Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 160 - 179)



  160. I would like to move on to appointments. I am glad we are getting away from the present system, I find it rather unusual that you could send out an appointment to a patient and it was an open loop system, where you get no feedback, so that letter could be gone to a house where the person has left, the person could have moved away or even died. I am told the amount people that do not turn up is quite high and it seems a bit late in the day to go into this booking system. I do urge the booking system to have people confirm whether they are going to attend so that they can get tied into a system.
  (Mr Crisp) Yes, yes.

  161. The system you are going to use, it seems to me we do not have a single consistent roll- out system for every hospital in the country?
  (Mr Crisp) Well, we do on booked admissions, Mr Fillingham can fill us in on that. We now understand how to do this much better, the standard information system and things like that, we are literally rolling that out.

  162. If we look at that, I can understand with administrators where they have money there is always a difficulty of where you are going to spend the money, are you going to spend it on patient care or on paperwork. There is a lot of pressure to spend it on patient care and the paperwork system gets pushed to the back of the queue when it comes to resourcing, this has been the case, why have we not ring-fenced the money that needs to go into the new systems?
  (Mr Crisp) Specifically and partly for the reasons you have just talked about, we have ring-fenced it for this booked admissions system, so there is money following it into the system. We need to drive it in. You are quite right, what is happening in the NHS is we have actually low costs on the overheads of the systems, as this report demonstrates, because we have tended to put money straight into the clinical issues.

  163. This choice of hospital scenario, there is obviously good reason why we are not going to get a choice of hospital because if we are told exactly how hospitals are doing and what the survival rates are that does not fit well with the hospitals and clinicians particularly and they are going to fight like hell to stop that information going out, so we are looking at the producers rather than the customers.
  (Mr Crisp) That is exactly what we are trying not to do. That is the change which is going through. The NHS Plan was set up specifically to design a service around the patient, and that means precisely what you are talking about, shifting from a producer focus to a customer focus. All the things we are doing at the moment to get patients more involved, the provision of more information, the question of where we can extend choice at the moment, which we need to do carefully because it must succeed, we cannot afford to fail, all of those things are about moving in the direction you are talking about.

  164. One of the reports today was with regard to survival rates for heart bypass operations.
  (Mr Crisp) This is Dr Foster.

  165. Yes. I challenge you to go back over every report that has been issued and show me a hospital somewhere at the bottom of the league where the chairman of the trust does not say, "Well, it is not the full picture, you know, because underlying that there are difficulties because we are the most deprived area, we have the hardest cases", there is some reason why they do not really belong at the bottom of the league. Someone has to be at the bottom of the league but they never admit to why they are there. Why?
  (Mr Crisp) That behaviour, because we have looked abroad at this, has been exactly what we have seen when the same thing happens in the States and so on. Two things happen, people immediately want to explain in the way you are talking about because that in a sense is human nature and some of it, of course, is right, some of it does justify the position. But, secondly, people then have looked at that information in a different way for the first time because somebody is holding a mirror out to them and you have seen change. The evidence from abroad is that change has happened when this has happened because you are putting a new pressure and a new dynamic into the system.

  166. So if you have a hospital which has the lowest survival rate in the country, where clinicians have walked in and had a vote of no confidence in the management, and you have a hospital which really has been going wrong on a number of occasions, how much power do you have to sack the chief executive?
  (Mr Crisp) I suspect you are talking about a specific case and we have made it clear that in a particular case if things are not improving within a timescale, which is a reasonable thing for us to say, then we will expect the management to be changed, and we have the ability to make that happen. The contract is with the employer but we can reasonably expect to see that change is brought through.

  167. When you say you have the ability, do you have the will to do it, because I think in some of these instances you are going to have to drive forward? Can you sack a chief executive, chairman of a trust and suspend a trust? Do you have that power?
  (Mr Crisp) There are some powers. The first point which needs to be made is that the chief executives actually work for individual trusts and their employment is with individual trusts, however, and I would have to check the exact powers, we have the right to intervene in cases where the Secretary of State deems this is the appropriate thing to do, and we can make changes in the management of the trust. I will have to give you the actual chapter and verse around that but, more importantly than that, at the point at which trust boards have maybe lost the confidence of the Department of Health—and if you look around the country you will see examples of where this has happened—then decisions are taken and we move on.[4]

  168. So we are prepared to do it and grab this nettle and say, "Yes, we are going to drive forward these changes against all the vested interests"?
  (Mr Crisp) Absolutely, where that is the right thing to do.

  Mr Jenkins: I look forward to the day.

Mr Gardiner

  169. Can I refer you to paragraph 3.5? "Under the NHS Plan every general practitioner practice and primary care group and trust must put in place, by April 2001, systems to monitor referral rates." How has that gone? Are they all in place and what is the feed-back we are getting from them?
  (Mr Crisp) This is from April 2001. I have not asked the question as you have asked it and we will not get the details on that for some time yet. I am not aware there is a problem with it. That is not one of the things which is flagging up on our systems saying there is a problem, but we will not get the full picture because it is only April 2001.

  170. So when will you get the full picture?
  (Mr Crisp) We will get it at the end of the year, the end of March. We will know where we are. If there are particular problems, our systems pick them up earlier in the year, so I am not aware there are particular problems.

  171. Perhaps you would be good enough to let us know what the outcome is.
  (Mr Crisp) Right.

  172. Under referral pools, Mr Osborne, my colleague, asked if pressure was being applied to GPs and there was the £1,000 example. I would rather look at it the other way and want to know if pressure is not being applied to GPs. Why, if we are not making GPs refer to pools, are we not putting in place a system where there are targets within the NHS Plan so that referrals should be to pools for the consultants then at a particular hospital to share them out, obviously as is appropriate with clinical expertise—and you talked about expertise in shoulders and so on—but surely the consultants can then take that decision as a pool?
  (Mr Crisp) We have actually got a lot of targets and, as you will be aware, from time to time we have been criticised for having too many specific targets. How we are approaching this is saying, we have to embed this in people's behaviour, not just whether or not they hit targets, and therefore we are firstly making clear we think this is the right way for us to go but, secondly, encouraging GPs and consultants to draw up referral protocols. So what happens in your particular patch has been discussed with the GPs and consultants so we can provide best practice, and there is a Steps guide which David and colleagues have produced which helps do that. But actually we have to embed it in people's behaviour rather than just instruct people, because we know that does not work.

  173. Your colleague is nodding furiously and looks as if he would like to add something.
  (Mr Fillingham) I think that is absolutely right. It is about making change sustainable. The way to do that is to engage staff in it and get them to want to make the changes because they can see it is in the best interests of patients. Sometimes that will mean a pool referral, that is quite an important way to go. Sometimes it will be alternative forms of provision without patients going to a hospital consultant at all. The exciting way forward is to get GPs, consultants, hospital managers, primary care groups, sitting down together to plan the system in a way which works.

  174. I do not doubt that referral protocols are very good and important and the right way to go, what I am keen to see is that you are monitoring the increase of pool referrals and that you have of yourself, if not for public consumption, some clear standards, clear targets, which you want to see achieved. Because otherwise it seems to me that one can say, "Let's agree it on a local basis" but we will not actually then go in the right direction.
  (Mr Fillingham) Absolutely. The way we are doing that is by getting local organisations to have ownership of those plans and targets. So hospital trusts were asked to produce outpatient improvement plans, to agree them with the local primary care groups and issues like pooled resources were included.

  175. Paragraph 3.6: I do not know whether you were, but I certainly was staggered to see that 20 per cent of the consultants considered that 80 per cent of the referrals were inappropriate.
  (Mr Crisp) Yes.

  176. Why? Are you not staggered by that?
  (Mr Crisp) Yes. I then wanted to ask the question which speciality it was and whether it was orthopaedics where I am less staggered actually because in certain parts of the country people have been referring to consultants who then refer back to physiotherapists, as I just said, and the most appropriate result might be to a physiotherapist in the first place. It is a very good example of where the surgeons and the GPs need to get together and agree what they are doing, GPs may be thinking they are referring to a consultant to get a physiotherapy appointment. Do you see what I mean?

  177. What you seem to be saying is that within certain disciplines there is likely to be a large percentage of wholly inappropriate referrals. Is that correct?
  (Mr Crisp) I think there may be if do we not have the local referrals protocol in place.

  178. I accept you are working to change it. What you are saying is that within certain specialties up to 80 per cent of referrals may be inappropriate, we are wasting 80 per cent of initial consultant's time.
  (Mr Crisp) Yes. I was surprised to see that, that is the reason why.

  179. You are telling us that is the reason why, are you not?
  (Mr Crisp) I am telling you I think that is the reason why. I was trying to give you an example of where I thought there was a reason for it. I am surprised to see that 80 per cent figure.

4   Ev 24, Appendix 1. Back

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