Examination of Witnesses (Questions 580
- 599)
WEDNESDAY 26 APRIL 2006
RT HON
PATRICIA HEWITT,
SIR IAN
CARRUTHERS OBE, MR
HUGH TAYLOR
CB AND DR
BILL KIRKUP
Q580 Mr Amess: Secretary of State,
I rejoice with you that this is the best year ever for the National
Health Service since its inception, but there are a number of
points about these independent treatment centres and the rationale
behind them that frankly have concerned me. To summarise everything,
you have just said we have got 100,000 staff being trained in
part of the modernisation service, but overall the reason for
these independent treatment centres is that there has been a failure
of National Health Service management. Now, you, Secretary of
State, have realised, and you have been very honest about it,
that there has been a failure in your Department because we have
got before us this morning the Acting Chief Executive of the NHS,
the Acting Permanent Secretary and the Acting Deputy Chief Medical
Officer, so everyone seems to be acting for all sorts of reasons,
so at least, Secretary of State, you have put your own house in
order. I am very, very concerned about your overall rationale
behind these centres, that you seem to be saying there is a failure
of management. Now, is it the fault of the doctors and nurses?
Given that this is the best year ever of the National Health Service,
who is actually to blame for the failure of management because
I understand that you are going to try and incentivise the NHS
to do better, but who is to blame?
Ms Hewitt: First of all, I am
not saying, and I do not believe, that there has been a failure
of management on the scale that you are talking about and, secondly,
I think trying to rush around the place saying who is to blame
is a complete waste of time. This is about everybody taking responsibility
for transforming the system. What I was talking about earlier,
and what we are doing, is moving the NHS from a monolithic system
to a new kind of system and the NHS has operated in one kind of
way for nearly 60 years. It was set up in the way that they set
up organisations after the Second World War because that was at
the time the best practice in organisational structure. You had
command and control organisations, you had public services that
were monolithic, that were, if you like, a provider monopoly and
because the NHS at the time was a transformation for patients,
it was the most enormous step forward for people, but we are nearly
60 years later. Patient expectations have changed, they are rising
very fast, the demands on the NHS are rising very fast, particularly
because of demographics, and medical technology and practice is
changing faster than I think most of us ever imagined possible.
Now we know, and we can see this in public service reform all
around the world, that we will achieve the next stage of improvements
in public services by giving people greater choice, by having
greater plurality and diversity of providers, by giving those
providers more freedom and more incentive to respond to what people
need and to adopt best practice and to innovate and underpinning
that of course with money following the patient and so on. Those
are the reforms that we are making, but that does not mean that
the old NHS was a failure of management; it was nothing of the
kind. It was, as Nye Bevan said, the most civilised thing in the
world and the changes that we are making are absolutely designed
to safeguard the founding principle of the NHS, that care should
be given to people on the basis of their clinical need, not their
ability to pay, that it should be funded by all of us through
our taxation contributions and that it should be free at the point
of need. By changing the NHS in the way we are, by meeting rising
expectations, by improving care and improving value for money,
I believe we will safeguard that founding principle and those
founding values.
Q581 Mr Amess: The only thing I would
say, Secretary of State, and I accept that everything you have
said is what you genuinely believe and what you are determined
to achieve, but I have sat on this Health Select Committee and
listened to Frank Dobson, Alan Milburn and your predecessor John
Reid. Do you accept, given that the general public and the staff
of the National Health Service have a certain view of we politicians,
and I have heard everything you have said about the organisation
for 60 years, but for the actual women and men who work in the
NHS, it is pretty tough for them given that it seems that there
have been different messages given by your three predecessors?
I am sure if we had the time to go over the transcripts of the
various hearings, your predecessors have said slightly different
things. I think it is just jolly, jolly tough on the NHS now for
all the staff just to sit back and accept what you have said without
raising any sort of concern at all.
Ms Hewitt: Well, I think the decisive
moment was the publication of the NHS Plan in 2000. That was the
beginning of a ten-year programme of investment, improvement and
reform in the NHS to move from the old NHS to the new NHS. Now,
obviously I have not had your experience of the Select Committee,
but I have read a number of evidence sessions with both Alan Milburn
and John Reid and I believe that what I am saying and doing is
absolutely consistent with what Alan Milburn set out in that 2000
NHS Improvement Plan and what John Reid said to this Committee,
I think, in December 2004 about the importance of patient choice
and the importance of seeing the NHS from the patient point of
view rather than simply the provider point of view. Now, our staff
in the NHS do a superb job and I am proud of the fact that we
have so many more of them, and we published earlier this week
the workforce survey figures, with 34,000 more staff just in the
last 12 months and I am proud of the fact that we are paying them
far better than ever before. The public service values which are
at the core of their commitment to the NHS will remain at the
heart of the new NHS. Other things will change, and I know that
is difficult because change is always difficult for all of us
and there are a lot of changes going on and we just need to keep
redoubling our efforts really to engage the staff in that, as
we did in Agenda for Change and as we will now do in implementing
Agenda for Change which will help to give us the flexibilities
and the dynamism within the NHS that we have been talking about.
Mr Amess: I will leave it there, Chairman.
Chairman: Could I thank you both for
that bit of respite, but could we now get back to the ISTCs!
Q582 Dr Taylor: First, I am afraid
I have got to try and lay to rest the myth once and for all about
cataract operations because we have been told absolutely clearly
on this Committee before that waiting times for cataract operations
were coming down very fast before the independent sector came
in to work. We have also been told that in a given year the independent
sector provided between 17,000 and 20,000 cataract operations,
whereas the NHS did 400,000. People sitting before us, high-ranking
officials, have said that the effect on cataract operations has
only been marginal, so I do think that we should get that absolutely
stated. Secondly, I am delighted Sir Ian talked about integration.
When we went to Redwood and when we went to Darent Valley, although
one is run by the private sector and one is run by the NHS, the
theme that made success was that in both of them the services
were being provided by NHS staff, the consultants were working
on Redwood as a part of their NHS job plan and integration worked.
When you have competition between independent sector treatment
centres located near NHS centres where they are not in any way
integrated, then there is the wrong sort of competition between
the two places and the system does not work. Now, coming back
to the script, you have mentioned dynamism and you have mentioned
innovation and you have acknowledged that innovation does exist
within the NHS. You have mentioned mobile cataracts and mobile
MRI scans as innovation in the private sector. I feel that, with
money given to the NHS, that could have been done just the same.
Could you give us any other examples of innovation which is absolutely
unique to the ISTC programme?
Ms Hewitt: No. I think the mobile
centres, yes, it would have been lovely if they had been done
by the NHS, but they were not, they were done by the independent
sector. They are terrific and I hope we will see a lot more mobile
centres in the future whether they are independent sector or NHS
because they are going to help us get better services, particularly
in rural areas. I think the other aspect of innovation is the
one I was talking about earlier which is bringing together a very
large number of different aspects of best practice in very detailed
aspects of clinical management and combining them all within a
single building and a single process. I know from my own experience
at the Department of Trade and Industry that although that is
not a headline-grabbing innovation, it is actually through that
kind of integration and adoption of best practice that the really
consistent improvements in productivity often get made.
Q583 Dr Taylor: Yes, thank you. I
am absolutely convinced the same innovations and more could have
been introduced, particularly, as with MRI scans, the private
sector programme was introduced at a time when some NHS MRI scanners
were idle because the PCTs did not have the money to pay for those
extra sessions, so if the money had been channelled to PCTs to
buy them for the NHS sector wherever possible, would that not
have been preferable?
Ms Hewitt: Well, this business
of scanners and the use of equipment is a very interesting one
because, as this Committee knows, there is equipment, very expensive
capital equipment, that is seriously under-utilised. Now, we are
putting enormous sums of money into the NHS and we are encouraging
hospitals, particularly through Agenda for Change, to use their
staff in much more flexible ways. I have seen examples, for instance,
in Huntingdon of superb practice in the NHS where radiologists
are now doing what only they need to do, radiographers are taking
on more of their work and then assistant radiographers and radiography
assistants are being trained up to do more of the work and, through
that kind of changing role, they are making far better use of
the equipment, they have slashed the reporting times from anything
up to 24 days to less than 24 hours, so that is happening. However,
it is not happening everywhere and last year we had some shocking
cases, headline cases, of patients, and one patient in particular
I remember who was told by the NHS, "You will have to wait
six or 12 months for an MRI scan", and then scribbled on
the letter she was sent was, "If you want to go private,
ring this number". Now, that is unacceptable and, as a result
of that, last November we introduced choice for scans at six months,
MRI and CT scans, and from April, from this month, we have introduced
choice at five months for all scans. Now, we have not yet got
the detailed monitoring data and we will obviously have to see
what impact it has, but for a very small number of hospitals,
and this is not yet statistically significant, we have seen a
massive reduction in waiting times since we introduced choice
of scan at six months. Since that is exactly what happened when
we introduced choice of operations, starting with heart operations
at six months, I would not be surprised if the effect we have
seen in a few hospitals actually was replicated in other places.
You need structural changes to get best practice as well as exhortation
and education.
Q584 Chairman: We did have a couple
of questions on local autonomy, but I think, in view of the time,
Secretary of State, we will skip over them and move on to the
issue of Phase 2 of the ISTC programme which is certainly more
relevant to our inquiry, I think. What stage is Phase 2 at now,
how many bids has the Department received and when will the contracts
be agreed?
Ms Hewitt: We have for tranche
one now had the expressions of interest in, we have issued the
invitations to negotiate and we are now working our way through
that process.
Q585 Chairman: Do you know how many
ISTCs you have commissioned?
Ms Hewitt: Yes, on the electives
there are 12 schemes which are in tranche one and tranche two.
The Invitations to Negotiate (ITNs) have gone out. We have had
responses on five schemes and bidders are assembling their responses
on the remaining seven, so we are currently evaluating the bids
for—shall I give you the detail? Anyway, we are evaluating
the bids for five schemes and we are waiting for the responses
on the remaining seven.
Q586 Chairman: Are there discussions
taking place with the local and wider health communities about
these or have there been in the recent past?
Ms Hewitt: There has been on each
of them before the invitations.
Q587 Chairman: I understand that
is taking place. Will take or pay contracts be a feature of Phase
2? We have heard this thing about ISTCs developed without this
financial safety net, but can they do that given the strong hostility
towards that part of the system as far as the NHS professionals
are concerned? What is your view on that?
Ms Hewitt: Well, as I said earlier,
take or pay contracts were needed to bring the new providers into
Wave 1. I would expect them to be a much less significant feature
of Wave 2, but it is too early to say whether we will need them
at all.
Q588 Chairman: We have heard this
issue about tapered take or pay. Is that something that you are
looking at?
Ms Hewitt: Yes, that is one of
the possibilities we are looking at.
Q589 Chairman: Does that relate to
the amount of referrals that you get from the rest of the health
community? We have had anecdotal evidence and we have discussed
with the health professionals about in some instances the reluctance
of the wider health communities to send or to refer people to
the current ISTCs.
Ms Hewitt: As we move to a system
of patient choice, it will be the patient who decides where they
actually go. The real issue here, I think, is risk. Do we ask
new providers or independent sector providers to invest in facilities
and simply do that on the basis that if they get the patients,
they get paid and if they do not get the patients, they do not?
Now, that will mean transferring the entire risk to those providers
and that is likely to cost more than if we share some of that
risk. Obviously with the take or pay contracts, really we carry
the whole of the risk and that is why you can look at variations
between all of the risk being held by the Department, all of the
risk being held by the contractor or the risk actually being shared,
so we have asked providers to bid on the basis of tapering guarantees
for contracts because we think that will be much more appropriate
in Wave 2 than these 100% take or pay contracts that were in Phase
1. What we want to get to is by the end of the initial guaranteed
contract period all independent sector providers should be providing
services obviously of NHS quality, but also at the equivalent
of NHS tariff with patients having free choice and a level playing
field.
Q590 Anne Milton: Can I ask you about
training. I do not know what your plans are for Phase 2, but will
the inclusion of training provision affect the rates which ISTCs
can offer?
Ms Hewitt: Yes, we are intending
to include training requirements in Phase 2 and I think that was
one of the very important lessons, if you like, learned from Phase
1. It really was not possible to build training in from the outset.
They were starting to do it in some of the Wave 1 centres, but
training not only for doctors, but also for nurses and allied
health professionals will be part of Wave 2, but what we are asking
the bidders to do is to look at the impact of providing training
on their own levels of productivity, if you like, and then costs
and, therefore, to give us prices.
Q591 Anne Milton: Will all the Phase
2 ISTCs have training potential?
Ms Hewitt: That is our intention,
yes. We are going to require ISTCs in Wave 2 to provide training
across the full range of clinical services. They will have to
provide it across clinical services and we may also ask them to
provide training in clinical management skills, the kind of thing
we were talking about earlier in relation to best practice.
Q592 Anne Milton: Would you at the
same time allow Phase 1 ISTCs to provide training because there
is some concern that they are not doing so?
Ms Hewitt: Yes, indeed there is
and we have already been working with the providers and with the
Royal Colleges and the deaneries to get training into some of
the Phase 1 providers.
Q593 Anne Milton: Some or all?
Ms Hewitt: At the moment it is
some, but there are discussions going on on this with in fact
most of them.
Q594 Anne Milton: Will anybody training
within an ISTC be trained by an NHS consultant or a recognised
trainer?
Ms Hewitt: An NHS trainer.
Q595 Anne Milton: So all of them
will be trained by NHS consultants or recognised trainers?
Ms Hewitt: There will be a recognised
NHS trainer delivering the training to clinicians in Wave 2.
Q596 Chairman: The issue of additionality
as far as Phase 2 is concerned, I would like to believe that that
is now going to be relaxed, the additionality of workforce which
in the vast majority of Phase 1 we understand that the majority
of the workforce, certainly the surgeons, most of them came from
outside this country actually.
Ms Hewitt: Yes.
Q597 Chairman: That is going to be
relaxed, so there are a number of questions, but I would just
like your wider view on it, and could I also couple with it the
issue of BUPA Redwood that we saw where there was actually this
joint venture where NHS staff and BUPA staff were working alongside
one another in a treatment centre, no matter how it is described
elsewhere. Is that the type of thing you see for the future, particularly
of Phase 2, in view of the relaxation of additionality if that
is going to go ahead?
Ms Hewitt: I will turn to Ian
in a moment on that point, but on additionality, I think it was
absolutely right to have very strict additionality rules for Wave
1 because we were desperately short of staff at that point and
the priority was to build that extra capacity as quickly as possible,
so we had a `no poaching from the NHS' rule because, otherwise,
we could have ended up simply moving staff from the NHS to the
independent sector with no overall gain to patients, hence the
additionality rules. Last year the Royal College of Surgeons,
in particular, and others talked to me and said, "Look, this
is becoming too restrictive and it is hampering the kind of integration
of services", which both Sir Ian and Dr Taylor were rightly
talking about, so we looked again at additionality and of course
we looked at it in the light of the fact that we have now got
so many more staff than we have ever had before and the new training
places for doctors and nurses are now delivering more graduates
than ever before, so we were able to relax the additionality criteria.
I think the Royal College of Surgeons and possibly the Royal College
of Radiologists would like us to go a little bit further and I
think there is still a balance to be struck here. For the shortage
occupations, and there is a worldwide shortage of radiologists,
if we relax the additionality requirements there, there is still
a real danger and all we do is shift or all we do is allow the
independent sector to poach very scarce staff from NHS providers
and that does not add to the capacity which is what we are trying
to do.
Q598 Chairman: Are we likely to see
this sort of BUPA Redwood joint venture?
Ms Hewitt: There is no reason
why there should not be more joint ventures in the future.
Q599 Chairman: In a sense, if you
wanted to, you could effectively stipulate that as part of Phase
2 or some parts of Phase 2, could you not?
Ms Hewitt: It is an issue that
we are keeping under review. A lot of foundation trusts, I think,
are interested in developing joint ventures, but there is also
an issue which I mentioned before about diversity and an element
of competition and challenge. We are not trying to create a private
market here, but we do want an element and, therefore, we do not
simply want foundation trusts and the independent sector taking
over everything together.
Sir Ian Carruthers: This has to
be seen in the overall development of the NHS and the reform programme.
Effectively what we want is diversity of provision and what we
want is provision that is actually integrated where arrangements
can be the most appropriate at the local level, so there is no
reason why that would be precluded. Indeed, in many hospitals
now and ISTCs, they have arrangements where not quite the same
thing occurs, but through the secondment scheme and other things,
people do work in the different centres. I go back to the point
that we made earlier, that we need to see this as an integrated
whole and how the various components can improve the NHS, and
I think that is the stance that needs to be pursued.
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