Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 80 - 89)



  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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