Examination of Witnesses (Questions 20 - 39)
MONDAY 19 JANUARY 1998
MR WIN
GRIFFITHS MP, MR
PETER GREGORY,
MR COLIN
WILLIAMS, DR
RUTH HALL
and DR GILL
TODD
20. So the 42 per cent relates purely to medical emergencies?
(Dr Todd) Medical and, on occasions, paediatric emergencies.
Chairman
21. Minister, in your written evidence, paragraph 9, you
suggested ways in which the £9.5 million might be used, such
as community and home care support, improved staffing and that
kind of thing. Presumably the system is designed at some stage
to cope with these emergency admissions and I think Mr Gregory
suggested that was the case and obviously it had to be the case
at some time in the past and not a new problem, as Dr Todd said,
so what is the main cause? I know you have been talking about
research into it, but is it that there are insufficient beds generally
or is it bed-blocking which is a problem in North Wales? Although
we do not have this problem which has become obvious in South
Wales, we do have, speaking to my local trust, problems of bed-blocking,
that is, people who need long-term geriatric care who are in beds
which should be used for acute services, or have the efficiency
savings referred to by Mr Gregory actually pared the system down
too far?
(Mr Griffiths) I would say, and perhaps Peter will
add more detail to this, but it is caused by a range of issues.
Yes, there is a balancing act to be performed here. You have got
a hospital which has so many beds and if it is going to run effectively
and efficiently, it has to have a high occupancy rate. That means
that whilst they can plan for what we might call normal emergency
work, there come the peaks when it will be difficult for them
to cope with that because of the other pressures on them, keeping
down waiting lists and so on, so to recognise that, we have tried
to introduce this system of effective networking so that when
one hospital is faced with a peak, there is available locally
another hospital which, because it has not got such a problem
at that particular time, is able to take the patient. If we could
attribute this to one specific thing, and we had a totally limitless
resource, but it would have to be limitless, yes, we may not have
to talk like this. But given all the pressures that there are,
we believe that we have in place in Wales now a highly effective
system for making sure that emergency medical admissions do not
have to be either taken by other hospitals or a GP is not having
to ring up hospital after hospital in order to find a bed. I do
not know, Peter, if you want to add anything further.
(Mr Gregory) Yes, perhaps just two things. One is
that this is an issue about the demand for care and its supply
and the interaction between those two things and both of those
elements are quite complicated. The demand issues are the sorts
of things that Ruth Hall and Gill Todd have been talking about.
It is a complex set of circumstances which are dependent upon
local morbidity, demography, the particular situations of the
weather and all the rest of it which come together to provide
a pattern of referral to hospital. The general pattern is that
the demand for health care increases year on year, whether that
is for elective or for emergency. That is a fact of life and that
is what the NHS has to cope with. So there is a whole set of issues
on the demand side and then there is the supply response to that
and, as I said in my initial remarks, the NHS has become progressively
more efficient because it has been required to in the way it deals
with that activity, and the Department is currently and has for
the last few years been expecting a productivity gain over and
above the growth of resources which the NHS receives. So it is
the interaction between those two factors which produces the situation
we have of gradual and growing, and sometimes quite abrupt, increases
in demand meeting a supply system which has been required to be
ever more efficient. However, in addition to that, we then get
the specific problems which can occur not just in the winter,
as Colin Williams has pointed out, and one of the interesting
things of the last two years is the extent to which we are increasingly
being told by the NHS about closures of hospitals outside historically
accepted periods of crisis.
(Mr Williams) Can I say, in my role of adding further
figures to things which colleagues have said in response to your
question, Mr Jones, that over Wales as a whole it has 30 per cent
more beds available to its patients than, proportionately, England
has available to its patients. It has more beds available to patients
in every specialty and in the care of the elderly specialty has
about 50 per cent more beds available to it than is the case in
England. And while beds have reduced in previous years, the number
of beds available to general medicine has gone up by about 22
per cent.
22. Given those figures, Mr Williams, how do you explain
that the rates are the same in England and Wales?
(Mr Williams) The rates of?
23. The rates of emergency admissions and why do we have
closures at all in Wales if we are that well endowed with beds?
(Mr Griffiths) If I could just interject on that particular
part, a large part of the reason is that if you look at the health
of people in Wales, we have got more problems as compared with
England, so that is a very important factor.
(Mr Williams) And there are a lot of other complicating
factors, as Peter Gregory has said. In addition to having more
beds in the public sector, we have far fewer beds in the private
sector which, in England, tends to syphon off some demand. But
also, as a consequence of some of the factors which both the Minister
and Ruth Hall have mentioned on the underlying health of the population,
we have about 18 per cent more in-patient admissions and higher
referral rates, higher consultation rates to GPs and higher referrals
by GPs on to hospitals. So it is a complicated pattern of activity
covering both supply and demand.
(Mr Gregory) Can I just say, Chairman, if you wanted
to pursue that line of inquiry, as it were, outside this discussion,
the recently published NHS Wales Service Review, which is an exhaustive
examination of the state of the NHS, has some very trenchant things
to say about the demand on the NHS and that includes the fact
that in most specialties, demand for health care in Wales is significantly
greater per 100,000 of the population than it is in England, so
we have more beds, we have more doctors, we use more resources,
we use those resources at least as effectively as in England,
but the effect of the general state of morbidity in Wales means
that there is higher demand. If you are running assets, therefore,
as efficiently as you can, higher demand means you have less flexibility
to respond to the kind of surges that I described in my earlier
answers.
Mr Livsey
24. Mr Chairman, in relation to what has just been said,
obviously social deprivation is one of the factors involved, but
demography must play a considerable part as well because we have
an element in Wales of a population exchange with older people
either coming back to Wales to retire or coming from England to
retire and in my experience the elderly population is certainly
far greater than one would find on average elsewhere. On the additional
beds that you referred to, is there any relationship between those
and the demography?
(Mr Williams) In the sense that there are more care-of-the-elderly
beds available in Wales than is the case in England, yes, there
is that relationship.
Mr Jones
25. Dr Todd, when she responded to a question from one of
my colleagues, indicated that it was expected that the increase
in the cost to the NHS of the emergency admissions for this current
year would be between 3 and 4 per cent. When the budget was allocated
to the health authorities at the beginning of the year, what was
the figure budgeted for?
(Mr Griffiths) Obviously you would have to ask the
previous administration exactly how they came up with the figure
that went into the finances for this financial year because those
were decided well before the May election, but in terms of what
Dr Todd had to say, and perhaps she could add to this, the health
authorities, in making their contracts with trusts and to the
money they had available, tried to take account of the additional
money needed for dealing with the increase in emergency services.
Would that not be true?
(Dr Todd) Yes. What health authorities did last year
was to plan for an increase in their emergency admissions. They
may have made that money available by taking it away from elsewhere,
they may have made that money available from the growth available
to them, or they may have made that money available from efficiency
savings, and that would be very much dependent on each and every
one of the five health authorities as to how they did that.
26. I think the point I am trying to get at is that if an
extra £9.5 million has to be made available, it is obvious
that somebody has under-estimated the likely increase.
(Mr Griffiths) But that £9.5 million did not
have to be made available. What happened was that after the election
when we came to power we decided that because we were concerned
about the issue of the rise in emergency admissions, it would
be worthwhile providing some extra money this year to, if you
like, ease us through what could well have been a difficult winter.
On top of that, the money we have made available has given a further
impetus to health authorities, trusts, GPs and social services
to work in an even more focused way and the North Wales Health
Authority is doing some specific research and monitoring for us
on what is happening this year with the additional money. And,
of course, given that we do not have any plans next year to provide
additional money other than what has already been announced, what
we are looking for at the moment are some more efficiencies in
the way the Health Service is run and we may now get systems in
place with the NHS and social services, who are acting even more
co-operatively, so that bed-blocking is reduced so that the need
for elderly people to go into hospital is reduced which will then
in itself make sure that there are more beds available for those
emergency admissions.
Chairman
27. Can I ask a potentially stupid question? If the mortality
rate is higher in Wales than in England, why are there more geriatric
beds in Wales than in England?
(Mr Griffiths) Well, because despite that-
28. Are we importing healthy old people from England?
(Mr Griffiths) To comfort you, Chairman, it is the
question which I did put some time ago as to why is it if more
people dying in Wales. In fact, if I recall correctly, and someone
will put me right if I get this wrong, I think we are predicting
that either by the year 2010 or 2015, there will be 14 per cent
more over-75s in Wales than in England, so that is an issue which
we in Wales are going to have to focus on much more than in England.
Maybe it is because of the congenial surroundings that Wales presents
and the confidence old people have in the service we are providing
that they are settling in Wales.
Chairman: It is very encouraging for somebody getting on
for 50!
Ms Morgan
29. How was the £9.5 million actually decided on, the
exact amount of money?
(Mr Griffiths) You mean, was the 9.5 a measured response
to what we thought the emergency was going to be or was it something
else? Well, it was something else.
Mr Jones
30. What you could get out of the Treasury, I suppose.
(Mr Griffiths) Inasmuch as that was the amount of
money that we could get to help the Service through the winter.
Ms Morgan
31. And going on to the other point, what percentage did
we get in comparison with the rest of Britain?
(Mr Griffiths) This was all settled through the Barnett
Formula, so we got our share of the money that was available for
the winter crisis. The whole of the package at the time it was
announced included within it specific monies which the Department
of Health in England had actually saved out of its own budget
and also an amount of money which they had previously been promised
by the Treasury to deal with the extra spending on their Drugs
Bill. But on the specific amount available for the winter crisis,
our money was determined by our share under the Barnett Formula.
Would that be right, Peter?
(Mr Gregory) Absolutely right, yes.
32. Because there were some criticisms at the time that we
were getting less than we should get.
(Mr Griffiths) That is right. It simply arose out
of the fact that the global amount was presented as £300
million, but within that I think it was something like £130
million, though I am not absolutely sure now, and it arose out
of direct savings within the Department of Health's budget, plus
an amount they had already been promised to deal with their Drugs
Bill.
(Mr Gregory) The actual amounts were about £30
million worth of savings which the Department of Health were declaring
themselves and £80 million which was available from the Treasury
to cover drugs bill overspends on the Family Health Services,
which meant that available for the winter crisis resourcing was
£190 million, of which England got £159 million and
we got the £9.5 million which you have referred to, and the
Scots and the Northern Irish got their Barnett Formula consequentials
as a direct result. So the amount which was allocated to the winter
crisis was exclusively allocated on the basis of the Barnett Formula.
33. Then, to follow that up, the University Hospital of Wales
Trust points out the need for a review if lessons are to be learned
for next year, so is there going to be any value-for-money evaluation
of how this £9.5 million is going to be spent?
(Mr Griffiths) Yes, I earlier referred to the North
Wales Health Authority study we are doing, but all of the health
authorities, once they had their individual allocations out of
the £9.5 million, they then provided us with plans of how
they intended to spend the money and what particular problems
they were going to focus on. Having done that, these plans are
being monitored and when the money has been spent, and we are
into the spring and the summer, we will be evaluating what has
happened. The North Wales Health Authority will have some more
specific and detailed work to do and the lessons we learn after
that I hope will help us to do an even better job next year, but
of course without another £9.5 million thrown in on top of
what has already been provided for next year.
Mr Caton
34. In your memorandum you say that the health authorities
and the trusts in Wales have given what you describe as a "landmark
commitment" about the treatment of patients over this winter
and you have expanded on that in your introductory remarks and
in response to a question from Mr Jones. I would be interested
to know what you mean by "landmark". Also, if they fail
to honour their guarantees, will there be any sanction?
(Mr Griffiths) Well, we called it a landmark decision
because this sort of guarantee had never been given before. Basically,
whilst in the past obviously health authorities, trusts and everybody
in the Health Service have been focusing on trying to provide
the best service as possible, if you like, this year the Secretary
of State felt that it would be a good idea if we could really
set ourselves a target which would be certainly very challenging,
but, on the other hand, which could be achievable with a lot of
extra work and I am grateful to all of those in the National Health
Service in Wales who have come together, and in local government,
of course, because social services departments are playing a role
in all this, who are working together to make sure that this guarantee
happens. It has never been given before and in that sense it is
landmark. Now, as far as failures are concerned, I think I have
indicated already that I am not contemplating failure in this
regard and certainly the way in which the Health Service has in
previous years made improvements in cutting down closures, I am
already confident that the management within the NHS is able to,
and has put together, a plan to avoid some of the disasters which
have happened in previous years. So I am happy about that. I think
we have learnt from the past. There have been good evaluations
in the past and we have learnt lessons. I am confident that managers
are able to cope. We will be evaluating what happens this year.
If it were to turn out that something did go disastrously wrong,
then it would be a question of whether that was caused by the
Hong Kong chicken flu, which it looks as though it is not going
to happen, but if suddenly a whole population was knocked out,
then that is something different, but if in looking at the level
of emergency admissions, there was not an incredibly unpredictable
peak, yet a hospital found itself closed for half of the rest
of the winter, then yes, we would want to ask questions and look
at whether there had been any professional failures, but, by and
large, I am confident that that sort of thing will not happen
and that because the Health Service is very aware of the need
to manage this at the highest levels, we are going to come through
this without any need for sanctions. In fact my emphasis is rather
on co-operating so that we can learn the good lessons to carry
on improving the service.
Ms Morgan
35. You have just mentioned co-operation and you say in your
memorandum that the guarantee "will require the co-operation
of social services departments, GPs and GP fundholders, trusts
and ambulance services as well as a recognition of the relationship
which exists with elective activity", so how sure are you
that you will be able to get the necessary co-operation from all
these different bodies that you mention?
(Mr Griffiths) Well, in a sense that is already being
done in that, first of all, we have to remember that there were
already co-operative systems in place before this winter and what
is perhaps a little different about this winter is that, if you
like, we have provided some pump-priming money and said to the
Health Service in Wales, "Now, here's a little bit of additional
money. Look hard at how you can use this money to improve further
your systems". Specifically we would like co-operation to
be improved, and so all the evidence we have so far is that this
is working and that where there were already fairly high levels
of co-operation, this has been cemented, if you like, by the additional
funding. I do not know, Gill, whether you would like to say anything
else about how this is working at the present time.
(Dr Todd) The task forces that are in place in each
of the health authorities include representatives of all these
bodies and they have been working now through the year and I think
that what has come out of that consistently is not just an identification
of those things which are going very well, but also those things
that could go better, that we are actually sitting within those
task forces, and in some cases small groups that have been put
together as a result of those task forces have been sharing experiences,
the good and the bad. As a result of that, there have been numbers
of solutions found to numbers of problems, but also a better understanding.
We heard earlier about bed-blocking and there is some work done
in various parts of Wales to look and to understand better bed-blocking
and to look and to understand how we can get patients actually
always in the place where they can receive the care at that point
in time that they require it. We must remember that for a lot
of very elderly, very vulnerable patients, that means being admitted
into a hospital bed, being assessed in an acute hospital and then
needing to be moved on to another type of hospital or even to
another environment and the smooth transfer of the patient from
one care location to another care location is a very important
part of the care. I think it is very interesting that a large
amount of the money which has been made available this winter
has been used to look at ways of making that easier. For example,
in one community trust, they have established what they call a
"virtual team" which means that they have got available
to them extra hours which are funded so that that care can be
targeted on those people who are particularly vulnerable and need
that extra care in order, if possible, to keep people in the community.
But the same sort of arrangement can occur when you are trying
to move people from a bed which they no longer require in a smooth
way because certainly we know that older people are made much
more vulnerable if they are moved in a way which is not properly
planned. So there is a lot in the system of medical admissions
which needs to be looked at and I think what this extra money
and the co-operation that we have got between the key players
is allowing us to do is to look at that across all agencies. One
of the most interesting things that has come out is the major
part which is played by voluntary organisations, particularly
Age Concern, and others in the care of elderly people and I think
that we will be very interested when we look around Easter at
the outcome of this year and the experience in those partnerships.
The partnership with general practitioners is increasing every
day with the experience of the last two or three years and now
with the White Paper that is focusing on where the majority of
care is provided, which is in general practice, and looking at
what general practitioners require as extra support to look after
patients in the community or for short spells in hospital. We
must remember that a lot of these emergency admissions only stay
one or two days in hospital, so a large number of emergency admissions
are very short admissions, but that does not mean that they are
wrong and they could have been avoided because they stay such
a short period of time, but because they have got an acute illness
which needs acute treatment for a short period of time, so some
of them may be people with asthma or with a respiratory disease
and they do not need a long time in hospital, so you have got
to have a system which is flexible and can account for all those
problems. The service has to deal with this multi-factorial problem
as there are a lot of different reasons why people get admitted
and a lot of reasons why social services, general practitioners,
ourselves and trusts need to work together to look at a whole
spectrum of types of demand, types of need, different sorts of
people who need different things at different times and it is
not a simple problem and I think that is what has caused so much
mystery about it.
Mr Livsey
36. I wonder if the Minister could tell us his views on the
importance of coterminosity of services with trusts, for example,
where the social services' boundaries of local authorities and
trusts could actually be coterminous, and not only that, but ambulance
services to some extent as well. There were some bad patches which
were fairly frequent in the past of the South-East Wales Ambulance
Trust and I remember a patient being delayed for three days because
no ambulance was turning up because of remote-controlled decision-making.
(Mr Griffiths) First of all, I think in this context
the White Paper announcement we made last week which will see
the introduction of Local Health Groups will, I think, also make
an additional contribution to dealing with the winter crisis problems
because these Local Health Groups will be based on local government
areas. In some of the bigger local authorities there may be more
than one, but essentially things will operate within the local
authority area, so there will be an even higher degree of planning
because now the health authority will hand over the whole of the
local health care budget to the Local Health Group and they will,
therefore, be making their own considerations about the need to
take account of medical emergency admissions. Also on that actual
commissioning body the local authorities will be present and I
am going to imagine that there will be very, very vigorous discussions
about not just what might be needed to handle the winter crisis,
but how best to improve care, particularly for elderly patients,
over the whole of the year and the linking with the local authority
is obviously going to be very, very important in that respect.
As far as ambulance services are concerned, we are having a review
of the best way of providing ambulance services in Wales. Whatever
the outcome of that review, I think the important thing that I
want to emphasise is that there must be very strong local management
in anything which arises out of it so that we do not get that
loss of local contact which can happen, so there has got to be
strong direction at the centre to enable it to happen locally,
but the guiding principle should be that within that strategic
framework there is strong local management. I am certainly looking
forward to the creation of the local health groups to provide
an impetus for even better planning of health services which will
once again help to deal with emergencies at whatever time of the
year they occur.
Ms Lawrence
37. Getting back to paragraph 11 in your submission, the
guarantee, you mentioned that increases in staff sickness rates
are a potential issue of concern and weekly reports will be sent
to the Welsh Office. What action could you take if staff sickness
rates did increase because surely the winter months are the time
when staff sickness rates are likely to increase anyway?
(Mr Griffiths) Well, obviously I think the principle
is that we want to be kept informed about this. One interesting
thing in my own trust in Bridgend is that over the last few years
there has been a general reduction in sickness rates, and whereas
previously the peaks used to be in winter, the peaks are now in
the summer, of sickness rates. But what we want to do is to try
to make sure that we are getting the right balance in terms of
providing a high-quality service without putting such a stress
on the staff that we find that sickness rates are rising and if
we do detect increases, we want to know why that is happening
to see what we need to do to help deal with it.
(Mr Gregory) Could I just follow that up and say,
if we just take sickness rates for the moment, that we are not
asking for that information because of a generalised concern about
sickness rates in the NHS as a whole, but it is particularly about
whether the NHS needs to take any special measures in respect
of increasing levels of sickness amongst the staff, for instance,
caused by an influenza epidemic to make sure that services can
still be run by, for instance, making sure that the appropriate
staff are vaccinated, so it is actually linked to the need for
local operational managers to be thinking about those issues rather
than some wider policy issue about the levels of sickness in the
NHS at large.
Mr Jones
38. Minister, I think you have made it perfectly clear to
us that there will be no extra £9.5 million next year and
I think it is also fairly clear, as you have told us, that you
will be sticking to your spending plans already announced for
next year. Now, given that you are asking managers to devote a
lot of their valuable time to reconfigurate trusts next year as
well and given that you have indicated to us that you are worried
about the extent of problems in the Health Service, particularly
about the increase in the cost of admissions, which is growing,
do you still think it is a good idea to let them spend their valuable
time looking at structures rather than delivering a better health
service?
(Mr Griffiths) Yes, I do because the two things are
interconnected, looking at the structures and delivering a better
health service, because one of the things which will come out
of such a reconfiguration is the provision of more money to be
spent directly on patient care. Now, depending upon the final
shape of the trusts, that could be anything between £5 million
and £10 million, so if we are getting up to the higher figure,
the pay-back could be, if you like, an extra £10 million
in a couple of years' time for additional spending in the winter.
Once the extra funding is made available and with the proposals
in the White Paper, taking all the changes together, we would
hope to unfold over a five-year period something like a £50
million saving and that money will go directly into patient care.
So I think, yes, it is important to improve the structures because
the pay-back will be more money for patient care.
39. I think there may be a case for saying that there will
be a pay-back eventually, but I think you have indicated that
it will take at least a couple of years for that to come through.
What will be the short-term cost of the management time devoted
to this for the next couple of years?
(Mr Griffiths) Well, do you want me to express that
in pounds, shillings and pence?
|
