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7 Mar 2007 : Column 475WH—continued
“This was not a love wedding, it was a reasonable wedding...But reasonableness is often more important for a long marriage. They’ve seen we are not nasty people working against poor countries and seeking only profits.”
That is a very good sign for the future, and perhaps in other fields we shall see the large pharmaceutical industries coming down on that side.
There have been newer developments in the field of private-public partnerships. The out-patient renal dialysis unit in my hospital is one such development. I am not going to talk about GPs. Everyone knows that they are independent providers who very much relish
that role, but I know very few who concentrate on private practice, so I shall not talk about them.
Before I examine the Government’s use of the private sector as health service provider, I want to explain what I see as two conflicting views of privatisation. My impression of the Government’s position is that they feel we have an NHS regardless of who provides the service as long as the patient does not pay. That does not reflect my views, or those of most NHS staff and a lot of patients. They believe that to have a true NHS, most services—particularly if we are talking about acute hospital services—must be provided by the NHS. It was Bevan’s revolution, as long ago as 1948, that meant that all NHS staff were paid on the same scales at a stroke, whether they were top teaching hospital consultants, lowly consultants in district general hospitals, matrons in huge hospitals or those in cottage hospitals. The unity of the quality of staff throughout the country was crucial. When I was looking for a consultant job, pay was not an issue; it was a question of the sort of work one wanted to do and the place one wanted to go. The fear is that a multiplicity of providers may lead to a loss of this strong influence of unity.
I want to examine in detail three aspects of health care provision: first, the treatment centres and services for investigations; secondly, clinical assessment, treatment and support services; and, thirdly, the private finance initiative. I intend to conclude with some terribly worrying warnings that have been expressed in some quarters about the future.
On treatment centres, there is no doubt that it is correct to separate elective work from emergency work. That means that we do not have cancellations and we can usually accommodate all the patients on the lists. An organisation called NHS Elect was set up to study that process in four or five centres, of which Kidderminster was one. Only eight months after setting the organisation up, instead of waiting to see what would happen, the Government produced phase 1 of the independent sector treatment initiative.
The Minister contributed to the Health Committee report of 2001-02. There were bits about which we both agreed, although there was one bit on which we did not.
David Taylor (North-West Leicestershire) (Lab/Co-op): I am grateful to my hon. Friend and namesake for giving way.
People are concerned that independent sector treatment centres do not necessarily provide value for money, although they may improve waiting times for elective surgery. They do not necessarily augment NHS capacity, but can have a damaging effect on the hospital where they are located. Queen’s hospital at Burton upon Trent is an example of that. Finally, they do not have any responsibility for the provision of undergraduate or postgraduate medical training and the integration of research. Those three areas are crucial, but the private sector is able to walk away, with its half-empty beds, while damaging the general hospital next door or just up the road.
Dr. Taylor: I shall cover all those points, so I shall continue and hope that I do so before the hon. Gentleman has to leave.
One of the conclusions of the report on the role of the private sector was:
“It remains to be demonstrated that greater use of the capacity of the independent sector poses no direct threat to resources in the public sector.”
The Government, in their response, said:
“The Government agrees with the Committee that it is important that new capacity is genuinely additional, and does not simply mean moving capacity from one place to another. This is true of the development of new capacity within NHS, as it is of the use of capacity in the independent sector.”
The first question is whether the capacity produced in the independent sector treatment centres is genuinely additional.
The Health Committee inquiry into independent sector treatment centres received a considerable amount of evidence that showed that the local capacity analysis was not full or accurate. Indeed, the private cataract unit in Oxford was imposed on the local NHS, rather against its wishes. Our report said:
“If there had been a severe shortage of capacity, the ISTC programme should have had little effect on capacity utilisation of NHS facilities. This has not been the case; according to NHS Elect, the introduction of ISTCs has led to under-utilisation of NHS Treatment Centres (because of the ‘take or pay’ contract).”
Andrew George (St. Ives) (LD): The hon. Gentleman makes a good and strong case, although I hope that I am not anticipating a point that he wishes to make later. He has certainly identified problems with independent treatment centres, but there are also private bodies that operate within NHS hospitals, as they do in my constituency. Clinicians who work for the NHS are at the same time in the market for providing services in the private sector, which clearly compromises their commitment to the NHS. Does he agree that those relationships need to be separated? Clinicians must make a decision: are they in the NHS or in the private sector?
Dr. Taylor: I shall touch on that point peripherally. Briefly, where NHS consultants are involved in independent sector treatment centres, it is clear that that should be part of their NHS contracts and not paid at extra rates. I shall come to that, although I agree that the long-term permission for consultants to do private work as well as NHS work must be carefully defined and monitored.
The Department of Health has perpetuated the myth that ISTCs have had a dramatic effect on waiting lists. The best evidence against that comes in the ophthalmic field. For example, at a time when more than 300,000 cataract operations were being done in the NHS, precisely 20,000 were being done in independent sector treatment centres. Waiting lists were falling because of hard NHS graft before the ISTCs came into operation. Ministers and civil servants acknowledged that in our inquiry. One of our conclusions was:
“ISTCs have not made a major direct contribution to increasing capacity, as the Department of Health has admitted. It is far from obvious that the capacity provided by the ISTCs was needed in all the areas where Phase 1 ISTCs have been built, despite claims by the Department that capacity needs were assessed locally.”
I shall digress briefly and discuss clinical investigation facilities. They fell outside the remit of our ISTC inquiry, but they are relevant to the notice taken by the Government of local capacity issues. I received a letter out of the blue from a former houseman who is now a professor of clinical magnetic resonance imaging in one of the major universities, and
therefore in charge of MRI scanning for a prestigious university hospital. He was not aware of any attempt to see whether extra capacity was needed in wave 1 of the ISTCs. It was not as if existing facilities in the NHS were underused; rather, they were underused only because of lack of resources. If the money had been put into those facilities, they could have done everything that the independent sector was going to do.
There was no consultation on wave 1, and even though that doctor’s trust turned wave 1 down because it did not need it, it was forced on it. If only the Government money had gone to the trust, it would have achieved exactly the same results. If primary care trusts are offered free centrally funded MRI scans, it is not very hard for them to choose those rather than the NHS ones, for which they would have to pay. There is no level playing field. The Health Service Journal recently surveyed 97 NHS chief executives, who were asked a series of questions. When asked about the playing field on which the private and public sectors competed, 97 per cent. said that it was unfair.
Dr. Ian Gibson (Norwich, North) (Lab): Is the hon. Gentleman saying that the centres that were set up received special compensation deals from the Department? Is there any evidence that money was being filtered in to encourage them to set up, to reduce their capital costs and to guarantee their futures?
Dr. Taylor: From the point of view of MRI scanning, the money was provided directly from the Department rather than going through the trusts. The independent sector treatment centres in the first wave were paid a premium. The answer to the questions that we have asked about that is that the premium was necessary because the ISTCs had to set up the services. I am not sure that I bought that argument, but perhaps the Minister will say something more about it.
What really bothered the Health Committee when we considered ISTCs was that there was no hard evidence on clinical outcomes. We heard alarming anecdotes about disasters, such as revisions of joint replacements and so on, but we could not get hard evidence either way because it did not exist. We therefore welcome the chief medical officer’s request to the Healthcare Commission to review the quality of care in independent sector treatment centres. The Government response to that inquiry gave the terms of reference, although to be honest we all thought that they were rather woolly. For instance, the current key performance indicators are a measure of process rather than of quality. The Healthcare Commission’s remit appeared to concentrate on process rather than outcomes. We were told that the inquiry was due in March 2007—this very month—so I wonder whether the Minister has any information about when it will arrive. Also, I understand that the Royal College of Surgeons is willing to set up another inquiry, into real outcomes, and I wonder whether he has any information about that.
Other concerns about ISTCs include their integration with the NHS. During the Health Committee inquiry we visited several independent sector treatment centres. Those that were working closely with the NHS, swapping staff, were working extremely well. Those centres that were working entirely separately were working in competition. The independent sector treatment centre for orthopaedics in my area is exactly like that. It is in
competition. The local NHS orthopods can see no good coming out of it, and have had no chance to get into it and try to improve it. There is also a weird clause of additionality, which goes against integration, but it is funny that it has been applied in some places and not others. There has been a report about the independent sector treatment centre at Queen’s hospital in Burton upon Trent, which is obviously one that works with NHS consultants. If that centre can do that, why cannot others?
Orthopaedics is a shortage specialty, so I understand that the additionality rule will not be lifted for the phase 2 ISTCs, which will be very sad. Integration will equate the standards and answer the other great criticism mentioned by the hon. Member for North-West Leicestershire (David Taylor): the lack of teaching in ISTCs. Worries have been expressed about the quality of the doctors who work in ISTCs; if they come from continental Europe, they will not necessarily have undergone the same stringent accreditation processes as we have in this country. Will they be adequately qualified to provide teaching in ISTCs?
Are ISTCs a threat to NHS services? The Health Committee could not come up with hard evidence on that, but we made two comments:
“The Phase 1 contracts, including the ‘take or pay’ elements, give ISTCs a significant advantage over NHS Treatment Centres and other NHS facilities. This is one of the reasons that several NHS Treatment Centres have spare capacity. In the longer term, there are good reasons for thinking that ISTCs could have a more significant effect on finances of NHS hospitals.”
We concluded the ISTC report with the following words:
“We are not convinced that ISTCs provide better value for money than other options such as NHS Treatment Centres, greater use of NHS facilities out-of-hours or partnership arrangements such as those at Redwood.”
Recently—in Hospital Doctor, I think—there were reports of the south-west London elective orthopaedic centre, a joint venture between four NHS trusts: Kingston Hospital NHS Trust, St. George’s Healthcare NHS Trust, Mayday Healthcare NHS Trust and Epsom and St. Helier NHS Trust. The centre provides NHS elective orthopaedic surgery, and is working very successfully. It treats more than 3,000 patients a year, and needs 300 a month to break even. However, staff there are terrified that new independent sector treatment centres proposed for the area could pose a threat.
Andrew George: I hope that, before the hon. Gentleman moves on, he will ask questions about an important issue—perhaps it is the worrying trend that he rather coyly mentioned in his opening remarks. We have been assured that the European Union is not interested in policies on nation-state issues such as health. However, it has become clear that the EU and the European Court is looking at the opening of the Pandora’s box of providing for the private sector in the NHS in the manner that he has described. They consider that, if the market is being opened up, the Government need to play by market rules; the Pandora’s box has been opened and cannot be closed. That is of great and deep concern to many right hon. and hon. Members.
Dr. Taylor: The hon. Gentleman is a mind reader; I shall come to exactly that point at the end. It is the potential bombshell.
I move on to CATS—or clinical assessment, treatment and support services—which are being consulted on in Cumbria and Lancashire. I am not sure whether the part of Lancashire represented by the Minister is involved, or whether it is the northern part of that county. I should like to draw attention to the consultation document, which is an absolute example of consultation pointing in one direction only. Its very title is, “Improving our Patients’ Experience of Healthcare in Cumbria and Lancashire”. It is highly significant that the introduction and welcome pages are signed by six PCT chief executives and one chair. The latter happens to chair the independent sector commissioning board, and one of the chief executives is the lead chief executive of the same board. Surely, that is a conflict of interest. Furthermore, not a single clinician is mentioned in the introduction—nor, as far as I can see, in the whole consultation document. There is certainly no mention of patients forum involvement or anything like that.
Tim Farron (Westmorland and Lonsdale) (LD): The hon. Gentleman referred to a state of affairs in my constituency. He may be aware that the CATS consultation came about only after extreme pressure; it is really only about how, rather than whether, CATS is imposed. Perhaps he will note that many clinicians in my constituency are concerned about the impact of CATS on local hospitals—particularly my local one, Westmorland General hospital. It is estimated that between 60 and 80 per cent. of current out-patient demand will disappear if the CATS centres arrive, therefore undermining the potential viability of my local hospital.
Dr. Taylor: I am aware of a lot of the things going on, but not the details of Westmorland and Lonsdale.
One has only to look at the contents of the consultation document to see which way it pushes people:
“CATS adds to existing health services...CATS is designed around the patient...CATS is intended to help reduce waiting times, simplify patients’ experience and add services closer to patients’ homes...We are designing CATS to meet the needs of patients...We intend to introduce eight CATS centres across Cumbria and Lancashire...The preferred bidder for CATS services is Netcare UK”.
There is a section entitled “What will the changes mean for my local hospital?”, and it is fairly dismissive. The most striking early sentence is about having a negative effect on hospitals not being
“the intention of introducing CATS.”
However, it says lower down that
“CATS will mean changes for hospitals”.
I am very bothered that continuity of care seems to be swept aside, but the document says that the huge advantage to local PCTs is that the introduction of CATS services is all free and that there is £23 million in additional money to fund it. The consultation’s response form, which has to be returned by 9 March, has no question allowing someone to disapprove of the proposal as a whole. I am still puzzled at why there is no contribution from medical or nursing staff to the document.
Dr. Gibson: Will the hon. Gentleman say whether certain specialties will be given to CATS? I had heard that there were six. Is that true, and what are they?
Dr. Taylor: It is true; there are six specialties. The ones about which I know most are rheumatology, gynaecology and orthopaedics, because they are the ones that people have spoken to me about.
I shall speak briefly about rheumatology; I do not think that the people who designed CATS know what specialist rheumatology hospital doctors do. They can cope with anything from painful shoulders and backache to the really crippling inflammatory arthritises and the very rare, life-threatening rheumatological diseases. There is no detail about who Netcare’s doctors will be—are they accredited rheumatologists, do they have experience as physicians? A great thing in rheumatology is the multi-professional team so essential to modern care.
Tim Farron: The hon. Gentleman is very generous in giving way. I shall be brief. Is he aware that rheumatology—which is indeed one of the specialisms in which CAT centres, in south Cumbria at least, are likely to specialise—has no waiting list to speak of whatever at the moment? Given that the official explanation for introducing and imposing CATS is the 18-week waiting time, it all seems completely off the mark and as if there has been no consultation.
Dr. Taylor: I am aware of that. The British Society for Rheumatology has been on to me. Rheumatology is a speciality that will be able to reach 18-week waiting lists across the whole region without a problem. If referrals to the NHS drop by 50 per cent., for example, the area will be able to afford only 7.5 whole-time equivalent rheumatologists across the region whereas at the moment 17 cover 16 hospital sites. On the gynaecology side, a gynaecologist expects the fallout from CATS to affect all trusts. He tells me that trust managers and local MPs are worried, to say nothing of the clinicians. The great problem with gynaecology is that the problems in different trusts are different. Some can do it; some cannot. The same goes for the other specialties.
A catch-all solution across the area does not seem to be necessary. The gynaecologist who has spoken to me says that the answer is better management by clinicians and managers of the existing NHS services and that, if the money that will go to CATS could go to them, they are sure that they could improve the services to get down towards the waiting time targets. There are many concerns about the CATS.
Let me say a few words about the private finance initiative. I want to take the Minister back to our first inquiry in 2001-02, when we were both new to the House of Commons and to the Health Committee. We did not agree on the main issue, but he agreed with many of the recommendations, and I want to ask him what has happened to some of those with the recent approvals for PFI hospitals. In particular, we asked for more transparency, stating that
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