Examination of Witnesses (Questions 142
- 159)
THURSDAY 16 MARCH 2006
DR THOMAS
MANN, MR
MIKE PARISH,
MR MARK
ADAMS, MR
PETER MARTIN
AND MR
ALAN PILGRIM
Q142 Chairman: Good morning. I recognise
the potential problem in having six witnesses and this list of
questions in front of us. It could go on for ever, as it were.
In view of the evidence session we had last week and the written
information we have received, probably the first question is something
I could tempt you all briefly to comment on, or indeed to say
if you disagree with what is being said. Maybe that would be a
way of doing it. Then, after that, hopefully we will try to put
some specific questions to individuals. Generally you say that
your appointment procedures are at least as stringent as they
are in the National Health Service. Could you tell us why you
believe that the colleges and other professional bodies seem so
critical of the procedures in terms of your appointments?
Mr Parish: I am happy to start
because we have had many telephone calls from patients in the
last week or so. They have been quite anxious, having read some
of the reports recently. Of course, we have invited them in again
to meet the doctors and be reassured, and happily they are. Many
of the comments that are made without evidence of actual reality
can cause patients concern. Hopefully, in our submission we have
set the record straight. I am happy to elaborate if you require
it. I think the motives are mostly genuine. There is a genuine
concern around change, and this is significant change. People
are seeking reassurance. Most of the reassurance is sought in
a professional and orderly manner. That has happened; we have
had many visits from patients and we have supplied that reassurance.
There is also a stake in the status quo. The reality is
that we have quite a quirky system in the UK in the way that doctors
in particular are remunerated. There is the old saying that the
NHS is for cachet and private for cash. It is quirky with something
like 30% of reward for 70% of the time and vice versa. Any perception
that that may be threatened can result in some difficult reactions.
We have seen quite a bit of that. There is mostly positive and
genuine concern but with elements of defensiveness.
Mr Adams: In the first wave of
the ISTCs it was important to introduce additionality so that
you could demonstrate that you were providing a supplementary
resource to the NHS to address some of the waiting list challenges
that existed around the UK. In the long term, the additionality
causes a challenge and a conflict with the establishment because
we are not working in partnership. We are not working on issues
ranging from our recruitment of British nurses and doctors through
to the training of British nurses and doctors, and that puts in
an artificial divide, which I guess you would not have chosen
if you were starting with a completely open canvas. For speed
of mobility, it was a sensible thing for the first wave but it
is one of the things we need to overcome as we go forward.
Mr Martin: A lot of the issues
are around education. This is a new initiative. There is still
a long way to go before everyone involved in the system is aware
of exactly what an independent sector treatment centre is and
what happens there. We have certainly found, from our own experience,
that at a local level the initial reaction from local trusts and
local clinicians has been one of resistance and in some cases
suspicion. We have worked very hard to bring the local clinicians
along with us and, in developing our integrated patient care pathways,
we have actually worked with local clinicians and got their sign-off
for those pathways. As a result, we feel that we have now developed
good relationships locally and those clinicians who initially
were opposed to what was going on are now supportive.
Mr Pilgrim: Whilst the fast track
MRI contract, which is Alliance' Medical's main contribution,
is not actually an ISTC, it is obviously another contribution
to the capacity agenda. Whilst we have seen initially the same
sort of resistance, you may have detected last week at the meeting
with Professor Husband that we were quite a long way down in terms
of the relationship with the radiologists. It boils down to the
proof of the pudding being in the eating. We have now demonstrated
that the radiologists that we are using, who are covered by the
additionality, are producing reports equivalent to the quality
of reports produced in the NHS. We are starting to see that radiologists
are accepting that in the UK. Our business across Europe has been
built on working with local radiologists. This contract that we
have is slightly odd compared with everything else we do. Ultimately,
we would like to see it moving towards us being able to work with
local radiologists, but there has been resistance and some of
the comments that Mr Parish made are valid in this regard.
Q143 Chairman: I understand about
the additionality and we may get on to that later. One of the
things that came out was this issue that obviously, because you
were not able to recruit effectively from the NHS as opposed to
the rest of the sector, you have to bring in a lot of overseas
doctors. There are issues about language and there is not the
back-up available for these doctors that there is in the National
Health Service. Has that been a problem in terms of language barriers
and things like that as employers?
Mr Pilgrim: We encountered certain
problems initially, partly not through language but the nature
of reports that were produced. Now I think we have sorted out
those problems. It really has been a question of evolving the
contract and the provision of the reports to enable NHS consultants
to review them.
Dr Mann: I think it is an important
challenge that we have had to deal with. Obviously, if you recruit
from the NHS, you are more likely to get doctors who not only
speak good English but who have actually practised in our system
and understand it well. If you have to recruit from outside, you
have to make sure that they do. A number of efforts have been
made and all this is undertaken to make sure that is the case.
There are also fail-safe mechanisms so that when we find that
somebody is not everything we hoped he would be, then we have
to deal with that, and we have done that.
Mr Parish: It is important to
note that we do not just employ people who put a hand up. There
is a rigorous selection process, and that includes language skills
and cultural adaptability. A lot of work is done to meld a team
together because these people come from different countries typically.
It has been done very successfully and I think that the expressions
of concern relations to a lack of awareness of our processes and
the fear factor. If we were just to take people who put their
hand up, then I too would be concerned. It is about doing that
professionally. Overall, I am a big supporter of additionality.
That has added real capacity to the NHS and I think it has helped
some of the commercial pressures that have led to a significant
and positive response across the NHS.
Q144 Chairman: In the Healthcare
written submission to us on this subject, they suggests the recruitment
procedures for ISTCs should be brought into line with the National
Health Service, including the introduction of the equivalent to
the advisory appointment committee system. I have seen written
evidence that suggests that something like that does take place
in certain areas. The written evidence we have this week is enlightening
on what was said or not said last week. Do you have any view about
the Healthcare Commission saying that you should look at this
type of appointment system?
Dr Mann: It is not just the Healthcare
Commission; the Royal Colleges have suggested the same thing.
We took the view that there were two issues here. One was whether
sufficiently expert doctors, nurses and others who are practised
not only in clinical skills but also in working in the NHS locally
were involved in the recruitment selection process or whether,
in addition to that, the people involved were representative of
certain national bodies. That is the critical difference. We believe,
and this is what we practise, that senior and competent specialists
from those appropriate specialties are there on our selection
panels. We have not sought to ensure that those people are delegates
from a particular national body but that they are representative
of the local specialist expertise.
Mr Martin: Speaking for my own
organisation, we believe we have already gone some way to come
into line with the NHS appointments procedure. Our interview panel
is led by our Medical Director, who is a former medical director
of an NHS foundation trust. We have also included on that panel
a senior member, a former Council member, of the Royal College
of Surgeons to bring a degree of independence to the selection
process.
Dr Smith: In general terms, the
more we can integrate with the NHS, both locally and in terms
of systems and quality, the better. The more convergence we can
have—I think the Healthcare Commission is trying to do this
on a number of fronts—the better it is for everyone. The
debate then moves from issues of incompatible systems or processes
to patients, which is really what this whole programme should
be about—quality care for patients and a fair deal for taxpayers.
Mr Adams: Again, there seems to
be a commonality in the panel in terms of the processes of selection
and the engagement and involvement of local specialists adding
to our own referencing and processing criteria. From my past experience
of when I used to have responsibility for the largest UK doctor
locum agency, if I look at the number of international doctors
that my previous business, Medacs, used to bring into the mainstream
NHS and at Netcare, then Netcare at the moment is probably working
with about 25 or 26 international doctors at consultant grade.
That is probably about 10% of what I know is brought into the
NHS from the various medical locum agencies that exist to supply
the NHS as a whole. I do not think it is just about international
doctors just being a component of the ISTC programme; it is just
the way the NHS has historically worked in general.
Q145 Dr Naysmith: I have a quick
question for Dr Mann on something he said when he was talking
particularly about the language and culture of some of the people
he employs. You said you took action when you came across people
who did not come up to standard. What does taking action mean?
Does it mean dismissing the individual or retraining them, or
what does it mean?
Dr Mann: It can mean both. First
of all, it means trying to find out if there is an issue, exactly
what the issue is, and then trying to make sure that we can correct
that and, if that is not the case, then dismissing the person,
if appropriate, and, if any other actions are needed, like reporting
them to the GMC or whatever, we would take that as responsible
employers of a clinical service.
Q146 Dr Naysmith: How frequently
does something like that happen?
Dr Mann: It has happened once
for us.
Q147 Mr Burstow: One of the things
that was very striking from the evidence session last week, and
I am sure you have all had a chance to read it and in some cases
may have been here to hear it, was the number of occasions on
which particularly the Department officials were offering to write
to us on items that the Committee could reasonably have expected
them to have answers to, and particularly regarding the issues
of what data is being collected by yourselves. One of the issues
that the Committee wanted to follow up on today was the question
of access to information regarding clinical outcomes and patient
safety data. We noted the submission that we had from the National
Centre for Health Care Outcomes and Development where they have
said specifically that there is a lack of data in terms of clinical
outcomes. Perhaps, starting with Mr Parish, you could tell us
a bit more about the work you are doing locally to ensure that
patient safety and clinical quality data is being collected and
how it is then validated because both of those issues seem to
be important. You seem to have supplied us with more information
on that than anyone else.
Mr Parish: We have supplied you
with the data that we report, which is essentially required in
the contract arrangements. I presume that is consistent across
all providers. That is essentially 26 key points in the data with
a subset of around 98 overall indicators.
Q148 Mr Burstow: The document you
have submitted, which on our list is down as ISTC 52A, which is
Partnership Health Group (PHG Trent and Peninsula ISTCs . .
.", is the data you are talking about?
Mr Parish: Yes, it is.
Q149 Mr Burstow: You say that this
is the product of what you are required contractually to provide?
Mr Parish: Yes, it is. That data
is generated by us and audited locally by the PCT, and obviously
the Health Care Commission when they review us. It is made available
within the unit to patients. We focus on continuing improvement
and therefore each of those statistics is reviewed on an ongoing
basis to seek improvement. Alongside are softer measures of patient
satisfaction, we have a computer tablet that patients are given
on a number of occasions during the day to record their satisfaction
with softer measures: food, staff attitude, et cetera.
Q150 Mr Burstow: Can I come back
to quality of life in a minute? That is important but I want to
stay focused on patient safety and clinical outcome to date.
Mr Parish: On the statistics we
have generated, our view is that they are creditable, given that
we are in a start-up phase, and we know they compare favourably
internationally. It is more difficult to compare them against
NHS statistics because those are more difficult to get. We thought
it would be useful also to include a one-off comparison that is
provided to us by our PCT sponsors with Nottingham City Hospital,
so that there is a direct comparison that we include there, too.
Q151 Mr Burstow: It would be your
understanding that the data you supplied us for today's hearing
is data that should be obtainable from all of your colleagues
in other ISTCs and should be drawn up on a comparable basis?
Mr Parish: Essentially, yes; it
is always difficult comparing one case mix or patient mix to another.
There needs to be a level of intelligent comparison rather than
a crude direct comparison, but essentially yes.
Q152 Mr Burstow: Why is it that you
think perhaps the Department did not seem to know that?
Mr Parish: I really cannot comment.
Q153 Mr Burstow: Can I ask one final
matter on this particular point? How do you actually ensure that
the data is externally validated? What is the mechanism for external
validation, peer review, and so on? Could anyone else add to that?
Mr Pilgrim: We have had an independent
audit of cases and reports. The first audit took place this time
last year. Professor Husband referred to the results of the report
which have not seen yet which took place this year and will be
published in April. That is an independent audit of our results
against NHS results. We have come out in line with the NHS on
both occasions.
Dr Mann: The data is collected
from all of us for our ISTC contract. Every month there is a review
of the data and a scrutiny of the results of that data, which
is jointly undertaken between the NHS and our own people in a
group that has a majority from the NHS locally. They go through
all the indicator data. We have the minutes of that. They go through
every individual line. We would be happy to make that available
to you.
Q154 Mr Burstow: That would be very
helpful. The point that has been made to us in other evidence
from a variety of sources is that whilst there is a dataset in
terms of KPIs which are about process, there is not so much data
in respect of clinical outcomes. You are saying that the data
you supply and go through is clinical outcome data.
Dr Mann: The indicators are outcome
indicators about various things like return to theatre and readmission;
those are available. Those are the ones that are scrutinised.
They are part of the 26 indicators that Mike Parish referred to.
That sort of indicator set is available in many parts of the NHS.
We do look for comparators there. In addition to that, we are
also trying to collect some very particular research-like clinical
outcome indicators, which we have not got yet, but they are not
available in most facilities.
Q155 Mr Burstow: I am labouring this
a bit because I think the answer we had from Mr Parish, which
was passed on in the information that has been supplied by your
company, and the answer we have just had from Dr Mann do suggest
there is some conclusion here in that there may be a standard
set of data that is being supplied as per the contract. The advice
we have been given by our advisers, Mr Parish, is that the data
you have supplied today is more than is expected within the contract.
That is why I want to be absolutely clear that your advice to
us today is that this is solely being provided because you are
being contractually required to provide it.
Mr Parish: I would need to seek
clarification on that. The only uncertainty I may have is where
we have supplied information over and above our contractual requirement.
We absolutely do not generate that information just because it
is required by contracts. We generate it because we depend on
it, our patients benefit from that information, and certainly
the referring GPs do. There may be elements of that information
that are over and above the contractual requirement, but I will
clarify that.
Q156 Mr Burstow: That would be very
helpful. Accepting this may well require notice as a question,
it would be very helpful if the others of you who are giving evidence
today could similarly set out for us what you are required by
contract to provide in terms of data and whether or not it is
the same data that is provided to us today by Care UK, so that
we can get a clear fix as to whether you are all collecting and
publishing the same information.
Mr Martin: I will add that the
Committee did ask for information on one of our centres, that
is Mercury Health, which we provided yesterday. You may not have
had a chance to look at that. We provided you the data in exactly
the form that is provided to the various authorities to which
we have to report. That has 26 or 27 key performance indicators,
most of which are clinically based and that we are required to
provide. You also referred to the report from the National
Centre for Health Outcomes Development. My reading of that report
was that there were three conclusions: that the QA system used
in ISTCs was more ambitious and demanding than in the NHS; that
the KPI data provided by ISTCs was more extensive; and that earlier
work on quality monitoring was encouraging. I think it is still
very early days. We found that an encouraging report.
Mr Burstow: They certainly said those
things but they did also raise the concern about access to data
or clinical outcomes and the need for independent validation as
other issues that certainly the Committee is interested in exploring.
If we could have that answer back, that would be very helpful,
Chairman.
Q157 Dr Stoate: There have been concerns
from a number of quarters about the effect of the ISTC programme
on the training of medical staff. I wonder if any of you can comment
on what you do, if anything, to train medical staff.
Dr Mann: We, and I think all my
colleagues, are in the throes of trying to set up training schemes
within our facilities. For the last year and a half we have been
in discussions, nationally and locally, both with the Royal Colleges,
training accreditation boards and local training schemes to see
how that can be realised. There is a pilot group to do that.
Q158 Dr Stoate: You are not doing
it at the moment then? There is no training at all at the moment
for medical staff in your programme?
Dr Mann: We have not started that
but we are due to start one later this year. We hope to roll them
all out in all our facilities over the next couple of years.
Q159 Dr Stoate: Do any of the others
do any training at all of medical staff?
Mr Martin: We are opening our
fourth centre in the summer, an elective orthopaedic centre in
Hayward's Heath. We will be offering training there from day one.
We are in discussions with the local deanery and local clinicians
around that. We will be offering both training for undergraduates
and postgraduates. The plan is that we will have 10 registrars,
10 SHOs, from the staff who will be training in our centre. In
addition, in our Portsmouth centre, we are in discussions about
providing training for paramedics, ultrasonographers and nurses.
We very much welcome the opportunity to become involved with training
as part of our partnership with the NHS.
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