Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 1 - 19)




  1. Good afternoon. This afternoon we are taking evidence on the National Audit Office Report on the National Blood Service. We have giving evidence Mr Nigel Crisp, the new Permanent Secretary, Department of Health and the Chief Executive of the NHS. Two heavy burdens, Mr Crisp.
  (Mr Crisp) Indeed.

  2. And Mr Martin Gorham, the Chief Executive of the National Blood Authority. Welcome to both of you.
  (Mr Gorham) Thank you.

  3. Now, Mr Crisp, I welcome you on your first appearance before this Committee as Accounting Officer. I suspect we are scheduled to see you a number of times in the coming months. We will come to be old friends. Let me perhaps start with an easy question for you.

  (Mr Crisp) Thank you.

  4. That is to say as one who has recently taken up his post as Permanent Secretary at the Department of Health and as Chief Executive of the NHS Executive, and with your experience of the NHS in London, can you give us an overall view of the performance of the National Blood Service and what key aspects do you hope to improve?
  (Mr Crisp) Right. Well, let me start with my initial impression on taking up office is that the Service has actually come a long way since the crisis of the 1990s, and I think this very helpful Report shows that. Indeed, I think as somebody coming into post as an Accounting Officer, to have this sort of Report which has gone into the detail around the Service is very helpful. I have also had a chance to go and look at one of the services as part of the Blood Service. I have been previously to other bases before hand. I must say I have been impressed by the professionalism, by the attention to detail, by the standards that are in place and by the commitment. I think the Blood Service has come a long way since those days. I have also been impressed, however, by the fact that there is no room for complacency here, particularly in terms of the public safety issues and particularly in terms of the fact that there is actually an awful lot of detailed work still to be done. I think what this Report is telling me and what my observations are telling me is that the broad thrust is right, we are getting the policies in place but there is a lot of detailed work to do to make sure that we are absolutely where we want to be.

  5. You will probably find me a little less sympathetic than the Report, but we will see as we go on.
  (Mr Crisp) Indeed.

  6. Let me turn to Mr Gorham. This is your first time as well, is it not?
  (Mr Gorham) It is indeed, Chairman, yes.

  7. I will try and give you the paragraph indicators. I will start with paragraph 1.25 which identifies two initiatives that are aimed at improving the use of blood in hospitals: the National Blood Service's National Blood Stocks Project and the Chief Medical Officer's `Better Blood Transfusion'. Can you tell the Committee how successful these have been in reducing wastage of blood within hospitals and improving the way it is used?
  (Mr Gorham) Yes, Chairman. We have seen a reduction in the wastage in blood. In fact, if I can refer you to table number 7, there is a table which shows wastage. We have actually seen a further reduction of about 0.4 per cent in wastage since that table was prepared. We think that is probably partly based on the Blood Stocks Project but I think it would be ambitious to try and get a direct relationship. The particular strength of the Blood Stocks Project has been to bring the NBS and a number of hospitals together, to work together, again doing some very detailed work. It set up a scheme, a daily check on stock levels and wastage and enabled hospitals to compare their performance with other hospitals' performance. As a result we had 67 per cent of hospitals reporting changes, either reductions in blood stocks or other changes in practice. We have now recruited 123 hospitals to the Blood Stocks Management Scheme which, if you like, is the successor to the Blood Stocks Project. That is going to be partially web based so it is going to be much easier to do information exchanges. Again, we think that is going a long way to building links between our Service and the NHS hospitals we serve. In terms of Better Blood Transfusion, obviously that has encouraged the development of transfusion committees in hospitals and the figure reported in here, we have a very high level of attendance to that. We have developed our own services to give better support to that in two ways. We have developed our hospital liaison function, which is to work very directly with hospitals, and we have also developed the organisation of our medical staff in such a way that they give better specialist advice to hospitals. So we think it is laying some very important building blocks in terms of taking us forward and bringing expertise and influence on blood usage in hospitals.

  8. Thank you for that. Others will no doubt come in on it. My only passing comment is that in my part of the world the National Blood Stocks Project was thought to be stud farms. Clearly some of the Committee Members do not understand the reference so I will let them work it out. The next question relates to figure 17 on page 25. This is a part, I have to say, where I am a little sterner in my view than perhaps the Report reflects because I am a would-be blood donor myself. What it shows is that existing donors stop giving blood at a rate of around 200,000 a year. Can you tell the Committee what action the National Blood Service is taking to reduce that rate of loss?
  (Mr Gorham) Yes. I think the context of this is that we have had to do a number of things to improve blood safety which, frankly, have not made life easier for donors. Clearly in particular the concern about the possibility of variant CJD being transmitted by blood led to a number of actions which actually makes the whole donation process longer. So we have had more safety checks, we have had the donor questionnaire. We have had more staggered operating procedures. We actually have a more complicated process all the way through. We extended our core computer system—Pulse—into the donor area. All of that frankly slowed the Service down. What we are now trying to do is to take steps to speed it up again without in any way compromising the safety. We have a whole set of initiatives that we have been preparing and we are going to be undertaking over the next year. Probably the most important is a review of the whole donor process which we are doing right across the country because, as I am sure you will have gleaned from the Report, practices vary in detail quite a bit in different parts of the country. If we are going to carry through change we have got to take the staff with us, they have got to see that it is taking account of their local practice. So we are doing a very major review of that. We are looking at the whole issue of session opening times and whether sessions are in the right place at the right time. We have a long historical record, maybe we have not moved things like that on as quickly as we might have done. That is another important aspect. We are looking at whether we can get more volunteers supporting the Service. A few years ago there was a lot of volunteer support, it is now quite patchy and we think if we could recapture that local connection that could very helpfully allow us to speed things up again. I think those are the major things that we are looking at in the short term. They will take time to work through because carrying through changes has got to be done against a context of maintaining safety all the time.

  9. I understand that. I am pleased to hear that you are reviewing session opening times and hopefully it will deliver some improvements. I have to say, however, and it is very dangerous to judge from anecdotal experience, but experience of being kept waiting a very long time, not for any apparent reason, or even having an appointment and turning up and them saying "join the end of the queue" is not very clever and does not arise out of safety measures from CJD or changes in the approach, it is just poor management.
  (Mr Gorham) Yes. We have been piloting appointment schemes and in some ways we have found it very helpful but it is not a panacea. What we have discovered is some donors do—

  10. Not if it does not work it is not a panacea.
  (Mr Gorham) We certainly have some work to do. On some sessions we simply have not got it right and we are working to get it right. Some donors do not want appointments, they value the ability to drop in. What we have found is that it is very difficult to have a system which is a mixture of appointments and drop-ins, that does not work well. The other problem we have had is that our donor IT system does not enable us to use technology to offer donors the ability to change their appointments and that is a service that donors can expect and are right to expect. Until we have sorted out the technology to enable us to do that we simply are not going to be able to offer a robust appointments system of the sort donors want and we want to give them.

  11. Just to press on, paragraph 3.6 tells us that in 1999-2000, 40 per cent of those who enroled as donors failed to give blood. Are the reasons the same and what are you going to do about it if they are not?
  (Mr Gorham) What we have discovered, again, from the work we have done is stating an intention to give blood and actually giving blood are two separate stages. I think in the past we have tended to think that people will automatically move on and that is clearly not the case. What we are now doing is being very much more active in going back to people who enroled much more quickly and offering them appointments. We have now developed a video to send to newly enroled donors which, again, encourages them to come forward. That is a very new initiative and we do not yet know whether it will work. From our survey work we did discover that if you did not invite people to an appointment within one to two months they were highly unlikely to turn up, so we have changed the whole way in which we react to newly enroled donors to try to get a better conversion rate.

  12. That is helpful. The National Audit Office's survey of the public and complaints from donors, as summarised at paragraph 3.14, indicated that the waiting time during donor sessions is a major problem. You have already talked a little bit about that but what are you doing to improve services to donors to minimise the time they have to wait?
  (Mr Gorham) Really the initiatives that I have been describing are aimed at trying to reduce waiting time.

  13. Are you measuring waiting time?
  (Mr Gorham) Yes, we do measure waiting time. It remains the biggest matter of complaint and it is the issue that we have to crack if we are going to continue to attract and retain new donors, which is why we have got such a wide range of initiatives to try to deal with it. I do not like waiting and I can understand other people not liking waiting.

  14. It may not be a matter of not liking waiting. If somebody is coming along in their lunchtime, it is not a question of liking or not liking, and they have got an appointment somewhere else they cannot do it.
  (Mr Gorham) I think that goes right back to the issue that some people want appointments and some people do not. If you go down into a rural area it is almost like a community event. My attitude still is people should not have to wait. If they choose to stay on afterwards because they are there with their friends that is fine, but we should not be making people wait. Until we sort that out we have got a real problem. I think the other thing that has had an impact on this is our tv advertising in particular has been very successful in bringing people forward to donate but it tends to have quite an immediate effect so we then get some very overloaded sessions and that has undoubtedly had an impact on this and made it worse.

  15. Thank you for that, Mr Gorham. I will come back to you at the end of the session but I will turn to Mr Crisp now, if I may, and give you a rest. Mr Crisp, we have seen press coverage of the Department's recent decision to require the use of disposable instruments in some operations because of the risk that sterilisation equipment will not be effective in removing things like the CJD prion presumably. Paragraphs 1.20 and 1.22 set out the measures put in place to reduce the theoretical risk of transmission of variant CJD through transfusion. Does the Department have any plans to reduce the risk further?
  (Mr Crisp) I think there are perhaps two points to make here. The first one is, as I understand it, all instruments that are to be used for taking blood are disposable, so we are not in that bit of the territory. There is a question that is raised around the use of fresh frozen plasma and that is an issue which is seriously being looked at right now. We are taking it through the normal processes, taking advice from the appropriate committee, which is the Microbiological Safety of Blood and Tissues for Transplantation Committee. We are literally at the point of looking at that now.

  16. Is that likely to come to a conclusion in the very near future?
  (Mr Crisp) I would think it would come to a conclusion pretty soon.

  17. Could you let us have a note if it is before we publish?[1]

  (Mr Crisp) Indeed.

  18. That would be helpful, thank you. Finally to you, Mr Gorham again, a question I forgot: what action have you taken to secure the widespread adoption of best practice and make full use of internal cost comparisons, as recommended in paragraph 13?
  (Mr Gorham) In a sense those are two separate questions, Chairman.

  19. They are related.
  (Mr Gorham) They are related certainly. In terms of best practice, the reason why we decided we had to adopt a genuinely national structure was because we did not think it was possible to get best practice throughout the Service unless the management lines cut through the Service in that way. That in no way conflicts with our belief that we are trying to offer local services within a national framework. We are conducting major reviews in all of our operational departments at the moment looking at current practice, practice variations and best practice, and over the next months we will be moving services towards those best practices. I suspect it is going to take quite a time to get there because we are looking at it against the background of very significant historical variations. In terms of costings, we have not enjoyed comparable cost bases in the different parts of the services. The three zonal costing systems actually had significant variations. We are taking the first real step in putting that right in this year's budgeting where we are moving things to common definitions and a common set of costings. I think we need a year's experience before we can say those are really robust but certainly we are determined to get to the position where we can make meaningful cost comparisons because, in the first instance, we actually think that is a more important approach to benchmarking than trying to move some international comparisons where you have got some quite significant variations, which is difficult to get out of the way, whereas with our own internal variations we have a sort out.

  Chairman: Thank you. Let us widen the issue out. Mr David Rendel first.

1   Note: See Evidence, Appendix 2, page 3 (PAC 2000-01/157). Back

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