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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 934 - ii House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE HEALTH COMMITTEE
INDEPENDENT SECTOR TREATMENT CENTRES
Thursday 16 March 2006 DR THOMAS MANN, MR MIKE PARISH, MR MARK ADAMS, MR PETER MARTIN, DR IAN SMITH and MR ALAN PILGRIM MS ANNA WALKER, PROFESSOR SIR GRAEME CATTO and PROFESSOR PETER RUBIN
PROFESSOR JOHN APPLEBY, DR SALLY RUANE, MR JAMES JOHNSON, DR PAUL MILLER and MR DANIEL EAYRES Evidence heard in Public Questions 142 - 337
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Health Committee on Thursday 16 March 2006 Members present Mr Kevin Barron, in the Chair Mr David Amess Charlotte Atkins Mr Paul Burstow Mr Ronnie Campbell Anne Milton Mike Penning Dr Doug Naysmith Dr Howard Stoate Dr Richard Taylor ________________ Witnesses: Dr Thomas Mann, Chief Executive of Capio Healthcare UK, Mr Mike Parish, Chief Executive of Care UK and Director Partnership Health Group, Mr Mark Adams, Chief Executive Officer of Netcare UK, Mr Peter Martin, Chief Executive of Mercury Health, Dr Ian Smith, Chief Executive of General Health Care Group, and Mr Alan Pilgrim, Chief Executive of Alliance Medical, gave evidence. Q142 Chairman: Good morning. I recognise the potential problem in having six witnesses and this list of questions in front of us. It could go on for ever, as it were. In view of the evidence session we had last week and the written information we have received, probably the first question is something I could tempt you all briefly to comment on, or indeed to say if you disagree with what is being said. Maybe that would be a way of doing it. Then, after that, hopefully we will try to put some specific questions to individuals. Generally you say that your appointment procedures are at least as stringent as they are in the National Health Service. Could you tell us why you believe that the colleges and other professional bodies seem so critical of the procedures in terms of your appointments? Mr Parish: I am happy to start because we have had many telephone calls from patients in the last week or so. They have been quite anxious, having read some of the reports recently. Of course, we have invited them in again to meet the doctors and be reassured, and happily they are. Many of the comments that are made without evidence of actual reality can cause patients concern. Hopefully, in our submission we have set the record straight. I am happy to elaborate if you require it. I think the motives are mostly genuine. There is a genuine concern around change, and this is significant change. People are seeking reassurance. Most of the reassurance is sought in a professional and orderly manner. That has happened; we have had many visits from patients and we have supplied that reassurance. There is also a stake in the status quo. The reality is that we have quite a quirky system in the UK in the way that doctors in particular are remunerated. There is the old saying that the NHS is for cash going in and private for cash. It is quirky with something like 30% of reward for 70% of the time and vice versa. Any perception that that may be threatened can result in some difficult reactions. We have seen quite a bit of that. There is mostly positive and genuine concern but with elements of defensiveness. Mr Adams: In the first wave of the ISTCs it was important to introduce additionality so that you could demonstrate that you were providing a supplementary resource to the NHS to address some of the waiting list challenges that existed around the UK. In the long term, the additionality causes a challenge and a conflict with the establishment because we are not working in partnership. We are not working on issues ranging from our recruitment of British nurses and doctors through to the training of British nurses and doctors, and that puts in an artificial divide, which I guess you would not have chosen if you were starting with a completely open canvas. For speed of mobility, it was a sensible thing for the first wave but it is one of the things we need to overcome as we go forward. Mr Martin: A lot of the issues are around education. This is a new initiative. There is still a long way to go before everyone involved in the system is aware of exactly what an independent sector treatment centre is and what happens there. We have certainly found, from our own experience, that at a local level the initial reaction from local trusts and local clinicians has been one of resistance and in some cases suspicion. We have worked very hard to bring the local clinicians along with us and, in developing our integrated patient care pathways, we have actually worked with local clinicians and got their sign-off for those pathways. As a result, we feel that we have now developed good relationships locally and those clinicians who initially were opposed to what was going on are now supportive. Mr Pilgrim: Whilst the fast track MRI contract, which is Alliance' Medical's main contribution, is not actually an ISTC, it is obviously another contribution to the capacity agenda. Whilst we have seen initially the same sort of resistance, you may have detected last week at the meeting with Professor Husband that we were quite a long way down in terms of the relationship with the radiologists. It boils down to the proof of the pudding being in the eating. We have now demonstrated that the radiologists that we are using, who are covered by the additionality, are producing reports equivalent to the quality of reports produced in the NHS. We are starting to see that radiologists are accepting that in the UK. Our business across Europe has been built on working with local radiologists. This contract that we have is slightly odd compared with everything else we do. Ultimately, we would like to see it moving towards us being able to work with local radiologists, but there has been resistance and some of the comments that Mr Parish made are valid in this regard. Q143 Chairman: I understand about the additionality and we may get on to that later. One of the things that came out was this issue that obviously, because you were not able to recruit effectively from the NHS as opposed to the rest of the sector, you have to bring in a lot of overseas doctors. There are issues about language and there is not the back-up available for these doctors that there is in the National Health Service. Has that been a problem in terms of language barriers and things like that as employers? Mr Pilgrim: We encountered certain problems initially, partly not through language but the nature of reports that were produced. Now I think we have sorted out those problems. It really has been a question of evolving the contract and the provision of the reports to enable NHS consultants to review them. Dr Mann: I think it is an important challenge that we have had to deal with. Obviously, if you recruit from the NHS, you are more likely to get doctors who not only speak good English but who have actually practised in our system and understand it well. If you have to recruit from outside, you have to make sure that they do. A number of efforts have been made and all this is undertaken to make sure that is the case. There are also fail-safe mechanisms so that when we find that somebody is not everything we hoped he would be, then we have to deal with that, and we have done that. Mr Parish: It is important to note that we do not just employ people who put a hand up. There is a rigorous selection process, and that includes language skills and cultural adaptability. A lot of work is done to meld a team together because these people come from different countries typically. It has been done very successfully and I think that goes back to the fear factor. If we were just to take people who put their hand up, then I too would be concerned. It is about doing that professionally. Overall, I am a big supporter of additionality. That has added real capacity to the NHS and I think it has helped some of the commercial pressures that have led to a significant and positive response across the NHS. Q144 Chairman: In the Healthcare written submission to us on this subject, they suggests the recruitment procedures for ISTCs should be brought into line with the National Health Service, including the introduction of the equivalent to the advisory appointment committee system. I have seen written evidence that suggests that something like that does take place in certain areas. The written evidence we have this week is enlightening on what was said or not said last week. Do you have any view about the Healthcare Commission saying that you should look at this type of appointment system? Dr Mann: It is not just the Healthcare Commission; the Royal Colleges have suggested the same thing. We took the view that there were two issues here. One was whether sufficiently expert doctors, nurses and others who are practised not only in clinical skills but also in working in the NHS locally were involved in the recruitment selection process or whether, in addition to that, the people involved were representative of certain national bodies. That is the critical difference. We believe, and this is what we practise, that senior and competent specialists from those appropriate specialties are there on our selection panels. We have not sought to ensure that those people are delegates from a particular national body but that they are representative of the local specialist expertise. Mr Martin: Speaking for my own organisation, we believe we have already gone some way to come into line with the NHS appointments procedure. Our interview panel is led by our Medical Director, who is a former medical director of an NHS foundation trust. We have also included on that panel a senior member, a former Council member, of the Royal College of Surgeons to bring a degree of independence to the selection process. Dr Smith: In general terms, the more we can integrate with the NHS, both locally and in terms of systems and quality, the better. The more convergence we can have - I think the Healthcare Commission is trying to do this on a number of fronts - the better it is for everyone. The debate then moves from issues of incompatible systems or processes to patients, which is really what this whole programme should be about - quality care for patients and a fair deal for taxpayers. Mr Adams: Again, there seems to be a commonality in the panel in terms of the processes of selection and the engagement and involvement of local specialists adding to our own referencing and processing criteria. From my past experience of when I used to have responsibility for the largest UK doctor locum agency, if I look at the number of international doctors that my previous business, Medacs, used to bring into the mainstream NHS and at Netcare, then Netcare at the moment is probably working with about 25 or 26 international doctors at consultant grade. That is probably about 10% of what I know is brought into the NHS from the various medical locum agencies that exist to supply the NHS as a whole. I do not think it is just about international doctors just being a component of the ISTC programme; it is just the way the NHS has historically worked in general. Q145 Dr Naysmith: I have a quick question for Dr Mann on something he said when he was talking particularly about the language and culture of some of the people he employs. You said you took action when you came across people who did not come up to standard. What does taking action mean? Does it mean dismissing the individual or retraining them, or what does it mean? Dr Mann: It can mean both. First of all, it means trying to find out if there is an issue, exactly what the issue is, and then trying to make sure that we can correct that and, if that is not the case, then dismissing the person, if appropriate, and, if any other actions are needed, like reporting them to the GMC or whatever, we would take that as responsible employers of a clinical service. Q146 Dr Naysmith: How frequently does something like that happen? Dr Mann: It has happened once for us. Q147 Mr Burstow: One of the things that was very striking from the evidence session last week, and I am sure you have all had a chance to read it and in some cases may have been here to hear it, was the number of occasions on which particularly the Department officials were offering to write to us on items that the Committee could reasonably have expected them to have answers to, and particularly regarding the issues of what data is being collected by yourselves. One of the issues that the Committee wanted to follow up on today was the question of access to information regarding clinical outcomes and patient safety data. We noted the submission that we had from the National Centre for Health Care Outcomes and Development where they have said specifically that there is a lack of data in terms of clinical outcomes. Perhaps, starting with Mr Parish, you could tell us a bit more about the work you are doing locally to ensure that patient safety and clinical quality data is being collected and how it is then validated because both of those issues seem to be important. You seem to have supplied us with more information on that than anyone else. Mr Parish: We have supplied you with the data that we report, which is essentially required in the contract arrangements. I presume that is consistent across all providers. That is essentially 26 key points in the data with a subset of around 98 overall indicators. Q148 Mr Burstow: The document you have submitted, which on our list is down as ISTC 52A, which is Partnership Health Group (PHG Trent and Peninsula ISTCs...", is the data you are talking about? Mr Parish: Yes, it is. Q149 Mr Burstow: You say that this is the product of what you are required contractually to provide? Mr Parish: Yes, it is. That data is generated and audited locally by the PCT, and obviously the Health Care Commission when they review it. It is made available within the unit to patients. We focus on continuing improvement and therefore each of those statistics is reviewed on an ongoing basis to seek improvement. Alongside softer measures of patient satisfaction, we have a tablet that patients are given on a number of occasions during the day to record their satisfaction with softer measures: food, staff attitude, et cetera. Q150 Mr Burstow: Can I come back to quality of life in a minute? That is important but I want to stay focused on patient safety and clinical outcome to date. Mr Parish: On the statistics we have generated, our view is that they are creditable, given that we are in a start-up phase, and we know they compare favourably internationally. It is more difficult to compare them against NHS statistics because those are more difficult to get. We thought it would be useful also to include a one-off comparison that is provided to us by our PCT sponsors with Nottingham City Hospital, so that there is a direct comparison that we include there, too. Q151 Mr Burstow: It would be your understanding that the data you supplied us for today's hearing is data that should be obtainable from all of your colleagues in other ISTCs and should be drawn up on a comparable basis? Mr Parish: Essentially, yes; it is always difficult comparing one case mix or patient mix to another. There needs to be a level of intelligent comparison rather than a crude direct comparison, but essentially yes. Q152 Mr Burstow: Why is it that you think perhaps the Department did not seem to know that? Mr Parish: I really cannot comment. Q153 Mr Burstow: Can I ask one final matter on this particular point? How do you actually ensure that the data is externally validated? What is the mechanism for external validation, peer review, and so on? Could anyone else add to that? Mr Pilgrim: We have had an independent audit of cases and reports. The first audit took place this time last year. Professor Husband referred to the results of the report which have not seen yet which took place this year and will be published in April. That is an independent audit of our results against NHS results. We have come out in line with the NHS on both occasions. Dr Mann: The data is collected from all of us for our ISTC contract. Every month there is a review of the data and a scrutiny of the results of that data, which is jointly undertaken between the NHS and our own people in a group that has a majority from the NHS locally. They go through all the indicator data. We have the minutes of that. They go through every individual line. We would be happy to make that available to you. Q154 Mr Burstow: That would be very helpful. The point that has been made to us in other evidence from a variety of sources is that whilst there is a dataset in terms of KPIs which are about process, there is not so much data in respect of clinical outcomes. You are saying that the data you supply and go through is clinical outcome data. Dr Mann: The indicators are outcome indicators about various things like return to theatre and readmission; those are available. Those are the ones that are scrutinised. They are part of the 26 indicators that Mike Parish referred to. That sort of indicator set is available in many parts of the NHS. We do look for comparators there. In addition to that, we are also trying to collect some very particular research-like clinical outcome indicators, which we have not got yet, but they are not available in most facilities. Q155 Mr Burstow: I am labouring this a bit because I think the answer we had from Mr Parish, which was passed on in the information that has been supplied by your company, and the answer we have just had from Dr Mann do suggest there is some conclusion here in that there may be a standard set of data that is being supplied as per the contract. The advice we have been given by our advisers, Mr Parish, is that the data you have supplied today is more than is expected within the contract. That is why I want to be absolutely clear that your advice to us today is that this is solely being provided because you are being contractually required to provide it. Mr Parish: I would need to seek clarification on that. The only uncertainty I may have is where we have supplied information over and above our contractual requirement. We absolutely do not generate that information just because it is required by contracts. We generate it because we depend on it, our patients benefit from that information, and certainly the referring GPs do. There may be elements of that information that are over and above the contractual requirement, but I will clarify that. Q156 Mr Burstow: That would be very helpful. Accepting this may well require notice as a question, it would be very helpful if the others of you who are giving evidence today could similarly set out for us what you are required by contract to provide in terms of data and whether or not it is the same data that is provided to us today by Care UK, so that we can get a clear fix as to whether you are all collecting and publishing the same information. Mr Martin: I will add that the Committee did ask for information on one of our centres, that is Mercury Health, which we provided yesterday. You may not have had a chance to look at that. We provided you the data in exactly the form that is provided to the various authorities to which we have to report. That has 26 or 27 key performance indicators, most of which are clinically based and that we are required to provide. You also referred to the report from the National Centre for Health Outcomes Development. My reading of that report was that there were three conclusions: that the QA system used in ISTCs was more ambitious and demanding than in the NHS; that the KPI data provided by ISTCs was more extensive; and that earlier work on quality monitoring was encouraging. I think it is still very early days. We found that an encouraging report. Mr Burstow: They certainly said those things but they did also raise the concern about access to data or clinical outcomes and the need for independent validation as other issues that certainly the Committee is interested in exploring. If we could have that answer back, that would be very helpful, Chairman. Q157 Dr Stoate: There have been concerns from a number of quarters about the effect of the ISTC programme on the training of medical staff. I wonder if any of you can comment on what you do, if anything, to train medical staff. Dr Mann: We, and I think all my colleagues, are in the throes of trying to set up training schemes within our facilities. For the last year and a half we have been in discussions, nationally and locally, both with the Royal Colleges, training accreditation boards and local training schemes to see how that can be realised. There is a pilot group to do that. Q158 Dr Stoate: You are not doing it at the moment then? There is no training at all at the moment for medical staff in your programme? Dr Mann: We have not started that but we are due to start one later this year. We hope to roll them all out in all our facilities over the next couple of years. Q159 Dr Stoate: Do any of the others do any training at all of medical staff? Mr Martin: We are opening our fourth centre in the summer, an elective orthopaedic centre in Hayward's Heath. We will be offering training there from day one. We are in discussions with the local deanery and local clinicians around that. We will be offering both training for undergraduates and postgraduates. The plan is that we will have 10 registrars, 10 SHOs, from the staff who will be training in our centre. In addition, in our Portsmouth centre, we are in discussions about providing training for paramedics, sonographers and nurses. We very much welcome the opportunity to become involved with training as part of our partnership with the NHS. Q160 Dr Stoate: None of you have had training as a requirement for setting up the ISTCs before this? Mr Martin: It was not a requirement of the Wave 1 contracts but, as I say, we have agreed to undertake training as an addition. Q161 Dr Stoate: Presumably there will be extra costs. Who is going to pay for it? Mr Martin: There is money available for training. Q162 Dr Stoate: Who pays? Mr Martin: We are still in discussions about who is going to provide the funding for the training. As you now, there are funding streams available for the training of clinicians. Q163 Dr Stoate: So none of you thought of training at the beginning when the ISTCs were set up and now you are all coming out for training? Why was not training an integral part of the contracts in the first place? Mr Adams: When the first ISTC programme started, it was largely around capacity and productivity, care and waiting lists. You would take on consultant grade doctors to come in to do a job of work, working with your local PCT partners. Clearly, if you got off the ground, you had to show you had postgraduates and that you had an impact on productivity in terms of the time to supervise, to coach and to allow them to have hands-on experience. You have a trade-off between productivity versus the education of a future doctor moving through their experience curve. As we become, hopefully, more of a long-term partnership with the NHS, clearly we cannot ignore the issue of training, and so all of us now, particularly in the second wave of ISTC opportunities, are asking: how do we integrate locally; and what kind of training partnerships can we put together:? Again, from our own perspective, we are starting to move at the moment into mentorship for student nurses. That is sill in the first wave of the ISTCs. We will be doing a lot more in the second wave of the ISTCs. Dr Mann: In the NHS there is a funding stream for service provision, a separate funding stream for research, and a separate funding stream for training. That training funding stream is subdivided into postgraduate, undergraduate and so on. When the ISTC programme was set up and we entered into contracts, those extra funding streams were not included in the contract price or in the activity, and it was purely a service delivery contract. At the time, we did not expect to have to do that, but, as soon as the Royal Colleges and others said that they felt there would be an impact on this, all the providers agreed that they would want to participate. The debate has been about two issues: how best to involve local trainers from the NHS in the process while trying to protect the contract around additionality; and how best to get the additional funding that is given in the NHS for training. I think we have made good progress. All of us expect to deliver that. It has just taken a little while to get those details agreed. Dr Smith: I think it is important to realise that this was not an issue of oversight or laziness on our part. Training is commissioned by the deaneries and the NHS is paid by the deaneries to conduct that training. Certainly for my part I would have preferred that we had, as an independent sector, been able to contract with the deaneries to provide that training, because I think it would have avoided a superficial interpretation that somehow we were free-riding on this. I am keen that in wave two, and I think many or all of my colleagues are too, we do engage in that training and therefore we can become a more integrated part of the NHS and avoid that sort of superficial accusation that somehow this was oversight or laziness. Mr Parish: Dr Stoate, initially I think the view was that the scale of the first wave of ISTCs was so small and insignificant that it would not impact on training availability. Clearly, people have identified that in local situations, because of the particular case mix, it may, and therefore it has gone up the agenda much more. Secondly, given the operational challenge of commencing a new service with a completely new team, it would probably have been inappropriate to include training in the initial phase of activity. It is far more appropriate to include it now that units are established. Q164 Dr Stoate: If you do establish training, how will you guarantee that it meets the same standards, quality and external inspection that NHS facilities have to undergo? Dr Mann: There are two benchmarks on this. One is that you do need to have proper accreditation to be allowed to train. There will be an independent assessment made of any facility providing training. In addition to that, we would intend, and I think my colleagues would all do so, to involve NHS trainers in that process so that not only was it of a sufficient standard but it was well in the swim of how it was done in the NHS Mr Parish: It is supervised by the Royal Colleges. Q165 Chairman: Did you see the article in the British Medical Journal by Angus Wallace? What did you think of it when he said that even if training were to be allowed in ISTCs, supervising surgeons may not be fully competent themselves, as previously mentioned, let alone competent as trainers, and consequently the confidence of our next generation of surgeons is in jeopardy? Can I have your views on that? Mr Parish: I think it was ill-informed and irresponsible. Dr Mann: If I may, Chairman, he may have thought that we were going to use trainers that they would not welcome, but in fact, from all the discussions we have had, and I think it is the case for others, we would use trainers recommended and approved and currently training in the NHS. Q166 Dr Taylor: I make a comment first. I think we found the lack of information from department officials last week rather staggering, particularly about outcomes, and now we are presented with exactly the sort of information we wanted. The only one I have seen so far is Care's, which gets away from KPIs, which we found entirely impossible to understand, and just gives us clear clinical outcomes. Thank you. I hope we get the same from the others. What I want to talk about is integration and partnership because it became very clear from some of the non-departmental witnesses last week that one of the problems is lack of integration, and this has automatically led to a certain amount of resistance from the NHS people. I think it was Mr Adams who said that this was an artificial divide. Mr Martin said that you were beginning to break down the barriers. Could you expand on that and, to any of you who have found ways of integrating, is it simply when we get rid of additionality that you will be able to integrate much more easily? Mr Martin: Clearly, additionality has not helped the integration between ISTCs and the NHS, although, as the Committee is aware, under the phase 2 proposals, additionality will be relaxed. It will not be removed entirely but it will be relaxed. As I mentioned earlier, we have sought very hard to develop good, working, constructive relationships with the local NHS. Again, as I think I mentioned earlier, in developing our integrated pathways, we actually worked with the local clinicians and had them sign off on those care pathways, so that there was no risk of patients falling through a gap between what we were doing in the ISTC and what the wider NHS was doing. We have also sought in other ways to forge better links with the NHS. At our centre in Medway, which is the centre we have provided information to the Committee on, our local medical director is an NHS neurologist and our deputy medical director is a consultant NHS anaesthetist. In another of our centres where we are providing diagnostic services, we are using local clinicians to provide quality assurance procedures. It is taking time. It is still early days, but we are trying hard and we believe making good progress in creating an integrated service with the local NHS. Q167 Dr Taylor: This is a question to Mr Parish. You transferred 23 patients to NHS trust hospitals. How easy or difficult was that? Mr Parish: It was very easy. The transfer arrangements are set up at the outset so that they work effectively when required. Q168 Dr Taylor: You have transfer arrangements set up in your initial contract? Mr Parish: Yes, between ourselves and the trust. Q169 Dr Taylor: Is that so for everybody? Mr Parish: Yes. Dr Taylor, as a point of clarification on the KPIs and clinical outcomes, those are one and the same. The KPIs are the clinical outcomes. Q170 Dr Taylor: I wish somebody had explained that to us last week. We will not go into that just at the moment. From talking to my own PCT and independent treatment centre that is just starting, there seems to be a certain amount of worry that they will actually be able to fulfil the contract and get enough work. Is that a common problem or are you all well up to schedule on fulfilling your contract? Mr Parish: That is probably a bigger point to integration than the additionality issues and a bit of a red herring when it comes to integration. The integration point is about integrating with the local health economy between and across facilities and particularly with primary care. That is the real point of integration. We found that once the facilities are established and those links are put in place, then we are running at our minimum take level and I anticipate exceeding it in due course. We have not been helped by some of the negative publicity, particularly in the early days. We were asked to set up an interim service for Trent and South Yorkshire whilst we were constructing a new facility. In the initial months, that did not meet its minimum take level. I think the main reason for that was some very negative campaigning from local consultants. Q171 Dr Taylor: In phase 2 will you be tied to the national tariff? Mr Parish: The national tariff is a point of comparison as opposed to a point of pricing. We submit our proposals. It depends on what we think that particular case mix and service will cost us. That goes through a competitive tender process and the selection is made. In assessing value, it is compared to the tariff. One needs to be careful in making a comparison between apples and pears, frankly, because if you look at what is made up in the NHS tariff, the reference pricing, there are different features. For example, we as independent operators have to pay in-bound VAT but cannot pass it on to our NHS customers, so that cost sticks with us. We have the full cost of pensions that is not passed through to the tariff and a number of other cost factors, as well as the cost of setting up from scratch new operations, new facilities. The biggest factor of all probably is volume and case mix because if we were to handle 10,000 major joint replacements, that would cost less per procedure than if we were handling 2,000. Each case has to be assessed on its own merits. Dr Taylor: As far as integration goes, you would all welcome increased integration? You all agree. Q172 Mike Penning: This is really a question for all of you. What hard evidence is there that ISTCs represent value for money within the NHS? Mr Parish: I start by saying that there is a direct link between what is being purchased and what is being provided. If 10,000 joint replacements are requested, they are provided by contract and there is a direct link between cause and effect, which is more difficult in terms of adding funding to the great big pot called the NHS. I think that gives a more direct impact on waiting lists, et cetera. Q173 Mike Penning: If I may stop you there, that is clearly not hard evidence of value for money. That is anecdotal. What hard evidence do you have? If you do not have any, that is fine. Mr Parish: It is hard evidence in terms of that volume of cases that has been delivered at that cost, that investment. Q174 Mike Penning: That could be delivered inside the NHS then? Mr Parish: Yes, it could. What I am suggesting is that there is a much more direct linkage to that procurement, to that service delivery. Q175 Mike Penning: I am not trying to be difficult. In other words, there is no hard evidence? Mr Pilgrim: Perhaps I could come in on the radiology contract. If you take the reference prices as a value for money in the NHS for MRI, our contract price when calculated is well less than half of the reference price for MRI. Q176 Mike Penning: There is no hard evidence then. We move on to the next point. Do you know of any comparisons that have been made between ISTC programmes and NHS treatment centres? This comes back to the comparison argument about whether it could be done in the NHS. Has a comparison been done as to what is the cost-effectiveness of what your companies are doing compared with what could be done inside the NHS and their treatment centres? Dr Smith: That is a difficult question for us to answer. We know exactly what our costs are, and I am certainly confident that we can deliver cost-effectively against the NHS. The problem is that we do not have the NHS costs to be able to compare ourselves against. In terms of value for money, we certainly do patient surveys and consistently have patient satisfaction surveys for NHS patients at the 98% level, which I believe is higher than the NHS. I am very confident that on our side we have the data and, if the comparison was on the other side, we would be able to conclude that we are making money. Q177 Mike Penning: No-one else is nodding, so I presume no-one is going to answer further. One of the problems we have is that this Committee has found it rather tricky to find out what value for money methodology the Department of Health has been using in issuing contracts. Would your companies be happy for that methodology to be made public? Dr Smith: Yes. Mr Martin: I am certainly not aware of what the VFM methodology is that is used by the Department. Q178 Mike Penning: One of the arguments they have always used for not putting it forward is that it would be sensitive in contract terms, but if you are not unhappy with the methodology they are using, I am sure the Committee and the public would like to know that. Mr Adams: I think, from the Department's perspective, they are trying to build a market here. They are looking at working with potential partners who can deliver clinically and can deliver good patient satisfaction results, and ultimately can come up with innovative solutions. With more public pricing, the openness of the bidding process and what has gone before, you perhaps inhibit that open market. I think the Department probably genuinely is saying that it would rather not issue amongst ourselves some of that data, but it is a guess why it cannot share that with you. Q179 Mike Penning: That is slightly cynical. If they do not deliver the information, we cannot compare it with the NHS. We do not know whether you are giving value for money to the public or not, and nor do you, to be frank. Mr Martin: The process used to offer these contracts was a very competitive tender process. Therefore, the organisations that won each individual contract were clearly providing value for money within the environment in which they were competing. They were coming out on top of a large number of tenders to provide this service. I think, in terms of whether it is value for money and in terms of what you can get from the independent sector, clearly the answer must be yes. Is it value for money against the NHS? We do not have the data to give you that comparison. Q180 Mike Penning: You do not know and we do not know. Dr Mann: There is some information. The tariff price is a weighted average, but there is available data about the full range of prices charged across the NHS. That is available. We have certainly looked at it. That shows a 20-fold variation in the prices within the NHS for certain procedures. If you look at that range of prices, you will find that all the contracts fall well to the middle range of that. Where prices for our contracts are perhaps above that, those differences can easily be accounted for by the additional investment of building new facilities and bringing in additional doctors. We could show that. I do not know whether you would consider that evidence to be objective and robust enough. We can give it to you but would you find that satisfactory? Q181 Mike Penning: To be fair, the question I asked you was to do with whether we would release information from the Department of Health as well as the information that you supply to the Committee being very useful. It is about trying to get the Department of Health to tell the public and this Committee what is going on. On that basis, would you be happy for the full business case that the Department has used in assessing the ISTC bids to be put in the public domain? What are your objections to that? Dr Mann: Is that the Department's business case or our business case? Q182 Mike Penning: Both the full business cases that were put forward on the bids: would you have any problems about those being put into the public domain? Mr Parish: Clearly not the Department's business case; it is not our business to object to that. If you were suggesting that we publish our own cost assumptions and pricing assumptions, that would be commercially sensitive, yes. Q183 Mike Penning: The Department's would not be? Mr Parish: One would expect the Department to justify and explain that. Q184 Mike Penning: They cannot use the excuse by saying, "We cannot release this because it would be sensitive"? Mr Parish: It depends what it is you are suggesting they would release. If they were releasing their business case in terms of why this investment, this programme makes good sense for the NHS --- Q185 Mike Penning: It is all very secretive, is it not? Dr Smith: Could I just add one comment to narrow the definition of value for money, and this is a very narrow definition? If you compare spot purchases from the private sector in previous years with spot purchases from the private sector now in the G sub-contract that we do or the ISTC contract, there is demonstrably more value for money; it is about half the price. Q186 Mike Penning: What we are trying to look at is hard evidence. Dr Smith: This is hard evidence, the price we would have charged for spot business from the NHS a year or two ago. Mike Penning: That is not my question, to be fair. Q187 Mr Burstow: If Mike does not mind, I want to pick up on this one step further. The business case of the Department is part of what we are interested in knowing. There is a possibility that there is some support for us having access to that. I also want to pick up on what Mr Parish was saying, however, about the business cases that you submitted to the Department as part of the bidding process and whether or not there is anything within those that you could exclude in order to release as much as possible of the business cases that you submitted so that we can actually have the open market that Mr Adams was talking about. My understanding of market theory is that a perfect market is one where there is full availability of information. We do not seem to have a perfect market here because an awful lot of the information is either buried in the Department and the officials do not seem to know what it is or it is within your businesses. I would want to know what you feel you are able to share, without of course breaching commercial confidentiality in a strictly narrow sense rather than in any other sense. Perhaps, Mr Parish, you could tell us what you think you could release to us. Mr Parish: Certainly, what is publicly available already is the price we are paid and the commitment in terms of case volume that we take on. There are two aspects to that. One is how we get there in terms of the prices we submit and the second is how it is evaluated by the Department. I think the evaluation by the Department is for you to discuss with the Department. In terms of how we get there, there is quite a bit of intellectual capital and property and competitive confidentiality in how we get there. Frankly, I do not think any market that I know would freely make available its cost assumptions and its solution methodology because these chaps sitting next to me would take it apart and benefit from it, I am sure, and we would from them. Q188 Dr Naysmith: There was a bit of confusion earlier and I take this chance to clear it up. I think Mr Parish's responses to Dr Taylor rather implied that KPIs (key performance indicators) and clinical outcomes were the same thing. In fact my information is that there are 26 KPIs and only eight of them are actually clinical. How do you square that with what you were saying to Dr Taylor? Mr Parish: Rather than risk adding to the confusion, why do we not send to the Committee the KPIs that we submit. I believe that the vast majority of those are clinical outcomes in nature. Let us clarify that in writing. Q189 Dr Naysmith: Our understanding, and our advisers agree, is that there are 26 KPIs and only eight refer to clinical outcomes. When the Department of Health was introducing and starting off ISTCs, I understand that they said, although I was not here, in evidence last week that one of their main reasons for doing it was to stimulate innovation and changes in the way that the National Health Service works and they were looking at the practices in the NHS to try to challenge them. I wonder - and I am doing what the Chair said you should not do - if you all think there are any examples from your contracts where this has happened but, because you have been operating a service, it has been a challenge to the National Health Service practices and you have changed some of them, possibly locally? Mr Parish: There is a tendency to look for rocket science when one says "innovation". Generally, I think it has applied good management practice. For example, and I would claim no intellectual capital on this, in terms of our one-stop shop methodology (where patients come to see us once and all the specialists that need to see them do so and all the tests that need to be taken are done there and then rather than their coming back to and fro on several different occasions) that is an example of very good practice that is very much appreciated by patients. It results in faster and better treatment because we then have a very short time for them to come in, a matter of weeks, which means that the data that is collected on their condition when they come in on that one occasion is unlikely to change in a matter of weeks, whereas if you are on a waiting list for several months, it does and therefore you get this horrible cycle of patients that keep returning and operations being deferred. Something like that is what I would put forward as an example of good practice. The use of the patient's own blood is a fairly recently development. It is not something we invented but we apply that because we organise ourselves effectively to apply it, and again it is significantly better for patient clinical outcomes. The general point here is that it does not have to be rocket science to be good practice and beneficial. Q190 Dr Naysmith: Is part of the reason for that that you are dealing with a relatively small area of clinical practice, whereas in many situations in the National Health Service you have a district general hospital or an acute hospital where there are all sorts of different specialities? Mr Parish: There are examples of good practice across the NHS that I admire hugely. Q191 Dr Naysmith: There are one-stop shops, for instance for cancer treatment? Mr Parish: Yes. What we do is not unique. I am a great admirer of the NHS and in places it works brilliantly. I think in other places the sheer burden of having to deal with the full case mix and endeavouring to do it on one site with one huge-scale solution is very difficult and challenging for them. Mr Martin: I would agree with Mike Parish. We have probably all tried to be innovative in developing our new centres. Have we produced anything that is unique? I suspect probably not. We have certainly worked hard at looking at the actual process, the patient pathway through a centre, and so we have worked very hard on things like patient education. We have looked to stagger appointments so that when the patients come in they are dealt with efficiently. In developing our facility design, we have looked to do that in a way that ensures there is a very efficient, productive pathway for the patient. We do not have anaesthetic rooms in our centres, again to aid efficiency. None of this is unique to us. All those things are happening no doubt in parts of the NHS. If we have tried to be innovative, have we affected the way the NHS behaves? I am not sure I can answer that. All we are doing is trying to provide the best service we can. Q192 Dr Naysmith: The interesting thing is that there has been best practice in parts of the National Health Service for ages and ages. The really difficult thing seems to be spreading it and making sure that it travels from the area where it needed. Mr Martin: I think it goes back to this issue about integration. Q193 Dr Naysmith: The reason I am asking this question is that it was part of the rationale for setting all of this up that you would introduce and innovate and that some of that would rub off locally. I am wondering if there are any examples anywhere of that. Mr Adams: I think the link in terms of talking about spreading good practice was the point I was going to make. At Netcare we were asked to meet a challenge to solve the cataract waiting list, or to be part of the solution. We fully acknowledge that there are phenomenal parts of the NHS doing an excellent job in terms of cataract surgery. We were asked, in these different geographic regions all over England and Wales, what we could do perhaps to meet the challenge. Effectively, by creating a mobile solution that would literally spend a week in Carlisle and then the following week doing surgical procedures in Cornwall, in an environment that is clinically safe and where the patient feedback is fantastic, we are carrying out procedures that can run from 20 to 24 a day for six days a week. I believe in a traditional surgery doing similar cataract procedures there would be 12 to 15 procedures a day. To have that mobile solution that can go and work with PCTs with particular problems has, I think, been an innovation that has actually worked, and the Department should be rightly proud. Mr Parish: In our case, it is about certainty of that best practice being delivered because if we do not provide that best practice in the way we set out, we will not exist. Our goal is to be a long-term player as part of the NHS. Therefore we live or fall by the implementation of our best practice. Dr Mann: A number of examples of innovative practice have been mentioned, and I agree with all of them, and many parts of the NHS employ one or more of them. I think perhaps the greatest innovation is that to survive we have to employ all or most of them. There is a logistical pressure on us to try to maximise quality and efficiency because we are new boys in the game and we absolutely have to demonstrate all these things in a way that perhaps some parts of the NHS have not had to. It is not that the NHS does not do it but that, because we have to do it everywhere and be seen to do it, in itself that highlights the need and the ability to innovate. Q194 Charlotte Atkins: Could you all indicate which of you are intending to bid for phase 2 contracts? You all are. How do you see the new phase 2 contracts developing - in the same way as the phase 1 or do you think there will be different features? Mr Adams: If I could start from Netcare's perspective, I think that there is a degree of soft landing in the Department's support to get the first wave of ISTCs off the ground. You will be familiar with the minimum take contracts and the support for saying that we want to encourage innovation and to get this thing going. Now that we have all had the opportunity actually to experience the ability of working in local markets and building that local PCT/SHA relationship, in the second wave of ISTCs there will be a bit of a risk transfer away from the Department of Health and to the provider where we will actually be looking at the tariff being an indicator, as Mike Parish mentioned. There will be many cases, I am sure, where the actual bids will come in beneath tariff. There will not be the guarantee and the volume of patients, and therefore there will be an assumption that the only way to make your business model work is fully to integrate with the local primary care trust and the local GPs, and to win their confidence and their support. A lot of that will be based on demonstrating your clinical excellence from the past. I think that it is maturing into something that will be more integrated and will be yet further competitive for the Department. Mr Parish: I welcome the relaxation of additionality that has appeared in the phase 2 contracts. I think that in phase 2 we will move much more towards what I would call a mixed economy where our centres are staffed by both UK-trained and qualified doctors and overseas doctors. I think that will assist enormously in developing the closer partnership and closer integration with the NHS. Q195 Charlotte Atkins: Why do you want to get rid of additionality? Mr Martin: Because it is a pain, to be honest! Q196 Charlotte Atkins: In what way is it a pain - for your commercial enterprise or because of good practice? Mr Martin: I do not think it is clinically the best solution. As we have discussed already, I think it has hindered developing close partnerships locally. It has hindered integration with the local health economy. I personally believe that the best overall solution for the Department and the NHS is by providing clinically robust solutions and high quality but on a cost-effective basis in this mixed economy where we have a mix of UK doctors and overseas doctors, and wave one did not allow us to do that. Q197 Charlotte Atkins: Overseas doctors are in the press at the moment because the NHS is being accused of robbing poor countries of doctors. What is your take on that? Mr Martin: We have only actually recruited doctors from one country outside of the UK, which is Hungary, and that is part of the EU. There is free movement of people within the EU, and so this actually has not arisen in terms of our recruitment. Mr Parish: Even if additionality was not required, we would still look to bring doctors in internationally because, frankly, the cost-base of UK doctors is not competitive; it is too high. That is evidenced in some of the pricing solutions we have been developing for the second wave. I do not think there has been anything like sufficient impact yet to drive to a different market. That is my first point. My second point would be that a key criterion for us going forward in terms of assessing the market is whether patients will be allowed to express their choice and go to where they choose. If patients are able to exercise their choice, I am sure that both in terms of cost and attractiveness to patients, and obviously that includes clinical outcomes significantly, we would we very competitive. Q198 Charlotte Atkins: Choice seems to be the name of the game at the moment but obviously price is also important. Do you expect your procedures to be comparable with the NHS tariff? We heard Mr Penning earlier on talking about value for money. Do you expect your tariff to be comparable? Mr Parish: On a like for like basis I am very confident that our costs will be very comparable and competitive. Q199 Charlotte Atkins: You also say that the reason you want overseas doctors is because they are cheaper. Is that correct? Mr Parish: They are cheaper than the private practice in the UK but not cheaper than NHS rates for consultants. Q200 Charlotte Atkins: Are you saying that you would not be able to meet the NHS tariff unless you had overseas doctors? Mr Parish: I would be surprised if we could get terribly many doctors working for us at their NHS rates and so we would be needing to pay the private practice rates and that is expensive. Q201 Charlotte Atkins: We were talking earlier about innovation. Surely if you were offering an attractive work environment then you could possibly tempt NHS doctors away from the NHS because you are hoping to innovate and provide greater freedom for doctors to break through those barriers. Mr Parish: I may be a bit of a lone voice in saying I am a supporter of additionality. If additionality had not applied to date and if it did not apply going forwards then we would be heavily criticised for causing a supply shortage problem within the NHS, which is quite possibly what could be the case. Dr Mann: The single greatest value of moving away from the current additionality position is that it allows us to work more effectively with NHS nurses and doctors and that will lead to debunking a lot of the myths that I think have grown up. I think there is a sense that we are separate from them and we do not use them and all of that. I am not persuaded that that additionality undermines quality or helps price although in some circumstances it will. I think we should be allowed to try and find solutions that give the NHS best value. As regards tariff and additionality and the contracts for Wave 2, my instinct is that you will find that our prices will converge to tariff very quickly. One of the advantages for having a looser arrangement around additionality is that we will begin to compete to provide services below tariff. If you put unnecessary constraints on things like additionality what you are actually doing is trying to give value for money but doing it with one hand tied behind your back. For me the real issue is why try and hinder good networking with local doctors and good value for money by something which if it is good value and good sense we would do anyway because that is in the nature of providing a good service. Q202 Charlotte Atkins: So you would be happy to see guaranteed referrals being swept away, would you? You are not interested in those sorts of aspects of the contract, are you? Dr Mann: I think that is going to happen anyway. I think in Wave 2 you will see that there will be a tapered commitment to commit to that particular area. By the end of the period you will find that the tariffs are fully aligned and the referral patterns will no longer be protected. We are committed to that because that is how we would be part of the NHS. Q203 Charlotte Atkins: Are you all committed to those restrictions being taken away? Dr Smith: Absolutely. I think you are seeing the good effects of competition here. My company will take a different strategy than Mike's and that is good and may the best man or woman win. I think that type of innovation, that type of competition or that type of trying to do things differently and offering a different service is a very good aspect of competition. The key to this is patient choice in my opinion. I think for too long in this country we have had a patient population that has been too compliant, that has not been given enough choices and therefore has not been able to choose and in the process of choosing to say this is a better service and I value this more than that. Patient choice was a key tenet of Nye Bevan's principles for the NHS in 1948, and I think this process is getting us back to patient choice and a position where we will give the right to patients to be able to make their own choices without the state telling them what they can and cannot do. For me that is the longer-term aim of this programme and minimum take and guarantees will have to go under that regime. We will have to live or die by whether we can offer a high quality clinical service at a cost-effective price. Q204 Charlotte Atkins: How many NHS doctors would agree with you that patients are too compliant? Dr Smith: I do not know. You will have to ask the doctors. Mr Pilgrim: In terms of Wave 2, our involvement will be on the diagnostic front. I think one of the most encouraging things about Wave 2 is that it is geared around bringing the diagnostic tools closer to the GPs. At the moment we have far less scanners than anywhere else in Western Europe and far less scans performed, that is the preserve of the Trust hospital nowadays, but in future it will be referred by GPs and they will use that diagnostic tool. I think a very important part of Wave 2 will be bringing the role of the PCTs and the purchasing skills within the PCTs up to the point where they can get best value and best care for their patients. How our organisation would respond will be at the diagnostic end of that. Q205 Charlotte Atkins: So you have a lot of faith in the PCTs to get value for money, have you? Mr Pilgrim: I have a lot of faith in the Department of Health process as it is very robust. You are hearing from six people here who are basically saying much the same things about the topic but who are competing toe to toe with each other on all of these tenders. In fact, Ian is linked with the major other company in the diagnostic field and we are going toe to toe for the next round of contracts and I think that will produce value for money, but there is a strong emphasis on quality as well and that will produce good results for patients. Mr Parish: Building on what Ian has been saying on the direction of travel and I agree the direction of travel should be a world without any kind of volume or revenue commitments, I have got to say that it may take some time to get there fully because it is about us being able to invest with confidence in the belief that that market opportunity will be there. I think we have got more confidence now than we had a couple of years ago when the first wave came along, but I am not sure the market will be sufficiently confident to invest £10, £20 or £30 million per facility totally at risk currently of the market being allowed to thrive. I think there needs to be a further evolution of patient choice, with patients being free to choose, PCTs being free to choose and doctors being free to refer before we invest fully in risk, which is why Tom talks about a tapered level of commitment in Wave 2. Q206 Charlotte Atkins: Finally, do you all believe that ICCs are an opponent part of the landscape within the NHS? Dr Mann: Yes. Dr Smith: We certainly like to think so, yes. Q207 Anne Milton: Do you think we are moving to a mixed economy of healthcare provision where you will be an integral part of - albeit paid for by the taxpayer - a mixed economy of provision? Dr Mann: We would hope so. Dr Smith: I think that is purely in the hands of the patients and depends on our ability to be efficient operators. The rights of the patient and the taxpayer here are predominant over the rights of the providers and it is they who should choose, and if we fail then they will not choose us and we will not be around. Q208 Anne Milton: Do you all feel that this first phase has gone well enough to indicate that that would be a possibility? Dr Smith: Yes. I am very encouraged that patients are getting a voice, yes. Q209 Anne Milton: Dr Mann, you are making a face as if to say you have got some reservations. Dr Mann: I think the first phase has achieved what we needed to do but, as Mike was suggesting and this Committee and all the press have suggested, there is a considerable sense both of resentment and of uncertainty amongst NHS clinicians and others. I think we will feel comfortable that we have got to a position where patients are going to choose when that sense of resentment and confusion is dispelled and the NHS truly believes that the mixed economy in provision is here. I suspect Select Committees like this can go a long way towards helping people understand that. We are not there yet but we are getting there. Q210 Anne Milton: Is that because at the moment you are seen as a competitor to the NHS? Dr Mann: I think it is more than that. People love the NHS and the NHS is a good thing. When you start to introduce an alien concept into something that is truly and properly cherished and loved then people, understandably, think is this good, is this bad, what is this all about? Critics come at this with a far more aggressive scrutiny than they would do otherwise. It is up to us to help people understand that we are as open as a commercial organisation can be, we publish information about clinical care and we try and work with local NHS colleagues as far as we are allowed to hence the discussion about additionality. I think we are getting there but it is not there yet. Q211 Anne Milton: I do not know if anybody else has got anything to add. Mr Parish: If we look at it from a patient's perspective, they consider us to be part of the NHS solution and that is very much where we view ourselves as very much empathetic and committed to the principles of the NHS but also a part of the solution to the NHS service. You may have anticipated there being quite a bit of resistance from patients and nervousness et cetera but there really has not been any, in fact there has been delight. As far as they are concerned they are getting a wonderful service through the NHS. Q212 Anne Milton: Patients want the treatment and maybe they are less fussy about where this comes from. They want high quality and effective treatment as soon as possible. Mr Parish: Yes. There will be strong opinions over how that treatment should be provided. Q213 Anne Milton: The resentments to some extent must arise from NHS staff who see you as a threat. Mr Parish, you have said with additionality going or being relaxed that will change things somewhat because the NHS staff will then be free to come and work for you. Dr Mann: My thesis is that that level of anxiety, concern and sometimes resentment is because they do not understand what we are about and that is made worse by additionality. I have no problem with additionality, but as an obligation it puts up barriers between us and NHS staff. Where we have worked with NHS staff closely those barriers have come down and they have worked well with us. Were we allowed to do that more often then in time a lot of these concerns would go. Mr Parish: We are on a sensitive market migration if that is what we are on. I think one needs to be careful in terms of the law of unintended consequences, which is why I think it is prudent to ease the additionality requirement gradually rather than risk destabilising existing supply arrangements within the NHS. Mr Pilgrim: Another contribution that this whole process has made is to get healthcare provided in the right facilities and the right facilities are not always a huge NHS Trust hospital. If you look around the rest of the world, many more of the health economies have a much wider range of different facilities and different providers than we do in the UK. There has been a tendency in the UK for us to focus all of our efforts on an NHS hospital where lots of things can be much better provided and ISTCs are a good example of that. Standalone diagnostic centres are very common throughout Europe and produce high quality of care and there is a competitive market for the services. I think those are all positive things coming out of this whole programme. Mr Parish: A key issue we have not talked about is the whole emphasis of the White Paper in terms of migrating treatment and care out of secondary care facilities, out of hospitals and into primary care and the community is a key feature of that market restructuring. I do not think we can look at ISTCs in isolation of that general change in the way services are delivered and in that regard obviously we have got something of a mixed economy already in the way GPs are engaged and I know that has got possibilities of going further. Q214 Anne Milton: With regard to the White Paper, there are quite a lot of PCTs closing community hospitals at the moment because of meeting short-term budget imperatives. If you had the opportunity, would you take over some of those facilities? Dr Smith: If it made economic sense, yes. Q215 Anne Milton: I gather there are around 90 of them up for grabs at the moment. Mr Parish: It would be on a case-by-case basis because they need to meet the needs of a more complete type of solution. Q216 Mr Campbell: I would like to know if you have carried out any analysis into the long-term and short-term results of the competition with a local hospital. Mr Parish: I am not sure I can answer that. Dr Smith: As the private sector we would depend upon the Department of Health to make that analysis and the colleges. Q217 Mr Campbell: At the minute you are cutting down the lists. If Alice in Wonderland was true and the list is going to be cut then there is going to be a market there and if you are still around you are going to be competing with the local hospital, are you not? Dr Smith: Yes, for elective surgery, absolutely. It is not our place to decide how to plan a healthcare economy. I think the Department of Health and the Government have reassured people that vital services will not be under threat. I think that would be stupid, frankly. Citizens and taxpayers would be very angry if vital services disappeared, especially A&E. I think we need a regulatory context and regime to make sure that does not happen. That is my personal view. I am not a policymaker. Dr Mann: When this whole programme was initiated there was a projection based on an analysis of information sent in by SHAs, regions and PCTs that a certain volume of additional activity would be needed every year not only to deal with the waiting lists but to maintain the waiting lists where they were. At the moment we are barely hitting that level of additional activity. My own judgment would be that at the level of additional activity the current programme has procured it is unlikely that we will get waiting lists going down to a point where we are competing for core business in the health service. I think what you will get is the additional activity helping to manage the waiting list and bringing it down to a point where patients are not waiting unnecessarily. I do not think the volume that has been injected into the service is such that it will make a major impact on many local elective services. Q218 Mr Campbell: Do you expect your contract to be renewed? I think you all agreed that it would be. Dr Mann: We do want to do that, yes. Q219 Mr Campbell: For the foreseeable future? Let us take it that we have got the list down. Dr Mann: Additional activity will be needed to keep the list down. There is a lot of history in the health service where people have felt that we do a piece of work and then everybody will be better and then you would be able to dismantle that piece of work. The reality is that you do that extra piece of work to manage a certain additional demand and you need to keep doing that because patient expectations are going up. We would want our contract renewed. Our investment is not about getting in there quickly, getting rich and getting out, it is about being part of the NHS locally. We have invested not just time and money but a commitment to be in the NHS. We would consider it a failure if we lost the contract after five years. Mr Martin: I would echo that. We certainly did not get involved in this because we were interested in running a contract for five years. What we were interested in was becoming a fully integrated and sustainable part of the local health economy. We expect to be running our centres for many years to come. I would be very surprised if the contract was renewed at the end of five years in the same terms on which it was originally let, but by that point we would expect to be a fully functioning part of the local health economy and if there was local competition then we would be quite happy to compete. Q220 Mr Campbell: Will you be working with the local hospitals? Mr Martin: Absolutely, yes. Q221 Dr Stoate: Mr Parish, you said earlier that private fees are much higher than the sort of fees that you are expected to pay in treatment centres and for surgeons in particular. What do you think the effect of the ISTCs is on private practice? Mr Parish: I think it has two effects. I have no quantification for this, but I think there is a direct impact on some private practices' demand, the waiting list element of that demand and then a general confidence in the NHS element of that demand because I think the more the public and companies feel confident in what the NHS can provide the less motivation there is to procure or provide private health insurance. Secondly, there is a direct competitive impact in terms of bringing in new providers to the marketplace because whilst there has been substantial numbers of doctors coming in serving the NHS, they all need to be on a specialist register to work within the NHS and because of the nature of their engagement in the NHS they are not able to establish a private practice. I think there is a fear as to why we think the doctors have been so vocal in their assault on the initiative. I think there is a fear that the ISTCs could be an entry vehicle to doctors setting up private practice in the UK. Q222 Dr Stoate: To quote Ken Clarke from times past, do you think some consultants are feeling nervously for their wallets in regard to ISTCs? Mr Parish: Yes, I do. Mr Adams: I used to run the second largest PMI company for my sins in the UK and that is a sector where if the NHS has had much published problems in terms of waiting lists for MRSA or other issues then it has helped the private funding sector to grow and prosper because people have said they want to make an alternative choice for their family. As the NHS demonstrates that the waiting list issue is fading away and the average standard of facility is averaged up and that ultimately it is an integrated sector embracing innovation then I think there is a real threat to the independent sector on the funding side. Q223 Mr Burstow: I want to pick up on something that Mr Parish was talking about earlier on in terms of risk. You said that in a way the ultimate goal will be that the private sector is investing "fully at risk". Presumably Phase 1 was not fully at risk to yourselves and presumably Phase 2 of this programme similarly is not fully at risk. How transparent do you think it is from the point of view of the taxpayer's interest and how much the taxpayer is bearing in terms of risk at the moment and indeed in Phase 2? Mr Parish: I think there are two areas of risk, there is demand risk and cost risk. We are fully at risk on costs, we put forward a price and we either achieve our objective or we do not. In the interim service that we provided we did not, there were all sorts of complications in that service and we lost money, but that is the market, that is the way it happens. There was plenty of risk being taken even in Wave 1. In terms of demand risk, it really is a question of when we would be prepared to go fully at risk and I think that is when we have got confidence that the market would be in a sense liberated, but I do not think it can ever be fully liberated because there needs to be the management of supply and capacity. At that point, in terms of value to the taxpayer, I think the Department of Health has got a job to do and I think they have done it very well in terms of professional procurement to purchase competitively. I think one needs to be very careful about some of the comparisons made because if you compare the whole price you would get from an independent sector provider to the NHS tariff which is made up of a loss of averages that tariff does not include the cost of the VAT, which is significant, it does not include the cost of NHS pensions, which for us to match would cost us 30-40% of our labour costs, it is not a like for like comparison. I think when the evaluation is fully carried out we will see that even Wave 1 is significant value for money. Q224 Mr Burstow: In a way the issue I was picking up on was that the aim would eventually be that you would be investing fully at risk. The implication of the way you said that was that you are not currently bearing the full risk. Mr Parish: We are not bearing the full demand risk. Q225 Mr Burstow: Do you think it is sufficiently transparent from the point of view of the taxpayer's interest? Mr Parish: Yes, I do because the taxpayer will be able to see via the NHS and the Treasury the cost of investment and the service provided for that investment very directly. There is no murkiness in there, it is very direct, ie that is what it cost and that is what I got, therefore I think there is transparency. Dr Mann: Mike put his finger on the fact that there are two kinds of risk. We are carrying all of the cost risk and that should not be under-estimated. The cost risk for the NHS has often been most onerous in major capital investments, recruitment, retention and other factors. We carry all that risk when we go into contracts. If you look at many of the PFI schemes and other major build schemes, they have gone from £130/140 million to £300/400 million. If that happens to us after we have signed the contract we will carry that risk. I am sure all of us have suffered those sorts of risks. I do not see that risk being mitigated in the future. It is a very important element of the risk transfer from the public purse to our businesses. Q226 Mr Burstow: You mentioned earlier on the question of openness, Dr Mann. Would you be happy for the details of your contracts to go into the public domain and, if not, what information should be withheld, and on what basis do you make that judgment? Dr Mann: The details we would not want released are the details that Mike identified around what are the judgments we make about how we can deliver a service more cost-effectively and around how we feel we are adding value to the business. We have a team of people who do that and that is how we think we get our competitive advantage and I would not want to lose that. What we would be willing to share is a lot of information that I think improves clinical practice across the NHS and amongst us. We have talked about innovation. I have to say that a lot of this is about diligence, it is about saying let us be very, very scrupulous about all the little things that you can do, let us do them. You will recall that the Audit Commission did a report some years ago about the ways in which hospitals in the NHS could reduce non-attendances and a range of other things and they went back some years later and reviewed that and what they found to their dismay is that only 5 or 10% of these things had been applied. We would share how we have done a lot of those things, but the commercial assessments and such like we would not be willing to share. Chairman: This has been a very informative session for us. May I thank you for the evidence that we received in writing this week. Hopefully at some stage in the future you will be able to read our report and its recommendations. Thank you very much for your attendance. Witnesses: Ms Anna Walker, Chief Executive, Healthcare Commission; Professor Sir Graeme Catto, President, General Medical Council; and Professor Peter Rubin, Chairman, Postgraduate Medical Education and Training Board (PMETB), gave evidence. Q227 Chairman: Could I welcome our next group of witnesses and ask you each to introduce yourselves and the organisations you are from. Professor Rubin: I am Peter Rubin. I am here as Chairman of the Postgraduate Medical Education and Training Board, but, for the record, I should also say that I chair the Education Committee at the GMC. Professor Sir Graeme Catto: I am Graeme Catto and I am President of the General Medical Council. Ms Walker: I am Anna Walker, the Chief Executive of the Healthcare Commission. Q228 Chairman: Could I declare my interest, that I am a lay member of the General Medical Council and have been since 1999. You may have heard or seen some of the issues which came out of our session last week, that the Royal College and other medical bodies were suggesting to us that clinical standards in independent sector treatment centres are inadequate. Do you have a view about that, whether they are or are not? Ms Walker: The first thing I would like to make clear is that the Healthcare Commission regulates all NHS and independent sector healthcare organisations. We do not have a view as a regulatory body on what type of organisations they should be; our job is to ensure that, when they are there, we regulate them effectively. We have a well-developed regulatory regime for the independent sector; it is more developed than that for the NHS in many ways and in that there are a series of regulations and standards which look to oversee clinical effectiveness. Ultimately, it must be for those actually running a particular organisation to be responsible for clinical effectiveness and clinical outcome and what the regulatory regime can do is to ensure that the key issues are encapsulated and overseen in regulatory terms. Q229 Chairman: Is there any comparison being made between the ISTCs and the National Health Service, from your perspective, in terms of clinical indicators? Ms Walker: No, not on a systematic basis. The origins of the regulatory regimes for the NHS and the independent sector and, therefore, for ISTCs are actually very different. That is one of the things that we are working on at the moment because the more a mixed economy comes into place - and we have actually had a mixed economy for a long time and the crucial issue is a mixed economy where the NHS patient is being treated in the independent sector - the more actually the patient, and it is the patient which is the focus of our activity, actually wants to know that they are being treated broadly comparably. As your previous discussion showed, in many ways there is more information available on clinical outcomes, particularly from independent treatment centres, because of contractual arrangements with the Department of Health than there is systematically available from the NHS. One point that did, however, strike me was that there is a big difference between information being available between the Department of Health as the contractor or us as the regulator and the independent treatment centres and what is available to the public and there is a gap in availability to the public, and that is perhaps an issue we can come back to. Q230 Chairman: Good data collected to make meaningful comparisons would be helpful, as far as you are concerned? Ms Walker: I absolutely think that is right and information which is about outcomes and in a format which is meaningful for somebody who is trying to decide, "Should I take up this offer or not?", I think that really is very important. Q231 Chairman: Could I go back to this issue about clinical standards and ISTCs. Do you have any views at all? Professor Sir Graeme Catto: Yes, the General Medical Council is responsible for regulating all doctors in the United Kingdom, including of course those who work within ISTCs. As the Committee has already heard, the doctors who work within ISTCs are predominantly senior doctors who are already trained and come from outwith the United Kingdom and again predominantly from the EEA. I should make it clear that the arrangements for regulating doctors, for admitting doctors into this country are quite different for doctors that come from within the EEA from those that come from the rest of the world, the so-called international medical graduates who come from any of the other countries outwith the United Kingdom and outwith the EEA. Before a doctor can be admitted on to the medical register, he or she must meet certain criteria; first of all, they have got to have their primary medical qualifications; secondly, they must have a certificate of good standing from the country of their origin and that needs to confirm the fitness and practice details that are relevant to that doctor, whether there have been any disciplinary hearings against them in their own country; and, finally, they need to make declarations to us about probity and health issues which might affect their ability to work in this country. I should make it clear at this point though that being on the medical register does not mean that a doctor is necessarily entirely competent to work in all environments or is necessarily able to work unsupervised or even able to practise all of the procedures within their given speciality. The GMC believes that there are at least four levels, four layers of regulation: first of all, there is the personal level where the doctor himself or herself must be aware of their limitations; secondly, the team in which they work need to be aware of what the doctor is required to do; thirdly, and perhaps most importantly, the employing organisation has a real responsibility both for induction and to make sure that the doctor is competent to perform the individual tasks required of him or her; and then, finally, of course the General Medical Council has got a real role in ensuring consistency and having a national overview, and we make no distinction between private sector, public sector or any of the four countries in the United Kingdom. Therefore, it is clear from what I have said already, I think, that there are some limitations to having your name on the medical register and it may be that the Committee at some point would like to explore some of our proposals for revalidation and for changes to the specialist register which would make more information available to the public. Q232 Dr Taylor: I really want to go on on that sort of theme because it has been pointed out to us or alleged to us by various people in some of the specialist fields that accreditation on the Continent, for example, is not accreditation to work unsupervised, but accreditation to work under a particular chief, and then people have alleged that they come then to this country and are accepted by you as fully qualified to work unsupervised. Is that correct or is that not correct? Professor Sir Graeme Catto: Well, under the European legislation, we have no option but to accept these doctors in at the speciality level, so they come to us if they have already been accredited specialists within their own country and we would have to have a reason for deciding not to take them on to the specialist register. Q233 Dr Taylor: But you would agree that that level of accreditation is perhaps slightly lower than ours? Professor Sir Graeme Catto: It may be different in a practical sense, but, from a legal point of view, once the agreement within Europe was signed on 1 May 2004, there was a general acceptance that doctors who had reached the speciality grade would be able to move from one country to another without hindrance, so we accept them on to the specialist register and we would have to have a reason for not doing so. Q234 Dr Taylor: So this is a very, very important point and the professionals who have talked to us do have a point? Professor Rubin: Perhaps it would be helpful if I explained to the Committee the three main routes on to the specialist register because it is relevant to this discussion, and the word "overseas" has been used a couple of times this morning. There are three main routes on to the specialist register. For UK graduates, they go through a rigorous and quality-assured undergraduate medical programme. They then work for a couple of years in a managed environment, showing that they can put in the practice, the knowledge and the skills required of students. Then they go through a rigorous and quality-assured postgraduate training programme and there are assessments all the way through from the first day as a student through to the end of the postgraduate programme. That is what UK doctors do to get on to the specialist register. For doctors outside the EEA, international medical graduates, they too have to go through a robust procedure for which my organisation, PMETB, is responsible in which they have to produce documentary evidence in terms of certificates and references and other things to show that their training and experience is equivalent to that of a doctor working as a consultant in the NHS, so that is IMGs. As Graeme was saying, in the case of the EEA, neither the PMETB nor the GMC has discretion in the matter, but we have to accept the equivalence of training, so at both the undergraduate and postgraduate level we have no discretion. Q235 Dr Taylor: So is there any obvious recommendation which we should be making from that? Professor Rubin: To repeat what Graeme said, and this is a message that I try to give whenever I have the opportunity to do so, it is for employers to look very carefully at what a doctor has done and, for the reasons that Graeme is saying, whatever the EU says about the equivalence, there may not be equivalence in terms of the culture in which a doctor worked and all sorts of differences may exist, so it is for the employer to look very carefully at what every individual doctor has done in their country of origin. Professor Sir Graeme Catto: The same caveat applies to language. The regulator is not able to assess language competence of doctors coming from the EEA, but they can of international medical graduates and again it would be up to employers themselves to ensure that the doctor was able to communicate with patients adequately. Q236 Dr Taylor: Sir Graeme, you said there were four strands, the personal one, then working with the team. Are you happy that in these independent sector treatment centres there are teams that would hold the boss of the team, the chap doing the operation, to account? Professor Sir Graeme Catto: I have no knowledge of that and it is beyond my competence to answer that question. It just seems important to the General Medical Council that there are sufficiently robust induction processes to ensure that people coming to work in this country are able actually to perform the tasks expected of them. Q237 Dr Taylor: So we go to the Healthcare Commission. Ms Walker: What I wanted to add, which I hope might be helpful here, is that the regulatory regime for the independent sector and, therefore, for the ISTCs as well does put emphasis on the management of a healthcare organisation to satisfy themselves of those that they are employing for clinical purposes. In other words, there is a regulatory arm to this which can help. Now, there may need to be a debate about whether we have phrased that in the right way and there is also obviously a question about then the rigorous follow-up which we try and ensure that there is in relation to our inspection. My point is that I think there is something here in the regulatory system that can help as well. Q238 Dr Taylor: So you would be able to pick up on your visits from members of the team, for example, if they were not happy about what was going on? Ms Walker: Yes, to some extent we could. I could not claim that we could do it in all circumstances, but procedures in place, recognising the importance of this, the very fact of that standard makes a difference and then the checking of the standard also helps. Q239 Dr Taylor: I think you said it is a specialist team that does the ISTCs, so it is a different team that inspects NHS treatment centres and ISTCs, is it? Ms Walker: No, we are actually increasingly integrating our staff across the piece because we feel that is the best thing going forward. What we have had is a small team in the centre because we have had to think through the regulatory issues, especially in relation to ISTCs. As they become established, the team will remain in the centre, but our regions, because we are regionalising the organisation so that we can be in touch on the ground with local organisations, will take over the regular relationship. Q240 Dr Taylor: So you then will be in a position to compare, as it were? Ms Walker: We will be in a position to compare, and we will have people locally, so, if we have a concern or if others have a concern, we can go and visit. Q241 Dr Taylor: You did say also that the Commission so far has only received one complaint against an ISTC. Could you give us any rough idea about how many of our NHSTCs there were? Ms Walker: There was one formal complaint about an ISCT. We receive about 9,000 complaints a year about the NHS. Now, that is clearly not a comparative figure and I am not suggesting for a moment it is a comparative figure. The complaints process takes complaints in the first instance to the provider of care in the independent sector and, if satisfaction is not available there, actually somebody being treated in an ISTC has two routes they can go: they can actually complain under the NHS processes or the independent sector processes; and, if they are not satisfied with their independent sector provider, they can come to us. Q242 Dr Taylor: We had a very impressive submission from Care UK which runs some of the centres and they said at one point, "An NHS-trained and experienced surgeon is appointed as a lead clinician at each site and is responsible for clinical governance and mentoring". Would you pick up if that existed in other sites? Ms Walker: Yes, in the sense that, when we look at things, we are actually trying to ensure that the basics are there. What you are describing looks like very best practice. Now, actually our statutory role is to encourage improvement, so we are concerned to pick up that best practice and, as far as we can, suggest or incorporate it. Q243 Dr Taylor: Any comments? Professor Sir Graeme Catto: None from me, sir. Q244 Dr Stoate: This does actually raise some extremely fundamental questions. Professor Catto, you are saying effectively then that you have someone on the specialist register from a European country and you have to accept them on to the register. We have also heard from other witnesses that some of them are trained not to the same level as an independent consultant in this country, but more as a sort of consultant under supervision, as it would be in another country, and you are saying that, as far as you are concerned, you cannot differentiate between the two. The question I want to ask is: were there to be a complaint to the GMC about a consultant who perhaps had acted beyond his competence because he was trained effectively as an understudy to a consultant in the EU, how would you handle that because you would have to accept that he was a consultant, you would have to accept that he was on the register, but he may be in fact acting beyond his actual personal competence in a particular field for which a UK consultant may have no problems? Professor Sir Graeme Catto: He would be treated in exactly the same way as any other doctor performing a task. The words sometimes get in the way. "Consultant" may or may not be the appropriate word here. This doctor is clearly taking a leading role in treating a patient and he or she must perform that within his or her own level of competence. The situation in Europe is that all doctors who have got to a speciality level are deemed to have got this CCT arrangement, certificate of completion of training, and, therefore, they should at that stage all be equal. That does not mean that they are all equally competent at any given task and it comes back again to ensuring that the doctor is not just clinically fit as he reaches certain standards in training, but is actually fit for the purpose for which he happens to be employed at the time. There is a real onus of responsibility on the employing organisation to ensure that, I think. Q245 Dr Stoate: So who is to blame then when a consultant perhaps does overstretch himself and is asked by his boss to do a procedure which he may not be totally qualified to do, even though he would be qualified to do the majority of procedures? Who is to blame in that situation? Professor Sir Graeme Catto: Well, the onus of responsibility must predominantly lie with the individual consultant or the individual doctor, it seems to me. If he or she ends up working in circumstances that cause difficulties, then the first port of call is for the doctor to put that right himself or herself, but I think we should try and get away from using terms like "specialist" or "consultant"; it is simply a doctor ensuring that he or she is competent for the task in hand. Q246 Chairman: Sir Graeme, has the General Medical Council got any adverse patterns in terms of complaints from ISTCs as opposed to other areas of NHS work? Professor Sir Graeme Catto: I looked into that before I came to the Committee today and the answer is no. That may of course be because the ISTCs have been in business for a relatively short period of time. We have got some doctors about whom complaints have been brought to the GMC, though none has gone through our processes completely yet, and we have got no reason to think there is a disproportionate number coming our way. Q247 Mr Amess: How should appointment procedures be improved? Ms Walker: Graeme actually talked about the onus being on the doctor. There must be a very significant onus on the employer, the management of the ISTC, to ensure that the doctor is qualified to look after the patients going through their care. Over and above that, I think the regulatory regime can help and it can help by holding management to account in the right way. We cannot take the responsibility from them, but we can ensure that in our regulatory regime the emphasis we put on our management ensuring themselves that they have got the right doctors doing the right things has sufficient emphasis. Professor Sir Graeme Catto: Perhaps I could just build on that because I think that is absolutely right. I myself worked in the United States for some time and it was very helpful to have a period of induction where I got used to the way in which that particular organisation worked, the facilities that were there and the equipment that was used, so, although my clinical skills were transferable, the way in which they were actually applied had to vary and had to be adapted to meet the local circumstances, so I think it is not just the interview process or the appointment process, but it is the induction process thereafter, I think, that is critically important in giving these individuals time to accommodate to a different situation. Professor Rubin: I do not have anything to add to those two answers. Q248 Mr Amess: Has the additionality principle which applied to Phase 1 contracts led to an over-reliance on overseas doctors and should it apply to Phase 2? Ms Walker: I can understand the reason why the Department of Health in Phase 1 wanted the additionality clause there. There is real concern that there could be otherwise some very adverse consequences for the NHS, whereas actually this programme was clearly about ensuring that the NHS could in one way or another cope with some of the peaks of demand. I think that moving towards a situation where the additionality is not removed, but relaxed where that can be borne by the local health economy is the really crucial issue. Q249 Mr Amess: Beautifully put! Professor Sir Graeme Catto: I thought the Committee might just be interested in some of the numbers associated with this because, with all I can tell you about the numbers of doctors who come on to the medical register, I cannot actually tell you where they are working or even if they are working. Some people may choose to be registered and not actually come to this country for some time. It is quite interesting that, if we look at international medical graduates, that is not UK graduates nor graduates from within the EEA, then in 2004 there were 104 that got on to the specialist register and in 2005 there were 36. If you look at doctors from the EEA, then in 2004 there were 1,329 and in 2005 there were 1,788, so there is a very small number coming from countries beyond Europe on to the specialist register, but apparently substantial numbers from within Europe coming on to the specialist register, though I cannot tell you where these colleagues are currently working. Q250 Charlotte Atkins: One of the issues which has been arising in our evidence sessions is about the follow-up treatment for patients treated in independent sector treatment centres. Have you got any evidence that it is inadequate? Ms Walker: No, we have not got evidence that it is inadequate, but it is one of the issues that in the early stages of the ISTCs has been raised with us in a number of ways. When it has been raised, what we have done, what our normal practice is, is to go into those particular centres, try and establish what is happening and find a way forward that is positive. In each case, we have been satisfied that there are appropriate new arrangements being made to ensure that that happens, so I think actually it was an issue which was not thought through clearly enough and that came back to us in terms of complaints and concerns. I think a lot of progress has been made on it. Q251 Charlotte Atkins: So are you saying that you now think that there is not a problem with follow-up treatment? Ms Walker: I could not say that I did not think there was in all circumstances, but I think two things have happened. Where there has clearly been a problem, then there has been a dialogue on putting it right and that has been generally taken as learning across the piece both by those of our staff who regulate and by the centres themselves and, I am sure, by the Department of Health. Q252 Charlotte Atkins: How many times have you had to go in and have a look at the situation? Ms Walker: Not that frequently. Again, in preparing for today, you can imagine that one of the questions which I asked was: what is the pattern of complaint or actually the thing which is reported to us, what is called in regulatory terms, a 'serious untoward incident'? The answer is that it has been broadly of a norm. Q253 Charlotte Atkins: So what sort of numbers are we talking about? Ms Walker: For serious untoward incidents, about 90. Now, in terms of comparisons, I am making those comparisons across the independent sector because we do not actually receive systematic information about serious untoward incidents in the NHS because that will tend to go to the strategic health authorities, so this is one of those areas where, because of the different backgrounds of the NHS and the independent sector, it may be that some thought needs to be given to getting a database, whoever is holding it, which is actually equal across both. Q254 Charlotte Atkins: What about across NHS treatment centres? Ms Walker: I do not know the answer to that. Q255 Charlotte Atkins: When you are talking about these 90 cases, was there a pattern whereby particular firms or particular companies were receiving more complaints than others? Ms Walker: There are two of the independent treatment centres which show higher serious untoward incidents than others. In each case, those statistics are not regularly published and they are not, as I say, for the NHS either. There is actually a debate of really some quite national significance over this, this question of wanting to ensure that that incident is reported so that the right action is taken compared with whether all of that is made publicly available. Anyway, the position at the moment is that that information is not publicly available. What we do, where there is a serious untoward incident, is we go into that particular treatment centre or organisation to satisfy ourselves that the appropriate follow-up action is being taken. If we have either a pattern of concerns or the particular concern is very significant, then we will actually insist on a root-cause analysis and satisfy ourselves that it is being followed up in that fundamental way. Q256 Charlotte Atkins: Did you do that in these cases? Ms Walker: Yes. Q257 Charlotte Atkins: Could you name those treatment centres? Ms Walker: No, I cannot, for obvious reasons. Mr Amess: What a pity! Charlotte Atkins: Absolutely. Q258 Mr Campbell: I just have a question on training and the ISTCs. Basically, do you foresee any problems with the training in these centres? Professor Rubin: I think, as with any new development, there are opportunities and there are risks. The opportunities come from a new provider coming up with new ideas and I do not think we should ignore that. There could well be innovative approaches to education and training coming out of the ISTCs and, as you have heard from previous witnesses this morning, in the first phase we are not required, or expected, to get into education and training because they had a task in hand which was to get through the large numbers of procedures. With respect to the next wave of ISTCs, there is a risk with respect to education and training, and the risk is that there will be a lack of clarity about what is expected by those who are commissioning the education and training and those in the ISTCs who are going to be providing it. Going back to the reasons of the ISTC: speed has been one of the reasons, to get through a reasonable number of procedures and to cut waiting lists. Once you start to train people, you would reduce the number of procedures you can do because you are taking time to show somebody else how to do that. For example, if you are doing cataracts, as a ball-park figure you might get through eight cataract procedures or so if you have a specialist who is doing the cataracts and not training; you might get through four or five if that specialist is training somebody else to do them. That is fine, as long as everyone goes into the arrangement, with respect to what is expected of the ISTC, understanding all the issues. It is not fine if the ISTC signed up to the same throughput as before while agreeing to take on training, unless that was explicitly acknowledged in some way in the contract. So there is a risk to the next phase of ISTCs and how they will handle the education and training aspect. Q259 Mr Campbell: Who would have to bear the cost? Do you have to bear the cost? Professor Rubin: The costs for undergraduate and postgraduate medical education are handled slightly differently. In the case of undergraduate medical education, there is more flexibility, in that there is something called SIFT which reflects the additional costs of education and training. In the case of postgraduate medical education, it is the salaries of the trainees that are held by postgraduate deans who are held responsible for postgraduate training. That is not the whole answer. Paying for the trainee is fine, but the trainee is being trained and you are still reducing the throughput while the trainee is being trained, so there has to be time to work through. What does it really mean to have educational training going on in ISTC? Those negotiations have to be intelligent and informed so that everybody goes into the arrangement with their eyes wide open. Q260 Mr Campbell: Would the Health Service have to pay that cost or IST centres? Professor Rubin: That would have to be done by local negotiation. Someone has to pay the costs or someone has to accept that the throughput will drop. That is the other consequence, you see, and in the next phase that could be the answer to including education and training. Q261 Mr Campbell: You are certainly saying that the training will be up to National Health standards. Professor Rubin: We at PMETB, as with the Healthcare Commission, have the legal power to go into and inspect the ISTCs, and will do so. Any training programme or training post, wherever it is happening in the UK, has to meet our requirements. Q262 Anne Milton: I would like to talk to you about innovation and improvement and whether you feel that the ISTCs have stimulated both in the NHS. Ms Walker: There is a sense, I think, that there is not a long enough history to look at that systematically, nor do I think, carrying out our regulatory function, that that is what we primarily expected. The point I am about to make is not a regulatory point, but it is about having recognised that the ISTCs were there to try to help with some of the waiting lists rather than innovation and improvement for its own sake. Q263 Anne Milton: We were told by the Department of Health that one of the aims of the ISTC programme was to stimulate innovation in fact. Ms Walker: I am not the Department. I do not know what they had in mind, so I simply cannot answer that. I think there is a regulatory issue around improvement. If I can put it like this, this question of the standard of care being provided is very much an issue for the regulatory function, and I do hope we have shown that we have as rigorous a system as we can for looking at that. Q264 Anne Milton: It is whether the ISTC has stimulated improvement and innovation in the NHS: Has their presence levered up or ratcheted up (or however you want to put it) standards within the NHS and innovation? Ms Walker: I have no evidence on that one way or another. Q265 Anne Milton: It can be your view; it does not have to be evidence based. Ms Walker: Yes. Professor Sir Graeme Catto: Could I look at it from a slightly different perspective. I think the discussions this morning and some of the discussions the Committee had last week have shown up some of the deficiencies in the current systems, and I think the ISTCs have highlighted some of those deficiencies and therefore I hope that will lead to improvement. I hinted, when I spoke first, that we in the General Medical Council need to move on, so that historical medical qualifications are no longer, in themselves, sufficient to guarantee quality. My name is on the Medical Register because I qualified in 1969 and I have not been caught doing anything so awful that it has yet been removed; but you could argue that I have not done anything particularly positive to ensure that it remains on the register. Thus, when we are looking at information that will become more available to patients as doctors move from one country to another, we need to be quicker in making sure that that information is more readily available. That means, I think, not having a licence for life/being on the register for life, but having a licence for a period of time, and that the doctor can justify that licence being renewed. And, back to revalidation and the additional information that patients and the public will expect of doctors in the years to come, that applies not just to revalidation but also to the specialist register of all the deficiencies that we have already discussed this morning. So I think inadvertently it will lead to changes which I think will be improvements. Q266 Anne Milton: It has turned the light on existing practice, in some ways. Professor Sir Graeme Catto: From our perspective, that has helped, yes. Q267 Anne Milton: Would you like to add anything, Professor Rubin? Professor Rubin: I think I would agree with the point Anna made, that it is a little too early to be sure, but, with respect to education and training, ISTCs can be innovative, they can bring new ideas, if they are allowed to do so under the contracts which are being negotiated at the present time. I think this is a very important point - and applying not just to ISTCs - that it is very important not just to look at the short-term imperative but the long term as well, the quality of the doctors we are going to have 10 or 15 years from now. If we are allowed to do so, I am really quite confident that the ISTCs will want to drive innovation in education and training. Q268 Anne Milton: If I could come back to the Healthcare Commission, I understand your organisation aims to find and promote examples of good practice. Can you highlight any areas of good practice that you have found within ISTCs? Professor Sir Graeme Catto: Oh, dear! Ms Walker: No, I cannot encapsulate one which would illustrate. Perhaps the best thing I can do is to say that there are areas, such as we were talking about earlier, the transfer of care, where issues did come to light about that and then the willingness with which the particular centres work with us - and with the local NHS as well - to try to put that right. The other piece of evidence which we have which I think might be helpful, particularly in the light of the previous discussions, was that we do notice that where there is greater integration between the ISTC and the local NHS, the local healthcare economy - it is to do with the local hospital and the local PCT - that where you have it working integrally as part of that local healthcare economy, it all works very much better. That is one of the reasons why in our evidence, where you asked us what did we think about what should happen under Wave 2, how the ISTC really does mesh in with the local NHS we think is extremely important. Q269 Anne Milton: I will come back to good practice in a minute, but I was going to ask you what you feel should be different about phase 2. If you had to give four or five things that would make phase 2 better, what would they be? Ms Walker: I have already talked about the transfer arrangements. The question, also, of integration one way or another in the local healthcare economy. Lifting additionality where it makes sense to do so - and that is an issue also about the position of the local healthcare economy. There is another point I would like to make about the medical training - and that is not a regulatory point, it is a much more general healthcare point - on this question about whether ISTCs should undertake medical training. We can understand why there is that debate, because this question of medical training is very important, particularly in relation to some of the activity which is going on in the ISTCs, so finding some solution to that which we could help underpin in a regulatory way, we think would be in the interest. There is one final point I would like to make, which I referred to at the beginning of the discussion: Wave 2, information available. You had a discussion about information being available between the contractor and the Department of Health - or it could be the NHS, in the future, the local PCT - and the providers. But there is also a question about the information that is available for the patient which I do think needs some attention, because the patient going into one of these centres wants some feel for what the outcomes are like compared with the NHS. That is not an easy job. This whole question of how you get comparable information and what indicators you choose which make sense to the patient is a big issue. We have begun some of it, because we have begun to talk to the providers about information that we would like on clinical outcomes, regularly from them, with a view to publishing that information and so making it available, but I think that is actually very important from the perspective of the patient. Q270 Anne Milton: Professor Catto, would you like to add anything? Professor Sir Graeme Catto: Perhaps just one wish from my perspective, and that is greater clarity on the role of the employer within the induction required for staff coming to work in the ISTCs. Secondly, I think this whole question of education and training is critically important. If we are going to have groups of patients segmented and dealt with in different ways, then it is clearly critically important that we get the education and training arrangements organised. These are my two wishes, I think, for the employers and the induction and education and training side. Professor Rubin: I would agree with all that, and particularly integration of the local health economy and joint planning with the local health economy. That is particularly relevant to education and training. It may be that, for all sorts of reasons, not all of the second wave of ISTCs would be appropriate to undertake education and training - maybe there is plenty of capacity in the local NHS - but joint planning from an early stage with the local health economy and the providers of education and training is key. If that does not happen, things will come to grief in terms of education and training. Q271 Anne Milton: If I may finish by coming back to the Healthcare Commission and good practice. I think we were slightly talking at cross-purposes, because you were describing what needs to happen to see it working well and I was saying: Have you, in an ISTC, thought "Wow!" I mean, have you? Have there been examples of something that is really, really excellent? Ms Walker: I am struggling a bit because I am not the one who goes in. I think the best thing I can do is to take that away and ask those who do go systematically in - and we will come back to you. Q272 Anne Milton: That would be quite helpful, because it would be very interesting to see that. Ms Walker: I shall ask them about those things of which they thought "Wow" at the time. Anne Milton: Exactly, yes. Q273 Chairman: Could I ask you about this issue of lifting additionality. What is the highest risk to the local health community of doing that? Ms Walker: If additionality were lifted totally, there must be some local health economies where the NHS could find that they were losing staff, and that was not one of the original aims of the ISTC programme and I suspect that needs to be kept in mind. I concede there is great sensitivity around that but some local health economies are in a very different position from others. There are some where there are staff available who would like to work in the ISTCs but the additionality is preventing it. So I think there has to be something very sensitive about relaxing the additionality. Q274 Chairman: Have you, as an organisation, looked at that in any way? Ms Walker: No, we have not looked at it systematically and in depth. It is something that in carrying out our regulatory regime we come across from time to time. Q275 Chairman: You would not be able to give us any guidance on that. Would any members of your staff be able to give us any guidance on that? Ms Walker: Again, I will go back and ask those concerned. Q276 Chairman: It might be quite useful. Ms Walker: Yes. Q277 Dr Stoate: I would like to explore very briefly with the Healthcare Commission some of these outcome data, which I think are absolutely fundamental to what we are doing. I chaired the All Party Group on Patient Safety. Professor Catto came in and we had a very interesting meeting this week about how we are going to change the culture to improve patient safety. One of the most important things is data on information. Ms Walker: Yes. Q278 Dr Stoate: I am appalled in some ways that you are saying to us that you have outcome data for ISTCs, you have comparable outcome data from the private sector, but you do not have access to outcome data from acute trusts and others because that disappears off to the region. My understanding is that the reporting arrangements that finally come out of trusts are, to say the least, variable - which is probably a charitable way of putting it - so how on earth does anybody like me advise a patient which centre to go to. I can say, "I have got outcome date for the ISTC and I can give you some outcome data for the local private hospital - but NHS outcome data? It all goes off to the region. It could not help you much." It is mind boggling. Ms Walker: It is a really complex picture. As a patient myself sometimes, looking at one organisation compared with another, I think to myself, "Where do I start?" There is of course some outcome information available for the NHS. I am not suggesting there is none, because there is some on emergency readmissions, there is some on waiting lists - which are an indicator of something. The point I really wanted to make was that the Department of Health set the ISTCs up and, as part of their contractual arrangements, there is a very significant flow of outcome information, but we do not actually automatically get all of that information, and that is one of the things which both we and the Department of Health have learnt from the ISTC process. Q279 Dr Stoate: Why are you not shouting at them, "We demand this information"? It is no good saying, "We only get a bit of it, some of it goes off to region, the Department has other bits" because the Department made it clear last week that they really do not have any that they are likely to share with us. Whether they do or not is another question, but they are certainly not about to show us any of the information they have. Why have you not shouted from the rooftops? Ms Walker: I think there is a principle. Particularly where the Department of Health is the contractor, the flow of outcome information should be shared with the regulatory body. We are doing something about this area. We are talking to the independent sector providers, including the ISTCs, about producing some outcome information. This is information like planned transfers, emergency readmissions, return to theatre - so they are some of those issues on which there are the greatest concerns in ISTCs - and infection control, collecting that information and then publishing it. We have already begun those discussions. Q280 Dr Stoate: I do not want to stop you, but I am still not satisfied. The fact is that you are doing something about it, you have got some of the information, you are making some progress. It is so fundamental, I cannot believe we are having this conversation. You should have access to all the information, all of which should be available to those who need it. As a GP, I have to decide which units patients should be referred to and I have no information to go on. The fact that you are working on it does not cut it. Ms Walker: A message to us which says: "This needs to be done and to be done as quickly as it possibly can" I entirely understand. There are two issues that make this more complex. This is not an excuse; it is an explanation. One is this question of the publication of this information in a genuinely understandable way and which takes account of differences that you may have in case mix. That is actually really important from the patient's point of view, because you do not want to frighten a patient who does not need to be frightened, so you do have to look at whether this information is properly adjusted. Q281 Dr Stoate: That is fair enough. I accept that. Ms Walker: So these things do take a bit of time. We have that. We have those discussions underway. We have a programme planned for it. A message from you as a committee which says: "This is important. Get on with it," we would understand. Q282 Dr Stoate: Do you ask for clinical outcome data before you inspect NHS providers? Ms Walker: No. We have a lot of information available on the NHS. It does not tend always to be systematic but, because there is a lot of information, we can put in place and have in place systematic processes for looking at it. That is different from whether it is publicly available. So we are making a lot of use of information in the NHS and we are moving to publishing more of that. One of the big questions I know we are going to face about the publication of information in the independent sector and ISTCs is: Is it systematically available in the same way as the NHS? - and that is something else we need to move forward. Q283 Dr Taylor: When you inspect an ISTC you obviously get a lot of data. We have been given this morning, by the partnership health group which is Care UK, an exemplary list of their readmission rates, their complications. The only thing that is missing from that, when they do a comparison with Nottingham City Hospital, is a statement of the different difficulties of the operations, because independent sector treatment centres only take the two lowest risks, I think. If you do these inspections, do you automatically have that sort of list available? - which seems to me everything you need to know about what is going on. Ms Walker: I do not know whether those who have gone into these particular ISTCs have had this list or not, but they do have information available on which they then carry out the check in relation to the standards and the regulations. And, of course, we also have that information, which is not systematically published, for the reasons I was explaining earlier, about encouraging patient safety on serious untoward incidents. So there is outcome information which is used for the purposes of inspection. Q284 Dr Taylor: And you have mentioned the information gap to the public and obviously the time that it takes to get the news out to the public that a particular place perhaps is not as safe as others. What can you do to minimise that? Ms Walker: I think there are two sorts of unsafe, if I may put it like that. I think where we need to be is: a regular flow of public information, so that that is always available to those who are taking a choice. Every so often, you will have a more significant and serious problem. If it is serious enough, then that information has to go into the public domain as an emergency. On the whole, we do not get those, but there is always the possibility that we will. Chairman: Could I thank you all very much indeed for this morning's, now this afternoon's, session. I am sorry we have overrun by a few minutes. I think that is the order of the day. We will have the report to you at some stage in the future with the recommendations. Thank you. Witnesses: Professor John Appleby, Chief Economist, The King's Fund, Mr James Johnson, Chairman, and Dr Paul Miller, Chairman of the Central Consultants and Specialist Committee, British Medical Association, Dr Sally Ruane, Senior Lecturer, Health Policy Research Unit, De Montfort University, and Mr Daniel Eayres, Public Health Information Specialist, National Centre for Health Outcomes Development, gave evidence. Q285 Chairman: Could I welcome you to the Committee. Thank you for coming along For the record, could I ask you to introduce yourselves and the organisations which you come from. Mr Eayres: Daniel Eayres. I work for the National Centre for Health Outcomes Development. We work under contract to the Department of Health, analysing the KPI data and the ISTCs. Mr Johnson: I am James Johnson. I am the Chairman of the British Medical Association and I am a consultant vascular surgeon in Cheshire. Dr Miller: I am Dr Paul Miller. I am Chairman of the British Medical Association Consultants Committee and I am a consultant psychiatrist in Sunderland. Professor Appleby: I am John Appleby. I am the Chief Economist at the King's Fund. Dr Ruane: I am Sally Ruane from the Health Policy Research Unit at De Montfort University in Leicester. Q286 Chairman: Could I ask a question of all of you: what research has been carried out into the effectiveness of ISTCs? Have there been any problems with carrying out research with this area? Dr Miller: The Health Policy and Economic Research Unit of the British Medical Association late last year surveyed clinical directors in anaesthetics, ophthalmology and orthopaedics, the three specialities far and away most likely to be affected by treatment centres. They surveyed them on their views and the impact on NHS treatment centres and the independent sector treatment centres. I think the main conclusions or headlines would be that the perception and the experience was that NHS treatment centres were more beneficial for patients than the independent sector ones, and this was overwhelmingly to do with integration with the rest of the NHS: that the continuity of patients' care, the availability of notes, the ability to talk to other doctors and consultants involved were much easier with the NHS treatment centres than they were with the independent sector treatment centres. Though I should say from the start that it was widely found that there were benefits to patients in terms of shortening waiting times. Q287 Chairman: Was there any clinical indication in this research at all? Was there any thing different there? Dr Miller: We did not go in any great depth into differences in clinical issues, though one of the outcomes that was found was that these clinical directors, in their experience, found there were more problems with readmissions post-operatively from the independent sector centres, almost certainly because they are not integrated with an NHS facility which would have the ability to deal with post-operative complications. That is not what the ISTCs are for. Professor Appleby: As far as I am aware, there has been very little systematic research into, as you say, the effectiveness of ISTCs. There is, as I understand it, an official Department of Health funded study of NHS TCs but no equipment on the independent sector side, which I think is rather remiss. In part, it depends what you mean by research into effectiveness. I suppose I would go back into research into achieving the aims and objectives of the ISTC programme, and as far as I am aware there is no research into that at all. Dr Ruane: The Health Service Journal conducted a survey of PCT and acute trust chief executives which was published in January last year. That was not specifically on effectiveness; it was more a question of how those chief executives perceived the impact of ISTCs on them and certainly the acute trusts. I think 79% of respondents of the acute trust chief executives believed they had had a significant impact on forcing their trusts either to reduce capacity or to forego growth as a result, and there seemed to be particular impact on orthopaedic work. I think some of the more qualitative material that came out of the HSJ survey is equally important though. One of the columnists commented that there had been more strength of feeling, and more, what he called, "alarmed and angry calls" to the Health Service Journal over this policy than over any other policy that had taken place over the last few years, and that this was perceived as a fundamental contradiction of other health service reforms. Mr Johnson: The research that has been referred to, both for the BMA and what you have just heard, is essentially extremely soft research: it is asking people who may well have pre-formed opinions about the general principles involved here what they think about how it is going. Probably that is all you can do at the moment, because even some of the first wave ISTCs have not even started taking patients yet, let alone the second wave, but we believe it is absolutely essential - and in the three-quarters of an hour I have been listening to your discussions, clearly so do you - that we have outcome data published from the treatment centres and equivalent outcome data from the NHS - which largely is absent - to compare it with. If you just have one and not the other, it is meaningless. If you have three complications, is that bad, is it good? Who knows! You need to know whether it is doing better or worse on average than a similar basket of NHS hospitals across the board. You heard in the last session that some outcome data is available. It is very mechanistic sort of outcome data that you can get off a computer: how many people returned to theatre? How many people were readmitted? When you hear the criticisms of the treatment centres - "The hips are not being done as well; they are having to be revised" - why are we not collecting data about revision rates for hips and comparing it with the NHS? It is absolutely essential, in our view. If you are going to make the system work, you must have the data and you must have the NHS data as well. Q288 Mr Burstow: That last comment is quite helpful. In some of the data we were supplied with in our first session this morning from Care UK, they do provide just that in the information - hip revisions, specifically. That is why I wanted to ask Mr Eayres if you could perhaps tell us a bit more about the research that you conducted, because, as I understand it, that is based very much on the key performance indicators collected from ISTCs. What did the research tell you about the standards of ISTCs? Mr Eayres: First of all, we are contracted to analyse and report on the 26 KPIs that are collected by the ISTCs. An aspect of that would also be to look at possible benchmarking against NHS or other external sources. I think we need some clarification about what the indicators are. We have heard about clinical indicators, clinical outcome indicators, performance indicators. Of the 26 performance indicators, some are what I would consider clinical indicators, in that they reflect some aspect of the clinical care of the patient. Some of these might be clinical outcome indicators, in that they reflect some outcome of the care. For example, one of the indicators is clinical cancellations: patients who have got an appointment but they have cancelled for some clinical reasons. You could argue that is a clinical indicator but it is not a clinical outcome indicator. Things like readmissions, transfers to another hospital, day cases that end up becoming inpatients, you could argue are clinical indicators and possibly clinical outcome indicators. There is also another set of indicators on which we have currently not received any data, which we would consider as pure clinical outcome indicators, and these are things like, for example, complication rates and wound infections, but also patient-reported outcome measures, where the status of the patient is measured before the operation and the status of the patient is measured again after the operation and some sort of measure of improvement or change or impact is made. At the moment, the key performance indicators that we have are some clinical ones, such as cancellation, readmission. Some are purely process ones, such as: Did referral lead to an inpatient appointment? Some of them do not reflect the patient pathway at all. For example, there is an indicator about additionality - you know: Were any staff employed who should not have been? - and that is in no way a clinical indicator or a patient noted indicator. We have looked solely at these, and, as I have said, on what we would call outcome indictors, KPI 15, no data has so far been collected and given to us. We understand from the Department of Health that that sort of information will be collected from April. These are the types of outcome indicators in which you were particularly interested. Q289 Mr Burstow: That is right. Before we go on to that, I just want to see if there is anything more you can tell us about the research you have done to date on the KPIs that have been published today and what they tell us about things. Mr Eayres: We have five key points about them. First, we had quibbles with some indicators, and particularly the way specification is related to the way in which they were reported, which gave us some problems in creating robust comparable indicators. There are a lot of issues around interpretation of the indicators by the different ISTCs. They interpreted definitions in different ways and supplied different data. There are issues around completeness and quality of the data that was returned. Although they were all supposed to be returning data on certain same KPIs, there was very little guidance from Department of Health in terms of in what format it should come. There was not a standard template, so there was a lot of variation in the completeness and quality that came in. Another issue we had was the lack of a clinical outcomes data, which was KPI 15. The final point was the way the data comes into us in terms of monthly aggregated returns and there is very little we could do in terms of validation of that data. We are basically accepting what the ISTC give us. They say, "Oh, yes, we had 100 admissions, five of those led to readmissions." They give us that; we cannot really validate it at the moment. Q290 Mr Burstow: That brings me back to the point you were making just now about the non-availability to you of this point about the clinical outcomes data. If you were here earlier on with our first session, you would have heard the exchanges we had with the various operators of the centre at the moment. My observations on that were that there seemed to be some confusion amongst operators as to what they were supplying at this stage, and that is something our advisors need to unpick, but one of the things which was also unclear was that at least one of the providers was putting into the public domain considerably more outcome data than the others at this stage. Do you believe that all the providers are currently collecting more outcome data but they are just not supplying it to the Department. What information or knowledge do you have of what is being collected, even if you are not being supplied it? Mr Eayres: I do not know what individual ISTCs are collecting internally or making available to patients or the public internally. All I am aware of is what Department of Health provides to us that they have collected from the ISTCs. Q291 Mr Burstow: Apart from this point about the Department providing a clearer framework in which data is collected so that the data is more comparable, are there any other points of learning you could draw from what you have done so far about how the system could be improved to make sure the data is being collected better? Mr Eayres: Yes. We have made a number of recommendations to the Department of Health about how the data ought to be collected. In particular, we recommended a move away from monthly aggregate returns, to a system whereby we build the indicators ourselves out of the patient level data which they are obliged to submit in the same way that NHS hospitals are obliged to submit. Some of the KPIs might require additional information outside of the standard data set, but that way we can then do all the aggregation of the data, and that would remove all the possibilities of different interpretations of definitions, etc, so we could standardise it a lot more. Q292 Mr Burstow: Has the Department responded to that? Mr Eayres: They have agreed in principle and they are in discussions along the lines of implementing that at some point in the near future. Q293 Mr Burstow: KPIs, you have outlined to us in some detail now what each of them might be in terms of the categories they broadly fall into, but what was the process for choosing the KPIs? How was that arrived at? Mr Eayres: We were not involved at that stage, when the KPIs were chosen. My understanding is that they were chosen to reflect in some way the patient pathway through the ISTC. But, for example, they start off with referral, so there is an indicator which says: How many patients were inappropriately referred? At the next stage there is an indicator saying: Of those referred, how many then led to an inpatient appointment? At the inpatient appointments, how many did not attend? How many were cancelled? And so on through the process, until we get to a stage where they have had the operation, and then: Did it lead to a transfer? Did it lead to a readmission? Did the patient then complain? If the patient complained, was that complaint dealt with within the appropriate time framework? Most KPIs are based on that sort of idea and then there are a few additional ones tagged on to the end. Q294 Mr Burstow: Would it be possible, if you had the disaggregated data, to reconstruct the KPIs in a way that would allow you to draw more meaningful comparisons with the equivalent data collected from direct NHS providers? Mr Eayres: Yes. That is one of the reasons why we recommend that the Department of Health do it that way. If the ISTCs are submitting the same minimum data sets that they are required to submit as the NHS do, we basically have the same data for ISTCs and NHS hospitals, and we can then write the same queries and create the same indicators for both. Q295 Mr Burstow: You said they have been agreed in principle. When do you think they might agree in practice? Mr Eayres: I cannot say. Q296 Mr Burstow: Maybe we will ask the Minister that question. Mr Eayres: It is within the philosophy of the national programme for IT within the NHS, in that we should be creating new return systems. Wherever possible, clinical data should be collected, and then administrative/performance management data should be extracted from that clinical information. There is even a secondary user service being set up as part of the information programme to do that. Our recommendation is that, for the ISTC programme, that information flow is channelled in through that programme. Mr Burstow: Thank you. Q297 Dr Taylor: Going back to aims and objectives, I think it was Professor Appleby who said that there has been no research or collection of data on the achievement of aims and objectives. Have any of you any impressions of the effect on waiting lists and how much of that has been due to the independent sector treatment centres? Dr Miller: Perhaps the one where the data is clearest is in cataract surgery. The independent sector treatment centre cataract programme so far had done 20,000 cataracts by the end of January 2006, but that needs to be put into perspective. The NHS itself is doing just over 300,000 a year, and the productivity of the NHS increased very greatly in recent years as a result of a joint project between the Department of Health and the Royal College of Ophthalmologists. They sat down a few years ago together and agreed a plan/arrangements to increase cataract operations in the NHS. That was done successfully, so that we now have a figure of 300,000 done on the NHS and the target per year is 9,000 in mobile cataract schemes. That gives you an idea of the relative contributions. Q298 Dr Taylor: We have had that several times from several people. Professor Appleby wants to come in. Professor Appleby: I would like to make the point, which I think partly Paul was making, that the NHS has been tremendously successful in reducing waiting times over the last three to four years. Actually, whether the ISTCs have had any added effect to that is very difficult to say. The one thing we do not know is how long patients have been waiting who have been treated by ISTCs. This is part of the information set we would like to have to which Daniel was referring earlier. I really do think that the ISTCs are treating NHS patients. The information about their treatment, their diagnosis, how long they have been on the list before they get treated and so on should be treated in just the same way as if they were treated in an NHS trust hospital; that is, it should become part of what is known as the hospital episodes statistics system, which we could then analyse in lots of different ways - and then we can start to make comparisons as well. The other thing I would like to mention is waiting times and waiting lists. We know they have been coming down over the last few year - in terms of waiting times, tremendously, and waiting lists have also started reducing recently quite significantly. It is not enormously clear why or how this has been happening. If you look at the numbers of patients taken off the waiting lists to be treated in NHS hospitals, it has actually been falling over the last five or six years. One would perhaps expect that if waiting lists were going down the NHS would be treating more patients. That does not seem to be the entire story, in that it also seems that not so many patients are going on to waiting lists in the first place. So the actual reasons why waiting lists and waiting times are not coming down is not solely a function of capacity. There is an issue around that which I still think needs exploring. Mr Johnson: I think one of the biggest factors in bringing down waiting lists is the recognition that if you separate acute care from elective care, you can guarantee to do the elective care. You do not turn up, as I do, not infrequently, to do an operating list and find that all the beds are full of acute medical admissions and my surgical patients have been sent home. If you do not allow that to happen - because, effectively, you deal with your elective patients in a separate institution that does not have emergency medical admissions and you know when you come in to do your operating list that you will do it - it runs more efficiently. If you separate these things, then you use the facilities far more efficiently. Probably that has had more to do with bringing waiting lists down than the independent sector ones, which, as I say, in the first phase some are not even on line yet. The impact they have had, purely because they have not been there very long, has not been very great. The sorts of figures Paul Miller gave to you about the cataracts indicate that, although they have done a lot of cases, in terms of the total numbers it is quite a small proportion. Q299 Dr Taylor: Do we have any similar figures for orthopaedics? Mr Johnson: Not that I know of. Professor Appleby: I think they have been made available recently in a PQ. I cannot remember the numbers offhand, though. Q300 Chairman: Has anybody ever done a study about where they are and where the waiting lists were? I represent a seat in South Yorkshire that has high waiting lists for orthopaedic surgery, and the ISTC has done thousands of operations, not just from South Yorkshire but from a wider area - in orthopaedics. There was an issue of geographically putting these in, as opposed to putting them in and seeing how it affects national things. Has anything like that been done to anybody's knowledge? Dr Ruane: I have not seen any study of that, but I note that some time ago - and the Department of Health representatives made a reference to this last week - SHAs and PCTs carried out an analysis in their own locale of capacity gaps and where they needed extra capacity. That would, I should have thought, reflect waiting lists. It may be possible to obtain some of that information from there, but of course that does not mean that that is up-to-date now. Q301 Chairman: If that treatment centre has done the thousands of operations that it has, is it not likely that that has helped to reduce the waiting lists in the area that it covers? Dr Ruane: I think there is some anecdotal evidence that patients have particularly welcomed rapid access to independent sector treatment centres - partly because they have tended to be underutilised, and so patients have been able to get in faster, perhaps. But I have not seen that quantified and I have not seen that pattern geographically. Q302 Dr Taylor: If the same money had been put into the NHS, would we have seen any more improvements? Professor Appleby: Possibly. Part of the whole research question around this issue is that we do not know. We can have a guess at that, but, as I say, possibly. Q303 Dr Taylor: What do any of you think of the financial planning of the programme? What financial planning was there? Dr Ruane: It seems to me that, in a number of respects, the policy has not reflected a certain amount of joined-up thinking, and I would have thought financial management would be one area where this would be the case. I think it is partly because the issue of waiting lists is clearly only one issue that went into influencing the implementation of this policy, and, again, I think the representatives from the Department indicated this last week that other factors kicked in, including the desire to open up to diverse providers and so on, so you tended to have treatment centres plonked down in different places. But certainly I think PCTs have had an important aspect of financial flexibility and the management of their finances taken away from them, because they have been tied into contracts with ISTCs that they have not always wanted, and I think something that comes across very strongly from the evidence that has been submitted, as well as from other sources, is that there is a strong degree of imposition about this policy. It has come from the centre and it has been imposed from the centre. Not all PCTs have wanted it. Although, again, I have not seen a total set of figures at all, you do get glimpses that PCTs in different parts of the countries have lost up to what tends to be in the realm of several hundred thousand pounds, through activity which they have had to pay for but which is then not taken up by patients, either because of referral patterns, patient choice, or for whatever reason - perhaps there was not a need in that particular area. I think the information from Dennis McDonald to this Committee is quite interesting, because he sets out activity rates in the North East by PCT, and you can see very, very different variable take-up amongst the PCTs, with several hundred procedures in some PCTs down to a couple/a few dozen in other PCTs. Perhaps that is because there were different morbidity profiles, a different need in those PCTs, but they have certainly lost out economically. I think the Department has stepped in with money, has it not? Am I right on that? I understand that there is a £100 million fund. I do not know if I am getting things mixed up here, but I think the Department of Health has accepted that it will take that financial burden now. But that is still resources lost to the NHS. Mr Johnson: Could I widen this slightly. The BMA is not in any way opposed to either treatment centres or the multi-provider NHS, so I am not trying to make points about this, but our biggest criticism is that, in setting up a multi-provider NHS (effectively, a market where different firms are competing with the State to provide services), a regulatory framework - the rules of the game, if you like - was not written, and we are playing Monopoly and making the rules up as we go along. That is unsatisfactory. We would have five areas where we think we need a written set of rules before you can play the game - and you have heard all of them this morning. The first one is an integrated service. If you are going to have different providers providing different bits of care, they must talk to each other. If you are going to go home from hospital and be looked after at home, the people at home have to know what operation you have had. We do not have an integrated, seamless service and there is not a set of rules for it. You must have - and we have talked at length about this - comprehensive audit of clinical outcomes (not these non-clinical ones) and the NHS ones to compare them with. If you do not have that, people will say, "Treatment in treatment centres is rubbish" and you cannot refute it and they cannot back it up. That is unsatisfactory. You need to have a regime for what happens when a hospital fails. It might not even be just that the orthopaedics goes out of the hospital into a treatment centre; you might so destabilise the situation that all the special things that the private sector does not want to provide (intensive care, maternity, A&E) are going to close down because there is no more money any more . We do not have an exit strategy and the Department is quite frank in saying we do not have an exit strategy, and we need that. We need to be able to train medically - we have talked extensively this morning and you have about training in treatment centres. Finally, we must ultimately, after these people have entered the market, have a level playing field. They think it is stacked against them, we think it is stacked against the NHS. It has to be transparent and a level playing field. When you have a set of rules for those five issues, you have a regulatory framework and you can play at markets. I have this summarised on a bit of paper, which I would be happy to submit as supplementary evidence. To develop these as you go along seems to us to be totally wrong. Professor Appleby: If I may just go back to your first question about the financial planning of the programme. From the Department of Health point of view, it goes to what Sally was saying. One of the aims, the vision, it seems to me, is the market creation: it is to fit in with the more pluralistic provider supply side and a desire, frankly, to put pressure and, in a sense, destabilise the NHS - not completely, of course, but to ginger up the market, if you like, with the independent sector. I guess that to entice them into this potential market, compromises were made on both sides, in terms of finances and the nature of the contract that was on the table, and that was accepted by the private sector and the Department, and PCTs were willing to provide. We heard earlier on about who is bearing the risk. It seems to me that is a really important question. It is a bit like around PFI as well, do we have the bearing of the risk right in terms of the rewards that are being offered. That is where some of the quibbles, or not quibbles but big questions, about value for money and so on arise. It seems to me, in a sense, that both sides made some compromises there. The NHS offered what was, in effect, competition for the market, not competition in the market, so a five-year contract more or less guaranteed work. Okay, there was risk borne by the private sector in terms of their costs, but presumably they came to the opinion they were worth bearing, given the rewards and so on. I think that there was sort of negotiation and splitting of the risks and so on relative to the costs and the rewards that went on. Whether that was worth it depends on our view or my view or your view about whether it is worth achieving the objectives, which is plurality of supplies and so on. That is the tricky thing about, say, doing some research into this to try to evaluate whether the ISTC programme is meeting that particular objective. We have not got there yet, to start with, so it is difficult to evaluate. Q304 Dr Taylor: That is very helpful. Dr Miller: I would like to come in on your question on planning too. My understanding is that when the survey of the Strategic Health Authority was carried out sometime ago for the shortfall, the initial answer they came back with was: Half a million procedures. They were told to go and look more carefully and came back with a second answer, which was: A quarter of a million procedures. Their third iteration apparently came up with 170,000 procedures' shortfall. I think that illustrates that the degree of planning involved in this is beyond the ability of the NHS to do very well. What else? I think it would be wrong to think that the objective of this programme is just about bringing down waiting times. It was clearly stated that one of the objectives of this was, indeed, to create a sustainable competitive market in the provision of services. I think that is fairly obvious from the way some of it has gone. Some of the other bits of planning that did not go too well would influence the additionality, which was not a terribly well-thought-out answer to some of the problems that have been discussed regarding Wave 1, such that, in fact, it has been changed and relaxed considerably for Wave 2 and is abolished completely for the Independent Sector Extended Choice Network currently being tendered for. On poor planning, the other example would be the Oxford eye capacity debacle, where it was only after some senior NHS managers had resigned from the service that they felt able to talk about the bullying and the pressure they had been put under to accept capacity that they had always thought they did not need. My understanding is that that spare capacity from Oxford is currently being hawked around the country to see if anyone will buy this surplus capacity. I also want to refer to the evidence on page EV165 about the North Tyneside ISTC. The evidence refers to the six PCTs being charged £200,000 each for this treatment centre and I would like to put some local knowledge on to that. It is not surprising that North Tyneside have 434 of the 1,047 patients treated there. It is in their patch. It is also perhaps completely unsurprising that Sunderland has only sent 63, despite paying the same £200,000. Sunderland City Hospital has a three star trust. It is one, I gather of only seven in the country that has been three-star in the star ratings. It does not, as I understand it, have a particular problem with waiting times. Lastly, Gateshead has only sent 14 patients there, despite spending the same £200,000. Why? Gateshead also has a reputation for good quality services, good management and - what else? - it has its own NHS treatment centre, so why would it be sending along the coast to an ISTC? I want to make that point to talk about what I would see as the poor planning of these services. Dr Taylor: Thank you for pointing that out. That is helpful. Q305 Dr Stoate: I have got a very simple question in a way for the BMA. One of the objectives the Department has come up with is that the ISTC programme has been designed to stimulate innovation and improve working practices. Is there any evidence that is the case and, if so, have you got any examples? Mr Johnson: No. Paul has been talking about whether Gateshead or wherever send people but ultimately with patient choice we will be talking about where the patients want to go and not where Gateshead PCT wants to send them and, therefore, what will matter will be whether the units are supplying what matter to patients. Probably one of the things the patient can judge least is how well the operation went because they have nothing to compare it with, they have not had three before. They do know if the doctor was nice to them and the nurse was polite, whether they were kept waiting or not, whether they could park their car and get a decent cup of coffee, and all of these things are going to be what matter to the patients. If a hospital can provide these things, which in medicine we have probably regarded as rather on the fringe of what mattered before, good medical care being everything, they will attract patients. I have no doubt at all that these treatment centres have got the message that these fringe activities, if you like, good parking and so on, are going to be very, very important in staying afloat. This is the sort of innovation, not wonderful clinical innovation, different ways of doing things that I think we will see in the first instance. They will provide a service that is very attractive to patients and patients will say to each other, "You want to go there, they don't keep you waiting, it is really good, et cetera". Q306 Dr Stoate: I am slightly concerned about this because I do not think those are fringe activities. I think that treating patients in a way that makes them feel comfortable and relaxed, to have someone who takes the time to come and talk to them, someone who sits them down and gives them a cup of tea, asks after their partner, "Can I get your partner a cup of tea?", all of these ---- Mr Johnson: I was trying to put fringe in inverted commas. Q307 Dr Stoate: Sure, but the NHS traditionally has been spectacularly poor at that. Mr Johnson: Exactly so. Q308 Dr Stoate: And in terms of what patients value those things come pretty high up on the list. My own view is that if the NHS is driven to provide these so-called "fringe activities" in order to compete that can only be a good thing. Mr Johnson: I agree. Dr Stoate: Thank you very much. Q309 Mr Campbell: I have got a question on value for money. I think I know what answer I will get from the panel, but I am still going to ask it anyway. Are we getting value for money and how can it be measured? It really cannot be after what you have just said. Professor Appleby: I think it can be measured, we just need to get the right data. We also need to ask ourselves what is the value of what do we want to measure: is it the cost per operation done; is it the cost in terms of creating some sort of expanded market or some sort of contestable market; is it the cost of reducing waiting times and so on? We need to pin that down and relate it back to what the objectives of this whole programme were, or are, or are emerging to be, and we need to be clear about that. Q310 Mr Campbell: We have got some data. Mr Miller gave us some little hints of centres not being used, so what has happened to the money? The NHS has lost that money if it is not being used. Professor Appleby: I do not want to say what the Department would say but I suppose there is a transition going on at the moment so, as I said earlier, there has been some compromise in terms of the length of the contract, the nature of the contract, what is being paid for, what is being provided, and so on. The evidence, such as it is that I have seen, suggests that the independent sector is providing operations which are at a higher average cost than the NHS. At first sight it does not look worthwhile in some sense. I suppose the argument could be, and certainly the ISTC people here earlier said, over time they will get the costs down, in terms of costs per patient it will become cheaper than the NHS possibly and there will be value for money. We are in a bit of a gamble here as to whether that will happen or not. Q311 Mr Campbell: Can you see in the foreseeable future that they can compete with the Health Service because if they cannot they are not going to be worth it, are they, at the end of the day? Professor Appleby: In part it depends on something that James raised which was the rules of the game and the rules of engagement here as to how the NHS market, and there is one, is going to develop in future and the extent to which we have market regulation and the nature of that. Will NHS Foundation Trusts be able to compete for these treatment centres, for example? Is there going to be competition for the market or is there competition in the market so that private centres can set up and if they take patients and patients want to go there, fair enough, if they do not they bear that risk? At the moment we are looking at a very regulated market, if you like. Q312 Mr Campbell: So what you are saying is that if the contracts come along to be had then the Health Service or a local hospital can compete for them. Professor Appleby: As I understand it, the contracts for Wave 1 and Wave 2 are simply within the private sector, as it were. The Department of Health do not invite bids from the existing NHS. Q313 Mr Campbell: But that could be opened up? Professor Appleby: Maybe that could, yes. Q314 Mr Campbell: That is a good point, we will have to remember that. Dr Miller: Could I address that question? There have been a number of reports of contracts for Wave 1 ISTCs where the workload contracted for has not been carried out and they still get paid because that is the nature of the contract. That has been reasonably well documented in a number of places. I wrote to the Department of Health specifically about how the contracts were structured and the response I got back, to be fair, was perhaps predictable, understandable and believable, dare I say. It was pointed out that this is a five year contract and you would perhaps not expect the business model to take off from day one and the expectation is that whilst they have not carried out 20% of the five year contract in year one there is an expectation that it will take off and be delivered in total over the five years. I think it is important to take that into account. The whole issue of value for money is more complicated still than that. Some of these contracts are at NHS tariff plus a few per cent, some are at less than NHS tariff, but what has not been mentioned today, as far as I am aware, is that some of them also have tie-ins. At the end of the five year contract there is a residual value agreed for their buildings and their equipment for which they will be paid at the end of the five years if the contract is not renewed, as I understand it. The whole question of value for money is a lot more complicated than just whether they do it at tariff plus 5% or tariff minus 10%, there is a lot more to it than that. Q315 Mr Campbell: IT centres are getting paid whether they do the procedures or not. Professor Appleby: Yes, they are. Q316 Dr Stoate: There is set money and that is it. If they do not do them they still get the set money. That does not happen in the Health Service, does it? Professor Appleby: Yes, they are, but I am saying the answer I got when I raised that was that the expectation is they will catch up over the five years and that we will have to wait and see. Professor Appleby: As far as I am aware that is a longer period than the NHS is being given in terms of the phasing in of the so-called payment by results. I would argue that I do not understand why the ISTCs cannot be part of that same phasing in. I heard some of the excuses, I suppose, earlier on about you cannot compare ISTC costs with NHS costs because, I do not know, the independent sector pays VAT and so on, there is this and that, pension issues and so on. Of course there are lots of variations within the NHS and different hospitals have different rates of efficiency and so on, so there are always quibbles about whether you can compare one hospital with another, but I would have thought on balance they have got to take the rough with the green on that one. One of the reasons the private sector give for why they want to enter the market is they can be innovative, at least perhaps on the cost side, that they have new ways of doing things, they employ Hungarian doctors and not UK doctors because there is an issue about private pay rates, for example. I think it should be able to compare the private sector and the NHS and make some judgment about value for money. Mr Campbell: It will be interesting to see what profits they make. Q317 Mr Amess: Dr Ruane, you made it very clear in your written evidence to the Committee that you are not very keen on these independent treatment centres. I would not call any of your evidence libellous but if you do want to libel someone it will certainly enliven our proceedings! You spoke about Canada and America specifically and said that you were aware of schemes with public-private partnerships that were not working out at all. I wonder if you could briefly give us some examples. Dr Ruane: I made a reference to Canadian and American research not because I was claiming or suggesting that the American healthcare market is analogous to ours, because it is not, but because that research has been mentioned a couple of times in very interesting Health Service journal articles and because there has been the suggestion in Canada in recent years that for-profit companies set up hospitals within their health economy, which is not identical to ours, and I thought it would be interesting to have a look at some of the evidence that has been collected. I was thinking particularly of the research by Devereaux and colleagues. Devereaux is based in McMasters in Canada and has worked with a team of colleagues in Canada and America. What they have done is to provide a systematic review and what they call a meta-analysis of pre-existing studies comparing for-profit and not for-profit and in some cases public hospitals. These have been compared around mortality rates. I thought it was worth looking at this material because I think it is methodologically quite sophisticated and it is methodologically quite transparent, so you can see whether you think they have done enough to make sure that their results are not biased. They have gone through all sorts of hoops to try to control confounding variables. They have evaluated studies blind, in other words not knowing what the outcome of the studies were, and they have pooled data around 26,000 hospitals and something like 34 million patients in the United States. What they found was that on mortality rates, for example, there is a 2% higher adjusted mortality rate in for-profit hospitals than not for-profit hospitals. They have also done work around comparing payments for care and found that for-profit hospitals take higher payments for care than not for-profit hospitals. There has been research by Vaillancourt, Rosenau & Linder around cost-effectiveness, access and quality using a different methodology comparing a large number of studies and, again, the studies came out overwhelmingly in favour of the not for-profit. I am not suggesting we can just transfer that to here because that is not what we are working with, but what that raised for me was there is evidence there that has been collected with some care and with some degree of methodological sophistication but what is the evidence base here for our policy. I am not sure what the evidence base is for this particular policy. There have not been pilots so far as I know, there has not even been a great deal of public discussion. I suppose what I was trying to flag up was I am not sure what the evidence base is and maybe we need to develop a stronger evidence base for this policy. Q318 Mr Amess: You said, disappointingly, absolutely nothing that is libellous. Dr Ruane: I am sorry. I will try harder next time. Professor Appleby: I was not going to offer anything libellous but maybe a little counterbalance to that. The economics literature around, in a sense, does it matter who owns the means of healthcare production is, to say the least, mixed. It depends what you look at. If you are looking at are the costs of for-profit or private sector hospitals higher than in public hospitals, probably yes is the answer but, again, it depends what you are looking at within that. In terms of access and health outcomes, the literature I have seen is reasonably mixed, to be honest. I wonder whether, in fact, who owns the means of healthcare production is the right question. You have to know what the financial incentives are in a particular healthcare system, how the contracts are set up, the nature of the contracts and so on. In a sense, it seems to me those are more important issues than the ownership issue. Mr Johnson: The other issue that makes it very difficult to compare with what we have just heard about the North American system is that an arbitrary decision has been made that the price is fixed, which is a very strange situation for any real market and, therefore, we compete on things other than price. Given that the price is fixed a lot of what we have heard about North America does not apply because the price is not fixed in North America and for-profit hospitals will be more expensive than not for-profit hospitals, and so on, and HMOs take different views in America about which hospitals they will pay for and which they will not. It is very difficult to draw analogies between those two systems. My personal view is that sustaining this policy of a fixed price is going to be extraordinarily difficult. If you have purchasers who are very strapped for cash three years down the line and an organisation, private or public, comes and says to them, "Look, we will do these for you below tariff because we think we can still make a profit", I find it very, very strange that the state would be able to say, "No, that is not allowed", there will be just some sort of cashback deal or something like that. Q319 Chairman: Do ISTCs destabilise the local health economy? Mr Johnson: Potentially they can. Q320 Chairman: Do they? Mr Johnson: There are one or two examples, and it is only one or two so far. There was one of orthopaedics in Southampton where the NHS unit closed because the patents were being sent to an ISTC in Salisbury. The only thing that closed was the orthopaedic unit so you could argue that you simply transferred the venue from where the orthopaedic surgery was done. Potentially it could go either way, you could have a whole hospital threatened because a lot of its surgical income would be taken away. Q321 Chairman: It is highly unlikely to have A&E taken into this process. We had people from the profession sitting there last week who said it made good sense to take elective surgery away from A&E because of the potential for A&E to disturb elective surgery because of incidents that happen on our roads and elsewhere during the day. You are not saying doing that would threaten it in that way, surely not? Mr Johnson: I would see it destabilising it because it would remove a sufficient chunk of the hospital's basic finance that the hospital might conceivably become unviable. Q322 Chairman: The other thing that was said earlier on was is their influence innovative on the National Health Service. Do you think any of your members have changed their work practice because they have had an ISTC in the neighbourhood? Mr Johnson: Some of them have gone to work for them in their spare time. I have no evidence that the practice has changed as yet. I would expect the change to be more along the lines I was talking about before to Dr Stoate of providing services that make the service more attractive to patients. Q323 Chairman: I accept that. One of the issues was about influencing what is happening inside the NHS. Mr Johnson: There was a case in, I think it was, Yarmouth over the orthopaedic surgeon who decided to run a production line and as one patient wound up in one theatre the next was put to sleep in the next theatre and he just went from one to the other. I am quite sure that was in response to the need to be productive and efficient but whether or not you could say that is a broad trend that is happening is rather unlikely at the moment. Q324 Chairman: I think he was trained in France, was he not? Do you think that is a good idea? Mr Johnson: There are arguments on both sides. The most dangerous time with an anaesthetic is when you are putting the patient to sleep and when you are waking them up. If you take your eye off the ball to put another patient to sleep at the same time you potentially have two crises going on at the same time. These things are not simple, you have got to have enough staff to do it with. Q325 Chairman: From what I read it was the surgeon who was moving. The Secretary of State has been using it quite regularly in her speeches. Mr Johnson: She has indeed. You need to have an extra anaesthetist to allow the surgeon to do that. If you are doing it without an extra anaesthetist it is probably not safe, but if you do it is safe. Q326 Chairman: Dr Miller, you have got something to say. Dr Miller: You asked about innovation and destabilisation. I think one of the ISTC representatives at the first session this morning said that he did not think there was anything truly unique or innovative that was not done anywhere in the NHS that was being done in their centres. I think it is important to remember that the NHS is innovative. It is not like the NHS has never changed or thought of anything new in the last 50/60 years. Treatment centres were developed in the NHS, the NHS had them before ISTCs. The NHS has made lots of innovations over the years. I do not like this atmosphere that is sometimes generated that the NHS has never had an original idea in the last 60 years, it is not true and it is not fair. As for destabilisation, the point has been made repeatedly today that we are still at the very, very early stage of the ISTC programme. ISTCs are doing what they were asked to do in a political and economic sense. They were never asked to do training so they have not done it. In Wave 2 they are being asked to do training and I am sure they will do it. As for the destabilisation, we have seen a small number of examples of where work has been handed over from an NHS unit to a treatment centre, not by patient choice, and that has destabilised or caused a service to close down or run down to some extent. As it takes off and there are many more treatment centres it is likely that there will be more destabilisation of NHS services but more particularly as we get into Phase 2, which is currently being tendered, where it is not just going to be orthopaedics and eyes, Wave 2 talks about gynaecology, urology, ENT, plastic surgery, cardiology, renal dialysis, a much broader range of services. It is highly likely that the destabilisation and knock-on effects on traditional NHS hospitals will be hugely greater once that is fully up and running. Q327 Chairman: Do you think that is a threat? Dr Miller: I think it is inevitably a threat. Q328 Chairman: If you have got a surgeon who is running two theatres, okay he has got to have a lot more support staff and everything else, and that surgeon might be used for an hour during that four hour process and an hour in a neighbouring one as well, surely that is of more benefit to the organisation, and particularly the patients, in as much as you are going to get into the theatre quicker if you have got surgeons delivering two forms of services at the same time. Mr Johnson: All other things being equal, yes. Q329 Chairman: I realise that and it may not be. That should not be perceived as a threat, it is a way that things may move in the future. Dr Miller: What I meant by a threat was even if by patient choice only 10% of patients looking for elective surgery chose, even just out of curiosity, to go to an ISTC, first that would not be surprising, I think the evidence is a lot of ISTCs do these things well that the NHS has not done well and give an attractive offering, the loss of 10% of elective income would be hugely destabilising for the NHS unit. Q330 Dr Taylor: We have heard a lot about the importance of integration and the value of integration between the NHS and the independent sector treatment centres. Have you any examples of useful interaction taking place already? Mr Johnson: Not yet. I work in a hospital where there is one being built in the back yard, sort of thing. One of the two principal limiting factors in my NHS hospital that is slowing down everything is lack of radiology. We have a complement of about 50% of the number of radiologists we ought to have. People stay in bed in hospital for days waiting for their ultrasound scan or something, a total waste of NHS money and their time. This new treatment centre, which is only going to have 40 beds, is going to be orthopaedics, it has got three general radiology rooms, a CT room and an MR room. It is going to be 100 yards across from us. It will be hugely underused from the point of view of the treatment centre firm. I cannot believe that we could not jointly use that facility so that they would get more money for using it and we would have access to radiology and become a lot more efficient as a hospital. These seem to be the sorts of examples where everybody gains from a bit of co-operation. Q331 Dr Taylor: The crucial question was really brought up by one of the independent sector people this morning, the question of salaries. Would NHS consultants be prepared to take a session on as part of their job plan under the NHS to work in that sector? Would that be possible, would that be practicable, or would they insist on the scale of salaries in private practice? Mr Johnson: I think in this instance it would be rather the other way around, we would be looking for their radiologists to come and work in the NHS, in which case we would presumably offer them NHS rates. I think these are negotiable. Frankly, if a surgeon or anaesthetist decides in his own time that instead of going to do some private practice on a Saturday morning he will go and work for a treatment centre it is a matter for negotiation what the deal is and if it is not satisfactory he will not do it. It will not necessarily be NHS rates. Q332 Dr Taylor: We hear of NHS surgeons doing crosswords on the news because there are no facilities for them to work at that time. If they have got spare slots on their job plans could they move those spare slots into an independent sector treatment centre? It would seem obvious that they should. Mr Johnson: With respect, I think the reference to crossword puzzles was due to the fact that the NHS has virtually been told to stop working for the last two months of the financial year because it has run out of money. That is a whole new ballgame but it is something I would not support or excuse for a moment. It seems a very mixed message to tell you to work and be productive and efficient for the first ten months of the year and then stop doing everything for the last two. That is just a bad system. That is what the crossword puzzles are about. If they were part of the job plan that it would be better done at the treatment centre it would be for the employer to second the consultant and say, "Rather than work for us for this session, you work there". That provision is available. Dr Taylor: This is a point we will take up in our workforce inquiry. Q333 Chairman: I am sure we will. The BMA would not have a problem with that, would they? Mr Johnson: Providing that the consultant was not sent against his will, no. Q334 Chairman: They would be going there on their NHS contract which could totally destabilise the private doctors who are working in there. You would not have a problem with that as an organisation, would you? Dr Miller: More than that, specifically we have been in talks and discussions and negotiations with the Department of Health to provide a framework in which such secondments could happen avoiding various pitfalls that could occur. Q335 Chairman: This would be effectively through local integration as opposed to national direction, is that what you are saying? Mr Johnson: We have no problem at all with that. Q336 Chairman: I think that is about it. Obviously you have had a taste of the first phase and the second phase is on the way. I think we have got most issues out of you. One thing I was going to ask was you do not see a problem with training people in ISTCs from the profession's point of view, do you, providing everything else is equal? Mr Johnson: It will not just happen. Q337 Chairman: It would slow down the activity, as training does, but you do not see a problem in relation to that? Mr Johnson: The problem will be that for the first time the costs of training will become transparent. It has been regarded in the NHS rather as something that you do. If the treatment centre firm says to the PCT or whoever is buying it, "Okay, you want us to train, this will cost you X extra", the PCT will say, "Hang on, we have never paid for training before, what is all this about?" It will start to make it transparent but that is probably no bad thing. Chairman: Sorry for the overrun. It happened in the first session and we consistently overran with the second and third as well. Thank you very much indeed for your evidence. We will at some stage be bringing out a report. Thank you. |