Examination of Witnesses (Questions 100
- 119)
THURSDAY 9 MARCH 2006
MR BERNARD
RIBEIRO, MR
SIMON KELLY,
PROFESSOR JANET
HUSBAND, DR
PETER SIMPSON
AND MR
IAN LESLIE
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.
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