Examination of Witnesses (Questions 820
THURSDAY 6 DECEMBER 2001
820. Good morning. May I welcome you to this
session of the Committee and welcome our witnesses. Could I ask
you briefly to introduce yourselves, starting with Ms Bryson.
I would like to thank you particularly for coming along today,
you are a substitute for a colleague who, unfortunately, is ill
and in hospital. We are grateful to you.
(Ms Bryson) I am Karen Bryson. I am currently
Director of the Cancer Services Collaborative for the South East
Region but was Project Manager and Assistant Director in East
Surrey Health Authority this time a year ago for the Private Provider
(Mr Hassell) My name is Barry Hassell.
I am the Chief Executive of the Independent Healthcare Association,
frequently called the IHA. The IHA represents the majority of
the mainstream independent acute hospitals in this country plus
mental health units, medical screening units, nursing and residential
(Mr Auld) I am Charles Auld, Chief Executive of General
(Mr Huntley) I am Peter Huntley. I am Chief Executive
of Channel Primary Care Group and I am responsible at the moment
for co-ordinating the overseas treatment test beds.
(Mr Fieldhouse) I am John Fieldhouse. I am a consultant
surgeon and I am here representing the Federation of Independent
Practitioners Organisation, usually shortened to FIPO. FIPO is
an umbrella organisation that brings together the Independent
Medical Practitioner Committees of the multiple generalist and
specialist organisations across the profession, and also the MACs
of private hospitals.
821. Thank you very much. Can I begin by asking
Mr Auld and Mr Hassell, obviously we are looking at the Concordat
and you know where I am coming from on this issue because we have
talked over many years and we have slightly different perspectives
on these questions. In looking at where the Government is going
at the moment, and we are told a statement today is going to be
made on issues of relevance to this inquiry, what proportion of
doctors within GHG and covered by your association, Mr Hassell,
also work in the NHS?
(Mr Hassell) My recollection, and I am trawling the
back of my mind, is thatI might not be absolutely accurate
with this percentagewhen the Monopolies and Mergers Commission
looked at an issue some years ago their estimate, which I think
is probably the best one around, was that something like 80 per
cent of all NHS doctors undertake some form of private practice,
but that varies quite considerably from just a few operations
a year to fairly significant private practice aspects.
(Mr Auld) We would believe, Chairman, that probably
of the order of 17,000 out of a possible 21,000 will be having
some form of private practice.
822. The question was working within your organisations,
not within the NHS.
(Mr Auld) Working within them?
823. Yes. I think you misunderstood the question.
What proportion of the people you are employing within the private
sector also work part-time within the NHS?
(Mr Auld) That is a very different question, forgive
me I did not understand that.
824. Of course it is, absolutely.
(Mr Auld) The Committee may not be fully aware of
the way in which private practice in the acute elective surgical
side of business of the independent sector works, but essentially
the consultants are clients bringing their patients to the private
facilities. It follows, therefore, that in very few of the independent
hospitals in the sector, and I am sure I am no exception to what
my colleague would say for the whole industry, there are very
few consultant surgeons who are employed by us. I am desperately
trying to think of any outside of IVF, fertilisation, but in terms
of most of the specialities that I think this Committee would
be particularly concerned with, I could safely say that all of
the consultants who are using our hospitals are, in fact, not
employed by us.
825. Perhaps I am not making it clear. What
I am trying to get at is how many consultants who are using your
hospitals for private treatment are actually working as well in
(Mr Auld) The vast majority, Chairman.
826. So we are talking 90 per cent?
(Mr Auld) In excess I would think.
827. In excess of 90 per cent?
(Mr Auld) Yes, I would think so.
828. That is the figure I am looking for, to
get an idea. We are talking about at least 90 per cent. Mr Hassell,
would you broadly agree?
(Mr Hassell) I have no evidence to counter that. What
I think is important, although you are only particularly talking
about consultants, is recognising the sector is actually an important
sector overall. We employ about three-quarters of a million people,
which is significant. Although you are taking a narrow view, I
think you need to remember that the sector is an important employer
of health care professionals.
829. Can I come to you, Mr Auld, in respect
of your evidence. On page five of your evidence, which is very
detailed and very helpful, you state in the first paragraph: "General
Healthcare Group estimates that without the operations carried
out under the Concordat, NHS waiting lists would now be some 70,000
patients higher than their current level." Can I turn it
the other way round. What would your estimate be of the impact
on NHS waiting lists if NHS part-time consultants who are not
also working in the private sector worked whole time in the NHS?
What would the impact on the waiting lists be?
(Mr Auld) I think that would be quite difficult to
estimate because the question is predicated on an assumption that
the only reason why the consultant could not perform that equivalent
procedure in the National Health Service is his absence from that
hospital and that is by no means the only reason that the procedure
would not be carried out. It is perfectly possible, as many people
have reported, to find that consultants are present in the National
Health Service, in their NHS practice, and not able to operate
for reasons that are not to do with their inclination.
830. I understand the point you are making about
(Mr Auld) So I do not know what the answer would be.
831. I understand fully.
(Mr Auld) What I certainly would not accept would
be what could perhaps be the drift of the question, that is to
say if the private sector did not exist then that 70,000 would
actually be done in the NHS, because it would not. I do not think
it would take too long to demolish that argument.
832. That was not necessarily what I was suggesting.
What I was suggesting was there was another view of this, and
you know my perspective because we have discussed this on previous
occasions. Can I come to Mr Fieldhouse, if I just flick through
and find your evidence.
(Mr Fieldhouse) May I just respond to that last point
because I think your question did make the supposition first of
all that consultants working in the private sector were not already
fulfilling their entire contractual commitment to the NHS and
all of the evidence is that those part-time consultants on maximum
part-time contracts that do work in private sector more than fulfil
their contracts to the NHS. The answer to your question would
require an estimate of what it would take to buy out their free
time to achieve that extra amount, also supposing, as Mr Auld
has mentioned, that the facilities were available either by buying
out private sector facilities or by increasing NHS facilities
which are already working to capacity.
833. You are making an assumption, that was
not the basis of my question. I think it is worthy of this Committee
looking at what the position would be in terms of waiting lists
if we had those consultants working full-time within the NHS instead
of part-time in the NHS. I accept entirely your point about capacity,
that is an issue we have looked at. What I wanted to ask you about
from FIPO's evidence is in your evidence you talk about the principles
and philosophy of your organisation and I am anxious to understand
where you are coming from because you say, in particular, "we
support treatment according to clinical need".
(Mr Fieldhouse) Correct.
834. I do not see how that squares up with the
situation we have had since the NHS came in where if you allow
part-time NHS consultants to have private practice we see quite
regularly the issue of patients not being treated on the basis
of clinical need but on the basis of their ability to pay for
that treatment. How do you square up your statement with that
(Mr Fieldhouse) The concept of a part-time consultant
is misguided and misleading. These consultants actually have a
contract within which they deliver a whole time commitment to
the NHS and their contractual commitment, as defined by part-time,
simply allows them to use their free time in an appropriate manner.
I must refute the concept that maybe Members of the Committee
might be gaining that they are somehow taking time away from the
NHS. It is on that basis that I must respond to your question.
If consultants are, therefore, already giving of their full time
the concept of FIPO and the ethos is that we are all consultants
in the NHS, all the board members are, and our members are almost
exceptionally, there are a few full-time consultants but the majority
are NHS consultants, and we believe in the NHS.
835. That does not answer the question at all.
I was saying I do not understand how you can state in terms of
your philosophy that you support treatment according to clinical
need when clearly your members are involved in systems that distort
that basic objective in the National Health Service.
(Mr Fieldhouse) I do not see there is a contradiction
in terms of members utilising their free time to further their
profession in the same way. It does not act as a contradiction
given the facilities, and as a point of principle they do believe
that patients should be able to receive treatment which is free
at the point of delivery.
836. That does not answer the point about clinical
need. What your organisation stands for is presumably allowing
patients to be treated not in accordance with clinical need.
(Mr Fieldhouse) The organisation essentially stands
for and believes in a plurality of provision of health care provider.
We do believe that there should be a mixed agenda of provider,
be that the state, the independent sector or the charitable sector.
We also believe in a mixed economy of funding streams to health
care, again be that the state, personal contributions and through
the PMI medical insurance industry.
837. And you do not see that that in any way
distorts this basic principle of treatment according to clinical
(Mr Fieldhouse) We do not feel that it distorts the
motivation of consultants, which is primarily the patient in front
of them and the delivery of optimum care to them. The funding
stream that brings that into being is a secondary issue, the delivery
of optimum care is the primary issue.
838. I do not think you have answered my question.
I cannot see how that squares up with what you stated in your
evidence because to me basically what your members, or some of
your members, are doing appears to completely undermine that principle.
(Mr Fieldhouse) I do not take that point, Sir, I am
839. You do not take the point or you do not
understand the point?
(Mr Fieldhouse) I do not agree with your point. I
have no problem with the fact that the consultants' first motivator
is the delivery of high quality of care to their patients. The
concept of where the funding comes from for that is very much
of secondary importance.