Letter from the Parliamentary Clerk, Department
of Health, to the Clerk of the Committee (PS 1A)
Thank you for your letter of 19 December. This
letter sets out the Department's response to the Committee on
the questions asked and provides some further information outstanding
from the first evidence session of 24 October 2001. I am sorry
that the Committee has not received this information sooner.
The Committee has asked for a note on how the
£20 million assigned to the concordat has been distributed
across the country and whether it has been distributed according
to where people had relationships with private sector partners
or according to need (question 1).
The money was provided to health authorities
in November 2000 and was used to purchase over 10,000 operations
from the independent health sector during the winter 2000-01.
The distribution was based upon the number of NHS cases that were
outstanding and needed to be undertaken and also the availability
of independent sector capacity to undertake the work. This helped
to ensure that elective activity rates remained as high as possible.
Information on the specialities involved is
not available. The cash distribution is as per table below. The
table also shows the amounts made available from NHS sources for
Local Authorities to address social care issues during that period.
The exact number of delayed transfers of care that directly resulted
from these transfers is not known.
|NHS Region Social|
|£'000s||Private Sector Allocation £'000s
||No of Cases Commissioned
|Northern & Yorkshire||3,323
The Committee has asked for our assessment of the relationship
between the Commission for Health Improvement and the National
Care Standards Commission (question 2). The Department recognises
the need for the Commission for Health Improvement and the National
Care Standards Commission to work closely together with respect
to independent health care.
However there are distinct differences between the two bodies:
The NCSC is a regulatory body and effectively
licences care providers, CHI is not a regulatory body.
The NCSC is mainly concerned with social care
services and health care services make up a small proportion of
the regulated services.
The NCSC will cover a wide range of independent
health care ranging from acute hospitals, through private doctors
to cosmetic surgery. In many of these regulated settings no NHS
patients will be treated.
We do recognise the need to ensure that there is close collaboration
between the two bodies and the two chief executives have met to
start putting in place such arrangements. These arrangements will
need to ensure that both bodies co-ordinate their inspection/review
programmes in relation to independent health care and share information
about their findings with respect to such services.
The Care Standards Act also includes a power at Section 9
which allows regulations to be made for either organisation to
delegate functions to the other. As only the NCSC is a regulatory
body the NCSC could only delegate inspections of independent health
care services to CHI, and not their full regulatory duties which
include registration, complaints investigation, enforcement action
and de-registration. The Department is discussing this delegation
power with the chief executives of the two bodies. However, as
the NCSC is not due to commence its statutory duties until 1 April
2002, and is still being set up, this is unlikely to happen from
this start date.
In question 3, the committee has asked about changes in capacity
over the last five years in terms of:
(a) The number of staffed in-patient beds by region and
(b) The number of day surgery beds.
(c) The number of whole time equivalent consultants by
region and specialty.
(d) The number of operational operating theatres.
(e) The number of surgical interventions by region and
(f) The number of available but not staffed in-patient
beds, by region.
(g) The number of available but not utilised operating
The Committee has also asked whether any studies have been
undertaken to identify what additional capacity could be available
and at what cost within the NHS (question 4).
The Secretary of State is keen to extend capacity to treat
NHS patients. That is why the NHS Plan announced:
7,000 extra beds by 2004, of these 2,100 in general
and acute wards;
5,000 extra intermediate care beds;
7,500 more consultants;
Some of this investment in additional capacity can already
be seen. For example there are over 250 additional operating theatres,
an increase of 12 per cent, since 1997. As a result the number
of operations has increased by over 500,000 in the same period.
At the same time 300,000 more emergencies are being dealt with
every year. The NHS Plan also announced a major expansion in new
Capital investment is reshaping services. We are developing
diagnostic and treatment centres, some in partnership with the
private sector, to increase the number of elective operations
which can be treated in a single day or with a short stay. Twenty
of these centres will be in development by 2004, by which time
eight will be fully operational, treating around 200,000 patients
per year. We expect a number of DTCs to be in operation by the
end of next year.
In addition to increasing capacity for NHS patients using
both the public and the private sector the Secretary of State
has set up the Modernisation Agency to improve services for patients.
The agency's work includes encouraging service redesign so that
better use is made of existing capacity.
In response to the specific questions:
a. The number of staffed in-patient beds by region and
This information was submitted to the Committee on 28 September
2001 as part of the Department's written evidence for the Public
Expenditure Enquiry 2001.Table 4.14.1, attached again as a Appendix
A for ease of reference, shows the five year time series by region
of available, and therefore staffed, beds. The Department does
not classify beds by specialty, but on a broad wards classification,
as shown in table 4.14.1
b. The number of day-surgery beds - Table 4.14.1 also contains
details of beds in dedicated day case units.
c. The number of Whole Time Equivalent consultants, by
region and specialty - A table giving this information
is at Appendix B.
d. The number of operational operating theatres-
(3.d) NUMBER OF NHS OPERATING THEATRES ENGLAND, 31 MARCH
1997 TO 2001
|Y01||Northern & Yorkshire
Source: Department of Health return KH 03.
e. The number of surgical interventions, by region, by
Information on surgical interventions (operations) comes
from the Department's Hospital Episodes Statistics (HES). This
gives the number of finished consultant episodes, ie periods of
care under one consultant in one health care provider. The attached
tables provide the information. However, there are some discontinuities
in the time series of information requested due to changes in
regional boundaries in 1999 and some coding of specialties. Figures
for England are shown in the table in Appendix C.
f. The number of available but not staffed in-patient beds,
by region - There are temporary bed closures where there is staff
sickness or shortage. For example, on 30 November 2001, 0.6 per
cent of total NHS general and acute beds were temporarily closed
due to staff shortages/illness. The table below shows the number
of G&A beds temporarily closed due to staff shortages. The
figures are from the Winter Bed Census 2001. This is the first
time this type of information has been collected in the bed census.
NUMBER OF NHS GENERAL AND ACUTE BEDS TEMPORARILY CLOSED
DUE TO STAFF SHORTAGES ENGLAND, 30 NOVEMBER 2001
|Y01||Northern & Yorkshire
Source: Department of Health Winter Bed Census 2001.
g. The number of available but not utilised operating theatres
- We do not have this information.
Question 5 asks whether the Department has considered what
additional capacity could be made available if consultant contracts
were made full time? What would be the additional salary cost?
Only 12 per cent of consultants work part-time (HCHS medical
and dental consultants, England at September 2000). If all these
consultants worked full-time this would, in theory, give an additional
6 per cent consultant hours for the NHS, equivalent to 1,500 wtes.
This would add £120 million to the consultant paybill, excluding
However, consultants choose to work part-time for a variety
of reasons, including domestic responsibilities, and many part-time
consultants have no private practice earnings. Not all would be
able to commit to working full-time, and the end effect of making
consultants work full-time would be that some of these staff could
be lost to the NHS as consultants.
The Committee may be thinking of consultants on maximum part-time
contracts, where a consultant foregoes one eleventh of whole-time
salary, in return for the removal of restrictions on private practice
earnings. The same work commitment is required from consultants
on whole-time and maximum part-time contracts, both of whom are
expected to devote substantially the whole of their professional
time to the NHS. The evidence does not suggest that maximum part-time
consultants are less productive than those on whole-time contracts.
The Committee has also asked what are the barriers to requiring
full time contracts for all new appointments and whether the Department
has considered making the acceptance of a full time contract a
condition of accepting a training position within the NHS.
The Department has considered this but has concluded that
imposing compulsory full-time contracts would be counter-productive.
The number of female doctors is increasing rapidly as more medical
training places are taken up by women. The Department is keen
to ensure that the expertise of doctors is not lost to the NHS,
particularly at key moments of their lives, eg when they wish
to raise a family. There is a concern about the lack of flexibility
for NHS staff who wish to combine a fulfilling career with domestic
responsibilities. At present, there are significant numbers of
doctors who are not actually working for the NHS because they
feel unable to combine work and domestic commitments. Requiring
newly trained doctors to work full-time may provide some additional
medical time but there is a strong risk that this would be outweighed
by time lost to the service, temporarily or permanently.
The Department is working under the Improving Working Lives
programme to offer more flexible working conditions for all staff,
including doctors. Offering more flexibility will enable NHS staff
to maintain career continuity throughout the course of their working
lives. The Department believes that requiring staff to commit
themselves to a full-time contract as a condition of accepting
a training position within the NHS would exacerbate rather than
alleviate the shortage situation.
The Committee will know that we are currently negotiating
with the British Medical Association on a new consultant contract.
The Government wants to use the new consultant contract to maximise
consultants' contribution to the NHS, but this does not mean preventing
doctors from working part-time if they wish to do so. The challenge
is not so much to make consultants work longer but to manage their
time more effectively. Too many consultants still do not have
job plans. Job planning, supported by the agreed appraisal system,
as a contractual requirement is a key feature of the new contract
under negotiation. This will help ensure that consultant time
and effort is most effectively focussed on service needs and priorities.
The new contract and the new clinical excellence award scheme
will also create a more explicit incentive and reward system linked
to NHS performance and NHS commitment.
Question 7 seeks an assessment of the retention of employment
model pilot schemes in Mandeville, Roehampton and Havering. The
Retention of Employment models at Stoke Mandeville, Roehampton
and Havering are developing well after final UNISON agreement
to participate in the pilot projects in November. Since then follow-up
meetings have been held with the private sector and the trusts.
Detailed contractual documentation has been sent out to trusts
and bidders with the instruction that they submit their comments
on the documentation before Christmas.
Once all comments have been received and analysed, formal
contracts will be issued and trusts will be instructed to invite
bidders to submit best and final offers (BAFO). It is anticipated
this process will take around a further month, with the evaluation
taking a further month. This indicates that it is likely we will
be able to let contracts, assuming that UNISON agree to the proposals
and it passes value for money tests, by the middle of March.
In addition to the three pilots, the scheme at Walsgrave
has also progressed to a stage where it needs to introduce RoE
principles. It is likely that Walsgrave will be in a position
to also let contracts under the RoE model by the middle of March.
Until the comments from the private sector have been fully
analysed and it is possible to estimate the likely pricing implications
of RoE, it is not possible to arrive at an assessment of the model.
Question 8 asks for information about a recent survey. Statisticians
in the Department have carried out a survey of NHS hospital trusts,
PCT/Gs and health authorities on NHS independent sector usage.
The survey was commissioned at the end of September 2001. Its
purpose was to understand the volume, cost and nature of elective
treatment being provided to the NHS by the independent sector.
The survey received responses from just under half of all
hospital trusts, PCTs and health authorities, with responses from
a small number of PCGs, together representing about half of all
NHS inpatient activity. The returning sample reported commissioning
over 13,600 finished consultant episodes from the private sector
between April and September 2001, and more than 15,000 planned
for between October and March 2002. These cases account for an
estimated 0.58 per cent of expected NHS inpatient activity over
the year. The survey was commissioned before the announcement
of the £40 million allocation to the NHS to buy activity
in the private sector over the winter months.
An estimated £22.5 million was spent by the survey sample
on independent sector treatment for patients between April and
September 2001. The survey indicated that the majority of independent
sector contracts are made between hospital trusts and independent
providers, although primary care trusts also play a substantive
role in commissioning work from the independent sector. Rates
of independent sector usage vary widely between different regions
of the country.
The Department will make available publicly further information
from the survey on the type of procedures making up the volume
of cases commissioned, also more detail on prices obtained by
the NHS. We also intend to re-run the survey to obtain actual
data for 2001-02 and planned activity for 2002-03.
The Committee may also be interested to know that the Independent
Healthcare Association collects data from its members. This shows
that since November 2000 at least 75,000 patients have been treated
in the independent sector, paid for by the NHS. This figure includes
outpatient appointments, day cases and inpatient treatment. A
breakdown by type of operation will shortly be placed in the Library
of the House.
FROM 24 OCTOBER
At the evidence session on 24 October, the Secretary of State
mentioned research done by York University (para 23 of the transcript
of the session). This was summarised in the British Medical
Journal: Dynamics of Bed Use in Accommodating Emergency Admissions:
Stochastic Simulation Model, by A Bagust et al; BMJ vol 319:pp155-8;
17 July 1999.
The Secretary of State promised Dr Taylor to set out the
recruitment and retention position for nurses within the Worcester
area (para 29).
Since 1997 the number of qualified nurses working in the
NHS in England has increased by 17,000 (headcount), I can confirm
that the vacancy position in the Worcester acute trusts has improved
from 117 vacancies in July this year to 59 vacancies in October.
The vacancy rate has also improved within the Worcester Community
Trust (from 26 vacancies in July to 0 vacancies in September).
This is as a result of newly qualified nurses taking up post and
the recruitment of overseas nurses.
In order to maintain this momentum, planned future events
include a recruitment open day in November for D and E grade nurses,
close liaison with the local universities to improve retention
of newly qualified nurses in the Worcester area, the introduction
of an internal bank system specifically for theatre and critical
care nurses, and the introduction of comprehensive Continuing
Professional Development programmes for nurses. In addition, so
far this year 12 nurses have returned to practice, there are currently
24 on Return to Practice programmes and a further 16 are waiting
for courses to commence.
Mr Austin asked for an assessment was made of the capacity
of trusts to meet repayments on PFI projects. Mr Coates from the
Department said that he would inform the Committee of the revenue
costs of PFI schemes as a proportion of total HCHS revenue (para
Total HCHS revenue in 2001-02 is £41.465 billion (HCHS,
excluding capital charges). Last year's peak revenue figure of
£317 million (amounting to 0.8 per cent of 2000-01 total
HCHS revenue) has risen this year to £445 million per annum.
This now represents 1.07 per cent of revenue and will rise proportionately
as further major schemes continue to reach financial close over
the next decade. There is no "cap" on the revenue ceiling
attributable to PFI projects but the proportions are reviewed
each year with the Treasury.
The total revenue cost of PFI of £445 million covers
both the repayment of capital and the consumption of support services
eg catering, cleaning etc. On average, half of a typical PFI contract's
fee is for services. If this is applied to the above figure, it
means only around £220 million is "extra" expenditure
Ms Drown requested a note for the committee to say how the
Department values cost and time over-runs (para 97). A note of
explanation on this is attached as Annex A to this minute.
There was not time for the Secretary of State to respond
to the final question from Mr Dowd, who asked for his views on
why the level of returns for PFI in the Health Service has been
somewhat less than in other sectors and whether this could be
because of the exclusion of clinical services (para 103).
The current PFI model has proved itself the best value for
money option for delivering large acute hospitals as well as a
growing number of medium sized community hospital and mental health
schemes. It therefore makes sense to use PFI where it offers the
taxpayer better value for money and a faster procurement rate.
This means that we are now able to devote public capital
to smaller projects, maintenance and equipment needs and specific
modernisation initiatives which are more difficult to fund using
PFI. An example is the upgrading of every A&E department in
We have been able to greatly increase the amount of exchequer
capital available to the NHSby the year 2001-02 public
capital expenditure will have risen by over 60 per cent since
1998-99and public capital will in fact continue to dominate
the capital investment programme in the NHS, providing well over
twice as much capital as will be provided by the private sector
under the PFI over the period of the Comprehensive Spending Review.
There is currently no sign that the private sector has the
capacity to manage the wide range of clinical services provided
by a district general hospital which would be involved in a major
PFI build. A different approach to the structure of acute sector
PFI schemes is not therefore an option.
I hope that the Committee will find this information helpful.
8 January 2002