Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 600 - 619)

THURSDAY 22 NOVEMBER 2001

KAREN WARD, PROFESSOR JOHN LILLEYMAN, MR ROGER SPILLER, DR RAY PRUDO-CHLEBOSZ AND GAIL WANNELL

  600. You do not really have a preference. You will offer either/or.
  (Dr Prudo-Chlebosz) Yes.

  601. What do you think about what you have just heard, Mr Spiller?
  (Mr Spiller) It is inappropriate if they are individual contracts for both to be on offer because this will create huge problems. If we were looking at this in a year's time, we would have a different attitude to it, and so would the private sector. I come back to agenda for change. Huge changes are taking place both in pay levels and in the way in which pay is determined. Some of the advantages which are perceived at the moment in the private sector will disappear because we believe the NHS arrangements which will come through agenda for change will be so much better than they are at the moment. We have been working for this very result for many years and we are pleased to see it on its way. One other thing I really need to say is that terms and conditions of employment are not necessarily the major issue that even we are concerned with. One way or another we know that the employer will have to pay sufficient to recruit and retain. That is a given. What we are more concerned with is the long-term viability of this process, particularly if the employer changes, as could happen for example with Ealing; having gone from the NHS to TDL, it could now go to Quest and that is a big concern. We are having this continual change of employer and although TUPE is there, it can create enormous difficulties when you are taking people in from different areas, some coming from the NHS, some coming from another private provider. We had this experience in the private sector with contracting where it creates huge anomalies, where people can stay on their previous terms and conditions of appointment and be working alongside somebody on different terms of employment. You can have three separate terms and conditions of employment. A computer company we deal with has 42 different sets of terms and conditions of employment as a result of TUPE which it has to operate within the same company; an almost impossible task. Our preference is that there should be retention within the NHS. We believe there is an important case to be made for introducing additional management into the NHS, there is a shortage of good management at the moment. The private sector may well be able to provide this and they may well be able to provide other elements and new ideas which are perhaps not in the NHS at the moment. We believe there are ways of doing this without changing the status or position of staff.

Andy Burnham

  602. Would you therefore see a viable model for the pathology service being the facilities, laboratories, capital equipment provided through the PFI route, staff employed by the NHS? Would that enable you to get the money into the modernisation of the bricks and mortar? Would that be your preferred model?
  (Mr Spiller) We take a pragmatic view on whether the private sector should be involved in those circumstances. If it delivers a better service to the patient at a better price, then we have no objection to that happening. The proposal you have put forward, the model you have put forward, is one we could certainly live with and where we could see some advantages.

  603. Does Ms Wannell's evidence not suggest that when the staff are also employed by the private sector, the quality is improved as well? Thinking about the service to patients and not just about the conditions of the staff, is there not some evidence that that has introduced quality gains?
  (Mr Spiller) No. No, the evidence on improved quality gains comes largely from the investment which is going in. Pathology has been starved of investment over the years and what we see now is the private sector coming along and putting investment in and that is why there is a big improvement in quality. It is not down necessarily to the way in which people work or their capabilities. One has to say as far as the private sector is concerned that where it previously existed, it has existed either because the private health sector was using it or the pharmaceutical companies and they had to have high standards.

  604. Has the introduction of a contract focused attention on performance in a way that there was no direct lever on performance under the old system? Would you accept that?
  (Mr Spiller) No, I do not think so. One of the areas of difficulty we find in contracts is that the transaction costs can be quite significant on occasions. One of the costs we are finding with private sector, or fears of our members have been expressed in this way, is double testing. Where a test comes out as not truly abnormal, but on the other hand not quite right as well, in a NHS laboratory this will always be investigated further at the initiative of the scientist who is dealing with it. The worry we have is that where there is a contractual arrangement which is trying to drive down the number of tests done, albeit that is what is required clinically, these opportunities are not there. They are much more cost conscious. That may be a good thing and it may be that one should get authority for those additional tasks but that happens at the moment and one can give a GP an answer which he was not expecting because you have done something extra which he did not ask for.

  605. West Middlesex seem to suggest they have solved this by having it clinician-led. Would you not accept that that always works?
  (Mr Spiller) It is always clinician-led in that sense. What we are trying to do is break away from it having to be clinician-led.

  606. What they are suggesting is that no-one would stop doing something because of a cost pressure. If it deserved further investigation they would do that.
  (Mr Spiller) No, no. I do not think that is necessarily true.

Jim Dowd

  607. I should like to come back to an expression you used a few moments ago about a shortage of management in the Health Service. Did you mean there are just too few managers or high vacancy levels or there is not enough management skill within the NHS? What did you actually mean by that?
  (Mr Spiller) That was a mistake of my own making because we represent managers as well in many areas. There are several features. The first is that the management structure in the NHS leaves a lot to be desired; we and indeed the DoH have found the independence of trusts has been a major problem. Secondly, the management style has been governed for the best part of 20 years by managers trying very hard to drive costs down and sometimes reduce resources and it takes time to change that management style around. Thirdly, there is simply a shortage in numbers of management and fourthly, there is something left to be desired among a lot of NHS managers as to levels of competence. In all respects I can see that there will be areas of the private sector which could help with that, certainly in terms of it lifting the number of good managers within the NHS. There is no question that we are short of good managers in the NHS and that is not in itself denigrating existing managers, it is simply that we are asking too much at the moment of managers to deal with the move to PCTs, where there is hardly any HR component.

  608. I am still not clear whether you are emphasising better managers or more managers.
  (Mr Spiller) More managers.

  609. More and better managers.
  (Mr Spiller) More managers; one would hope obviously that they would be better.

Dr Naysmith

  610. Earlier you were suggesting that in terms of improving the career prospects of your members, particularly technical staff in the service, there was an indication that things were getting a little bit blurred between the clinical pathologists and staff in that your members were beginning to take more decisions than perhaps they used to. I think that is an excellent idea and it reflects things which are happening elsewhere in the National Health Service: radiology and radiographers for instance are becoming a bit blurred and some of the things doctors used to do which nurses are now being entitled to do by legislation. I just want to know whether you think that is going to happen more. Then I am going to ask Professor Lilleyman what he thinks about that. It is a very interesting area. Do you think it is likely to carry on expanding, particularly in the light of what else we have been hearing this morning about separating off technicians in the service from the actual hospitals and a central organisation which might be a long way away from where the clinical decisions are made?
  (Mr Spiller) It is a trend which is developing for very positive reasons, partly driven by the shortage of consultants and looking at ways of trying to enable the decisions to be made which consultants would otherwise be doing. An example of this is that one of the sections of our union, the medical practitioners' union, has recently proposed that the new surgical diagnostic units which are being proposed should be run by nurses and operated by nurses rather than doctors, that many of the features of those could be done by well-trained nurses rather than necessarily using doctors to do that. Some very fundamental changes are being proposed. Intermediate level of professions is something which is seen as being much more desirable now, much more possible, It happens in many other places in the world. We have very clear professional lines of accountability in the Health Service in Britain. That is going to become blurred as there is going to be much more work across professions and across departments.

  611. You certainly see this as a positive move for the people you represent.
  (Mr Spiller) Most definitely. Even though some of our members' work will be given to people who might be seen as being lower skilled than they are, we see this as a positive move both to reduce the shortages which exist, but also to be more positive, to give people a higher level of skills and better commitment to the work they are doing.

  612. Professor Lilleyman, far be it for me to suggest that your College is equivalent to a trade union, but what do your members feel about this kind of thing?
  (Professor Lilleyman) May I first of all point out that 20 per cent of our members are not doctors and we are unique as a medical Royal College in that regard. It is something we are actually rather proud of and that constituency is increasing. That in itself is a testament to the fact that we have no difficulty whatsoever embracing the skills of our scientific colleagues. I should point out something which has not actually arisen this morning so far and that is that there are three professional tribes in NHS pathology, not just two as we have been talking about. We have the medical practitioners, we have clinical scientists, who are separately regulated under the Council for the Professions Supplementary to Medicine and we have the MLSOs. The fuzziness, the blurring of the boundaries is not just going to occur between the scientists and doctors, it is also going to occur between two different types of scientists. Witness to this fact of course is that those two tribes are already merged into one in the independent sector. They do not exist as two separate tribes outside the NHS. I and most of the members and fellows of the College would have no difficulty at all embracing flexible working in all its aspects in the delivery of pathology services. We see this as not only essential due to workforce problems but highly desirable from a professional point of view.

  613. Are you encouraging it?
  (Professor Lilleyman) Yes.

  614. Karen Ward, how do you see this when what you want really in the setup you are proposing is to have a much more factory scale thing where you get through more and more tests in as short as possible time, in some cases away from the clinical setting? How do you see this fitting in with your plans?
  (Ms Ward) Everyone has this fear of the factory laboratory and most people seem to focus on that as the big issue for them.

  615. Reassure us.
  (Ms Ward) Our approach is that the configuration of a laboratory, where it is, how big it is, what tests are done there, is really the last decision which is made. We always start from the premise that you design a service based on the needs of the users of that service. If the clinicians of an acute trust have a particular profile, they have oncology clinics, they may have rheumatology clinics, then the service is designed to support that clinical activity. Once you have done that with all of the users of the service, designing the laboratory to support that activity is a relatively easy step. It is not a decision we as a company would make on our own. We feel one of the problems with the current procurement process, for example, is that it keeps people apart for too long a time. You really need to involve the professional groups at a much earlier stage. They are the ones who are going to have a big impact on how services can best be delivered. What we see as a partnership is bringing together the strengths of the two parties. It is not a question of a company like ourselves coming in and saying this is how it is going to be folks, like it or lump it. It is a question of working in partnership as we do with the consultants at the West Middlesex and the staff of the West Middlesex and many of our staff are key people in determining changes to service provision. As far as we are concerned, they all have a contribution to make. There is no one particular organisation which holds sway over any other, it is a true partnership. Gail Wannell was talking earlier about looking at how services are best used. It is not in our interest for the use of the service to go through the roof, because if the trust cannot afford to pay for that, then that is not in their interest or in our interest. What we are aiming for is appropriate use of the service, use of the service based on best practice, based on testing protocols so that there are clear paths through to audit, so you can see that what you are doing in a laboratory is providing benefit to the doctors and to the patients who are using it. Roger's comments earlier on about the staff being concerned about not being able to do additional work on samples is certainly something our staff would find a complete anathema.

  616. What would they do if they came across such a situation?
  (Ms Ward) Exactly what they did before the partnership developed.

  617. Which is?
  (Ms Ward) If a specimen needs further tests then that would be done. It is based on clinical need and they are as responsible people as you would find anywhere. They are very highly trained, very highly skilled and in their view, they are looking after the patient just as much as anyone else is. We would expect them to do that. Our response would be that if someone did not perform an additional test because they were concerned about being allowed to do it under the contract, that would be the wrong approach as far as we were concerned.

Andy Burnham

  618. Do you lose money as a company when they do that further testing?
  (Ms Ward) I am not sure I can answer that question because the service is designed to produce outcomes. What we are looking at here is delivering a service, we are not delivering a certain number of washers. What we are trying to do is provide effective management of a particular patient to the trust. If we were to say, for example, that we do not do that test and we have to wait for it to be requested by the doctor, that patient would stay in hospital longer. What we are saying is that no, we are there to provide a service, we are there to provide effective services to the trust. Anything that helps the trust treat that patient better and the doctors treat that patient better is a good thing for both of us.

Dr Naysmith

  619. I want to give Dr Prudo a chance to say what he thinks about this.
  (Dr Prudo-Chlebosz) In addition to what has been said, modern technology is driving much of this. When we went to Ealing, most of the pathology reports were signed off by a consultant pathologist. We introduced rules-based reporting which is that the consultant sets up a set of rules and these are incorporated in a software programme and you only sign off exceptions.


 
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