Examination of Witnesses (Questions 80
MONDAY 19 NOVEMBER 2001
80. Tell me about bed availability and bed blocking,
it is the case that some people in the nursing home industry say
had there is almost a shortage of nursing homes, particularly
in London and the southeast, and people are selling up and going
into residential homes, normal people who do not need support,
and in fact the cost of beds in nursing homes is appreciably less
than the NHS. Do we have the numbers wrong, should we invest more
in nursing homes and less in marginal beds in the NHS?
(Mr Crisp) This is taking us into another hugely big
and important topic.
81. It does impact on waiting lists.
(Mr Crisp) But it is not quite exactly as you describe
it. We have this year about the same number of people delayed
in hospital by lack of a transfer to nursing homes as we have
had in previous years.
82. Too many.
(Mr Crisp) Too many. We need to understand why and
what we can do about it, because it is not just as simple as putting
up the price of nursing homes or creating new ones. There is a
whole series of interventions we need to put in place. You are
quite right, when we have people in hospitals who do not need
to be in hospital, we cannot put people in hospital who do need
to be in hospital. So it is all part of a much bigger system.
83. What I am getting at in simple terms is
that the cost of an extra bed in the NHS is the same as the cost
of two beds in the nursing home sector, so clearly at the margin
you start shifting resources.
(Mr Crisp) But if you have also worked in the airline
industry, you will know the marginal cost of a seat in the airline
industry is pretty small, and if we shift two people out of Mayday
Hospital and put them in nursing homes, we will only release the
marginal cost in Mayday and it is not as big as the cost of putting
them all in nursing homes for the next three years, which is the
average length of stay people have in nursing homes.
84. These people do end up in nursing homes,
so it is a question of when they go in.
(Mr Crisp) But they go in through a properly planned
and funded stream. It is not as simple as saying, "You can
take the marginal cost out of hospital", which is by and
large smaller than the cost of introducing a new residential bed.
85. Actually the marginal cost of acquiring
an extra bed and not using it but buying it is more than the average
cost, is it not?
(Mr Crisp) We can open this up for a longer discussion.
86. I will move on. A comment I made the last
time you appeared before us was something along the lines that
various royal colleges were saying that because of recent cases
of negligence claims have been successful against doctors, and
doctors are reluctant to rush through very large numbers of patients
they are diagnosing in case they make a mistake, and because of
that the Royal College of Surgeons, the Royal College of Physicians,
the Royal College of Ophthalmology and indeed Urology and Orthopaedics
as well, as I understand it, are recommending that they look at
15 minutes per patient, or 20 minutes for a new patient, 10 minutes
for a follow-up. Given that is quite a lot more than currently
they take to see these, does that not mean there will be an increase
in waiting lists, other things being equal, although I realise
more money is going in? Secondly, that the average cost would
go up? In other words, because there is more pressure and more
concern even though there is more money, we are going to see costs
rising and the waiting list erosion is going to be less than we
might have hoped.
(Mr Crisp) You are quite right that royal colleges
and others are seeking to introduce new standards which would
have that effect, but that is not the end of the story. We are
also engaged in discussions with the royal colleges about whether
we can do things differently, because that is assuming we run
things exactly as we have run them to date, and maybe we can do
things in different ways perhaps with different groups of staff
doing different jobs and so on. So that is a pressure but one
we have to make sure does not have the effect you are talking
87. If we are not to put more pressure on them
and not increase the amount of time per patient, what will we
do? Give them more legal protection?
(Mr Crisp) You can see a whole series of things which
are happening in the NHS where we are doing things differently,
so the anaesthetist may be seeing them at a particular time of
day, we may be bringing them in in the morning rather than overnight.
There are lots of other things we can do to increase throughput,
if you like, in terms of the number of patients going through
the system which are not purely dependent on that point. We can
do things differently.
88. Finally, is your general view that things
are getting better although there is room for improvement?
(Mr Crisp) Yes. There is a big underlying infrastructure
renewal happening at the moment. There is a lot of learning, a
lot of spreading of good practice, some very good things going
on through the programmes of the Modernisation Agency, but it
is taking time to come through.
89. Mr Crisp, you said earlier to members of
this Committee that waiting times are the important issue, and
I would agree with you. Do you think it was a mistake for the
NHS to target waiting lists instead of waiting times for four
(Mr Crisp) I think again that was actually a policy
decision which it does not seem to me I should be commenting on.
There is an advantage, however, in the argument of targeting waiting
lists as well, which is we need to bring them down overall because
if we are going to get the waiting times down to an appropriate
point we need to have reduced our waiting lists to do that.
90. That is a policy issue.
(Mr Crisp) Yes.
91. Do you agree with the King's Fund which
says that national waiting list targets divert attention away
from the issue which matter most to patients, by focusing simply
on the number of people waiting for treatment after seeing a hospital
consultant, and that the list ignores the time people are waiting
and the severity of their need?
(Mr Crisp) I did say earlier that the policy as it
stands at the moment within the Department is that we are focusing
very much on waiting times and specifically on reducing waiting
times for the most seriously ill patients.
Mr Osborne: So you do not agree with the Chairman
of the BMA Consultants Committee who said that the waiting list
issue had distorted clinical priority and denied care to people
in most acute medical need, that the NHS must end its obsession
with numbers on lists and focus on patients in greatest need?
92. You can answer that or not as you wish,
(Mr Crisp) Let me make the point that I have recently
written to the chairman of the BMA setting out where money is
being spent within the NHS and how we are targeting long waiters.
I think I have already answered the point in that we have put
within our overall policies, our deliberate attention on the most
seriously ill people.
93. If I could turn to the NAO survey at paragraph
2.22, which we have already discussed, and I take your point about
the sample, I was slightly surprised to hear you say that you
did not think this was particularly widespread due to the sample
and the kind of consultants who had been interviewed. Can you
give me some indication of how widespread you think it was at
the time the report was put together that some consultants were
distorting clinical priorities?
(Mr Crisp) The first answer is not enough to distort
the overall figures, because if I look over this period the number
of patients who have been admitted within three months of waiting
has stayed broadly level. That would indicate we are giving the
same level of priority as we always have done to those people
who have the most difficult clinical conditions. So not enough
to show up in those figures, otherwise we would have seen a trend
in the under three months coming down as a proportion, would we
94. A large number of organisations, the BMA,
the King's Fund and so on have said the same thing. The chief
executive of the Nuffield Orthopaedic Centre said that "the
name of the game is to get numbers off the list" (Electronic
Telegraph, 15/11/98) so it is going to be more beneficial
to focus on the cheaper procedures and that by deploying such
a process he successfully cut 400 patients off the list in four
months. Surely all these signals must be coming into the Permanent
Secretary's office that consultants around the country are distorting
(Mr Crisp) This report entirely fairly says we have
issued guidance and instructions on this many times, we have also
invested money in the high profile and important procedures such
as coronary heart disease, and if you start to look at the figures
on a widespread basis you will actually see that does not appear
to be happening. There may be quite a lot anecdotal cases, and
I have no doubt there are specific instances where that will happen,
and I have also no doubt that people can see incentives in making
that happen, just as you have described the chief executive of
the Nuffield Orthopaedic Centre did. That does not mean to say
it is widespread. Where we come across that as an issue we need
to do something about it and make sure it is not continuing to
happen, but I am not complacent about it.
95. You conceded there are specific instances
and specific incentives, do you think it is possible that anyone
has died because they were not treated with the degree of clinical
need they should have been because someone was trying to meet
(Mr Crisp) I would have no way of knowing that. Nobody
has brought that sort of case to my attention.
96. No one has brought it to your attention?
(Mr Crisp) No. My point is undoubtedly in a service
which sees 5½ million elective patients on an annual basis
there will be some instances where there will have been some distortion
of clinical priorities, but not at a level which is enough to
distort the overall figures and show there is a real pattern of
97. There was an interview in which Peter Wilde,
a heart specialist at the Bristol Royal Infirmary, said of the
20 patients on his heart operating waiting list who had died in
the past six months: "If those patients, who had been classified
as urgent, had been operated on within a month we would have saved
half of them." (Daily Telegraph 1/3/00)
(Mr Crisp) I cannot comment on that particular
example, I am not sure if that is the same thing.
98. He was attacking the waiting list targets.
(Mr Crisp) He was not implying that instead he had
been asked to operate on people of a lower priority. I do not
know the particular quotation, I do not think I can frankly comment
99. Can I turn to outpatient lists? Do you think
it is possible that the pressure to reduce inpatient lists resulted
in a surge on the outpatients list?
(Mr Crisp) I think there are some figures here which
I am desperately trying to find.