Examination of Witnesses (Questions 120
- 139)
THURSDAY 9 MARCH 2006
MR BERNARD
RIBEIRO, MR
SIMON KELLY,
PROFESSOR JANET
HUSBAND, DR
PETER SIMPSON
AND MR
IAN LESLIE
Q120 Dr Stoate: No. It is actually
National Economic Research Associates, December 2003.
Mr Kelly: Well, there is always
a danger of comparing apples with oranges and the point is that,
for example, in NHS practice an NHS surgeon doing an ophthalmic
list is probably going to get paid about £100 to £150
a session, and if that surgeon does 10 cases you can see that
is very good value indeed; if he does five cases you can see it
is still very good value indeed. So if you are comparing like
with like that may well be a more fair comparison. The figures
from across Europe are the figures reimbursed by the state to
surgeons and anaesthetists working in the independent sector as
part of social insurance. Now it is not my specialist field and
I do not know, but I do know that little bit. That may be something
the Committee might want to take more evidence on? Even though
you have addressed this in the past.
Q121 Dr Taylor: Several of you have
said we must draw a line under Phase 1 and go on to Phase 2, but
generally how are the colleges involved with trying to influence
the future and the way that Phase 2 ISTCs work?
Professor Husband: In terms of
radiology we are developing clinical pathways through our input
from the MR guardian, but of course Wave 2 is going to be CT and
ultrasound as well. We have more concerns about ultrasound than
CT and MR because it really needs to be interactive. You cannot
give a report on an ultrasound in the same way as you can—
Q122 Dr Taylor: Unless you have actually
done it?
Professor Husband: Yes. You really
need to be doing it yourself so we have some concerns there. We
are also developing an accreditation scheme for radiological services
from our College which will be a multi professional, multi disciplinary
scheme looking at quality, and this would be applicable to both
the private sector and to NHS services. It would, of course, be
voluntary to start with but we hope to have this up and running
by the end of the year and we are working with the Department
of Health to bring this in. I think that would be very valuable
in raising quality and providing a uniform quality of care. So
we are also providing protocols for imaging so that the imaging
that is done in the private sector reaches the standards approved
by the College in the different specialties.
Q123 Dr Taylor: And you have already
said it is rather limiting if radiologists are working only in
ISTCs.
Professor Husband: Yes. Absolutely.
Dr Simpson: In terms of Wave 2
what we would hope and what seems to be happening is that actually
there is much more integration so that the ISTC, whether sited
locally or remotely, is part of the local training environment.
We have not spoken a lot about training but I think we should,
and one of the points is that if a new ISTC on Wave 2 wants to
train then it can perfectly well do so; there is a perfectly easy
way in which it can be incorporated. For example, PMETB accredits
training environments, and basically a person in anaesthetics
for want of a better example is doing a training programme in
a particular area. If there is experience to be gained in that
TC then that TC will have to be accredited for training like anywhere
else. It all fits in, and people can be rotated through quite
happily. The other issue that goes away is that if, as the Secretary
of State has announced, you can use NHS consultants in these things
then NHS consultants are accredited trainers, so a lot of the
issues go away from that point of view.
Q124 Dr Taylor: I think we were told
by the first set of witnesses that there is a draft statement
on training coming.
Mr Ribeiro: I received mine in
e-mail this morning actually from the Department of Health—
Q125 Chairman: It is the influence
of our sitting as a Committee!
Mr Ribeiro: Absolutely. Incredible
timing, is it not! As you know, the Secretary of State in a speech
on January 10 did say about the independent sector: "But
I recognise that other reasons for using the independent sector
to add to the innovations already happening within the NHS and
to introduce an element of competition and challenge to underperforming
services is a harder argument to win, so we will continue to respond
to legitimate concerns, for instance to ensure that training for
junior doctors is provided within the Independent Sector Treatment
Centres and more generally to provide a level playing field for
different providers within the NHS . . ." That statement
is what we seek, and I think in the submission given to you by
the Healthcare Commission they too stress two things. One is the
introduction of training and two is the removal of additionality,
and I think if the Secretary of State has put a flag on the mast
to say that is what they seek then that is what the Colleges would
like to do in the next phase. We have already as a College during
the last year had several discussions with the private sector,
the independent private sector, in fact before they folded the
Independent Health Forum, about the possibility of having training
in their hospitals and they were very receptive. What we want
as a standard is to use the consultants in the NHS whose training
abilities we know and whose results we know, to do the training
in the new wave ISTCs, and I think that is the positive way forward.
I should say in Wrightington, which is exactly where John Charnley
did all his experimental work in the early days of hip procedures,
there is excellent training in that DTC and trainees are queuing
up to go there because it is uninterrupted work and they get good
training. The Department of Health has now said it wishes to engage
in discussions on training: I wish they had done that two years
ago, frankly. It is a bit late, but your Committee perhaps has
helped ginger things up a bit. I hope that continues.
Q126 Dr Taylor: Would we be allowed
to have a copy of your e-mail?
Mr Ribeiro: I will leave it to
you to copy afterwards, certainly.
Mr Leslie: I do not think in terms
of Wave 2 any of my colleagues in orthopaedic surgery will be
happy until there is a quality assurance of the surgery and the
surgeons that are coming into this country to operate on patients
who they have seen often in NHS clinics, the patients have gone
away, had their operation and they come back to the NHS clinic
with their problem. The quality assurance issue of these surgeons
in orthopaedics, I cannot speak for other specialties, needs to
be absolute. When you are appointed to an NHS consultant job you
are on the Specialist Register, but equally you go before an interview
committee where there is a member of the College of Surgeons who
assesses your training and your abilities, and it is not done
by a manager. You might be familiar with the Foster Report from
Queensland where there was a problem with Bundaberg Hospital and
one of the comments of that report was that colleges were not
involved with the appointment of those personnel, and unless that
is sorted out you will still get the negative effect, I am afraid,
from the orthopaedic community which is not self interest. From
all the letters I have had it is, that these patients are suffering
unnecessarily. You can say the ISTCs have been successful in waiting
lists but at a price, both a monetary one and also a lot of patients
out there are having problems as a result of that innovation.
Q127 Chairman: How many of your members
were trained overseas, Mr Leslie?
Mr Leslie: I for one was trained
overseas, but trained overseas in terms of their surgery. Probably
a small number. We have a lot of overseas fellows.
Q128 Chairman: Presumably they compare
well with those trained at home, in the United Kingdom?
Mr Leslie: Yes. Because they have
been appointed to NHS consultant positions they have been selected
by an appropriate appointment committee. For instance, I could
not go to Canada, US, Australia or New Zealand and just go and
practise there. I would be mentored for a year in Australia, if
I wanted to seek registration, by a senior person before I was
given the chance to operate independently, yet so many people
can come here from Europe. They are very good surgeons there,
do not get me wrong, but if you put me in a hospital in Sweden
for two weeks my complication rate would be higher than if I am
operating in my home hospital all the time with my team. So the
places where the surgeons have come in and the local NHS surgeons
have been involved, they get on well and work with each other.
It is this flying teams in and out again which our members totally
object to.
Q129 Chairman: Why has your association
not got evidence then to say that these doctors coming in, flying
in here, to do these operations are not good doctors? That is
what you were suggesting and that is what was suggested back in
2003, but there is no evidence for this.
Mr Leslie: What we have said is
we are unsure of the quality, and what I am asking for in a second
phase is that quality is assured, and it can only be assured by
those in the profession who know, which means the Colleges. We
are not saying that every surgeon who comes in is bad, not at
all; nor am I saying that every surgeon in the NHS is perfect
either, but we are looking at complication rates. We have evidence.
For instance, a revision rate, and I have the figures here, of
0.7 per hundred in an NHS hospital versus 2.3 per hundred in an
ISTC. There is another study from Cheltenham, but the difficulty
is our finding out the information. We do not know, and I do not
know, how many operations have been done in the ISTCs.
Mr Ribeiro: Just coming back on
that, in order to raise our concerns about ISTCs we had a meeting
on 10 January with Sir Nigel Crisp and Bob Ricketts—myself,
Peter Simpson and Professor David Wong representing ophthalmology—and
we had explained to us by Sir Nigel that there were four areas
that were important, policy, training, clinical care and audit,
and on the issue of audit he recognised it was important to acknowledge
that patient confidence needed to be established in the ISTCs.
He also recognised that it was important, and we offered to help
him with this, to develop outcome data that would allow for true
comparisons between the NHS and the ISTCs, and rather than taking
a personal issue as to overseas doctors and whatever it is, there
are overseas doctors in the NHS and there are overseas doctors
outside and that is your point, but let's prove the pattern and
find out whether the quality of work coming out of ISTCs is equivalent
to that coming out of the NHS. Ken Anderson in his report refers
to 95% patient satisfaction. Well, it depends what parameters
you are asking the questions on as to whether they are satisfied
or not. We know for example on the KP9, the key performance index,
that the one on the re-admission rate has been subject to some
concern about how the data is collected, so let us do a proper
study. My College is quite prepared to get engaged with its partner
in health and do it. We have a clinical effectiveness unit at
the College which would be happy to undertake this work, and if
it can be funded we will do it tomorrow. So the challenge is let
us find out, and let us not be anecdotal.
Mr Kelly: On your point about
how do we know whether these doctors are safe or not, the reality
is that some of them are probably very good and some of them are
probably mixed. We could probably say the same about all the doctors
working in the United Kingdom and about engineers or architects
or any other profession, but the key issue in medicine is that
doctors work in teams and it is the team, just like driving an
aeroplane, that underpins safety. Mr Leslie's point that if he
went to Copenhagen to do some surgery he would be out of his depth
for the first few days—because of using different instruments
and one thing and another is exactly this point. That is where
we have issues. Professor Ribeiro has made the point that audit
is the way to track this. At present the audit that has been done
has been rather patchy in the ISTCs. We have seen the NCHOD Report
which Dr Taylor has raised. I have done a critique of the NCHOD
Report on behalf our College and can circulate that to members,
if you wish. Our College provided it to the Department of Health's
Central Clinical Management Unit: we have had no response from
them. As regards patient satisfaction, the patient satisfaction
levels in some of the surveys that have been done have been high
but one needs to be very careful—and Ms Milton made the
point about "how do you know where to go"—about
satisfaction surveys asked of patients immediately following their
procedure by the doctors and nurses who were treating them. "Was
it good for you? How was it?" Most people—on the evidence
available—actually want to agree with the clinician giving
them their care, so most people say: "Yes, the service was
good." It is within the few complaints which is where the
grit and granularity is, and that is what we need to focus. Regrettably
in your documents you do have a list of letters that we have had
in at our College, because we have found ourselves in the first
wave of this. They are therein; the patient details have been
anonymised; and they are worked detail of people up and down the
country. This is a worry to us, that the system is not really
addressing the patient safety issues in ISTCs. And this is occurring
just at a time when we all recognise that a systems and integrated
approach is the way forward for improving patient safety.
Professor Husband: I would like
to make a point about training in the radiology MRI centres. Because
the reports are done overseas there is one centre in Brussels,
one in Barcelona, one in Cape Town and one in Scotland which have
all been visited by our MR guardian and the quality is good now.
One of the centres is not listed, one in Spain I think, and has
been removed from the list, so the quality is good but of course
the training cannot happen because these radiologists are not
in the vans to do the training, so that is another reason why
additionality must go. Our second audit is going to be published
in April and has shown good quality across the board.
Mr Leslie: Just coming back again
to audit of the work. Two years ago the BOA went to Aidan Halligan,
who was then the Deputy Chief Medical Officer and in charge of
clinical governance, and we strongly recommended to him at that
stage that we should conduct an audit which should include an
audit of an NHS hospital and should be comparative. We pushed
that very strongly, and nothing ever happened.
Dr Simpson: Just generally I think
there is a belief out there that NHS doctors do not care about
their patients at the level we are talking about but I think they
care passionately about their patients. For example, I live in
Bristol. I had an anaesthetic a few weeks ago; I did not know
who was going to give me the anaesthetic in advance and I did
not bother because they are all good, and the problem is the uncertainty
of another group of people coming in who we just do not know about.
That is why we, and patients, need the opportunity to be informed
about that.
Q130 Anne Milton: Professor Husband,
you said that there were 20 MRI scanners not working to full capacity.
How would you, for clarification, define "full capacity"?
Professor Husband: I do not mean
extended hours; I mean working eight till five.
Q131 Anne Milton: Five days a week.
Professor Husband: There is not
sufficient funding to resource the machines to work all the time.
There is also a shortage of radiographers which is being addressed,
and I think double the number are qualifying this year, so that
will not be a problem that will be on-going so much, but radiographers
are also leaving the NHS to go into private work and then into
the Independent Sector Treatment Centres, or MRI vans of Wave
1 Alliance Medical, so although they cannot jump straight from
NHS to Alliance they are going via another private centre and
then to Alliance, so that is causing a further reduction in the
number of radiographers, but also the actual finances to run the
scanners is a major problem. So there are examples of MRI scanners
in hospitals in the United Kingdom which are not being used at
all, and some only being used half of the week.
Q132 Anne Milton: Do you know where
they are?
Professor Husband: I could get
that information for you.[6]
Q133 Mike Penning: Is there a link
between the areas which are suffering under financial deficits
and those scanners that are not being used?
Professor Husband: I believe so
but I have not got facts and figures on that. I believe that is
the case.
Q134 Anne Milton: It would be very
helpful to have the list. Can I ask you all to what extent the
ISTCs are cherry-picking cases?
Mr Ribeiro: In our submission
we leant heavily on the orthopaedic submission, and we have good
evidence in Southampton, for example, where the Capio contract
has taken a significant number of cases of low co-morbidity. We
use a grading, the American Society of Anaesthesiology grading,
to determine how sick a patient is and we have very good evidence
that a significant number of ASA 1 and 2 low grades have gone,
leaving behind a lot of ASA 3 cases to be done, which clearly
are more technically difficult and therefore are not good training
opportunities. So we have good evidence all over the place. But
touching on what Mr Penning has said there is another more critical
matter which I hope we can get on to in this discussion today,
which is what the effect of ISTCs are on the economy and on the
health economy of the hospitals around and about. I recently went
to Trafford, the Greater Manchester surgical centre, and in Trafford
two of the wards have been closed as a result of the contracted
work going from the PCTs to the ISTC; £2 million worth of
work in the first six months has left the Trust in the PCTs to
go elsewhere.[7]
This has to have a significant effect on the NHS and it will have
an impact. In my own little area in Essex the Government has decided
it is going to put in a £45 million ISTC with the intention
of taking work from Southend, Basildon, Chelmsford, Colchester,
and take from each of these hospitals the equivalent of 20% of
their elected work. That will have, with payment by results, a
significant effect on the functionality of those NHS hospitals,
and that is what I would like to move on to in our discussion
now. We have said a lot about personal private practice and so
forth but I am more concerned about health economics and what
is going to happen to the future of those NHS hospitals.
Q135 Anne Milton: Just picking up
on that, the two gentlemen previously denied that.
Mr Ribeiro: Well, I was not here
and I am sorry, I hate to use the word "nonsense" but
I will. I still work in the NHS and I had this discussion with
my Chief Executive on Monday, and in your constituency, Dr Stoate,
Darent, you know well Sue Jennings produced and opened two wards
next to the treatment centre to use with the theatres, and those
two wards have been shut because of the financial pressures. Now,
you cannot tell me nothing is happening and there is no impact.
I can cite many more examples where it is happening. The policy
was right initially to find extra capacity and, again, I will
give you an example why the NHS has not been able to do this.
When I was appointed as a consultant surgeon in 1979 there were
14 surgeons in the whole hospital and we had 10 operating theatres
between us. Today there are 34 surgeons in the hospital I work
in, and we have only 12 operating theatres. Capacity was the problem.
The Government gave us capacity through ISTCs but I think somewhere
along the line it has lost the plot because what it is doing by
throwing all this money into ISTCs is challenging the existing
NHS—and it will go down. And if you listen to people like
Chris Ham they say "Right, so what? What we need to do is
come down from 200 NHS hospitals to 50, make them more effective,
more efficient." Is that what the public want? Have we gone
out to consultation? Have we asked them? It may be the right way
to go. After all, my College for years have said that we should
have hospitals of 500,000 population and economies of scale and
so forth and it may be that is where we need to move to, but I
think we can get there by better networking of hospitals. But
I would like this Committee to focus much more on the impact that
this will have long term on existing NHS hospitals rather than
nitpick over issues about private practice and those sorts of
elements.
Q136 Anne Milton: To some extent
one of the reasons we bring up what might feel nit-picking to
you is because that is in the evidence we have received and those
are the anecdotes that people say to us in our constituencies,
and therefore it is important to address it even if you might
feel it is not a central part of the issue. Mr Kelly?
Mr Kelly: On cherry-picking from
an ophthalmic perspective there is no doubt whatsoever that there
is cherry-picking in cataract surgery in the mobile units, and
it would be scandalous if there was not because quite frankly
they are mobile units with no facilities for general anaesthesia
or for children, or for a whole host of patients with complications,
so only the fittest patients can go to the mobile unit. Now, the
effect of that is that the more complex cases remain at the base
hospitals. For example, patients with Downs Syndrome frequently
get cataracts and they require cataract surgery under general
anaesthesia and can be challenging for our anaesthetic colleagues.
Those patients receive the same tariff under the new Payment by
Results—which actually is payment by activity, I have to
say, not by results—as do the most straightforward case
done in the ISTC. Professor Ribeiro is quite right to bring to
the table the impacts on the local NHS services because these
impacts are going to really play in when Payments by Results come
in. So while cherry-picking has got safety reasons why it is done;
but it has implications for the services back home on the base
and for the cost. Also, I am a resident in Trafford and the local
MP, Mr Lloyd, for Central Manchester, has already raised in this
House concerns about the impact of the Greater Manchester Surgical
Unit, which as I understand it is going to take £70 odd million
out of the Greater Manchester surgical provision from across all
Greater Manchester PCTs. Mr Ribeiro made the point about Trafford
Hospital, which—as I understood it, was the home of the
NHS and is now one of the hospitals suffering. We in our hospital
in Bolton are suffering the same effect. So all of this has consequences
and impacts for local clinicians and residents.
Dr Simpson: On the question about
cherry-picking, although it may appear to refer to the type of
surgical operation, it actually refers much more to the anaesthetic
state of the patient and this creates, in fact, a very unlevel
playing field, because if you have people who either need a general
anaesthetic when they would otherwise not or, worse still, complicated
general anaesthetic cases, by inference they stay in overnight
or two days, and immediately the NHS hospital is tarred with the
brush that says: "Of course all your patients stay in twice
as long as those down the road", and it is not true at all.
It is a different group of patients.
Professor Husband: On cherry-picking,
because the service is provided in mobile vans only very simple
cases are suitable to be examined on the vans and therefore it
is inevitable. It is not exactly cherry picking; it is only that
a certain group of suitable patients.
Q137 Anne Milton: Fit for purpose?
Professor Husband: Yes.
Mr Leslie: One of the people wrote
back and said the average length of stay for their NHS patients
now has gone up by two days since the introduction of ISTC. Now
they are slightly damned for that because you are now in for eight
days instead of six, and that is on the length of stay. I think
it is difficult for constituents to understand the health economy
and that is why they probably do not ask the question, and our
patients do not understand the health economy and it is up to
us to try and steer that and I think that is reasonable. Patients
are interested in getting the safest treatment. We heard about
choice this morning from the Department of Health but a patient
has not got a clue really what is available because there is no
information out there, and the GP who looks at his screen when
you are consulting does not have much of an idea either of the
important indicators for an NHS hospital. We have a patient liaison
group, as many groups do now, which looked at our submission and
supported it wholeheartedly. They want to know just where it is
safe because, if you have a good hospital down the road which
has a high standard and has a short waiting time, why do you need
choice?
Q138 Anne Milton: There will be conflict
about people who actually choose to have their non urgent operation
beyond the Government's targets and waiting times. "Will
you be allowed to have your operation in 21 weeks?"
Mr Leslie: Well, you are not actually,
no. Some of my patients would like to say that. They say, "I
would like to stay with you but it means spilling over six months
and that is not allowed", and that is not choice.
Anne Milton: Precisely. Thank you.
Mr Amess: Chairman, I just wanted to
say what a joy it is to have quality witnesses like this who know
what they are talking about, we can understand what they are saying,
who have come up with some positive solutions to the challenges
we put. Also, what a tragedy it is that these people, and I think
you mentioned nine months, were not engaged with policy makers
at a very early stage. I had been intending to ask you questions
on training, accreditation procedures and foreign doctors, but
because you have been so articulate I think, frankly, these questions
are all a waste of time. You have covered everything and I was
just going to suggest, Mr Chairman, that perhaps, given that Mr
Ribeiro, who is splendid, obviously wanted to say a lot more about
the future of the NHS and the work force, we could have them back
as witnesses for our inquiry into the work force?
Q139 Chairman: Another day, perhaps.
Witnesses will be aware of our future timetable in terms of inquiries.
Mr Ribeiro: We have made a submission
so we would be very happy to come back. Thank you.
Dr Simpson: And I am going away
to write it now!
Dr Taylor: May I make a couple of comments?
First, I would like to reassure our witnesses that health economics
will be very important and we will take it up with future witnesses.
Secondly, obviously one of our recommendations should be that
the Royal College of Surgeons' Clinical Effectiveness Unit is
funded to start this review of all that we want to know—outcomes,
complications—tomorrow, if not before.
6 Ev 182 Volume III Back
7
Following the oral evidence session on 9 March, the Chief Executives
of Trafford Healthcare NHS Trust and Oldham PCT wrote to Mr Ribeiro
about his evidence to the Committee. In their letter they stated,
". . . your references to ward closures and loss of income
are entirely untrue. We both wish to confirm to you that no wards
have been closed in Trafford Healthcare NHS Trust, nor has any
funding been diverted from this Acute Trust as a consequence of
the Greater Manchester ISTC programme coming into operation".
Mr Ribeiro replied to apologise and say he had been mis-informed.
He has asked that this be made clear to the Committee. Back
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