Examination of Witnesses (Questions 880
THURSDAY 6 DECEMBER 2001
880. Thank you. Briefly to Mr Hassell and Mr
Auld. In your submissions you both make reference to the trials
in East Surry, the local initiatives there, and you mention the
question of best value cost benefit. There is some confusion,
is there not, between the price of procedures to an individual
who is presenting as a private patient to the bulk purchase price
the NHS may be able to effect and the cost that the insurance
company might pick up on behalf of one of their clients covered
by this. What are the comparisons for any given procedure between
those three categories of cost?
(Mr Auld) Perhaps I could attempt to answer the question.
A key point to make is, as in anything else, if you are buying
a product rather than a service you would expect the unit price
of that product would come down if you buy half a dozen of them
or if you buy 300 of them. You would not expect to just pay 300
times the single price if you only bought one. The quite proper
concept of discounting against volume, repeat procedures in this
case, is very much alive and well. I am sure that would not surprise
the Committee. At the top of the list, and I think it probably
unproductive to get into absolute prices, for reasons I could
come on to, in terms of the relativities of price, therefore,
a patient coming in on his or her own initiative and paying for
a procedure you would expect would typically be the most expensive
price you would pay for that procedure unless, of course, there
are particular reasons in a hospital for wanting to attract more
of that nature of patient.
881. If there is a special offer on?
(Mr Auld) There may be good reasons for that. For
example, a mobile scanner may have come to the hospital for a
complete day and the hospital has not got bookings for the whole
day. It has got to pay for the scanner for the day but could actually
put another three or four patients through it, it is that sort
of thing. Typically a self-pay patient would be paying, relatively
speaking, the most for a given procedure. The NHS price, if it
was for a single procedure, is clearly going to be a lot more
than if, as has been the case with Ms Bryson and her colleagues,
they approach the sector and say "this is what we want to
do, now we are going to negotiate very fiercely on bringing the
price down because we are going to offer you X number of cataracts".
The price that would be available, I imagine, for that sort of
approach, which the independent sector has been urging on health
authorities and other Commissioners up and down the country for
years, is a price that is of the same order as the best price
that insurance companies would receive because the concept of
volume is there. We can plan across a period of days, weeks and
months when we can call off the patients, working with the Commissioner,
so our costs associated with treating these patients will come
down. It does make sense, as this excellent study shows, if a
Commissioner sits down with private sector operators and says
"Here is my year, my six months, here are 1,000 patients
I want treated", or in the case of Mr Milburn he is saying
"There are 275,000-odd patients who now need treating because
they are sitting for more than six months on the waiting list,
how are we going to do it?", he is just kicking off that
882. So the NHS patients under the bulk purchasing
arrangements get as good a deal as any major insurance company
could get for them?
(Mr Auld) Yes. If I could just say something about
the price because I would suggest price over the next weeks and
months is going to become one of the focuses of discussion. One
of the things we do find difficult is to try to make sense of
pricing, so-called, in the National Health Service. There is a
suggestion that we should be pricing with reference to what are
called the Reference Costs of the National Health Service, and
that is a table of costs, a range of costs, by procedure. If I
tell you the scale of our problem. If you take hip replacements,
at one end of the range of costs there are some hospitals in the
NHS who say they are charging of the order of £10,000 for
a hip replacement and, believe it or not, at the other end of
that range are hospitals who say that they are charging £800
for a hip replacement. Chairman, you cannot buy the prosthesis
and the cement for that, far less the theatre time, the cost of
employing the doctors, the nurses and all the others. What we
are suggesting is that pricing ought to be with reference to the
internal market pricing that there is already existing in the
National Health Service.
Chairman: Do any of my colleagues have any further
questions on the Concordat? I want to move on to look at the issue
of sending patients overseas.
883. I have just a very quick question. We have
not been talking about this but General Healthcare has argued
that its expertise lies in the provision of small elective surgical
units. We have been looking at PFI in previous sessions, can I
ask Mr Hassell if any of his members would be interested in providing
clinical services under PFI schemes?
(Mr Hassell) We are already providing clinical services
as part of the Concordat.
884. Particularly under Private Finance Initiative
(Mr Hassell) I think that, again, is for them individually
to answer. I think their experience in recent years has not been
particularly rewarding. We are concentrating much more on Public-Private
Partnerships rather than PFI. As was illustrated in an earlier
session, I think even some of the building companies have found
the risk there is too great for them to actually survive through.
As far as the majority of the Independent Healthcare Association
members are concerned, Concordat arrangements, Public-Private
Partnerships, are our main priority rather than PFI deals.
(Mr Auld) PFI is too slow, too cumbersome, too expensive
to operate, and we as a company do not like PFI for that reason.
We tried it and it is too slow.
Dr Taylor: May I apologise for being late.
Chairman: Let me explain to our witnesses that
there is a Health Committee Bill going on, as you are probably
aware, and three of our Members are involved in that as well.
It is no disrespect that they have not been here.
Dr Taylor: I would much prefer to have been
Chairman: You have missed some very interesting
John Austin: You can read the minutes.
Dr Taylor: Two quick questions, forgive me if
they have been asked, please just tell me. Looking at the memorandum
from the Medway Trust, they give us a figure of
Chairman: The Medway Trust are not here unfortunately,
the witness is currently in hospital, so they probably cannot
answer that question.
885. I think we should write that to them because
it is quite important. If I could just go on to the sorts of elective
operations that are done in the private sector. What I would like
to ask is what sort of arrangements are in place when you get
on to the moderate to major sort of operations? I would put hip
and knee replacement operations in that sort of category. What
sort of safety arrangements are in place if things go wrong?
(Mr Hassell) I am certainly happy to make some general
comments, it may be others would wish to add some specific comments.
Clearly there is a risk assessment of any patient entering into
the hospital and predominantly the consultant always says, and
indeed all the professional bodies say, the responsibility is
that of the consultant to make sure there are adequate facilities
in place. Equally, of course, the sector hospital will want to
make sure that they will only undertake procedures which they
are geared up for in terms of equipment, experience and professional
support before they undertake that work. The important thing is
the risk assessment at the beginning.
886. I ask this specifically because of the
news yesterday that the new fast track Diagnostic and Treatment
Centre in Surrey is going to do hip and knee replacements as a
part of the fast track Diagnostic and Treatment Centre. Apart
from risk assessment, if the risk assessment has said the patient
can be operated on, if there is an unexpected cardiac arrest in
the middle of a hip replacement, what back-up facilities would
a private hospital or a Diagnostic and Treatment Centre have?
(Mr Fieldhouse) I think the answer effectively is
that the Care Standards Act provisions, which come into effect
next April but are being put into place at this time, provide
through the legislation a legislative framework for all the requirements
to deliver appropriate quality of care for all national service
frameworks and recognised Royal College of Surgeons and Physicians'
frameworks for quality of care as well. Effectively the Care Standards
Act provides on my reading of it, and I was on the external consultation
committee that drafted the regulations, that which should provide
for equal standards of care between the NHS and the independent
sector in these sorts of situations.
Dr Taylor: I find that extremely helpful because
in my own neck of the woods in a Diagnostic and Treatment Centre
that is being established we are told that we cannot do exactly
these operations that are being done in the private sector. That
is very helpful.
Chairman: Can we move on. We have got Mr Huntley
here and we want to look at the issue of sending patients overseas.
887. This is primarily to Mr Huntley, but feel
free to chip in afterwards. In a press release you mentioned that
all the pilot schemes have received "numerous requests"
from patients seeking treatment abroad. I would like you to define
"numerous" because it means different things to different
people. What percentage of those requests have resulted in a patient
going abroad to have an operation? What work is in hand to establish
what factors are persuading them to take that step or deciding
whether to wait in the UK for their turn to come?
(Mr Huntley) If I could take the second point first.
We have not actually sent anyone overseas yet and that is a deliberate
decision not to send anyone overseas yet. I would like to go back
to Mr Fieldhouse's earlier comment about ensuring quality and
ensuring treatment plans. We made a positive decision that we
would not go to any hospital overseas or agree to send patients
to any hospital overseas until we were 100 per cent assured of
the quality of treatment that can be produced within those hospitals
and they abide by what are seen as the maximum standards required
within the NHS. In terms of numbers that have contacted us direct,
in terms of the three pilots I cannot give you a definitive number
but in terms of East Kent, where my office is based, we have had
40 patients write directly to us asking to be treated overseas.
That is without having the first one gone and with only the small
amount of publicity, although it does not feel like it, that has
gone on in terms of overseas treatment. In terms of factors, there
are a multitude of factors which encourage patients either to
go or not to go. In terms of wanting to go, the first is the time
on the waiting list, the second is the amount of pain they are
in if we are talking about hips and knees, thirdly if we talk
about cataracts their quality of life is impaired because they
are unable to continue with their quality of life, and the other
one is about being able to have a guarantee within a certain time
frame that they will be operated upon and can plan their life
around it. They are the reasons they wish to go. There are as
many, if not more, reasons they do not wish to go. They include
leaving their family, never having travelled abroad to a strange
environment, not understanding that environment and, particularly
as a lot of people on the waiting lists are elderly, leaving what
will be their relatives and perhaps carers.
888. I am just curious. You said you have not
sent any abroad yet, you have to make sure they are of the right
standards, etc., and you are dangerously close to sounding xenophobic,
I have to say. You have had four months to decide the criteria
and investigate this. Why is it taking so long? Surely it is a
question of setting the standards, seeing that they can be achieved
and getting on with it.
(Mr Huntley) With respect, we have only been at this
for about seven weeks.
889. The Government announced it
(Mr Huntley) The Government announced it on 24 August,
that was when the Secretary of State made his statement. It was
not until early October that we, as an organisation, were given
the go-ahead to start to look. As I am sure you will be aware,
trying to find sites and visit sites and discover issues around
capacity and to start to negotiate a contract, which is something
the NHS in terms of overseas delivery has never done in the past,
does take some time. Also, I am sure Members will be aware there
are legal issues, that we had to ensure we were open and fair
and seen to be.
890. What impact do you think the service will
have on the local health economy? Will there be any take-up from
outside the South East? I can see an attraction for people in
my area where they are having to wait four years from referral
from the doctor to actually having a hip operation and they could
just hop over the Channelor not, if they are waiting for
a hip operation. I cannot see quite such an attraction for somebody
from the North West or North East.
(Mr Huntley) We have been contacted by a considerable
number of health authorities, many of them from the North, who
say that they have concerns about being able to meet their waiting
list targets because their local providers cannot fulfil the capacity
and as a flight to Hamburg, for example, is less than two hours
from the North East why can they not send their patients there,
because it is as quick as, if not quicker than, moving outside
of their particular area. In terms of take-up, that is a totally
separate issue. We have done some market research in terms of
asking patients would they be prepared to move out of their area,
and if I go back to the experience we had with fundholding many
years ago, and the pros and cons of fundholding are not open for
discussion in terms of this, but in terms of patients wishing
to move outside their area, only one in six wanted to move outside
their area. In terms of the market research we have done for overseas,
that figure is going up to one in ten. To answer your first question
about will this have a large impact on the NHS, the answer is
it will have an impact on the NHS but in terms of large numbers,
until people are happy that the quality of treatment, the speed
of treatment and the ease of being moved has been sorted, I do
not think patients will want to go in huge numbers, but the option
is there for patient choice.
891. So is this a gimmick really?
(Mr Huntley) No, I do not believe it is a gimmick.
I believe it is first of all the patients come first and it is
patient choice first. If patients want to move then we should
have the opportunity to move them in a timely manner. There is
a lot for the NHS to learn from overseas and there is a lot for
overseas to learn from the NHS. Certainly in some of the high
quality places we have visited, their terms for their informed
consent, for example, are far more detailed overseas than in this
country and it is something that we should learn from.
892. Mr Fieldhouse?
(Mr Fieldhouse) Could I respond on the same subject.
It has been suggested that in some ways consultants were contributing
to the delay in this process getting off the ground, particularly
in relation to quality. Mr Huntley has referred to the concept
of obtaining assurances and guarantees from these sites that the
quality of care is up to NHS standards as a minimum. What I would
bring to your notice is that the independent sector in the UK
is now subject to a legislative framework under the Care Standards
Act with an entire inspectorate that goes into ensuring standards
that are legislative UK requirements, and that is a very different
kettle of fish from an assurance that is obtained.
(Mr Huntley) If I may come back on that. What we are
talking about is going to different countries to look at what
their health services assure us in terms of ranking. For example,
in France they have published a list of the top 50 hospitals and
one in France I visited yesterday was the sixth best hospital
for delivery of health care within France. If European countries
can grade their hospitals to that degree based on quality and
outcome then that is the sort of area that I think we ought to
be looking at.
(Mr Hassell) Could I just follow up on that point?
I agree entirely with what Mr Fieldhouse said in that the independent
sector is, of course, already heavily regulated and there will
be stronger regulation from 1st April next year. To bring that
into context, I would like to refer to the Medical Director's
Bulletin of October of this year where there is a quote which
says "... Mr Milburn has stressed that authorities will be
expected to apply the same principles to European providers as
to private providers in this country...", not the NHS, "...including
patients' safety, quality, aftercare arrangements and complaints".
I would like to think that whatever consultation is being published
today it will not be the maximum standards in the NHS but the
maximum standards in the independent sector which will be applied
to European placements.
893. In evidence to this Committee which you
will not be aware of yetalthough it went on the internetAlan
Milburn indicated that it was likely that the Commission for Health
Improvement could be involved in the vetting practice of overseas
(Mr Hassell) Yes.
894. How do you think that might work in practice?
(Mr Hassell) Some Members of this Committee will be
well aware of the debate we had several years ago over the need
for regulation in the independent sector. I think a number of
us, and correct me if I am wrong, including this Committee felt
that there should be one single regulatory system in this country
with a preference for CHI being that body. That was not accepted
by the Government and it was stated that CHI would only apply
to the independent sector and that the National Commission for
Care Standards was created to regulate and inspect the independent
sector. Actually I think that CHI looking at services in Europe
would be inadequate because, as has clearly been said in the quote
I gave a moment ago, they are predominately private providers
in Europe so it is the standards which apply to private providers
in this country which should be the test for them.
895. It raises a whole range of issues about
patient representation as well and the rights of successor bodies.
Commenting on what Sandra Gidley was saying, we recognise that
as a result of the court decision it would be unlawful to deny
a person access to services just because they are elsewhere in
Europe. Really at the end of the day is this going to make very
much impact or is it a minor issue in terms of numbers which will
be dealt with in this country?
(Mr Huntley) I think that is difficult to answer at
the moment in terms of we have identified sufficient capacity
within the near continent to be able to deliver what is required
of us by next April.
896. What sort of numbers are we talking about?
(Mr Huntley) In terms of the near continent we could
deliver for the three pilot sites several hundred patients moved
in a couple of months. We have done that fairly easily. In terms
ofand I have not read it in detail yetthe consultation
document released by Mr Milburn today, where he talks of requiring
to move several thousand or tens of thousands, the issue is, as
I am sure Members are aware, the capacity within Europe is considerably
higher because of the 20 years of over-investment and they are
looking to downsize in Europe because they have too much capacity.
Chairman: You have not met Mr Wanless in your
travels around Europe.
897. Are you suggesting that we spend up to
their proportion of GDP?
(Mr Huntley) No, I am not. That decision, of course,
is for ministers and the Government not me. They have got converse
problems. They have got as many problems in Europe as we have
got for different reasons.
(Mr Huntley) There are issues around ensuring that
if we have to move patients overseas I do not believe we will
be able to move more than 10-20,000 maximum, certainly from what
we have seen now. If we start looking further afield, apart from
the near continent, then perhaps issues will be different but
it takes a lot of work.
899. Leaving aside the difficult issues that
Doug Naysmith raised about indemnity and negligence and when things
go wrong, what estimates have you made of the cost of sending
NHS patients abroad relative to (a) treatment in NHS hospitals
or (b) the independent sector?
(Mr Huntley) I would like to just put a point before
that. One of the points that we were asked to consider when looking
at overseas treatment was to ensure that no additional workload
was put upon the NHS. Therefore it is slightly difficult for us