Examination of Witnesses (Questions 200
- 219)
THURSDAY 16 MARCH 2006
DR THOMAS
MANN, MR
MIKE PARISH,
MR MARK
ADAMS, MR
PETER MARTIN
AND MR
ALAN PILGRIM
Q200 Charlotte Atkins: Are you saying
that you would not be able to meet the NHS tariff unless you had
overseas doctors?
Mr Parish: I would be surprised
if we could get terribly many doctors working for us at their
NHS rates and so we would be needing to pay the private practice
rates and that is expensive.
Q201 Charlotte Atkins: We were talking
earlier about innovation. Surely if you were offering an attractive
work environment then you could possibly tempt NHS doctors away
from the NHS because you are hoping to innovate and provide greater
freedom for doctors to break through those barriers.
Mr Parish: I may be a bit of a
lone voice in saying I am a supporter of additionality. If additionality
had not applied to date and if it did not apply going forwards
then we would be heavily criticised for causing a supply shortage
problem within the NHS, which is quite possibly what could be
the case.
Dr Mann: The single greatest value
of moving away from the current additionality position is that
it allows us to work more effectively with NHS nurses and doctors
and that will lead to debunking a lot of the myths that I think
have grown up. I think there is a sense that we are separate from
them and we do not use them and all of that. I am not persuaded
that that additionality undermines quality or helps price although
in some circumstances it will. I think we should be allowed to
try and find solutions that give the NHS best value. As regards
tariff and additionality and the contracts for Wave 2, my instinct
is that you will find that our prices will converge to tariff
very quickly. One of the advantages for having a looser arrangement
around additionality is that we will begin to compete to provide
services below tariff. If you put unnecessary constraints on things
like additionality what you are actually doing is trying to give
value for money but doing it with one hand tied behind your back.
For me the real issue is why try and hinder good networking with
local doctors and good value for money by something which if it
is good value and good sense we would do anyway because that is
in the nature of providing a good service.
Q202 Charlotte Atkins: So you would
be happy to see guaranteed referrals being swept away, would you?
You are not interested in those sorts of aspects of the contract,
are you?
Dr Mann: I think that is going
to happen anyway. I think in Wave 2 you will see that there will
be a tapered commitment to commit to that particular area. By
the end of the period you will find that the tariffs are fully
aligned and the referral patterns will no longer be protected.
We are committed to that because that is how we would be part
of the NHS.
Q203 Charlotte Atkins: Are you all
committed to those restrictions being taken away?
Dr Smith: Absolutely. I think
you are seeing the good effects of competition here. My company
will take a different strategy than Mike's and that is good and
may the best man or woman win. I think that type of innovation,
that type of competition or that type of trying to do things differently
and offering a different service is a very good aspect of competition.
The key to this is patient choice in my opinion. I think for too
long in this country we have had a patient population that has
been too compliant, that has not been given enough choices and
therefore has not been able to choose and in the process of choosing
to say this is a better service and I value this more than that.
Patient choice was a key tenet of Nye Bevan's principles for the
NHS in 1948, and I think this process is getting us back to patient
choice and a position where we will give the right to patients
to be able to make their own choices without the state telling
them what they can and cannot do. For me that is the longer-term
aim of this programme and minimum take and guarantees will have
to go under that regime. We will have to live or die by whether
we can offer a high quality clinical service at a cost-effective
price.
Q204 Charlotte Atkins: How many NHS
doctors would agree with you that patients are too compliant?
Dr Smith: I do not know. You will
have to ask the doctors.
Mr Pilgrim: In terms of Wave 2,
our involvement will be on the diagnostic front. I think one of
the most encouraging things about Wave 2 is that it is geared
around bringing the diagnostic tools closer to the GPs. At the
moment we have far less scanners than anywhere else in Western
Europe and far less scans performed, that is the preserve of the
Trust hospital nowadays, but in future it will be referred by
GPs and they will use that diagnostic tool. I think a very important
part of Wave 2 will be bringing the role of the PCTs and the purchasing
skills within the PCTs up to the point where they can get best
value and best care for their patients. How our organisation would
respond will be at the diagnostic end of that.
Q205 Charlotte Atkins: So you have
a lot of faith in the PCTs to get value for money, have you?
Mr Pilgrim: I have a lot of faith
in the Department of Health process as it is very robust. You
are hearing from six people here who are basically saying much
the same things about the topic but who are competing toe to toe
with each other on all of these tenders. In fact, Ian is linked
with the major other company in the diagnostic field and we are
going toe to toe for the next round of contracts and I think that
will produce value for money, but there is a strong emphasis on
quality as well and that will produce good results for patients.
Mr Parish: Building on what Ian
has been saying on the direction of travel and I agree the direction
of travel should be a world without any kind of volume or revenue
commitments, I have got to say that it may take some time to get
there fully because it is about us being able to invest with confidence
in the belief that that market opportunity will be there. I think
we have got more confidence now than we had a couple of years
ago when the first wave came along, but I am not sure the market
will be sufficiently confident to invest £10, £20 or
£30 million per facility totally at risk currently of the
market being allowed to thrive. I think there needs to be a further
evolution of patient choice, with patients being free to choose,
PCTs being free to choose and doctors being free to refer before
we invest fully at risk, which is why Tom talks about a tapered
level of commitment in Wave 2.
Q206 Charlotte Atkins: Finally, do
you all believe that ICCs are an opponent part of the landscape
within the NHS?
Dr Mann: Yes.
Dr Smith: We certainly like to
think so, yes.
Q207 Anne Milton: Do you think we
are moving to a mixed economy of healthcare provision where you
will be an integral part of—albeit paid for by the taxpayer—a
mixed economy of provision?
Dr Mann: We would hope so.
Dr Smith: I think that is purely
in the hands of the patients and depends on our ability to be
efficient operators. The rights of the patient and the taxpayer
here are predominant over the rights of the providers and it is
they who should choose, and if we fail then they will not choose
us and we will not be around.
Q208 Anne Milton: Do you all feel
that this first phase has gone well enough to indicate that that
would be a possibility?
Dr Smith: Yes. I am very encouraged
that patients are getting a voice, yes.
Q209 Anne Milton: Dr Mann, you are
making a face as if to say you have got some reservations.
Dr Mann: I think the first phase
has achieved what we needed to do but, as Mike was suggesting
and this Committee and all the press have suggested, there is
a considerable sense both of resentment and of uncertainty amongst
NHS clinicians and others. I think we will feel comfortable that
we have got to a position where patients are going to choose when
that sense of resentment and confusion is dispelled and the NHS
truly believes that the mixed economy in provision is here. I
suspect Select Committees like this can go a long way towards
helping people understand that. We are not there yet but we are
getting there.
Q210 Anne Milton: Is that because
at the moment you are seen as a competitor to the NHS?
Dr Mann: I think it is more than
that. People love the NHS and the NHS is a good thing. When you
start to introduce an alien concept into something that is truly
and properly cherished and loved then people, understandably,
think is this good, is this bad, what is this all about? Critics
come at this with a far more aggressive scrutiny than they would
do otherwise. It is up to us to help people understand that we
are as open as a commercial organisation can be, we publish information
about clinical care and we try and work with local NHS colleagues
as far as we are allowed to hence the discussion about additionality.
I think we are getting there but it is not there yet.
Q211 Anne Milton: I do not know if
anybody else has got anything to add.
Mr Parish: If we look at it from
a patient's perspective, they consider us to be part of the NHS
solution and that is very much where we view ourselves as very
much empathetic and committed to the principles of the NHS but
also a part of the solution to the NHS service. You may have anticipated
there being quite a bit of resistance from patients and nervousness
et cetera but there really has not been any, in fact there has
been delight. As far as they are concerned they are getting a
wonderful service from us as part of the NHS.
Q212 Anne Milton: Patients want the
treatment and maybe they are less fussy about where this comes
from. They want high quality and effective treatment as soon as
possible.
Mr Parish: Yes. There will be
strong opinions over how that treatment should be provided.
Q213 Anne Milton: The resentments
to some extent must arise from NHS staff who see you as a threat.
Mr Parish, you have said with additionality going or being relaxed
that will change things somewhat because the NHS staff will then
be free to come and work for you.
Dr Mann: My thesis is that that
level of anxiety, concern and sometimes resentment is because
they do not understand what we are about and that is made worse
by additionality. I have no problem with additionality, but as
an obligation it puts up barriers between us and NHS staff. Where
we have worked with NHS staff closely those barriers have come
down and they have worked well with us. Were we allowed to do
that more often then in time a lot of these concerns would go.
Mr Parish: We are on a sensitive
market migration if that is what we are on. I think one needs
to be careful in terms of the law of unintended consequences,
which is why I think it is prudent to ease the additionality requirement
gradually rather than risk destabilising existing supply arrangements
within the NHS.
Mr Pilgrim: Another contribution
that this whole process has made is to get healthcare provided
in the right facilities and the right facilities are not always
a huge NHS Trust hospital. If you look around the rest of the
world, many more of the health economies have a much wider range
of different facilities and different providers than we do in
the UK. There has been a tendency in the UK for us to focus all
of our efforts on an NHS hospital where lots of things can be
much better provided and ISTCs are a good example of that. Standalone
diagnostic centres are very common throughout Europe and produce
high quality of care and there is a competitive market for the
services. I think those are all positive things coming out of
this whole programme.
Mr Parish: A key issue we have
not talked about is the whole emphasis of the White Paper in terms
of migrating treatment and care out of secondary care facilities,
out of hospitals and into primary care and the community is a
key feature of that market restructuring. I do not think we can
look at ISTCs in isolation of that general change in the way services
are delivered. In primary care we have got something of a mixed
economy already in the way GPs are engaged and I know that has
got possibilities of going further.
Q214 Anne Milton: With regard to
the White Paper, there are quite a lot of PCTs closing community
hospitals at the moment because of meeting short-term budget imperatives.
If you had the opportunity, would you take over some of those
facilities?
Dr Smith: If it made economic
sense, yes.
Q215 Anne Milton: I gather there
are around 90 of them up for grabs at the moment.
Mr Parish: It would be on a case-by-case
basis because they need to meet the needs of a poly-clinic type
of solution.
Q216 Mr Campbell: I would like to
know if you have carried out any analysis into the long-term and
short-term results of the competition with a local hospital.
Mr Parish: I am not sure I can
answer that.
Dr Smith: As the private sector
we would depend upon the Department of Health to make that analysis
and the colleges.
Q217 Mr Campbell: At the minute you
are cutting down the lists. If Alice in Wonderland was
true and the list is going to be cut then there is going to be
a market there and if you are still around you are going to be
competing with the local hospital, are you not?
Dr Smith: Yes, for elective surgery,
absolutely. It is not our place to decide how to plan a healthcare
economy. I think the Department of Health and the Government have
reassured people that vital services will not be under threat.
I think that would be stupid, frankly. Citizens and taxpayers
would be very angry if vital services disappeared, especially
A&E. I think we need a regulatory context and regime to make
sure that does not happen. That is my personal view. I am not
a policymaker.
Dr Mann: When this whole programme
was initiated there was a projection based on an analysis of information
sent in by SHAs, regions and PCTs that a certain volume of additional
activity would be needed every year not only to deal with the
waiting lists but to maintain the waiting lists where they were.
At the moment we are barely hitting that level of additional activity.
My own judgment would be that at the level of additional activity
the current programme has procured it is unlikely that we will
get waiting lists going down to a point where we are competing
for core business in the health service. I think what you will
get is the additional activity helping to manage the waiting list
and bringing it down to a point where patients are not waiting
unnecessarily. I do not think the volume that has been injected
into the service is such that it will make a major impact on many
local elective services.
Q218 Mr Campbell: Do you expect your
contract to be renewed? I think you all agreed that it would be.
Dr Mann: We do want to do that,
yes.
Q219 Mr Campbell: For the foreseeable
future? Let us take it that we have got the list down.
Dr Mann: Additional activity will
be needed to keep the list down. There is a lot of history in
the health service where people have felt that we do a piece of
work and then everybody will be better and then you would be able
to dismantle that piece of work. The reality is that you do that
extra piece of work to manage a certain additional demand and
you need to keep doing that because patient expectations are going
up. We would want our contract renewed. Our investment is not
about getting in there quickly, getting rich and getting out,
it is about being part of the NHS locally. We have invested not
just time and money but a commitment to be in the NHS. We would
consider it a failure if we lost the contract after five years.
Mr Martin: I would echo that.
We certainly did not get involved in this because we were interested
in running a contract for only five years. What we were interested
in was becoming a fully integrated and sustainable part of the
local health economy. We expect to be running our centres for
many years to come. I would be very surprised if the contract
was renewed at the end of five years in the same terms on which
it was originally let, but by that point we would expect to be
a fully functioning part of the local health economy and if there
was local competition then we would be quite happy to compete.
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