Examination of witnesses (Questions 20 - 39)
WEDNESDAY 17 JUNE 1998
MR
GEOFF SCAIFE,
DR PETER
COLLINGS and MR GERRY
MARR
20. As delighted as I am
to hear that a minister will be personally pushing on this, he
is not a medical man and what are you going to do if there are
critical systems that are not compliant by the start of the new
Millennium?
(Mr Scaife) Chairman, the way we are approaching
this is to do everything that we can possibly can to ensure that
we do achieve compliance.
21. Let us take that for granted. It would
be madness for you to suggest otherwise and it would be, I think,
wrong of this Committee to assume that you will not be doing everything,
but what will you do if there are critical systems that are not
compliant?
(Mr Scaife) We would then obviously need a coherent
contingency plan. In Scotland we do need to have contingency plans.
We are subject from time to time to all kinds of unpredicted emergencies,
largely to do with very adverse weather conditions, and, of course,
we are used to putting in place contingency plans very quickly
and we usually do extremely well in making certain that patient
care does not suffer. So we have the track record of doing this
but, in my judgment, the time to be firming up arrangements to
help survive for that critical period from Christmas 1999 is during
1999 and we will obviously be doing that, by which time we will
be much clearer about where the potential risks lie and we will,
therefore, be dovetailing contingency arrangements to actual need
rather than starting now, when we could be, frankly, wasting resources.
22. I am not looking for you to waste resources
but have you done any tests or trials whatsoever that give an
indication of how long it will take you to work up a contingency
plan? I am not asking and saying you should have one in place
right now, but have you any idea of what is involved if certain
critical systems are not compliant and what one has to do in a
hospital to make sure that patients' safety is paramount?
(Mr Scaife) As I have already answered, Chairman,
the contingency planning is an issue for 1999. This year is about
solving the problem and we are confident that the 12 months of
1999 will be sufficient time in order to put in place the kind
of contingency arrangements that might be required, but the energy
is going into solving the problem.
23. May I ask you one further question,
which again follows on the line of questioning by the Chairman,
and that is the number of claims of clinical and medical negligence.
They are a matter of obvious concern and they are a matter where
I think the nation is becoming more litigious and it is going
to be something that is going to arise more and more. Do you do
any evaluation between Trusts to find out whether one Trust is
in fact more likely to be taken to court and have claims against
it than another? Do you do any form of clinical audit against
the surgeons and physicians inside the various trusts?
(Mr Scaife) Yes, we do. In Scotland we have given
a great deal of energy and considerable resources to the question
of the quality of clinical care, both in relation to clinical
audit and in relation to the question of the development of indicators
about the effectiveness of care. In fact, since 1994 we have put
into the public domain detailed reports comparing the outcomes
of clinical activity at the level of individual Trusts. Moreover,
we have followed up, evaluated, in a systematic way the use of
those clinical outcome indicators. I can give you an example.
In Falkirk & District Royal Infirmary, for example, the clinical
outcome indicators suggested that the outcomes in terms of mortality
for the care of patients who had suffered a stroke did not quite
stack up compared to those elsewhere. We then had to-ing and fro-ing
about whether the figures were right and all the rest of it, but
as a direct consequence of a warning flag going up from the production
and publication of these clinical indicators the hospital trust
created a new acute stroke unit. They have been evaluating performance
since then and their 30 day mortality rate has reduced, the rate
of complications has reduced, and they are confident and clear
that the quality of service they offer has improved. This publication
of data comparing clinical care between teams of doctors working
in different Trusts has been part of the Scottish scene since
1994. Clinical audit actually started in the Lothian region in
Scotland 52 years ago. In Scotland we have a very well established
system of clinical audit. The question we are addressing now is
whether we can go further in relation to the clinical governance,
whether we need to develop a new and better data service, because
the indicators that we have been publishing has been from routine
data that we have had available to us. You will have seen the
proposals to develop quality assurance, accreditation, and the
whole idea of clinical governance throughout the NHS in Scotland.
24. I shall look forward to the future when
every single one of these claims are going to vanish to zero because
everybody will be 100 per cent satisfied.
(Mr Scaife) That will be wonderful.
Mr Page: Thank you.
Maria Eagle
25. Mr Scaife, just on the millennium bug
problem, are you satisfied that the categorisation between critical
and non-critical systems is adequate?
(Mr Scaife) Yes I am, Chairman, and perhaps more
importantly so are the people working at the sharp end in the
hospital Trusts who have been directly involved in doing the detailed
work.
26. Tell me whether or not a lift is a critical
system or a non-critical system?
(Mr Scaife) A lift is a critical system if in
a hospital you require to use a lift to move between patient ward
areas and theatres. A lift is not a critical system if it needs
to go between areas of the hospital that do not involve the transport
of patients directly.
27. One of the problems with the millennium
bug in the past has been people think it just relates to IT systems
and they think if their computer will turn on properly it is all
alright. Are you satisfied that in the Scottish NHS in all the
Trusts that you are responsible for they have got well past that
stage?
(Mr Scaife) I am certainly satisfied that they
have got the characterisation right and that this is not regarded
as an IT problem. When we looked at, as I say, 116,000 systems
or items of equipment the critical categories included 89 per
cent of all medical devices, 61 per cent of all estate systems,
which would pick up things like lifts, and only 40 per cent of
IT systems. In many respects it was the non-IT systems that were
critical and had to be got right.
28. I want to move on to the Lothian Health
Board. How can you possibly justify a Health Board having surpluses,
appearing to behave as some kind of bank handing out cash flows?
Are there not people in Lothian waiting to be treated upon whom
this money could be spent?
(Mr Scaife) Yes, Chairman, in common with every
other Health Board there are patients in Lothian waiting to be
treated. I can understand the Health Board looking towards the
end of the financial year at the resources available to it. We
would expect Health Boards to use the full allocation that they
receive from Government for patient care. We would not expect
Health Boards to hold on to year end balances.
29. What are you doing to ensure that Lothian
behaves a little bit better next year?
(Mr Scaife) We are obviously in very close touch
with Lothian and encouraging them to get this right. We take seriously
the need to make sure that the money is used for the purpose for
which it is allocated. The Health Boards are in no doubt about
that. We have reinforced the message in all Health Boards. In
1996 and 1997 we issued very clear reminders to our Health Boards
about the need to get this right and to operate by the rules of
good accounting.
30. In respect of the possible unlawful
payments, the overpayments in 6.2 on page xx of the C&AG's
report, you said to the Chairman earlier that the overpayments
have effectively now been written off because they cannot be recovered.
Presumably they cannot be recovered because any recovery action
through the courts would be time barred, so short of asking these
people who have taken away the overpayments to hand them back
there is nothing you can do. Limitation will be six years, how
could it possibly take six years for you to discover and investigate
these overpayments?
(Mr Scaife) Chairman, I have explained that there
were 18 such payments and every single one was chased vigorously,
every single one was reported to the Treasury. We took a view,
as did the Treasury, about the prospects of recovery.
31. How soon did you take that view after
the overpayments were made?
(Mr Scaife) Once the overpayments were identified.
32. Once they were identified. Were they
all identified at the same time?
(Mr Scaife) No, they were not. They were identified
progressively over time.
33. Would it not have been possible to take
recovery action immediately through the courts as they were identified?
Presumably they were not all identified after the limitation date,
were they, after any such case could be time barred? They were
not all identified six years after they were claimed.
(Mr Scaife) There was obviously a period of being
clear on what basis the payments had been made and what the rules
were and lots of sorting out between colleagues in the Treasury
and colleagues in the Department of Health itself.
34. Did this sorting-out take you over the
limitation date and mean that you could not recover? What I am
trying to get at is, would it not have been possible for you to
initiate recovery action through the courts in time and then sort
things out afterwards between yourselves and the Treasury about
whether this money was to be written off? You could have instituted
the recovery action within the court time limits, could you not?
Six years is normally long enough to do so?
(Mr Scaife) Chairman, I have explained the process
and the question of recovery is not just to do with timescales.
Questions of recovery are to do with the size of the sum involved
and the potential cost of achieving recovery as well as the circumstances
of the payment. I said in response to an earlier question that
payments were actually made in good faith and that the payments
were received in good faith.
35. I am sure they were received very——
(Mr Scaife) Therefore, there is a question arising
as to whether they could have been recovered.
36. You understand that certainly some of
us on this Committee take a very dim view of public money being
handed out that should not be handed out and then not recovered.
There is probably nothing worse, and despite the fact that these
sums are relatively small, it does not exactly send out a good
signal about the grip which your Department has on its spending
of public money, does it?
(Mr Scaife) Chairman, we have obviously picked
up this ball in terms of future arrangements and made sure that
this kind of situation cannot arise again.
37. You are satisfied that it will not arise
in future?
(Mr Scaife) I am, because we have specific steps
in place now to make sure that the Health Boards cannot act unilaterally
in authorising such payments. Every single payment of this type
has now to be cleared with us in advance. That was obviously not
the arrangement that applied going back over years.
38. I am glad to hear it. Is there a similar
arrangement made in respect of Trusts?
(Mr Scaife) Chairman, the situation with regard
to Trusts, NHS Trusts, is rather more complicated, in that although
we have direct powers over Health Boards, the Government's powers
in relation to NHS Trusts are much more limited. The issue of
termination settlements in Health Boards arose from the fact that
time-limited, fixed-term contracts were introduced into the NHS
in about 1986, so what we did in July was to signal to Trusts
that open-ended contracts, not fixed-term contracts which leave
open the question of payment, were the norm and in the White Paper
the Government signalled the clear intent that, subject to its
ability to secure legislation, it would take the necessary powers
to be able to direct the affairs of Trusts.
39. Thank you. I want to move on to the
question of clinical and medical negligence. As somebody, I suppose
I ought to say, who used to conduct medical negligence claims,
I am not convinced that logging complaints at the time at which
you get the letter before action or a writ gives you a realistic
picture of the nature and the extent of the problem. Would it
not be better for you to institute a system whereby complaints
are logged at the time of the incident? Most doctors and clinicians
know when circumstances have arisen which may give rise to a claim.
Would it not be better in terms of secure and proper provision
and getting a full handle on the extent of this problem, to institute
a system whereby you get clinicians to indicate to you when a
potential problem arises rather than when a claim is made?
(Mr Scaife) Chairman, I have already explained
about the efforts that we are making to improve the quality of
care and to try to reduce the incidence of problems resulting
in claims. I have also explained the numbers of cases arising
in each year and the fact that in Scotland they are remarkably
constant, and the budgetary provision we have made. We think we
do have a handle on the number of cases coming forward and we
think we do have a handle on the size of provision we need to
make in the accounts in the event of a claim.
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