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10 May 2007 : Column 144WH—continued


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ISTCs may be making and may continue to make a valuable and considerable contribution to efficiency, innovation and choice in the health economy. However, the case cannot be made by default; we look to the Government to make their case actively, improve the programme, collect the appropriate data and allow genuine quality to be assessed and therefore genuine choices to be made. We do not want what we still have now: anecdotal evidence on the rights and wrongs of independent sector treatment centres going between us as legislators and some in the medical profession.

I shall finish now. I hope that not only Health Committee members, but other Members with other experiences of ISTCs, will have the opportunity to make their contributions.

Dr. Murrison: On a point of order, Dr. McCrea. I am wondering whether the self-styled party of effective opposition—the Liberal Democrat party—has given any indication of why it has not sent a Front-Bench spokesman to this extremely important debate.

Dr. William McCrea (in the Chair): That is not a point of order. It is up to hon. Members whether they desire to attend the debate.

2.54 pm

Mr. David Amess (Southend, West) (Con): I congratulate my colleagues on producing yet another splendid report. However, I do not congratulate the Government on their response, which was late and less than robust in dealing with the 25 recommendations. The Minister was a splendid member of the Health Committee. He made a unique contribution to our report on obesity, so he knows only too well how important our work is and how worth while it is for the Government to read our report carefully and respond to it positively.

To follow on from the Committee Chairman, the right hon. Member for Rother Valley (Mr. Barron), I should say that we heard some robust evidence. However, I can certainly recall one or two occasions when the evidence was less than robust and extremely disappointing. I completely absolve from that Mr. Bernard Ribeiro, the president of the Royal College of Surgeons, to whom the Committee Chairman has referred. When I was Member of Parliament for Basildon, Mr. Ribeiro led the local teaching faculty. His evidence was impressive.

I shall not name the disappointing performers, but I say gently to the Minister that when people give evidence to the Health Committee, they should take that seriously and be properly prepared. To shrug their shoulders as if it is not their responsibility, when it jolly well is, is very disappointing.

As we all know, the ISTCs were opened in 2003 under an agreement between the NHS and the private sector to carry out specific procedures to help with the NHS waiting list and mitigate the lack of capacity. I shall not make an intellectual contribution; I shall leave that to others. However, this occasion is useful because it gives the House an opportunity to have an intellectual debate about how the private and public sectors work together in practice. My hon. Friend the
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Member for Westbury (Dr. Murrison) has mentioned the absence of the third party, but the two main parties have a real interest in considering the twists and turns of the issue. I should not forget the hon. Member for Wyre Forest (Dr. Taylor), an independent Member of Parliament.

When measuring the success of the ISTCs, it is important that we remember the objectives of involving the private sector in the health service, about which the Government now seem enthusiastic. One objective is to increase the elective capacity available to the NHS to reduce waiting lists and times. The Opposition have a real interest in how that happens in practice. Other objectives include reducing spot purchase prices in the private sector, increasing patient choice within the NHS—how that works out in practice has yet to be proved—and encouraging best practice and innovation.

However, it is also important that we focus on the impact that ISTCs will have on local hospitals and the NHS in general. One or two of the Members in the Chamber who are not on the Health Committee will hope to catch your eye and reflect on how the issues work out in practice, Dr. McCrea. I have recently received representations from the hospital in my constituency about the commissioning of an ISTC in Essex; the contracts are expected to be finalised at any time. I say to the Minister that I genuinely welcome the involvement of the private sector in the health service, and I was encouraged by our Committee’s finding that the ISTCs have gone some way to meeting their objectives.

However, although I agree with the principle of involving to some measure the private sector in the health service, I object to the centrist slant put on the implementation by the Government. I intend to list the concerns that have been raised about ISTCs and the fact that the Government’s response to the Health Committee document does not adequately address the matters at stake.

I say again that there is no point in the Health Committee spending great time producing reports if the Government seem not to take the findings too seriously or are less than robust in their response. I am delighted that we have been given the opportunity to have a debate, and I welcome that. However, I hope that the debate will be ongoing and that the Government will take our recommendations a little more seriously.

First, let me deal with waiting lists and times. Since the introduction of ISTCs, waiting lists have dropped. There is no doubt about that, so I congratulate the Government. However, it is disappointing that we are unsure about how far waiting lists have dropped. It is extraordinary, too. The NHS has changed in response to the ISTCs, or because of additional NHS funding, and the intense focus on waiting list targets over that period has had an adverse effect on clinical priorities.

The Health Committee was surprised that no attempt was made to assess the effect that competition from ISTCs would have on the NHS. It is extraordinary that no such attempt was made. The absence of conclusive information has prevented the Health Committee from making observations in a number of areas. Did that merely happen, or have our objectives been obstructed in some way? I do not know, but that is certainly one of the main criticisms that I want to level at the Department.


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Secondly, let me deal with the aim to reduce spot purchase prices. I welcome the Health Committee’s conclusion that ISTCs have successfully reduced the purchase price as intended. We certainly welcome that. I was pleased to learn that as well as reducing the spot purchase prices in the private sector, ISTCs have a more general impact on charges in the private sector. That is excellent. The Health Committee was told by Robin Smith, chief executive of Mendip primary care trust, that fees for some operations had fallen by as much as 50 per cent. as a result of the ISTCs. That is splendid. The Committee also heard that the NHS is no longer as reliant on spot purchasing as it once was, and that is excellent news.

Mr. Gordon Prentice: Before the hon. Gentleman moves off that point, the Government told us in their response to the report that the private sector is paid a premium of 11.2 per cent. more than NHS organisations to carry out exactly the same clinical procedure. When the Committee discussed those matters, did it think that that was fair?

Mr. Amess: The hon. Gentleman has helpfully fired a missile right at the point that I was trying to make. The Minister will have heard the point, and I hope that he will address it when he responds. The hon. Gentleman should be reassured that during our inquiry those points were made in public, and it is right that the Minister should deal with the fairness of the “competition element”.

Assessing the extent to which ISTCs have facilitated patient choice, a central objective of the programme, is not straightforward. ISTCs enable some patients to received treatment earlier than they might through the NHS, and they are also given a choice of location at which to be treated. The Committee reported:

However, those choices are limited. For example, if the existence of ISTCs in the long run leads to the closure of NHS facilities, as we heard, patients will once again have limited choice.

More worrying is that patients cannot make informed choices on where they receive treatment. We were given evidence to that effect in one sitting. There is a gulf in the information that relates to the clinical quality of treatments in ISTCs. The lack of centrally held information, such as that on complication rates and other measures of clinical quality, seems to have prevented patients and the Health Committee from drawing conclusions about the standard of care offered by ISTCs. We pressed the witnesses on that point, and we got nowhere.

I was pleased to learn that the Department of Health recognises the need for information on clinical quality to be available to patients, and that it is looking at ways in which it can meet that challenge. I look forward to seeing how far the Department manages to meet its objective to publish

when that document is published. I am also keen to learn of the progress of the information taskforce, which was set up with the aim of developing and overseeing a work programme to identify indicators of
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clinical outcome relevant to patient choice. I am not looking for a conspiracy, but that is all likely to happen when we adjourn for the summer recess and we will not be able to hold the Executive to account until the autumn. However, I want to flag up to the Minister that we are aware of those dates, which are important in the context of the report.

Central to the aims of the programme is that ISTCs encourage best practice and innovation. The Health Committee found that:

although it also reflected:

Furthermore, it reported:

We received no evidence at all about that.

I appreciate the Government’s response that ISTCs are in their early stages and cannot be expected to be more efficient than NHS treatment centres. The Committee accepts that. I agree with the Department of Health that ISTCs offer an excellent opportunity to draw together best practice from a wide variety of sources, in particular when the NHS and ISTCs are more integrated.

On the subject of best practice, I was particularly alarmed by the questions that were raised about the quality of staff employed in ISTCs. It has been argued that ISTCs are too reliant on overseas staff, and we heard evidence about that. As a result of the European legislation, the regulation of foreign-trained European economic area clinicians, who make up the majority of doctors in ISTCs, is not as rigorous as it should be. The evidence showed the problems that patients encounter with foreign doctors, which include language barriers since language tests cannot be imposed on doctors from the EEA. It is fundamental, in a situation that can be frightening and stressful for many, that patients can communicate effectively with the staff who will care for them.

The Health Committee recommended that ISTC clinical appointments for overseas doctors should incorporate a standardised, independent assessment system based on competency. What thought has the Minister given to that critical recommendation? It does not seem to have been properly addressed in the Government’s response.

Finally, I want to mention my local hospital in Southend. One of the most important aspects of the ISTC programme is its impact on the NHS. Again, it is most frustrating that no attempt has been made systematically to assess and quantify the possible effects. John Gilham, chief executive of Southend university hospital—he is an old boy of the school that I attended, St. Bonaventure’s grammar school, and so the House will understand that I hold him in high esteem—has brought some concerns to my attention about value for money. Mr. Gilham is concerned that, as the ISTCs increase their overall capacity in Essex, possibly above initial assumptions, and if other trusts actively compete along with Southend hospital for
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service choice, there is a greater probability that ISTC capacity will be underutilised. He has pointed out that underutilisation of capacity in the ISTCs will be underwritten—I think that that may have been the concern of the hon. Member for Pendle (Mr. Prentice). That would result in underwritten payments being made to the ISTC for no activity, with a financial cost throughout the country.

On the other hand, if the ISTC was successful in attracting activity, Southend and other acute trusts in Essex would need to reduce capacity further, with a consequent loss of income. That would increase the proportionate costs of existing overheads, which does not seem particularly fair. In some cases, hospitals will be limited in their ability to reduce overheads, which would in turn limit the opportunities for investment in improving core local health care facilities.

Southend university hospital does a splendid job, and it too is concerned about which specialities the ISTC would take responsibility for. The hospital could be required to provide more by way of emergency services than by way of a balanced mix of elective and emergency services, and that could have adverse affects on hospital funding. Local residents would be concerned about that.

I understand that, in worst-case scenarios, local hospitals could even be forced to close. In February, Southend university hospital estimated that the financial impact of an Essex ISTC would be something in the region of £7 million, which is a huge figure. The ISTC programme has repercussions for a number of local hospitals, and I have outlined pressing financial concerns regarding the costs of the programme for local hospitals and for the nation as a whole.

Lack of information has marred the success of the ISTC programme, particularly with regard to patient choice. I was disappointed that the Department of Health seems to have hindered the Health Committee's inquiries by misrepresenting situations, withholding information and producing confusing figures. The Health Committee is non-partisan, but it is perhaps slightly easier for me to be robust on that point. I am particularly concerned that the Department is withholding information regarding the significant effects that ISTCs could have on the finances of NHS hospitals. Why is the Department concealing such information, when hospital closures could result?

Although I am confident that there is a bright future for private sector involvement in health care, I am currently frustrated that we cannot see the tangible benefits of the programme.

Mr. Prentice: Was the hon. Gentleman frustrated by the Committee’s inability to look at the terms of the contract between the Department and the independent sector providers?

Mr. Amess: The hon. Member for Pendle has flushed out that point. Yes, the Committee was concerned about it. Such voids in information make us unsure about exactly how beneficial ISTCs are to the health services—whether standards are being maintained and whether ISTCs are really contributing to cutting waiting lists and increasing patient choice. I look
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forward to the Healthcare Commission’s imminent report on the quality of care provided by ISTCs and to learning of the progress of the information taskforce. Above all, I look forward to the Minister’s response to the report.

3.14 pm

Hugh Bayley (City of York) (Lab): I rise not as a Committee member but as the representative of a constituency that has an independent sector treatment centre. The centre is run by Capio UK, which is a Swedish company. Let me say from the outset that I am not unsympathetic to the concept of using independent centres to treat NHS patients; it is hardly an innovation—the NHS has commissioned waiting-list initiative cases from private providers for many years. There has perhaps been a policy move, however, in that the centres have institutionalised the practice of NHS patients being treated in private units at NHS expense by providing dedicated units for that purpose.

I spoke to Capio before the centre opened, when the concept was still at the design stage, and I visited the centre in the week of opening on 3 February 2006. It has 24 beds, six of which are in individual rooms, with nine in double rooms. It provides a mix of elective treatments in orthopaedic and general surgery, and has five consultation and examination rooms for out-patients, together with an in-house laboratory, and X-ray and ultrasound facilities. All of the patients come under the care of consultants from the York Hospitals NHS Foundation Trust, which provides reassurance about standards and helps to ensure satisfactory integration between the services provided at the centre and those provided through the trust. However, that drives a coach and horses through the concept of contestability. If the purpose of setting up independently owned, run and managed treatment centres to operate in competition with NHS trusts is to determine whether a different pattern of management or different ways of working can produce either better quality of care or more cost-effective care, that is unlikely to occur if the same doctors provide the same range of treatments in both places.

Dr. Stoate: Does not it also drive a coach and horses through the idea of additionality? If the same consultants work in the independent sector and in the NHS trust, does not that undermine the very principle that the Government had in mind in the first place—that independent sector treatment centres should use staff who are additional to the NHS staff, rather than staff who are already in the NHS with the result that centres could be accused of having poached them from services that might have been provided to the NHS?

Hugh Bayley: My hon. Friend makes a valid point, and I hope that the Minister will respond both to that and to the points that I have made. The most generous thing that can be said is that the Government have put their toes in the water and have tested different policy responses to determine whether they improve standards of care or throughput or cost-effectiveness. The York experiment is one such experiment and it would be interesting to know the results of it with respect to the quality of care and treatment costs. I shall address that further in a moment, but on the face
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of it one would expect not to get the contestability that seemed to be the ideological underpinning of the initiative.

I sought an update from Capio this week. So far, it tells me that the centre in York has carried out 3,306 out-patient consultations for NHS patients and has admitted 2,047 NHS patients for elective surgery—largely hip and knee replacements, hand and foot surgery, and knee arthroscopy. It gave a figure, in an e-mail that it sent me this week, of


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