Examination of Witnesses (Questions 260
- 279)
THURSDAY 16 MARCH 2006
MS ANNA
WALKER, PROFESSOR
SIR GRAEME
CATTO AND
PROFESSOR PETER
RUBIN
Q260 Mr Campbell: Would the Health
Service have to pay that cost or IST centres?
Professor Rubin: That would have
to be done by local negotiation. Someone has to pay the costs
or someone has to accept that the throughput will drop. That is
the other consequence, you see, and in the next phase that could
be the answer to including education and training.
Q261 Mr Campbell: You are certainly
saying that the training will be up to National Health standards.
Professor Rubin: We at PMETB,
as with the Healthcare Commission, have the legal power to go
into and inspect the ISTCs, and will do so. Any training programme
or training post, wherever it is happening in the UK, has to meet
our requirements.
Q262 Anne Milton: I would like to
talk to you about innovation and improvement and whether you feel
that the ISTCs have stimulated both in the NHS.
Ms Walker: There is a sense, I
think, that there is not a long enough history to look at that
systematically, nor do I think, carrying out our regulatory function,
that that is what we primarily expected. The point I am about
to make is not a regulatory point, but it is about having recognised
that the ISTCs were there to try to help with some of the waiting
lists rather than innovation and improvement for its own sake.
Q263 Anne Milton: We were told by
the Department of Health that one of the aims of the ISTC programme
was to stimulate innovation in fact.
Ms Walker: I am not the Department.
I do not know what they had in mind, so I simply cannot answer
that. I think there is a regulatory issue around improvement.
If I can put it like this, this question of the standard of care
being provided is very much an issue for the regulatory function,
and I do hope we have shown that we have as rigorous a system
as we can for looking at that.
Q264 Anne Milton: It is whether the
ISTC has stimulated improvement and innovation in the NHS: Has
their presence levered up or ratcheted up (or however you want
to put it) standards within the NHS and innovation?
Ms Walker: I have no evidence
on that one way or another.
Q265 Anne Milton: It can be your
view; it does not have to be evidence based.
Ms Walker: Yes.
Professor Sir Graeme Catto: Could
I look at it from a slightly different perspective. I think the
discussions this morning and some of the discussions the Committee
had last week have shown up some of the deficiencies in the current
systems, and I think the ISTCs have highlighted some of those
deficiencies and therefore I hope that will lead to improvement.
I hinted, when I spoke first, that we in the General Medical Council
need to move on, so that historical medical qualifications are
no longer, in themselves, sufficient to guarantee quality. My
name is on the Medical Register because I qualified in 1969 and
I have not been caught doing anything so awful that it has yet
been removed; but you could argue that I have not done anything
particularly positive to ensure that it remains on the register.
Thus, when we are looking at information that will become more
available to patients as doctors move from one country to another,
we need to be quicker in making sure that that information is
more readily available. That means, I think, not having a licence
for life/being on the register for life, but having a licence
for a period of time, and that the doctor can justify that licence
being renewed. And, back to revalidation and the additional information
that patients and the public will expect of doctors in the years
to come, that applies not just to revalidation but also to the
specialist register of all the deficiencies that we have already
discussed this morning. So I think inadvertently it will lead
to changes which I think will be improvements.
Q266 Anne Milton: It has turned the
light on existing practice, in some ways.
Professor Sir Graeme Catto: From
our perspective, that has helped, yes.
Q267 Anne Milton: Would you like
to add anything, Professor Rubin?
Professor Rubin: I think I would
agree with the point Anna made, that it is a little too early
to be sure, but, with respect to education and training, ISTCs
can be innovative, they can bring new ideas, if they are allowed
to do so under the contracts which are being negotiated at the
present time. I think this is a very important point—and
applying not just to ISTCs—that it is very important not
just to look at the short-term imperative but the long term as
well, the quality of the doctors we are going to have 10 or 15
years from now. If we are allowed to do so, I am really quite
confident that the ISTCs will want to drive innovation in education
and training.
Q268 Anne Milton: If I could come
back to the Healthcare Commission, I understand your organisation
aims to find and promote examples of good practice. Can you highlight
any areas of good practice that you have found within ISTCs?
Mr Amess: Oh, dear!
Ms Walker: No, I cannot encapsulate
one which would illustrate. Perhaps the best thing I can do is
to say that there are areas, such as we were talking about earlier,
the transfer of care, where issues did come to light about that
and then the willingness with which the particular centres work
with us—and with the local NHS as well—to try to put
that right. The other piece of evidence which we have which I
think might be helpful, particularly in the light of the previous
discussions, was that we do notice that where there is greater
integration between the ISTC and the local NHS, the local healthcare
economy—it is to do with the local hospital and the local
PCT—that where you have it working integrally as part of
that local healthcare economy, it all works very much better.
That is one of the reasons why in our evidence, where you asked
us what did we think about what should happen under Wave 2, how
the ISTC really does mesh in with the local NHS we think is extremely
important.
Q269 Anne Milton: I will come back
to good practice in a minute, but I was going to ask you what
you feel should be different about Phase 2. If you had to give
four or five things that would make Phase 2 better, what would
they be?
Ms Walker: I have already talked
about the transfer arrangements. The question, also, of integration
one way or another in the local healthcare economy. Lifting additionality
where it makes sense to do so—and that is an issue also
about the position of the local healthcare economy. There is another
point I would like to make about the medical training—and
that is not a regulatory point, it is a much more general healthcare
point—on this question about whether ISTCs should undertake
medical training. We can understand why there is that debate,
because this question of medical training is very important, particularly
in relation to some of the activity which is going on in the ISTCs,
so finding some solution to that which we could help underpin
in a regulatory way, we think would be in the interest. There
is one final point I would like to make, which I referred to at
the beginning of the discussion: Wave 2, information available.
You had a discussion about information being available between
the contractor and the Department of Health—or it could
be the NHS, in the future, the local PCT—and the providers.
But there is also a question about the information that is available
for the patient which I do think needs some attention, because
the patient going into one of these centres wants some feel for
what the outcomes are like compared with the NHS. That is not
an easy job. This whole question of how you get comparable information
and what indicators you choose which make sense to the patient
is a big issue. We have begun some of it, because we have begun
to talk to the providers about information that we would like
on clinical outcomes, regularly from them, with a view to publishing
that information and so making it available, but I think that
is actually very important from the perspective of the patient.
Q270 Anne Milton: Professor Catto,
would you like to add anything?
Professor Sir Graeme Catto: Perhaps
just one wish from my perspective, and that is greater clarity
on the role of the employer within the induction required for
staff coming to work in the ISTCs. Secondly, I think this whole
question of education and training is critically important. If
we are going to have groups of patients segmented and dealt with
in different ways, then it is clearly critically important that
we get the education and training arrangements organised. These
are my two wishes, I think, for the employers and the induction
and education and training side.
Professor Rubin: I would agree
with all that, and particularly integration of the local health
economy and joint planning with the local health economy. That
is particularly relevant to education and training. It may be
that, for all sorts of reasons, not all of the second wave of
ISTCs would be appropriate to undertake education and training—maybe
there is plenty of capacity in the local NHS—but joint planning
from an early stage with the local health economy and the providers
of education and training is key. If that does not happen, things
will come to grief in terms of education and training.
Q271 Anne Milton: If I may finish
by coming back to the Healthcare Commission and good practice.
I think we were slightly talking at cross-purposes, because you
were describing what needs to happen to see it working well and
I was saying: Have you, in an ISTC, thought "Wow!" I
mean, have you? Have there been examples of something that is
really, really excellent?
Ms Walker: I am struggling a bit
because I am not the one who goes in. I think the best thing I
can do is to take that away and ask those who do go systematically
in—and we will come back to you.
Q272 Anne Milton: That would be quite
helpful, because it would be very interesting to see that.
Ms Walker: I shall ask them about
those things of which they thought "Wow" at the time.
Anne Milton: Exactly, yes.
Q273 Chairman: Could I ask you about
this issue of lifting additionality. What is the highest risk
to the local health community of doing that?
Ms Walker: If additionality were
lifted totally, there must be some local health economies where
the NHS could find that they were losing staff, and that was not
one of the original aims of the ISTC programme and I suspect that
needs to be kept in mind. I concede there is great sensitivity
around that but some local health economies are in a very different
position from others. There are some where there are staff available
who would like to work in the ISTCs but the additionality is preventing
it. So I think there has to be something very sensitive about
relaxing the additionality.
Q274 Chairman: Have you, as an organisation,
looked at that in any way?
Ms Walker: No, we have not looked
at it systematically and in depth. It is something that in carrying
out our regulatory regime we come across from time to time.
Q275 Chairman: You would not be able
to give us any guidance on that. Would any members of your staff
be able to give us any guidance on that?
Ms Walker: Again, I will go back
and ask those concerned.
Q276 Chairman: It might be quite
useful.
Ms Walker: Yes.
Q277 Dr Stoate: I would like to explore
very briefly with the Healthcare Commission some of these outcome
data, which I think are absolutely fundamental to what we are
doing. I chaired the All Party Group on Patient Safety. Professor
Catto came in and we had a very interesting meeting this week
about how we are going to change the culture to improve patient
safety. One of the most important things is data on information.
Ms Walker: Yes.
Q278 Dr Stoate: I am appalled in
some ways that you are saying to us that you have outcome data
for ISTCs, you have comparable outcome data from the private sector,
but you do not have access to outcome data from acute trusts and
others because that disappears off to the region. My understanding
is that the reporting arrangements that finally come out of trusts
are, to say the least, variable—which is probably a charitable
way of putting it—so how on earth does anybody like me advise
a patient which centre to go to. I can say, "I have got outcome
date for the ISTC and I can give you some outcome data for the
local private hospital—but NHS outcome data? It all goes
off to the region. It could not help you much." It is mind
boggling.
Ms Walker: It is a really complex
picture. As a patient myself sometimes, looking at one organisation
compared with another, I think to myself, "Where do I start?"
There is of course some outcome information available for the
NHS. I am not suggesting there is none, because there is some
on emergency readmissions, there is some on waiting lists—which
are an indicator of something. The point I really wanted to make
was that the Department of Health set the ISTCs up and, as part
of their contractual arrangements, there is a very significant
flow of outcome information, but we do not actually automatically
get all of that information, and that is one of the things which
both we and the Department of Health have learnt from the ISTC
process.
Q279 Dr Stoate: Why are you not shouting
at them, "We demand this information"? It is no good
saying, "We only get a bit of it, some of it goes off to
region, the Department has other bits" because the Department
made it clear last week that they really do not have any that
they are likely to share with us. Whether they do or not is another
question, but they are certainly not about to show us any of the
information they have. Why have you not shouted from the rooftops?
Ms Walker: I think there is a
principle. Particularly where the Department of Health is the
contractor, the flow of outcome information should be shared with
the regulatory body. We are doing something about this area. We
are talking to the independent sector providers, including the
ISTCs, about producing some outcome information. This is information
like planned transfers, emergency readmissions, return to theatre—so
they are some of those issues on which there are the greatest
concerns in ISTCs—and infection control, collecting that
information and then publishing it. We have already begun those
discussions.
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