Examination of Witnesses (Questions 560
- 579)
WEDNESDAY 26 APRIL 2006
RT HON
PATRICIA HEWITT,
SIR IAN
CARRUTHERS OBE, MR
HUGH TAYLOR
CB AND DR
BILL KIRKUP
Q560 Mike Penning: We have already
heard, earlier on, that the use of the ISTCs is at something around
40% or 50%. Surely, then, the argument that they were so desperately
needed and the NHS could not cope without them is, perhaps, flawed.
Ms Hewitt: These judgments about
capacity were made at the time by the local NHS, and I think it
is fair to say that capacity planning is quite a difficult thing
to do. I think it is also true to say that once we had announced
patient choice at six months and we had announced the first wave
of the ISTC programme, actually the NHS responded, in some cases,
by changing the way that hospitals worked and got those waiting
times down. I would be very happy to give the Committee a copy
of the slide[1]
which I was showing Cabinet colleagues last week which shows very
clearly that between March 2000 and September 2002 the number
of patients waiting more than six months barely changed at all,
despite the fact there was more money going into the system. When
we announced choice at six months and the beginning of the ISTC
programme, those waiting times absolutely plummeted, and it comes
back to the point about the dynamic effect of even quite a small
number of new providers changing practice, improving the use of
resources and therefore improving productivity.
Q561 Mike Penning: I do not want
to dwell because there are lots of other Members that would like
to ask questions and the answers are very long. Can I ask you,
Secretary of State, how many NHS facilities you are happy to see
closed—that have been closed or will continue to close—for
the ISTCs to go forward? In some hospitals you are going to demolish
hospitals and build ISTC centres. How many of these hospitals
are you happy to see closed?
Ms Hewitt: I do not regard that
as, if I may say so, a right measure.
Q562 Mike Penning: It is a question
though, is it not? I have asked a question on behalf of the Committee
and I would like you to answer it.
Ms Hewitt: My answer is that what
we are doing is building new NHS hospitals, including of course
the proposed PFI in Bedfordshire and Hertfordshire. We are also
commissioning ISTCs—a small number and a very small proportion
of the total budget—but in many cases because the local
NHS believes that that is a better way of delivering faster and
better patient care—
Q563 Mike Penning: You are not willing
to answer the question?
Ms Hewitt: My criterion for success
is simply: are we giving patients the best possible care with
the best possible value for money?
Q564 Mike Penning: So the answer
to the very simple question of how many NHS departments and hospitals
you are happy to see closed so that the ISTC project can go forward
is that you are not going to answer the question?
Ms Hewitt: It is not a question
of closing NHS facilities in order that—
Q565 Mike Penning: It is a question
from this Committee to you, Secretary of State.
Ms Hewitt: It is not a question
that I am—
Q566 Mike Penning:—willing
to answer?
Ms Hewitt:—willing to answer
in that form because that is not how the system works. When patients
have free choice of where they have their elective operations
(which I would have hoped, Mr Penning, is a goal that you would
support) it will be the patients who decide which facilities flourish
and which facilities are to change.
Mike Penning: There is no choice if you
close hospitals, Secretary of State. It is simple.
Chairman: Secretary of State, I want
to move on to Charlotte but can I just say that the thing you
shared with the Cabinet last week we would be more than happy
if you shared it with the Committee. If there is anything in terms
of numbers of patient alongside that it would be very useful to
us.
Q567 Charlotte Atkins: Good morning.
In the statements you have kindly provided to us it says that
ISTCS have played a major role in increasing capacity to NHS patients
but it also says that you have to get this into perspective, that
ISTCs have only treated 3% of those NHS patients having routine
elective surgery. That appears, on the face of it, to be somewhat
contradictory. Are you saying that the dynamic you were talking
about closes that particular gap?
Ms Hewitt: Yes, I think the effect
of the ISTC, in terms of capacity, has been two-fold: there has
been the direct contribution (modest but significant) and there
has been the indirect contribution that together with choice (this
greater plurality of providers) has encouraged other parts of
the NHS to make more effective use of their own capacity.
Q568 Charlotte Atkins: So, basically,
then, it is not the ISTCs that have been responsible per se for
the reduction in waiting lists and waiting times, it is, in fact,
the NHS providers who should actually get their just desserts,
in the sense that they are the ones who have actually reduced
waiting times down to less than six months.
Ms Hewitt: It is actually both.
I take the example of cataracts, which I know is controversial
with some of our NHS colleagues, and if you look at that there
is no doubt at all that the majority of cataract operations are
done, and always have been, within the NHS. I have no doubt that
will continue to be the case. If you look at the number of additional
operations that had to be done to get those waiting times down
to a maximum of just three months, around a third, I think, of
those additional operations were done by the ISTCs—not the
majority but, nonetheless a significant contribution. On top of
that you have this really exciting example of innovation which
was the mobile surgical units going around to those parts of the
country that have the greatest waiting lists and really helping
to get them down. So a significant contribution. I have never
said that the ISTCs were purely responsible for the really extraordinary
fall in cataract waiting times (we have hit the three-month target
four years earlier than we said we would) but they have made an
important contribution and both should be recognised. The other
example I would give you is MRI scanning. That was really very
important because under the contract that we had with Alliance
Medical about 113,000 NHS patients directly got faster scans—that
is by February of this year—as a result of that service.
Again, what Alliance did was to bring in a mobile operation which
saw a very, very dramatic fall in waits for MRI scans in some
parts of the country, from the order of six months or more to
the order of six, eight or 10 weeks—that sort of area. So
very big reductions there in waiting times for some patients in
some areas, and as we move towards the 18 week target at the end
of 2008 we need both a massive expansion in diagnostics in the
NHS but we will also need a significant contribution from the
independent sector just to hit that contract.
Q569 Charlotte Atkins: If NHS facilities
were given the same resources why would they not be capable of
doing exactly the same thing in terms of bringing down waiting
times to the 18 week target? Is there any particular reason, given
now that you have introduced this new dynamic?
Ms Hewitt: This really goes to
the whole question of innovation and best practice and how you
get a dynamic system that incentivises both innovation and best
practice. I think most people would agree that the NHS is superb
in places at innovation and creating best practice, and on almost
any aspect of patient care you care to name you will find best
practice somewhere in the NHS; it is there, particularly, but
not only, of course, in our brilliant teaching hospitals. However,
what the system, taken as a whole, has been very poor at doing
is incentivising best practice—not as the occasional result
of superb clinicians and entrepreneurs and so on but as the norm.
By putting more diversity and more competition into the NHS as
a whole we are incentivising best practice and innovation throughout
the entire service. This is really important, because what we
are finding with the ISTCs is that, partly because they are set
up on Greenfield sites but also because they come from a different
culture, they are institutionalising as best practice a whole
series of things about how you treat patients. For instance, the
idea that every patient is seen for a proper assessment before
they are admitted; that every patient is telephoned before they
are admitted to make sure they still need the surgery, the date
is convenient and all of that. I can send you a very detailed
note because I am not going to give you a long answer—I
could go on for ages on this—but a whole series of aspects
of best practice, each of which taken on its own represents common
sense but which are not the norm throughout the NHS. I know this
can be difficult for NHS colleagues and all of us who love the
NHS to admit, but I will give you just one example that I picked
up the other day: two orthopaedic surgeons working side-by-side
in the same hospital. One of them has his secretary ring every
patient the previous week to check that they know they are coming
in, they know what the procedure involves, they know what they
have to do to prepare and they know what will follow after the
operation. Not surprisingly, most of his patients turn up for
the operation. The next orthopaedic surgeon, working in exactly
the same hospital, does not do that. His secretary looks at the
list on the Friday, starts `phoning them and says: "Pack
your bag; you are coming in on Monday". Now, which consultant
has the better rates of attendance at the surgery? It is blindingly
obvious. But, actually, there should not be that kind of variation;
best practice says you know what the best way is and you do it
like that for everybody. It is that kind of attention to detail
and building in best practice to the design of the building, the
design of the processes as well as the clinical quality that the
ISTCs actually exemplify. Parts of the NHS equally exemplify it,
but to get it generalised across the NHS as a whole, which is
what we have to do to get best value for money across the NHS,
we need diversity, we need choice and we need an element of challenge
and competition.
Q570 Charlotte Atkins: Given how
much we are now paying NHS consultants, I would have hoped that
that increase in productivity would have been, effectively, part
of their contract. It seems to me that if we are paying them more
they should be delivering more and, perhaps, they are not always
doing that.
Ms Hewitt: I think consultants
are often let down by the systems within which they work. A very
senior consultant surgeon whom I was talking to just last week
said that when he arrives at his hospital for, let us say, a Friday
session, there are occasions when there are too many patients
and too few beds, there are occasions when there are too few patients
because they have not been checked in advance and they have not
turned up, so there are occasions when he is overworked and there
are occasions when he is sitting around doing nothing. That is
because the system within that hospital is inefficient and there
is not the collaboration between the managers, the nursing and
the clinical staff required to deliver the best possible use of
your most expensive resource, which undoubtedly is the consultant—he
or she is your most skilled resource.
Q571 Charlotte Atkins: You have just
given us a perfect example yourself of two surgeons who behave
totally differently. It seems to me that the NHS should be ensuring
not that we necessarily incentivise surgeons to do that but that
we require it of them. I want to go on to an issue because I know
that we are short of time—
Ms Hewitt: You can require, but
actually incentivising best practice is quite a good way of getting
it.
Q572 Charlotte Atkins: Absolutely,
but it should just be part of the normal process; they should
not expect more money to do what we would expect them to do in
a normal situation. We visited, as a Committee, the Woodland NHS
Treatment Centre in Dartford. That facility, which is obviously
an NHS facility, is delivering excellent results next door to
the hospital delivering fantastic elective care. It seems to me,
certainly, having seen that, that I do not see why the rest of
the NHS treatment centres should not be delivering the same as
ISTCs. To all intents and purposes it was operating just the same
as an ISTC and why should we not expect those treatment centres
to multiply within the NHS? Why do we have to rely on the private
sector to provide them?
Ms Hewitt: I think we need both.
Sir Ian Carruthers: If I can just
come in there, we are in danger of saying one is good and one
is bad. The fact is we are not saying that; we are actually saying
that NHS hospitals—just to give you some context—in
some places do fantastically well but, as you would expect
across a big range of organisations, there is variability. Exactly
the same can be said of NHS treatment centres: there are some
that function very well; there are some that are less productive
than others. I think what we really need to look at is what can
be achieved in terms of the integrated impact of treatment centres
and NHS hospitals in proving their effectiveness and efficiency,
and indeed ISTCs. Actually, it is the integrated part and the
impact of that which is really important. If I could just refer
back to a comment which has been made to illustrate this, ISTCs
have made an impact on reducing waiting lists but, overwhelmingly
(and the cataract is a great example of where they have made that
impact) we should be saying very well done to NHS hospitals, because
actually over time they have done that. The real question is how
do we move to the next phase on 18 weeks? What will we need? There
is little doubt that, as the Secretary of State has said—and
I can give some local examples of this—when you introduce
an ISTC you are not working from the same practices that have
grown up in some of the other organisations over many years. We
need to look at two things, two impacts. One is the impact in
terms of capacity, ie, doing more operations, and they do that,
but the most important impact is the impact they often have on
the local NHS which is about how they improve their practice,
and the Secretary of State has mentioned some of those. Also we
should not forget the impact it has on local clinicians because
quite often they will go and adjust their practice and I am sure
that there are examples where lengths of stay and other things
have occurred as a result of that injection. I think that it is
really important that we see this as part of an integrated development
of more provision where each can play its part, but actually we
need all components to make a success if success is better outcome,
more up-to-date practice, capacity to reduce waits and the driver
for value for money because I am sure we will not drive value
for money without some of these processes. I would not like to
say where, but I think if we asked for the same quantum, and in
fact I could ask for the same quantum, of treatment that we are
getting from some ISTCs from the normal planning processes of
hospitals, the costs would be greater because of the way it is
done. I think we have got to see this in the round rather than
saying that one is good and one is bad. The fact is that it is
the interaction of both that is going to transform the healthcare
system and that is why it is crucial to reform.
Q573 Charlotte Atkins: But the Woodland
NHS Centre seems to be achieving the same as ISTCs without the
benefits of a take or pay contract. That is the point, that they
are driving those improvements without the advantages that you
seem to be piling on to the private sector. Now, the Secretary
of State has said that they could create a dynamic. Is, therefore,
this support for the private sector driven by ideology rather
than by looking at what places like Woodland actually produce
and would actually create?
Ms Hewitt: Well, as I said a few
moments ago, there are superb examples of best practice and innovation
on every aspect of care you care to name within the NHS itself
and there are indeed some excellent treatment centres, but the
point Sir Ian has just made is a very important one, that it is
actually much easier not just to innovate, but to embed every
aspect of best practice in a total system if you are starting
on a greenfield site and you do not have established ways of working
or an established culture of, "This is how we've always done
it". I think that is probably one of the main reasons why
in 2002 in the very early stages of this the NHS Modernisation
Agency reported that the good practices that they identified at
the time in the NHS treatment centres were not widespread, nor
did any treatment centre embody more than a few of them, whereas
actually a lot of the gains are to be found if you have every
aspect of best practice in every aspect of care and you try and
get the whole lot together. Now, by no means are all the independent
sector treatment centres doing the best on absolutely everything,
but the advantage of a new provider on a greenfield site is that
you can design the whole thing from scratch and you can then leap
ahead not of best practice, but of most existing practice and
show people what can be done. That is a very powerful dynamic
for change, so our commitment to greater diversity of provision,
which is foundation trusts as well as the independent sector,
is not driven by ideology, it is driven by the experience of virtually
every sector not just in our country, but across the world, that
actually you need an element of diversity and pluralism in order
to get an entire system operating on the basis of best practice,
best clinical outcomes and best value for money.
Q574 Charlotte Atkins: Ultimately
then why are we not giving NHS treatment centres exactly the same
advantages as the ISTCs in terms of the take or pay contracts?
Ultimately our objective is to improve the NHS, improve its productivity
and improve its dynamism, so why are we not doing that with the
NHS treatment centres that we have ongoing at the moment?
Ms Hewitt: Well, we do not have
contracts with NHS hospitals, except for foundation trust hospitals
which are now in a rather different category because they are
freestanding and responsible for their own futures and taking
the risk associated with it. The reason we had to have take or
pay contracts for Wave 1 was because the judgment was made at
the time that we simply would not have been able to get new providers
into the system if we had not been willing to share that or to
take that degree of risk away from them. The Wave 2 contracts
are likely to be done on a rather different basis, but of course
that is something we are exploring at the moment in the procurement
process.
Q575 Jim Dowd: The ISTC and the treatment
centre programme really cannot be anything more than a temporary,
and I was going to say "expedient", but I do not think
that is the right word, a temporary device because we have received
evidence that at the outset when there was a great differential
in waiting times between going to a treatment centre and going
to a closer local unit, there was a much higher take-up rate.
As the effect of the existence of the treatment centre drove down
improved practices locally and drove down the waiting times and
the differential became much narrower, the use of the treatment
centres dropped off quite sharply. Surely how are you going to
sustain it as an incentivising component of the organisation if
the work and demand, as the rest of the organisation improves,
takes away much of the work it has got to do?
Ms Hewitt: Well, I do not look
at this from the point of view of the providers. I do not stay
awake at night worrying about whether this centre or that centre
is going to have enough patients. What I worry about is the patients
and I think increasingly what will drive the system is not our
contracts or our targets or our top-down performance managements
systems, it will be patient choice and stronger commissioning
both by primary care practices and the primary care trusts. That
is what will drive the system and patients themselves will decide
where they want to have their hip replacement or their other elective
operation done.
Q576 Jim Dowd: The point I was making
is that the more effective it becomes, the more expensive at the
margin it also becomes and, therefore, unsustainable over the
long term to provide a permanent pressure, a permanent incentive,
if you like, on the NHS sector not just to improve its performance
to get rid of it, but actually to sustain it over time.
Ms Hewitt: I think what we will
see is a growing impact from foundation trusts and of course we
will over time have significantly more foundation trusts, so we
will have NHS hospitals themselves with far more freedom to innovate
and respond to what patients need and improve their services in
order to attract those patients and that is going to be a new
element of dynamism in the system. However, the NHS has always
used the private sector and we should not pretend otherwise, and
I believe that the independent sector for diagnostics and electives
as well as other aspects of care will be a permanent part of the
NHS family.
Sir Ian Carruthers: I just wanted
to add to that because there is an assumption behind the question
in fact that we have this one list of patients waiting on a common
threshold and, therefore, somehow when we get through them all
with the capacity it will become poor value for money. The plain
truth is that if you compare our healthcare with other areas of
Europe and the world, they all operate at different thresholds
for accessing care. In fact if you look at the cataract example,
it was very common in this country and it may be the case where
if you had a treatment required in two eyes, the priority was
to give you treatment in one and then wait for the second. Now,
the threshold for that will change and I think if you look at
how people get access to hip surgery, we have tended to have a
situation where people in this country have waited longer than
in other countries. I think that what we have got to realise is
that the dynamic in this is that, as practice moves, public expectation
will grow and interventions will become sooner to improve the
quality of life so that in fact we are not dealing with a static
population because what this enables us to do as we move on and,
if you like, clear off the backlog, which was implicit in that
question, so will the referral thresholds and the treatment thresholds
be adjusted to fit the capacity. We should not just think that
every referral is made on the same basis because there is a whole
set of factors. I actually believe that, as you move on, you are
absolutely right, where waiting times are very low, people feel
less need for choice unless it is for other reasons, but the plain
fact is that actually access to care and the quality of life we
are able to give people by early intervention will improve. That
is why I come back to the point that it is an integrated issue
which is about how we use the totality for the best benefit of
the population. The other feature of course is that most of the
ISTCs are on four- and five-year contracts, so it does build in
that adjustment in a way that we would not have if we were expending
the capital stock of the NHS, so I think it is important to take
into account those two because, for me, there is something that
says, "When do we have a problem?", and it is actually
when there is no one waiting and we have got idle facilities.
The difficulty that we have to handle in the intermediate term
has been there since NHS Select and all the other things that
have been successful which is how we marry the demand, and this
has to be done through choice and the incentive system, to the
capability that we have got, and I think that is the key.
Q577 Dr Stoate: I certainly understand
your frustration that best practice is not always delivered in
the NHS, whereas of course it can be, but it does not always happen.
I also understand your view that ISTCs, particularly on greenfield
sites, might be able to drive best practice and might be able
to deliver that, but can you actually give any examples or think
of where this really is happening? In other words, it is nice
in theory, this idea that ISTCs might drive best practice, but
do you actually have any evidence that it is?
Ms Hewitt: I am very happy to
send you a more detailed note[2]
because it really would take too long to go through it, but it
comes back to the point I was making earlier, that if you are
starting on a greenfield site and if success or failure on the
contract you have entered into absolutely depends upon reaching
your clinical quality standards, but doing that with best value,
you are going to organise things in a way that absolutely maximises
efficient use of time.
Q578 Dr Stoate: I entirely appreciate
that.
Ms Hewitt: The result of that
is, for instance, that the best, it is not all of them, but the
best ISTCs are doing six to seven arthroscopies a day compared
with three or four typically in the NHS and that is because they
have gone through the process in grinding detail and something,
for instance, like going through the consent process for the operation,
they do all that in advance at the outpatient appointment instead
of doing it when the patient comes in at the beginning. Now, I
am sure that happens in some places in the NHS, but what I am
saying is that with the ISTCs, they are routinising best practice.
Q579 Dr Stoate: But the question
is: are they giving the necessary kick up the backside to those
parts of the NHS that are not doing best practice to make sure
that they do? That is my question. Are the other parts of the
NHS that are not currently delivering best practice looking on
and actually being given this necessary kick?
Ms Hewitt: We have sought for
many years to spread best practice more effectively in the NHS.
That was why the Modernisation Agency was set up and now the NHS
Institute. It is why over many years we have trained well over
100,000 staff in all the techniques, if you like, of modernisation
and service transformation, but there is no doubt at all that
if you build these incentives into the system, you get results,
well, I think you get them on a different scale. Now, I would
offer you the two pieces of evidence. One is the graph that we
will send you about the waiting times that were pretty static
and then came down when we made some structural changes and injected
some dynamism into the system. The other is anecdotal and is simply
to do with the number of hospital chief executives who have said,
and it is a bit unpopular to say it, or it was when they were
able to say, for instance, to some of their consultants, "Well,
if we don't get our waiting times down, patients will go somewhere
else after six months or there'll be an ISTC down the road",
and actually they got the change in practice that they wanted.
Now, that probably makes it sound too adversarial and I suspect
it is not as adversarial as that, but there is evidence of that
happening and of course as the reforms we are making take effect,
and we can see it happening at the moment, many of those hospitals
that have got deficits have got deficits because they have not
been institutionalising best practice and they are now having
to do so.
1 Ev 155 Volume III Back
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