Examination of Witnesses (Questions 1
MONDAY 14 JANUARY 2002
1. Good afternoon, ladies and gentlemen, and
welcome to the Committee of Public Accounts. We welcome today
Mr Crisp. Perhaps you would introduce your colleague.
(Mr Crisp) Can I introduce Mr Andrew
Foster who is the Director of Human Resources for the NHS and
Department of Health.
2. Thank you. Today, of course, we are talking
about an issue which is of enormous importance, namely, inappropriate
adjustments to NHS waiting lists. Perhaps I can just introduce
a few topics so that my colleagues can go through them in more
detail if they wish. I want to start off by talking about the
extent of inappropriate adjustments. If you turn to page 5, paragraph
12, Mr Crisp, you will see that only five of the nine cases of
misstatement were spotted by the NHS's own systems. How then do
you know that this is not just the tip of the iceberg?
(Mr Crisp) Can I, first of all, say that, as you have
said, this is an extremely serious issue and one we take extremely
seriously and one we have taken seriously for some time as well.
The history of this is that when we identified the first one of
these, which did indeed come about because of it being raised
externally to the NHS, we first of all in London and then across
the country drew the attention of Chief Executives to the issue
about the number of patients on suspended waiting lists, so that
we were therefore deliberately wishing to check with them whether
other people had been doing what had been happening in Redbridge.
We followed that up and we follow that through regular monitoring.
As a result of that and the raising of awareness in this issue
in the NHS, a number of other cases have become apparent which
have now been looked at by the Audit Office. We have now gone
further than that. We are formally introducing triggers at the
point at which we want to review with individual trusts whether
their waiting lists are being properly managed and they will be
the sort of things that are identified in the National Audit Office
Reportwhere we have got a suspended waiting list of more
than ten per cent, where we have got very long waiting lists or
where we have got concerns about waiting lists. In addition to
that, what we have done is we have now, as you know, written to
the Audit Commission to ask them to introduce a series of spot
checks which we are in the process of agreeing how that will happen,
and at a later stage in the meeting perhaps I can expand.
3. You mentioned this point about triggers which
is very interesting. If I now refer you to paragraph 3 of the
Report on page 3, you will see that there are 13 trusts mentioned
in that paragraph. How have you assured yourself that there has
not been manipulation in the case of these 13 trusts?
(Mr Crisp) Again on the basis of what I just said,
most of those 13 had passed the trigger points that we already
had in place so we had already been undertaking reviews with those
4. What have you found?
(Mr Crisp) We have not yet found any inappropriate
manipulation in the ones that we have looked at. All have now
been contacted. There are some things that require a degree of
explanation. Could I take an example with you and talk it through,
would that be reasonable at this point?
5. Yes, thank you.
(Mr Crisp) One of the trusts, which is the trust with
the highest number of suspensions in the country (which is not
on the National Audit Office list simply because it does not have
long waiters) is the one that has the highest number of suspensions,
at 700, which is about the same as other trusts which have that
level of throughput of patients, but because it has concentrated
very hard on its waiting lists and therefore it has a much smaller
waiting list, the proportion of suspensions is what you might
expect from a trust of that size but they show up as a much higher
percentage. So you will find there are perfectly legitimate reasons
why there are anomalies in suspensions and I could give you some
other examples as well.
6. You have not yet, despite the fact that these
are trusts that there might be a problem in because of the trigger
mechanism that appears to come up, found any problems. Does this
lead you to believe that perhaps this is less of a problem in
the NHS than we might have feared or do you want to share any
views you have from your initial enquiries about the nature of
this problem throughout the NHS?
(Mr Crisp) It is significant for the patients involvedand
I think none of us should under-estimate the fact that for the
approximately 6,000 (which was the best estimate that the NAO
Report picked out) this is a very serious matter. I do think from
our review of it that a) it is at the margins of activity, it
is small percentages of what is happening and b) and perhaps I
can make this as a very strong point, we are moving to a much
more open system about information in the NHS and that has got
a number of points, one directly relevant to your inquiry on waiting
lists when we were last in this room together. We will be publishing
from the new financial year waiting times by individual consultants
on the Internet and by individual hospitals. That will pick up
a point made particularly by Mr Steinberg about that information
not being available. We will also be moving to booked admissions.
This means that it will be that much more easy for patients to
check themselves that we are handling their administration appropriately.
7. But you are setting ever more challenging
(Mr Crisp) They are more challenging targets, indeed
that is right.
8. Are you not worried that this will put further
pressure on Chief Executives?
(Mr Crisp) I have no doubt that the targets are stretching
but the vast amount of evidence shows they can be achieved without
resort to anything inappropriate, whether it is changing waiting
lists or anything else, and we have seen that throughout the country.
I do recognise, and it is important that we should all recognise
in looking at this, that the targets for waiting lists are challenging,
and rightly so because people in this country want us to bring
down waiting lists. I also think when you look at these trusts
you will see a number of them are run by very good people where
they have a number of other difficulties as well as the ones that
are described here. People are working under pressure in the NHS
but that is no reason to resort to the sort of practices which
are highlighted in some cases here.
9. Are you confident that the spot checks that
you have referred to will be a sufficient counterbalance to distorted
figures and do you think that you should have introduced some
kind of formal external annual validation for key NHS performance
(Mr Crisp) If I pursue the second part of the question
first which is further about openness, we are making much more
information available to patients, as I have said. We have now
got much better systems for whistle blowing so that individuals
can draw this to our attention internally. We are now putting
in place an independent inspection system through the Commission
for Health Improvement and we have said, and we will be saying,
that they will be having a much bigger role in publishing information
so that information will be coming much more from an independent
source on NHS activity.
10. But not yet formal external annual validation
for key performance indicators?
(Mr Crisp) If the information is being pushed by someone
like the Commission for Health Improvement then they will need
to satisfy themselves. Your last Report said that the level of
data quality of waiting lists was probably satisfactory and that
it was probably appropriate that we did not put much more resource
into making them absolutely precisely accurate, and that there
was a trade-off to be drawn between the amount of expenditure
on doing that and getting the absolute accuracy of the figures.
This is live management information. I personally think the biggest
safeguard is when patients can look at the Internet or get somebody
to look for them on the Internet and see the waiting time for
that individual consultant is of the order of three months, or
whatever it is, and can also have a booked appointment so they
can see how they rate, and giving patients information is probably
the single biggest safeguard we can bring.
11. Other colleagues can pursue questions on
the extent of inappropriate adjustment. I now want to ask you
questions about how the investigations into the adjustments were
handled. At the end of the day, despite investigations into these
irregularities, no one was dismissed, the process in some cases
was clearly inadequate, many of those accused complain about its
quality and fairness. What are you doing to ensure that, in future,
investigations are undertaken quickly, professionally and fairly?
(Mr Crisp) Again, I am sure we will cover some of
this. I do accept that some of the investigations in hindsight
were not satisfactory. In fact, what took so long in a number
of cases was the decision-making and preparation for disciplinary
action outside the investigation, although some of the investigations
were good. What we are doing is putting in place a standard format
for investigations of this sort and we will be introducing that
just as soon as we can.
12. Others can ask further questions on that.
The last area I want to deal with you of course concerns the disciplinary
action taken and the compensation payments that were made, which
I am sure you were expecting us to ask you about. If you look
at page 9 and if you refer to paragraphs 28 and 29, you will see
that individuals there were subject to these inquiries, they resigned
during the process, they were then re-employed within the NHS
and the NHS apparently cannot pursue disciplinary action against
them. This seems to an outsider to be an extraordinary state of
affairs. How can this be?
(Mr Crisp) That happened in some cases, not in all
13. I accept that.
(Mr Crisp) And the information is described there.
We also want to take action to prevent that happening in future
and what we are doing specifically around the guidelines by bringing
them up to the force of direction around some of the issues to
do with termination of contracts and so on, we can talk about
in more detail in a moment. I think the other strong point here
is that we are introducing a Management Code of Conduct so that
if somebody is adjudged to have broken that Management Code of
Conduct in one setting as a manager of the NHS, they should not
be employed as a manager anywhere else in the NHS. That does not
exist yet. It is a recommendation of the Bristol Royal Infirmary
inquiry and it is one we are bringing in and we are taking steps
to do that. The point at the moment is that different NHS organisations
are different employers and they have the right to employ people.
We will be introducing this new arrangement whereby senior managers,
or managers, in the NHS will be expected to conform with the Code
14. That is the problem, that you are currently
dealing with a number of different trusts and your powers are
somewhat limited. I take it that answer means that there is now
going to be a framework within the NHS to allow continued action
against staff who move around? That is what I take your answer
(Mr Crisp) Yes, on the management issues specifically,
just as there is on other professional issues.
15. Right. Coming out from this Report it is
clear that NHS trusts , or some of them, do not have the skills
to handle these complex disciplinary cases. Do you think that
there should be an NHS Litigation Authority?
(Mr Crisp) You mean specifically internally for dealing
with disciplinary issues?
16. Yes, an expert group to deal with these
sorts of problems?
(Mr Crisp) The way that we are moving in the NHS is
to actually give more freedom and more responsibility to local
organisations. What I think there should be is perhaps clearer
guidance and a clearer framework and perhaps more support for
people to do that. Sometimes we ask relatively inexperienced people,
some of those non-executives, to take big and difficult decisions
and I think this Report does raise the question as to whether
we always give them enough support. What we are not going to do
though is renationalise managers' contracts within this and make
it a national system, we are going the other way.
17. The thing which will really shock colleagues
and other people outside is that four senior managers who left
received payouts totalling £260,000 even though they were
allegedly involved in these irregularities. What are you doing
about this state of affairs?
(Mr Crisp) Can I firstly say that in one of those
the agreed termination happened before the irregularities were
found, so it is actually two cases involving three managers. What
we are doing about precisely that is we are making it clear firstly
by bringing guidance up to the force of instruction in regard
to how you terminate a contract, secondly we are making it absolutely
clear to people that we expect them to go through a disciplinary
procedure in these cases and that it is not appropriate where
the integrity of the organisation, and therefore indeed the integrity
of the NHS, is called into question that we do those sort of compromise
agreements in future.
18. The last question I want to you ask you
about, which again is a matter which irritates this Committee
and we have raised it on many previous occasions, is that compensation
agreements have confidentiality clauses which we do not think
is acceptable in the public sector. What is your guidance about
such clauses and what are you going to do to ensure that they
are not used again?
(Mr Crisp) May I make two points. Firstly, this is
one of the issues where our guidance, which fits in with your
views, is guidance at this stage and we will add to it the force
of direction to make sure that happens. I can talk you through
again, either now or in response to one of your colleagues, what
actually happened in one or two of the individual cases.
Chairman: I have no doubt this will come up
again. I will now pass over to Alan Williams.
19. Thank you, Chairman. Mr Crisp, you are relatively
new to this particular role. I have been on this Committee over
12 years and I find this the most sickening report I have seen
in that 12 years. Would you agree that it is the lowest form of
cynicism for managers to protect their own backs and their own
jobs at the risk of extending and aggravating the suffering of
patients waiting for treatment?
(Mr Crisp) I too find some of the things in this Report
shocking where what you have described is the case. Let us be
clear that we all have the right to expect better standards from
NHS managers and in general we get them.