Examination of Witnesses (Questions 80
- 89)
THURSDAY 9 MARCH 2006
MR KEN
ANDERSON AND
MR BOB
RICKETTS
Q80 Dr Stoate: It will do because
you are not employing the same people. The ISTC will be employing
a very high proportion of overseas doctors, whereas the trust
may not be. You are not talking about the same doctors. How are
they going to get training for the next generation of orthopaedic
surgeons if all the hip replacements are being carried out by
South African doctors in the ISTC?
Mr Ricketts: There are two things
there. One is the use of non-contracted hours and also relaxation
around additionality gives us an ability certainly outside orthopaedics
to do that. Non-contracted hours also apply to orthopaedics. It
is not my area of expertise but in terms of the rules around additionality
there are specific requirements in relation to relaxing that for
supervision. We would have to come back to you in terms of how
that works but that should not be an impediment.[4]
It is part of the detail we need to explore with the colleges.
Once we have agreed what the roles are—and we have said
very clearly we want to encourage ISTC providers to do training;
they want to do it—we are going to have to work through
the fine detail of how we get the NHS hospital consultants to
work effectively with the independent sector provider, how they
may share staffing supervision and all those sorts of things,
but we are not at that level of detail yet. We are just trying
to set out the principles and the funding so that at least people
understand that. We are then going to have to do a lot of detailed
work to avoid the situation you describe.
Q81 Dr Stoate: I would be very interested
to hear what the colleges have to say and we will be speaking
to them shortly. I still have concerns. I still do not see how
my orthopaedic registrar working in the district hospital, if
he has no hip replacements to practise on because they have all
gone to the ISTC, can be trained properly.
Mr Ricketts: He will be able to
undertake the hip replacements within the ISTC and that is the
point in terms of moving the training across.
Mr Anderson: The example that
you have illustrated would probably suggest in that instance that
additionality would not apply. If you have a wholesale movement
of orthopaedics to a different facility—
Q82 Dr Stoate: Additionality would
be the bugbear because additionality means that the ISTC must
employ overseas doctors, for example, to carry out hip replacements
and effectively, if the majority of hip replacements from that
area go to the ISTC, how is the NHS orthopaedic surgeon going
to get any practice on hip replacements?
Mr Anderson: I understand. First
of all, we do not have any instances of that.
Q83 Dr Stoate: I am looking to the
future.
Mr Anderson: Given the example
that you have illustrated here, additionality would not apply
in that case if there is that wholesale movement. Therefore, that
doctor would have the ability, because additionality did not apply,
to work in the facility.
Q84 Dr Stoate: The DGH still loses
its credibility as a training centre for orthopaedics because
they have all moved to the ISTC. Where is my hospital going to
train orthopaedic surgeons in future?
Mr Ricketts: Perhaps in ISTCs.
Q85 Mr Amess: Gentlemen, I hope you
are not going to make promotional videos about these treatment
centres because if that is your intention I suspect you may struggle
to convince people. Indeed, in the earlier part of this session,
I wondered if we had the right witnesses here because they seemed
to struggle to be able to answer anything. All I can suggest is
that Sir Nigel Crisp's departure must have temporarily destabilised
the department. It has been reported that the Government wants
to see between 10 and 15% of patients being treated by the independent
sector. If this does represent the Government's aims the philosophy
behind it is certainly obscure. The Secretary of State was reluctant
to admit to such an intention and in December 2005 she told the
Committee: "I do not think this is ideological. John Reid
made the point that looking at what he thought was needed he did
not believe—I think his phrase was—in his political
lifetime that it would be more than 15%." Can you two gentlemen
clearly tell the Committee what the department's long term aim
is for these treatment centres?
Mr Anderson: We have not announced
a Wave 3. We are procuring Wave 2. I do not know the political
background for that. It is not for me to comment on. I do know
that we have gone out with Wave 1. We have procured that, and
on the back of the success of that, as we perceive it and calculate
it, we have decided to do a Wave 2.
Q86 Mr Amess: It is a terribly weak
answer. It is fair enough you cannot respond politically but for
God's sake. This is a huge thing that is happening. Surely you
must be able to tell us what the department's long term aims for
these treatment centres are. What you have just said is waffle.
Mr Anderson: The long term aim
for the treatment centres as they exist is that they go out and
bring waiting times down. They integrate into the NHS family of
providers and provide good, high quality, reasonably priced care
for patients.
Q87 Mr Amess: Let me try something
else. There are fears that increasing these treatment centres'
capacities combined with payment by result will destabilise the
National Health Service. How will the department ensure that this
does not happen?
Mr Ricketts: It is very difficult,
given the volumes of work that will be carried out by the independent
sector, to look at Wave 1 and Wave 2, quite frankly, and how they
could destabilise the NHS. It is very difficult to see how they
could destabilise an individual hospital. There may well be circumstances
where the effect of an ISTC and choice combined places pressure
on an individual service, where that service is not held in high
repute by GPs and patients. That is where you are likely to have
the impact on an individual service. In those circumstances, there
is a responsibility particularly on the local strategic health
authority to work through the consequences and make sure that
local patients have access to services. If you are talking realistically,
if you add together Waves 1 and 2 at something around 7 or 8%
of elective care, I really cannot envisage the situation—that
is only elective care which is a minority of the spending and
the work carried out by the NHS—where it could destabilise
the NHS. I cannot see it destabilising a hospital. There will
inevitably be issues around services but choice will generate
that where patients and GPs are unhappy with the quality of service.
Q88 Mr Amess: We will wait and see
what the other witnesses have to say on that point. It is claimed
that the existence of these centres frees up the NHS capacity
for emergency work. I would like the department to offer a view
on how it will manage and, if necessary, resolve tensions between
the NHS and the independent sector as the provision of the latter
expands. Can you say something about how you see this working
out in practice?
Mr Ricketts: Mr Anderson has made
it clear that there are not plans beyond a Wave 2 so we are talking
about something of the size of Wave 1 and 2 combined. There will
be some tensions potentially at local level around services. That
will be for PCTs in their key commissioning role to work through
to ensure that patients retain access to services. It is not something
that the department is in a position to direct; it is something
that local commissioners will be expected to take responsibility
for in the same way that they will be expected to take responsibility
for a poor or failing service currently.
Q89 Mr Amess: There is also a fear
that the removal of elective procedures to these independent treatment
centres, combined with the introduction of payment by result,
will have an adverse effect on National Health Service finances.
Do you anticipate that the hospitals of the future could be purely
elective and purely emergency?
Mr Anderson: We have to return
to Mr Ricketts's answer around destabilisation from a financial
standpoint. In comparison to the total spend of the NHS, this
is a very small amount of money. To suggest that that would significantly
undermine the finances of the NHS would not be appropriate. The
second part of your question is how would we envision the reconfiguration
of services as we go forward. That is a question for local health
economies, based on demographics and the patients' needs in that
area. There is a move worldwide to take elective surgical care
and minimally invasive surgical care and stream them separately
from tertiary care, because those two, from the standpoint of
throughput and quality of service, do not exist very comfortably
together. What the hospital of the future will look like will
vary by community. You will see, I would hope, a lot more streaming
of elective and tertiary throughput from the surgical standpoint
particularly.
Chairman: Could I thank you both very
much indeed for coming along and answering our questions this
morning? We get the professionalism we expect and we should thank
you for it. We just assume that civil servants will come in. I
think you have done a very good job this morning and I would like
to thank you both on behalf of the Committee.
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