Examination of Witnesses (Questions 320
- 337)
THURSDAY 16 MARCH 2006
PROFESSOR JOHN
APPLEBY, MR
JAMES JOHNSON,
DR PAUL
MILLER, DR
SALLY RUANE
AND MR
DANIEL EAYRES
Q320 Chairman: Do they?
Mr Johnson: There are one or two
examples, and it is only one or two so far. There was one of orthopaedics
in Southampton where the NHS unit closed because the patents were
being sent to an ISTC in Salisbury. The only thing that closed
was the orthopaedic unit so you could argue that you simply transferred
the venue from where the orthopaedic surgery was done. Potentially
it could go either way, you could have a whole hospital threatened
because a lot of its surgical income would be taken away.
Q321 Chairman: It is highly unlikely
to have A&E taken into this process. We had people from the
profession sitting there last week who said it made good sense
to take elective surgery away from A&E because of the potential
for A&E to disturb elective surgery because of incidents that
happen on our roads and elsewhere during the day. You are not
saying doing that would threaten it in that way, surely not?
Mr Johnson: I would see it destabilising
it because it would remove a sufficient chunk of the hospital's
basic finance that the hospital might conceivably become unviable.
Q322 Chairman: The other thing that
was said earlier on was is their influence innovative on the National
Health Service. Do you think any of your members have changed
their work practice because they have had an ISTC in the neighbourhood?
Mr Johnson: Some of them have
gone to work for them in their spare time. I have no evidence
that the practice has changed as yet. I would expect the change
to be more along the lines I was talking about before to Dr Stoate
of providing services that make the service more attractive to
patients.
Q323 Chairman: I accept that. One
of the issues was about influencing what is happening inside the
NHS.
Mr Johnson: There was a case in,
I think it was, Yarmouth over the orthopaedic surgeon who decided
to run a production line and as one patient wound up in one theatre
the next was put to sleep in the next theatre and he just went
from one to the other. I am quite sure that was in response to
the need to be productive and efficient but whether or not you
could say that is a broad trend that is happening is rather unlikely
at the moment.
Q324 Chairman: I think he was trained
in France, was he not? Do you think that is a good idea?
Mr Johnson: There are arguments
on both sides. The most dangerous time with an anaesthetic is
when you are putting the patient to sleep and when you are waking
them up. If you take your eye off the ball to put another patient
to sleep at the same time you potentially have two crises going
on at the same time. These things are not simple, you have got
to have enough staff to do it with.
Q325 Chairman: From what I read it
was the surgeon who was moving. The Secretary of State has been
using it quite regularly in her speeches.
Mr Johnson: She has indeed. You
need to have an extra anaesthetist to allow the surgeon to do
that. If you are doing it without an extra anaesthetist it is
probably not safe, but if you do it is safe.
Q326 Chairman: Dr Miller, you have
got something to say.
Dr Miller: You asked about innovation
and destabilisation. I think one of the ISTC representatives at
the first session this morning said that he did not think there
was anything truly unique or innovative that was not done anywhere
in the NHS that was being done in their centres. I think it is
important to remember that the NHS is innovative. It is not like
the NHS has never changed or thought of anything new in the last
50/60 years. Treatment centres were developed in the NHS, the
NHS had them before ISTCs. The NHS has made lots of innovations
over the years. I do not like this atmosphere that is sometimes
generated that the NHS has never had an original idea in the last
60 years, it is not true and it is not fair. As for destabilisation,
the point has been made repeatedly today that we are still at
the very, very early stage of the ISTC programme. ISTCs are doing
what they were asked to do in a political and economic sense.
They were never asked to do training so they have not done it.
In Wave 2 they are being asked to do training and I am sure they
will do it. As for the destabilisation, we have seen a small number
of examples of where work has been handed over from an NHS unit
to a treatment centre, not by patient choice, and that has destabilised
or caused a service to close down or run down to some extent.
As it takes off and there are many more treatment centres it is
likely that there will be more destabilisation of NHS services
but more particularly as we get into Phase 2, which is currently
being tendered, where it is not just going to be orthopaedics
and eyes, Wave 2 talks about gynaecology, urology, ENT, plastic
surgery, cardiology, renal dialysis, a much broader range of services.
It is highly likely that the destabilisation and knock-on effects
on traditional NHS hospitals will be hugely greater once that
is fully up and running.
Q327 Chairman: Do you think that
is a threat?
Dr Miller: I think it is inevitably
a threat.
Q328 Chairman: If you have got a
surgeon who is running two theatres, okay he has got to have a
lot more support staff and everything else, and that surgeon might
be used for an hour during that four hour process and an hour
in a neighbouring one as well, surely that is of more benefit
to the organisation, and particularly the patients, in as much
as you are going to get into the theatre quicker if you have got
surgeons delivering two forms of services at the same time.
Mr Johnson: All other things being
equal, yes.
Q329 Chairman: I realise that and
it may not be. That should not be perceived as a threat, it is
a way that things may move in the future.
Dr Miller: What I meant by a threat
was even if by patient choice only 10% of patients looking for
elective surgery chose, even just out of curiosity, to go to an
ISTC, first that would not be surprising, I think the evidence
is a lot of ISTCs do these things well that the NHS has not done
well and give an attractive offering, the loss of 10% of elective
income would be hugely destabilising for the NHS unit.
Q330 Dr Taylor: We have heard a lot
about the importance of integration and the value of integration
between the NHS and the independent sector treatment centres.
Have you any examples of useful interaction taking place already?
Mr Johnson: Not yet. I work in
a hospital where there is one being built in the back yard, sort
of thing. One of the two principal limiting factors in my NHS
hospital that is slowing down everything is lack of radiology.
We have a complement of about 50% of the number of radiologists
we ought to have. People stay in bed in hospital for days waiting
for their ultrasound scan or something, a total waste of NHS money
and their time. This new treatment centre, which is only going
to have 40 beds, is going to be orthopaedics. It has got three
general radiology rooms, a CT room and an MRI room. It is going
to be 100 yards across from us. It will be hugely underused from
the point of view of the treatment centre firm. I cannot believe
that we could not jointly use that facility so that they would
get more money for using it and we would have access to radiology
and become a lot more efficient as a hospital. These seem to be
the sorts of examples where everybody gains from a bit of co-operation.
Q331 Dr Taylor: The crucial question
was really brought up by one of the independent sector people
this morning, the question of salaries. Would NHS consultants
be prepared to take a session on as part of their job plan under
the NHS to work in that sector? Would that be possible, would
that be practicable, or would they insist on the scale of salaries
in private practice?
Mr Johnson: I think in this instance
it would be rather the other way around. We would be looking for
their radiologists to come and work in the NHS, in which case
we would presumably offer them NHS rates. I think these are negotiable.
Frankly, if a surgeon or anaesthetist decides in his own time
that instead of going to do some private practice on a Saturday
morning he will go and work for a treatment centre it is a matter
for negotiation what the deal is and if it is not satisfactory
he will not do it. It will not necessarily be NHS rates.
Q332 Dr Taylor: We hear of NHS surgeons
doing crosswords on the news because there are no facilities for
them to work at that time. If they have got spare slots on their
job plans could they move those spare slots into an independent
sector treatment centre? It would seem obvious that they should.
Mr Johnson: With respect, I think
the reference to crossword puzzles was due to the fact that the
NHS has virtually been told to stop working for the last two months
of the financial year because it has run out of money. That is
a whole new ballgame but it is something I would not support or
excuse for a moment. It seems a very mixed message to tell you
to work and be productive and efficient for the first 10 months
of the year and then stop doing everything for the last two. That
is just a bad system. That is what the crossword puzzles are about.
If it were part of the job plan that it would be better done at
the treatment centre it would be for the employer to second the
consultant and say, "Rather than work for us for this session,
you work there". That provision is available.
Dr Taylor: This is a point we will take
up in our workforce inquiry.
Q333 Chairman: I am sure we will.
The BMA would not have a problem with that, would they?
Mr Johnson: Providing that the
consultant was not sent against his will, no.
Q334 Chairman: They would be going
there on their NHS contract which could totally destabilise the
private doctors who are working in there. You would not have a
problem with that as an organisation, would you?
Dr Miller: More than that, specifically
we have been in talks and discussions and negotiations with the
Department of Health to provide a framework in which such secondments
could happen avoiding various pitfalls that could occur.
Q335 Chairman: This would be effectively
through local integration as opposed to national direction, is
that what you are saying?
Mr Johnson: We have no problem
at all with that.
Q336 Chairman: I think that is about
it. Obviously you have had a taste of the first phase and the
second phase is on the way. I think we have got most issues out
of you. One thing I was going to ask was you do not see a problem
with training people in ISTCs from the profession's point of view,
do you, providing everything else is equal?
Mr Johnson: It will not just happen.
Q337 Chairman: It would slow down
the activity, as training does, but you do not see a problem in
relation to that?
Mr Johnson: The problem will be
that for the first time the costs of training will become transparent.
It has been regarded in the NHS rather as something that you do.
If the treatment centre firm says to the PCT or whoever is buying
it, "Okay, you want us to train, this will cost you X extra",
the PCT will say, "Hang on, we have never paid for training
before, what is all this about?" It will start to make it
transparent but that is probably no bad thing.
Chairman: Sorry for the overrun. It happened
in the first session and we consistently overran with the second
and third as well. Thank you very much indeed for your evidence.
We will at some stage be bringing out a report. Thank you.
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