Examination of Witnesses (Questions 260-279)|
Ms Jo Webber, Ms Susan Williams and Mr Tim Curry
4 DECEMBER 2008
Q260 Lord Lea of Crondall: Obviously
one of the emotive questions to do with the private versus public
is queue jumping. How do you get information across that you have
spare capacity, that you can take a patient at that point in time?
Or do you take the patient who is at the top of the queue? How
does all that work?
Mr Curry: Slowly. It is genuinely difficult.
There is an issue of capacity within the NHS. Many Trusts are
operating at high levels of capacity that the private sector simply
would not operate at because they operate in that kind of market
where they need to have flexibility to meet consumer need. The
NHS is already working at 90% to 95% capacity in many cases. How
do you achieve it?
Lord Lea of Crondall: In this cross-border
Chairman: I think we had better move
back into Europe. I think you are asking the $50,000 question.
Q261 Lord Lea of Crondall: No, I mentioned
it in the European context.
Mr Curry: If you look at the different
healthcare systems, some which are very much driven by an insurance
system where that kind of information is routinely gathered and
used, that might be very simple for some countries to do because
they do that anyway as part of their system for delivering care.
In this country, I would suggest, it would be slightly harder,
but it is something that I do believe is getting better because
of the way that information is now flowing throughout the system.
Chairman: Perhaps we could move on, because
we are running very short of time, to Lord Wade and the co-operation
between Member States.
Q262 Lord Wade of Chorlton: I want to
ask you a series of questions on co-operation. Could you explain
to us your personal experience of existing methods of co-operation?
What is your view on the draft Directive's provision for co-operation
between Member States, including European reference networks?
What do you consider to be the potential advantages and/or drawbacks
of such provisions, and what other measures, if any, do you think
should be introduced?
Ms Webber: From a Confederation point
of view, we have a great interest in the EU reference network
system, particularly issues around e-health and new technologies.
Our experience shows that the progress is best when it is done
through specific project-based work. There is a lot of co-operation
between Member States in some of these areas. This may or may
not be funded through EU programmes, but obviously the EU funding
streams do help some of these cross-border projects. I have to
say we are not convinced of the benefits of their provisions in
the draft Directive. I think one of the issues is the risk that
the work gets bogged down in bureaucracy and undermines some of
the existing work and puts back future development rather than
enhances it. But I think there are some elements, such as prescription
charges, where the recognition of these could be of benefit, particularly
if you look at Northern Ireland and the border with the Republic
of Ireland as well. We just feel at the moment that the project-based
approach to co-operation probably gets us further than some of
the provisions laid out in the draft Directive.
Ms Williams: I would like to make some
broader comments and then Tim is going to comment particularly
on e-health, which is one of the areas. In terms of co-operation,
I have mentioned that we have been collaborating with our sister
organisations for many years and our experience of collaboration
across Europe is that it can be very beneficial. In fact that
collaboration began with all the work that was done around the
EU Nursing Directives and mutual recognition of qualifications.
We are generally in favour of organisations across Europe coming
together, therefore, not necessarily to take a uniform approach
but because they can learn a lot from each other. One of the issues
linked to the question before around information, and particularly
information around quality and outcomes, is that there needs to
be an awful lot more work done in terms of collaboration across
countries on quality and quality indicators. That is at a very,
very early stage, and there are very, very many different systems.
Again, we would not necessarily be promoting them as one-size-fits-all,
but we need to accept that there is a lot more work that can be
done, and, rather than that being dictated in a Directive, that
is something where organisations should be encouraged to collaborate.
I will hand over to Tim because we think the e-health issues are
Mr Curry: I will try to be brief on this
because e-health covers a range of issues, telemedicine, telecare,
electronic prescriptions, electronic patient records, and that
in itself is worthy of a few days' discussion. Across a European
level again, we come back to the point about interoperability,
that co-operation between the industry, between providers, between
Member States and commissioners, will need to be really improved.
Although there is already some, it needs to be improved. Making
systems talk to each other, even within NHS England, has proven
to be a challenge, if I might be so polite, and there will be
even more significant challenges going across borders if you add
to that language barriers, differential diagnoses, and different
terminologies. The Royal College of Nursing released a leaflet,
a very short affair, a few months back, called Make IT Safe,
and there are four broad principles that we think all systems
should adhere to. The first is that the systems should have within
them standardised terminology. There are international standards
for health, things like SNOMED CT and so on. The platform and
the product itself should be acceptable to clinicians and to the
public. It should be useful, not an added burden. The technology
needs to be fit for purpose. It needs to be robust and not breakdown
and be able to be portable and taken around. Of course it needs
to be evidence-based. We need to develop systems which are based
on the best evidence we have. In terms of co-operation across
borders, it is absolutely essential that we learn from the best
and offer that across borders, to encourage the development of
good systems which can talk to each other because, at the end
of the day, e-health is about improving patient safety and the
quality of patient care.
Chairman: We would value you sending us a few of
those leaflets, if you are able to.
Q263 Lord Wade of Chorlton: I wonder
if you have considered the longer-term implications of this Directive.
What do you see happening? Quite clearly you are indicating certain
co-operative activities which will probably improve and probably
some which will be a bit more difficult to bring about. Do you
envisage that ultimately we will find the health services throughout
Europe becoming much more the same? At what level might that be
likely to happen? Clearly there will be an impact of all this
which is going to change the whole picture of what takes place
in health care in Europe. Would you agree with that?
Mr Curry: I would very briefly say that
I doubt if the systems will ever truly become the same but I think
we should agree that there are things which should become the
same, the notions of safety and quality, or at least there should
be benchmarksso that we can all say that this represents
quality, this is safe, this is good, this is bad. Those are the
things which I think it would be good to aspire to.
Ms Williams: I think we should also accept
that whether this Directive exists or not, there is much more
collaboration taking place. There is a lot more collaborative
research being undertaken, not to make everyone the same but to
learn from experiences in other countries. That is a reality,
whether this Directive is introduced or not.
Q264 Chairman: They are taking the best.
Ms Williams: Yes.
Chairman: We need to move on to this
vexed question of prior authorisation and Lady Neuberger is going
to probe that in a little more detail.
Q265 Baroness Neuberger: I need to declare
an interest as well, because I am a non-Executive Director of
the Voluntary Health Insurance system in Ireland, which is a semi-state
insurer, and obviously people come the other way, from Ireland
to here, which is part of this issue. You have already said something
about prior authorisation, and I suppose I would like both organisations
to say what their basic view is about that, but I particularly
want to pick up on the NHS Confederation's view that a recommendation
should be made that all patients seeking care abroad should be
subject to a prior authorisation procedure. I think that is quite
interesting, particularly if it is not people who are going to
be paid for by the NHS. Perhaps you could have a general canter
around it and then I will pick up little bits.
Ms Webber: As you quite rightly have
said, we strongly support prior authorisation, not because this
is a way of rationing the care but because this does enable people
to make informed choices and it does enable people also to go
into some of the quality and safety issues that have also been
raised by my colleagues at the table with me. We also feel that
it enables people's expectations to be realistic about what they
are going to receive or not receive, and it also enables people
to understand the long-term implications, particularly issues
like complications arising or where treatment is
Q266 Baroness Neuberger: Aftercare?
Ms Webber: Aftercare as well.
Q267 Baroness Neuberger: Could I pick
you up about realistic expectations. Do you really think there
is any difference between the realistic expectations of care abroad
rather than care here?
Ms Webber: I think it has the potential
to be different, because people do look at those other systems
based on public information about things and think that things
are going to be better elsewhere. For instance, they think that
somehow MRSA is entirely an English problem and the quality is
going to be better elsewhere. I think there are some expectations
that do need to be met. We find the distinction between hospital
and non-hospital care quite false. We believe that if you are
going to have prior authorisation and an enabling of choice then
that needs to be for care whether it is delivered in hospital
or out of hospital.
Q268 Baroness Neuberger: It simply does
not make sense, because there is such variation across Europe
as to what is done where.
Ms Webber: Absolutely.
Q269 Baroness Neuberger: Presumably you
would say that not only is it a false distinction, but it does
not tell you anything about how the systems operate in different
Ms Webber: The issue is that you can
have some quite complex treatments delivered out of hospital and
quite safely out of hospital.
Q270 Baroness Neuberger: In polyclinics.
Ms Webber: Prior authorisation just being
part of hospital care does not seem a sensible way for us. We
do believe also that Member States need to decide for themselves
really the circumstances for those systems. We do not think that
the idea of prior authorisation just being there in exceptional
cases meets the needs of individual patients or the systems. We
also would say that the rules need to be set out nationally, so
that people understand and have some transparency of the process
which they are going to go through if they choose to have their
care in another EU country.
Q271 Baroness Neuberger: Who would you
expect to organise the rules of prior authorisation? Would you
expect that to be the Department of Health?
Mr Curry: I think that needs to be done
on a national level.
Ms Williams: Our view is largely similar.
There are potentially constraints around European Court of Justice
rulings, so there is a question about what should happen but there
is also an issue about what can happen and what has already been
ruled in law. There is question of interpreting those European
Court of Justice rulings. The Commission has made an assumption
that those Court of Justice rulings are saying that you are not
required to have prior authorisation for non-hospital care, so
there may be some work that needs to be done on how much leeway
there is on that. That is why we have looked more at incentivising
prior authorisation. That is particularly with hospital care,
but, as we have said, the distinction between what is provided
in a hospital and what is provided in another setting is shifting
all the time. It is not even a static position, as care changes.
We should be looking at encouraging patients to seek prior authorisation
for all the other reasons we have mentioned, which is that there
is then an opportunity for them not to have to pay upfront, they
can discuss issues around continuity of care, et cetera, but it
may not be possible to require prior authorisation in all circumstances.
I can imagine that if somebody is accessing primary care because
they happen to be abroad for two or three months, and there are
small payments for that and they do not see it as practicable
to come back to the UK or back to their country to seek prior
authorisation, from a pragmatic point of view there seems little
point in requiring it for those types of treatments.
Q272 Baroness Neuberger: Perhaps I could
just pick that up, because I think this is where it is going to
be key. You are going to have people living abroad or being abroad
for three months, sayand that is common. They are going
to be treated in a polyclinic, say in Italy, where they are all
over the place, which is not defined at the moment as a hospital.
You would say that pragmatically there is not a lot you can do
about that, and in a sense you probably cannot have prior authorisation.
What would the Confederation's view be on that?
Ms Webber: I think you have to have some
pragmatism about this. There are some things that potentially
you would get, through maybe using your EHIC when you are on holiday,
for which you would not expect to have prior authorisation, but
in the main, as standard procedure, we would suggest prior authorisation.
Q273 Baroness Neuberger: For somebody
who is going from A to B, as opposed to somebody who happens to
Ms Webber: Yes.
Chairman: Lord Lea, you wanted to pursue
this issue about liaison between service providers across the
Lord Lea of Crondall: Yes, I was very
interested in Ms Williams referring to 30 years' experience in
talking to other colleagues in Brussels and so on. I remember
about 35 years ago, as a TUC official, that the RCN asked for
some advice and whether we could show them around Brussels, which
we did. Anyway, I do not know whether both of you would like to
say what the setup in Brussels that you work within is. Secondly,
in that collective body you may have agreements and disagreements.
Can you tell me, are there any different points of emphasis on
this? Finallyif I may trespass slightly, ChairmanI
still do not understand how information is agreed on whether a
bed is availablesay the four months waiting for a kidney
transplant here or something which we have been through in another
context. Are people supposed to have beds available as a priority
if it is from somebody else? How do you discuss that? I am sorry,
that is a slight trespass, but it gives an illustration of what
you might call
Q274 Chairman: Can I ask you to concentrate
first of all on the question about liaison. We may come back at
the end to some of the other issues.
Ms Williams: The Royal College of Nursing
is a member of several European networks but the two key ones
are the one I have mentioned, the European Federation of Nurses
Associations, which brings together professional and trade union
nursing bodies, and also the European Federation of Public Service
Unions, which is a wider collaboration of public sector trade
unions, not only in health but in other areas as well. Within
the discussionsbecause obviously there is a lot of debate
going on in Brussels about this, and both of those organisations
have permanent bases in Brussels with whom we liaise regularlythe
key areas which we have highlighted, which are also areas that
they have highlighted, are those around equity, so there are concerns
about equity between socio-economic groups and the issue about
upfront payments. The other one is around the importance of ensuring
continuity of care and quality and safety frameworks, so not necessarily
the detail of quality and safety but the need to ensure that those
frameworks are in place. We should also say that there are other
proposals coming out of the European Commission around patient
safety and infection control, so there is a wider package of measures.
One of the things that both of those European alliances have highlighted,
which has not been a particular focus for us and which is also
what they would see as the challenge, is the fact that they see
this Directive as largely offering cross-border care more to the
North and West European countries. For those in the South and
Central and Eastern Europe, the costs that they would either be
reimbursed or paid upfront, because healthcare costs are lower
in their countries, would not cover a large amount of the treatment
in North and West Europe. Our European bodies are also flagging
up an inequity at that level. The other one to say about our trade
union colleaguesand again that is an issue of emphasis
because it is a much broader concern that they have overallis
the concern about internal market and competition policy in the
European Union and the way that may impinge on public services
and public service delivery in Member States. They have for a
long time had a separate campaign to have a framework Directive
relating to public services, so I think they would see this Directive
as one element of potentially promoting internal market and free
movement and competition rather than the provision of public services
that are equitable for all.
Q275 Chairman: Lord Lea, I am going to
hold your other question for a momentI know you have asked
it and it is an important questionbecause we are running
short of time. We can always do with more time when we have witnesses
who are giving us good information. I am sorry, Ms Webber, is
there something else you want to say?
Ms Webber: Yes, in terms of our liaison
with other EU bodies, we host the NHS European Office, which is
based in Brussels and funded through the strategic health authorities.
This office is the only one we know of in Brussels that represents
a whole health system. It obviously gives us quite a high level
of access to policymakers and we engage directly with the Commission
and with European Parliament Members but we also work with relevant
representative bodies, including HOPE, the European Hospital and
Healthcare Federation, which has members from 32 organisations,
representing 26 different EU countries and Switzerland, and obviously
liaises between different healthcare systems. We do know that
our views are aligned with HOPE's views in terms of the issues
around prior authorisation and that HOPE has a position paper
which is available on their website outlining their position on
this. We also work with EHMA, the European Health Management Association,
and through NHS Employers with an organisation called HOSPEEM,
the Hospital and Healthcare Employers Association. Again that
enables us to gauge what the views are across other Member States.
Our feeling is that there are some common issues around patient
information and the impact on equity that will be picked up by
Q276 Lord Eames: We have been talking
about cross-borders and what-have-you. Now let us look at the
UK. Devolution has caused as many problems as it has solved. I
should declare an interest on this! It may be obvious.
Ms Williams: In terms of our response
and what we feel is appropriate from a European Directive, the
main issue for us has been that as long as there are transparent
systems in place about what healthcare is available in any one
of the four countries and what would normally be covered for funding,
and as long as those systems are transparent and accountable,
then we would want to ensure that any Directive at EU level does
not take away the rights of the four countries to determine how
they are going to prioritise health and that there will be differences.
Mr Curry: Could I make a very quick illustration
of some of the challenges in devolution around how care is funded
for within the NHS. In England we have a system called Payment
by Results, a system of paying for activity really, and that has
been constructed quite uniquely in NHS England. The other three
countries do not use a system like that, although Northern Ireland
is piloting similar approaches. We are left, therefore, with confusions
about how reference costs are created or how prices are made.
That has been manifest in cross-border care between England and
Wales, between specialist children's services in the Welsh borders,
and between Scotland and England, and between Northern Ireland
and Southern Ireland as well. So, although the case-mix payment
systems are common through many parts of the world, even within
the UK there are substantial differences of interpretation about
what is a cost and what is not a cost, what is a diagnosis and
what is not, who is involved in that process and how transparent
it is, and so on and so forth. Devolution has provided some difficulties
there but they are not insurmountable.
Ms Webber: We would absolutely agree
that in terms of the framework the Directive needs to provide
a framework but it would still be down to the local health systems.
There are issues of difference between the four health systems
within the devolved administrations and England. We would not
want for a European Directive to make that situation more complicated
than it is at the present time. Obviously the more guidance you
have, the more room there is for some of those complications to
Q277 Lord Eames: Whose responsibility
do you think it should be to try to tackle some of these things?
Are they more piecemeal or is there any attempt to wave a stick
at everybody and say, "For goodness' sake solve these problems"?
Ms Webber: Between the European system?
Q278 Lord Eames: Within the UK devolved
Ms Webber: I think with devolved administrations
we are always going to get differences in approach towards things.
The real point is to make sure that where people live at the edge
of one system, in particular, they do not get disadvantaged.
Q279 Lord Eames: This is the point.
Ms Webber: There has already been a lot
of work between the English and the Welsh systems and I think
that is where we should continue.
Chairman: We are through the hour, but
if you are happy to continue, although we will lose one or two
Members because they will have to go to the next session, we would
like to continue for a few minutes.