Select Committee on Public Accounts Minutes of Evidence


Examination of Witnesses (Questions 100 - 119)

MONDAY 19 NOVEMBER 2001

MR NIGEL CRISP AND MR DAVID FILLINGHAM

  100. Figure 6, page 12, maybe.
  (Mr Crisp) The one before that. What you have seen is that may have been the case initially but if you look at 2000 and 2001 on pages 11 and page 12, where you have the inpatient waiting list on one and the outpatient waiting list on the other, then you can see that in the last two years both have been coming down for the first time ever.

  101. I certainly agree with you on that. If you look at figure 6, the first bar graph, there is quite a steep rise when inpatient waiting lists have been targeted, there is quite a steep rise in the outpatient waiting list, do you think the two are linked?
  (Mr Crisp) They may be, certainly. The other point to make about the outpatient waiting list, this is the long wait, this is not everyone on the outpatient list, this is people waiting over 13 weeks. There may or may not be a link between the two. However, having seen that steep line in the outpatient waiting list what we did in the Department was to refocus attention on the outpatient waiting list as well and make sure that we drove both of them.

  102. I feel you are being a bit evasive, you must have seen these figures rising dramatically and I am quite willing to accept that you took action that was successful in bringing those lists down, but you must have had some idea why suddenly outpatient waiting lists were going through the roof?
  (Mr Crisp) If you look at 1998 on these two cases you will see that the inpatient and the outpatient waiting list rose in 1997 and 1998, both lots rose, there was only one year where what you are talking about happened, which is 1999, where the outpatients continued to go up and the inpatients came down. There may or may not be a direct connection between the two. The important thing is that the corner was turned on them.

  103. Is pressure being applied to GPs to curb patient referrals in order to reduce outpatient lists?
  (Mr Crisp) Not as such. Not that I am aware of. What I think is happening is that GPs, as with other clinicians, are looking at places where they can get treatment done in different ways, so they will be looking all of the time at that. If you look at the first outpatient attendances you can see year-on-year outpatient attendances are going up, which are linked to the number of GP referrals going up over that same period, I think it is broadly on the same curve. GPs will need to look and see if they are getting the right treatment for their patients so there is no pressure on the hospital.

  104. According to Doctor magazine last year two schemes in the primary care groups in North Staffordshire—I know Mr Fillingham is going to be very interested in this two schemes—offered GPs up to £1,000 to meet outpatient referral targets in a North Staffordshire hospital, is that practice widespread?
  (Mr Crisp) That is an incentivisation to do what?

  105. To meet outpatient referral targets.
  (Mr Fillingham) Mr Fillingham: I was familiar with North Staffordshire, what that was about was incentivising better referral practice, not simply about reducing outpatient waits. Just as there is variability across the country in hospitals there is considerable variability across general practice. Using the best clinical advice it is sometimes clear that some practices are very high referral, some practices are quite low in referrals, because they are not referring enough, and what those two primary care groups are doing is working with good clinical advice to try to incentivise better referral practice. The key to all this, which is what the agency is working hard on, is getting GPs and consultants together to agree what is appropriate clinical practice and then to incentivise that behaviour. As part of that quite often it does become clear patients did not need to be referred to hospital, they did not need to see hospital consultants, they could have been treated in other ways.

  106. In this case you are saying they are offered £1,000 to hit specific outpatient referral targets?
  (Mr Fillingham) If they were successful those payments were used for facilities within the general practice for the benefit of patients. Just as in previous times when we had prescribing incentive schemes, which are aimed to incentivise good practice, that money again has been able to be used for equipment, for a physiotherapist within the practice, and so on.

  107. I do not doubt it is an attractive sum of money, that is what I am saying, it might influence a doctor's decision to refer somebody to a consultant in order to get £1,000
  (Mr Fillingham) The intention was to influence more appropriate referral practice and if this was done with good clinical advice that seems to me to be right and proper, just as we want less variation across hospitals and good practice we want the same within primary care.
  (Mr Crisp) That is drawn out in this report, you have the same example of consultants making comments about GP referral practice and the wide variations within it.

  108. It does not really work in North Staffordshire because they have the highest outpatient list in the country?
  (Mr Fillingham) They do. It was starting to have an effect. For example, linked to that scheme was the development of the Back Pain Service, that was physio and OT led, it was quite clearly demonstrated that only about seven per cent of the patients that were going to see an orthopaedic consultant for back pain actually needed to see that consultant, the rest could be dealt with by physio and OT instead. North Staffordshire have a particular problem, they have a steep hill to climb and they are getting there. In every area we need to understand what is okay and what needs new investment and what we can achieve by doing things differently and by promoting good practice, and that is as true in North Staffordshire as anywhere else.

  109. Are you going to use that to modernise the NHS?
  (Mr Fillingham) I am certainly going to use my experience of understanding the very real pressures there are. You will also be aware that North Staffordshire does very, very well on the inpatient day case figures. The major problem is in outpatients and that is what we have started to tackle.

  110. On the inpatient list it is sad to see that one of my own health authorities with many of my constituents, North Cheshire, is the worst performing health authority when it comes to inpatient lists. Can I finish, since my time is almost up, with a very general point, why is there such an enormous variation? Any Member looking at these will be astonished by the fact that in some health authorities, for example in North Cheshire, 49.9 of all ear, noise and throat patients wait almost six months for an operation, yet in Rotherham, so it is not a question necessarily of more affluent areas doing better, only 1 per cent of patients wait. North Cheshire 49 per cent and Rotherham 1 per cent and Dorset zero per cent. Why is there such an extraordinary variation between different health authorities?
  (Mr Crisp) I think it is individual cases. The example we were just given of Croydon shows that in the particular instance of orthopaedics it was an outlier for Croydon compared to other specialities in Croydon. It is a mix of capacity, and historical capacity, and in some cases just how effectively the management system works. It is both and we have to tackle both.

  Mr Osborne: Thank you.

Chairman

  111. I do think that is something that we need to investigate further, you have been asked this question several times and you keep saying it is a question of capacity. It would be interesting to go into it deeper?
  (Mr Crisp) Do you want a note on that?

  112. Yes. It does not really bring the debate forward much more if you say, that is a very interesting statistic, it is a question of capacity. Do you understand?
  (Mr Crisp) I take the point but we can illustrate it with North Staffordshire where there is a serious under-capacity in acute facilities, but we will produce a note, Mr Chairman.[2]

  Chairman: Thank you very much.

Jon Trickett

  113. I want to follow on from the point you have just been making, Chairman. When you look at my home health authority, which is Wakefield, and using the data which is in front of us, it turns out Wakefield Health Authority does worse than all the other adjacent authorities in terms of inpatients per thousand, in terms of inpatients waiting for more than six months in trauma, in urology and in ear, nose and throat. In some cases the differences are quite striking and in fact alarming really. I do not expect you to know the geography of the area, I will talk about that in a minute, but first of all can you comment and give any reason why Wakefield should do worse than all the adjacent authorities and the English average as well?
  (Mr Crisp) I can obviously, and would be happy to, produce you a note on the specifics of Wakefield but I do not have that with me at the moment.[3]

  114. There are these quite severe disparities. My first assumption was that Wakefield does very poorly in terms of health, given the industrial heritage of the coalmining industry, that was probably the explanation, but then I looked at comparisons with Doncaster and Barnsley, which are adjacent, and discovered extremely disturbing disparities. For example in ear, nose and throat we have over a quarter, 26 per cent, waiting more than six months in Wakefield but in Barnsley and Doncaster, which are adjacent, in Barnsley it is only 3 per cent, which is an eight-fold difference, and in Doncaster it is 4.5 per cent, which is a six-fold difference. Do you have any comments at all about those quite alarming differences, all of which are coalmining communities?
  (Mr Crisp) I am sorry, I will have to give you a note on the specifics of your constituency. I am afraid I just do not have them with me.

  115. The Chairman has asked for more work to be done on capacity and I wonder whether we have any information about output or productivity, or is it too vulgar to apply the notion of output to consultants?
  (Mr Crisp) We do know the number of units of activity in a hospital and we do know the number of consultants within a hospital and within specialities.

  116. Presumably there are variations, are there, between consultants?
  (Mr Crisp) There are.

  117. Do you find that groups of consultants within a trust also vary in terms of the number of outputs per personnel relative to other trusts? Are there differences in productivity between one trust and another per specialism?
  (Mr Crisp) There will be and in cases like ENT there undoubtedly will be, not least because some units are very specialised and do the long, major pieces of surgery, and some do the shorter ones.

  118. Barnsley, Doncaster and Wakefield Trusts are not specialists in ENT, so I have no knowledge of any specialism being done on a sub-regional basis, outside of Leeds probably, on ENT. I wonder why the C&AG did not look at that because clearly the productivity of consultants, whether as individuals or groups, must impact on the disparities between trusts. Is it not something you chose to look at?
  (Sir John Bourn) It certainly is something well worth looking at. We did not look at it but that does not mean to say the point is not a good one.

  119. I think the data will be very interesting. Whether or not we find Wakefield is more or less productive than the surrounding authorities I think will be very interesting. It would be interesting to try to do some kind of scatter graph to see whether you can get some statistical correlation between waiting lists, waiting times and the productivity of consultants. After all, if coalminers are judged by the amount of coal they produce, why should consultants not be judged by their productivity? I want to go on to two specific questions in the time left available to me. The first relates to this issue of capacity. We have touched on human productivity but capacity also relates to physical capital.
  (Mr Crisp) Yes.


2   Ev 24, Appendix 1. Back

3   Ev 24, Appendix 1. Back


 
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