Examination of Witnesses (Questions 380
- 399)
THURSDAY 23 MARCH 2006
MS JANE
HANNA AND
MR ROBIN
SMITH
Q380 Charlotte Atkins: Without any
adverse effect on patients?
Mr Smith: None at all, in fact
in some ways a better experience because a patient is not in the
theatre as long and they are treated very well. I did an initiative
prior to the treatment centre where I used a private sector supplier.
I got a local ophthalmologist to audit the work and I said have
free access to it. He came back with a very full exposition of
what he thought of the treatment. His only comment was that they
only dealt with the cataract and clearly if there were other presenting
symptoms they had to be treated as well. Clearly what we were
doing in this operation was giving people their eyesight and allowing
them to live full and active lives. We could deal with the chronic
illness subsequent to the giving back of sight. One hospital locally
changed its whole operating procedure to do left and right eyes
instead of having left and right eyes going through the same theatre.
Those are just some of the spin-offs. The other thing, of course,
is that we are only tied to this for five years if we want it
and if we do not want it after five years we stop doing it. We
have not invested hundreds of millions of pounds in a permanent
facility which has a life of 60 years, which you cannot use for
the purpose for which it was intended, so you get flexibility.
You probably gather I am slightly less concerned about the programme
because of the wider impact. Our experience working with the provider
that we have has been very positive, they have been very open
and very anxious to work with the NHS family as well.
Q381 Charlotte Atkins: Any changes
in Phase 2?
Mr Smith: I think Phase 2 is going
to be harder for the ICT providers because the learning from Phase
1 is clear and, therefore, we are more able to drive a slightly
harder bargain, and that is clearly the intention. We would hope
with the experience of working with this in Wave 1 they will be
able to operate the tariff and move forward from there.
Q382 Dr Stoate: You mentioned, just
briefly in your answer, that there had been a significant change
in private fee structure.
Mr Smith: Yes.
Q383 Dr Stoate: Could you expand
on that a bit because that is quite interesting.
Mr Smith: A typical hip in the
UK private sector prior to the treatment centre would cost me
between £7,000—£10,000 depending whether you went
to BMI Nuffield or one of the other BUPA hospitals and it depended
how busy they were and how desperate we were. Bearing in mind
we were trying to deliver faster treatments for patients and meet
the waiting list targets which were set us, with the introduction
of "the picture on the wall" we reduced that price by
£3,000 per procedure.
Q384 Dr Stoate: That is very interesting,
and you think that could happen across the country?
Mr Smith: I do not know, I am
only representing my local experience. You do have to watch very
carefully because if it was a spinal procedure, I am not doing
spinal procedures in the treatment centre so, therefore, negotiating
on spinal procedures with the UK private sector is different from
negotiating on hips if you understand.
Q385 Dr Stoate: You think the element
of competition brought in by the ISTC has significantly impacted
upon the private sector?
Mr Smith: Yes, absolutely.
Dr Stoate: That is very interesting.
Thank you.
Q386 Dr Naysmith: As you probably
know, I know quite a bit about some of the area that you are talking
about and I can confirm what you are saying about cataracts, it
has completely changed the waiting lists for cataracts in Bristol
as well as in the area that you are talking about. I want to talk
about some of the things you have said already. The analysis that
was made before the treatment centre was opened, did people look
to see what its effect would be on the National Health Service?
Did they document and talk about it or was it seen as an additional
thing in getting the waiting list and waiting times down?
Mr Smith: You will appreciate
there was a great deal of concern expressed by local NHS providers,
particularly the clinical community. What we did with them was,
prior to establishing a contract, we explained what the impact
would be as a result of the changes. If we were, talking again
about my local area, at the two acute hospitals in Somerset, we
kept investment levels at the same level and asked for more performance,
in other words to reduce waiting times even further. We have one
local hospital which is likely to reach 18 weeks by 2007 as a
result of maintaining investment and allowing them to treat their
patients and get the patients treated they could not treat in
the treatment centre. With hospitals more distant, such as the
Royal United Hospital in Bath and the United Bristol Hospitals
Trust—
Q387 Dr Naysmith: The Eye Hospital.
Mr Smith:—the orthopaedic
centre, the Bristol Royal Infirmary as far as general surgery
is concerned and the eye hospital, because we do cataracts, general
surgery and orthopaedic and some diagnostics in the treatment
centre, we explained to them well in advance what we would expect
the change in the activity to be. We agreed with them and listened
to their concerns.
Q388 Dr Naysmith: Do you think this
was widely done in the area?
Mr Smith: Yes.
Q389 Charlotte Atkins: Ms Hanna,
it is obviously different from what happened in Oxfordshire because
it seems to have been rather a secret.
Mr Smith: I am afraid I do not
know about Oxfordshire.
Q390 Dr Naysmith: No, I am asking
Ms Hanna.
Ms Hanna: I think in Oxfordshire
the non-executives were very concerned that any views of local
professionals which were expressing concerns about the treatment
centre, whether it was needed and issues of quality and impact
on local services, were kept away from the board. That did not
just include local specialists who were providing the NHS service,
it included the optometrists in the local community who wrote
to the chief executive asking for information to be placed before
the board expressing their concerns that by transferring activity
from the eye hospital to the private provider it would seriously
prejudice training and would impact negatively on quality of clinical
services for the future. They were expressing concern that they
were very happy with the local service and it was looking to meet
target and, therefore, why was the change being made to an unknown
provider. That piece of paper was simply not shown to the board.
The local impact statement by the specialist at the eye hospital
was not shown to the board before we made our decision, even though
the non-executives were constantly asking for information about
local impact. I think overall our impression was that anything
that was potentially negative about the treatment centres was
kept away from board members and papers were written nearly always
with a positive spin so one could not trust the information that
was coming to the board as independent and objective. I think
that was a key concern, that we lost trust in the process.
Q391 Dr Naysmith: Presumably, Mr
Smith, you kept your board well informed about what was going
on?
Mr Smith: Yes. The concerns expressed
by local clinicians I would imagine were very similar to those
expressed in the Oxford area and there remains a debate about
ensuring that junior doctors get appropriate training. I think
we do need to ensure that happens and, again, in discussions locally
we are monitoring that very carefully to ensure that is not an
issue and we are trying to make arrangements for sharing of experience
in the treatment centre with the local NHS. We are only six months
on and it is work in progress but I cannot see that should be
a problem. The facilities are usually first-class and if junior
doctors need to be trained they could be trained at our treatment
centre as well as they could be trained at an acute hospital locally.
Q392 Dr Naysmith: One final question.
In a way, cataracts and hips, which must be the main things you
are dealing with, are seen as relatively easy things to provide
for. Certainly some clinicians have said to me one of their objections
is you cherry-pick and take the easy things and leave the really
complicated stuff. I was going to ask a slightly different question
from the one you were just about to reply to. What has the effect
been of the treatment centres on the wider National Health Service
and the general morale in the National Health Service? Do they
feel they will be picked off next?
Mr Smith: I think there are lots
of questions in people's minds and I think it is fair to accept
that there will be because this is a significant change. It would
be wrong of us to ignore those anxieties and concerns and not
look at them very carefully. I have no reason to believe from
the work we have done so far that the process we are going through
will not do that and respond to any issues that arise. You mention
the impact of cherry-picking, did you want me to respond to that?
Q393 Dr Naysmith: I was going to
say you can respond to the cherry-picking bit now because you
obviously want to.
Mr Smith: It is interesting to
try and assess what is defined as cherry-picking. We are working
very carefully locally to ensure that if the morbidity of the
patients in the local acute hospitals increases such that their
workload is heavier, and we have asked them to tell us about that,
we would look to review the tariff for that local hospital to
recognise the shift in workload, if you like. At this time we
have not had sufficient evidence to support that shift but we
have reassured them that we would work with them if that was the
case because clearly if you are dealing with people who require
post-operative intensive care or the risks are greater with that
particular patient then you may need to go more cautiously with
the procedure and the post-discharge period may be slightly longer.
Again, we have no concrete evidence to support that concern but
we are not dismissing it.
Q394 Dr Taylor: This is mainly to
Mr Smith, I think. We have learnt in our previous two sessions
that there is quite a body of opinion that feels that closer integration
between the independent sector treatment centres and the local
NHS services would be a great advantage. Now from the very geography
of your situation this would be extraordinarily difficult because
you are 20 miles from Yeovil, 30 miles from Taunton, so you have
not got an acute DGH anywhere near you. Integration would be very
difficult. Going on from there, in the NHS as a whole in previous
years there has been a move to close isolated units which do surgery.
How do you convince people that you are safe? As Doug has said,
do you take the people with no risk or as low risk as possible?
What medical back-up do you have at night?
Mr Smith: There are in the centre
anaesthetists on call 24 hours a day, seven days a week and, as
you will appreciate, the anaesthetists are the people you need
if someone goes off. Those are there. We do not profess to run
an ICU or high dependency unit. Some treatment centres do, they
run three or four beds for high dependency. We made a deliberate
decision not to do that and have proper arrangements for effective
transfer of patients to the local NHS hospital in the event of
them not being well. We are confident that the immediate care
of the patient will be properly managed and that has been demonstrated
on two or three transfers. The competencies of the staff there
are equal to that of the NHS in a similar setting. We would only
need the expert support in the event of sustaining life for other
post-operative complications and you will appreciate once the
patient has been stabilised time is not a significant issue, it
is more about transferring to an appropriate centre, depending
on the circumstances presenting at the time. There are qualified
surgeons available 24 hours a day and they live locally so it
is an elective centre with skilled surgeons and anaesthetists
available to it all day every day, 365 days a year.
Q395 Dr Taylor: Can I just pick you
up on that. They live locally?
Mr Smith: They do, yes.
Q396 Dr Taylor: You are not importing
surgeons and anaesthetists from abroad to work in your centre?
Mr Smith: Most of them have come
from Europe, Sweden and Iceland but they have moved their families
into the local area. They live in Shepton Mallet, in the surrounding
areas and they are there for five years in the main.
Q397 Dr Taylor: That is very interesting.
Do you ever keep people as an in-patient over the weekend or is
it strictly five day admissions?
Mr Smith: Over a weekend, absolutely,
yes.
Q398 Dr Taylor: You can keep them
over the weekend?
Mr Smith: Yes, and we operate
on Saturdays.
Q399 Dr Taylor: Going to your paper,
the referral process, because a theoretical problem would be persuading
people to go from Bristol, Salisbury, Bath, 20 to 30 miles for
their surgery, now your referral process seems to go perhaps a
bit across a GP's desires to decide exactly where he sends a patient.
Do you have any comments on that? The Somerset Referral Management
Centre, does that take the decision away from the GP?
Mr Smith: Absolutely not, the
GP's decision has primacy. What we do is we feed all of GP referrals
through a referral management centre to ensure that we are getting
the full utilisation of all the NHS services. If a GP says "I
want to refer to Dr Smith" then we would refer on to Dr Smith.
If a GP says "I want an orthopaedic surgeon to see this patient"
then we will send the patient to where the shortest waiting time
is.
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