Mr. Kevin Barron (Rother Valley) (Lab): This is my first debate in this or any other place where you have been in the Chair, Dr. McCrea. It is very nice to see you, particularly given the good news that has come out of the Province of late.
I shall provide some background to the debate. Members know that the dates on the report and the Governments response are somewhat dated: we published the report on 25 July 2006, and the response came in October. We made one or two observations, and we wanted to consider the subject, because back then, there was a general debate about independent sector treatment centres.
One issue that we seized on quickly was the separation of elective from emergency procedures. We found out that clinicians had advocated separation since the 1990s. In 2002, the Government announced the creation of a series of NHS treatment centres to make systematic the approach to elective treatment, and later that year, the Department of Health decided to commission a number of independent treatment centres to handle NHS patients who required relatively straightforward or diagnostic procedures. I shall describe later what we found out about that issue.
Increasing elective capacity available to the NHS in order to reduce waiting lists and times; Reducing the spot purchase price in the private sector; Increasing patient choice within the NHS; Encouraging best practice and innovation; Stimulating reform within the NHS through competition.
One of the most significant findings was an alarming absence of evidence, which consisted of two different problems: first, the Government refused on the ground of commercial confidentiality to give the Committee the information that they had collected on ISTCs, so although it was being collected, it was difficult for us to make a judgment about it; and secondly, there was a failure to collect proper data to assess the effectiveness of ISTCs. We found that both supporters and opponents of ISTCs were making claims that were not backed up by evidence.
We concluded that treatment centres are a good idea. Separating elective and emergency procedures reduces the length of stay, helps reduce waiting lists and times and improves hospital organisations. We visited the centre to which my hon. Friend the Member for Dartford (Dr. Stoate) sometimes sends his patients, and it was a real eye-openerfirst, to the situation inside the national health service. The centre is an NHS institution, brand new and effectively part of a brand new private finance initiative hospital. Our visit showed us the precise benefits of separation.
One of our first and prime witnesses was the president of the Royal College of Surgeons, Bernard Ribeiro. In evidence, he explained to us that he could remember going to work as a surgeon expecting a list of seven patients in any one day, and that one day, when he was on his third patient, an accident happened on a local road. Everything was commandeered for the emergency, as we all accept, because an emergency is exactly thatan emergency. However, three or four of his patients did not have their operation that day, because elective and emergency surgery facilities were located together, in the same hospital.
Why separation has not been the pattern throughout the lifetime of the NHS, I do not know. As somebody who thought he knew a bit about the NHS, it strikes me as obvious. Time and again, people have gone into hospital for elective surgery and had it postponed or delayed. Over the years and on a number of occasions, the issue of delays has been raised in the media and in debates in the House, but there have not been any systematic arrangements in the NHS to do what has been done in Dartford and other places.
ISTCs have had a significant effect on spot purchase prices
and increased patient choice, offering more locations and earlier treatment.
If someone had visited my constituency five years ago for a knee or hip operation, they would have been given a long wait for surgery. The Committee did not find that out; it is my own comment on the issue. Some consultants, however, would have offered patients surgery nearby, in an independent hospital in Sheffield, and within a few weeks, providing that the patient was prepared to pay the surgeon a few thousand pounds. That choice is rarely discussed, and it has now gone. It is not offered to my constituents anymore, and I am very pleased about that. They are offered surgery in NHS hospitals and in a neighbouring constituencys ISTC.
We concluded that ISTCs have demonstrated good practice and pioneered some innovative techniques. However, good practice and innovation can also be found in NHS treatment centres and elsewhere, so there is not any convincing evidence that NHS facilities are systematically adopting techniques that ISTCs have introduced. We were told that ISTCs would spread best practice, but we did not see any evidence of it. However, with the non-collection of evidence, we could not make real comparisons between the independent sector and the NHS. It was always going to be difficult.
ISTCs have not made a major direct contribution to increasing capacity
in the NHS. They represent a very small percentage of the overall capacity. I could not understand why ISTCs were not introduced in areas with high waiting lists, particularly when they were created to reduce elective surgery waiting times and lists. We tried to find out the reason behind elective surgery ISTCs. Was it the need to reduce waiting lists and to see patients quicker? Sadly, we could not find out.
The threat of competition from ISTCs may have had an effect on the NHS, but again, we have only anecdotal evidence to support that assertion. The Government have failed to collect the data to allow them to quantify the changes. In my own view, owing to the political sensitivity of rolling out the independent sector in that way, it is amazing that systematic data collection was not undertaken so that direct comparisons could have been made between ISTCs and the NHS.
The Committee also found two significant areas in which the ISTCs were problematic. They proved to be poorly integrated with the NHS, partly because of the policy of additionality, under which they cannot employ staff who have recently worked in the NHS. In a sense, that was to protect the national health service, so that a situation did not arise where clinicians were moving into the independent sector and we were unable to provide the service in the NHS. We therefore understand that point, too, although we did not think that there had been enough integration, even early.
We visited one establishment, which was not an ISTC, but a BUPA-run centre at Redwood in Surrey. We saw NHS staff and BUPA staff working alongside one another, to the general good of patients there, without any of the animosity that everybody predicated would arise if the independent and national health service sectors were mixed. There are clear lessons to be learnt from such examples.
We also heard from some witnesses that standards of care were poor in ISTCs, although those claims were not supported by quantifiable evidence. The Committee concluded that there were substantial failings in data collection; and one could not say that the claims were true, based on what people had said about the failings in standards. One of the national organisations representing surgeons actually told us that there were high levels of complications in ISTCs, because people were having elective surgery, but then having to get back into the NHS pretty quickly because the treatment had not been up to standard. Although that had been said by some eminent people and on websites, we found no evidence for it whatever. However, the ground shifted a little when those witnesses were challenged, because they moved from complications on to the issue of quality.
Dr. Andrew Murrison (Westbury) (Con): The right hon. Gentleman said that there had been insufficient data gathering in and around ISTCs. He also said that there was no evidence that the complication rate in ISTCs was worse than in comparable hospitals, but how does he tie the two together? If the data are not being collected, surely we cannot infer that the complication rate is higher or lower, either among ISTCs or between ISTCs and the mainstream NHS.
Mr. Barron: On the face of it, I would agree with the hon. Gentleman. Some clinicians were clearly drawing those conclusions without the evidence for them, and we were quite critical of that, because the evidence was not there. However, the simple answer to the hon. Gentlemans question is that we asked other organisations, such as the General Medical Council, of which I am a lay member. When the GMC came before us as a witness, we asked whether anything in its fitness to practise proceedings showed that the independent sector was receiving more complaints about its professional attitude than the rest of the national health service. The simple answer was that there was nothing.
We looked where we could to make that judgment, and the simple answer is that, no, we cannot make that allegation. We were trying to make sense of the allegations that were made to us that, again, could only have been anecdotal and which are still around. I have no doubt that, like me, the hon. Gentleman will have received letters this week from the British Orthopaedic Association, which is still looking round, hoping at some stage to prove the allegations to us, although we have still not seen any of the evidence that we asked it for in July 2006. We criticised the association, inasmuch as the allegations that were being made were unsubstantiated. My personal view is that those allegations should be substantiated or withdrawn.
Dr. Howard Stoate (Dartford) (Lab): Just to echo that point, we did seek evidence for the allegations being made that there was a higher complication rate or a lower quality rate, but nobody was able to produce any. My right hon. Friend is quite right: we found no evidence, because none was presented to us, although the anecdotes continued to fly in all directions.
Mr. Barron: And still do. None the less, we tried to get the evidence, although only through adverse results of fitness to practise proceedings by the regulatory bodies for doctors, which would have known, as they cover all doctors on the register, not just those in the NHS.
Mr. Gordon Prentice (Pendle) (Lab): Is it not simply scandalous that we are pressing ahead with the second wave of ISTCs, even though the Healthcare Commission has had to postpone its report, which was due in the spring, until the summer, because it cannot get a handle on the data, which either are not available or are not being collected?
One of the most contentious parts of the ISTC programme was the use of take or pay contracts. They meant that the NHS had to pay independent providers for a set volume of work, whether or not it was carried out. The Government defended those contracts by saying that they were necessary to encourage the private sector to participate in the programme, although they also caused considerable disquiet among NHS providers.
On the day we went down to the constituency of my hon. Friend the Member for Dartford, we visited a day treatment centre. It was early afternoon when we
arrived and the centre was very quiet, running at about 50 per cent. of its capacity. Many reasons were givenmost of them anecdotalfor why that centre and others were not as active as they should be. One reason was that the referral patterns were not as active as they should be, because some people did not want to refer.
I came across anecdotal evidence for that when I visited the ISTC in my area, in north Derbyshire, a couple of miles from my constituency. The guy who was the NHS-ISTC link there told me that the biggest problem was getting health professionals with contracts with the NHS to refer people there. I met two constituents when I was there, completely unplanned, and asked them, How did you know? Word of mouth from people whove been in as patients, they said. So it wasnt your doctor, then? I asked. No, it wasnt, they replied, although they were quite happy with the treatment that they were receiving. That was a big issue for the Committee, although I do not know how big an issue it is today.
We concluded that although the decision to create the ISTC programme had not necessarily been a bad one and had brought several benefits, it had not been supported by evidence and wasto quote the phrase used in the reporta leap in the dark. I have heard that phrase on many occasions in the media since, but I have to tell my hon. Friend the Minister that that was the case. We often smile about the decision makingor the lack of itin the NHS without good evidence, but it was clear that the original decision was driven by other things, not by any evidence at the time.
The Government response, which was published in October 2006, accepted some of the Committees criticisms and said that there would be a series of improvements. One of those, which my hon. Friend the Member for Pendle (Mr. Prentice) has mentioned, was that the Healthcare Commission was asked to carry out a detailed comparison of the standards of care in ISTCs and those in the NHS. However, it is now many months down the road and we are still not there yet. That is disappointing. However, sooner than rush, and jump to conclusions, which people have been doing for a number of yearsalbeit anecdotal, rather than real conclusionsI hope that, when that piece of work comes out, we will be able to go into what has been happening in detail and see what the real comparisons are.
Phase 2 of the ISTC programme would make provision for the training of doctors and other clinical staff a contractual requirement, which, in a sense, was a weakness. We could have had the additionality rule, whereby phase 1s were able to set up, but without poaching people from the NHS. It was right to ensure that phase 1s did not do that, because it would have weakened the NHS.
On the other hand, there was a question whether we could have had surgeons in there, training. The volume of elective surgery done in ISTCs, undisturbed by anything else in the establishmentthere are no A and E departments to disturb the elective surgery listcreates the ideal opportunity to obtain experience. My hon. Friend the Member for Dartford described it as an ideal time for young surgeons to practise on people. I would not have put it quite like that, but training with such a volume of surgery, on lists that are not complicated, would be much more predictable than training in a district general
hospital as an A and E tag-on, which might also disturb the list of the day. I hope that my hon. Friend the Minister will talk about phases 2s and whether that training is now taking place.
New ISTCs would also be better integrated with the local NHS, by requiring integration to be part of the planning process and allowing NHS staff to work in ISTCs during their non-contracted hours. Again, we felt that that would be a step towards breaking down the barrier that had been set up by the additionality rule, under which a person could not work in the NHS and also cross over to work in an ISTC. Does my hon. Friend the Minister have any experience of that to share with us?
The Government committed to spending £550 million a year on the ISTC programme. We were uncomfortable with that pledge because without doing the real work, one could not say whether that was driven by clinical need. As we said in the report:
The decision to maintain the commitment to spend £550 million per year despite changing circumstances has not been explained, and seems to sit uncomfortably with the Secretary of States admission that in other [areas] it has become clear that the level of capacity required by the local NHS does not justify new ISTC schemes.
At the time of the inquiry, for the first time that I had known, all the national health service institutions in my own area of south Yorkshire were united in their opposition to phase 2 in the area, so it did not go ahead. However, the Secretary of State told us that the money would still be spent. It was extraordinary for the Government to say that, although they would not be going ahead with certain parts of phase 2, they would still spend the same amount of money that they were going to spend anyway. I do not know whether that has changed in the many months that separate us from the evidence that we took at that time.
I am looking forward to hearing my hon. Friend the Minister explain the Governments current plans and whether the commitment to £550 million still stands even though a substantial number of phase 2s have not taken place. Obviously, the collection of data must also be significantly improved. I hope that the Healthcare Commissions report will show how well things are going, although I am not sure when we will get it. My hon. Friend the Member for Pendle said that we would get it in
The Department should have ensured that such data
were collected from both providers
and published in order accurately to assess quality of care, complication rates and other quality measures.