be doing
it with the next phase, particularly on diagnostics? Will you
look towards the NHS first of all and whether that can be used
more effectively by using it out of hours?
Mr Anderson: Most definitely.
The process with Wave 1 was non-static that we went through around
the gap analysis. We had started out initially with the NHS telling
us that we should procure 250,000 procedures and we actually procured
170,000 and that will continue in Wave 2. I would not wish to
be flippant, but it is really too early to tell exactly what those
service redesigns and configurations will look like, particularly
around the diagnostic piece.
Mr Ricketts: What you are suggesting
is exactly our strategy in terms of diagnostics. We have got to
deliver a huge increase in diagnostic provision, particularly
scanning, in the next two years to deliver 18 weeks because we
need 900,000 more MRI scans and over half a million CT scans.
We are getting less than half of that from the independent sector.
At the same time as we procure diagnostic capacity from the independent
sector we have also strongly encouraged local NHS Trusts to increase
their diagnostic capacity. We will not hit 18 weeks if we solely
rely on the independent sector. The strategy you are talking about
where trusts are encouraged over the next two years to use their
scans to best effect and so on is exactly what we are looking
for, it is an investment into a growing NHS capacity or using
it effectively to hit diagnostics as well as investing in the
independent sector. Even at the end of 2007-08, if you take MRI,
only 25% of total scans will be provided by the independent sector,
the overwhelming majority will be through the NHS mainly by encouraging
them to use their facilities for longer hours and to change their
skills mix and so on in the way you are suggesting.
Q23 Dr Taylor: Can you give us any
idea of the proportion of overseas to home trained surgeons in
the ISTCs?
Mr Anderson: I cannot here. I
could write to you with that.[3]
Q24 Dr Taylor: Is it pretty much
the vast majority who are overseas trained or is that impression
wrong?
Mr Anderson: I would not want
to proffer an answer and be wrong. It would be my sense that that
would be correct, but I would not want to mislead you. I will
write to you on that.
Q25 Dr Taylor: That would be very
useful. In your report to the Secretary of State, dated 16 February,
you say that all clinicians are on the appropriate specialist
register of the GMC as in the NHS. Is the accreditation process
exactly the same for people coming from other countries as from
this country?
Mr Anderson: The accreditation
process is handled by the General Medical Council. Everyone is
registered with the GMC.
Q26 Dr Taylor: So these are questions
we should put to them. Are you not aware of differences in accreditation?
Mr Anderson: I believe that there
is no difference, but if you want to ask questions around that
area I suggest you talk to the GMC.
Mr Ricketts: The requirements
are exactly the same in terms of registration and being on the
specialist register. It is a contractual requirement of the programme.
We could confirm that in writing.
Q27 Dr Taylor: We will take that
up with the GMC when we see them.
Mr Anderson: Dr Taylor, I have
just been passed an answer for you. I am told that one in four
in the NHS itself is overseas trained and that the vast majority
in the IS are overseas trained.
Q28 Dr Taylor: That is very useful.
You have talked a little bit about complaints. Are there any figures
for complication rates between NHS Treatment Centres and ISTCs?
Mr Anderson: We collect them in
the ISTCs. The problem we have is that a lot of the data we collect
under our Key Performance Indicators is not routinely collected
in the NHS. We find it very hard to compare complication rates.
The more you get into the granularity of data the harder it is
to compare apples to apples. Again, that is a clinical question.
I do not know that I have the specific answer in front of me.
I will put that to our clinical colleagues.
Q29 Dr Taylor: We have got this horrendous
paper entitled "Preliminary Overview Report for Schemes:
ISTC Performance Management Analysis Service" which is going
to put anybody off after just one glance at it because it is all
figures. Could either of you give us a thumbnail sketch of what
it says? It is prepared by the National Centre for Health Outcomes
Development. Is this a new arm's length body?
Mr Anderson: No. They are attached
to a university. It is not an arm's length body. That is clinical
in nature.
Mr Amess: They will write to you, Richard.
Dr Taylor: I will not be able to understand
that either!
Q30 Anne Milton: Are you saying that
complications of procedures is information that is not collected
within the NHS?
Mr Anderson: In some areas they
do collect that data. My area of expertise is not in the NHS,
it is around these centres. From the standpoint of serious untoward
incidents, that is not collected. Below that level of granularity
I do not know exactly in specific areas what is collected and
what is not.
Q31 Anne Milton: Mr Ricketts, maybe
you can answer that.
Mr Ricketts: There is a problem
for some specialties and some procedures that colleges collect
through audit of complication rates, and cataracts would be a
good example. Once you are outside cataracts you start to struggle
in terms of having reliable published data that is statistically
significant and that covers all providers. It is a problem we
hit when we published the patient choice booklets in December
where I had hoped that in addition to the information on waiting
times and some of the other Healthcare Commission data we could
provide some meaningful clinical indicators. It is an area that
we recognise, as the Department, we have to work on with the professionals
and patients so that we can publish meaningful clinical quality
data, including complications, across all providers and at a sufficient
level of detail to be sensible, which probably means at specialty
level and so on. It is a great difficulty. So we hit that problem
in terms of the choice booklets. I think Mr Anderson's observation
is right.
Q32 Anne Milton: Can I suggest that
I do not have a choice unless I have got some clinical indicators
because my choice should be informed. If it is not informed by
the fact that this hospital or that hospital or this ISTC has
complication rates then I am not making a choice.
Mr Ricketts: I would agree that
you are not making as informed a choice.
Q33 Anne Milton: The complication
rates is fairly fundamental information.
Mr Ricketts: I agree with that.
In terms of the introduction of choice, we have to work from where
we are. It is really important that any information which is provided
to patients for choice is reliable and published by an independent
body. We pushed the Healthcare Commission very hard. We used the
information that was published by the Healthcare Commission so
that we would not mislead a patient if they are relying on that.
Clearly they also have the conversation with their GP who will
steer them in terms of their perception of clinical quality, but
again I recognise it is very difficult for GPs in those circumstances
depending on what they know of the provider. That is why we have
signaled that one of the key next developments in the choice policy
is to move away from waiting times and satisfaction rates, which
are important to patients, into developing some measures of clinical
quality that can be published and that can be used by GPs and
patients to inform choice, but we are not there yet. In terms
of what is nationally published, it is very limited in terms of
clinical quality. I am not trying to avoid the question, I am
just stating where we are.
Anne Milton: It is very difficult if
we have not got any information on complaints, we do not know
what an untoward incident is and we have got no information on
complications to compare.
Dr Stoate: I share your point of view
on patient safety. One of the things that trusts are required
to do is to report adverse patient incidents which could affect
patient safety. However, the quality of reporting is fantastically
variable, with some trusts returning a nil return, which means
they have no adverse incidents and which beggars belief. The quality
of data which is submitted by trusts is extremely poor.
Anne Milton: So patients are not going
to be able to exercise an informed choice, it is as simple as
that.
Q34 Chairman: Has any comparative
assessment been made between independent and NHS Treatment Centres?
Mr Ricketts: Not a direct comparison,
no. The National Centre for Health Outcomes Development (NCHOD)
report could not do that in detail last year when it was published
simply because the number of patients treated would not be meaningful
statistically. When we publish in the autumn the next version
of the NCHOD report, because we will have many more patients that
will have gone through the programme and therefore the KPIs will
be more meaningful, we will be able to provide much more comprehensive
information on clinical quality, but at the time they produced
the report they had comparatively few cases and certainly not
enough to draw meaningful comparisons.
Mr Anderson: From the standpoint
of ISTCs, I do not have that granularity of data at hand. We collect
data as a matter of course through the contractual environment
and through the Key Performance Indicators that we ask of the
firms who are doing the work. So that data is out there. I just
do not have the specifics in front of me.
Q35 Chairman: You do not ask for
it of NHS Treatment Centres, is that what you are saying?
Mr Anderson: NHS Treatment Centres
are not within my realm of expertise.
Q36 Chairman: It seems that doing
any comparison is going to be very difficult if you are not comparing
like with like.
Mr Ricketts: What we are doing
as part of the next phase of choice is we are working currently
with the NHS Confederation, the Foundation Trust network and also
the independent sector to look to develop, before the autumn patient
choice booklets, meaningful measures where you can compare NHS
and independent sector providers like for like. That work is being
developed. It is not that information is not out there, it is
that it is not pulled together in a way that would be meaningful
and, crucially, some of it is quite variable, so we need to improve
the quality. We are trying to do all we can to ensure that over
the course of the next year, as choice rolls out, more and more
information is available for patients and GPs to take those choices,
but we have had to start from where we are.
Q37 Dr Stoate: One of the things
we have picked up from some of the evidence we have had is that
people are concerned about continuity of care, the aftercare from
these Independent Sector Treatment Centres, not so much the operation
itself but what happens afterwards. How are the contracts worded
to ensure that there really is safeguarded continuity of care
for NHS patients?
Mr Anderson: When we set about
trying to determine what the needs of the local economies were
we worked on a pathway basis and so we asked the NHS about the
pathway and in some cases they could do a significant part of
the pathway but maybe not the surgical part of it. So maybe they
could do the pre-operative care and the post-operative care but
the actual surgical intervention was not possible in their area.
So it varies, to be very honest with you, among contracts. Some
contracts can stipulate that the provider has to provide all of
the front-end surgical and back-end care, whether that is physiotherapy
or other modalities post-surgery. It can stipulate that all that
they do, depending on the area, is just the surgery itself. We
definitely look at that as a pathway concept. We used that as
an integration tool from the NHS into the ISTCs and then back
into the NHS after post-operative care.
Q38 Dr Stoate: So as far as you are
concerned the entire patient pathway is covered in the contract,
is it?
Mr Anderson: No. What is covered
in the contract is the portion of the pathway that the NHS has
asked the independent sector treatment provider to provide.
Q39 Dr Stoate: Does that mean there
are no gaps in the pathway as far as you are concerned and that
someone has picked up every aspect of them? What we are hearing
from various groups is that there are gaps in this pathway and,
particularly when there has been a complication during a surgical
procedure, that somehow somebody else, which is not always very
well defined, is left to pick up the pieces and that does cause
distress. How can you guarantee that that has been covered?
Mr Anderson: In all honesty, we
have had teething problems. This is a new concept. It has not
been without some issues. When those occur, we look at them and
we fix them. Specifically down at NHS local level, I do not have
the detail. I do know of what you speak. The issue is less about
a gap in the pathway and more about, since it is a new service,
whether it has been joined up appropriately.
3 See Q 27 Back
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