Examination of Witnesses (Questions 1 - 19)
MONDAY 19 JANUARY 1998
MR WIN
GRIFFITHS MP, MR
PETER GREGORY,
MR COLIN
WILLIAMS, DR
RUTH HALL
and DR GILL
TODD
Chairman
1. The Committee, as you know, Minister, is looking into
emergency hospital admissions during the forthcoming winter. We
are grateful for your coming this afternoon to give evidence.
I understand you would like to make a short introductory statement.
(Mr Griffiths) If I could, Mr Chairman, yes. I am
pleased to be here before you today to discuss the improvements
we have introduced in the management of emergency admissions over
the winter period and the measures we have taken to underpin their
success. I have with me three of the leading officials in the
Welsh Office, Dr Ruth Hall, Peter Gregory and Colin Williams,
and Dr Gill Todd, the Chief Executive of Bro Taf Health Authority,
who has been responsible for co-ordinating the arrangements, and
at some points during the giving of evidence I may refer to them
for more detailed answers or information which may not be readily
at my disposal or in my memory as far as it goes. Obviously the
rise in the number of emergency admissions and the pressures that
this puts upon the system is not just a problem in Wales; it is
a problem that arises throughout the United Kingdom. There is
increased demand for hospital services. A large number of factors,
the ageing population, higher patient expectations, improved opportunities
for treatment and many other things, they have all got implications
for the NHS and of course for social services. In 1995 the Welsh
Office took a lead in a joint review with the NHS of the management
of emergency admissions. It was felt in this review that this
issue should be given priority and new measures were taken to
ensure that the NHS and its colleague organisations in social
services could give patients the care they needed. First and foremost,
the NHS must ensure that its emergency services are there when
people need them. This is why we have given emergency admissions
the top priority that they deserve. As a result of the review,
action plans were drawn up by health authorities and NHS trusts
which led to a better handling of emergency admissions in 1995/96.
Project managers were appointed to identify best practice in hospital
bed management, admissions and discharge, to work collaboratively
and to develop systems to monitor admissions, delays in discharge
and lengths of stay in hospital. It was also recognised that longer-term
strategic mechanisms were needed. This collaborative effort continued
into 1996/97 and as a result of the lessons learned the previous
year, the Joint Health Authority and Trust Conference was held
in September 1996 to review the outcome of the arrangements that
had been put in place and to agree the way forward for 1996/97.
This resulted in emergency admissions task forces being set up
in each health authority area with input from trusts, GPs and
social services departments. They were charged with providing
effective planning and managing of emergency admissions not just
over the winter period, but throughout the year because there
is evidence coming through now that this is an all-year-round
problem unfortunately. The establishment of the task forces led
to positive results and, as a consequence of their activities,
extra beds were provided at times of peak pressure, patients were
better served and hospital closures in 1996/97 were much reduced
from the previous year. Now, for 1997/98, this year, I announced
in November an additional £9½ million for health authorities
in Wales together with a further £600,000 to improve cancer
services. Now, this was additional to the £2½ million
package of measures announced in July 1997 to develop and improve
primary care which included£ million for additional nursing
home cover over the winter period. This money has been allocated
to health authorities to ease the pressures on the health and
social care system over the winter period and help contain any
growth in elective waiting lists and waiting times. It is being
used to increase hospital capacity by providing extra beds, additional
nursing staff at times of peak demand and better discharge arrangements.
It is also being used to strengthen community services and home
care support to reduce the need for people to go into hospital
or to support them when they have been discharged. Finally, all
health authorities have given me a guarantee, the first in the
United Kingdom, about the treatment of patients over the winter
months. Subject of course to a major disaster or the impact of
natural events over which the NHS can have no control, all patients
needing emergency admission will be admitted to their own appropriate
local hospital or to the nearest one with available beds. Health
authorities have also pledged to work to eliminate the unacceptable
practice of patients being referred to several hospitals which
are closed to admissions. This undertaking requires very close
co-operation between social services departments, GPs, trusts
and ambulance services. I am confident that the extra investment
activity as a result of the additional resources made available
will enable the NHS in Wales to cope even better with the additional
pressures this winter. I know from my own visits to health authorities
over the last few weeks to discuss the progress they are making
that the extra resources are paying dividends. So far, the NHS
in Wales has coped very well and, in spite of heavy pressure on
beds and on front-line staff over the last few weeks due to the
rise in emergency admissions, the NHS has met the challenge. There
has been a marked decrease in closures compared to the corresponding
period last year and in those cases where hospitals have closed
for short periods, patients have been admitted without delay to
neighbouring hospitals. We will continue to monitor closely the
NHS progress over the next few critical weeks and to continue
to work with them to learn and apply the lessons that 1997/98
will reveal.
2. Thank you, Minister. I think you have answered or at least
partially answered some of our questions, but we are going to
ask them anyway. In your written evidence, you suggest that the
demand has been highest in South Wales. I am not sure whether
the 14 per cent rise in demand that you suggest is an all-Wales
figure or whether it applies particularly in certain areas. Can
you tell me what have been the worst affected areas?
(Mr Griffiths) Well, the picture is that since 1993/94
up to last year there has been an overall 14 per cent increase
in admissions. Now, in these years there has been quite a range
of differences from a 10 per cent reduction in Wrexham, for example,
and you may be pleased to hear that, whereas in Swansea it has
been a 42 per cent increase and they have had all that extra work
to cope with. Consistently along the South Wales corridor, the
M4 corridor in South Wales, Swansea at 42 per cent is the highest,
but the lowest in the South Wales corridor is a 22 per cent increase
and in Bridgend, my own hospital, I think it was 24 or 25 per
cent. Looking at the health authority level over this same period,
it varies from a 3.2 per cent increase up to 34 per cent over
the period, so you can see the changes are quite different in
different places.
3. Have any hospitals had to turn away patients this winter?
(Mr Griffiths) Today there are two hospitals closed,
Morriston and Neath, but there are hospitals nearby in both cases
which are ready to take any emergency admissions which those two
hospitals cannot take. So far in this year there have been 30
official closures, which is considerably down on last year, but
in each case I think the important thing is that we have had the
experience of ambulances or doctors ringing half a dozen hospitals
in order to find a place for a patient.
4. How does the rise in demand in Wales compare with England?
Is there a difference?
(Mr Griffiths) The 14 per cent figure is for a period,
and we have not yet got the English figures, but for a period
of comparison, 1992/93 up to 1995/96, it was 10 per cent in Wales
and 10 per cent in England, so it has been broadly similar.
5. So there is no scope perhaps for patients going to hospitals
across the border?
(Mr Griffiths) Not really. Obviously occasionally
there will be a need to use English hospitals because in terms
of after-care there will be specialisms there which are not always
available in Wales, but no, there would be no point in doing that.
What I can say though in terms of the UK experience is that whilst
we have put a lot of time and effort in within Wales to find solutions,
to reducing closures and to improving emergency admissions procedures,
we have also drawn very heavily from the UK experience because
of course the NHS in the UK is looking at this problem.
6. You give a series of reasons for the increase in demand
in your written evidence, Minister. Is that list exhaustive or
does it indicate some other underlying problems, such as relative
deprivation, bearing in mind the difference between north and
south?
(Mr Griffiths) Obviously the list was not an exhaustive
one, but perhaps Dr Hall, our Chief Medical Officer, might like
to say a little bit more on this particular problem.
(Dr Hall) Certainly we understand that the situation
is very complex and that there are many factors coming together.
The list which the Minister mentioned includes some very important
ones and we know, for example, that we have a rising proportion
of the elderly in our population, that the management of acute
care for the elderly has become much more dynamic, certainly over
the last decade, there are improved techniques available for them
and we tend to intervene earlier rather than later. We also know
that there are factors which determine health which vary from
one community to another and one population to another and there
are social factors, such as unemployment, and there are environmental
factors, such as those associated with respiratory disease and
including those as obvious as the weather which causes increases
in accidents amongst elderly people and on the roads. We have
a situation where we have higher patient expectation with evidence
of increased consultations for GPs and possibly GPs who would
prefer to act earlier rather than wait if there is any doubt.
Patients also value a consultant opinion and that is in the context
of a situation where we know that some people may be less able
to cope with illness in the home than previously, where there
are single parents or where carers are at work in the daytime,
so social factors are also very important. I think the summation
of this is that this is extremely complex, it may vary from one
part of the country to another, and although there is a substantial
body of work at the UK level looking at the causal factors, there
still is scope to look locally at what is happening within Wales.
7. It is perhaps one of the reasons that people are more
inclined to go to accident and emergency departments rather than
their GPs these days. Is that a possibility?
(Mr Griffiths) I would say there is no consistent
evidence to show that, but it can be in some areas that that does
happen.
Chairman: It is a complex issue.
Ms Lawrence
8. Referring to the submissions that we have had, there was
one anomaly that I picked up. Morriston Hospital says it would
like to see a "fundamental review" of the reasons for
the rises in both medical and emergency surgical admissions over
the winter months. Contrary to that, the University Hospital of
Wales Trust say, on the other hand, that "much work has been
done to analyse the reasons for the rise in emergency admissions".
Those two things do seem to be contradictory. Is anyone doing
specific research into this? If so, to what extent are the results
being disseminated?
(Mr Griffiths) Well, the answer is yes, a lot of research
is being done both in Wales and across the United Kingdom and
I think the outcome of the evidence so far is that there is a
good understanding of the underlying issues within the limitations
of not being able often to forecast exactly what happens. There
have been a number of research reports. There was also the Health
Authority Task Force Report in September 1997 and there has been
an all-Wales Service Review. There are other reports and, for
example, right now as part of this year's project, the North Wales
Health Authority is doing a lot of work to analyse the relationship,
for example, between the NHS and social services departments,
so we are seeking at all times to evaluate these things and we
then are disseminating this information through the Health Service.
I mentioned earlier that there had been the conference in September
1996 at which a lot of the work was done which resulted in the
improvements in the reduction in closures following on from that,
so I am happy that the NHS in Wales and in the United Kingdom
is working hard on both analysing why this is happening and then
not only putting into effect systems to make the emergency admissions
system more effective, but actually looking at ways in which we
can reduce the numbers having to go into hospital by better care
in the community, for example.
Ms Morgan
9. The Welsh Office started the joint Welsh Office/NHS review
in December 1995. Do we know why it was not started earlier? Obviously
you were not there then, so we do not expect you to take personal
responsibility, but I wondered if you knew why it had not started
earlier. Was it because the emergency admissions then had just
started to increase or were there any other reasons?
(Mr Griffiths) I think perhaps, first of all, it needs
to be said that from the time the NHS was established a major
element, in fact the major element in its service was that of
dealing with emergency admissions, so it has always been a priority
within the Health Service and over the years it has been a feature
of annual reviews. I think what happened in 1995 was that there
was a heightened knowledge about the way in which the Health Service
was working. I think the purchaser/provider split, with more trusts
coming on stream, let us say, perhaps exposed more the way in
which the Health Service worked and we, therefore, came to target
on these things more effectively. This work actually began to
take shape at the beginning of 1995. That winter happened to be
a particularly bad one and there was a particular crisis and a
very big increase in emergency admissions which then put further
pressure on the NHS in Wales to work much harder at dealing with
this particular problem. So, yes, in 1995 there was a heightened
awareness and a recognition of a greater effort having to be made,
but even before that it was something which the NHS had as a priority.
Peter, would you like to say anything else?
(Mr Gregory) I think you have summed it up very well.
I think there were two critical issues in 1995. One was that there
was a very significant overall increase in the number of emergency
admissions, significantly greater, and we had started work in
trying to analyse that much earlier in 1995. The issue about December
1995 is that during the course of November and into December it
became apparent that that increase was having a very significant
effect on hospitals' capacity to respond and, as a consequence,
we had detailed discussions with health authorities and trusts
about how we should react to that and that also focused our attention
on the need to be more proactive in dealing with the issue in
the future. Then we had immediately after Christmas and just before
the New Year a very significant flu epidemic, a very considerable
drop in the temperature, which caused a lot of respiratory problems,
and then we had, as some of you may remember, an overnight shower
of rain and the following morning the whole of South Wales was
a sheet of glass and we had a lot of fractures. All of those things
came together in a very short space of time. So against a background
of a rising pressure on emergency admissions, which we were conscious
of and tried to plan for, on top of that we had this sudden enormous
surge in admissions right at the end of the year and it was as
a consequence of the impact on hospitals all the way along the
M4 that we redoubled our efforts and you know from the evidence
we have provided how the Department, the health authorities and
the trusts have subsequently decided that that has to be managed
through task forces in each health authority, organising the response
to these problems more effectively than hitherto.
Mr Jones
10. Minister, can I take you back to your opening statement
where I think you said that health authorities had given you guarantees
about the fact that either they would ensure that there was access
to district general hospitals for an emergency either at a particular
hospital or the nearest hospital. Is that an assurance you have
had or a guarantee you have had from North Wales Health Authority?
(Mr Griffiths) Yes, all health authorities in Wales
have given that guarantee and certainly so far I have received
no report that it has failed and, as far as I am concerned, no
patient has had to turn up at several hospitals before getting
a bed and if one hospital has not been able to take that patient,
the doctor or the ambulance has been told immediately where a
bed is available.
11. I think you have indicated to us that in South Wales
you have a number of district general hospitals very close together
so that if one hospital cannot take an emergency admission, it
does not take a great deal of time to go to the next one, but
if you are a patient in Holyhead and the nearest one to you is
Wrexham, it is a pretty fair journey, is it not, if it is an emergency?
(Mr Griffiths) Obviously that would be. It would also
mean that two major hospitals would be closed in between and the
record is fortunately that North Wales has had a very, very good
experience in keeping open and there have been very few closures.
In fact, this year there have not been any.
12. The reason I was asking you that is that I was rather
surprised that the guarantee given by North Wales was not even
better. In other words, why could they not guarantee that there
would be no closures in any of the district general hospitals?
(Mr Griffiths) Well, I suppose it is difficult to
be absolutely certain about that, but what I can say is that the
so-called "blue light" admissions, absolute emergencies,
every hospital is open for those at all times, so that type of
emergency will always be dealt with at the nearest hospital.
13. But, just to clarify the point, if the case were to be
that a patient had to go to Wrexham from Holyhead, that would
be within the terms of the guarantee you have had from the Health
Authority?
(Mr Griffiths) Provided that that was the hospital
they were immediately told was the only one open in North Wales,
but I think we have to face the historic fact that that is never
likely to happen. I have put my head on the chopping block now!
14. Thank you, Minister. Can I come back to the action plan
which is referred to in paragraph 3 of your evidence to us about
the need in 1995/96 to have an action plan to avoid hospital closures.
Now, we have heard a little bit about the impact of the problems
in 1995/96, but, generally speaking, what actually leads to the
fact that you have these hospital closures in emergencies? Is
it simply a case of lack of resources or are there any other issues,
apart from, one would expect, an increase in admissions over the
winter months?
(Mr Griffiths) Well, in a sense it is an increase
of demand beyond that which had been planned for as a matter of
course, I suppose is what we would have to say. Perhaps while
I am on this subject, I ought to mention that I made a little
slip in my submission in comparing the English and the Welsh for
the 10 per cent. It should have been 1991/92 and not 1992/93 as
the starting point. It is in the written submission, but I just
correct that. The point is that a hospital can never be absolutely
sure how many people are going to turn up at the accident and
emergency reception area. Over the years plans have been made
to cope with this as best they can, but there are peaks and troughs
and there are those occasions at peak times when a hospital has
not got sufficient places to deal with everybody who would like
to come there, and this happens particularly in the urban areas,
but fortunately hospitals do tend to be a bit closer than they
are in North Wales, for example, so along the South Wales corridor,
in Bridgend, for example, a patient, say, could get to about six
or seven hospitals within about 25 minutes in an emergency, so
we are reasonably well blessed in that respect, but the fact that
an emergency is unplanned means that you can never plan for every
emergency. The health authorities put additional money into their
budgets to help the trusts cope with emergencies by planning a
3 or 4 per cent increase, let us say, as they have for the present
financial year, but you can never be absolutely sure because for
three or four months emergencies might be running at a rate of
2 per cent over the previous year and in another month they may
go 10 per cent above, so it is really coping with that demand
which can vary from place to place that the health authorities
are co-operating to ensure that patients will know exactly where
they can go immediately if a local hospital is closed.
Mr Caton
15. Minister, continuing to look back to 1995, how successful
do you believe the programme of action for 1995/96 was and also
were none of the things that you list in paragraph 4 of your memorandum
done previously and, if not, has your Department an explanation
as to why not?
(Mr Griffiths) Well, without my looking at the evidence
directly, as best as I can recall, yes, of course in these things
an effort was made to take account of some, if not all, of them,
but what happened after 1995 is that a far greater focus was placed
on the problem and in dealing with it. Peter, I do not know whether
you would like to say anything about this.
(Mr Gregory) Yes, could I just make a couple of points
perhaps going back to Mr Ieuan Wyn Jones' point about the pressures
in the system. I think we have to be conscious that emergency
admissions form a very large proportion of Health Service activity.
They are not a separate slice which is dealt with, as it were,
outwith the rest of hospital services, but they are an integral
and major part of it, and part of the trick, as it were, of dealing
with them is to mediate that balance between the elective and
the emergency aspects of hospital activity. The second thing is
that this is an issue which has been present in the NHS all its
life. There have always been pressures on the NHS to respond to
emergency admissions. That has in part been exacerbated in recent
years by the extent to which we have required more and more efficiency
from the NHS. The NHS is required to deliver its efficiency savings
every year and that inevitably means that trusts are running their
assets, the resources they use in terms of beds and people, that
much hotter, if I can put it that way. If you look at bed occupancy
rates, bed occupancy rates have gradually increased and that reduces
to a degree the flexibility that trusts have. Now, what has to
happen in that context is that trusts have to be more agile in
responding to crises and that means that the organisation of the
NHS as a whole has to be better limbered up to deal with the problems
as they arise. As a consequence, during the 1990s with the rising
level of bed occupancy and with the increasing year-on-year level
of emergency admissions, inevitably there was a process by which
that tightened the NHS's ability to respond and by 1995 it became
apparent that this needed measures over and above those in place
for many years before that by which hospitals dealt with the issue
themselves. The only other point to make is to refer to what the
Minister has said about the effect of the internal market on all
of that because of course prior to 1990 the responsibility for
dealing with it both in terms of planning and operation was the
health authority. Each of the health authorities had their own
responsibility for planning health services and for delivering
them. Once, after 1991, that responsibility became separated into
commissioner and provider responsibilities, then the need for
organisational co-operation became more acute, so you have the
interaction of a whole series of issues here and by 1994/95 it
became apparent that something more than the processes which were
in place before then was needed and that is why we instituted
the work we did in early 1995, producing an action plan and then
ultimately producing the system we have now where health authorities
have specific responsibilities for garnering information on a
very regular basis, keeping a close monitoring of the system,
keeping in touch with the trusts in terms of how they respond
and making sure that all the partners in the system, ambulances,
hospitals, social services, health authorities and GPs, understand
the situation and are able to respond to it appropriately, depending
on the level of pressure that there is.
(Mr Griffiths) We have mentioned health authorities
a lot in the answers we have made and perhaps Dr Gill Todd, the
Chief Executive of Bro Taf, would just like to say something about
the hands-on experience before and after 1995.
(Dr Todd) I think that what we did in 1995/96 as health
authorities was to formalise the arrangements by setting up the
task groups, whereas prior to that there was a lot of networking.
A lot of hard work over the years has gone into managing the emergency
admissions because emergency admissions are not a new problem
in the Health Service. After the introduction of the internal
market, there was a need to formalise the arrangements in terms
of people working together and seeing this as a problem which
needed an investment of senior management time both at health
authority and at trust level, involving GPs and particularly social
services departments. In 1995/96 we had a lot of hospital closures
and the situation along the M4 corridor during that winter, which
was a very bad winter, was extremely difficult to handle. What
we have done is we have handled that situation over the last two
years by investing more in beds and facilities where they are
required, where the pressures are. However, what we cannot say
year on year is exactly where next year's pressures are going
to be because there is definitely a variation and what we know,
for example, this winter is that one of the reasons why there
has been a decrease in closures is not only because we have made
investments and, we hope, got some of our forecasting of where
the pressure is going to be right, but we have also not experienced
this winter the peaks and troughs and we have had a much steadier
flow of emergencies through. Mondays and Fridays are traditionally
very difficult and the Christmas and New Year period between those
two holidays is traditionally very, very tight and we usually
get a lot of admissions. But the peaks and troughs have not yet
come this winter and they are likely to if we get a cold snap,
so I think it is early days in this winter yet, but it is not
the big surge. One of the important bits of research health authorities
are doing is in partnership with general practitioners because
we should not look just at what has happened when a patient gets
into hospital. We are working with groups of general practitioners
who are based on populations and looking at what their experience
is, so we are actually measuring how many patients consult them,
how many of those patients day in and day out are referred through
to hospital, how many of those are admitted and how that is affected
at night or at the weekends by the out-of-hours arrangements,
and there is some very interesting research work which will come
out in a year's time about that sort of look at populations. You
have really got to start at the very base at which the general
practitioner and the patient first come together to make those
decisions, so it is important that that work is ongoing.
(Mr Williams) Chairman, I wonder if I can add just
one gloss to what Dr Todd has just said and what the Minister
said earlier about differential rates of growth and the difficulty
across Wales. Not only has the rate varied from trust to trust
and from health authority to health authority, but the picture
has varied in-year from year to year. If you look at 1994/95,
the peak was in the last week of December and the first week or
so of January and that is the only thing that was consistent across
the succeeding two years, 1995/96 and 1996/97. In each of those
years there was a sharp peak of the kind that Dr Todd is describing
at the very end of December and in the first ten days or so of
January. But in 1994/95 the other peak in the year was the second
week in February. In 1995/96 it was the third week in May and
the last week in September. In 1996/97 it was also the third week
in May, but there was another peak in July and another peak in
the middle of August, so not only are the peaks moving between
health authority and health authority and differentially between
hospital and hospital, but also differentially from year to year.
And we know that in 1997/98 the problems which hitherto have been
slightly smaller in North Wales may be more significant in that
part of the world in the early part of the year, though that increase
may not continue over the second half of the year. So the picture
is fluid year on year, area on area. Just finally to deal with
a point that Mr Ieuan Wyn Jones made. Just to give a sense of
this, in the consistent peak period, end of December/beginning
of January, typically, hospitals experience an increase of about
a 27 per cent rise in emergency activity over the average for
the year. In the big hospitals, the biggest hospitals, those hospitals
with the biggest accident and emergency departments, that sharp
rise can peak at 100 per cent in that particular time of the year.
It is that very sharp peaking which the new arrangements for sharing
responsibility over a wider area are intended to address.
Mr Livsey
16. Could I ask you, Mr Williams, following on from what
you have just said, there has been a lot of mention of the M4
corridor and North Wales, but the situation in Powys is very different
where a lot of patients go to England, they go to Hereford or
Shrewsbury. Do the statistics take account of those-I assume they
do-and are there any differences in the patterns which have emerged
now where we have quite a lot of elderly people, far more than
the average, in Wales?
(Mr Williams) I think the picture is true for Dyfed
Powys as for elsewhere and I will ask Dr Todd to pick this up
in a minute, but the actual numbers that we collect come from
two sources: either in respect of the resident population of the
health authorities; or in respect of the figures by the hospitals
within Wales. We do not collect figures for hospitals in England,
but the generality of the picture is true in England as it is
in Wales and the rise in England, as the Minister said in his
opening comments, was about 10 per cent in both countries.
(Mr Griffiths) Could I ask you, Richard, because it
might be interesting, have you had experience as the Member for
Brecon and Radnorshire of patients going to Shrewsbury or Hereford
and being turned away?
17. No, I have not really. It has not been a major problem
anyway. There might have been the odd delay of 24 hours or so.
What I am concerned about actually is the formulation of the statistics
themselves as to whether these admissions, even though the patients
are going to be treated in England, are aggregated as part of
the statistics you are actually collecting.
(Mr Williams) Well, for the resident population of
the health authority and the figures reported to the health authority,
the change for Dyfed Powys, for example, between March 1993 and
March 1997 was 13 per cent and that is typical of the problem
experienced across Wales. So it is no different in Dyfed Powys.
Ms Lawrence
18. You mentioned earlier, Minister, in answer to my previous
question the research that was being done into the reasons for
emergency admissions, but also we have heard about the variations
month by month, year by year. I would like to know on what basis
the health authority then calculated that emergency admissions
in 1996/97 would increase by 8.6 per cent, which seems a very
specific sum, and also what is the expected outcome for 1997/98?
(Dr Todd) If you look at the underlying percentage
increase, we have had about a 3 to 4 per cent overall increase
in Wales per year over the last few years and what happened in
1996/97 was that health authorities looked very carefully at the
pressure which had been experienced the year before. They took
account of the increases that had happened, recognised that they
were above what they had expected, adjusted for that and increased
their target within the contracts by a further 3 to 4 per cent
and that is why there is this strange figure of 8.6 per cent.
It was not a figure, as such, but that figure comes from adding
together the very careful work done in all the five health authorities
and it came out at 8.6 per cent and it includes, of course, the
increases for patients who go over the border naturally, the North
Wales population that go across the border, and the Powys population
who go across the border. So it included adding it up, but that
is the figure that came out. When we looked at the end of the
year, it turned out that that figure was a very good estimate
and at the year-end was almost on across Wales as a whole. There
were a few variations, some hospitals slightly increased and some
hospitals decreased, but on the whole it was a fairly good estimate.
This year the view of Welsh health authorities is that we would
see a further 3 to 4 per cent increase, that it would be likely
to hit in areas in which they knew about those pressures and they
felt those were the areas where this was to be felt, and that
has been planned into contracts. We are not yet sure how 1997/98
is going to end up. We have not had the busiest time of the year
and we are still looking at the outturn of November/December at
the present moment to be certain. But we hope, particularly with
the extra resources which have been put in, that we will not be
very much out in the contracts that were set with an estimate
of about, across Wales, 3 to 4 per cent, but differentially targeted
to those areas by both demography and other local circumstances
which means that you have got to understand exactly what happens.
There are very major variations not just between hospitals, not
just between authorities, not just between days of the week and
times of the year, but also between general practices. If you
look at various populations and general practitioners, the referral
rates for emergency admissions are very, very different, so you
will see some general practitioners who refer a very much larger
number of patients for emergency admission and I think that that
is the area where we need to know much more about what is happening
there and that is the work that is being done. So in a way health
authorities are doing their best to estimate and the forecasting
has improved. We discuss it very regularly on an all-Wales basis,
but it is not a perfect science.
19. Under the contracting system as it now stands, you will
still get areas of big pressure, as we have heard, of up to 100
per cent in the larger hospitals, but you are still faced with
the problem that some hospitals, therefore, like Morriston with
a 42 per cent increase at the moment, have to close their A&E,
so there seem to be two different issues there in a way.
(Dr Todd) We do not have a situation in which an accident
and emergency department has closed. I think that we need to be
quite clear that we are talking separately here about medical
emergencies which are patients who have been seen at home, assessed
by the general practitioner, the general practitioner rings to
obtain a bed and if they cannot get a bed in their first hospital
of choice, they are told which hospital will take that patient
and they will ring that hospital because they may wish to speak
with the doctor that they are referring the patient to and to
hand over the patient's medical condition, and then call an ambulance
which takes the patient to that hospital. The second type of patient
is the patient where the family or the patient dials 999, where
they have an accident on the motorway, they fall over, or they
have a heart attack when they are shopping. Those are the patients
who come in on so-called blue lights and they come to the nearest
accident and emergency department. We have not experienced the
closure of accident and emergency departments to 999 calls in
Wales, so if you have a heart attack and you come into a hospital
which is unable to take medical admissions, you will find that
those hospitals which take 999s try their best to take those patients
and in most circumstances they keep a small number of beds ready
to take 999 calls. So the closures that we are talking about are
to medical patients who have come from the GP, been seen by the
GP and assessed by the GP. It is quite difficult not to get confused
between those two, but it is important that they are separated.
We have not seen closures of hospitals taking 999 calls, so emergency
patients have gone through all the time in Wales.
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