Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 60 - 79)



  60. So why do some consultants have extra long waiting lists? I can understand that some consultants get many more referrals but why else do some consultants have these huge waiting lists?
  (Mr Crisp) It can be a whole mix of issues including, as you said, some people have a particular reputation for shoulders or whatever it is. It can be that in some cases we have not got enough consultants in that speciality in that area. It can be in some cases because of management issues either for the trust or for the individual consultant.

  61. Is it because consultants do not do enough work?
  (Mr Crisp) In some cases that might be true but in general our view is that consultants do more than they are contracted to do across the NHS as a whole. There will be some exceptions in any fairly large group.

  62. Have you ever checked with consultants who have really long lists how much private work they do?
  (Mr Crisp) Some of that work has been done through a number of different studies. There is no direct pattern, which is the obvious question.

  63. I am not sure about that. I am not going to give you information because that would be unfair but a certain Chief Executive of a trust told me that he experienced in the job that he has at the present time and in the one previously consultants that he could not handle, he could not manage, because they were a law unto themselves. They decided how much work they would do, they decided how much private work they would do and they were not prepared to help the system and they had long lists.
  (Mr Crisp) I think there are two points here. The first one you make, which is actually managing hospitals, managing professional people within a setting like a hospital, is very difficult and there can be some cases where precisely what you describe is true. These are difficult jobs that people are doing and most of these trusts, if you look at them, are not only suffering from a particular issue like a waiting list fiddle of some sort, they have also got other points they are trying to deal with.

  64. So is there any mechanism to have a look, where you have lists of 12 months or longer, at those particular consultants who have those lists? Are they monitored to see how much work they actually do?
  (Mr Crisp) There are two things. Firstly, can I just go back to our conversation of three months ago when you asked me about two consultants at the same hospital having different waiting times for outpatients. We will in future publish that on the Internet so the patients can see that. That is in direct response to—

  65. That is after five years. Will doctors also be given that explanation so that a doctor cannot say to me "I have not got time to look and see how long lists are, I just refer to the hospital"?
  (Mr Crisp) GPs already have that information, as we had the discussion in October.

  66. Will you ensure that GPs use that information?
  (Mr Crisp) I think, and I said it earlier, that the biggest method for making sure this gets better is giving patients more power and more information and when patients have that information it will be better. To go back to your particular point about do we look to see if it is the consultant who is at fault, what we do where we have waiting list problems of whatever sort, and some of them may be about long waiters or particular problems, is in general we will ask one of our NPAT teams—National Patient Access Teams—to look and to identify the problems. What we tend to find is they are a mix of things, they are not just one thing. They are not just a difficult consultant, if that was your hypothesis, there may be a whole mix of different things.

  67. It will be interesting to have a look at the 13 trusts who meet the criteria of ten per cent of patients who are suspended and more than two per cent of patients waiting more than 12 months, which is on page three, to monitor and see how much work they do.
  (Mr Crisp) Particularly on the 13, that is not something that we are doing to look at the 13 in isolation from others, that is a particular group of 13 which the NAO has suggested. However, consultant workload is one of the issues that we do look at. Can I again bring in Mr Foster on this because he has got some direct experience.
  (Mr Foster) I would like to make the general point that the information we have is that the vast majority of consultants, as Mr Crisp has said, actually work significantly in excess of their contractual obligations, and it is very unfortunate that—

  68. Absolutely, but it is a very small minority we are talking about here anyway.
  (Mr Foster) Absolutely and I would not want the vast majority to be tarred by some of these allegations about a relatively small number of individuals.

  69. But you agree that there are these relatively small numbers of people?
  (Mr Foster) There are anecdotal instances of a few individuals, yes, indeed there are. What I would say in answer to your general question is first of all we are in the process of negotiating a new consultant contract and the Government has announced proposals to take more direct control of consultants' working week to remove some of the distinctions of the 1948 contract that have left certain areas ambiguous, so we will have a much clearer control, allied to a much more sophisticated information system where we will be able to gather increasingly more sophisticated information about consultants' workload and as we become reassured by the robustness of that information increasingly publish it. So that is part of the same drift of making the information available to patients so that it is transparent for all.

  70. What about the consultant who invites a patient in for an operation, the patient goes in the evening beforehand and is woken at six o'clock in the morning for the operation, the consultant then comes in and says "I have not got the parts to do the operation", it is a hip operation, "go and see your MP and tell him"? Why was the patient called in in the first place if he knew that the parts were not there the night before?
  (Mr Crisp) I think we cannot answer the individual occasion.

  71. No, of course not, I would not expect you to. This is what worries me greatly about some of the statistics and some of the attitudes coming from some of our consultants frankly. I will move on. Why do people have to wait 12 months? If a manager is doing his job properly, or a consultant, and they see the lists are over 12 months long, why do they not do something about it, why do they allow it to go on for 12 months? It just seems common sense to me that the hospital would see there is a waiting list of 12 months and say "we have got to do something about it". Why do they not? It is no good saying because they are short of that particular speciality.
  (Mr Crisp) I think the biggest single issue is capacity.

  72. Why do they not—what is the word—hive it off to another trust?
  (Mr Crisp) As you are aware, that is what we are doing. As you will be aware, we are introducing at some point for next year for coronary heart disease patients in the first place the option if they have waited six months of going somewhere else to help drive down this waiting list. The single bottleneck on that is having the capacity elsewhere for people to go to because whilst some hospitals have got very short waiting lists we have still got too many that are 12 months. We need to bring the whole thing down and that means more capacity, and more capacity is coming but it will take time.

  73. Let me move off that point now, we have got a bit bogged down. Page four, paragraph seven, here we are told, this was the fiddling that went on, ". . . the adjustments were made in the context of pressure on trusts and particularly Chief Executives to meet key departmental targets." How much credence is there for that excuse?
  (Mr Crisp) The wording here is very carefully worded, it is in the context of pressure, it is in the context of a lot of different things, if I may put it like that.

  74. Was it pressure or just plain cheating?
  (Mr Crisp) There is no evidence that it was pressure because if it was then everybody would be doing it, would they not?

  75. That is my point.
  (Mr Crisp) Pressure is no excuse for doing these sorts of things. Just to take the point further, other trusts when have they have got 18 month waiters have come and told us, they have held up their hands and been honest, and that is why this should not slur everybody.

  76. You have anticipated the question I was going to ask. If the majority of trusts were able to achieve the Government targets, why were these trusts not able to? If they knew that they could not meet these targets, why did they not do something about it, why did they not come and report it?
  (Mr Crisp) To be entirely fair, some of these trusts had a range of difficulties and problems that they were trying to deal with and individuals within the system presumably, and I can only say presumably, felt that their only option was in some way to cheat to make it better. They may have thought they were doing that in the interest of I do not know what, I have no insight into it.

  77. What role does the Government have in dealing with the cheats?
  (Mr Crisp) I think our role, and I am speaking here as a Chief Executive rather than Government in that sense, is where we discover that something is going wrong we act as quickly as we can to put it right. I take a degree of comfort that in every one of these cases the first thing that happened was the patients' welfare was taken into account. I do think it is important that Government sets up the sort of arrangements that you have obviously got that exposes this problem so that we can tackle it. Those are the things that I think are right for us to be handling centrally.

  78. The Report clearly states that perhaps pressure was the reason and that the targets may have been too severe but my understanding, if you read the Report, is that the targets are going to be even more severe, are they not? The targets are not 12 months now but are six months.
  (Mr Crisp) They were 18, then they will be 15 and then they will be 12 and so on. I do not accept that pressure was the reason and I did not think you accepted that pressure was the reason.

  79. No.
  (Mr Crisp) I think pressure is part of the context but these are difficult jobs and that is why we have good people on the whole managing these organisations, and good non-executives.

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