Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 140 - 151)

MONDAY 29 OCTOBER 2001

CLLR KEVIN EARLEY, MR STEVEN MASON, MR ANTHONY RABIN, MR MIKE ARCHBOLD, MR JEFF THORNTON AND MR JOHN FLOOK

  140. It has been suggested because of the costs the Trust faces now in terms of its payment to the contractor that that does not enable you to fully staff all of the beds in the hospital, something like only 350 are staffed, is that correct?
  (Mr Mason) That is not correct. I have to say in fairness when you look at the full business case there was assumptions made in the full business case that there was a level of occupancy of 70 per cent when the hospital opened. That clearly is not the case, obviously it is significantly higher than that. We did carry out a review of all nursing establishments and we are now at the sort of mid range use in the district audit comparative analysis. We have looked at this on a number of occasions in a fairly detailed internal review and also sought opinions externally in terms of what would be the correct level of staff and the wards are staffed on the levels of occupancy they are currently experiencing. It is fair to say the full business case did assume staffing of occupancy levels of 70 per cent.

  141. What is the current occupancy level? We know you had trouble with bed shortages over the summer?
  (Mr Mason) At midnight we are running at levels of occupancy of 90 per cent, which is in excess of the recent bed review, which suggested it should be running at 82.5 per cent and during the day we can run at over 100 per cent.

  142. Given that you had that during the summer does this suggest with winter pressures coming on there is cause for concern and occupancy levels are not leaving you with a great deal of scope.

  (Mr Mason) I am concerned at the occupancy levels because I think there is enough evidence to suggest if a hospital is operating at very high levels of occupancy you have very limited amounts of flexibility and that does tend to lead to more cancellations on the day of surgery, obviously there are concerns round that but there is not really the distinction between summer and winter we often talk about. If you look at general medicine it tends to be pressurised for eleven months of the year and it is often only in August or September, which might be connected with the holiday season, where it tends to noticeably drop. We tend to have one or two months in the winter that tend do have spikes of activity. We are now closely working with the social services department locally and primary care groups about trying to put extra capacity from late November onwards to try and put more beds into the system so that we have some flexibility to deal with that type of activity. Obviously we would like to be running at the 82.5 per cent level that is recommended in the recent report if at all possible. The key to that might not necessarily be more beds within the hospital, it might be eliminating the problem of delayed discharges.
  (Mr Flook) The Health Authority were very supportive of the independent studies into the cost base of the Trust and the clinical service performance for the simple reason we were anxious not to put the Trust in the position of signing up to something that could not be delivered. In the circumstances that existed at the time the outcome of those independent reports was that these things were achievable and that the changes in working practice in the hospital, these clinical standards, were achievable. Whether they are still relevant I think is a point that Steven is moving on to at the end in answer to another of your questions and, yes, a lot has moved round since the time we had those independent reports.

  143. Are you victims of changing philosophy generally the Health Service?
  (Mr Flook) There are a lot of dynamics constantly moving round in the Health Service and some of those have not moved the right way since this was done.

Chairman

  144. One of those dynamics may be the concept of intermediate care, it is a very old concept in a sense but it seems to have been revived for some reason recently. Presumably your bed blocking problem is long-standing, what assumptions were made about the role of social services when you began to look at your bed numbers? Were the local authority involved in discussing how you make provision in the scheme for assisting them? Was there any discussion? Were they involved in the project?
  (Mr Mason) When the business case was developed the configuration of services within North Durham was different than it is now and it will change again next year because there has been at lot of organisational change. The business case itself did focus very much on acute hospital perspectives in terms of delivery of health care. Within the business case there was an assumption that community services would be developed to the tune of £1.5 million per annum to support the reduction in the beds. It is fair to say there was an investment of about £1.5 million, some of that has gone to improve the existing infrastructure of where the services are delivered. About £850,000 of that money is round the development, for example at Shortley Bridge. That is not adding to the quantum of services available but improves services provided. We commissioned an intermediate to care strategy and we now have people signed up to that within social services and primary care and within the Trust to work together to improve that. With the benefit of hindsight it would be nicer to have had it earlier. We are working through that within terms of how we manage.
  (Cllr Earley) We should have thought about issues at the beginning, the more pressure put on hospitals the more you put on the social services. They are queueing up at the door to get out. If you are putting more pressure on social services to perform the more you use hospital at home, you are sending people at home when you have occupancy rates of 118 per cent. They are sick people who need a lot of nursing time. The people who are in and out for surgery, who used to spend ten days, you do not have those taking up hospital beds, you have somebody else sick who needs attention. That is a day-to-day human story for your staff. You have to bear that in mind when you are upping your efficiency.

  145. Presumably you are on the social services authority?
  (Cllr Earley) I am on the district authority.

  146. Would you say if the social service authority had been more involved with the scheme initially the arrangements might be some what different to what we have?
  (Cllr Earley) There you get very focussed. I think you need to get down a bit in the bunker and see the price. As John was saying, 30 years without any significant investment. All of the things we talk about, getting design right and all of the business information and developing relationships that does fill the horizon a bit. If we look at it a bit broader, things are changing, we have made some good inroads with our friends at Kenby Hall and there is a lot of stuff that will come in which will help, and the extra money that the government is putting into bed blocking.

Andy Burnham

  147. There have been reports because of bed capacity complaints, are you considering a partnership with Nuffield hospitals and if that is the case how would that arrangement work?
  (Mr Mason) We are considering a number of options. We are busy reviewing the hospital design internally to look at some areas that are not as well utilised and if they cannot be made better use of by changing them. For example, there is an area within theatres for second stage recovery which could convert into additional beds, we are examining the feasibility of that. We are looking at the feasibility of an extension, not just to provide some extra capacity but also to look at the provision of service. I think most people realise there is quite a difference between where we are now and the accommodation that is available within the new hospital. We have looked potentially at whether that could be with the private sector, such as Nuffield, or another private provider or whether we could do it ourselves. We are looking at a number of options as to whether we are going to have an extension with our partners in terms of a PFI extension or whether we would not put it up as a publicly funded extension, but again you get back to is the money available centrally. To have a publicly fund extension you have to look at what represents best value. We are at the very earlier stages of doing the business case and that will be submitted to the primary care groups and then on to the regional office for consideration. One of reasons we need to look at extra capacity is the NHS plan has set very challenging targets for waiting times. If we are going to achieve those standards it undoubtedly true that we are going to have to have some extra capacity as well as a further review of working practices. Also within Durham the elderly population is projected to increase quite dramatically over the next 10 years. Obviously we need to build that in and plan for the future. In many ways that comes back to my earlier point, the health service has not traditionally been very good at planning ahead, you tend to get a new facility to cope with the existing service configuration. I think it is inevitable whether it was a PFI or a publically funded hospital we will be look at some form of extension in the future. If we are doing that now because we have the local Modernisation Review that is focussing everyone's mind.
  (Cllr Earley) The other thing we mentioned a couple of years ago was whether the elective surgical unit would be a way of using existing resources to get more people through. It is going to be a £67 million PFI general hospital and if you want to make some use of it then it may be there to be used as an elective surgical unit for orthopaedics or whatever.
  (Mr Flook) In the light of NHS plan and the National Bed Review the Health Authority has recently started a complete comprehensive review of acute sector bed need and utilisation across the county and that will have implications for this hospital we are sat in at the moment, Darlington Memorial and Bishop Auckland Hospitals.

Dr Naysmith

  148. A question that comes up on the back of all that, and which you talked about a lot, is getting involved in the design and so on. There have been suggestions from think tanks that the contractor could take on provision of all the hospital services, including clinical services, I am not advocating that, but that would mean the Trust would not need to be involved in the design of a hospital like this. Maybe we should ask the representative of Balfour Beatty, after you have commented, Mr Mason, on that.
  (Mr Mason) I am aware that the idea has been suggested but I have not studied any documents in detail to say how that would work. It is theoretically possible to contract it out to the management of a local health care facility. I think we need to look at it very carefully because management of a Trust is a very complicated business and I think the private would have to look at the relevant risk associated with that before they would make a commercial decision about whether it was worthwhile. I am aware of the proposal. It is possible but I think the devil would be in the detail really.
  (Mr Rabin) I can respond by saying that Balfour Beatty have no plans to be involved in that area—

  149. You must have considered.
  (Mr Rabin) A very simple reason. That which we do as subcontractors here, either in terms of building the hospital or providing the service as we do, is part of our bread and butter existence. We believe that it is a natural and logical extension of activity. We do not provide clinical services as part of our bread and butter activity and therein lies the fundamental and essential distinction.

John Austin

  150. Are there any private beds in the new hospital?
  (Mr Mason) There are not at the current time. It is part of the review I referred to earlier to look at the provision of some private beds but not a significant number.

Dr Taylor

  151. The term "affordability gap" has been coined by some of the critics of the private finance initiative, I would like to know how you answer that? The figures that are given are that from the Trust's own accounts only seven per cent of income is available to pay for capital and the amount you are having to pay is obviously a great deal more than that seven per cent. Are those figures wrong? Do you have the amount to pay? Is there an affordability gap? How much money do you get from the government as smoothing funds that are given to ease the gap?
  (Mr Flook) I have been associated with major capital schemes for 30 years now in this region, the Freeman Hospital, the Memorial Hospital, Northallerton and North Tees. Every new hospital costs extra to run. When capital was a free good the extra cost was primarily about additional clinical staff and services, that was the climate at the time, and it was a genuine development of services for people when they got a new hospital. Those days have past partly because people started to abuse it and it got discredited. Capital is no longer a free good and the reason why additional costs are incurred when you replace old building with new buildings is because there is a financing cost to capital, it has to be paid. There is no affordability gap, as such, because in the full business case the Health Authority took it into consideration, decided it was affordable, it was worth paying, the money was put aside and the Trust has been funded to cover that.

  Chairman: Can I thank you for your participation. I wonder if it might be possible for you to remain with us because there are areas where we may wish to come back to you arising from the next group of witness. We hope to conclude not long after 5 o'clock, so we hope it will not be too long. Thank you very much.



 
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