Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 60 - 79)



  60. You mentioned earlier Norway and the fact that as from January of this year in Norway people have a free choice of hospital. The Telegraph reported the other day that you will be able to have a choice if you have been waiting more than 12 months. Is that right, that you will have a free choice of hospital if you have been waiting for more than 12 months?
  (Mr Crisp) Happily I am not here to speak on behalf of the Telegraph or any other paper, but we are certainly, as Mr Milburn has made clear, looking at how we can introduce more choices in the system. There are some choices in the system at the moment and we want to emphasise them and make it clear that patients have more control in the ways I talked to Mr Steinberg about earlier. Whether that particular report is accurate or not, I do not know.

  61. But you are the Chief Executive of the NHS.
  (Mr Crisp) But not of the Daily Telegraph. My interest is in looking at firming up exactly how we introduce choice into the NHS.

  62. Is it not possible we could have a free choice of hospital throughout Britain without waiting 12 months first of all?
  (Mr Crisp) I think that would be highly desirable. Let us be clear though that we are coming from a position which is, as this report says—and this is what I am relying on, I am not remotely complacent about it—unsatisfactory. We need to make a lot of changes here and we need to increase activity, increase staffing, improve the way we are doing things. Over that period of time we will, I believe, get to a point where the patients will be much more in control and where we should be able to look at choices in the way you are talking about.


  63. Before I turn to the next member can I ask a question of the Comptroller? It arose from an answer given by Mr Crisp on paragraph 2.22, where Mr Crisp mentioned the very low numbers who responded to the survey, 558 out of 20,000, and Mr Crisp seemed to be suggesting that this threw into doubt the validity of the conclusions reached. Would the Comptroller or somebody from the National Audit Office like to comment on that?
  (Sir John Bourn) The position on the figures, Chairman, is that we got the fullest information we could in the time available and we discussed it and the number of cases with the Department, but we are not claiming that the figures meet the highest criteria of the statistical profession. Nonetheless, we think they give to the Committee a good indication of the thrust and the nature of the issue.

  64. But of course Mr Crisp has agreed this report, so presumably you both agreed that although it is a low sample it does have a real validity for our deliberations, otherwise you should not have agreed the report.
  (Mr Crisp) I intended to make the point, and am happy to make it now, that this sample, 50 per cent of which is from one speciality, is an indication that we have a problem. My point was that it is not so it is a problem across all specialities and there may be some other areas where this is not an issue, so we need to treat it as a problem and identify it as a problem and deal with it but there are some other aspects to take into account as well. That is all I can say.

  65. But if you had some further information that this was giving us a wrong view of it, because of the other specialities, you might share that with us in a note?
  (Mr Crisp) Indeed, let me come back to you on that.

Geraint Davies

  66. Turning to the point that has just been made, in Croydon, which is my patch, it says that 52 per cent of orthopaedic patients have to wait over six months, which sounds appalling. At the same time, when I quizzed the Trust they said to me between March 1997 and March 2001 there was a 13 per cent overall reduction in inpatients and a 44 per cent reduction in outpatients. How would you comment on that? Is that something that underlines your earlier comments, namely this is very tightly focussed on certain disciplines and we cannot infer it across the board or is Croydon trying to pull the wool over my eyes?
  (Mr Crisp) I have a briefing here from Mayday. I think what they have illustrated to you is that they have focussed on a set number of issues, they have actually made a significant improvement in quite a lot of areas but I think they are also recommending they have further to go and the capacity issues around orthopaedics are significant, it is a very high number.

  67. They have to try to make improvements but I am only commenting on the point that has been made by the Chairman of the C&AG that it appears in that case that we cannot infer from specifics, in general they seem to be doing very well and in specifics they seem to be doing very badly.
  (Mr Crisp) I think that is right. I also think the point there is that we have to look at this in each trust to understand what is really going on.

  68. There is trade-off, if one wanted to be a statistical manipulator, working in the trust between producing the overall numbers on the list and getting maybe a quarter of patients and making them wait an extra six months, you keep a certain section of people waiting an enormous amount of time and you push through a lot more people and therefore reduce your overall waiting list, is that a strategy you see adopted?
  (Mr Crisp) I do not think it works like that. What you need to do, what the chief executive needs to look at is to understand the composition of people on their list and they need to understand the people in each speciality by the clinical severity. They need to make sure that people who are most clinically urgent are got through quickest and even within a category the people who have waited longest are dealt with first, sometimes it is just as basic as that.

  69. There is trade-off in there because even if one went down the line that it has to be clinical importance first then you would never treat anyone with an ingrown toe nail, would you?
  (Mr Crisp) On paragraph 2.21 of the Report there is an important balance to be struck. There needs to be some flexibility in the order in which patients are treated. We must not do it too far the other way, but the point that is made here is that on an operating list you know you are able to do two big cases and three little ones.

  70. If there is a little bit of space over I can have my ingrown toe sorted out. The point I am making is that unless you say that it is not the case that the more serious ailments are dealt with then we are never going to deal with minor ailments, other that in the five minutes at the end of your session.
  (Mr Crisp) You can do it in a planned way, if you look at the more serious ones and you conclude they need to be done in the next four weeks or five weeks you can plan to do that, but if you have the right strategy you can also plan to do the people who have been waiting up to 12 months. You can actually do it a planned way and manage to achieve getting clinical priority right and also getting admission for the more minor cases.

  71. The NHS plan pushes forward a more ambitious target, you no longer have to wait more than six months by 2005. Coming back to my ingrown toe nail, does that mean there is enormous pressure suddenly to deal with large numbers of minor and relatively trivial cases?
  (Mr Crisp) We may put more capacity on to it, perhaps I can give you another illustration, we do as a matter of practice make sure that we get patients of clinical, with some minor exceptions, importance, that does not mean to say we should not also plan for the people who are less clinically important. I note that the Royal Marsden, which specialises in cancer, seems to have an average waiting least of seven weeks whereas the average waiting time across the country as a whole is three months. You can see we are putting resources in places where people have greater clinical need, you have to do both.

  72. You are not encouraging people where there are longer waiting lists to go to the Royal Marsden?
  (Mr Crisp) There may be some scope for that but currently people will be referred to the Royal Marsden primarily based on geography and clinical need.

  73. If you did allow Mr Steinberg's suggestion will find that the Royal Marsden waiting list is increasing again?
  (Mr Crisp) I am sorry we have opened up the whole question and debate of whether or not we should have an internal market for this because you are assuming certain consequences of doing that. I think there is scope for us to introduce choice for patients in a controlled way and in looking at it we need to make sure there are not negative effects that come out of it.

  74. We would all agree with that. 46 per of chief executives are said to have redefined the way they accounted information in the year 1999/2000, of which nearly 90 per cent said that meant a reduction in waiting lists. Are you finding that a preoccupation inconsistent with other trusts and is this going to be straightened out so that we do not have apples compared with oranges?
  (Mr Crisp) Yes, we are. Firstly, the definitions have remained consistent through this period. It may be that people may be looking at how those definitions have been applied in their own hospitals.

  75. It says in the Report, "redefined the way it counted its inpatients and nearly halved it in one year", the definitions have not remained the same.
  (Mr Crisp) What you will find that that means, as I understand, is that some procedures which have previously been treated as inpatients have become outpatients, so that something like an endoscopy or a cataract operation will have transferred from an inpatient procedure to being an outpatient procedure. That is because medical practice is changing. That is why that is happening. We have kept the definition consistent through this period and that will continue to happen, more and more people will be treated as day patients who have previously been treated as inpatients.

  76. In terms of definitions this Report does not include Accident & Emergency, pregnancy admissions or anything like that, does it? From the point of view of inpatients that does not include second or subsequent appointments, just the first appointment.
  (Mr Crisp) It does not.

  77. There are limitations to this Report, are there not? Tell me about the 1.5 million patients who are scheduled to have a first appointment and the 13.7 million who do not turn up, what are we doing about that?
  (Mr Crisp) One very strong thing we are doing about that is moving to a booked admission system. What I mean by that is at the point at which it is decided that you need an operation or an outpatients appointment—Mr Fillingham can explain the system much more clearly - you will have the choice of a date and you are able to be slotted into a diary.

  78. It is extraordinary that we are only just starting that. At one point I ran a travel business where people telephoned and said, can we go on holiday on this particular date in this particular place. You booked them, or not, they either go somewhere else earlier on or later, there will always be trade-off in booking appointments in the NHS. It is amazing to me that we have waited this long for people to know when they have their appointment rather than some time in six months. Is that not one of the reasons why we get so many people not turning up, because there is no clarity from the NHS when they are supposed to go and if they do not turn up there is no sanction against them?
  (Mr Crisp) In general I agree with you, which is why we are introducing the booked admission system. Where we have introduced this the evidence has shown that we are reducing the number of people who do not attend. That is where we need to go. By March 31 five million patients will be in the booking system, so we are moving there.

  79. Operating theatres are normally open between 8.30 and 5.30 normally, something like 40 per cent go over that. What I do not understand is why they are not open 24 hours a day?
  (Mr Crisp) Let me just pull out two points here, in every acute hospital there will be some theatres that are because of emergencies, we will have that continuation. In terms of planned lists in general we are working a day that is between 8.30 and 5.30, as you say. The limiting factor there is other aspects of capacity, most notably staffing, including surgeons and secondly bed availability. Our theatres are not in general bottlenecks for getting more people through.

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