CORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 934-i

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

 

 

INDEPENDENT SECTOR TREATMENT CENTRES

 

 

Thursday 9 March 2006

MR KEN ANDERSON and MR BOB RICKETTS

MR BERNARD RIBEIRO CBE, MR SIMON KELLY, PROFESSOR JANET HUSBAND OBE, DR PETER SIMPSON and MR IAN LESLIE

Evidence heard in Public Questions 1 - 141

 

 

USE OF THE TRANSCRIPT

1.	This is a corrected transcript of evidence taken in public and reported to the House. This transcript has been placed on the internet on the authority of the Committee, and copies have been made available by the Vote Office for the use of Members and others.
2.	The transcript is an approved formal record of these proceedings. It will be printed in due course.

 

Oral Evidence

Taken before the Health Committee

on Thursday 9 March 2006

Members present

Mr Kevin Barron, in the Chair

Mr David Amess

Jim Dowd

Anne Milton

Mike Penning

Dr Howard Stoate

Dr Richard Taylor

________________

Witnesses: Mr Ken Anderson, Commercial Director, and Mr Bob Ricketts, Head of Demand Side Reform, Department of Health, gave evidence.

Q1 Chairman: Good morning, gentlemen. I wonder if I could ask you to introduce yourselves for the sake of the record and to tell us what area of expertise you bring to us this morning.

Mr Anderson: Good morning. I am Ken Anderson. I am the Commercial Director of the Department of Health.

Mr Ricketts: I am Bob Ricketts. I am with the Department of Health and I lead on policy for commissioning and choice.

Q2 Chairman: Thank you very much for coming along. This is our first sitting on our inquiry into the ISTCs. I wonder if you could start by telling the Committee how many ISTCs and National Health Service Treatment Centres there are at the moment or under development.

Mr Ricketts: There are 20 open ISTCs. My recollection is that there are approximately 45-50 NHS Treatment Centres depending on how you categorise them, but I would need to check that figure and come back to you.

Mr Anderson: I would defer to Bob on the NHS, which is not my area of expertise, but we do have 20 ISTCs with another ten to follow.

Q3 Chairman: What are the objectives of the ISTC programmes, and how much importance do you give to the objectives? Initially the three objectives of the programme were to increase capacity, offer patients a choice of venues for treatment and to stimulate innovation. Then we also had the introduction of this word contestability which came into the frame as well. What are the objectives? Does that cover all of them?

Mr Anderson: It covers a number of them. Probably the main objective at the time was for capacity. The process that we went through was one where we would go out to the local NHS through the strategic health authorities and ask them what capacity gaps they had and what they could not accomplish or provide themselves either efficiently or at all. The primary objective was the capacity issue. There were other goals that we hoped to accomplish through the ISTC programme.

Q4 Chairman: It was the capacity issue which seemed to be the obvious one that went round in the public domain at the time. Was that because NHS Treatment Centres were not capable of filling up the capacity?

Mr Anderson: The SHAs in conjunction with the PCTs did an assessment of the capacity needs of the area and, more importantly, they determined whether or not they could fulfil those capacity needs. We received a series of submissions to the Department on the back of that and that was fairly comprehensive work that outlined in detail what the needs were in the local area. That is how we were informed at the departmental level of what the needs were, particularly around capacity.

Q5 Chairman: Was the location of the first phase to do with where the capacity was needed as it were? There is one just south of my own constituency which covers North Trent and South Yorkshire. Was that because of the need for orthopaedic surgery in that particular area?

Mr Anderson: That is exactly right. We were informed by your local health economy that they needed orthopaedic capacity in the case of Trent and therefore we procured that capacity for them.

Q6 Chairman: That was a response to the waiting times and the waiting lists.

Mr Anderson: That is correct. I cannot speak for Trent itself. There was probably a variety of issues that came up in the local economy that we are not aware of at our level that they would have put into the pot to come up with the answer that they ultimately gave us from the standpoint of their needs.

Q7 Chairman: You will be very familiar with the fact that some parts of the National Health Service felt that the location of these could destabilise local hospitals. Is that something that you took into account when the first phases were located?

Mr Anderson: Again, the capacity planning was done at a local economy level. It was not for us to try to determine at our level. We would not have had the capability because we do not have the granularity of data to go out and make those decisions for a local health economy.

Mr Ricketts: It is worthwhile adding, Chairman, since I was leading on the capacity planning, that those discussions were very detailed with the health authorities and PCTs. Back in 2002 there was a very real risk of not delivering the six month waiting time target and certainly, looking at all the projections of capacity for the NHS, there was a clear need to rapidly expand the NHS Treatment Centre programme and to bring in additional independent sector capacity not just to help hit the six month target but also because in some places the non-elective targets and priorities were under pressure. A secondary aim of the programme was to take some of the pressure off so that some trusts could then reconfigure and have more physical space to handle some of their emergency pressures because at the time, as you will remember, waiting time issues and also emergency admissions were very high priorities. We were trying to address several issues when we were looking at whether we needed this amount of capacity in a given health system.

Q8 Chairman: Issues like choice came along at a later stage as far as the Department is concerned.

Mr Ricketts: Strictly speaking, no. Choice was at a very early stage of development. When Alan Milburn announced the first wave of the procurement in December 2002 he put the emphasis on cutting waiting times, but he also referred to an objective which was to increase patient choice clearly with a view that in three years' time we would have to offer choice. We were running with two objectives then, the primary one being capacity, which was to hit the six month target and to ease some of the pressure on A&E and the non-elective work.

Q9 Dr Stoate: I understand why the objective was to improve capacity, particularly in areas where there was a shortage and you needed government targets to get the times down. Did you make any assessment at the time of whether increasing that capacity or bringing new capacity into the system would have any effect on existing NHS hospitals?

Mr Ricketts: We asked health authorities and PCTs to consider whether there was likely to be an impact. If we are talking there about Wave 1, which was the procurement launched in December 2002, particularly when taking into account the amount of elective work being done by the NHS, the overall size of that was really too small certainly nationally and in most health areas to have an impact. In terms of the ISTCs that are open now, they are doing 60,000 Finished Consultant Episodes (FCEs) a year this year and the total the NHS is doing is 5.6 million. Potentially if we had got the case mix wrong one could have had an impact at specialty level in an economy. We had one example of that in Southampton where we had to adjust the case mix and likewise in terms of cataracts, but the volumes of additional capacity we brought in from the independent sector were unlikely to destabilise local economies.

Q10 Dr Stoate: Certainly they would not destabilise the economy as a whole. You did not do any specific research on whether there were locally specialty difficulties, did you?

Mr Ricketts: Where concerns were raised, we went back and challenged SHAs and PCTs on whether these figures looked right and that led, for example, in the case of Oxfordshire, to a reduction in the activity requirements. We offered to move some of that capacity, because it is a mobile service, to those places which had got their numbers wrong in the sense of a shortfall. We were actually aware of that, but we did take the view that for the first wave, because everybody needed the capacity to get to six months, it was very unlikely that it would tip any service over. Where concerns were raised, we followed those up and we reduced the level of activity in the case of cataracts.

Q11 Dr Stoate: What you are saying is that, so far as you are aware, there has been no destabilisation or undermining of local hospitals because of these centres, is it not?

Mr Ricketts: Very much so. They are doing only 60,000 FCEs this year and next year it is going to be 117,000, but the NHS will do nearly 6 million. It is difficult to see how it can have a serious destabilising effect. I think the bigger issue which has been raised by the service is the impact on training, which is something where we recognise that if you are moving out many of the frequent but simpler procedures that junior medical staff train on then that is one of the areas where we do need to avoid inadvertently destabilising training networks. I think that feels like the bigger risk rather than causing a service to fail, which is why we have been in discussions with the Royal Colleges around how we manage the training element of ISTCs.

Q12 Dr Taylor: Could you explain additionality to us? Why was it such a crucial part of the ISTC programme?

Mr Ricketts: At the time when we launched the procurement we were very concerned about having sufficient capacity, not just physical but also workforce, to hit the six month target. There was a concern amongst ministers and the professions that there was the risk that the independent sector providers might "poach" staff from the NHS and we might end up moving workforce shortages. Therefore, we agreed with ministers to take a very strict view of additionality, which was that no independent sector provider could employ anybody who had worked for an NHS secondary care organisation in the last six months. We have relaxed that rule for the current wave of procurement because the workforce situation has improved, but at the time we all thought the prudent thing to do was to have some very strict rules around basically forcing independent sector providers, unless it was a joint venture, to obtain their staff from a non-NHS source because of the need to protect NHS services.

Mr Anderson: Even more important than that was the need to bring in extra resource to do the surgeries. As a country we did not have at our disposal the number of nurses and doctors that we needed to perform procedures and to bring the waiting lists down. It was a very specific part of policy that looked at ensuring bringing in that extra capacity both in terms of buildings, people and clinicians.

Q13 Dr Taylor: You are saying that it is being relaxed with the second wave.

Mr Ricketts: It has been relaxed for the second wave for those groups of staff where there are no longer significant forecast shortages. Where we know we are going to have some shortages potentially and we do not have a surplus of staff, like radiology, radiography and some of the more specialist nurses, then we have said that we intend to maintain additionality for Wave 2. We have been in six or seven months of negotiations and discussions with the key trade unions and the staff associations around what should be the list of those staff groups to whom additionality should still apply.

Mr Anderson: We also see additionality and the need to relax it as a way to start to integrate these facilities into the local health economy and so a relaxation of the additionality requirement will allow that to occur. We have had quite a bit of commentary from the Royal Colleges and others saying that that is not being allowed to occur because of the additionality issue. So we have taken that into consideration and, through ministers, we have decided to change that.

Q14 Dr Taylor: To me that is one of the most important bits because at the moment there is a divorce between the ISTCs and the local NHS economy. In places where there are, for example, NHS orthopaedic surgeons who could take on some extra work, could that now be allowed?

Mr Anderson: It could be. It would be looked at on a specific basis depending on the area but based on the things that Bob has just mentioned and whether or not there is a shortage or a deficiency because we do not want to move staff out of the NHS into an Independent Sector Treatment Centre and remove a resource that is needed in the NHS.

Q15 Dr Taylor: Unless you could be sure it was not taking away from that capability within the NHS.

Mr Anderson: That is correct.

Mr Ricketts: What we have done is introduce something called non-contracted hours so that particularly medical staff, who are maybe not using the non-contracted hours and who are not being used to the benefit of the NHS could work for a private insurer or to do something else, who are subject to strict controls around safe working, could then work in an Independent Sector Treatment Centre. That is something that we have had strong support from the medical profession for in terms of being slightly more flexible and allowing people to use their spare resources as long as it does not prejudice NHS care and it does not lead to somebody working too many hours.

Q16 Anne Milton: How do complaints about ISTCs compare with the NHS as a whole?

Mr Anderson: Currently we track through our Key Performance Indicators (KPIs) serious untoward incidents. Serious untoward incidents - and you have to understand, to date we have done 49,000 elective procedures - are of the order of one quarter of 1%. I do not know how that compares to the NHS because in many cases they do not collect that data so a comparison is not possible.

Q17 Anne Milton: What is a serious untoward event?

Mr Anderson: I could not define that for you appropriately. I could come back to you in writing on that.[1]

Q18 Anne Milton: A serious untoward event presumably is an event that everybody knows has occurred. I was actually asking about complaints.

Mr Anderson: I do not have that figure in front of me. Again, I could write to you and give that to you.[2] I do know that the satisfaction rates in the ISTC run at 97% in comparison to 91% in the NHS.

Q19 Anne Milton: What outcomes are measured, quality of life and morbidity et cetera?

Mr Anderson: That is a fair question. First of all, I am not a clinician so I cannot go into the detail, but what I can tell you is that we have a set of 26 Key Performance Indicators that are contained in the contractual relationship with the providers and they are clinical performance referrals and the contractual obligations just generally of the provider. Again, if you wanted specific detail on that, I could have somebody from the DCMO's office write to you about that as it is outside my area of expertise. We do collect them on a monthly basis; they are monitored. The quality assurance process is basically a mirror of the NHS quality assurance process. Patients are NHS patients when they are in the ISTCs and they have all of the same rights and capabilities of complaint as an NHS patient does. I do not have those figures in front of me from a complaint standpoint, but we can get back to you on that.

Q20 Anne Milton: And if you could also let us know what a serious untoward incident is.

Mr Anderson: We will define that for you.

Q21 Anne Milton: It has to be said that theatres in the NHS throughout the night lie dormant. On the basis that you were attracting medical and nursing staff from elsewhere because of additionality, would it have been possible not to have started the ISTCs and to use the theatres overnight and to bring in staff from elsewhere if there was not capacity in the medical and nursing staff?

Mr Anderson: In some cases we did that. Depending on the contract and the availability and capability within the local economy, we did use existing NHS facilities. There is a difference between currently elective surgical throughput and it basically relates to keyhole surgery and whether or not those facilities are up to doing it because it is a completely different type of surgical event. What we were trying to do, along with the all the other things we mentioned at the beginning, was to bring in innovation as well, new working techniques, so that we could increase throughput and, more importantly, quality for the patient and a lot of times that entailed that we had to go out and build fit for purpose facilities.

Q22 Anne Milton: Will you be doing it with the next phase, particularly on diagnostics? Will you look towards the NHS first of all and whether that can be used more effectively by using it out of hours?

Mr Anderson: Most definitely. The process with Wave 1 was non-static that we went through around the gap analysis. We had started out initially with the NHS telling us that we should procure 250,000 procedures and we actually procured 170,000 and that will continue in Wave 2. I would not wish to be flippant, but it is really too early to tell exactly what those service redesigns and configurations will look like, particularly around the diagnostic piece.

Mr Ricketts: What you are suggesting is exactly our strategy in terms of diagnostics. We have got to deliver a huge increase in diagnostic provision, particularly scanning, in the next two years to deliver 18 weeks because we need 900,000 more MRI scans and over half a million CT scans. We are getting less than half of that from the independent sector. At the same time as we procure diagnostic capacity from the independent sector we have also strongly encouraged local NHS Trusts to increase their diagnostic capacity. We will not hit 18 weeks if we solely rely on the independent sector. The strategy you are talking about where trusts are encouraged over the next two years to use their scans to best effect and so on is exactly what we are looking for, it is an investment into a growing NHS capacity or using it effectively to hit diagnostics as well as investing in the independent sector. Even at the end of 2007/08, if you take MRI, only 25% of total scans will be provided by the independent sector, the overwhelming majority will be through the NHS mainly by encouraging them to use their facilities for longer hours and to change their skills mix and so on in the way you are suggesting.

Q23 Dr Taylor: Can you give us any idea of the proportion of overseas to home trained surgeons in the ISTCs?

Mr Anderson: I cannot here. I could write to you with that.[3]

Q24 Dr Taylor: Is it pretty much the vast majority who are overseas trained or is that impression wrong?

Mr Anderson: I would not want to proffer an answer and be wrong. It would be my sense that that would be correct, but I would not want to mislead you. I will write to you on that.

Q25 Dr Taylor: That would be very useful. In your report to the Secretary of State, dated 16 February, you say that all clinicians are on the appropriate specialist register of the GMC as in the NHS. Is the accreditation process exactly the same for people coming from other countries as from this country?

Mr Anderson: The accreditation process is handled by the General Medical Council. Everyone is registered with the GMC.

Q26 Dr Taylor: So these are questions we should put to them. Are you not aware of differences in accreditation?

Mr Anderson: I believe that there is no difference, but if you want to ask questions around that area I suggest you talk to the GMC.

Mr Ricketts: The requirements are exactly the same in terms of registration and being on the specialist register. It is a contractual requirement of the programme. We could confirm that in writing.[4]

Q27 Dr Taylor: We will take that up with the GMC when we see them.

Mr Anderson: Dr Taylor, I have just been passed an answer for you. I am told that one in four in the NHS itself is overseas trained and that the vast majority in the IS are overseas trained.

Q28 Dr Taylor: That is very useful. You have talked a little bit about complaints. Are there any figures for complication rates between NHS Treatment Centres and ISTCs?

Mr Anderson: We collect them in the ISTCs. The problem we have is that a lot of the data we collect under our Key Performance Indicators is not routinely collected in the NHS. We find it very hard to compare complication rates. The more you get into the granularity of data the harder it is to compare apples to apples. Again, that is a clinical question. I do not know that I have the specific answer in front of me. I will put that to our clinical colleagues.

Q29 Dr Taylor: We have got this horrendous paper entitled "Preliminary Overview Report for Schemes: ISTC Performance Management Analysis Service" which is going to put anybody off after just one glance at it because it is all figures. Could either of you give us a thumbnail sketch of what it says? It is prepared by the National Centre for Health Outcomes Development. Is this a new arm's length body?

Mr Anderson: No. They are attached to a university. It is not an arm's length body. That is clinical in nature.

Mr Amess: They will write to you, Richard.

Dr Taylor: I will not be able to understand that either!

Q30 Anne Milton: Are you saying that complications of procedures is information that is not collected within the NHS?

Mr Anderson: In some areas they do collect that data. My area of expertise is not in the NHS, it is around these centres. From the standpoint of serious untoward incidents, that is not collected. Below that level of granularity I do not know exactly in specific areas what is collected and what is not.

Q31 Anne Milton: Mr Ricketts, maybe you can answer that.

Mr Ricketts: There is a problem for some specialties and some procedures that colleges collect through audit of complication rates, and cataracts would be a good example. Once you are outside cataracts you start to struggle in terms of having reliable published data that is statistically significant and that covers all providers. It is a problem we hit when we published the patient choice booklets in December where I had hoped that in addition to the information on waiting times and some of the other Healthcare Commission data we could provide some meaningful clinical indicators. It is an area that we recognise, as the Department, we have to work on with the professionals and patients so that we can publish meaningful clinical quality data, including complications, across all providers and at a sufficient level of detail to be sensible, which probably means at specialty level and so on. It is a great difficulty. So we hit that problem in terms of the choice booklets. I think Mr Anderson's observation is right.

Q32 Anne Milton: Can I suggest that I do not have a choice unless I have got some clinical indicators because my choice should be informed. If it is not informed by the fact that this hospital or that hospital or this ISTC has complication rates then I am not making a choice.

Mr Ricketts: I would agree that you are not making as informed a choice.

Q33 Anne Milton: The complication rates is fairly fundamental information.

Mr Ricketts: I agree with that. In terms of the introduction of choice, we have to work from where we are. It is really important that any information which is provided to patients for choice is reliable and published by an independent body. We pushed the Healthcare Commission very hard. We used the information that was published by the Healthcare Commission so that we would not mislead a patient if they are relying on that. Clearly they also have the conversation with their GP who will steer them in terms of their perception of clinical quality, but again I recognise it is very difficult for GPs in those circumstances depending on what they know of the provider. That is why we have signaled that one of the key next developments in the choice policy is to move away from waiting times and satisfaction rates, which are important to patients, into developing some measures of clinical quality that can be published and that can be used by GPs and patients to inform choice, but we are not there yet. In terms of what is nationally published, it is very limited in terms of clinical quality. I am not trying to avoid the question, I am just stating where we are.

Anne Milton: It is very difficult if we have not got any information on complaints, we do not know what an untoward incident is and we have got no information on complications to compare.

Dr Stoate: I share your point of view on patient safety. One of the things that trusts are required to do is to report adverse patient incidents which could affect patient safety. However, the quality of reporting is fantastically variable, with some trusts returning a nil return, which means they have no adverse incidents and which beggars belief. The quality of data which is submitted by trusts is extremely poor.

Anne Milton: So patients are not going to be able to exercise an informed choice, it is as simple as that.

Q34 Chairman: Has any comparative assessment been made between independent and NHS Treatment Centres?

Mr Ricketts: Not a direct comparison, no. The National Centre for Health Outcomes Development (NCHOD) report could not do that in detail last year when it was published simply because the number of patients treated would not be meaningful statistically. When we publish in the autumn the next version of the NCHOD report, because we will have many more patients that will have gone through the programme and therefore the KPIs will be more meaningful, we will be able to provide much more comprehensive information on clinical quality, but at the time they produced the report they had comparatively few cases and certainly not enough to draw meaningful comparisons.

Mr Anderson: From the standpoint of ISTCs, I do not have that granularity of data at hand. We collect data as a matter of course through the contractual environment and through the Key Performance Indicators that we ask of the firms who are doing the work. So that data is out there. I just do not have the specifics in front of me.

Q35 Chairman: You do not ask for it of NHS Treatment Centres, is that what you are saying?

Mr Anderson: NHS Treatment Centres are not within my realm of expertise.

Q36 Chairman: It seems that doing any comparison is going to be very difficult if you are not comparing like with like.

Mr Ricketts: What we are doing as part of the next phase of choice is we are working currently with the NHS Confederation, the Foundation Trust network and also the independent sector to look to develop, before the autumn patient choice booklets, meaningful measures where you can compare NHS and independent sector providers like for like. That work is being developed. It is not that information is not out there, it is that it is not pulled together in a way that would be meaningful and, crucially, some of it is quite variable, so we need to improve the quality. We are trying to do all we can to ensure that over the course of the next year, as choice rolls out, more and more information is available for patients and GPs to take those choices, but we have had to start from where we are.

Q37 Dr Stoate: One of the things we have picked up from some of the evidence we have had is that people are concerned about continuity of care, the aftercare from these Independent Sector Treatment Centres, not so much the operation itself but what happens afterwards. How are the contracts worded to ensure that there really is safeguarded continuity of care for NHS patients?

Mr Anderson: When we set about trying to determine what the needs of the local economies were we worked on a pathway basis and so we asked the NHS about the pathway and in some cases they could do a significant part of the pathway but maybe not the surgical part of it. So maybe they could do the pre-operative care and the post-operative care but the actual surgical intervention was not possible in their area. So it varies, to be very honest with you, among contracts. Some contracts can stipulate that the provider has to provide all of the front-end surgical and back-end care, whether that is physiotherapy or other modalities post-surgery. It can stipulate that all that they do, depending on the area, is just the surgery itself. We definitely look at that as a pathway concept. We used that as an integration tool from the NHS into the ISTCs and then back into the NHS after post-operative care.

Q38 Dr Stoate: So as far as you are concerned the entire patient pathway is covered in the contract, is it?

Mr Anderson: No. What is covered in the contract is the portion of the pathway that the NHS has asked the independent sector treatment provider to provide.

Q39 Dr Stoate: Does that mean there are no gaps in the pathway as far as you are concerned and that someone has picked up every aspect of them? What we are hearing from various groups is that there are gaps in this pathway and, particularly when there has been a complication during a surgical procedure, that somehow somebody else, which is not always very well defined, is left to pick up the pieces and that does cause distress. How can you guarantee that that has been covered?

Mr Anderson: In all honesty, we have had teething problems. This is a new concept. It has not been without some issues. When those occur, we look at them and we fix them. Specifically down at NHS local level, I do not have the detail. I do know of what you speak. The issue is less about a gap in the pathway and more about, since it is a new service, whether it has been joined up appropriately.

Q40 Dr Stoate: If there has been a complication and the person ends up in an NHS hospital, are there sanctions on the ISTC either to cover the costs of the care or to make some repatriation where it is found the ISTC is at fault of a wrong procedure or a complication that the NHS subsequently has to pick up?

Mr Anderson: If a provider is at fault, there are financial penalties within the contract, yes.

Q41 Dr Stoate: If somebody had got a complication after a hip replacement and had to have the operation revised in an NHS hospital, you would send the bill to the ISTC, is that right?

Mr Anderson: That would be based on the local area. There is a lot of local involvement in these contracts. The local provider or the sponsor of the contract will sit down with the provider and come to a conclusion as to whether or not it was a fault against contractual constraints and therefore a penalty was advised or not. In general terms that is the way that it works.

Q42 Dr Taylor: Is there any record of the numbers of patients who have been operated on in ISTCs who have subsequently had to be admitted to NHS hospitals?

Mr Anderson: I do not know if we keep that information. I cannot honestly answer that question.

Q43 Dr Taylor: How would we get at that?

Mr Anderson: I would imagine that within our KPI list that may be picked up. We do keep a readmission rate when we ask for Key Performance Indicators.

Q44 Dr Taylor: A readmission rate to you?

Mr Anderson: No, to any hospital post-surgery.

Q45 Dr Taylor: So that is available, is it?

Mr Anderson: We should be able to get that.

Q46 Dr Taylor: That would be very useful to have. One thing that alarms us is that when a commissioner contracts a service it is for a certain number of procedures over a certain time, which might be as long as five years. Have you any record of how ISTCs are keeping up with those contracts? If a contract has gone one year out of five, is there anything to say they have done a fifth of the number contracted? I am pretty concerned that some of the PCTs are going to be unable to get providers to do all the cases they have contracted for which obviously is going to put the price up.

Mr Anderson: It has no relational value to the price.

Q47 Dr Taylor: If you only do 1,000 operations instead of 2,000 effectively ---

Mr Anderson: It will reduce the value for money. The programme is truly in its infancy. We only have one contract that I know of that has been in place over one year. We brokerage within contracts when throughput is not taken up and we do track it. On the figure at the end of the contractual period, it is too early to say if that loss value has occurred because they are live contracts. We do have the ability to brokerage activity again within contracts and we do that very effectively and very proactively.

Q48 Dr Taylor: Are they mostly five-year contracts?

Mr Anderson: They vary throughout the piece. I could not give you an average figure, but a lot of them are for five years, yes.

Q49 Dr Taylor: So it is too early to ask you for a table showing how far down the line of completing their commitments different ISTCs have gone, is it?

Mr Anderson: Within the contract and the way it is written it is because that only translates into a snapshot of where we are and not a real value assessment of the contract itself because it has not been completed.

Q50 Dr Taylor: If we were half-way through a contract, would you then be able to give us figures?

Mr Anderson: Yes. I apologise to the Committee, but a lot of it is the lack of maturity in this programme. As it matures we fully anticipate, because we do collect a very rich set of Key Performance Indicators, being able to come back to you in a year and being far more specific about the effects and, more importantly, the contracts.

Q51 Dr Taylor: Let us go on to waiting times. We keep hearing ministers claiming that it is the ISTCs that are reducing NHS waiting times and yet Mr Ricketts has given us the figure of 60,000 as opposed to 5.5 million. When we had some of your officials before us a few weeks ago they said, in all honesty, the effect of ISTCs on waiting times was only marginal. Would you agree with that?

Mr Ricketts: Yes, I would. Not to be pejorative about the impact of the ISTC programme, but if you look at the timing, as these facilities open they will have more and more of an effect in terms of sustaining waiting time targets and reducing waiting times further. If you look at the straight numbers in terms of delivering the six month waiting time target, NHS facilities have largely done that. That is not to say, particularly in some areas like cataracts, the ISTC providers have not contributed directly by providing extra capacity, so there has been a contribution. They will be more important over the next couple of years in terms of sustaining that and also helping us, along with the Wave 2 programme, by hitting the 18-week target. Your observation is absolutely right in terms of delivering six months predominantly NHS provision in terms of direct capacity. They have, however, helped to take some of the pressure off. That is one of the reasons, if you are looking at changing behaviours in terms of the NHS, there has been the effect of galvanising productivity. The six month waiting time was delivered by the NHS. I think the Secretary of State has said that.

Q52 Dr Taylor: I think we will probably hear an argument against that from our next set of witnesses because certainly if you look at cataracts, the rate of increase in the numbers done was going up long before the independent sector programme came in.

Mr Ricketts: I absolutely agree with that. One of the areas I led until very recently was ophthalmology and I was very much involved in the initiative to get down to a three month waiting time target for cataracts. I have been very clear that the majority of the contribution even in cataracts was from the NHS. As it happened, some of our earlier ISTC programmes were in ophthalmology so there was a bigger proportionate contribution, but I would certainly want to go on record as saying that, in terms of delivering three months for cataracts, the NHS did it because at the time the majority of the facilities were NHS facilities. We had seen a big increase in cataract activity and a fall in waiting times from before the ISTC programme was announced and so I would not disagree with you.

Q53 Dr Taylor: I think you were responsible for NHS Treatment Centres initially.

Mr Ricketts: Initially, yes.

Q54 Dr Taylor: Is it right that organisations like NHS Elect feel they are being dumbed down by the independent sector?

Mr Ricketts: I do not think it would be appropriate for me to comment on that. I have not had a recent conversation with NHS Elect. NHS Elect is now in a position where their success or failure depends on attracting patients and whether GPs have a higher view of NHS Elect than other NHS hospitals or the independent sector. I think they will either have to sink or swim in terms of how attractive they are to patients and GPs.

Q55 Dr Taylor: Is competition between them on a level playing field?

Mr Ricketts: In terms of attracting the referrals, yes. Since the introduction of patient choice it is for the GP and patient to decide which hospital they go do. The NHS Elect treatment centres are in the patient choice leaflets in the same way that NHS hospitals and the open ISTCs are. It is a patient/GP decision now; it is not the PCT directing people to go that way or the other way.

Q56 Dr Taylor: Do you think we could have got to the 18-week target without the use of the independent sector?

Mr Ricketts: We have not got to it.

Q57 Dr Taylor: Could we get to it without that?

Mr Ricketts: I think it would be impossible in terms of diagnostics because of the amount of expansion. In some cases we need to double the amount of diagnostic capacity. In terms of electives, we still need very substantial growth to deliver 18 weeks. It is difficult to see the NHS delivering all of that. There is a debate in terms of what the proportion should be, but certainly we need extra capacity. We needed it at the time of six months to sustain it. I think the case for diagnostics is unanswerable given in actual fact the huge increase we have got to deliver. So I think it has a role to play in delivering 18 weeks in several years' time.

Q58 Chairman: We have heard that ISTC prices are lower than the current spot-purchase prices of the independent sector. Is that the case?

Mr Anderson: Yes, they are. When we first started the programme probably the biggest change before any ISTC even had planning permission was the change in the incumbent private sector. BUPA reorganised completely and sold 12 hospitals; BMI streamed its business into two halves, one addressing specifically the NHS and the other taking care of their private patient base, and Capio, which is owned by a Swedish company, did a lot of changes and became more efficient. As a result of that we gained significantly in the spot-purchase market from the efficiencies that were inbuilt in the incumbent private providers. Once we started letting contracts the price transparency also turned a light on the commercial environment that had not been there before and all of that accumulated to bringing down the spot-purchase market.

Q59 Dr Taylor: Do you think it is a good value for money comparator to be able to look at it that way or not?

Mr Anderson: If we had based our value for money calculation on that one indicator the answer would be no. There are a variety of VFM measures that we take into account that have been internally improved by our Finance Director, externally looked at by the OGC and ultimately approved by Her Majesty's Treasury. It is actually a far more involved set of calculations than just basing it on a spot-purchase market.

Q60 Dr Taylor: Do you think there is going to be any further movement? Could you see a situation where we would get down to the NHS tariff rates?

Mr Anderson: We will have to. The intention of the Department through the policy push is to get everyone a tariff and if private sector providers cannot compete at tariff once that is instituted then they will not be providing the care to patients.

Q61 Anne Milton: Can you tell me how much the ISTC programme has cost to date?

Mr Anderson: Just in terms of the procedures that we have bought, we have done 49,000 procedures, it is £106 million.

Q62 Anne Milton: Do you think that is good value for money? The three things, the ISTCs, the NHS Treatment Centres and then there is what would happen in the NHS normally, how do they all compare?

Mr Anderson: You have to understand that if the NHS could have created this capacity and they told us they could not --- There is an incremental cost to providing new treatment centres even in the NHS. You have to go out and build a building and theatres.

Q63 Anne Milton: Or you could use the theatres overnight.

Mr Anderson: Based on the evaluations that we did on the bids - and we went through a very robust procurement process and a resultant force within that was the fact that the spot-purchase market came down significantly - we did achieve value for money and we had a set of procurement tools that we utilised and then ultimately the decision was based on a value for money calculation and we achieved value for money within that environment.

Q64 Anne Milton: I am missing a bit of this story. You said you achieved value for money based on what? How do you measure that? What is your evidence for making that statement?

Mr Anderson: Our evidence for making value for money statements is that we went out with a mandate from the local NHS who said we needed to go and have capacity put in place to take care of patients and bring down waiting times. The value for money process is based on the fact that the NHS could not do that, that we had a robust procurement process in place and that we went out and procured the appropriate - as specified by the NHS - throughput at prices that we could benchmark against an NHS equivalent cost.

Q65 Chairman: Let us move on now to Phase 2. I realise it has not been laid out in many ways. How will the location of Phase 2 ISTCs be decided? You hinted that the first ones were decided on the basis of the need for elective surgery. Presumably surgery lists were a good indicator of where they should go in geographically. Is that going to be the case for Phase 2?

Mr Ricketts: Phase 2 is about additional capacity in some health economies. In some places there is still a need for significant capacity to do 18 weeks. Cumbria and Lancashire would be a good example of that, Chester and Merseyside, Greater Manchester and West Midlands South. Some of those are a combination of elective capacity and what we call ICATS, so it is like a combination of diagnostic capacity and assessment, a bit like an assessment centre for patients that then go on to electives. It is therefore not the same as schemes in the traditional Wave 1 programme, but that is very much based on local economies' needs in terms of delivering 18 weeks or whether they need to change services. Some of it is around there being a need for capacity. There are issues around improving access. In West Midlands South we were asked to look at a mobile service to improve access. We have also had a look at that in some of the more rural areas like the south-west peninsula and so on. There is also the need in some locations to improve patient choice and in other areas we have said that we need to use the independent sector programme as one of the levers to improve NHS productivity and responsiveness in a given economy, which is what is behind some of the schemes in Avon, Gloucester and Wiltshire and Essex and so on. The exact rationale does vary from place to place. In some places it is absolutely about pure capacity to do 18 weeks; in other places it is more around creating some further competition to drive up standards in the NHS and/or it is greater financial choice. It is much more variable in terms of the reasons why we are proposing putting something somewhere than in Wave 1.

Q66 Chairman: On the issue of choice, I mentioned very early on this awful word contestability which I think we have now got rid of and said it is competition. Where you have got a situation where an area has effectively not had a great call on the independent sector in the past --- My area would be one of those areas. There are some independent sectors there but not on the scale that there are in other parts of the country. A cynic might turn round and say that the reason why the second wave is going in there is because they want competition and the only way that you really get it is by bolstering the independent sector by bringing in a second wave ISTC. What do you say to that?

Mr Ricketts: It would be inappropriate to comment on South Yorkshire ---

Q67 Chairman: It is an area that does not have an independent hospital.

Mr Ricketts: There are various ways of getting competition. The point of competition - and it is not something we are pursuing in its own right - is to drive up NHS productivity and standards in those areas. In some cases you can deliver competition and those improvements through the Foundation Trusts' programme. That is one element of getting increasing competition, to drive up standards and so on. In the independent sector we have the main ISTC procurement, we also having something called Extended Choice, which is focused around using some of the incumbent independent sector to offer patient choices at tariffs and we have the main procurements. What we have been doing is looking in each of the areas at what is the right balance. If you take somewhere like South Yorkshire then it is difficult. Yes, arguably there is a lot of patient choice in terms of Foundation Trusts, but we also have two PCTs where over 90% of their elective work comes from one provider. I think there is quite a sensitive discussion to have around that. In certain circumstances an NHS provider can so dominate a local economy, but you need to have a discussion around how you make sure that the commissioners, working on behalf of patients, have enough leverage to make sure that that big provider is responsive to patients, keeps up-to-date with clinical practice and so on. That balance of is there enough choice and is there enough contestability are the sort of factors that would be taken into account before ITNs are issued for areas and it is one of the factors that has been fed back to us by both the Foundation Trust chairmen and clinicians in South Yorkshire and that Lord Warner is considering. I think it is right that we consider those things. You might have Foundations Trusts but, equally, you might have a very big NHS provider where there is an issue around whether you need to strengthen PCTs' ability to commission the right services to their patients.

Q68 Chairman: Presumably you have more than anecdotal evidence that work practices are changing inside the National Health Service primarily because of ISTCs.

Mr Ricketts: It is very difficult to quantify that. We have got a lot of anecdotal evidence from both the NHS and the independent sector of people saying their behaviour has been changed - not just because of the ISTC programme but the combined influence of choice and payment by results. Trying to say there has been X improvement in Y place specifically because an ISTC was proposed or it is the effect of choice, you cannot make those conclusions. Unfortunately the evidence is anecdotal.

Q69 Chairman: You have put the case that that may be one of the reasons you would put a second wave into an area.

Mr Ricketts: I think it is one of the reasons why I would explore putting it into that area. We would want to look at the implications, which is why ministers are very keen to look at the proposal in the round and at the implications before they take the decision to issue an ITN.

Q70 Chairman: Will additionality still continue to be a part of the ISTC programme?

Mr Ricketts: We have said that for Wave 2, apart from diagnostics where there are still major skill shortages, we are relaxing it for those groups of staff where we do not have a problem. For those groups like radiology, radiography and orthopaedic surgeons it is still an issue. For the time being we still think there is that need to protect the NHS and also to encourage independent sector providers to bring in additional capacity. If we have still got skill shortages in radiographers, radiologists, orthopaedic surgeons and other groups it does make sense to incentivise IS providers to try to bring them in from outside the NHS.

Mr Anderson: Wave 1 was blanket additionality with no exceptions. Wave 2 has been looked at on a case-by-case basis.

Q71 Chairman: What about first phase funding? We have all got anecdotal comments about money having to be put in even if the elective surgery did not take place. Is that going to be the same for Phase 2?

Mr Anderson: Again, you have a maturing market and a maturing provider base. We anticipate - and I cannot tell you categorically this will happen - that as these providers become more a part of the NHS landscape they will want to rely less on us and more on their ability to attract patients to their facilities. We have made it very clear as we have gone out for tender on the Wave 2 procurement that that is what we are looking for. We have given a very clear steer to the providers who were involved in this that we are anticipating that we have a more mature market. Underpinned volumes will become less of an issue within the contracts.

Q72 Chairman: Effectively the funding is not going to be guaranteed as it was in the first phase; it is something that will have to be worked for. Would that be the right expression?

Mr Anderson: It will be variable. It is our intention that it will be significantly less on the guaranteed side than it was on Wave 1 or at least it should be if we did our job correctly on Wave 1.

Q73 Dr Taylor: I was a bit rude about the Preliminary Overview Report. In contrast, I think your detailed report on the whole thing in our green book is very helpful. You have given us the cost of delivering an 18-week target time, which will be £1.4 billion in 2006/07 and £2.7 billion in 2007/08. This is not the right time to ask you how the NHS is going to find the money. How much of these totals will go into ISTCs? Is that something that you can answer?

Mr Ricketts: We can definitely tell you that we approximate 3% of total elective activity will be provided by ISTCs in 2006/07 and that will rise to 7% of elected activity by 2008.

Q74 Dr Taylor: 3% of elective activity, 2006/07; up to 7% to 2008.

Mr Anderson: That is correct.

Q75 Dr Taylor: We can take roughly the percentages of those figures.

Mr Anderson: That is specifically elective activity. That is not total surgical activity. That is the elective component of surgery.

Q76 Dr Taylor: Are ISTCs doing anything other than elective surgery?

Mr Ricketts: They are doing an increasing volume of assessment and diagnostics.

Q77 Dr Taylor: None is doing any sort of emergency work?

Mr Ricketts: No.

Q78 Dr Stoate: I am particularly concerned about training. Much of the evidence we have taken has concentrated on the fact that if you take cases away from trainees in NHS hospitals there is going to be a possible impact on training. How are you going to make sure that provision for training is included in Phase 2?

Mr Ricketts: I have to apologise to the Committee. Sir Nigel and I met Bernard Ribeiro and other clinical colleagues a couple of months ago and we recognised that there was a need for the Department to clarify the position of ISTCs on training. In the last day, we have sent a draft statement to the colleges, the BMA and other staff associations, spelling out that it is for consultation, a very clear statement of ISTC engagement in training. We can make a copy of that available for you but can I take one minute to take you through three or four key points? It may be helpful for your next conversation. That statement says very clearly that ISTCs will be expected to play their part in training medical and other clinical staff. The ISTCs in Wave 2 are being required contractually to provide training across the full range of the clinical services they provide for the NHS. That would be medical, nursing and AHP. They may also be required to provide some training where it is requested in non-clinical skills like outcome measurement, audit and so on. The training provided in ISTCs will be required to meet the same standards as training in NHS organisations. This was a concern from the colleges. The responsibility for setting those standards will rest with the accrediting bodies. There will be no compromise around training standards. Training will be funded through the Multiprofessional Educational Training Levy, as for the NHS, and where ISTCs provide training clearly they will be entitled to their fair share of those funds although, as you know, we have now moved to a commissioning arrangement in terms of medical training. It will be for deans locally to decide from whence they want to secure their training. Mr Anderson has required independent sector bidders, as part of the process, to submit two sets of prices, one price including training provision where it has an impact on productivity so that one can insist that IS providers, where deans and local communities want them to do the training, do so. Strategic health authorities will be responsible for ensuring that that training is delivered. They are likely to discharge that through Deans and the PMET board arrangements. There is more detail in the statement but I thought it was important that you and the Committee knew that the department has stated that as clearly as we can. It is in draft form for initial discussion with the colleges, the British Orthopaedic Association, the BMA and others. Once we have had their initial comments, we will issue something formally for consultation in April but it is an area where we recognise that we need to provide a much clearer statement to the NHS and the colleges around our ISTC responsibility for training.

Mr Anderson: The initial Wave 1 was all about going out and trying to bring waiting times down and therefore patient suffering and the other things that go along with that quickly. Towards the end of the Wave 1 procurement, we did start addressing a lot of the training issues. Nottingham is a good example of that where £4 million was included in the contractual value and it was specifically for training. The provider base that is providing services to patients absolutely wants to be involved in training as far as we can tell. We have had conversations with the providers and they are very up for doing the training. Wave 2 will be a completely different environment. Again, it goes back to the services' and more importantly the patients' need to integrate this into the wider NHS provider framework.

Q79 Dr Stoate: That is a very detailed answer you have both given. I have been concerned about this for some time. It still leaves one concern and that is, where an ISTC effectively takes over a large chunk of work from a local DGH - for example, all the elective hip operations - do you see that as undermining the training of the generalist surgeons in orthopaedics or ophthalmology for the future, because my worry is that even if the ISTCs are training some of these specialists for the future if the training programme for a hospital department is undermined by them, that must mean they lose accreditation as a training hospital, which may have other implications for workforces in the future.

Mr Ricketts: That is the next thing that needs to follow. The department is now in the process of clarifying exactly what the training requirements are. Stage 2, once we have reached agreement on that - we have only just sent it to the colleges - is to ensure that locally deans and others in terms of the commissioning arrangements ensure that when they are looking at training accreditation and what they are commissioning they look across the health economy so that you get any independent sector provision included in the training network, if that is appropriate. You then move away from the debate where there is perceived to be a threat to the training accreditation of an NHS hospital. You are looking to get accreditation across the whole of the economy. That is one of the issues we have been in discussion on in Southampton, for example, where there is an ISTC. How do we ensure that accreditation is maintained? That will mean ultimately some training being undertaken in the ISTC. In terms of supervision and so on, it needs to be integrated into how training is done across the patch. I recognise that we are going to need to do some work, both locally and nationally, to make sure that all the local players, the trusts, the Deans and so on understand the proposed new arrangements. We will also need to work with the colleges more to unpick exactly how this should work. The fact that you are moving work - it is analogous to moving it into an NHS treatment centre - into another building from another organisation should not put a threat on accreditation for that health economy.

Q80 Dr Stoate: It will do because you are not employing the same people. The ISTC will be employing a very high proportion of overseas doctors, whereas the trust may not be. You are not talking about the same doctors. How are they going to get training for the next generation of orthopaedic surgeons if all the hip replacements are being carried out by South African doctors in the ISTC?

Mr Ricketts: There are two things there. One is the use of non-contracted hours and also relaxation around additionality gives us an ability certainly outside orthopaedics to do that. Non-contracted hours also apply to orthopaedics. It is not my area of expertise but in terms of the rules around additionality there are specific requirements in relation to relaxing that for supervision. We would have to come back to you in terms of how that works but that should not be an impediment.[5] It is part of the detail we need to explore with the colleges. Once we have agreed what the roles are - and we have said very clearly we want to encourage ISTC providers to do training; they want to do it - we are going to have to work through the fine detail of how we get the NHS hospital consultants to work effectively with the independent sector provider, how they may share staffing supervision and all those sorts of things, but we are not at that level of detail yet. We are just trying to set out the principles and the funding so that at least people understand that. We are then going to have to do a lot of detailed work to avoid the situation you describe.

Q81 Dr Stoate: I would be very interested to hear what the colleges have to say and we will be speaking to them shortly. I still have concerns. I still do not see how my orthopaedic registrar working in the district hospital, if he has no hip replacements to practise on because they have all gone to the ISTC, can be trained properly.

Mr Ricketts: He will be able to undertake the hip replacements within the ISTC and that is the point in terms of moving the training across.

Mr Anderson: The example that you have illustrated would probably suggest in that instance that additionality would not apply. If you have a wholesale movement of orthopaedics to a different facility ----

Q82 Dr Stoate: Additionality would be the bugbear because additionality means that the ISTC must employ overseas doctors, for example, to carry out hip replacements and effectively, if the majority of hip replacements from that area go to the ISTC, how is the NHS orthopaedic surgeon going to get any practice on hip replacements?

Mr Anderson: I understand. First of all, we do not have any instances of that.

Q83 Dr Stoate: I am looking to the future.

Mr Anderson: Given the example that you have illustrated here, additionality would not apply in that case if there is that wholesale movement. Therefore, that doctor would have the ability, because additionality did not apply, to work in the facility.

Q84 Dr Stoate: The DGH still loses its credibility as a training centre for orthopaedics because they have all moved to the ISTC. Where is my hospital going to train orthopaedic surgeons in future?

Mr Ricketts: Perhaps in ISTCs.

Q85 Mr Amess: Gentlemen, I hope you are not going to make promotional videos about these treatment centres because if that is your intention I suspect you may struggle to convince people. Indeed, in the earlier part of this session, I wondered if we had the right witnesses here because they seemed to struggle to be able to answer anything. All I can suggest is that Sir Nigel Crisp's departure must have temporarily destabilised the department. It has been reported that the Government wants to see between 10 and 15% of patients being treated by the independent sector. If this does represent the Government's aims the philosophy behind it is certainly obscure. The Secretary of State was reluctant to admit to such an intention and in December 2005 she told the Committee: "I do not think this is ideological. John Reid made the point that looking at what he thought was needed he did not believe - I think his phrase was - in his political lifetime that it would be more than 15%." Can you two gentlemen clearly tell the Committee what the department's long term aim is for these treatment centres?

Mr Anderson: We have not announced a Wave 3. We are procuring Wave 2. I do not know the political background for that. It is not for me to comment on. I do know that we have gone out with Wave 1. We have procured that, and on the back of the success of that, as we perceive it and calculate it, we have decided to do a Wave 2.

Q86 Mr Amess: It is a terribly weak answer. It is fair enough you cannot respond politically but for God's sake. This is a huge thing that is happening. Surely you must be able to tell us what the department's long term aims for these treatment centres are. What you have just said is waffle.

Mr Anderson: The long term aim for the treatment centres as they exist is that they go out and bring waiting times down. They integrate into the NHS family of providers and provide good, high quality, reasonably priced care for patients.

Q87 Mr Amess: Let me try something else. There are fears that increasing these treatment centres' capacities combined with payment by result will destabilise the National Health Service. How will the department ensure that this does not happen?

Mr Ricketts: It is very difficult, given the volumes of work that will be carried out by the independent sector, to look at Wave 1 and Wave 2, quite frankly, and how they could destabilise the NHS. It is very difficult to see how they could destabilise an individual hospital. There may well be circumstances where the effect of an ISTC and choice combined places pressure on an individual service, where that service is not held in high repute by GPs and patients. That is where you are likely to have the impact on an individual service. In those circumstances, there is a responsibility particularly on the local strategic health authority to work through the consequences and make sure that local patients have access to services. If you are talking realistically, if you add together Waves 1 and 2 at something around 7 or 8% of elective care, I really cannot envisage the situation - that is only elective care which is a minority of the spending and the work carried out by the NHS - where it could destabilise the NHS. I cannot see it destabilising a hospital. There will inevitably be issues around services but choice will generate that where patients and GPs are unhappy with the quality of service.

Q88 Mr Amess: We will wait and see what the other witnesses have to say on that point. It is claimed that the existence of these centres frees up the NHS capacity for emergency work. I would like the department to offer a view on how it will manage and, if necessary, resolve tensions between the NHS and the independent sector as the provision of the latter expands. Can you say something about how you see this working out in practice?

Mr Ricketts: Mr Anderson has made it clear that there are not plans beyond a Wave 2 so we are talking about something of the size of Wave 1 and 2 combined. There will be some tensions potentially at local level around services. That will be for PCTs in their key commissioning role to work through to ensure that patients retain access to services. It is not something that the department is in a position to direct; it is something that local commissioners will be expected to take responsibility for in the same way that they will be expected to take responsibility for a poor or failing service currently.

Q89 Mr Amess: There is also a fear that the removal of elective procedures to these independent treatment centres, combined with the introduction of payment by result, will have an adverse effect on National Health Service finances. Do you anticipate that the hospitals of the future could be purely elective and purely emergency?

Mr Anderson: We have to return to Mr Ricketts's answer around destabilisation from a financial standpoint. In comparison to the total spend of the NHS, this is a very small amount of money. To suggest that that would significantly undermine the finances of the NHS would not be appropriate. The second part of your question is how would we envision the reconfiguration of services as we go forward. That is a question for local health economies, based on demographics and the patients' needs in that area. There is a move worldwide to take elective surgical care and minimally invasive surgical care and stream them separately from tertiary care, because those two, from the standpoint of throughput and quality of service, do not exist very comfortably together. What the hospital of the future will look like will vary by community. You will see, I would hope, a lot more streaming of elective and tertiary throughput from the surgical standpoint particularly.

Chairman: Could I thank you both very much indeed for coming along and answering our questions this morning? We get the professionalism we expect and we should thank you for it. We just assume that civil servants will come in. I think you have done a very good job this morning and I would like to thank you both on behalf of the Committee.

Witnesses: Mr Bernard Ribeiro, CBE, President, Royal College of Surgeons of England, Mr Simon Kelly, Bolton Hospitals NHS Trust, Royal College of Ophthalmologists, Professor Janet Husband, OBE, President, Royal College of Radiologists, Dr Peter Simpson, President, Royal College of Anaesthetists, and Mr Ian Leslie, President, British Orthopaedic Association, gave evidence.

Q90 Chairman: Good morning. Could you introduce yourselves for the record with your name, organisation and where you come from?

Mr Kelly: I am Simon Kelly. I am a consultant ophthalmic surgeon at Bolton Hospitals NHS Trust. I am representing the Royal College of Ophthalmologists here and I have been involved with the former National Implementation Team since 2004 on the Royal College Leads meetings and I have also been quite involved with the ophthalmic ISTC schemes since they started.[6]

Dr Simpson: I am Dr Peter Simpson. I am a consultant anaesthetist at Frenchay Hospital, North Bristol. I am President of the Royal College of Anaesthetists and I am Deputy Chairman of the Postgraduate Medical Education and Training Board (PMETB).

Mr Ribeiro: Bernard Ribeiro, general surgeon at Basildon Hospital. I am President of the Royal College of Surgeons of England.

Professor Husband: Janet Husband, President of the Royal College of Radiologists and Consultant Radiologist at the Royal Marsden Hospital.

Mr Leslie: Ian Leslie, orthopaedic surgeon from Bristol and president of the British Orthopaedic Association.

Q91 Chairman: Welcome. I am tempted to ask you all for your comments on what most of you have just heard from our previous witnesses. You may not have a collective view but let us try the individuals. Mr Kelly?

Mr Kelly: I was here and there are a number of points. If I stick with cataracts, because that is my field, I was interested to hear Mr Ricketts say that in the early stage of the Phase 1 development the capacity planning had been decided locally and, in the question about Phase 2, that this would be decided locally again. When questioned, "Was it not the case that the cataract requirement was not necessary?" he did concede that. He conceded that the Phase 1 ophthalmic cataract scheme, the Netcare scheme, was possibly needless. That is quite a significant learning point. Just to put it in context, that is a £40 million scheme. He also said that one of the benefits of the schemes was to drive up productivity - and this new word "contestability" has been brought into the lexicon - or competition. The concept that competition would only occur by the stimulation of the ISTCs I also found somewhat abhorrent because the medical profession has always maintained high standards. NHS management have always maintained high standards in local hospitals. It is the College who worked with the Department of Health to drive up the standards in the Action on Cataracts scheme which brought modernisation to cataract surgery, long before modernisation had become a contemporary buzzword. I do not really see much merit in that. Furthermore, there was mention made of great innovations in Phase 1. Quite frankly, I do not see any innovation in Phase 1 in cataract surgery that did not already exist in the existing cataract schemes. We are able to do the same amount of cataract surgery as the independent sector do in the schemes, if necessary. Finally, when the scheme was announced, it made me somewhat breathless to hear that colleagues from South Africa - where there are big backlogs of cataracts to be done - were going to come to the UK. I have worked in West Africa so I understand the situation a little bit there. They were going to come and work in the UK and this was going to be in mobile units frequently which were going to be parked within a mile or so of local NHS units. I still find that concept somewhat difficult to understand.

Mr Leslie: There are many parts I would like to comment on but one is the key indicators which are quoted as being a method of assessing outcome. The key indicators in orthopaedic surgery are not whether the bed was clean or whether the hospital was clean. They are to do with dislocation and revision rates after they have left hospital. None of those key indicators addresses the after hospital events which take place. The complications are clearly definable in the NHS and the British Orthopaedic Association (BOA) was very instrumental in getting the National Joint Registry (NJR) off the ground. There are many audits round the country which will tell you the complication rates in NHS hospitals, but there is absolutely no information on the ISTCs. Readmission rates are not possible to do. Readmissions are to various hospitals, sometimes within 100 miles, and we have asked the National Audit Office when they do this to send a questionnaire to each of the patients who are admitted. Then we might establish what the readmission rate is. Readmission rates are available to me in my hospital as an indicator of performance. When patients are admitted to other NHS hospitals from ISTCs, they are admitted under the care of the consultant on call if there is a complication, not under the name of the operating surgeon. There are many more comments but I will not go on.

Q92 Chairman: Would that be the same if people had been in the independent sector for an operation and then they had complications?

Mr Leslie: In the independent sector there is a continuity of care in private hospitals. The consultant who did the operation would be a local surgeon and if there was a complication that happened to go back to an NHS hospital, I would expect a colleague to hand that patient back to me, under my name, so there is a continuity in the private hospital system. A surgeon who has disappeared back to Poland or Sweden is not around to deal with a complication.

Q93 Chairman: You see no difference in that a surgeon who has somebody as a private patient who gets complications will just take that complication over as an NHS patient?

Mr Leslie: No, sorry. I thought you meant if he was admitted as an emergency to an NHS hospital.

Q94 Chairman: With a complication from the original procedure.

Mr Leslie: He would expect, to my knowledge, to take that over again, yes, or take it back to the private hospital. I did not mean they went the other way.

Q95 Chairman: Janet Husband, have you anything to add to what you heard?

Professor Husband: I would like to make a point about additionality. Radiology and radiography were pointed out as the two specialties where additionality would be maintained. This is the major problem. We need to have an integrated service between the NHS and the independent sector so that clinical governance issues can be properly addressed, so that we can have clinical leadership. It is very different in the radiology independent sector where the reports are done overseas remotely and there is no link, so if the clinician has a lack of confidence in the reports there is no input into the multidisciplinary team meetings where major management decisions are made. If additionality were completely relaxed, this would be a major benefit. The other point in relation to that is that there are different scenarios in different parts of the country. In the south east, there are enough radiologists who could provide service to areas in the Midlands. They could do the reporting and work in that way. We have the proposal that NHS trusts could second a radiologist to the independent sector for, say, a day a week, but the independent sector would pay the trust who could then bring in more radiologists so that the whole system was integrated rather than in different silos, where all the problems have been related to this separate process.

Q96 Chairman: Do you think the first phase is changing work practices inside the National Health Service? There was a hint in the evidence we took earlier that probably your members are changing their attitude in terms of work and changing work practices which makes the NHS more efficient. Do you think that is true or not?

Mr Ribeiro: We must draw a line under the first wave ISTCs. They were brought in for a specific purpose which was to reduce waiting lists and to some extent that was achieved. The methodology that was used and the people who were brought in to do the work are another issue. In terms of change of practice, what has been demonstrated by ISTCs - and it is government policy - was the need to separate emergency from elective work. We from the college and specialist associations have for the last 10, 12, 15 years been talking about separating emergency from elective work. Currently some 64% of consultant general surgeons are on call for emergencies when they are doing elective work. The NHS has to deal with emergencies at the same time as it does its elective work. We have evidence of at least 38 NHS Diagnostic Treatment Centres (DTCs) where there has been separation of elective and emergency. I have been to Central Middlesex when it first started. I have been to Hinchinbrook. There are a whole lot of these which are very effectively run and very efficient proving the fact that if you separate elective from emergency you will get good treatment. That was there before independent sector ISTCs came on the ground. The fact is that there is a lack of will to follow through by having these centres in the NHS because it is government policy to contest, challenge, the NHS, put ISTCs close by and see whether the NHS hospital nearby will deliver. If it cannot deliver, it goes down. It is policy that is driving the change rather than practice and benefit. You asked are there any benefits. Last week, I went to the Greater Manchester Surgical Centre in Trafford which is an ISTC. It is a bit of a surprise for a member of our profession to do that in the private sector we are supposed to be criticising but it was a very well run centre, run by Netcare. It had a very good throughput of work. It had good facilities but there were issues over the fact that the contractual arrangements that are made there are such that if patients do not turn up they still get paid. If operations are not done they still get paid. Those issues, I am sure, have been addressed. They have surgeons from overseas, from Hungary - where a large number came through - who do three hip or prosthetic procedures and stop. The practice is well managed and well done. One thing they have to teach us however is - and this was identified in Ken Anderson's paper - about stocktaking and the keeping of prostheses. In the Trafford centre, they only have one prosthetic part and that is by Stryker. All the instrumentation is by Stryker. The surgeons who work there have to be trained to use Stryker equipment. In the NHS, surgeons are trained in lots of different units to use lots of different bits of equipment. Therefore, what you find is a cost effective exercise with no instruments on the shelf because Stryker employ a full time employee who is there to make sure that the equipment you need is available for you at the time. These are lessons that we can learn. That is the positive side, but I would like to underpin it by saying the experiment had already been done. What we are missing is a will on behalf of government to develop DTCs within existing NHS hospitals, rather than without.

Q97 Chairman: Does anybody else have a view?

Dr Simpson: I would like to echo what Bernie Ribeiro said. The word Janet Husband used earlier was "integration". Ours is a service specialty in anaesthesia. As such, with intensive care together, we provide a service for the surgery that goes on. If you say, "Has anaesthetic practice in the UK been changed by the introduction of treatment centres?", no. It is the same. If you say, "Is the standard of anaesthetics likely to be any worse in treatment centres?" it is very difficult to say without auditing it and you need to be very careful about what you audit. If you audit severe morbidity and mortality, I would be absolutely appalled if it was any different. The quality issues are the things that matter to patients. As a college, what we are concerned with are two things with treatment centres. One is the quality and safety of patient care and the other is training. For us, if we can achieve both those as an integrated part of the local health care economy, that is fine but we have a number of examples of where the introduction of a treatment centre distorts local health care and also the supervision of trainees in the base hospital, which is a significant issue that I will enlarge on if you wish.

Mr Kelly: I fully support Mr Ribeiro's argument on the separation of elective and emergency care. That already exists in day case units and in five day wards and in NHS Treatment Centres. It makes all sorts of operational and patient safety sense. The problem is if you separate it on two different sites, if you have elective surgery done on one site and emergency surgery done on the other site. For most of the specialties in the UK, it is at this moment in time the same surgeons and the same anaesthetists providing the care. If care has to be provided over two sites, it is much more problematic. It is sensible to have it integrated on the same site so that we are all singing from the same song sheet, singing to our strengths. That also underpins training and safety. Whilst Dr Simpson has said that the two issues for the College are about training and patient safety, our College has exactly the same two issues. They are the key issues for us. We do have a third issue, interestingly. We are concerned about the impact of the ISTC procurement on local NHS facilities, on local NHS Hospital Eye Services, because the issue is that in the Hospital Eye Service we provide comprehensive, holistic care in which we are integrated with the patient groups, with the Royal National Institute for the Blind, with the Patients Association and many local organisations. We are also providing care for the chronic, blinding eye diseases and for children. What has happened is that one segment of our work - cataract surgery - has been pulled out and moved into a separate group. The effect of this is that it destabilises the manpower planning for the future generation of consultants. We have seen that the number of consultant appointments advertised in the BMJ in the last 18 months is 40% of what it should have been. This is occurring ironically at a time when our own UK graduates are coming out of the training schemes and are unable to get consultant positions and also at a time when there is going to be an increase in the medical school production. Our third reservation is the impact on the local NHS services. Finally, there is another issue which is also an impact on local services. There is an issue on the impact on the ethos of medicine as a profession as currently delivered and on the impact on the morale of doctors working in the existing NHS. The reason I say that is there has been little or no engagement between the medical profession and the Department of Health in planning these arrangements which are policy driven. I can say that having attended the National Implementation Team for the last two years. It was made clear to us that the Implementation Team, which is under the Commercial Directorate - Ken Anderson is the lead; Dr Tom Mann was the first Clinical Director. He has moved on to the independent sector himself. The current Clinical Director is Dr Bruce Websdale. NIT is there to implement policy. It is not there to consider the voice of the medical profession or of the nursing profession for that matter. They are there to implement policy that is coming right from the top. I think this cuts to the core of medicine as a profession.

Professor Husband: There are two points on the effect on the NHS. One is that because a lot of the radiology reports are being done outside the UK they are different. They are not necessarily incorrect but they are much more descriptive. They tend to hedge bets. They will come back with recommendations for further investigations, perhaps two or three, so they are increasing the workload within the NHS, not with necessarily necessary tests. Also, there has to be a lot of re-reporting by the radiologists back at the base, who are trusted by the clinicians before they go and operate on a patient where they are not happy with the report. Thirdly, the simple tests are going out of the hospital. This leaves all the complex tests within the department which has an effect on stress and the morale of the radiologists who are left with all the complex work. It also has an impact for radiographers who are working with just complex cases and there is no simple work to intervene in that. Finally, there have been major problems in terms of the NOF funded equipment which has been put into a department - for example, a new MRI scanner - when the local resources are not available to run that machine so it is lying idle. The independent sector provision is then the way of working. There are about 20 MRI scanners in the country that are currently not working to full capacity, semi-mothballed.

Mr Leslie: I have not from any of our members found one group that has said that things have improved as a result of a local ISTC. There is no evidence whatsoever for the comment that it would benefit and improve things. There has been a statement by the Secretary of State that in Plymouth they innovated a blood transfusion technique and that was an innovation from the ISTC. That has been present in orthopaedics. We have a blue book two years old stating that. These concepts of innovations in ISTCs and changing NHS hospitals have been more negative than positive. They have decreased morale. Perhaps I could support Professor Husband's comment about MRIs. We do use a lot of MRI scans in orthopaedic surgery and one reason for the increase in use is the number of people who are able now to order MRI scans, mainly the Extended Role Practitioners. That will increase your volume of requests for MRI scans. We get reports back from a radiologist maybe in Holland or somewhere else. You cannot talk to the radiologist because you cannot find him on a telephone. I like to talk to the radiologist about what he has described. Those are all negative effects. I cannot find one positive effect in what was stated.

Q98 Chairman: I ought to say that the memorandum that all your organisations have submitted, and others, is being published today. Your Association (BOA) was extremely negative in terms of ISTCs. At least it was consistent. I went on the web and I found an article written by presumably your predecessor, D H A Jones, in 2003, which was extremely negative about ISTCs. In view of some of the comments that your colleagues have made about this first wave, whilst not overwhelmingly supportive of them, do you think there are some positive things from them or not?

Mr Leslie: If we go back, first of all, orthopaedics was a big player in this as well as eyes because we have waiting lists. When this came in, we learned about it as an association some nine months after it was all taking place. To support my colleagues, there was no collaboration with the professionals who knew something about hip replacements and how they are done during the early times. It was on our approach to the Department of Health that we managed to get a hearing. In 2004, we sat down with Tom Mann and drew up an agreement about how this could go forward in a positive way. One of the things we said in that agreement was that there should be collaboration between where the ISTC is and local orthopaedic surgeons. For some reason, that collaboration statement was squashed. They said, "No, you cannot go ahead with that." The involvement of the orthopaedic world was very scant. I can give you a list of the meetings and the correspondence we have had with the Department of Health, trying to say where we believe they are going wrong. It was not necessarily, "This is wrong", but, "You are doing it the wrong way." If we come onto importation, why we are negative is because so many surgeons were imported into this country to operate for a short time and then went back to their country. My colleagues were seeing the bad results. It is anecdotal, but there is now enough evidence gathering out there. There is the Portsmouth Inquiry which substantiated what we said. My colleagues see the bad results coming back. Bad results perhaps in eye surgery or hernia surgery occur rapidly. In orthopaedic surgery, they occur over five or maybe ten years. We are seeing dislocation and high revision rates. If one is seeing that with patients it is no wonder that we are negative about the way it is being done. We could be positive about the future and I support my colleagues in that. I think we did have good grounds for being negative.

Q99 Chairman: Have any of your members changed any work practices in the last three years?

Mr Leslie: Not to my knowledge. They have improved them but not because of an ISTC.

Q100 Dr Taylor: I was so encouraged with our first lot of witnesses when they suggested that integration was going to be possible. You have mostly talked about integration on the same site. What are your views about integration at a site, say, 10, 15 or 20 miles from the acute hospital?

Mr Ribeiro: I would like to draw a line under what has passed. There is a huge potential for the future. We should come back to the financial implications of ISTCs present and future on the NHS. I think that is an important aspect within this particular financial climate that we have of funding the NHS. Coming back to your question, our college has been very clear. We are prepared to train our trainees anywhere as long as the facilities provided are up to the standard the college would accept for training. As you know, not a million miles away from where you are, there is a DTC in Kidderminster which was set up by Professor Ara Darzi in his investigations. We have evidence from Kidderminster that there is one SpR - a training registrar - who has had approval from the Specialty Advisory Committee to work at this DTC for four months. The training record from that trainee has shown that he has had good, valuable training working for about nine different consultants. That proves that it is possible for the college to organise training programmes where trainees and consultants will move to other hospitals to work. In this situation the trainee is there for four months, working with a multitude of consultants. We can develop other programmes where a modular training system would allow a trainee to move into a centre for a week, two weeks or whatever to get training. For that to happen though, one thing is essential. We need to have this separation between emergency and elective. We have currently 36% of consultants who are not on call when they are doing elective work. There are many hospitals around the country where this is happening. They all say one thing: it improves the quality of training; it improves continuity of care; it puts consultants to the front line of the management of emergencies. I would put it to the Committee that the treatment of our acutely ill patients is the most important thing we do. We have always had this over-emphasis on waiting lists. The government seems to think they are the only things that matter. For us as a profession, we want front line, best trained surgeons to be managing the sick and the ill. Yes, we can go out there. We would prefer them built in our own backyard because it would be convenient. In some of the new ISTCs that have been produced - Nottingham, for example - there has been a situation where the private sector has moved and built in the NHS hospital with secondment of staff to go in. The key is get rid of additionality; open it up to NHS consultants so that we can use the capacity - which is what all this was about in the first place - out there for training our trainees. That is the message.

Dr Simpson: There are two points which are different if you are a service specialty, which are important. One is to emphasise that if a surgical operation is straightforward, it may be a straightforward operation but it may not be a straightforward anaesthetic. For example, a laparoscopy, keyhole surgery in the abdomen, is quite a complicated anaesthetic and therefore not necessarily transferable to remote sites all the time. It is possible to do these things but they need to be thought through. The second point is that for a service specialty like ours if you take the consultants from the base hospital to a remote hospital to staff your TC what are left behind are the trainees. The consultants do not only train; they supervise. If I take an orthopaedic surgeon to a remote centre, he will not leave his trainees back operating because his list will be in the remote site. The anaesthetic trainees of course work across a range of specialties and therefore are often left back at the base hospital relatively unsupervised. We have had problems with that and the training scenario in places I could tell you about.

Q101 Dr Taylor: Could not rotas of consultants be organised so that there was always somebody back at the base to cover?

Dr Simpson: Yes, rotational arrangements are possible but it depends on the degree of supervision that the junior doctors need.

Q102 Dr Taylor: Mr Kelly, I get the impression that ophthalmology is not the shortage specialty that orthopaedics and radiology are. Therefore, it was easier for you to say that you could have covered the waiting list problem without ISTCs. Is that fair?

Mr Kelly: In ophthalmology, it is one very specific procedure. It is cataract surgery only. There are problems in ophthalmology in the blinding eye diseases of macular degeneration, glaucoma, diabetic retinopathy and eye problems in children and in the care of the chronic eye disorders. What this scheme has done is to put disproportionate resources into one particular clinical area and, as a result of that, the indications for cataract surgery have dropped down greatly. We are now operating on patients at a much earlier stage than before. A second issue is, because of the direct referral from optometrists, which I support and we believe in as an organisation, because the ISTC contracts have to be met and are paid for, we are seeing patients referred directly from optometry with cataracts to the Netcare scheme and being operated on very early. Meanwhile, the next door neighbour of that patient who has really serious problems - such as diabetic retinopathy - is left to lie fallow; whereas if the funds were in the local NHS eye unit the clinicians in the unit could make the decisions how best to allocate them within their own unit. Equally, if there is going to be national guidance, for example, from NICE or somebody to say that the blind are more important to us or less important to us - which is what this scheme is saying - than people who have mild cataract, so be it, but at least an informed decision could be made with patient and public involvement. That has not happened.

Q103 Dr Taylor: Integration, if it came, would also help on that score.

Mr Kelly: We have already heard about NHS Treatment Centres based within the NHS unit in all the surgical specialties. In my own case, we are a unit in Bolton that benefited from the funds from 'Action on Cataract'. We essentially have a cataract treatment unit within an ophthalmic treatment suite. We are doing it and there are many other examples up and down the country: eg Peterborough and Moorfields Hospital in London. That integrated model within the NHS already existed.

Q104 Dr Taylor: Do you think, in your specialty, Netcare and mobile cataract units are superfluous?

Mr Kelly: Yes.

Q105 Dr Taylor: What should happen to them?

Mr Kelly: That is an excellent question. The team working in them is efficient. The units are very clean. I visited a unit in Liverpool recently. I have colleagues in South Africa. The President of the Ophthalmological Society of South Africa, Dr Kruger, recently told me that there is a huge backlog of cataracts to be done in South Africa, particularly in the back streets of the deprived areas, and in the homelands. An idea thus may be to take those mobile units out there, because there is good ophthalmic provision in the private sector in Cape Town and Johannesburg. That might be a move for the units?

Q106 Dr Taylor: In a way, you have been almost complimentary about the service in Netcare. Are you less worried about complications than the orthopaedic people, for example?

Mr Kelly: We have seen our own bevy of complications. It was intriguing that Mr Anderson and Mr Ricketts were not able to comment on that, but they did say that they were not clinicians. Mr Anderson used the lovely words, "That is the granularity of the system". That granularity is individual patients going blind or going lame. These have surfaced in media investigations. Channel 4 News have done some good stuff. Journalists have done some work. There is litigation going on. Clinical negligence litigation and media exposure are not the best ways to improve patient safety. It has to be a whole systems re-organisation.

Q107 Dr Taylor: In a word why was the ISTC programme dreamed up?

Mr Kelly: I do not know. It was announced on Christmas Eve 2002 and why it was announced on Christmas Eve I do not know.

Q108 Dr Taylor: Have you any comments?

Mr Ribeiro: Yes. It was to win an election. It was to reduce waiting lists. This policy is to get waiting lists down. We heard last year that in Birmingham 1,000 patients were corralled into a hall. It cost £25 million to get the answers out and the net result was waiting lists were the first priority that patients wanted dealt with. If you couch policy on reducing waiting lists, that is why you have ISTCs. The fact of the matter is the waiting list problem and the work that was done before identified cataracts or orthopaedic procedures as the ones that were most needy. General surgery, interestingly, did not have much of a problem. In my hospital we have hardly any waiting lists at all in general surgery because we keep on top of things. I will give you an anecdotal example of how things can go desperately wrong if we do not move to separation. On Monday, I had an operating list at Basildon. I had two laparoscopic cholecystectomies and three hernias to do, ideal training operations. I now act more like an assistant to my trainees who do the operating. At two o'clock when we were about to start, a ruptured aortic aneurysm came in. Mine was the only theatre that did not have the patient asleep. My patient was moved into the recovery area where she stayed for three hours until the aneurysm was dealt with. I had to cancel the three hernias who went home. That is the day to day reality of working in the NHS. If you were to put me into an ISTC in my hospital away from that, my team could have completed a day's operating and that is what it is all about. That happens on a regular basis in the NHS. Therefore, what the NHS is saying and what we are saying on behalf of the NHS is give us a level playing field. Do not give us a situation where ISTCs are getting 11% on costs to get started, a little bit more on top and it does not matter whether they do the work or not; they get paid. Give us a level playing field where the NHS is doing the work on exactly the same terms as the ISTCs. The government has made its point. It can get waiting lists down. Great. We are all very pleased about it but let us move on to the next stage and make some progress.

Mr Leslie: In terms of training outside the centre, this has been going on in orthopaedics since about 1998. The Horder Centre near Brighton is a charity which has been contracting work from the NHS and that has been approved for training for orthopaedic registrars since about that time. It is possible to do it, and it is done because the local NHS surgeons go there to do the operating. When I come back to qualifications, Bob Ricketts spoke about qualifications. Being on the specialist register of the GMC does not necessarily mean that you can go and do a safe hip replacement. What it means is that in Europe, if you reach a certain level of training in any European country - and they are all different in terms of the end point of training - you are automatically, due to European law, allowed on the Specialist Register of the GMC. There is nothing else to do except to send in a piece of paper. In Italy, you get your CCT or Certificate of Completion of Training at the end of doing a certain number of procedures. For a complex one you might get 100 points; for a simple one you get ten and when you have built up enough points you get your CCT. How do they do that? At the end of training you then are under very strict supervision in a hospital system whereby you are still under the master for some years after that. In the UK, we train people to operate independently at a certain point in time so that they can go to the Isle of Skye and be an independent orthopaedic surgeon if necessary. We put them into independent practice. It does require whoever is training them to be up to scratch as to our standards of training and that has been built up over many years.

Q109 Dr Taylor: We are certainly going to take that up with the GMC when we see them.

Professor Husband: I wanted to make a positive point. There has been under-investment in imaging over the years. MRI waiting times were something up to two years. They are now down to 13 weeks and that is of major importance obviously for the individual patient. I do not think we must throw that point out of the window. It is important. As a college, we have been very proactive in working with the Department of Health on quality issues. We have undertaken audits between the independent sector and the NHS. We have worked with the National Imaging Lead in the Department of Health. We have an MR guardian who is a college officer, who has been reviewing the CVs of every radiologist working in this scheme. Nevertheless, my big point is integration. Get rid of additionality and we can work a good system. For example, we have to also take into account that there has been a major investment in academics for training radiologists, many millions. I will not give a precise number in case I get that wrong. We have taken an additional 20% of trainees in radiology this year and that will continue. Very soon we will have more qualified radiologists and we need to bring them in and integrate them into the service. Just a final point on whether we could work with an independent centre ten miles away with programmes of rotas, that would work very well. One of the problems with radiographers is, if they are appointed to the independent sector, then they are just going to do simple investigations for their workload and in terms of continual professional development that is a disaster. They need to be integrated within a team so that they can have the benefits of a full career, and it is the same for radiologists. Finally, 70-80% of individuals coming out of medical school will be women. A lot of these people do not want to work full time and this would be an excellent way of them working in an integrated fashion within the NHS and the independent centre.

Q110 Dr Stoate: It has been suggested by the BMA that the ISTC programme has caused private practice incomes to fall. Is this true?

Mr Ribeiro: I would not know, sir, but to answer that question I think there is no question that you will find instances where people's income has fallen but, on the other hand, if you take cardiac surgery we know there has been a natural fall of income in cardiac surgery because an awful lot of cardiac surgery has gone to intervention procedures and not the actual bypasses, so that may demonstrate a fall of income there. I think that in niche markets like London, London is a peculiar sort of place where private practice perhaps carries on without any impact from outside, but clearly there has always been this feeling that consultants keep their waiting lists deliberately long in order to encourage private practice.

Q111 Dr Stoate: This has certainly been suggested at a previous inquiry I was involved in some time ago.

Mr Ribeiro: Absolutely. I think it is a lot of hocum, frankly; I have always thought that. I know there has been a perpetuation for years. It is like the question why is it that we now find a huge amount of money has gone on to consultant salaries in the last round? Because everybody thought they were doing private practices and were around the golf courses.

Q112 Dr Stoate: But do any of you, or your colleagues, offer private treatment where NHS waiting lists are longer than acceptable?

Mr Ribeiro: I can only speak for myself. I have a private practice - and still do although I probably will wind down by the end of this year because I am too busy doing other things - where I give my NHS patients exactly the same amount of time and consultation as I give my private patients, and in fact I can get an NHS patient on my list for surgery for a hernia in six weeks and I would have difficulty sometimes in getting that in private practice because I do not have the time availability to do it. So I do not think this is an issue. I think it is one that has been brought up time and time again. People do their private work in their own free time and put the effort into it.

Q113 Dr Stoate: But certainly the BMA has suggested to us that this is at least a factor. Do you think it could be part of the reason why there is so much resistance by professional ‑‑

Mr Ribeiro: No, I do not. I think the profession resisted ISTCs because we have been encouraged and asked to consider working in teams. Part of the paranoia about consultants is that they are arrogant, distant, they do their own things and they are Lancelot Sprats, etc, and there has been a big change in the profession post Bristol, post Alder Hey, post all the disasters. We have been really under the microscope as a profession, not just surgeons but everybody, and the emphasis on surgery has been working in teams more collaboratively and working within a team structure. Now, that creates a completely different culture and climate in which to work. So I do not think that is an issue, the one you are raising.

Dr Simpson: Anaesthetists do not admit patients in their own name; we only respond to the workload that comes to us. I certainly do not believe that anaesthetists do not offer the same quality of care in the two sectors; they do the same. If you use the BMA figures, if you factor into that loss of waiting list initiative money, because the waiting lists are being dealt with in ISTC treatment centres, then I think their incomes have gone down, because that was work that they did to take account of waiting lists but within their base hospital in their own time ‑ at evenings, weekends whatever.

Q114 Dr Stoate: Professor Leslie, it is a big area where there is a lot of private practice still occurring. What is your view?

Mr Leslie: There are two criticisms of orthopaedic surgeons and their waiting lists ‑ one they are on the golf course and two they are in private practice - which have been levelled at us constantly but there is a shortage of manpower in orthopaedics which we told the then Government about in 1995. We had a manpower document which we published and it showed the number of orthopaedic surgeons we should be heading for. So waiting lists were not created by the orthopaedic surgeons but by a chap called John Charnley, who invented a hip replacement, and all of a sudden there is a whole lot of people out there who find that life will be better with a total hip and a total knee replacement so that the demand went up. No government or hospital kept pace with that demand and so a waiting list built up. Now, besides Ireland and I think Hungary we are the worst supplied of orthopaedic surgeons in the whole of Europe in terms of numbers. We are 1:39,000 per population. Sweden, where the doctors come over here, are 1:7,000 of population, so there is a shortage of manpower. So if there is a demand out there for something to be done in private practice then people will go and do it. In answer to your question I think private practice has gone down, perhaps manifested by the way the private health insurance companies are getting rather nervous and very worried about their future in terms of their income because I think a lot of corporate groups have stopped their private insurance, because the waiting list has come down. They used to insure them so you were not away from work that long to get private treatment. I think the corporate insurance has gone down so I think you are right, but none of my colleagues like having waiting lists. I hate having mine.

Q115 Dr Stoate: Certainly when waiting lists for hip replacements were two years plus I referred a lot more people at patients' request to the private sector. Now I can say to somebody "I can get that hip changed within six months" I am referring very few people to the private sector so there must be a factor there. I am just asking whether you think that factor is material in some of the opposition of some of your colleagues.

Mr Leslie: I think it is material and I would hesitate to say no. I would agree with you that amongst some of my colleagues perhaps, but I think as a body of people most of my colleagues detest having to tell someone they are going to even now have to wait six months for their operation. Telling them it would be two years was terrible, but I think it is an argument which really needs to be put on the shelf. You will find the odd person but I think as a group we are destined to try and get waiting times down but in the safest manner.

Q116 Dr Stoate: I would like to now light the blue touch paper and ask all of you why it is then that private fees in Britain are so much higher than in almost any other country in the world? Why?

Mr Leslie: The fee for a total hip replacement on BUPA's rates have not changed more than 3% since 1992.

Q117 Dr Stoate: I have some figures here. For example, if we take hip replacements, which is your specialty, in Canada it is 50% cheaper, this is the consultant's fee, and in Germany it is something like 60/70% cheaper ‑‑

Mr Leslie: But Canada does not have private practice. That is the fee paid by the Government to the surgeon.

Q118 Dr Stoate: So surgeons in Canada are charging far less per procedure than here, and the same with cataract surgery. 60% cheaper in Canada, 50‑60% cheaper in Germany and Spain. Why is that?

Mr Kelly: I will answer as best I can the second part, and I have to declare an interest. First of all, I am an overseas graduate; I am qualified in Ireland but have been working in the United Kingdom since 1983. The argument you have advanced there, and it goes back to the 2002 Inquiry, that consultants are opposed to these things because it affects their private practice, the so‑called "perverse incentive argument" which I think Professor Chris Ham and others advance, personally I find it abhorrent, and I think the profession does and I would hope that NHS management finds it abhorrent, because one of the beauties about working in the NHS is that you are working in a very regulated environment. We have Appraisal and Job Planning. So if there was any hint of consultants somehow manipulating patients this is a matter actually for the local employer to investigate, and also a matter for the GMC.

Q119 Dr Stoate: I am not suggesting for a moment that you treat your patients any worse or in any different way; that is not for a moment the suggestion. The suggestion purely is whether the fee structure of consultants in private practice is anything to do with opposition to the Independent Sector Treatment Centres? It is nothing to do with standards of care or quality of outcome.

Mr Kelly: You have two separate questions there and I will take these one at a time, if I may. Just going back to the so‑called 'perverse incentive', colleagues have already pointed out that most doctors do not wish to have long waiting lists, and the long waiting lists have been due to the under provision of surgeons. The orthopaedic example has been given but I will give you an ophthalmic example. There are a thousand ophthalmic surgeons in NHS practice in the United Kingdom, France has a similar population with five times more, so therefore - surprise, surprise - waiting times are shorter. People choose to go privately for various reasons that are best known to themselves, just like the way some people travel First Class by train or by air. We have difficulties with the patients being forced to go privately because of long waiting lists and thankfully, because of the investment in the NHS in recent years, waiting times have come down and therefore that segment of the private medical market has probably gone down. That is actually very worthwhile, so I do not think any of us have any difficulties about it. On your second question about the international comparisons, I do not have the figures in front of me but I think you are possibly referring to the Newchurch Research.

Q120 Dr Stoate: No. It is actually National Economic Research Associates, December 2003.

Mr Kelly: Well, there is always a danger of comparing apples with oranges and the point is that, for example, in NHS practice an NHS surgeon doing an ophthalmic list is probably going to get paid about £100 to £150 a session, and if that surgeon does ten cases you can see that is very good value indeed; if he does five cases you can see it is still very good value indeed. So if you are comparing like with like that may well be a more fair comparison. The figures from across Europe are the figures reimbursed by the state to surgeons and anaesthetists working in the independent sector as part of social insurance. Now it is not my specialist field and I do not know, but I do know that little bit. That may be something the Committee might want to take more evidence on? Even though you have addressed this in the past.

Q121 Dr Taylor: Several of you have said we must draw a line under Phase 1 and go on to Phase 2, but generally how are the colleges involved with trying to influence the future and the way that Phase 2 ISTCs work?

Professor Husband: In terms of radiology we are developing clinical pathways through our input from the MR guardian, but of course Wave 2 is going to be CT and ultrasound as well. We have more concerns about ultrasound than CT and MR because it really needs to be interactive. You cannot give a report on an ultrasound in the same way as you can ‑‑

Q122 Dr Taylor: Unless you have actually done it?

Professor Husband: Yes. You really need to be doing it yourself so we have some concerns there. We are also developing an accreditation scheme for radiological services from our College which will be a multi professional, multi disciplinary scheme looking at quality, and this would be applicable to both the private sector and to NHS services. It would, of course, be voluntary to start with but we hope to have this up and running by the end of the year and we are working with the Department of Health to bring this in. I think that would be very valuable in raising quality and providing a uniform quality of care. So we are also providing protocols for imaging so that the imaging that is done in the private sector reaches the standards approved by the College in the different specialties.

Q123 Dr Taylor: And you have already said it is rather limiting if radiologists are working only in ISTCs.

Professor Husband: Yes. Absolutely.

Dr Simpson: In terms of Wave 2 what we would hope and what seems to be happening is that actually there is much more integration so that the ISTC, whether sited locally or remotely, is part of the local training environment. We have not spoken a lot about training but I think we should, and one of the points is that if a new ISTC on Wave 2 wants to train then it can perfectly well do so; there is a perfectly easy way in which it can be incorporated. For example, PMETB accredits training environments, and basically a person in anaesthetics for want of a better example is doing a training programme in a particular area. If there is experience to be gained in that TC then that TC will have to be accredited for training like anywhere else. It all fits in, and people can be rotated through quite happily. The other issue that goes away is that if, as the Secretary of State has announced, you can use NHS consultants in these things then NHS consultants are accredited trainers, so a lot of the issues go away from that point of view.

Q124 Dr Taylor: I think we were told by the first set of witnesses that there is a draft statement on training coming.

Mr Ribeiro: I received mine in e‑mail this morning actually from the Department of Health ‑‑

Q125 Chairman: It is the influence of our sitting as a Committee!

Mr Ribeiro: Absolutely. Incredible timing, is it not! As you know, the Secretary of State in a speech on January 10 did say about the independent sector: "But I recognise that other reasons for using the independent sector to add to the innovations already happening within the NHS and to introduce an element of competition and challenge to underperforming services is a harder argument to win, so we will continue to respond to legitimate concerns, for instance to ensure that training for junior doctors is provided within the Independent Sector Treatment Centres and more generally to provide a level playing field for different providers within the NHS ..." That statement is what we seek, and I think in the submission given to you by the Healthcare Commission they too stress two things. One is the introduction of training and two is the removal of additionality, and I think if the Secretary of State has put a flag on the mast to say that is what they seek then that is what the Colleges would like to do in the next phase. We have already as a College during the last year had several discussions with the private sector, the independent private sector, in fact before they folded the Independent Health Forum, about the possibility of having training in their hospitals and they were very receptive. What we want as a standard is to use the consultants in the NHS whose training abilities we know and whose results we know, to do the training in the new wave ISTCs, and I think that is the positive way forward. I should say in Wrightington, which is exactly where John Charnley did all his experimental work in the early days of hip procedures, there is excellent training in that DTC and trainees are queuing up to go there because it is uninterrupted work and they get good training. The Department of Health has now said it wishes to engage in discussions on training: I wish they had done that two years ago, frankly. It is a bit late, but your Committee perhaps has helped ginger things up a bit. I hope that continues.

Q126 Dr Taylor: Would we be allowed to have a copy of your e‑mail?

Mr Ribeiro: I will leave it to you to copy afterwards, certainly.

Mr Leslie: I do not think in terms of Wave 2 any of my colleagues in orthopaedic surgery will be happy until there is a quality assurance of the surgery and the surgeons that are coming into this country to operate on patients who they have seen often in NHS clinics, the patients have gone away, had their operation and they come back to the NHS clinic with their problem. The quality assurance issue of these surgeons in orthopaedics, I cannot speak for other specialties, needs to be absolute. When you are appointed to an NHS consultant job you are on the Specialist Register, but equally you go before an interview committee where there is a member of the College of Surgeons who assesses your training and your abilities, and it is not done by a manager. You might be familiar with the Foster Report from Queensland where there was a problem with Bundaberg Hospital and one of the comments of that report was that colleges were not involved with the appointment of those personnel, and unless that is sorted out you will still get the negative effect, I am afraid, from the orthopaedic community which is not self interest. From all the letters I have had it is, that these patients are suffering unnecessarily. You can say the ISTCs have been successful in waiting lists but at a price, both a monetary one and also a lot of patients out there are having problems as a result of that innovation.

Q127 Chairman: How many of your members were trained overseas, Mr Leslie?

Mr Leslie: I for one was trained overseas, but trained overseas in terms of their surgery. Probably a small number. We have a lot of overseas fellows.

Q128 Chairman: Presumably they compare well with those trained at home, in the United Kingdom?

Mr Leslie: Yes. Because they have been appointed to NHS consultant positions they have been selected by an appropriate appointment committee. For instance, I could not go to Canada, US, Australia or New Zealand and just go and practise there. I would be mentored for a year in Australia, if I wanted to seek registration, by a senior person before I was given the chance to operate independently, yet so many people can come here from Europe. They are very good surgeons there, do not get me wrong, but if you put me in a hospital in Sweden for two weeks my complication rate would be higher than if I am operating in my home hospital all the time with my team. So the places where the surgeons have come in and the local NHS surgeons have been involved, they get on well and work with each other. It is this flying teams in and out again which our members totally object to.

Q129 Chairman: Why has your association not got evidence then to say that these doctors coming in, flying in here, to do these operations are not good doctors? That is what you were suggesting and that is what was suggested back in 2003, but there is no evidence for this.

Mr Leslie: What we have said is we are unsure of the quality, and what I am asking for in a second phase is that quality is assured, and it can only be assured by those in the profession who know, which means the Colleges. We are not saying that every surgeon who comes in is bad, not at all; nor am I saying that every surgeon in the NHS is perfect either, but we are looking at complication rates. We have evidence. For instance, a revision rate, and I have the figures here, of 0.7 per hundred in an NHS hospital versus 2.3 per hundred in an ISTC. There is another study from Cheltenham, but the difficulty is our finding out the information. We do not know, and I do not know, how many operations have been done in the ISTCs.

Mr Ribeiro: Just coming back on that, in order to raise our concerns about ISTCs we had a meeting on 10 January with Sir Nigel Crisp and Bob Ricketts ‑ myself, Peter Simpson and Professor David Wong representing ophthalmology - and we had explained to us by Sir Nigel that there were four areas that were important, policy, training, clinical care and audit, and on the issue of audit he recognised it was important to acknowledge that patient confidence needed to be established in the ISTCs. He also recognised that it was important, and we offered to help him with this, to develop outcome data that would allow for true comparisons between the NHS and the ISTCs, and rather than taking a personal issue as to overseas doctors and whatever it is, there are overseas doctors in the NHS and there are overseas doctors outside and that is your point, but let's prove the pattern and find out whether the quality of work coming out of ISTCs is equivalent to that coming out of the NHS. Ken Anderson in his report refers to 95% patient satisfaction. Well, it depends what parameters you are asking the questions on as to whether they are satisfied or not. We know for example on the KP9, the key performance index, that the one on the re‑admission rate has been subject to some concern about how the data is collected, so let us do a proper study. My College is quite prepared to get engaged with its partner in health and do it. We have a clinical effectiveness unit at the College which would be happy to undertake this work, and if it can be funded we will do it tomorrow. So the challenge is let us find out, and let us not be anecdotal.

Mr Kelly: On your point about how do we know whether these doctors are safe or not, the reality is that some of them are probably very good and some of them are probably mixed. We could probably say the same about all the doctors working in the United Kingdom and about engineers or architects or any other profession, but the key issue in medicine is that doctors work in teams and it is the team, just like driving an aeroplane, that underpins safety. Mr Leslie's point that if he went to Copenhagen to do some surgery he would be out of his depth for the first few days - because of using different instruments and one thing and another is exactly this point. That is where we have issues. Professor Ribeiro has made the point that audit is the way to track this. At present the audit that has been done has been rather patchy in the ISTCs. We have seen the NCHOD Report which Dr Taylor has raised. I have done a critique of the NCHOD Report on behalf our College and can circulate that to members, if you wish.[7] Our College provided it to the Department of Health's Central Clinical Management Unit: we have had no response from them. As regards patient satisfaction, the patient satisfaction levels in some of the surveys that have been done have been high but one needs to be very careful ‑ and Ms Milton made the point about "how do you know where to go" - about satisfaction surveys asked of patients immediately following their procedure by the doctors and nurses who were treating them. "Was it good for you? How was it?" Most people - on the evidence available - actually want to agree with the clinician giving them their care, so most people say: "Yes, the service was good." It is within the few complaints which is where the grit and granularity is, and that is what we need to focus. Regrettably in your documents you do have a list of letters that we have had in at our College, because we have found ourselves in the first wave of this. They are therein; the patient details have been anonymised; and they are worked detail of people up and down the country. This is a worry to us, that the system is not really addressing the patient safety issues in ISTCs. And this is occurring just at a time when we all recognise that a systems and integrated approach is the way forward for improving patient safety.

Professor Husband: I would like to make a point about training in the radiology MRI centres. Because the reports are done overseas there is one centre in Brussels, one in Barcelona, one in Cape Town and one in Scotland which have all been visited by our MR guardian and the quality is good now. One of the centres is not listed, one in Spain I think, and has been removed from the list, so the quality is good but of course the training cannot happen because these radiologists are not in the vans to do the training, so that is another reason why additionality must go. Our second audit is going to be published in April and has shown good quality across the board.

Mr Leslie: Just coming back again to audit of the work. Two years ago the BOA went to Aidan Halligan, who was then the Deputy Chief Medical Officer and in charge of clinical governance, and we strongly recommended to him at that stage that we should conduct an audit which should include an audit of an NHS hospital and should be comparative. We pushed that very strongly, and nothing ever happened.

Dr Simpson: Just generally I think there is a belief out there that NHS doctors do not care about their patients at the level we are talking about but I think they care passionately about their patients. For example, I live in Bristol. I had an anaesthetic a few weeks ago; I did not know who was going to give me the anaesthetic in advance and I did not bother because they are all good, and the problem is the uncertainty of another group of people coming in who we just do not know about. That is why we, and patients, need the opportunity to be informed about that.

Q130 Anne Milton: Professor Husband, you said that there were 20 MRI scanners not working to full capacity. How would you, for clarification, define "full capacity"?

Professor Husband: I do not mean extended hours; I mean working eight till five.

Q131 Anne Milton: Five days a week.

Professor Husband: There is not sufficient funding to resource the machines to work all the time. There is also a shortage of radiographers which is being addressed, and I think double the number are qualifying this year, so that will not be a problem that will be on-going so much, but radiographers are also leaving the NHS to go into private work and then into the Independent Sector Treatment Centres, or MRI vans of Wave 1 Alliance Medical, so although they cannot jump straight from NHS to Alliance they are going via another private centre and then to Alliance, so that is causing a further reduction in the number of radiographers, but also the actual finances to run the scanners is a major problem. So there are examples of MRI scanners in hospitals in the United Kingdom which are not being used at all, and some only being used half of the week.

Q132 Anne Milton: Do you know where they are?

Professor Husband: I could get that information for you.[8]

Q133 Mike Penning: Is there a link between the areas which are suffering under financial deficits and those scanners that are not being used?

Professor Husband: I believe so but I have not got facts and figures on that. I believe that is the case.

Q134 Anne Milton: It would be very helpful to have the list. Can I ask you all to what extent the ISTCs are cherry‑picking cases?

Mr Ribeiro: In our submission we leant heavily on the orthopaedic submission, and we have good evidence in Southampton, for example, where the Capio contract has taken a significant number of cases of low co-morbidity. We use a grading, the American Society of Anaesthesiology grading, to determine how sick a patient is and we have very good evidence that a significant number of ASA 1 and 2 low grades have gone, leaving behind a lot of ASA 3 cases to be done, which clearly are more technically difficult and therefore are not good training opportunities. So we have good evidence all over the place. But touching on what Mr Penning has said there is another more critical matter which I hope we can get on to in this discussion today, which is what the effect of ISTCs are on the economy and on the health economy of the hospitals around and about. I recently went to Trafford, the Greater Manchester surgical centre, and in Trafford two of the wards have been closed as a result of the contracted work going from the PCTs to the ISTC; £2 million worth of work in the first six months has left the Trust in the PCTs to go elsewhere.[9] This has to have a significant effect on the NHS and it will have an impact. In my own little area in Essex the Government has decided it is going to put in a £45 million ISTC with the intention of taking work from Southend, Basildon, Chelmsford, Colchester, and take from each of these hospitals the equivalent of 20% of their elected work. That will have, with payment by results, a significant effect on the functionality of those NHS hospitals, and that is what I would like to move on to in our discussion now. We have said a lot about personal private practice and so forth but I am more concerned about health economics and what is going to happen to the future of those NHS hospitals.

Q135 Anne Milton: Just picking up on that, the two gentlemen previously denied that.

Mr Ribeiro: Well, I was not here and I am sorry, I hate to use the word "nonsense" but I will. I still work in the NHS and I had this discussion with my Chief Executive on Monday, and in your constituency, Dr Stoate, Darent, you know well Sue Jennings produced and opened two wards next to the treatment centre to use with the theatres, and those two wards have been shut because of the financial pressures. Now, you cannot tell me nothing is happening and there is no impact. I can cite many more examples where it is happening. The policy was right initially to find extra capacity and, again, I will give you an example why the NHS has not been able to do this. When I was appointed as a consultant surgeon in 1979 there were 14 surgeons in the whole hospital and we had ten operating theatres between us. Today there are 34 surgeons in the hospital I work in, and we have only 12 operating theatres. Capacity was the problem. The Government gave us capacity through ISTCs but I think somewhere along the line it has lost the plot because what it is doing by throwing all this money into ISTCs is challenging the existing NHS - and it will go down. And if you listen to people like Chris Ham they say "Right, so what? What we need to do is come down from 200 NHS hospitals to 50, make them more effective, more efficient." Is that what the public want? Have we gone out to consultation? Have we asked them? It may be the right way to go. After all, my College for years have said that we should have hospitals of 500,000 population and economies of scale and so forth and it may be that is where we need to move to, but I think we can get there by better networking of hospitals. But I would like this Committee to focus much more on the impact that this will have long term on existing NHS hospitals rather than nitpick over issues about private practice and those sorts of elements.

Q136 Anne Milton: To some extent one of the reasons we bring up what might feel nit‑picking to you is because that is in the evidence we have received and those are the anecdotes that people say to us in our constituencies, and therefore it is important to address it even if you might feel it is not a central part of the issue. Mr Kelly?

Mr Kelly: On cherry‑picking from an ophthalmic perspective there is no doubt whatsoever that there is cherry‑picking in cataract surgery in the mobile units, and it would be scandalous if there was not because quite frankly they are mobile units with no facilities for general anaesthesia or for children, or for a whole host of patients with complications, so only the fittest patients can go to the mobile unit. Now, the effect of that is that the more complex cases remain at the base hospitals. For example, patients with Downs Syndrome frequently get cataracts and they require cataract surgery under general anaesthesia and can be challenging for our anaesthetic colleagues. Those patients receive the same tariff under the new Payment by Results ‑ which actually is payment by activity, I have to say, not by results ‑ as do the most straightforward case done in the ISTC. Professor Ribeiro is quite right to bring to the table the impacts on the local NHS services because these impacts are going to really play in when Payments by Results come in. So while cherry‑picking has got safety reasons why it is done; but it has implications for the services back home on the base and for the cost. Also, I am a resident in Trafford and the local MP, Mr Lloyd, for Central Manchester, has already raised in this House concerns about the impact of the Greater Manchester Surgical Unit, which as I understand it is going to take £70 odd million out of the Greater Manchester surgical provision from across all Greater Manchester PCTs. Mr Ribeiro made the point about Trafford Hospital, which - as I understood it, was the home of the NHS and is now one of the hospitals suffering. We in our hospital in Bolton are suffering the same effect. So all of this has consequences and impacts for local clinicians and residents.

Dr Simpson: On the question about cherry‑picking, although it may appear to refer to the type of surgical operation, it actually refers much more to the anaesthetic state of the patient and this creates, in fact, a very unlevel playing field, because if you have people who either need a general anaesthetic when they would otherwise not or, worse still, complicated general anaesthetic cases, by inference they stay in overnight or two days, and immediately the NHS hospital is tarred with the brush that says: "Of course all your patients stay in twice as long as those down the road", and it is not true at all. It is a different group of patients.

Professor Husband: On cherry‑picking, because the service is provided in mobile vans only very simple cases are suitable to be examined on the vans and therefore it is inevitable. It is not exactly cherry picking; it is only that a certain group of suitable patients.

Q137 Anne Milton: Fit for purpose?

Professor Husband: Yes.

Mr Leslie: One of the people wrote back and said the average length of stay for their NHS patients now has gone up by two days since the introduction of ISTC. Now they are slightly damned for that because you are now in for eight days instead of six, and that is on the length of stay. I think it is difficult for constituents to understand the health economy and that is why they probably do not ask the question, and our patients do not understand the health economy and it is up to us to try and steer that and I think that is reasonable. Patients are interested in getting the safest treatment. We heard about choice this morning from the Department of Health but a patient has not got a clue really what is available because there is no information out there, and the GP who looks at his screen when you are consulting does not have much of an idea either of the important indicators for an NHS hospital. We have a patient liaison group, as many groups do now, which looked at our submission and supported it wholeheartedly. They want to know just where it is safe because, if you have a good hospital down the road which has a high standard and has a short waiting time, why do you need choice?

Q138 Anne Milton: There will be conflict about people who actually choose to have their non urgent operation beyond the Government's targets and waiting times. "Will you be allowed to have your operation in 21 weeks?"

Mr Leslie: Well, you are not actually, no. Some of my patients would like to say that. They say, "I would like to stay with you but it means spilling over six months and that is not allowed", and that is not choice.

Anne Milton: Precisely. Thank you.

Mr Amess: Chairman, I just wanted to say what a joy it is to have quality witnesses like this who know what they are talking about, we can understand what they are saying, who have come up with some positive solutions to the challenges we put. Also, what a tragedy it is that these people, and I think you mentioned nine months, were not engaged with policy makers at a very early stage. I had been intending to ask you questions on training, accreditation procedures and foreign doctors, but because you have been so articulate I think, frankly, these questions are all a waste of time. You have covered everything and I was just going to suggest, Mr Chairman, that perhaps, given that Mr Ribeiro, who is splendid, obviously wanted to say a lot more about the future of the NHS and the work force, we could have them back as witnesses for our inquiry into the work force?

Q139 Chairman: Another day, perhaps. Witnesses will be aware of our future timetable in terms of inquiries.

Mr Ribeiro: We have made a submission so we would be very happy to come back. Thank you.

Dr Simpson: And I am going away to write it now!

Dr Taylor: May I make a couple of comments? First, I would like to reassure our witnesses that health economics will be very important and we will take it up with future witnesses. Secondly, obviously one of our recommendations should be that the Royal College of Surgeons' Clinical Effectiveness Unit is funded to start this review of all that we want to know ‑ outcomes, complications ‑ tomorrow, if not before.

Q140 Chairman: I am very grateful to you for writing the report! To say that while we are in the first witness session is commendable! Just to finish this session, and I would like to go across the piece on this one with all of you, what would be the one thing that you would add to Phase 2, if that is what you were doing, and I know Phase 2 is on its way now, and what would you take away from Phase 2, or from Phase 1, as it were?

Mr Ribeiro: When I went to the Trafford centre, the Greater Manchester centre, I did a rather unusual thing which was I officially opened an ISTC centre and cut the ribbon, and in my opening speech I said to the CEO, Dr Eduard Lotz, that I would hope that in five years' time this splendid hospital would be part and parcel of the NHS.

Professor Husband: I would take away additionality completely and add in clinical radiology leadership for the programme to be integrated.

Mr Leslie: I would echo that it should be incorporated in the NHS and, in the meantime, quality assurance of the work being done needs to be absolute.

Dr Simpson: I think we should be grateful that effectively we are being provided with ring‑fenced surgical beds, which is what it is, but they must be integrated into the NHS plan and pattern of work.

Mr Kelly: I would support everything that my colleagues have said, and I think it is absolutely vital that there must be clinical leadership in discussions with the Department which have been sadly lacking in the earlier phases. This is necessary and it has to be done by specialty and also by locality. It is probably also worth bearing in mind that none of the advisers at the National Implementation Team have much, if any, clinical background. Most of them are independent consultants, many from management consultancy agencies, and there is also a danger that they tell senior policy people and ministers what they want to hear. The voice of the College may sometimes tell people what they do not want to hear, but it is a voice that needs to be heard. The Colleges have been here for a long time, and will be here for a long time, and patient and public safety and training is our underlying bedrock.

Q141 Chairman: Could I thank you all very much indeed for this session. I am sure it is going to be very useful when we come to make our recommendations to Government in this area.

Mr Ribeiro: On our behalf may we thank you for your civility and kindness to us during today's meeting.

---

[1] Ev x

[2] Ev x

[3] See Q 27

[4] Ev x

[5] Ev x

[6] Mr Kelly submitted two published articles as evidence to the Committee: Kelly, S P, Cataract Care is Mobile. Is direction correct? British Journal of Ophthalmology, 2006, Vol 90, Issue 1: pp 7-9; and Kelly, S P, Recurring policy errors: blind spots over cataracts, Lancet, 12 November 2005; Vol 366, Issue 9498, pp 1691.

[7] Ev x

[8] Ev x

[9] Following the oral evidence session on 9 March, the Chief Executives of Trafford Healthcare NHS Trust and Oldham PCT wrote to Mr Ribeiro about his evidence to the Committee. In their letter they stated, "...your references to ward closures and loss of income are entirely untrue. We both wish to confirm to you that no wards have been closed in Trafford Healthcare NHS Trust, nor has any funding been diverted from this Acute Trust as a consequence of the Greater Manchester ISTC programme coming into operation". Mr Ribeiro replied to apologise and say he had been mis-informed. He has asked that this be made clear to the Committee.