Examination of Witnesses (Questions 90
- 99)
THURSDAY 9 MARCH 2006
MR BERNARD
RIBEIRO, MR
SIMON KELLY,
PROFESSOR JANET
HUSBAND, DR
PETER SIMPSON
AND MR
IAN LESLIE
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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