Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 90 - 99)



  Q90  Chairman: Good morning. Could you introduce yourselves for the record with your name, organisation and where you come from?

  Mr Kelly: I am Simon Kelly. I am a consultant ophthalmic surgeon at Bolton Hospitals NHS Trust. I am representing the Royal College of Ophthalmologists here and I have been involved with the former National Implementation Team since 2004 on the Royal College heads meeting and I have also been quite involved with the ophthalmic ISTC schemes since they started.[5]

  Dr Simpson: I am Dr Peter Simpson. I am a consultant anaesthetist at Frenchay Hospital, North Bristol. I am President of the Royal College of Anaesthetists and I am Deputy Chairman of the Postgraduate-Medical Education and Training Board (PMETB).

  Mr Ribeiro: Bernard Ribeiro, general surgeon at Basildon Hospital. I am President of the Royal College of Surgeons of England.

  Professor Husband: Janet Husband, President of the Royal College of Radiologists and Consultant Radiologist at the Royal Marsden Hospital.

  Mr Leslie: Ian Leslie, orthopaedic surgeon from Bristol and president of the British Orthopaedic Association.

  Q91  Chairman: Welcome. I am tempted to ask you all for your comments on what most of you have just heard from our previous witnesses. You may not have a collective view but let us try the individuals. Mr Kelly?

  Mr Kelly: I was here and there are a number of points. If I stick with cataracts, because that is my field, I was interested to hear Mr Ricketts say that in the early stage of the Phase 1 development the capacity planning had been decided locally and, in the question about Phase 2, that this would be decided locally again. When questioned, "Was it not the case that the cataract requirement was not necessary?" he did concede that. He conceded that the Phase 1 ophthalmic cataract scheme, the Netcare scheme, was possibly needless. That is quite a significant learning point. Just to put it in context, that is a £40 million scheme. He also said that one of the benefits of the schemes was to drive up productivity—and this new word "contestability" has been brought into the lexicon—or competition. The concept that competition would only occur by the stimulation of the ISTCs I also found somewhat abhorrent because the medical profession has always maintained high standards. NHS management have always maintained high standards in local hospitals. It is the College who worked with the Department of Health to drive up the standards in the Action on Cataracts scheme which brought modernisation to cataract surgery, long before modernisation had become a contemporary buzzword. I do not really see much merit in that. Furthermore, there was mention made of great innovations in Phase 1. Quite frankly, I do not see any innovation in Phase 1 in cataract surgery that did not already exist in the existing cataract schemes. We are able to do the same amount of cataract surgery as the independent sector do in the schemes, if necessary. Finally, when the scheme was announced, it made me somewhat breathless to hear that colleagues from South Africa—where there are big backlogs of cataracts to be done—were going to come to the UK. I have worked in West Africa so I understand the situation a little bit there. They were going to come and work in the UK and this was going to be in mobile units frequently which were going to be parked within a mile or so of local NHS units. I still find that concept somewhat difficult to understand.

  Mr Leslie: There are many parts I would like to comment on but one is the key indicators which are quoted as being a method of assessing outcome. The key indicators in orthopaedic surgery are not whether the bed was clean or whether the hospital was clean. They are to do with dislocation and revision rates after they have left hospital. None of those key indicators addresses the after hospital events which take place. The complications are clearly definable in the NHS and the British Orthopaedic Association (BOA) was very instrumental in getting the National Joint Registry (NJR) off the ground. There are many audits round the country which will tell you the complication rates in NHS hospitals, but there is absolutely no information on the ISTCs. Readmission rates are not possible to do. Readmissions are to various hospitals, sometimes within 100 miles, and we have asked the National Audit Office when they do this to send a questionnaire to each of the patients who are admitted. Then we might establish what the readmission rate is. Readmission rates are available to me in my hospital as an indicator of performance. When patients are admitted to other NHS hospitals from ISTCs, they are admitted under the care of the consultant on call if there is a complication, not under the name of the operating surgeon. There are many more comments but I will not go on.

  Q92  Chairman: Would that be the same if people had been in the independent sector for an operation and then they had complications?

  Mr Leslie: In the independent sector there is a continuity of care in private hospitals. The consultant who did the operation would be a local surgeon and if there was a complication that happened to go back to an NHS hospital, I would expect a colleague to hand that patient back to me, under my name, so there is a continuity in the private hospital system. A surgeon who has disappeared back to Poland or Sweden is not around to deal with a complication.

  Q93  Chairman: You see no difference in that a surgeon who has somebody as a private patient who gets complications will just take that complication over as an NHS patient?

  Mr Leslie: No, sorry. I thought you meant if he was admitted as an emergency to an NHS hospital.

  Q94  Chairman: With a complication from the original procedure.

  Mr Leslie: He would expect, to my knowledge, to take that over again, yes, or take it back to the private hospital. I did not mean they went the other way.

  Q95  Chairman: Janet Husband, have you anything to add to what you heard?

  Professor Husband: I would like to make a point about additionality. Radiology and radiography were pointed out as the two specialties where additionality would be maintained. This is the major problem. We need to have an integrated service between the NHS and the independent sector so that clinical governance issues can be properly addressed, so that we can have clinical leadership. It is very different in the radiology independent sector where the reports are done overseas remotely and there is no link, so if the clinician has a lack of confidence in the reports there is no input into the multidisciplinary team meetings where major management decisions are made. If additionality were completely relaxed, this would be a major benefit. The other point in relation to that is that there are different scenarios in different parts of the country. In the south east, there are enough radiologists who could provide service to areas in the Midlands. They could do the reporting and work in that way. We have the proposal that NHS trusts could second a radiologist to the independent sector for, say, a day a week, but the independent sector would pay the trust who could then bring in more radiologists so that the whole system was integrated rather than in different silos, where all the problems have been related to this separate process.

  Q96  Chairman: Do you think the first phase is changing work practices inside the National Health Service? There was a hint in the evidence we took earlier that probably your members are changing their attitude in terms of work and changing work practices which makes the NHS more efficient. Do you think that is true or not?

  Mr Ribeiro: We must draw a line under the first wave ISTCs. They were brought in for a specific purpose which was to reduce waiting lists and to some extent that was achieved. The methodology that was used and the people who were brought in to do the work are another issue. In terms of change of practice, what has been demonstrated by ISTCs—and it is government policy—was the need to separate emergency from elective work. We from the college and specialist associations have for the last 10, 12, 15 years been talking about separating emergency from elective work. Currently some 64% of consultant general surgeons are on call for emergencies when they are doing elective work. The NHS has to deal with emergencies at the same time as it does its elective work. We have evidence of at least 38 NHS Diagnostic Treatment Centres (DTCs) where there has been separation of elective and emergency. I have been to Central Middlesex when it first started. I have been to Hinchinbrook. There are a whole lot of these which are very effectively run and very efficient proving the fact that if you separate elective from emergency you will get good treatment. That was there before independent sector TCs came on the ground. The fact is that there is a lack of will to follow through by having these centres in the NHS because it is government policy to contest, challenge, the NHS, put ISTCs close by and see whether the NHS hospital nearby will deliver. If it cannot deliver, it goes down. It is policy that is driving the change rather than practice and benefit. You asked are there any benefits. Last week, I went to the Greater Manchester Surgical Centre in Trafford which is an ISTC. It is a bit of a surprise for a member of our profession to do that in the private sector we are supposed to be criticising but it was a very well run centre, run by Netcare. It had a very good throughput of work. It had good facilities but there were issues over the fact that the contractual arrangements that are made there are such that if patients do not turn up they still get paid. If operations are not done they still get paid. Those issues, I am sure, have been addressed. They have surgeons from overseas, from Hungary—where a large number came through—who do three hip or prosthetic procedures and stop. The practice is well managed and well done. One thing they have to teach us however is—and this was identified in Ken Anderson's paper—about stocktaking and the keeping of prostheses. In the Trafford centre, they only have one prosthetic part and that is by Stryker. All the instrumentation is by Stryker. The surgeons who work there have to be trained to use Stryker equipment. In the NHS, surgeons are trained in lots of different units to use lots of different bits of equipment. Therefore, what you find is a cost effective exercise with no instruments on the shelf because Stryker employ a full time employee who is there to make sure that the equipment you need is available for you at the time. These are lessons that we can learn. That is the positive side, but I would like to underpin it by saying the experiment had already been done. What we are missing is a will on behalf of government to develop DTCs within existing NHS hospitals, rather than without.

  Q97  Chairman: Does anybody else have a view?

  Dr Simpson: I would like to echo what Bernie Ribeiro said. The word Janet Husband used earlier was "integration". Ours is a service specialty in anaesthesia. As such, with intensive care together, we provide a service for the surgery that goes on. If you say, "Has anaesthetic practice in the UK been changed by the introduction of treatment centres?", no. It is the same. If you say, "Is the standard of anaesthetics likely to be any worse in treatment centres?" it is very difficult to say without auditing it and you need to be very careful about what you audit. If you audit severe morbidity and mortality, I would be absolutely appalled if it was any different. The quality issues are the things that matter to patients. As a college, what we are concerned with are two things with treatment centres. One is the quality and safety of patient care and the other is training. For us, if we can achieve both those as an integrated part of the local health care economy, that is fine but we have a number of examples of where the introduction of a treatment centre distorts local health care and also the supervision of trainees in the base hospital, which is a significant issue that I will enlarge on if you wish.

  Mr Kelly: I fully support Mr Ribeiro's argument on the separation of elective and emergency care. That already exists in day case units and in five day wards and in NHS Treatment Centres. It makes all sorts of operational and patient safety sense. The problem is if you separate it on two different sites, if you have elective surgery done on one site and emergency surgery done on the other site. For most of the specialties in the UK, it is at this moment in time the same surgeons and the same anaesthetists providing the care. If care has to be provided over two sites, it is much more problematic. It is sensible to have it integrated on the same site so that we are all singing from the same song sheet, singing to our strengths. That also underpins training and safety. Whilst Dr Simpson has said that the two issues for the College are about training and patient safety, our College has exactly the same two issues. They are the key issues for us. We do have a third issue, interestingly. We are concerned about the impact of the ISTC procurement on local NHS facilities, on local NHS Hospital Eye Services, because the issue is that in the Hospital Eye Service we provide comprehensive, holistic care in which we are integrated with the patient groups, with the Royal National Institute for the Blind, with the Patients Association and many local organisations. We are also providing care for the chronic, blinding eye diseases and for children. What has happened is that one segment of our work—cataract surgery—has been pulled out and moved into a separate group. The effect of this is that it destabilises the manpower planning for the future generation of consultants. We have seen that the number of consultant appointments advertised in the BMJ in the last 18 months is 40% of what it should have been. This is occurring ironically at a time when our own UK graduates are coming out of the training schemes and are unable to get consultant positions and also at a time when there is going to be an increase in the medical school production. Our third reservation is the impact on the local NHS services. Finally, there is another issue which is also an impact on local services. There is an issue on the impact on the ethos of medicine as a profession as currently delivered and on the impact on the morale of doctors working in the existing NHS. The reason I say that is there has been little or no engagement between the medical profession and the Department of Health in planning these arrangements which are policy driven. I can say that having attended the National Implementation Team for the last two years. It was made clear to us that the Implementation Team, which is under the Commercial Directorate—Ken Anderson is the lead; Dr Tom Mann was the first Clinical Director. He has moved on to the independent sector himself. The current Clinical Director is Dr Bruce Websdale. NIT is there to implement policy. It is not there to consider the voice of the medical profession or of the nursing profession for that matter. They are there to implement policy that is coming right from the top. I think this cuts to the core of medicine as a profession.

  Professor Husband: There are two points on the effect on the NHS. One is that because a lot of the radiology reports are being done outside the UK they are different. They are not necessarily incorrect but they are much more descriptive. They tend to   hedge bets. They will come back with recommendations for further investigations, perhaps two or three, so they are increasing the workload within the NHS, not with necessarily necessary tests. Also, there has to be a lot of re-reporting by the radiologists back at the base, who are trusted by the clinicians before they go and operate on a patient where they are not happy with the report. Thirdly, the simple tests are going out of the hospital. This leaves all the complex tests within the department which has an effect on stress and the morale of the radiologists who are left with all the complex work. It also has an impact for radiographers who are working with just complex cases and there is no simple work to intervene in that. Finally, there have been major problems in terms of the NOF funded equipment which has been put into a department—for example, a new MRI scanner—when the local resources are not available to run that machine so it is lying idle. The independent sector provision is then the way of working. There are about 20 MRI scanners in the country that are currently not working to full capacity, semi-mothballed.

  Mr Leslie: I have not from any of our members found one group that has said that things have improved as a result of a local ISTC. There is no evidence whatsoever for the comment that it would benefit and improve things. There has been a statement by the Secretary of State that in Plymouth they innovated a blood transfusion technique and that was an innovation from the ISTC. That has been present in orthopaedics. We have a blue book two years old stating that. These concepts of innovations in ISTCs and changing NHS hospitals have been more negative than positive. They have decreased morale. Perhaps I could support Professor Husband's comment about MRIs. We do use a lot of MRI scans in orthopaedic surgery and one reason for the increase in use is the number of people who are able now to order MRI scans, mainly the Extended Role Practitioners. That will increase your volume of requests for MRI scans. We get reports back from a radiologist maybe in Holland or somewhere else. You cannot talk to the radiologist because you cannot find him on a telephone. I like to talk to the radiologist about what he has described. Those are all negative effects. I cannot find one positive effect in what was stated.

  Q98  Chairman: I ought to say that the memorandum that all your organisations have submitted, and others, is being published today. Your Association (BOA) was extremely negative in terms of ISTCs. At least it was consistent. I went on the web and I found an article written by presumably your predecessor, D H A Jones, in 2003, which was extremely negative about ISTCs. In view of some of the comments that your colleagues have made about this first wave, whilst not overwhelmingly supportive of them, do you think there are some positive things from them or not?

  Mr Leslie: If we go back, first of all, orthopaedics was a big player in this as well as eyes because we have waiting lists. When this came in, we learned about it as an association some nine months after it was all taking place. To support my colleagues, there was no collaboration with the professionals who knew something about hip replacements and how they are done during the early times. It was on our approach to the Department of Health that we managed to get a hearing. In 2004, we sat down with Tom Mann and drew up an agreement about how this could go forward in a positive way. One of the things we said in that agreement was that there should be collaboration between where the ISTC is and local orthopaedic surgeons. For some reason, that collaboration statement was squashed. They said, "No, you cannot go ahead with that." The involvement of the orthopaedic world was very scant. I can give you a list of the meetings and the correspondence we have had with the Department of Health, trying to say where we believe they are going wrong. It was not necessarily, "This is wrong", but, "You are doing it the wrong way." If we come onto importation, why we are negative is because so many surgeons were imported into this country to operate for a short time and then went back to their country. My colleagues were seeing the bad results. It is anecdotal, but there is now enough evidence gathering out there. There is the Portsmouth Inquiry which substantiated what we said. My colleagues see the bad results coming back. Bad results perhaps in eye surgery or hernia surgery occur rapidly. In orthopaedic surgery, they occur over five or maybe 10 years. We are seeing dislocation and high revision rates. If one is seeing that with patients it is no wonder that we are negative about the way it is being done. We could be positive about the future and I support my colleagues in that. I think we did have good grounds for being negative.

  Q99  Chairman: Have any of your members changed any work practices in the last three years?

  Mr Leslie: Not to my knowledge. They have improved them but not because of an ISTC.

5   Mr Kelly submitted two published articles as evidence to the Committee: Kelly, S P, Cataract Care is Mobile. Is direction correct? British Journal of Ophthalmology, 2006, Vol 90, Issue 1: pp 7-9; and Kelly, S P, Recurring policy errors: blind spots over cataracts, Lancet, 12 November 2005; Vol 366, Issue 9498, pp 1691. Back

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