Examination of Witnesses (Questions 100
MONDAY 14 JANUARY 2002
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
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
(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
(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.
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
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.
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
(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.
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