Select Committee on Public Accounts Minutes of Evidence


Examination of Witnesses (Questions 200 - 219)

MONDAY 19 NOVEMBER 2001

MR NIGEL CRISP AND MR DAVID FILLINGHAM

  200. How?
  (Mr Crisp) Specifically by the mechanism that is in place, which is that there should be a review with each consultant each year on the basis of what their job programme is, and as part of that they should be looking at what they are doing in the private sector, and they need to make a return on it.

  201. But the 10 per cent is not a matter of the number of contracts, it is the amount of money. Who monitors the 10 per cent is 10 per cent of salary?
  (Mr Crisp) Trust chief executives.

  202. And you do not know on what basis?
  (Mr Crisp) I was explaining on what basis, which is that there is an annual meeting.

  203. If, for example, of the 20,000 all were full-time, we would be needing to employ an extra 2,000 consultants just to make up the 10 per cent they are doing outside the Health Service?
  (Mr Crisp) If we want to talk about consultants' workload there are a number of other figures you want, such as how many hours consultants are working for the NHS.

  204. It is almost impossible to get that from the chief executives. I have been trying with mine in Wales for some time to get the figures, and they refuse to give them.
  (Mr Crisp) There are a lot of studies which show by and large the vast majority of consultants, part-time or full-time in this country, work longer than the hours for which they are contracted and do more work than the hours for which they are contracted, and their 10 per cent private work is Saturdays or Sundays or whatever.

  205. When one of my colleagues asked about operating theatres and the 8.30 to 5.30 timescale, you said that operating theatres were not the bottleneck.
  (Mr Crisp) Yes, generally.

  206. So what is the bottleneck?
  (Mr Crisp) Staff.

  207. Consultants and other staff?
  (Mr Crisp) Nurses more than doctors.

  208. So if the doctors who are working part-time elsewhere were not, we would be able to make more use of the theatres which are already there and are under-utilised?
  (Mr Crisp) That is certainly potentially true, but the bottleneck is not actually consultants, the bottleneck generally is the ancillary staff and nurses who actually provide those services rather than doctors. You will no doubt also have come across doctors who say they would like to operate more but they cannot get the facilities, by which they normally mean staff.

  209. Do you have any measure of the physical surplus capacity which is in there? Working 8.30 to 5.30 means there is a less than 50 per cent usage of the hardware facility.
  (Mr Crisp) Of some of the hardware facility.

  210. So one could use that much more intensively.
  (Mr Crisp) But it is only a bit of the system, because by and large you need beds to put the patients into afterwards—not always, there are day surgery units which operate on longer hours, day surgery units which operate 6 in the morning until 10 at night to take advantage of that. We have more theatre space but we do not necessarily have the beds and the staff to go with it.

  211. You were rather dismissive when one of my colleagues—Geraint I think—raised the issue of bed blocking. You said that a whole series of interventions are needed but you did not seem to regard it as a matter of some significance, whereas most of us in our own constituencies probably think it is a matter of some significance.
  (Mr Crisp) My tone of voice obviously came over wrongly. I think the two biggest issues we are facing are bed blocking and staffing, the two issues we are talking about, and that is why, during the course of this year, we have invested an additional £300 million in bed blocking and that has not effectively happened for anything else. It is because chief executives from Croydon and elsewhere have pointed out to us this is the most significant problem they have, or one of the two.

  212. Alan Langlands pointed this out some years ago at a hearing here. He made the point, which is a valid one, which is a point for politicians, not for you, that while you have the division between social services with responsibility for post-hospital care and the hospitals who are left saddled with the people who are not accommodated by social services, you are never going to be able to use the facilities efficiently. So how would the 300 million resolve it?
  (Mr Crisp) That was the point of the fact that this money has come to social services on the understanding that they spend it alongside health and that they use the Health Act flexibilities to do that, which are about joint budgets, joint management and so on, which is a move towards systems integration if not actually merger of the organisations. It is precisely for that reason.

  213. The other major problem in terms of surplus capacity which several of my colleagues have touched on, Mr Trickett in particular, is the health authorities' blindness across the borders and their inability to look beyond their own borders to use what is clear surplus capacity perhaps a few miles from where they are working.
  (Mr Crisp) Your colleagues have shown the problems at particular boundaries. Next year, we will have primary care trusts, which will be in general smaller than the current health authorities, making these decisions closer to their patients perhaps. They will therefore be able to make the sort of decisions we are talking about so in an area like Mr Trickett's health authority they could use the other hospitals rather than the one they usually refer to.

  214. Is there any reason to think that a multitude of small authorities will be more efficient in their use of facilities than a relatively small number of large authorities, which should be able to find out where the surplus capacity is?
  (Mr Crisp) The point which I think you and colleagues have been making is that health authorities may be a bit distant and bureaucratic and look at things on a planned basis. Primary care trusts are going to be very interesting, new organisations with a chair, a chief executive and lead doctor, and I expect on the basis of that they will be making decisions in a rather different way and more locally.

  215. But if you are having a diffusion of decision-making, you also need a diffusion of information to people.
  (Mr Crisp) I agree.

  216. Our experience in this Committee has been rather sad as far as IT is concerned in the Health Service. We had the disaster with Wessex and then we had the NHS Hospital Information Service which lost £60-odd million. Have we made any worthwhile progress in the extension of the use of IT within the Health Service?
  (Mr Crisp) This Committee is managing to range over most of the current issues in the Health Service. There is a lot of work which has gone on in putting in infrastructure over the last two years which is starting to bear fruit. For simply getting information to GPs about inpatient and outpatient waiting times, faxes will do and those arrangements are in place. They should have that information anyway.

  217. You say, "faxes will do", I suppose it seems rather bureaucratic when you can just get information on the screen. With dozens of doctors in any one hospital area making arrangements in any one day it would obviously be far better if there were an IT solution rather than a fax solution?
  (Mr Crisp) I misunderstood you, I thought you were asking the hospitals to give the GPs information, I am saying that they already have that, they can get that through whatever route is appropriate. If you are talking about an electronic booking system then there are clear plans to introduce that by 2005, and I think we just said we are on time to do that. That will allow people to book through their GPs.

  218. Now we are back on sensitive ground, you have plans to do that, we have been through other plans, do your plans have a grandiose software or hardware project at the heart of them or is there something less sophisticated?
  (Mr Fillingham) We certainly need to invest in information technology in order to deliver electronic systems. We do not envisage grandiose national schemes to do that. Some local organisations have their technology in place, King's Hospital in London have 24 general practices already linked-in electronically, three quarters of all their appointments are booked electronically. What used to take three weeks takes a matter of minutes. We need to get the rest of the NHS up to that kind of level and standard. We are learning some lessons from IT development, the intention is very clear, national specifications, clear project management to make sure benefits are delivered, systems that fit well with what we already have in existence and which deliver the end result overall.

  219. With the PFI hospitals do you work on the planning possible throughput as far as the use of their theatres are concerned? Do you work on the same assumption in terms of utilisation of the physical resources of their operating theatres as you apply to existing hospitals?
  (Mr Crisp) It varies. And as I said, for some theatres we do use them more extensively than 8.30 to 5.30 for day procedures and there are some that work on Saturdays. By and large, planning has been done on the basis of what we do now, plus an estimate of some improvement.


 
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