Examination of Witnesses (Questions 940
THURSDAY 6 DECEMBER 2001
940. Mr Roy?
(Mr Roy) Could I make a couple of points. First of
all, I think we have to make it clear that from a strategic planning
point of view the NHS has power over what it provides to a quite
different degree from what it contracts for. Essentially if a
private provider were to choose to take the strategic decision
to withdraw or to substantially vary its service, it is not clear
what powers anybody would have to do anything about that. This
is in fact worse than, for example, arguments about PFI because
most PFI contracts at least have a step in clause. If you are
talking about buying private capacity, there is nothing to stop
the owner of private capacity at one stage deciding that for various
reasons they do not wish to continue to provide it. Within the
NHS there is quite a strong process, which I hope will continue
whether or not CHCs are still around to enforce it, for discussing
whether there should be changes in capacity and in provision.
This process, if it is used properly, can do quite a lot in terms
of providing good strategic planning and keeping things on course.
I cannot see how such a process could be made to apply to a private
provider. It might not matter if the private sector remains marginal
but if for various reasons it ceases to be marginal then the status
of that capacity and access to it would become quite a serious
941. What is your definition of "marginal"?
(Mr Roy) Well, I think the current ten per cent or
less in terms of beds is probably something that is pretty marginal.
There could be local situations, I do not know of any myself,
if, say, something like 30 per cent or 40 per cent of your local
health economy acute bed capacity was in the private sector and
was, therefore, a rather different basis from the NHS in terms
of ability to change it, then I think that would cease to be marginal,
942. Generally then, what do any of you see
as the practical limitations of the involvement in the private
(Mr Roy) I would see it as being a useful adjunct.
I tend to see it as the oil on the wheels, the thing which makes
the system work a little bit better, the thing which can be brought
in, occasionally used to buy you time to adjust capacity in the
public system. That would be my way of looking at it. Also, possibly,
occasionally useful in terms of getting good innovations. I think
one should not neglect the ability of clinicians, managers and
others in the NHS to produce sensible innovations as well.
(Mr Catton) There is no large scale private district
general hospital. There is not the expertise or the experience
there, that would not seem to be appropriate. I think there is
an issue around being clear on charging. Creeping charges, whether
they be for TVs and radios and then whether it be laundry and
food and clinical services, there should not be any charging for
clinical services, but are we clear on what clinical services
are and the risk, therefore, about whether top ups could be offered.
There would be a basic or core service and then there would be
a fee or charge and a top up. I think those issues need clearly
943. It is just the area of what is called simple
surgery we are talking about, we are not talking about acute,
significant involvement in acute care. We are talking about simple
surgery, simple procedures, not talking about emergency procedures?
(Mr Catton) Yes.
944. Does it matter from the taxpayer's point
of view, the patient's point of view, who provides these things?
(Mr Roy) I think it can do. There is the other issue
which I do not think has been raised so far which is the issue
of protection, complaints processes, etc, if something goes wrong.
With the best will in the world things will go wrong. One of the
things we at the Association have been very keen to do is to try
to ensure that whether it is us or some kind of successor along
the lines that may emerge from the Committee down the corridor,
their remit should extend into the private sector so that you
do not have a situation where there is a two tier level of protection.
In fact, that is one of the things we have pushed for in terms
of the implementation of the Care Standards Act. We have specifically
in the consultation of the Care Standards Act requested that in
addition to frequency of inspection of independent hospitals being
maintained at current levels rather than reduced, as is currently
proposed, there should also be a procedure that in fact the CHC
on an interim basis and in the event of us being replaced by some
other suitable organisation, that organisation should be given
(Mr Catton) In terms of does it matter, if there are
clear systems there to ensure quality, that services are being
provided on the basis of need, that it is transparent how those
decisions about who is going to provide it so that you can hold
people to account, if it is not in the public interest, it is
not providing wider goals of social responsibility and social
equity, if those sorts of systems around accountability and equality,
involvement and transparency are in place, then it may not but
the concern is at the moment those are woolly, not clear.
Jim Dowd: Those are the responsibilities of
the strategic authority and the commission. They are the ones
who will impose the quality standards.
945. Could I come back to the patient, patient
representation and influence in the NHS. Even if we get the structures
right, is it not inevitable that the complexity of the mixed economy
will make it more difficult for patients to have an influence
on the NHS?
(Mr Roy) I think initially that is true. However,
if you have a structure which is based on flexible and adaptable
organisations, and ones which are not so closely related to particular
trusts and are more related to the actual patient journeybecause
patients quite often, even without leaving the NHS may travel
across several trustsif you have that kind of structure,
if you have proper resourcing so that the ability to go into the
private sector which would involve obviously more people doing
visits etc, is properly resourced then I think that could be managed.
Obviously it is a bit more complex but, to be honest with you,
even the existing NHS with the number of different trusts interacting
with one another is pretty complex and it is going to get more
complex, in my view, in terms of the patient pathway because of
the other sensible development of things like clinical networks
and greater degrees of specialisation between acute hospitals.
Chairman: If I could just come in. You talk
about a patient journeying across several trusts, across several
countries we have heard this morning, I am interested in what
your thoughts are. We are trying to look at models and if we replace
CHCs what those models will be.
Siobhain McDonagh: I want to be on the CHC which
goes to Spain.
946. How do we take account of the fact patients
will be travelling far and wide?
(Mr Roy) I think there are ways of doing it. I should
say I am speaking personally because we have not yet formally
considered this even among the honorary officers of ACHCEW. My
view would be that just as between CHCs at the moment we quite
often have what are known as host arrangements, that is if there
is a patient coming from one particular geographical area who
is being treated in a trust somewhere else we will have conventions
as to who deals with their problems, who does the visiting and
so on. For example, I am Wandsworth CHC, I occasionally visit
Barnes Hospital which is strictly the responsibility of Richmond
and Twickenham. If we go to Barnes Hospital we make sure there
is one observer from Richmond and Twickenham CHC with us and that
works perfectly satisfactorily. If we are talking about long distance
stuff, I think we probably need to go from a host to a pooling
arrangement where you might have a situation where you might accredit
a CHC or successor organisation to be of a standard where it is
appropriate for them to be sent on to visit overseas.
Chairman: I think perhaps I have taken you down
a questionable direction in terms of our specific inquiry. Richard,
do you want to come in here?
947. I want to go back to charges and costs
because those have only been just very briefly mentioned and really
to Mr Campbell Davis. As I see it there are really two ways that
consultants can do NHS work in the private sector. Firstly, if
a list of their's is cancelled in advance then that list can perhaps
be reinstated in the private sector so they are doing NHS work
in their NHS time in the private sector, that is one scenario.
The other is obviously if extra sessions are put on in the private
sector, which is not in their NHS time. Are there actual agreed
arrangements for paying consultants for those two different types
of work because I am retired, I no longer have an interest in
this at all?
(Mr Campbell Davis) Yes, those are the two methods
by which they can do it.
(Mr Campbell Davis) There are arrangements made by
individual trusts with individual consultants about how they would
pay for that. As you know, the consultant contract is under discussion
nationally and I imagine those negotiations may take some aspects
of this into account. As things stand I believe the arrangements
tend to be local and tend to be with the doctors working in a
949. So there is not an agreement yet that if
they are doing NHS work in NHS time in a private hospital they
do not get paid extra?
(Mr Campbell Davis) They certainly do not in the trusts
I have been associated with.
950. They do not?
(Mr Campbell Davis) They do not. It may be that particular
hospitals have made that arrangement if it facilitates getting
that workload carried out elsewhere.
951. So there is no rule either way on that?
(Mr Campbell Davis) I am not aware of one.
952. I believe in my own part of the country
if they are doing extra lists in their own time they get paid
something like half the ordinary private sector rates, is that
(Mr Campbell Davis) Again, it is determined by the
individual hospital. In the case of my own hospital we have such
an arrangement and we pay at a higher rate but nothing like as
high as they would be paid if they were working for the private
953. Just a quick question to conclude. You
mentioned before to Dr Taylor seven per cent of nurses were leaving
the profession a year. How many of your members now are non NHS,
do you have that figure?
(Mr Catton) Yes. 25 per cent of our membership work
in the non NHS sector but I think it is important to mention that
can be in a range of settings, for example in industry, it can
be independent care homes, private, charitable.
954. Might you be able to write to us and say
how the balances have changed over the years, the pie chart, as
it were? Presumably it is increasing year by year at the moment,
I would have thought.
(Mr Catton) Certainly I will look at that and try
and find you some more information. The other interesting figure
from our membership is people who are leaving the profession,
so this is based on our membership records, and the people who
leave the RCN give us the reason they are leaving because they
are leaving the profession and last year that was at 20 per cent.
955. Just on this issue of mixed economy of
health, what do you see the problem for your membership of working
within that environment is?
(Mr Catton) The complexity issue which was raised
a minute ago, I think, yes, systems and structures could be more
complex but so is the whole nature of health: more information
from e-mail, treatment options and all the rest of it. I think
there is a much bigger issue there about what the future health
care worker will do and some of that may well be around the guider
and the interpreter, more accompanying the patient through their
journey because of this massive information and different structures.
I have talked about the difficulty with fragmentation and commissioning
and equality. There are some key workforce issues that if there
is a mixed economy, if people are moving between sectors will
their continuity of employment be protected? Pensions is a big
issue. There is a difficulty in recruiting from the private and
independent sector. Similarly, opportunities for career development
and promotion, whether those are balanced across the sectors.
956. Equally, in terms of the pure self-interest
of your members, presumably it is a much better environment to
be because they have much more power and they have much more choice
open to them. I am thinking specifically of agency nurses who
have gone over to an agency and then there are nursing homes particularly
where they have gone back to the same nursing home at a much higher
rate and then they have been taken back on to the nursing home
staff at a higher rate than they were before.
(Mr Catton) Higher pay rate?
957. Yes. So in terms of the interest of your
members it might refer to the mixed economy because there is more
(Mr Catton) Nurses have always moved between the different
sectors, and that may have increased in recent years but that
has always been the case. The private independent sector employers
will often say to us that they have a problem with people not
staying with them because promotional and career development opportunities
are back in the NHS. Also, they have a problem in recruiting around
the pension issue as well, that mixed career path, and moving
in different areas has always been a feature.
958. We have heard a lot recently about the
amount that trusts are paying for agency staff. Do you expect
in the next few years to see a migration back from agencies to
the NHS but also staff coming back being at significantly higher
levels of pay given that might save money for the NHS long term?
(Mr Catton) The difficulty is that in our experience
the NHS has been reluctant to pay overtime rates. If they needed
extra staff to cover a shift they may have offered time back or
they may have offered it at plain time rates but they were very
reluctant to pay the nationally agreed weekly overtime rate to
do that work. There were real difficulties for nursing staff because
they ultimately felt as though there was pressure put on them
to cover a colleague who had gone. Then they went and did agency
work. If the appropriate rates were paid the NHS nurses would
do it. There is also the issue of continuity as well, they have
got the same staff looking after them rather than this mix of
959. Do you think it is a fair criticism that
trusts have been too short sighted? They have not foreseen what
would happen by being perhaps too rigid? Nursing staff have gone
over to the agencies and the NHS is paying out a lot more now
because of that.
(Mr Campbell Davis) It is changing. Certainly it happened
in the past but, of course, it is a consequence of trusts being
as short of money over many years as they have been and trying
to do everything all at once which means that you squeeze everywhere
you can. When you look at your overtime bills and your agency
bills and those you pay the bank nurses working within the hospital,
in the case of some of the London trusts it is six or eight million
pounds a year. So the advent of NHS professionals, which is the
NHS as a managerial way reacting to that and saying "Let
us bring this in-house. Let us stop feeding this into the private
sector to this degree" I think will transform it over the
next couple of years.
Julia Drown: The Committee did not want to let
the NHS Confederation go without picking up some of the points
you make about the PFI in your evidence. You may want to respond
to some of this in writing. Four brief things from it. First of
all, you talked about the need to have flexibility in PFI schemes.
You suggest that the private sector is prepared to absorb, contractors
may not be willing to take on any flexibility considerations for
long term future. Also, again on risk transfer, you said in 5.2.1
of your evidence how some of the transfer of risk has not been
particularly valid. I would like to hear more about that. We were
also quite interested in your work on the future hospital network
which showed best practice of future hospital developments, and
we would be interested in your thoughts and what has come out
of that so far? Finally, we have been interested in how the PFI
could be made to be accountable and more obvious to the public?
In your view, do you think it would be possible on a sheet of
A4 to be able to quite easily explain to the public the difference
in cost between the PFI option and the public sector comparator?
Chairman: That is some question at five to one,