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Independent Sector Treatment Centres

I congratulate the Chairman and members of the Health Committee on producing the report, which is excellent and very fair. It is a pity that it has taken so long for this issue to be debated, as it now lacks an element of currency, but the debate is quite timely given the impending decisions that Ministers have to make about phase 2 ISTCs. I hope that the Minister is going to say something about those. It is a mark of the times in which we live that the campaign group ““Keep Our NHS Public”” has accused Ministers of acting ideologically because of their apparent preference for supporting the independent sector in health care. I certainly would not accuse Ministers of being ideological in that respect, but I shall ask the Minister to account for many of the elements of ISTCs that were highlighted by the Select Committee. What matters for us is what works. Like Ministers, I hope, we have no particular ideological hang-ups about public, private and not-for-profit. Surely what matters—I hope that we can all agree on this—is what delivers outcomes for patients. The report focused very well on issues such as choice, quality, cost-effectiveness and innovation. We, too, need to focus on them, as well as on supplementary areas such as training, about which we have rightly heard today. We need to focus on the impact that ISTCs might have on those areas, and on the extent to which those issues might have been overlooked by Ministers in their pursuit of ISTCs. There is clearly a case to answer, because some of those elements have been recognised and addressed as part of phase 2. I know that this matter is of great interest to the Labour party and has caused quite a lot of unhappiness. It divided the party conference and caused some problems for the Health Secretary at that time. Helpful as ever, my hon. Friend the Member for South Cambridgeshire (Mr. Lansley) offered some words to the Health Secretary back in September. He said that she"““would not have this problem if she had listened to our advice and created genuine competition, not preferential competition, which means that independent treatment centres currently carry out 73 per cent. of work, but are paid for 100 per cent. This is why hospitals are closing down wards.””" The Department of Health has analysed the possible effects of independent sector treatment centres on district general hospitals, but has refused to be entirely candid about the results of that analysis. That is a great pity. We have heard about our ability to hold the Government to account, which we do largely through Select Committees. If the Department of Health feels unable to share that kind of information, that degrades our ability, as parliamentarians, to call the Government to account and is a serious matter. We need to know why the Committee and the House have been denied that information. That is particularly important at this point, because district general hospitals are facing something of a pincer movement. They are facing threats from ISTCs and from the move towards tertiary centres. We have had the Boyle and Alberti reports recently, and the idea that trauma should be centralised and that some accident and emergency departments should, perhaps, be downsized. Those factors have serious implications for the concept of district general hospitals. Ministers are right to say that nothing should stand still and that a model that was created in the 1960s needs to be updated. However, we need to celebrate what is best in our health service and we must also remember that district general hospitals provide a whole range of things in addition to direct patient outputs. We have talked about training and I hope that the Minister will talk about it a little more. Tomorrow, I am going to visit the Gloucestershire Royal hospital, where I worked briefly before I was elected. No doubt, the hospital will want to discuss what phase 2 will mean for it. There seems to be some confusion out there in the provider arm of the national health service about what independent sector treatment centres there are going to be and when contracts are going to be signed off. It is also important to recognise that it is not only large district general hospitals that are affected by ISTCs. The hon. Member for Dartford (Dr. Stoate) mentioned primary care, and rightly so. Community hospitals will also be affected. I know, to my cost, that a very valuable cataract service at Westbury community hospital has ceased to exist; of course, those sorts of services are threatened when ISTCs appear. One of the selling points of ISTCs was the idea of innovation: that ISTCs were going to innovate and bring new things to health services. There is nothing particularly new about stand-alone centres of these sorts. I recall a hospital called Black Notley near Braintree, which closed down in 1998. It had provided services for local communities, particularly cold orthopaedic surgeries, since 1904. We can sign up to the concept that cold and non-acute cases might usefully be separated from emergency cases if cold cases are consistently being delayed or de-prioritised. We must also recognise that there need not necessarily be an ISTC model delivering services. Other hon. Members have discussed how that problem, which affects the cold, elective part of the health care service when it is faced with the priority of emergencies—of course, priorities come with emergencies—can be addressed. I am also less than convinced, as I believe the Committee was, by the idea that ISTCs brought innovations to the health service. Interestingly, Professor Karol Sikora was talking about cancer treatment on this morning’s ““Today”” programme, and parallels do exist because his concern is not that the NHS is not good at innovation and research, but simply that it is not terribly good at rolling out its results. I have seen no evidence––neither, clearly, has the Committee––for suggesting that ISTCs, rather than the wider service, have been the crucible for innovation. The problem has been that the wider service has perhaps not rolled out innovations in quite the way that we might have hoped; in a sense, they have been reinvented in a number of ISTCs. One or two hon. Members mentioned the avoidance of cancellations. I support measures that will avoid the awful situation where people are phoned on the morning of their operation and told, ““Don’t come in, because we are full. We have emergencies and we simply cannot accommodate you.”” Such situations are not always due to emergency surgery, because they can occur for a range of other reasons. Recently, wards have unfortunately had to be closed because of infections. I do not discern any difference in the pace of that cancellation rate. The rate remains, and these situations are deeply distressing, particularly for patients who have worked themselves up for operations. I am thinking of elderly patients and those requiring hip replacement surgery. Often such people have starved themselves overnight only to be told not to come in, sometimes on a serial basis. I commend Ministers to examine measures that might avoid that happening. This issue is important and cancellations are still occurring. The case mix on pages 12 and 13 of the report shows that ISTCs are not necessarily doing the sort of stuff that is likely to be subject to cancellation. Orthopaedics are clearly in the frame, because where an emergency requires theatre time, cold cases—orthopaedic cases and elective cases—will be cancelled, but ISTCs are doing a range of other things: ophthalmology; dermatology; ear, nose and throat—ENT; rheumatology; and endoscopies. Such things require different practitioners from those who might be involved in emergency cases, different facilities and different operating theatres. It is unlikely that ISTCs, certainly as currently configured, will make a big impact on avoiding hospital operation cancellations. I wish that they would, but I simply do not see it happening, given the case mix displayed. Training is vital and topical. Ministers have to deal with the debacle of modernising medical careers and the medical training application system—MTAS. There is a real problem in the training of junior doctors. Phase 1 ISTCs did not do training in any meaningful and systematic way. To be fair, the Government response appears to have recognised that and at least says that they will ensure that training is a part of phase 2, but the Minister needs to give us more detail. What does he mean by training? Who will be trained? To what standard will they be trained? Will those doing the training be competent? Will they be in a position to train juniors in the kind of competency-based way that we expect these days? It is bizarre that additionality means that NHS juniors will not be trained because we are effectively importing overseas doctors under the additionality rule. That is odd indeed. I hope that as part of phase 2 and the contracts which we believe are up for signing shortly, Ministers will ensure that additional training capacity is created. We were told recently in the House that it would be, in order to sort out some of the shortfall that we expect shortly and the medical unemployment that seems likely. This seems to be an opportunity, and I should be interested to hear from the Minister what he has done with independent sector providers to ensure that capacity for training within ISTCs has been upgraded to fulfil the Health Secretary’s promise that additional places will be created. There appears to be an element of job loss within the service. I recently received a note from a consultant at the Royal United hospital in Bath on the impact of ISTCs on his institution. It starts extremely well, saying:"““First, I just wanted to say how much I appreciate your strong and high-profile campaigning on the NHS nationally.””" Naturally enough, I warmed to this correspondent immediately. He went on to say:"““Regarding the imminent cutbacks and job-losses at the RUH…I just wanted to make a point which I feel is not really being highlighted and yet I feel is very relevant. It is no surprise that job-losses are felt necessary by our trust’s management. One contributing factor is the so-called Treatment Centre…nearby in Shepton Mallet…which is treating straightforward patients for routine ops at an inflated tariff and leaving the more complex cases as well as sorting out their errors, to the local NHS.””" That is a pervading worry of ours. Because we have not got the data to refute it, there will always be a suspicion that ISTCs are in some way poaching staff and providing a service that is not as effective as that in the mainstream NHS. The fault lies with data collection: if we do not have the data, we cannot refute the allegation. The hon. Member for Wyre Forest (Dr. Taylor) talked about consultants ““kicking around””—I believe that those were his words. I think that he meant that they had some spare capacity. The British Orthopaedic Association, which is vilified directly and indirectly in the report and the Government response, says that at least 30 trained surgeons with certificates of completion of training are unable to get jobs and cannot work in ISTCs because of the rules on additionality. The Minister says that phase 2 will involve a relaxation of the additionality rule, which must be welcome. Apparently, there is a list of shortage professions whose members will not be admitted to work in ISTCs but everybody else, by implication, will be. But of course, shortages mean many things and one cannot simply identify a shortage profession. Is that list speciality-sensitive? Is it geographically defined? Is it grade-specific? Much has been said about the quality of output from ISTCs. In January, a Department of Health document was leaked. It pointed out that national data on the clinical quality of ISTCs are"““incomplete and of extremely poor quality””" I am left wondering why, in this day and age when we are so focused on governance and when this Government have put so much effort into obliging doctors to do governance, it is felt that that governance does not necessarily extend to the Department of Health. In governance, one must ensure that one measures what one does, that one audits everything that one does and that one looks back to try to determine how one might do things better. In this respect, this Government, pretty well by their own admission, have simply not bothered to collect the kind of data that would enable one to do that kind of auditing exercise. Such an exercise would enable one to compare and contrast ISTCs, one with another, the effectiveness of private sector providers, one with another, and it would allow comparisons to be made with the mainstream NHS. That is a serious omission. It mirrors omissions of a similar sort in public health. We shall be debating the alcohol harm reduction strategy on Tuesday. Its first phase has not been assessed in any meaningful way, so how on earth can we go on to the second phase? In respect of modernising medical careers and MTAS, it is clear from the Health Secretary’s hesitant response to questions put by my hon. Friend the Member for South Cambridgeshire about quality assurance that little of it was built in to that adventure. I suspect that that is part of the problem. Both the Health Committee and the Government said that organisations such as the British Orthopaedic Association have been alarmist in their assessment of poor quality, but the Government cannot say that such organisations of professionals in the field are being alarmist if they have not acquired the data to refute the allegations. I am afraid that the Government have done themselves no good in failing to acquire that data.