Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 100 - 119)



  Q100  Dr Taylor: I was so encouraged with our first lot of witnesses when they suggested that integration was going to be possible. You have mostly talked about integration on the same site. What are your views about integration at a site, say, 10, 15 or 20 miles from the acute hospital?

  Mr Ribeiro: I would like to draw a line under what has passed. There is a huge potential for the future. We should come back to the financial implications of ISTCs present and future on the NHS. I think that is an important aspect within this particular financial climate that we have of funding the NHS. Coming back to your question, our college has been very clear. We are prepared to train our trainees anywhere as long as the facilities provided are up to the standard the college would accept for training. As you know, not a million miles away from where you are, there is a DTC in Kidderminster which was set up by Professor Ara Darzi in his investigations. We have evidence from Kidderminster that there is one SpR—a training registrar—who has had approval from the Specialty Advisory Committee to work at this DTC for four months. The training record from that trainee has shown that he has had good, valuable training working for about nine different consultants. That proves that it is possible for the college to organise training programmes where trainees and consultants will move to other hospitals to work. In this situation the trainee is there for four months, working with a multitude of consultants. We can develop other programmes where a modular training system would allow a trainee to move into a centre for a week, two weeks or whatever to get training. For that to happen though, one thing is essential. We need to have this separation between emergency and elective. We have currently 36% of consultants who are not on call when they are doing elective work. There are many hospitals around the country where this is happening. They all say one thing: it improves the quality of training; it improves continuity of care; it puts consultants to the front line of the management of emergencies. I would put it to the Committee that the treatment of our acutely ill patients is the most important thing we do. We have always had this over-emphasis on waiting lists. The government seems to think they are the only things that matter. For us as a profession, we want front line, best trained surgeons to be managing the sick and the ill. Yes, we can go out there. We would prefer them built in our own backyard because it would be convenient. In some of the new ISTCs that have been produced—Nottingham, for example—there has been a situation where the private sector has moved and built in the NHS hospital with secondment of staff to go in. The key is get rid of additionality; open it up to NHS consultants so that we can use the capacity—which is what all this was about in the first place—out there for training our trainees. That is the message.

  Dr Simpson: There are two points which are different if you are a service specialty, which are important. One is to emphasise that if a surgical operation is straightforward, it may be a straightforward operation but it may not be a straightforward anaesthetic. For example, a laparoscopy, keyhole surgery in the abdomen, is quite a complicated anaesthetic and therefore not necessarily transferable to remote sites all the time. It is possible to do these things but they need to be thought through. The second point is that for a service specialty like ours if you take the consultants from the base hospital to a remote hospital to staff your TC what are left behind are the trainees. The consultants do not only train; they supervise. If I take an orthopaedic surgeon to a remote centre, he will not leave his trainees back operating because his list will be in the remote site. The anaesthetic trainees of course work across a range of specialties and therefore are often left back at the base hospital relatively unsupervised. We have had problems with that and the training scenario in places I could tell you about.

  Q101  Dr Taylor: Could not rotas of consultants be organised so that there was always somebody back at the base to cover?

  Dr Simpson: Yes, rotational arrangements are possible but it depends on the degree of supervision that the junior doctors need.

  Q102  Dr Taylor: Mr Kelly, I get the impression that ophthalmology is not the shortage specialty that orthopaedics and radiology are. Therefore, it was easier for you to say that you could have covered the waiting list problem without ISTCs. Is that fair?

  Mr Kelly: In ophthalmology, it is one very specific procedure. It is cataract surgery only. There are problems in ophthalmology in the blinding eye diseases of macular degeneration, glaucoma, diabetic retinopathy and eye problems in children and in the care of the chronic eye disorders. What this scheme has done is to put disproportionate resources into one particular clinical area and, as a result of that, the indications for cataract surgery have dropped down greatly. We are now operating on patients at a much earlier stage than before. A second issue is, because of the direct referral from optometrists, which I support and we believe in as an organisation, because the ISTC contracts have to be met and are paid for, we are seeing patients referred directly from optometry with cataracts to the Netcare scheme and being operated on very early. Meanwhile, the next door neighbour of that patient who has really serious problems—such as diabetic retinopathy—is left to lie fallow; whereas if the funds were in the local NHS eye unit the clinicians in the unit could make the decisions how best to allocate them within their own unit. Equally, if there is going to be national guidance, for example, from NICE or somebody to say that the blind are more important to us or less important to us—which is what this scheme is saying—than people who have mild cataract, so be it, but at least an informed decision could be made with patient and public involvement. That has not happened.

  Q103  Dr Taylor: Integration, if it came, would also help on that score.

  Mr Kelly: We have already heard about NHS Treatment Centres based within the NHS unit in all the surgical specialties. In my own case, we are a unit in Bolton that benefited from the funds from `Action on Cataract'. We essentially have a cataract treatment unit within an ophthalmic treatment suite. We are doing it and there are many other examples up and down the country: eg Peterborough and Moorfields Hospital in London. That integrated model within the NHS already existed.

  Q104  Dr Taylor: Do you think, in your specialty, Netcare and mobile cataract units are superfluous?

  Mr Kelly: Yes.

  Q105  Dr Taylor: What should happen to them?

  Mr Kelly: That is an excellent question. The team working in them is efficient. The units are very clean. I visited a unit in Liverpool recently. I have colleagues in South Africa. The President of the Ophthalmological Society of South Africa, Dr Kruger, recently told me that there is a huge backlog of cataracts to be done in South Africa, particularly in the back streets of the deprived areas, and in the homelands. An idea thus may be to take those mobile units out there, because there is good ophthalmic provision in the private sector in Cape Town and Johannesburg. That might be a move for the units?

  Q106  Dr Taylor: In a way, you have been almost complimentary about the service in Netcare. Are you less worried about complications than the orthopaedic people, for example?

  Mr Kelly: We have seen our own bevy of complications. It was intriguing that Mr Anderson and Mr Ricketts were not able to comment on that, but they did say that they were not clinicians. Mr Anderson used the lovely words, "That is the granularity of the system". That granularity is individual patients going blind or going lame. These have surfaced in media investigations. Channel 4 News have done some good stuff. Journalists have done some work. There is litigation going on. Clinical negligence litigation and media exposure are not the best ways to improve patient safety. It has to be a whole systems re-organisation.

  Q107  Dr Taylor: In a word why was the ISTC programme dreamed up?

  Mr Kelly: I do not know. It was announced on Christmas Eve 2002 and why it was announced on Christmas Eve I do not know.

  Q108  Dr Taylor: Have you any comments?

  Mr Ribeiro: Yes. It was to win an election. It was to reduce waiting lists. This policy is to get waiting lists down. We heard last year that in Birmingham 1,000 patients were corralled into a hall. It cost £25 million to get the answers out and the net result was waiting lists were the first priority that patients wanted dealt with. If you couch policy on reducing waiting lists, that is why you have ISTCs. The fact of the matter is the waiting list problem and the work that was done  before identified cataracts or orthopaedic procedures as the ones that were most needy. General surgery, interestingly, did not have much of a problem. In my hospital we have hardly any waiting lists at all in general surgery because we keep on top of things. I will give you an anecdotal example of how things can go desperately wrong if we do not move to separation. On Monday, I had an operating list at Basildon. I had two laparoscopic cholecystectomies and three hernias to do, ideal training operations. I now act more like an assistant to my trainees who do the operating. At two o'clock when we were about to start, a ruptured aortic aneurysm came in. Mine was the only theatre that did not have the patient asleep. My patient was moved into the recovery area where she stayed for three hours until the aneurysm was dealt with. I had to cancel the three hernias who went home. That is the day to day reality of working in the NHS. If you were to put me into an ISTC in my hospital away from that, my team could have completed a day's operating and that is what it is all about. That happens on a regular basis in the NHS. Therefore, what the NHS is saying and what we are saying on behalf of the NHS is give us a level playing field. Do not give us a situation where ISTCs are getting 11% on costs to get started, a little bit more on top and it does not matter whether they do the work or not; they get paid. Give us a level playing field where the NHS is doing the work on exactly the same terms as the ISTCs. The government has made its point. It can get waiting lists down. Great. We are all very pleased about it but let us move on to the next stage and make some progress.

  Mr Leslie: In terms of training outside the centre, this has been going on in orthopaedics since about 1998. The Horder Centre near Brighton is a charity which has been contracting work from the NHS and that has been approved for training for orthopaedic registrars since about that time. It is possible to do it, and it is done because the local NHS surgeons go there to do the operating. When I come back to   qualifications, Bob Ricketts spoke about qualifications. Being on the specialist register of the GMC does not necessarily mean that you can go and do a safe hip replacement. What it means is that in Europe, if you reach a certain level of training in any European country—and they are all different in terms of the end point of training—you are automatically, due to European law, allowed on the Specialist Register of the GMC. There is nothing else to do except to send in a piece of paper. In Italy, you get your CCT or Certificate of Completion of Training at the end of doing a certain number of procedures. For a complex one you might get 100 points; for a simple one you get 10 and when you have built up enough points you get your CCT. How do they do that? At the end of training you then are under very strict supervision in a hospital system whereby you are still under the master for some years after that. In the UK, we train people to operate independently at a certain point in time so that they can go to the Isle of Skye and be an independent orthopaedic surgeon if necessary. We put them into independent practice. It does require whoever is training them to be up to scratch as to our standards of training and that has been built up over many years.

  Q109  Dr Taylor: We are certainly going to take that up with the GMC when we see them.

  Professor Husband: I wanted to make a positive point. There has been under-investment in imaging over the years. MRI waiting times were something up to two years. They are now down to 13 weeks and that is of major importance obviously for the individual patient. I do not think we must throw that point out of the window. It is important. As a college, we have been very proactive in working with the Department of Health on quality issues. We have undertaken audits between the independent sector and the NHS. We have worked with the National Imaging lead in the Department of Health. We have an MR guardian who is a college officer, who has been reviewing the CVs of every radiologist working in this scheme. Nevertheless, my big point is integration. Get rid of additionality and we can work a good system. For example, we have to also take into account that there has been a major investment in academies for training radiologists, many millions. I will not give a precise number in case I get that wrong. We have taken an additional 20% of trainees in radiology this year and that will continue. Very soon we will have more qualified radiologists and we need to bring them in and integrate them into the service. Just a final point on whether we could work with an independent centre 10 miles away with programmes of rotas, that would work very well. One of the problems with radiographers is, if they are appointed to the independent sector, then they are just going to do simple investigations for their workload and in terms of continual professional development that is a disaster. They need to be integrated within a team so that they can have the benefits of a full career, and it is the same for radiologists. Finally, 70-80% of individuals coming out of medical school will be women. A lot of these people do not want to work full time and this would be an excellent way of them working in an integrated fashion within the NHS and the independent centre.

  Q110  Dr Stoate: It has been suggested by the BMA that the ISTC programme has caused private practice incomes to fall. Is this true?

  Mr Ribeiro: I would not know, sir, but to answer that question I think there is no question that you will find instances where people's income has fallen but, on the other hand, if you take cardiac surgery we know there has been a natural fall of income in cardiac surgery because an awful lot of cardiac surgery has gone to intervention procedures and not the actual bypasses, so that may demonstrate a fall of income there. I think that in niche markets like London, London is a peculiar sort of place where private practice perhaps carries on without any impact from outside, but clearly there has always been this feeling that consultants keep their waiting lists deliberately long in order to encourage private practice.

  Q111  Dr Stoate: This has certainly been suggested at a previous inquiry I was involved in some time ago.

  Mr Ribeiro: Absolutely. I think it is a lot of hocum, frankly; I have always thought that. I know there has been a perpetuation for years. It is like the question why is it that we now find a huge amount of money has gone on to consultant salaries in the last round? Because everybody thought they were doing private practices and were around the golf courses.

  Q112  Dr Stoate: But do any of you, or your colleagues, offer private treatment where NHS waiting lists are longer than acceptable?

  Mr Ribeiro: I can only speak for myself. I have a private practice—and still do although I probably will wind down by the end of this year because I am too busy doing other things—where I give my NHS patients exactly the same amount of time and consultation as I give my private patients, and in fact I can get an NHS patient on my list for surgery for a hernia in six weeks and I would have difficulty sometimes in getting that in private practice because I do not have the time availability to do it. So I do not think this is an issue. I think it is one that has been brought up time and time again. People do their private work in their own free time and put the effort into it.

  Q113  Dr Stoate: But certainly the BMA has suggested to us that this is at least a factor. Do you think it could be part of the reason why there is so much resistance by professional—

  Mr Ribeiro: No, I do not. I think the profession resisted ISTCs because we have been encouraged and asked to consider working in teams. Part of the paranoia about consultants is that they are arrogant, distant, they do their own things and they are Lancelot Sprats, etc, and there has been a big change in the profession post Bristol, post Alder Hey, post all the disasters. We have been really under the microscope as a profession, not just surgeons but everybody, and the emphasis on surgery has been working in teams more collaboratively and working within a team structure. Now, that creates a completely different culture and climate in which to work. So I do not think that is an issue, the one you are raising.

  Dr Simpson: Anaesthetists do not admit patients in their own name; we only respond to the workload that comes to us. I certainly do not believe that anaesthetists do not offer the same quality of care in the two sectors; they do the same. If you use the BMA figures, if you factor into that loss of waiting list initiative money, because the waiting lists are being dealt with in ISTC treatment centres, then I think their incomes have gone down, because that was work that they did to take account of waiting lists but within their base hospital in their own time—at evenings, weekends whatever.

  Q114  Dr Stoate: Professor Leslie, it is a big area where there is a lot of private practice still occurring. What is your view?

  Mr Leslie: There are two criticisms of orthopaedic surgeons and their waiting lists—one they are on the golf course and two they are in private practice—which have been levelled at us constantly but there is a shortage of manpower in orthopaedics which we told the then Government about in 1995. We had a manpower document which we published and it showed the number of orthopaedic surgeons we should be heading for. So waiting lists were not created by the orthopaedic surgeons but by a chap called John Charnley, who invented a hip replacement, and all of a sudden there is a whole lot of people out there who find that life will be better with a total hip and a total knee replacement so that the demand went up. No government or hospital kept pace with that demand and so a waiting list built up. Now, besides Ireland and I think Hungary we are the worst supplied of orthopaedic surgeons in the whole of Europe in terms of numbers. We are 1:39,000 per population. Sweden, where the doctors come over here, are 1:7,000 of population, so there is a shortage of manpower. So if there is a demand out there for something to be done in private practice then people will go and do it. In answer to your question I think private practice has gone down, perhaps manifested by the way the private health insurance companies are getting rather nervous and very worried about their future in terms of their income because I think a lot of corporate groups have stopped their private insurance, because the waiting list has come down. They used to insure them so you were not away from work that long to get private treatment. I think the corporate insurance has gone down so I think you are right, but none of my colleagues like having waiting lists. I hate having mine.

  Q115  Dr Stoate: Certainly when waiting lists for hip replacements were two years plus I referred a lot more people at patients' request to the private sector. Now I can say to somebody "I can get that hip changed within six months" I am referring very few people to the private sector so there must be a factor there. I am just asking whether you think that factor is material in some of the opposition of some of your colleagues.

  Mr Leslie: I think it is material and I would hesitate to say no. I would agree with you that amongst some of my colleagues perhaps, but I think as a body of people most of my colleagues detest having to tell someone they are going to even now have to wait six months for their operation. Telling them it would be two years was terrible, but I think it is an argument which really needs to be put on the shelf. You will find the odd person but I think as a group we are destined to try and get waiting times down but in the safest manner.

  Q116  Dr Stoate: I would like to now light the blue touch paper and ask all of you why it is then that private fees in Britain are so much higher than in almost any other country in the world? Why?

  Mr Leslie: The fee for a total hip replacement on BUPA's rates have not changed more than 3% since 1992.

  Q117  Dr Stoate: I have some figures here. For example, if we take hip replacements, which is your specialty, in Canada it is 50% cheaper, this is the consultant's fee, and in Germany it is something like 60-70% cheaper—

  Mr Leslie: But Canada does not have private practice. That is the fee paid by the Government to the surgeon.

  Q118  Dr Stoate: So surgeons in Canada are charging far less per procedure than here, and the same with cataract surgery. 60% cheaper in Canada, 50-60% cheaper in Germany and Spain. Why is that?

  Mr Kelly: I will answer as best I can the second part, and I have to declare an interest. First of all, I am an overseas graduate; I am qualified in Ireland but have been working in the United Kingdom since 1983. The argument you have advanced there, and it goes back to the 2002 Inquiry, that consultants are opposed to these things because it affects their private practice, the so-called "perverse incentive argument" which I think Professor Chris Ham and others advance, personally I find it abhorrent, and I think the profession does and I would hope that NHS management finds it abhorrent, because one of the beauties about working in the NHS is that you are working in a very regulated environment. We have Appraisal and Job Planning. So if there was any hint of consultants somehow manipulating patients this is a matter actually for the local employer to investigate, and also a matter for the GMC.

  Q119  Dr Stoate: I am not suggesting for a moment that you treat your patients any worse or in any different way; that is not for a moment the suggestion. The suggestion purely is whether the fee structure of consultants in private practice is anything to do with opposition to the Independent Sector Treatment Centres? It is nothing to do with standards of care or quality of outcome.

  Mr Kelly: You have two separate questions there and I will take these one at a time, if I may. Just going back to the so-called `perverse incentive', colleagues have already pointed out that most doctors do not wish to have long waiting lists, and the long waiting lists have been due to the under provision of surgeons. The orthopaedic example has been given but I will give you an ophthalmic example. There are a thousand ophthalmic surgeons in NHS practice in the United Kingdom, France has a similar population with five times more, so therefore—surprise, surprise—waiting times are shorter. People choose to go privately for various reasons that are best known to themselves, just like the way some people travel First Class by train or by air. We have difficulties with the patients being forced to go privately because of long waiting lists and thankfully, because of the investment in the NHS in recent years, waiting times have come down and therefore that segment of the private medical market has probably gone down. That is actually very worthwhile, so I do not think any of us have any difficulties about it. On your second question about the international comparisons, I do not have the figures in front of me but I think you are possibly referring to the Newchurch Research.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2006
Prepared 25 July 2006