Examination of Witnesses (Questions 840
THURSDAY 6 DECEMBER 2001
840. I will pass on to colleagues in a moment.
So if you have a consultant who has a lengthy waiting list, and
some have argued in front of this Committee that waiting lists
may in some instances be constructed to create a demand for private
medical consultations, if that consultant cannot see a patient
and the GP says "you can pay to see the consultant privately
and gain access to that consultant", that does not in any
way undermine the treatment according to clinical need principle
that you subscribe to?
(Mr Fieldhouse) If a patient is referred to an NHS
consultant, and I do not accept the point that waiting lists are
manipulated in any way
841. We have certainly had people suggesting
to the Committee that is the case.
(Mr Fieldhouse) I have heard those suggestions. I
have never seen any evidence that bears that out. Certainly we
would not support such manipulation of waiting lists, if there
was any evidence, for one moment.
842. Why would I choose as an NHS patient to
pay to go privately if I did not have to wait on a long waiting
list? If there was not an NHS waiting list would people honestly
choose to pay for private access to a consultant?
(Mr Fieldhouse) It is our belief that if there was
not an NHS waiting list then, yes, some patients would choose.
843. I do not think they would in my part of
(Mr Fieldhouse) I think there is a lot of evidence
that some patients would choose to go into the independent sector.
Whether that be for personal convenience, for business convenience
or for the ancillary comforts that may go with what the independent
sector can provide or, indeed, for choosing and defining the person
who actually renders their treatment, all of those are factors
which make people use their own funds for that purpose.
844. That may be true around the margins but
I think the point that the Chairman was trying to make was about
the failure to separate properly the public and private provision.
If I could just read something which was in an article on integrated
health care in The House magazine, which may not be your
regular reading material. It is an excellent article written by
the Chairman. He said "Would we honestly tolerate teachers
in state schools saying to parents `my class is full and I cannot
teach your child, but if you pay me a fee I will ensure he or
she receives proper tuition'. Would we allow teachers to build
up class sizes and spend less time with their class in order to
give private tuition to fee payers? We do not allow it in education,
why should we allow it in the Health Service?"
(Mr Fieldhouse) Effectively, and I cannot comment
on the teaching profession, I am not aware that consultants are
in some way, as you seem to be suggesting, saying to their patients
in NHS clinics "I am sorry the waiting list is this long
but pay me and you can come and see me privately". Effectively
they may be referred privately but my experience in the private
sector is that decision is almost universally made outside the
NHS referral system and often normally before it, in other words
a patient with PMI insurance who wishes to go down that pathway
makes that decision in advance and follows an alternative pathway.
Dr Naysmith: This has partly been covered already
but I have people who come to see me in my surgery who tell me
Julia Drown: Me too.
845. That they have been seen by a consultant
on a National Health Service referral and the consultant says
"It will be six or nine months until this can be done under
the National Health Service" but, and I know this is not
supposed to happen, the suggestion is made to them if they are
prepared to go private they can have their varicose veins done
in three or four weeks' time. It happens so often, and all of
my colleagues around the table will back me up, that I cannot
see how it can possibly not be true.
(Mr Fieldhouse) I accept what you say but we would
not support such behaviour is all I can say.
846. It happens all the time. You say you would
not support that behaviour?
(Mr Fieldhouse) I do not think it is appropriate for
consultants to suggest to patients in an NHS consulting room that
they should go down a private sector pathway. It is perfectly
appropriate, because patients ask all the time, to ask what the
waiting time is.
847. So what would you do to try to discourage
this happening, if anything?
(Mr Fieldhouse) I think the guidance from all the
professional associations is already there. This is an inappropriate
way of conducting one's NHS practice and it certainly is not something
we would foster as appropriate behaviour for a consultant.
848. I know anecdotal evidence obviously annoys
you terribly but I am more than happy to give you names and addresses
of people who have had that experience. It seems to me, not trying
to cast the consultant in the money grabbing mould, for somebody
who has got a serious condition, and I am thinking of a lady who
has since passed away who was told she had a very serious heart
condition and her husband claims she was told she was a ticking
time bomb and told he could not do anything for her for a year,
it was only a very short step for them to say "And if we
want it privately, what is going to happen?" I do not believe
there is anybody here who has not had that experience.
(Mr Fieldhouse) If I may say to you, I think you are
unfolding the circumstances in the different direction of a patient
asking for information, whereas the suggestion has been there
is a sales pitch from the consultant.
849. I was much more subtle than that.
(Mr Fieldhouse) If the patient is asking for information
then I think it would be very difficult and perhaps even inappropriate
not to give that information because it may well be that they
would seek that treatment not from you but from somewhere entirely
different. If it is information given in the patient's best interests
on a knowledge basis, and has been requested, then I cannot see
that that is an inappropriate pathway. The reverse, as we dealt
with earlier, of an attempt in some way to foster a private practice
by volunteering certain information when a patient has not asked
for it I think is inappropriate.
(Mr Hassell) Firstly, Chairman, you were quite clear
at the beginning about your own position and we know of your opposition
to private health care.
850. You know my position well.
(Mr Hassell) I think I should try and balance for
the record my position certainly and that is my understanding
is the main thrust of this Committee's purpose is to examine the
workings of the Concordat and I would like to place on record
my congratulations to the Secretary of State, Alan Milburn, and
the Government for having the vision to actually agree the Concordat
and other Public-Private Partnerships. From my point of view I
find it disappointing that you are addressing the issue of consultants'
activities in the NHS rather than addressing the benefits to patients.
If there are 70,000 patients, as you referred to Charles Auld
a moment ago, surely it is important that there are 70,000-odd
NHS patients who are benefiting from faster treatment?
851. If I can come back to you on that. My concern
is in the short-term I have constituents who have gone to private
hospitals and are happy to have their operations done but certainly
one or two have asked me questions as to why it is they have seen
in the private hospital the same consultant they should have seen
in the NHS but could not see them. We need to get to the bottom
(Mr Hassell) In a previous session Dr Taylor, who
is not here this morning, referred to one of the consultants who
for 18 months had not been able to undertake work in an NHS hospital
but it was not his fault at all, that was due to the unavailability
of theatre time or other issues. There are issues such as that,
not just the issue of how a consultant spends his time but how
the infrastructure is or is not supporting the consultant.
Chairman: I want to come back on that specific
question to Mr Auld because one of the concerns I have got in
terms of Mr Auld's evidence is he refers to our Committee's visit
in 1999 to Stockton Hall as part of our mental health inquiry,
and we were grateful to your organisation for facilitating that,
and I think it is a fair summary that in terms of our reaction
to the quality of care it was a positive reaction, but in answer
to your point, Mr Hassell, about my views on this, my particular
concern is we are thinking particularly in the short-term motivated
by waiting list targets and not thinking of the longer term effects
on the Health Service. Stockton Hall is a good example. It is
a psychiatric hospital based near York, not far from where I come
from, and my colleagues, certainly Mr Austin who was present,
will confirm that what concerned us in particular about that unit
provided by a private company was it was virtually full of young
black men from London who were being treated for serious psychiatric
problems and why on earth should that unit be 200 miles away from
where they came from. I think the feeling was, and we said this
in our Committee, that by going to the private sector for a short-term
answer to the difficulties, the long-term development of more
appropriate facilities is retarded. I do not know if you want
to comment as you were present, John?
852. That is true. We commented on the quality
of care and we had no queries about that, but clearly it was inappropriate
provision because of its location purely because there was spare
capacity in the private sector and a failure to invest. If you
go for this short-term expediency, and there is an argument for
it, it then removes the resources that ought to be available to
redress the problem that is there in the first place, which in
this case was the non-provision of proper facilities in the London
(Mr Auld) Could I respond, please? I think, first
of all, just to address the issue of-short-termism of the solution,
I would have to remind certain Members of the Committee that Partnerships
in Care has been doing what it does now for about 20 years, so
I think in answer to any fears that one might have in terms of
the latest developments of the Concordat and the recent announcements
and developments, one might be tempted to look at the way in which
a similar form of partnership has been evolving over some two
decades in the psychiatric rehabilitation field. I am very pleased
that the Committee has endorsed the quality of the care and there
is certainly no anxiety about that. We would share the previous
expressed concern that the Committee had about location of treatment.
In one sense this is in part to do with the nature of the conditions
that have to be treated. As many of you would know, they are not
very frequent as a percentage of the population. The consequence
is that to have the right critical mass of a centre or a hospital
to treat these conditions you tend not to have too many of these
hospitals. That said, it is also fair to say that we, and we are
on record as saying, have been trying very hard to improve the
locational aspect of treatment. We were the first since the war
to set up an inner city psychiatric hospital, Redford Lodge which
is in Edmonton and that is a major catchment area in that part
of the South-East. In the area of the treatment of women, many
of whom have come out of the special hospitals, we now have hospitals
up and down the country and are treating more of that category
of patient than the Health Service is in terms of special beds.
I accept that there is more that could be done in terms of improving
the locational aspect. I agree with you that I think the quality
is there. Importantly, we would say perhaps it is a model of the
way that the acute sector will go. The important thing is that
patients are being treated, patients who if we were not around
I believe would not be being treated.
(Ms Bryson) I would just like to agree with Mr Auld.
The project that we did this time last year treated almost 1,000
patients in the private sector and the majority of these patients
were patients who had been waiting a very long time on waiting
lists, some very elderly patients waiting for cataract and hip
operations that the NHS at that time could not deliver and they
were very grateful and very pleased to have their treatment in
the private sector. To pick up on a previous point, we did encounter
difficulties with consultants and some blockages to transferring
these patients into the private sector, to quote some of them,
because it would affect their private list.
853. Could you say that again, please?
(Ms Bryson) It would affect their private list. Some
were particularly obstructive with it and we had quite a lot of
difficulty circumventing that. I think there is a cause for concern
in terms of how one manages the consultants if one is going to
use the private sector. Maybe there should be a debate as to who
holds the NHS waiting list. I would argue it should not be the
consultants because they should not be allowed to have that control
over where and when patients are treated.
854. You were saying there was some obstruction
by NHS consultants about moving people from their waiting lists
into the private sector because that would impact upon their private
(Ms Bryson) Yes.
Chairman: A very interesting point.
855. Just following up on some of the points
made. First of all, on the point Mr Auld was making about trying
to make sure there is provision in the right place and picking
up the Chairman's point on this. The Concordat does clearly say
that capacity is going to be used in the private sector. This
is really a question for Mr Hassell. Because the Concordat is
in place is the independent sector expanding provision, or planning
to expand provision, either in terms of building or in terms of
recruiting more staff?
(Mr Hassell) I can only answer from my perspective
in representing members, I do not have detailed knowledge of their
individual business plans. I am not aware of the sector having
any massive expansion plans, or indeed any expansion plans, that
were not in place prior to the Concordat being signed. I do not
see that the Concordat actually is against the objectives that
the Chairman wishes to achieve for the longer term because a major
tenet of the Concordat is that there should be joint planning
and that planning should involve the independent sector and the
public sector. Therefore, I think by working towards we can move
towards the strategic objectives that the Chairman was suggesting,
which has to be beneficial for patients. We are talking about
the use of scarce resources, which I think we all agree on although
we may have a slightly different viewpoint on it. By working together
I think we can make sure that patients benefit by siting establishments
closer to the area of need and ensuring that it benefits all patients,
whether they be NHS or independent sector funded patients.
856. It is about using spare capacity that is
(Mr Hassell) There is capacity there and, indeed,
as I think was mentioned on Tuesday when the Secretary of State
made an announcement about a fast track surgical centre, there
are plans for another 20 such centres over the next few years.
I have no knowledge at all as to whether they will be within the
NHS or in the private sector, but I think those sorts of initiatives,
well planned, have to be beneficial to bring down the million-plus
waiting list. I think that is where the central debate has to
be, on the patient.
857. We will come back to those issues later.
Do you accept in terms of the general provision through the Concordat
that your members, in so far as they help in dealing with the
waiting list, might be dealing with a one-off problem and you
will do better for a while but if the waiting list goes down there
will not be the work so the work might not be there in future
years and in that sense you are being used?
(Mr Hassell) I do not think that is the case. The
model you are thinking about there makes some static assumptions.
I think demand will change over the years and expectations will
continue to grow on the part of consumers. I suspect, and I have
no knowledge of this, it is no more than a personal gut feel,
that there will be quite sufficient demand to challenge both the
NHS and the independent sector, that is why it is important we
858. Are you entering the deals only on the
assumption that work will carry on?
(Mr Hassell) I am not an operator so it is difficult
for me to answer that. I suspect that my members, all of whom
are committed health and social care professionals, will have
taken a long look at the markets they are working in at the moment
and I am sure they are motivated for the right reasons of ensuring
patients have services where they need them.
859. Mr Huntley has been sitting quietly with
various expressions on his face. Do you have any thoughts on the
general points we have covered from your perspective within the
(Mr Huntley) Not on those specific issues because,
as you are aware, Chairman, we are actually dealing with overseas