Examination of Witnesses (Questions 140
MONDAY 19 NOVEMBER 2001
140. You are coming to my next question.
(Mr Crisp) Actually if we tell people the date when
they can come in at the point at which agreement is reached, by
and large they come in, and we know there are improvements which
can be made in that way.
141. You have described this fully integrated
booking system which you hope will be available by 2005, that
is four years awaywe fought the First World War in that
timewhy do you not just do what they do in Denmark, stick
it on the internet so people can look? Although it might not be
integrated in a nice management consultant way with bar charts,
you are effectively letting the patients figure it out for themselves,
if you give them the information.
(Mr Crisp) That is a different thing from the booking
system. The booking system is about booking appointments and so
on. I take the point about providing more information and you
will be aware the information being provided in a national newspaper
today has been supported by the Department of Health. We see it
as very important that we do get as much information as possible
to the public because the people who will provide some of the
dynamic for change here are the public.
142. Absolutely. Are you going to put this information
on the internet and, if so, how long will that take?
(Mr Crisp) I am afraid my answer is still, we are
looking at it, but that may be an interim step to what we are
talking about here.
143. Why do you not just do it?
(Mr Crisp) I will take your advice. We will no doubt
be able to report to the Committee in due course.
144. Paragraph 2.36. Mr Davies made the point
that a lot of chief executives have varied their definitions of
what constitutes outpatient waiting lists and, surprise, surprise,
in almost every case the number of outpatients fell, 88 per cent
fell. I am right, am I not, that since 31 March 2000 outpatients
have gone up by 80,000 and inpatients by 30,000?
(Mr Crisp) This year, the long-waiting outpatients
have gone up, you are right.
145. Outpatients by 80,000 and inpatients by
30,000 between the end of March and end of June, yet this paragraph,
2.36, implies that people are managing their lists better and
that the result is a reduction in the number of waiting lists.
(Mr Crisp) The figures you have quoted are the three
months figures. They are three months figures which have gone
the wrong way and have gone against the trend of the last two
years and need to be tackled. You are quite right, it has not
146. Can I return to Scandinavia. The report
mentions Norway where there is a choice of hospitals. Perhaps
I can put the question more generally, and this again may be a
question for Mr Fillingham, plainly there is a lot of good practice
overseas, people generally have a perception that things are done
better in many cases overseas than they are here. You often hear
France, Germany, Scandinavia quoted. What are you doing in a systematic
way to look at what is going on overseas and learn from it?
(Mr Crisp) Again, if I may, that is not the total
story. People from abroad come and visit us and look at the things
we are doing, and things like our National Service Frameworks
and the fact we have national standards are rated very highly
by a lot of different countries.
(Mr Fillingham) There is a considerable programme
which includes research and development work to consider what
is happening and looking at how that can be applied to the UK,
but we also have strong links with other health care organisations
not only in Europe but in the US, Australia and New Zealand as
well. So there is a considerable amount of effort which goes into
comparing notes and making sure we are adopting best practice,
in just the kind of way you have suggested yourself.
147. I would like to return to choice. Mr Crisp
said that you were looking at introducing an element of choice
for patients. I think most patients would regard that as a little
understated. They are the people who are providing this £47,000
million you are using, and you are saying, "We are introducing
an element of choice."
(Mr Crisp) Over and above what is already there because
patients are involved in their own care. If you think about what
patients are saying to us about choice, they want to be involved
in the decision-making about their own care, that is very important,
and a lot of the work Mr Fillingham's agency is doing such as
on cancer is actually about developing that patient-professional
relationship, and there are choices in terms of care. There is
generally more choice around in maternity care as well. We are
talking about the relatively limited aspect of choice in acute
hospitals when you have an elective case. I think there are arguments
which Mr Milburn has spelt out as Secretary of State for why we
now need to be looking at that and finding ways of improving the
amount of choice which is in the system, but I do not have any
announcement to make to this Committee, that is merely an up-date
of where we are.
148. Can I draw your attention to paragraph
3.21 which talks about effective discharge plans to ensure that
admissions and operations are not cancelled due to beds being
occupied by patients who should have been discharged. It goes
on in paragraph 3.23 to say, "NHS acute trusts could use
their knowledge of patterns of emergency admissions to help plan
more effectively the number and type of inpatient admissions."
My perception of my own constituency, and this is probably shared
by colleagues, is that this is going in the other direction, that
things are getting worse. Could you comment on the question of
discharges and bed blocking and what steps you are trying to take
to get round this?
(Mr Crisp) There are several things to say. The first
thing is that for the first time this year we asked health and
social care jointly to produce for us a capacity plan, and this
is a capacity plan which will not only deal with beds in acute
hospitals but with the issue of residential homes and care homes
and also with the amount of capability of social services departments
to provide packages of care for people at home. So it is a full
capacity plan. We got those in at the end of September so we could
begin to analyse them and understand what the picture is looking
like and, secondly, so we could get in to do what we are trying
to do all the time now which is share good practice and make sure
that one area learns from another. The second significant thing
we have done in recognising the problems which are around the
care home market and the residential home market in particular
is provide an additional £300 million£100 this
year and £200 next yearto social services departments
to develop plans for improving the position on bed blocking jointly
with the Health Service, which is the first most important point,
so they are not just a way of disappearing into the social services
budget if you like. That money is recurring. That is important
because it is not just a bit of sticking plaster this year, it
is about a longer-term strategy.
149. One more bite of the cherry, then I have
to stop, you must have looked at the question of what it would
cost to provide a guarantee, whether the threshold is three months,
six months or nine months, you could say that either you would
either provide the service yourself within that time to make a
guarantee to the patient or if you could not you would find another
way of having it done in the private sector or you would fly them
off to Sweden or wherever it would be?
(Mr Crisp) There has been debate around this and there
is debate continuing. The one guarantee we are bringing in next
year is the one that if your operation is cancelled we will either
admit you again within 28 days or you can go to a hospital of
your choice. That is how the words are written, maybe we are starting
down that route.
150. Mr Crisp, I have been striking questions
off as we have gone through some of the stuff and I will not go
over it again. I see the list in front of us with regard to our
own constituencies and our own local areas, it is rather illuminating
insofar as I have one inpatient waiting six months or more for
urology, and I have 23.6, and in the four areas I have 8.2, 6.1,
5.2 and 10.6. I have a better case than that, I can give you an
instance of two people living opposite one another on the road
where they both want the same operation, hip replacement, in their
own hospital. They are in the same location, with the same surgeon
and the same operation, one would have to wait for maybe up to
three months and the other would have to wait 15 to 18 months
due to the contract of the hospital health authority drawn up
by this particular hospital, this is simply down to funding.
(Mr Crisp) If it can be done
151. It is quite simple, it is what is called
in terms of standard assessment, it is a weighted average, they
put money together and they give authorities and areas different
amounts of money to treat the population.
(Mr Crisp) Your road has two health authorities, one
on each side.
152. That is right.
(Mr Crisp) They will receive money as health authorities
on the basis of the formula
(Mr Crisp) That formula will be weighted for the age
of the population, and so on, and they will then locally make
the decision about the priorities that they need for categories
of patients and there may be a difference between the two, except
where we have a national policy which says they have to be the
154. Yes. The formula is wrong quite simply
because the formula was derived to produce the same level of service
depending on the make-up of the population and it is simply not
doing so. It produces extra waiting time and waiting lists in
under funded areas.
(Mr Crisp) There is a very extensive academic study
going on at the moment which is due to report sometime soonish
to advise us on how to create a formula that may be better, but
it is not a simple answer. At the moment the formula is weighted
towards areas of greater need and to some extent towards areas
of greater cost.
155. Here they are starting to show up with
regard to extra waiting time, they have to suffer because of a
lack of funding and they should be produced at the same hospital,
producing roughly the same waiting times. If I can move on to
one other thing, the doctor referrals, I have the impression it
has being going up because doctors are making more referrals,
would you say this is down to the public's expectation of being
able to the treated for everything at any time and their right
to go to a consultant or would you say that it is also being influenced
by the medical insurance that doctors have to carry to cover that
shift in risk?
(Mr Crisp) The figure here shows it is going up. There
is another thing, which is probably the strongest driver of that
going up in some areas, which is that we introduced national standards.
When you introduce national standards we then introduce the doctor's
expectations of their referral patterns to hospitals. The people
who were already referring at that high level do not refer any
less and the people who refer less will refer more. We will gradually
see as we introduce and drive through in some areas an increase.
In other areas, Mr Fillingham gave an example, we will see less
because they will be referred to physiotherapists straightaway,
whereas sometimes it is up to the consultant. There are two different
dynamics going on here, the quality one is a big one, the national
standards one is a big driver.
156. Not and insurance one?
(Mr Crisp) I am not convinced how big a driver that
is, it may influence people to follow the national standards.
157. I notice one of things we have in our locality
is A&E is going up by 9 per cent, apart from the ones turning
up with cuts and bruises because they cannot see a doctor, because
the system is not flexible enough. We have a situation with regard
to doctors who open from 9 am to 4 pm, when most people are at
work, and do not open in the evenings or at weekends, so people
go down the hospital and once again they are involved in blocking
the system up. What are you prepared to do about it?
(Mr Crisp) The one about the people with the more
(Mr Crisp) Again we have about three different programmes
reflecting that, one is the introduction of minor injury units,
which are nurse-led and designed specifically to deal with such
issues. Having visited a number I am aware that they run to about
10 o' clock or 11 o'clock at night and at the weekends. The second
one is, walk-in centres, again typically nurse-led and these are
for people particularly in those areas where people are not registered
with a doctor, where there is a high level of refugees, and so
on. That is certainly happening. The third thing is that we have
introduced NHS Direct so that people can ring up. Seven and half
million people we think will use that this year, seven and a half
million people will ring up to ask for advice from a nurse on
their particular problem. It is the biggest call centre of its
kind in the world, it is a very substantial increase. There are
a lot of big things happening now and I think we will see more
159. Why then have A&Es gone up by 9 per
(Mr Crisp) I have seen two sets of figures. I have
not seen the Staffordshire ones, overall A&E attendances have
fallen slightly but admissions through A&E, ie the most serious
patients, have gone up. It has only gone up by about 3 per cent.
More serious cases seem to be coming in, which is a worry because
we need to plan much more for them, it is much easier to deal
with the less serious ones.