Select Committee on Public Accounts Minutes of Evidence


Examination of Witnesses (Questions 120 - 139)

MONDAY 19 NOVEMBER 2001

MR NIGEL CRISP AND MR DAVID FILLINGHAM

  120. A striking fact which has already been referred to is that theatres are actually closed more than they are open during the week, but how many wards are actually closed each week or for parts of the week?
  (Mr Crisp) That is certainly not a piece of information we collect. We do collect the information retrospectively on the number of beds open as opposed to wards.

  121. Would it surprise you if I said that within the last three months I have visited a hospital and found wards padlocked with chains and padlocks on the doors which led both to beds and also to theatres being sealed? This was a very, very large general hospital.
  (Mr Crisp) If that is what you found, I would be interested to know why that was the case.

  122. Are you not aware that is happening?
  (Mr Crisp) I do not know the context but let me say that we have very recently received the analysis of the number of beds open last year as opposed to the year before, based on a daily census, and that has gone up. We are having another census very shortly, on 30 November I think, when we will be looking around the country to see what capacity we have in place for winter. If there are any doubts or questions about it, we will be picking up the issues as to why in Wakefield, or wherever it is, you have this.

  123. It was in Leeds. My father was being treated late on a Friday afternoon in an emergency admission, and we discovered there were two wards and several theatres with padlocks and chains at 4.30 on a Friday afternoon. Apparently, the padlocks and chains were not removed, and never are, at the weekend in those theatres. The staff were available and actually came in and did the operation and he was put into another part of the hospital.
  (Mr Crisp) In that case, it sounds to me as if it was a planned process for running five-day wards. There are a number of procedures, which are not normally conducted on a Friday afternoon, where the length of stay is one, two or three days, and we find it is an effective way to run our facilities with the staff we have to run them Monday to Friday on a five day week and close them down at the weekend. There will be a number of wards like that.

  124. The staff were available and were brought in, in fact they were being paid to stay at home. I spoke to all the staff because I was admitted into the theatre and discovered they were being paid to stay at home and the wards and the theatres were locked. If this is a practice which you are aware of, it is a rather surprising one.
  (Mr Crisp) Not as described by you. There are in any hospital emergency wards which are open all week round, all year round, and theatres running all week round and all day round, there are then day facilities which are only open 8 to 8, there are then outpatient facilities which are open something like 8 to 8, and then there will be five-day wards designed specifically for certain categories of surgery. Obviously, I do not know the case and I do not understand why staff should be waiting at home rather than being in the theatre or in the ward, but hospitals are not just one thing, there are all different streams of patients and some patients need different treatments.

  125. There is no company which would have an amount of capital plant tied up and closed more often and for more hours in a week than actually being open and used. When we talk about optimising, on page 26, the capacity of clinics and the capacity of operating theatres, we are actually optimising all of the plant which is available in a hospital. By the way, I could take you to another hospital where there are three wards which are permanently closed and padlocked and have been since I was elected an MP in 1996, although other parts of the hospital are in use. I think there are a large number of wards which are simply padlocked either for parts of weeks or whole weeks.
  (Mr Crisp) Can I make one comment on that. The bottleneck is staff by and large within the NHS rather than physical facilities. I do not know the state of those wards, they may need refurbishment. By and large if we could get staff we could open more beds. Beds are increasing, by beds we mean staffed beds.

  126. We have beds which are not being used. We do not need more beds, we need to optimise and possibly maximise bed space and theatres. There are empty beds and theatres throughout the country in significant numbers. I did not go looking for them.
  (Mr Crisp) There is hard worked staff.

  127. We have had the questions already about private medicine and the way in which there are operatives, it is made convenient for them to work weekends in private medicine when there are NHS facility closed. That is probably a policy issue which you and I ought not to trot into this afternoon. Can I move on to one other thing, which is the apparent conspiracy between GPs and consultants, again for the interests of the patient. I come back to these figures about Barnsley, Doncaster and Wakefield, what separates my constituency from Barnsley and Doncaster is a stream which I can bestride, I have quite long legs and it is not a very wide stream. In terms of my own constituency, it is actually nearer to Barnsley and Doncaster than it is to Wakefield hospitals, why do the GPs not take advantage of these really quite astounding differences in the waiting times to refer the patients to Barnsley or Doncaster? I do not ask you about specifics, but the general principle of extra contractual referrals across trusts boundaries?
  (Mr Crisp) The responsibility for planning at a local level rests at the moment with health authorities and they reach agreements with hospitals to provide for their local population. They can change that on a year-on-year basis and they can determine that your part of their health authority should go to those hospitals rather than the other hospitals, I do not know why they do not. However, the point that Mr Steinberg has raised is that maybe patients should have more say in that and we should introduce an element of choice into that, that is certainly something that we are looking at to see whether or not we can actually do.

  128. What would happen if my local GP, at the moment the GP is administered by Wakefield Health Authority or the health within his boundary, but for historic, cultural and I think administrative and bureaucratic reasons he refers patients to a longer waiting list in Wakefield or Pontefract than exists cross this stream in Barnsley on Doncaster. I think there must be some organisation or bureaucratic imperative to do that. I just remember vaguely being on a health authority at one stage in Leeds and I remember extra contractual referrals, which really means crossing boundaries, was frowned upon at the time.
  (Mr Crisp) It is because we have basically a planned system and basically we are planning for the people within a particular health authority.

  129. You are planning for people to wait in effect, are you not?
  (Mr Crisp) This is the point Mr Steinberg made, we do have a release valve which is called extra contractual referral but by and large that should be used for specialist services that are not available within your normal pattern of availability. It is, undoubtedly, an issue and one we are looking at.

  130. Is it not true that health authorities measure GPs by the number of ECRs and those GP practices which are looking after the patients that may be across a boundary are frowned on because they are not "loyal" to the bureaucratic imperative. Is that not the reason why my patients are waiting more than six months when they could be in Barnsley or Doncaster and be seen?
  (Mr Crisp) GPs have contracts with the NHS and they have a number of duties to fulfil. In addition to that they are expected to take part in things which are about looking at their referral practices, comparing their referral practices to others, there are things to learn within all of that system. The point you make and Mr Steinberg has made is how do you explain that to patients? That is difficult.

  131. I agree. You have to explain to yourself and go to bed with a clean conscience, but the fact is that you are accepting, I think, the scenario, which is wholly missing from this Report, that there is pressure on GPs not to engage in ECRs. It is this question of extra contractual referrals across trust boundaries which could make a massive impact into waiting lists in those areas where the waiting lists are particularly acute, especially where the boundary separates good practice and bad practice as it appears to do between Wakefield, Doncaster and Barnsley?
  (Mr Crisp) We do have a planned Health Service, it is a Health Service that is planned through the health authorities and we do want GPs to be part of that, indeed we are making the changes in the system to give them more control within the system so that they will be making decisions that are appropriate. If they are part of the planned system they can have more say over things, precisely the ones that you are talking about. I also want to make one minor correction, they used to be called extra contractual referrals they are now called out of area treatments.

  Jon Trickett: For the record, the plans you make involve people in my parts waiting longer than if they moved across the road in another area. If that is the planned Health Service you are constructing I do not find it very satisfactory.

Mr Bacon

  132. Mr Crisp, could I take you back to paragraph 2.22 and this question of distortion of clinical priorities. I understand you to have said, I wrote down what you said, "it is not enough to distort the figures". I remember when this Report was published, it was on the front page of a number of newspapers, and the topic of the BBC Today programme two days running, when I read this paragraph I read the words, "we contacted a representative sample within three specialities, granted 50 per cent might have been in trauma, to give a a broad indication across the whole spectrum". 558 consultants were interviewed, of which 52 per cent said they considered a distortion had occurred. You will know that a typical opinion poll is conducted on the basis of 1,000 people, that is to represent 30 million, in terms of voting intentions. I would have thought that 558 out of 20,000 is a pretty good sample, do I understand you to say that you basically disagree with this paragraph, that is what I think you said earlier?
  (Mr Crisp) I think what I said, and let me try and repeat it, was that they need to be seen in context, this is not the whole of the story. This is a worrying and important point that is being made here which does need attention, that is why, as I said before, we have both put out some clear statements about where priorities need to be so that people understand that if they are doing that that is not what we are trying to get them to do and, secondly, why we are doing so much work through the Modernisation Agency to improve the way in which waiting lists are managed. There is a lot of work round that. It is not the whole picture, because in other areas we are clearly targeting the highest priority of clinical cases.

  133. Do you think it is still going on?
  (Mr Crisp) I do not know whether or not this is still going on. If it is it will be decreasing for the two reasons of, firstly, the instructions we have sent out and, secondly, the fact that the management of waiting lists is improving.

  134. I wanted to come on to that. You also said that if the waiting list system is run effectively this need not happen. The Report provides quite a lot of evidence that the system is not being managed efficiently, may I start with paragraph 2.29, which talks about the patient administration system and how they vary, yet some of the software was not designed to provide key waiting list management data that trusts are now required to produce. Why would the trusts go off and buy computer systems that did not enable them to provide the basic information?
  (Mr Crisp) My understanding on what that is referring to is that some of these patient administration systems are relatively old and at that point we were not requiring hospitals to manage outpatient systems in the way we are doing. They are patient administration systems, the route into the hospital, they are not designed to collect that sort of information. We have a big programme of introducing new electronic patient records across the country as a whole which will be, I think, in place by 2005.
  (Mr Fillingham) Two things, as well as looking at the IT solution we are also looking at what information is of most help to help the NHS improve. There is the review of waiting and booking information systems project which is working with 12 trusts on a pilot basis which is due to report in February next year. That will help on the information side. I think your earlier point was also about, is there something about the design of hospital systems that could be improved? I think it is absolutely the case that there is and that is what the modernisation is all about.

  135. If I may interrupt, my next point 2.33, when the NAO visited the 50 trusts, six trusts had no agreement on even draft waiting list policy at the time of our visit, and it was not that long ago? It was not that long ago, what is the position now?
  (Mr Fillingham) That is clearly an unacceptable situation. Trusts should have not only clear policies and procedures but strong clinical involvement with them.

  136. They range, in the next paragraph, 2.34, from two to 66 pages. Have you told trusts what you expect them to have in a clear, simple, understandable form?
  (Mr Fillingham) We certainly have issued guidance but it is clearly in an organisation of a million people not simply about issuing guidance, it is about bringing about improvements in practice. The way we have structures now we have service improvement managers working on a regional basis with local trusts, we have a team tackling outpatients, other teams tackling theatres, tackling pre-operative assessments, and what we are starting to see are some considerable improvements. For example, if you just take outpatients, we ran a learning set for 11 trusts which had the most difficulty in terms of outpatients, and three of those have moved into the top quarter in terms of performance. So when you work with people on the ground, when you invest in learning and development, when you provide the support and information, you do get results.

  137. Paragraph 2.25 talks about outpatient validation. "Nearly half of the trusts were not undertaking validation . . . When they were, most outpatients ...", who had been validated, ". . . had been on the list for 13 weeks, but the criteria ranged from 9 to 26 weeks. As a result of this work, these trusts . . . ", which had done validation, ". . . had been able to remove 5 to 15 per cent of patients who should not have still been on the outpatient waiting list." Yet half of the hospitals in the NHS are not doing this work at all.
  (Mr Fillingham) It is a major challenge to make sure that is happening everywhere.

  138. What is going on? You are the accounting officer, you spend £47,000 million—and I think I am right in saying that apart from Social Security you are the biggest—
  (Mr Crisp) Yes.

  139. What interests me is ensuring that that money reaches the people who need it, the people who phone us up and say, "I cannot get an appointment". The point Mr Steinberg made very powerfully is that actually the resources are in some cases there, £737 million is being flung at the system, yet for one reason or another, be it the doctor does not want to look on the list to see 200 miles away there is someone with a two week waiting list or whatever, hospitals are not actually checking or validating—half are, half are not—and I am not persuaded you are managing the resources you have effectively enough.
  (Mr Crisp) This report identifies a number of weaknesses, clearly, and this is one. What we are doing on this one is, apart from issuing the instructions and the best practice here as well, introducing the booked admissions system which I talked about before.


 
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