Examination of Witnesses (Questions 700
THURSDAY 29 NOVEMBER 2001
STANTON, OBE, AND
700. One of the issues I raised with the Secretary
of State when he came at the start of this inquiry was evidence
which I personally received that patients waiting to see particular
consultants on NHS waiting lists are told under the concordat
they will be seen instead within the private sector; go to a private
hospital and see exactly the same consultant in their private
time in a private hospital. Is that something which is happening
in any widespread way or is it just an odd example I have in my
area which is not replicated elsewhere?
(Dr Fradd) We are not inundated with correspondence
on that and certainly in my personal experience as a GP, I have
not experienced it. I am sure there are cases around the country
but there is pressure on the NHS to deliver the service so that
they do not lose the resources to the private sector. In a way
that may be a positive incentive to make sure that the system
701. Nobody would really write to you to complain
about that situation, so it may not be an issue drawn to your
(Dr Fradd) It may not be an issue.
702. Would you share my concern if that were
happening to any great degree?
(Dr Fradd) Yes, I would.
703. In what area do you practice when you are
practising as a general practitioner?
(Dr Fradd) I practice in inner city Nottingham, a
very deprived area, one of the old city challenge areas.
704. Do you have any thoughts on these general
points from your perspective in the Alliance?
(Dr Dixon) Yes, there is a capacity problem in the
NHS, both in terms of resources and manning, as we all know. Private
capacity does potentially offer something; potentially certainly
in the short term in terms of lopping off some of the long waits
and work that is required. We also need to look at the short term
and the long term. We need to look at the way in which short-term
solutions might impact upon more important developments within
the NHS capacity which we need to be working on. Not a great deal
of it is going on at the moment because PCTs and PCGs are such
new organisations. The importance for this Committee is to look
at how, particularly in primary care, we are going to go about
it. I see that as the purpose of today.
705. One of the areas which has been drawn to
my attention and the Committee had some evidence on in a previous
inquiry was the correlation occasionally between lengthy waiting
lists and the private practice of the consultants concerned. I
am making no suggestions other than to report some interesting
correlation. In terms of logic, it does not seem to me to make
a great deal of sense to be sending people to see these consultants
in the private sector without addressing why we have these long
waiting lists in the first place. Do you see that there is some
degree of inconsistency between on the one hand attempts under
the consultants' contracts to retain people for the first seven
years to work wholly in the NHS and at the same time putting additional
work into the private sector?
(Dr Dixon) There is the conflict of interest you relate
to. What we need to do is to try to reduce that conflict of interest
and incentivise consultants and all practitioners working within
NHS to take some responsibility, particularly for waiting within
the NHS. At the moment the conflict actually splits them in two.
There are ways of doing that and what evidence suggests is that
those trusts, for instance, which have the best waiting lists,
are those where they have most involved the clinicians in the
initiatives they have done. It is a question of making sure that
the team is working for the NHS and is not split between its private
and its public responsibilities.
706. Dr Stanton, you cannot answer for your
BMA consultant colleagues, but you may have your own opinion on
this area. Do you have any thoughts on that point?
(Dr Stanton) I am also Secretary of the London Group
of local medical committees, so have a number of established primary
care trusts on my patch and also most of the London hospitals.
Certainly the overwhelming difficulty for those primary care trusts
in London, which have already been established is simply trying
to juggle their budgets essentially to keep their NHS hospital
services going. There is no spare capacity or particular wish
to be diverting money into the private sector. My impression is
that it is not really the work pattern of consultants which leads
to the block, it is actually the lack of resources within NHS
hospitals which leads to these problems, lack of operating time
and nursing staff where there is a crucial shortage. It is a huge
707. It is nothing to do with the fact that
some of them spend rather a lot of time in the private sector.
(Dr Stanton) That has always been the case in some
708. Does it always have to be the case?
(Dr Stanton) I am sure not.
709. What you seem to imply, Dr Fradd, is that
the spending patterns that the PCTs have inherited are historic
and that there is no room to change them.
(Dr Fradd) It is remarkably difficult to shift money
about which is going to have a negative effect. Trying to close
the most expensive parts of the service, neo-natal intensive care
and intensive care beds, because that would have enormous implications
in lower tech care, is very difficult and there is always going
to be a demand. We would share the desire that there should always
be the facilities for such care. They take precedence over dealing
with what may be perceived as much less exciting care of a routine
nature. So repairing a hernia does not have the same attraction
for publicity as doing coronary artery grafts or major work like
that. The reality is of course that it is just as devastating
for the individual doing manual work as there is no way you can
work if you have a hernia. The problem is that the resources are
fully committed historically, as you put it, and there is almost
no freedom of manoeuvre to do anything because there is no
710. Surely part of the role of the PCTs was
to unblock that historical pattern.
(Dr Fradd) Of course, but you cannot actually look
at the problem
711. Yes, I understand that. We can always do
more with more money. There will never be an infinite amount of
money. There will always be a limitation.
(Dr Fradd) I totally agree.
712. But surely the PCT's responsibility is
primarily the service it provides to its local community, local
citizens, rather than a kind of secondary involvement in the infrastructure
of the acute sector.
(Dr Fradd) I am sorry, I stand by what I say. You
can delegate responsibility, but if you do not delegate the power
to do anything about it, then it is pretty useless. We have had
amazing commitments from this Government to the NHS. We had £1
billion only this week. What we need to do is to make sure that
extra resources do not get earmarked before we have the opportunity
to make those developments. There is the most enormous potential
for development within primary care in particular, but we have
to have the spare capacity. Nobody is going to allow me as a member
of a primary care trust to start closing hospital beds with long
waiting lists because I want to start getting something off the
ground in primary care which would probably have a run-in period
of several months if not years.
713. That is not a decision for you at the PCT
about beds at the local acute ward.
(Dr Fradd) Of course it is in terms of the funding.
714. It is in the way it knocks on but your
task is getting best value for public money and best service to
the patients and that is where your priority should be.
(Dr Fradd) The way my colleagues see it is that we
have to maintain the historic standard and it has to be done out
of private money.
715. You rendered the question I was going to
ask quite redundant. I was going to ask whether you were happy
to see a mix of commissioning from PCTs
(Dr Fradd) Of course but given the resources.
716. If you say that all you have done is inherited
what has gone before then actually what you are saying is that
there is something you can do about it.
(Dr Fradd) To a large extent I am saying that. Without
the necessary resources we do want to do that, we do want to get
into the driving seat. But you would be the first person, if a
maternity unit were closed locally to say your constituents were
not happy with that. To a certain extent we have to recognise
the nature of the NHS is such that it takes an awful long time
to move it. The public rightly demand that they at least have
a certain level of service and if in trying to improve that service
you are not given the seed money to get that off the ground, then
I do not see how you move it forward.
(Dr Dixon) This is an evolutionary process. Unified
budgets are very new and the management infrastructure and primary
care trusts are fairly undeveloped at present. The priorities
over the last year or two have been mainly secondary care and
80 per cent of primary care trusts have been asked in-year to
help towards secondary care overspends. That is the reality of
the pressures on the system at the moment. You are dead right.
In the future, the unified budget will be there to be used flexibly.
I am also the commissioning chair of three PCTs. At the moment
I find much of my work is simply following the NHS, following
many of the central directions and much of the secondary care
agenda and that does not give much room for manoeuvre. For the
future, yes, as a commissioning chair I see myself looking at
options quite seriously. When I find myself blocked by services
in the public sector in the way that can happen sometimes because
of the disparate interest between private and public, then there
will be chances where we might start looking at commissioning
services elsewhere. It is a stage of evolution. That is next year
and the year after and it does depend also on capacity in the
NHS and also the amount of money at my disposal for doing that.
717. It seems a curious formulation that you
need more money in order to spend the money you have better, although
I do accept there is a degree
(Dr Dixon) It is about closing ward.
718. In the BMA memorandum to the Committee
you said that GPs are well placed to deliver an improvement to
services and introduce innovative ways of working. Can you expand
on that, given the constraints you have now said they are working
under in PCTs?
(Dr Fradd) Yes. Again it depends on capacity and that
does tie in with what you are pushing at which is the possibility
of new ways of working. We have suffered under three reorganisations
in my working lifetime which have thrown up enormous burdens just
in adapting to the organisational structure of the NHS. We are
now in the middle of probably the most major one I have ever seen
with the move to strategic health authorities. That actually consumes
quite a lot of medical time and other people's time which necessarily
takes away from innovative working at the coal face. Having said
that, we have made some very radical changes. If you look at diabetic
care, ten years ago that was a hospital-based care package. That
is now almost entirely based in general practice and certainly
the upper end of the profession would like to see it all managed
within general practice. There are the potentials for things like
intermediate care for specialist services, but only if we can
look at new ways of working in some of those areas of care which
do not really require the service of the general practitioner.
Let me give you one example: a minor self-limiting illness, particularly
at this time of year, upper respiratory tract infection. That
is not a problem to take to a doctor. It is something to be taken
to the pharmacist. Unfortunately the Crown report is very nearly
two years' old now to empower pharmacists to prescribe. You will
not unlock that problem at my inner city practice for patients
who get free prescriptions by moving them to the pharmacist if
the consequence is that they have to pay for those drugs, albeit
relatively small costs and even in NHS terms. There are things
which we need to do to empower my colleagues to shift the work.
I think we are at a very exciting time. We are currently locked
into negotiations with the NHS Confederation on the new contract.
We certainly have a very similar view of the problems and these
keys which need to be turned on both sides in order to move it
forward. My fear is that we shall not be allowed to reach a conclusion
in those negotiations and then see them implemented, that we shall
see ministerial interference in the outcome of those negotiations.
I am not saying that Ministers do not have a right, but they are
going to be included in feedback on those negotiations as they
go through. We do have a brave new world which is possible but
it will demand some regulatory change such as pharmacy prescribing,
it will mean that we have to be allowed to reorganise the way
services are delivered at the level of the practice and PCT.
719. I was very interested in the point you
made about the use of pharmacists. Unfortunately our pharmacist
is on another committee this morning because she could probably
take this point further. You implied that in a week when we have
had the very important reports which have informed debate about
general taxation resource in the NHS we need to look perhaps at
how we use access to GPs. The implication was that because we
have a financial incentive for a patient to see you on the basis
of getting a free prescription, that results perhaps in more cost
to the NHS than looking at unravelling the prescriptions to enable
people to go straight to the pharmacist; it is a cost issue. Have
you researched this in any way in detail to look at what this
cost implication might be? You are implying to me that there ought
to be a shift in policy to make more effective use of pharmacists,
reduce the burden upon GPs and that that may well be an area which
reduces the costs to the NHS in the longer term. We were talking
this morning in the press about how many billions we need. A lot
of us round this table think we can spend existing money far more
effectively and I am sure you would agree with that.
(Dr Fradd) I certainly would agree with that. Some
very good pilot studies have been done, one in Newcastle which
I am very happy to let the Committee have the details of, where
they have earmarked funds through the health authority for pharmacists
to be able to prescribe under patient group directives. The trouble
with that is that you have to be very specific about the range
of activity which is going to be allowed, whereas I believe that
pharmacists, where they are dealing with over-the-counter drugs
are already in effect prescribing to those people who can afford
to buy those drugs. So what is the difference in giving them a
Government piece of paper which gives them eligibility for those
drugs for free? The costings on that are extremely competitive
on that Newcastle project. They demonstrated that, even though
they paid an incentive to the pharmacist to participate and we
do have to remember that we must resource the colleagues who are
taking on this work. It is no good expecting people to take on
more work and more responsibility without giving them some reward
for that and making sure they have the money for infrastructure
like private rooms within a pharmacy to deal with personal problems.
In terms of resourcing, coming back to your question, the pilots
which are out there demonstrate very good value for money and
not least the opportunity cost because the thing we are shortest
of is people with skills, nurses, doctors. Therefore if we can
free up time from them, we can get much more out of the system.
We need to have a move to the right where we move the less complicated
work down to people with less experience, fewer skills. My colleagues
and I can then move to higher added work.