Examination of Witnesses (Questions 120
MONDAY 19 NOVEMBER 2001
120. A striking fact which has already been
referred to is that theatres are actually closed more than they
are open during the week, but how many wards are actually closed
each week or for parts of the week?
(Mr Crisp) That is certainly not a piece of information
we collect. We do collect the information retrospectively on the
number of beds open as opposed to wards.
121. Would it surprise you if I said that within
the last three months I have visited a hospital and found wards
padlocked with chains and padlocks on the doors which led both
to beds and also to theatres being sealed? This was a very, very
large general hospital.
(Mr Crisp) If that is what you found, I would be interested
to know why that was the case.
122. Are you not aware that is happening?
(Mr Crisp) I do not know the context but let me say
that we have very recently received the analysis of the number
of beds open last year as opposed to the year before, based on
a daily census, and that has gone up. We are having another census
very shortly, on 30 November I think, when we will be looking
around the country to see what capacity we have in place for winter.
If there are any doubts or questions about it, we will be picking
up the issues as to why in Wakefield, or wherever it is, you have
123. It was in Leeds. My father was being treated
late on a Friday afternoon in an emergency admission, and we discovered
there were two wards and several theatres with padlocks and chains
at 4.30 on a Friday afternoon. Apparently, the padlocks and chains
were not removed, and never are, at the weekend in those theatres.
The staff were available and actually came in and did the operation
and he was put into another part of the hospital.
(Mr Crisp) In that case, it sounds to me as if it
was a planned process for running five-day wards. There are a
number of procedures, which are not normally conducted on a Friday
afternoon, where the length of stay is one, two or three days,
and we find it is an effective way to run our facilities with
the staff we have to run them Monday to Friday on a five day week
and close them down at the weekend. There will be a number of
wards like that.
124. The staff were available and were brought
in, in fact they were being paid to stay at home. I spoke to all
the staff because I was admitted into the theatre and discovered
they were being paid to stay at home and the wards and the theatres
were locked. If this is a practice which you are aware of, it
is a rather surprising one.
(Mr Crisp) Not as described by you. There are in any
hospital emergency wards which are open all week round, all year
round, and theatres running all week round and all day round,
there are then day facilities which are only open 8 to 8, there
are then outpatient facilities which are open something like 8
to 8, and then there will be five-day wards designed specifically
for certain categories of surgery. Obviously, I do not know the
case and I do not understand why staff should be waiting at home
rather than being in the theatre or in the ward, but hospitals
are not just one thing, there are all different streams of patients
and some patients need different treatments.
125. There is no company which would have an
amount of capital plant tied up and closed more often and for
more hours in a week than actually being open and used. When we
talk about optimising, on page 26, the capacity of clinics and
the capacity of operating theatres, we are actually optimising
all of the plant which is available in a hospital. By the way,
I could take you to another hospital where there are three wards
which are permanently closed and padlocked and have been since
I was elected an MP in 1996, although other parts of the hospital
are in use. I think there are a large number of wards which are
simply padlocked either for parts of weeks or whole weeks.
(Mr Crisp) Can I make one comment on that. The bottleneck
is staff by and large within the NHS rather than physical facilities.
I do not know the state of those wards, they may need refurbishment.
By and large if we could get staff we could open more beds. Beds
are increasing, by beds we mean staffed beds.
126. We have beds which are not being used.
We do not need more beds, we need to optimise and possibly maximise
bed space and theatres. There are empty beds and theatres throughout
the country in significant numbers. I did not go looking for them.
(Mr Crisp) There is hard worked staff.
127. We have had the questions already about
private medicine and the way in which there are operatives, it
is made convenient for them to work weekends in private medicine
when there are NHS facility closed. That is probably a policy
issue which you and I ought not to trot into this afternoon. Can
I move on to one other thing, which is the apparent conspiracy
between GPs and consultants, again for the interests of the patient.
I come back to these figures about Barnsley, Doncaster and Wakefield,
what separates my constituency from Barnsley and Doncaster is
a stream which I can bestride, I have quite long legs and it is
not a very wide stream. In terms of my own constituency, it is
actually nearer to Barnsley and Doncaster than it is to Wakefield
hospitals, why do the GPs not take advantage of these really quite
astounding differences in the waiting times to refer the patients
to Barnsley or Doncaster? I do not ask you about specifics, but
the general principle of extra contractual referrals across trusts
(Mr Crisp) The responsibility for planning at a local
level rests at the moment with health authorities and they reach
agreements with hospitals to provide for their local population.
They can change that on a year-on-year basis and they can determine
that your part of their health authority should go to those hospitals
rather than the other hospitals, I do not know why they do not.
However, the point that Mr Steinberg has raised is that maybe
patients should have more say in that and we should introduce
an element of choice into that, that is certainly something that
we are looking at to see whether or not we can actually do.
128. What would happen if my local GP, at the
moment the GP is administered by Wakefield Health Authority or
the health within his boundary, but for historic, cultural and
I think administrative and bureaucratic reasons he refers patients
to a longer waiting list in Wakefield or Pontefract than exists
cross this stream in Barnsley on Doncaster. I think there must
be some organisation or bureaucratic imperative to do that. I
just remember vaguely being on a health authority at one stage
in Leeds and I remember extra contractual referrals, which really
means crossing boundaries, was frowned upon at the time.
(Mr Crisp) It is because we have basically a planned
system and basically we are planning for the people within a particular
129. You are planning for people to wait in
effect, are you not?
(Mr Crisp) This is the point Mr Steinberg made, we
do have a release valve which is called extra contractual referral
but by and large that should be used for specialist services that
are not available within your normal pattern of availability.
It is, undoubtedly, an issue and one we are looking at.
130. Is it not true that health authorities
measure GPs by the number of ECRs and those GP practices which
are looking after the patients that may be across a boundary are
frowned on because they are not "loyal" to the bureaucratic
imperative. Is that not the reason why my patients are waiting
more than six months when they could be in Barnsley or Doncaster
and be seen?
(Mr Crisp) GPs have contracts with the NHS and they
have a number of duties to fulfil. In addition to that they are
expected to take part in things which are about looking at their
referral practices, comparing their referral practices to others,
there are things to learn within all of that system. The point
you make and Mr Steinberg has made is how do you explain that
to patients? That is difficult.
131. I agree. You have to explain to yourself
and go to bed with a clean conscience, but the fact is that you
are accepting, I think, the scenario, which is wholly missing
from this Report, that there is pressure on GPs not to engage
in ECRs. It is this question of extra contractual referrals across
trust boundaries which could make a massive impact into waiting
lists in those areas where the waiting lists are particularly
acute, especially where the boundary separates good practice and
bad practice as it appears to do between Wakefield, Doncaster
(Mr Crisp) We do have a planned Health Service, it
is a Health Service that is planned through the health authorities
and we do want GPs to be part of that, indeed we are making the
changes in the system to give them more control within the system
so that they will be making decisions that are appropriate. If
they are part of the planned system they can have more say over
things, precisely the ones that you are talking about. I also
want to make one minor correction, they used to be called extra
contractual referrals they are now called out of area treatments.
Jon Trickett: For the record, the plans you
make involve people in my parts waiting longer than if they moved
across the road in another area. If that is the planned Health
Service you are constructing I do not find it very satisfactory.
132. Mr Crisp, could I take you back to paragraph
2.22 and this question of distortion of clinical priorities. I
understand you to have said, I wrote down what you said, "it
is not enough to distort the figures". I remember when this
Report was published, it was on the front page of a number of
newspapers, and the topic of the BBC Today programme two
days running, when I read this paragraph I read the words, "we
contacted a representative sample within three specialities, granted
50 per cent might have been in trauma, to give a a broad indication
across the whole spectrum". 558 consultants were interviewed,
of which 52 per cent said they considered a distortion had occurred.
You will know that a typical opinion poll is conducted on the
basis of 1,000 people, that is to represent 30 million, in terms
of voting intentions. I would have thought that 558 out of 20,000
is a pretty good sample, do I understand you to say that you basically
disagree with this paragraph, that is what I think you said earlier?
(Mr Crisp) I think what I said, and let me try and
repeat it, was that they need to be seen in context, this is not
the whole of the story. This is a worrying and important point
that is being made here which does need attention, that is why,
as I said before, we have both put out some clear statements about
where priorities need to be so that people understand that if
they are doing that that is not what we are trying to get them
to do and, secondly, why we are doing so much work through the
Modernisation Agency to improve the way in which waiting lists
are managed. There is a lot of work round that. It is not the
whole picture, because in other areas we are clearly targeting
the highest priority of clinical cases.
133. Do you think it is still going on?
(Mr Crisp) I do not know whether or not this is still
going on. If it is it will be decreasing for the two reasons of,
firstly, the instructions we have sent out and, secondly, the
fact that the management of waiting lists is improving.
134. I wanted to come on to that. You also said
that if the waiting list system is run effectively this need not
happen. The Report provides quite a lot of evidence that the system
is not being managed efficiently, may I start with paragraph 2.29,
which talks about the patient administration system and how they
vary, yet some of the software was not designed to provide key
waiting list management data that trusts are now required to produce.
Why would the trusts go off and buy computer systems that did
not enable them to provide the basic information?
(Mr Crisp) My understanding on what that is referring
to is that some of these patient administration systems are relatively
old and at that point we were not requiring hospitals to manage
outpatient systems in the way we are doing. They are patient administration
systems, the route into the hospital, they are not designed to
collect that sort of information. We have a big programme of introducing
new electronic patient records across the country as a whole which
will be, I think, in place by 2005.
(Mr Fillingham) Two things, as well as looking at
the IT solution we are also looking at what information is of
most help to help the NHS improve. There is the review of waiting
and booking information systems project which is working with
12 trusts on a pilot basis which is due to report in February
next year. That will help on the information side. I think your
earlier point was also about, is there something about the design
of hospital systems that could be improved? I think it is absolutely
the case that there is and that is what the modernisation is all
135. If I may interrupt, my next point 2.33,
when the NAO visited the 50 trusts, six trusts had no agreement
on even draft waiting list policy at the time of our visit, and
it was not that long ago? It was not that long ago, what is the
(Mr Fillingham) That is clearly an unacceptable situation.
Trusts should have not only clear policies and procedures but
strong clinical involvement with them.
136. They range, in the next paragraph, 2.34,
from two to 66 pages. Have you told trusts what you expect them
to have in a clear, simple, understandable form?
(Mr Fillingham) We certainly have issued guidance
but it is clearly in an organisation of a million people not simply
about issuing guidance, it is about bringing about improvements
in practice. The way we have structures now we have service improvement
managers working on a regional basis with local trusts, we have
a team tackling outpatients, other teams tackling theatres, tackling
pre-operative assessments, and what we are starting to see are
some considerable improvements. For example, if you just take
outpatients, we ran a learning set for 11 trusts which had the
most difficulty in terms of outpatients, and three of those have
moved into the top quarter in terms of performance. So when you
work with people on the ground, when you invest in learning and
development, when you provide the support and information, you
do get results.
137. Paragraph 2.25 talks about outpatient validation.
"Nearly half of the trusts were not undertaking validation
. . . When they were, most outpatients ...", who had been
validated, ". . . had been on the list for 13 weeks, but
the criteria ranged from 9 to 26 weeks. As a result of this work,
these trusts . . . ", which had done validation, ".
. . had been able to remove 5 to 15 per cent of patients who should
not have still been on the outpatient waiting list." Yet
half of the hospitals in the NHS are not doing this work at all.
(Mr Fillingham) It is a major challenge to make sure
that is happening everywhere.
138. What is going on? You are the accounting
officer, you spend £47,000 millionand I think I am
right in saying that apart from Social Security you are the biggest
(Mr Crisp) Yes.
139. What interests me is ensuring that that
money reaches the people who need it, the people who phone us
up and say, "I cannot get an appointment". The point
Mr Steinberg made very powerfully is that actually the resources
are in some cases there, £737 million is being flung at the
system, yet for one reason or another, be it the doctor does not
want to look on the list to see 200 miles away there is someone
with a two week waiting list or whatever, hospitals are not actually
checking or validatinghalf are, half are notand
I am not persuaded you are managing the resources you have effectively
(Mr Crisp) This report identifies a number of weaknesses,
clearly, and this is one. What we are doing on this one is, apart
from issuing the instructions and the best practice here as well,
introducing the booked admissions system which I talked about