Select Committee on Public Accounts Minutes of Evidence


Examination of Witnesses (Questions 100 - 119)

MONDAY 14 JANUARY 2002

MR NIGEL CRISP AND MR ANDREW FOSTER

  100. So we are talking about 6,000 out of five million patients affected, so small numbers of people, and you are taking these initiatives in terms of the Internet and whistle-blowing and the Commission for Health Improvement. I think that is very good, but given we are talking about this niche problem, it is all the more important that those people who are identified as being serial manipulators of data, who are affecting patients welfare, should be tagged, as Mr Foster puts it, and we should ensure that they do not end up in another job. Of the people in the summary on page 2 who have left, without going through them all, do you know of any people in senior positions in the nine cases who suddenly left what was obviously a sinking ship and who now find themselves in other positions of senior management in other trusts?
  (Mr Crisp) Let's pick up the point that Mr Foster made. I think we need to distinguish between a suspicion and proof.

  101. Yes, this is a difficulty of life.
  (Mr Crisp) But even where there is only a suspicion, somebody at an interview ought to disclose to a future employer there has been a problem. That seems to me to be appropriate.

  102. Where we have got suspicion and somebody goes for a new job and the balance of justice says we must give them another chance, are we taking special measures to interrogate the statistics to ensure that there is not any serial manipulation?
  (Mr Crisp) If the same thing has happened again in another place?

  103. Yes. Do you check them knowing that they might be villains in the past?
  (Mr Crisp) No, we are not, but I think the senior people who I can identify who have moved on into the NHS in this, and there is a relatively small number, are not in similar sorts of jobs and in some cases are in more junior jobs than the ones that they were in before and not in jobs where they could be in a position to do that.

  104. They might end up there within the context of management structures?
  (Mr Crisp) That is conceivable. All their employers know about this and no doubt also know about this hearing.

  105. Can I just ask you a simple question about the logistics of this Internet management of who has got the lowest waiting lists. It is something that Mr Steinberg has mentioned a few times. First can I ask something about the simple practicalities of this. If you look up on the Internet the varying sizes of waiting lists by consultant, is it the case that that information will be instantaneously out of date because everybody will say "I will opt for Dr Jones" and then he will be the longest rather than the shortest and it will be counterproductive?
  (Mr Crisp) I think that is a risk we should take. The example Mr Steinberg gave me last time was 18 weeks and four weeks, or something, for two consultants. I have no doubt that this will result in some equalisation of that. It may also make it more 18 weeks and more four weeks because there may be a particular reason or a particular speciality.

  106. It must be the case that this data will be instantaneously updated and it might be the best strategy to go for the third down the list because everyone will be going for number one and number two.
  (Mr Crisp) There are all kinds of games theory that one might apply to this, I appreciate that. We are going to do it. At the moment we provide this information to GPs in a written form, I think on a monthly basis, I would have to check what that was from individual trusts. The issue, as you say, is keeping it absolutely up to date.

  107. Can I just ask you about suspensions, because I do not have much time now. Presumably there are a number of legitimate reasons for suspending people from waiting lists, are there not?
  (Mr Crisp) Yes.

  108. What are they?
  (Mr Crisp) Illness would be the classic example.

  109. To summarise, my understanding of this Report is that there is a very small number of trusts who are providing abuse and fraud and you have got strategies in place both to improve the service and you are tracking and tagging the people involved and taking a much harder line on that and you do not accept the proposition that increased pressure on waiting lists is an excuse to expect this problem to grow. You expect this problem to actually fall, is that right? Do you predict now that there will be less cases of this in a year?
  (Mr Crisp) I would strongly believe that partly because of all of this publicity but actually I do think patients knowing more about the NHS will be a very powerful lever. Can I just make one final point because I think there are a lot of very honest people of considerable integrity who have been caught up in this in some way because they may have been parts of boards where this may have been happening. I think we need to be very careful about damning everybody in these organisations or, indeed, damning these organisations because this has happened. They have been relatively marginal even within the organisations.

  110. So we are talking about something in the order of 6,000 out of five million patients, you accept that this is of key importance to those people and you need to drive that figure down?
  (Mr Crisp) Absolutely. And it was five at UCL, which is a very large hospital, and they were done for what the person thought were good reasons.

Mr Gibb

  111. How confident are you that all the people genuinely responsible for these irregularities have been identified?
  (Mr Crisp) I think within the limits of where we are that has happened. I have, as a result of this, had discussions with, or interviewed, one or two additional people to make sure I have understood what was going on. I think we have identified those we can identify.

  112. You think there might be others you have not been able to identify?
  (Mr Crisp) Inevitably in one or two cases it has not been absolutely clear who was at fault.

  113. I was slightly alarmed by your answer to one of my colleagues that you were not able to prove some of these cases and, therefore, you had to make these compromise arrangements. That does alarm me. We have clearly got what Mr Williams has called one of the worst examples of irregularities he has seen in the course of this Committee and you are not able to prove that a number of people were actually responsible for what are very clear-cut irregularities identified in the Report.
  (Mr Crisp) This is not universally the case but in some of these investigations, and bear in mind two are continuing, so two of these nine are not completed and in some cases it has been very clear, such as the UCL one and so on, in some of these cases the quality of the investigation was such that it identified all the patients, and that was our first concern, and it identified what needed to be done and what action needed to be taken to get it right, and there are great long action lists about that. In some of these cases they did not satisfactorily bottom out precisely who was responsible, and even where they thought they had they did not then follow it through with a disciplinary action which would lead us to be confidently saying whose fault it was. That is a failing in this and one that we want to make sure does not happen in the future.

  114. You often say that phrase "something we do not want to see in the future" and you say you want to see higher standards in the future but all you seem to have the power to do, Mr Crisp, is issue guidelines, directives, codes of conduct, but it seems to end there. What power do you have to ensure that the health service is run as a national organisation efficiently and in accordance with all the guidelines issued centrally? Is not a comparison in the private sector with a franchise operation where there is absolute discipline from the centre to ensure that the franchise maintains its reputation and there are conferences, training seminars, continual meeting of all these top people and training for low level managers to ensure that these guidelines and codes of conduct are adhered to?
  (Mr Crisp) I think your approach is exactly right and exactly the one that we are moving to. There is only so far you can get from sending out directives from the centre, whether you are a private organisation or a public organisation. It is why we have created the Modernisation Agency which is the good practice agency, as you may be aware, within the NHS, precisely because in the NHS, which is a huge set of organisations, we need vibrant local organisations that can make decisions and we need to support them. What we are doing where we find anomalies even if they are at the margins, as by and large they are in this case, we need to make sure that we put in place the right national guidelines but also the support to people.

  115. Where are we in those two inquiries that are still outstanding?
  (Mr Crisp) I understand that they have both now moved to disciplinary proceedings being taken. We are on to the disciplinary phase.

  116. Will we see a report at some stage?
  (Mr Crisp) I imagine if you ask for one we can let you know what has happened in the two outstanding cases.[4]

  117. In the Report it talks about you going to implement these spot-checks which we have touched on already. How frequently will they be and how extensive will those spot-checks be?
  (Mr Crisp) Bearing in mind this is all pretty new, and I contacted Sir Andrew Foster of the Audit Commission on 19 December, where we have got to is the Audit Commission is doing a data quality check across the NHS next year anyway, this is in the next financial year, and we are adding to it a request that where we have identified trusts that we have any concern about because of these trigger points that I mentioned earlier, they will tackle those particular issues early within that system. They also are saying to us they want to consider whether there are other conditions or other circumstances where they would want to do that. We are actively engaged in discussion about exactly how it will work.

  118. Similarly, there is an action plan on page 34 of the Report that all these nine trusts that have been fingered are going to implement. Is that action plan going to be implemented by all 300 trusts or is it just for those nine?
  (Mr Crisp) I cannot find the action plan.

  119. It is page 34. Paragraph 34, page ten.
  (Mr Crisp) What we have got here is this will happen to the particular ones that are exampled here, absolutely, but actually all of these things are effectively good practice and fall into the context of what we are talking about. For example, on the bottom one, "better capacity planning and modelling", we have issued some advice on that already, that was something we were doing already. We have from the Modernisation Agency anyway a waiting list handbook, which again was discussed at this Committee at its last health hearing, and it picks up a lot of these issues. This is about remedial work with these nine but it is also about good practice for everybody else.


4   Ev 22, Appendix 1. Back


 
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