Examination of Witnesses (Questions 40 - 54)
MONDAY 19 JANUARY 1998
MR WIN
GRIFFITHS MP, MR
PETER GREGORY,
MR COLIN
WILLIAMS, DR
RUTH HALL
and DR GILL
TODD
40. Have you made an estimate of how much management time
will be involved?
(Mr Griffiths) Peter, I do not think we have made
an actual estimate of that because it would involve you spending
a lot of time on something.
(Mr Gregory) What we have done is undertaken a risk
analysis of what are the factors which are at play when we are
going through the reconfiguration process and one of them which
we are clear about and the NHS has discussed with us is the issue
of the extent to which the NHS managers and clinicians are beavering
away on plans for trust reconfiguration and they cannot be doing
other things, and we accept that that is the case. As the Minister
has said, however, the Government believes that the configuration
of trusts in Wales was so ad hoc, if I can put it that way, and
in need of proper evaluation and consideration that we have gone
about this in a way which tries to bind the NHS in as active participants
and leaders of the exercise at the local level so that we will
get out of it a configuration of trusts which makes more sense,
not just in terms of making savings through management costs,
but, more importantly, through making sure that the management
of clinical services is better configured and we hope to get some
benefits out of that. However, you are quite right, that there
is a risk in all of this that people will take their eye off the
ball. What matters in that sense is the extent to which we at
the centre through the health authorities and through them to
the trusts are able to sustain the degree of downward pressure
that is needed to make sure that the NHS as a whole responds to
the emergency admissions issue throughout the year and, in particular,
in the lead-up to the winter. Finally, I should say that we are
not oblivious to the kind of distraction that you are describing
and we understand that that is a factor and we are actively working
with the NHS to make sure that the risks, and there are other
risks as well in this process, are properly managed.
41. Can I put it to you in terms of the £9.5 million
that I think the trusts have indicated to us that they would have
preferred in an ideal world to have been told much earlier in
the year that this money was available. Is that something that
you are conscious of and sensitive to?
(Mr Griffiths) Yes, the view that I take on this is
that it was better to have been able to make that announcement
and make the money available than to have not been able to make
the announcement. I appreciate very much that the health authorities
and the rest of the NHS in Wales has had to work very hard to
put together these proposals for improvement and I am thankful
and very grateful for that, just as I am for all the work that
is going on in relation to reconfiguring the trusts. What I am
hoping is that out of the additional work and out of the risks
that are there, we will, nevertheless, be able to manage this
process through and at the end of it come out with significant
additional monies to be spent on health care in Wales.
Mr Caton
42. Minister, it has been suggested to us by trusts across
Wales and others that there is now a shortage of nurses available
for recruitment and also that it is difficult to recruit additional
medical and social care staff on a short-term basis. What is your
reaction to this and do you perceive a more general recruitment
problem?
(Mr Griffiths) I would certainly acknowledge that
there are difficulties in the recruitment of nurses in specific
specialties, such as intensive and critical care. That is certainly
the case. In theatres, too, in accident and emergency, yes, there
are, if you like, hot-spots where additional nurses are required.
If we look at the size of the recruitment pool in Wales, we do
not have precise figures, but we know that there are about 31,000
registered nurses in Wales and that currently about 17,000 of
those are involved in the Health Service. Our own Education and
Training Group has examined the problems here about recruitment
and retention and they will be reporting back to us on how to
deal with those problems. At the same time we have to recognise
that there are a certain number of nurses every year, young people
in the main, but older ones as well, who will go on to training
courses and at the end of the day not then use that skill or expertise
or even drop out perhaps just before the course is completed and
these current wastage rates are running at about 6 per cent. We
also recognise that within trusts there are different problems
about recruitment. Some trusts have got relatively few recruitment
problems and others have got more serious ones. In Bro Taf and
in Morgannwg, for instance, we are aware of some recruitment problems.
As I said, the Education and Training Group is looking at these
issues and they are going to report back to us. This problem has
been recognised previously: in 1996, for example, when £70,000
was made available by the Welsh Office to fund return-to-nursing
courses. So, to sum up, we recognise the problem, it does vary
from place to place, and our Education and Training Group is looking
at it to see what can be done to overcome it for the future.
43. Would you accept that the non-recurring nature of the
£9.5 million has presented a particular problem to some trusts
in that with these recruitment difficulties, actually utilising
the money for what probably they would prefer to use it for, increasing
personnel on the wards, is not realistically an option because
they just cannot recruit people and, therefore, they look for
capital expenditure or something else?
(Mr Griffiths) Well, in the case of this £9.5
million, that would not be used for capital expenditure. This,
principally, is about trying to make sure that there are more
effective services available. Some of the money, for example,
has been used in arrangements with local authorities to provide
better nursing care in the community. Really, I suppose, in each
area there has been a combination of the things that can be done
to ease the problem, looking at the resource available and trying
to match the two and perhaps in different health authority areas
there have been different priorities, depending upon the additional
professional resource that is available. I would agree with you,
that it has not been an easy thing to manage, but I think on the
whole the NHS has been reasonably happy that it has had the problem
to grapple with and to use the extra resource.
Mr Livsey
44. The NHS Confederation, Minister, also suggests in its
submission that it might have been preferable to have concentrated
the extra funding solely on emergency admissions on the grounds
that this would have had in any case a beneficial effect on waiting
lists. What led you to adopt a two-pronged approach?
(Mr Griffiths) Well, because we believed that whilst
we wanted to concentrate to a degree on making sure that an emergency
admission would go straight to a hospital which was open, whether
it was the local one or the next available one, that in setting
the health authorities and the NHS that challenging target, if
we did not also say, "But look, you are also free to use
some of this money to make sure you keep an eye on your elective
waiting lists", it might have been that the elective waiting
lists would have grown longer and, therefore, by asking health
authorities both to address the emergency problem, but not to
forget the elective waiting lists, we would help to manage both
together. Because I think, in a way, as the NHS Confederation
is implying, the two things do run together and by making emergency
admissions the priority, but saying, "Don't forget about
the elective lists and you are free to use some of the money for
that as well", I think we will deal with the emergency problem,
but not allow the elective waiting list problem to get too far
out of hand as it so easily could.
(Mr Williams) Could I just add two things? I think
there is an element of "red herringry" in that suggestion
by the Confederation because the text of the letter which invites
the NHS to put in bids to use the £9.5 million not only makes,
I hope, transparently clear that the priority is on the management
of emergency activity over the winter months, but also gives some
ideas for the way in which that money might be spent in addressing
that problem. So it ought to be clear, and I think it is clear,
to the NHS that the key priority is the management of emergency
activity over the winter months. In his speech to the Confederation
Conference before Christmas, the Minister made quite clear that
the pressures of the winter might very well lead to increases
in parts of the elective lists and that part of the money could
be used to contain and address that problem, without losing priority
for the management of winter emergencies. So I do not think there
is any confusion in the NHS about the priority which attaches
to the use of the £9.5 million.
Mr Jones
45. Minister, not unnaturally the witnesses have told us
that they would like more money next year as well and the year
after. Can you hold out any hope for them?
(Mr Griffiths) I think, if I could just say, next
year there is going to be £2,455 million going into the National
Health Service in Wales and that is almost £114 million more
than this current year. It is a cash increase of 4.9 per cent
and a real increase of 2.1 per cent. We have also asked the Health
Service itself to find some efficiency savings so that between
the two we are certainly hoping that we will get more patients
treated next year than before. We will get an effective emergency
service bringing down again the number of days on which hospitals
have to close during a year, and again we would hope that some
of the lessons learned from this year will help to improve the
service next year. I suppose this does give me an opportunity
to underline that I can see no prospect of being able to find
£9½ million additional in the late summer/early autumn
to go into dealing with the increasing emergencies we are likely
to see next winter, but what I am hoping is that the additional
resources which has been made available on top of what was planned
for next year and the lessons learned from this year will mean
a more effective use of resource and also improve the long-term
planning of health care in Wales.
46. So no more extra money next year?
(Mr Griffiths) I would say no more extra money and,
although perhaps I should not say this, the fact is that we want
to make sure that we can meet the demands which are already in
the system which are giving us a great deal of food for thought
in making sure that the Health Service can continue to cope with
the demands upon it.
Ms Morgan
47. Llandough Trust suggests that trusts are being asked
to do too many things with very stretched resources and says that
inevitably there are a "few occasions when all the balls
cannot be kept in the air", and the University Hospital of
Wales Trust also makes the same point, asking for clearer priorities
for the targets that they have to achieve. Do you agree that there
needs to be a clearer hierarchy for priorities in the NHS?
(Mr Griffiths) I would have thought that the planning
framework and the guidance and the priorities that we have provided,
yes, they are challenging and yes, it does mean that you have
to keep your eye on more than one ball in the Health Service.
But there is a strategic framework and I believe it cannot be
too prescriptive in saying, "Every one of these priorities
we have identified has got to be treated in exactly the same way"
because in different health authority areas, different priorities
apply. For example, historically it would be the case that in
South Wales far greater attention will have needed to be provided
on dealing with the emergency admissions problem than in North
Wales. We know that in North Wales now that that is becoming a
bigger problem and given the nature of the NHS in Wales, there
is a fair chance that they will be able to pick up tips on good
practice from South Wales, so I do not think we should reduce
the aims and objectives of the Health Service in Wales. There
is the broad strategic framework in each area and in each trust;
they will have particular issues to tackle and I think perhaps
what I ought to say is that I would not expect every trust just
to look at the framework and say, "We have got to give everything
absolutely equal treatment". But what they have got to do
is to look at the service they are providing and to make priorities
where they see the greatest need. Peter, I do not know whether
you would like to add anything to that.
(Mr Gregory) Yes, I would like to say one or two things.
One is that I think in the way you couched your question, the
fact of the matter is that we do prioritise these things and our
plans and priorities guidance for the NHS in the last two years
has been absolutely clear about what the priority is. The second
thing is which element do you take out? This is a whole system
problem. It is about the way in which resources are used, the
way in which the NHS responds to need, the way in which the NHS
accounts for the way in which public resources are utilised in
support of a great national public service. As a consequence,
the NHS has to go on managing this in a way which recognises the
interdependence of these elements and the fact that we are talking
about a whole-system problem and not isolated packages of management
activity which are unrelated to anything else. So I would want
to impress on you that we have sought to prioritise and the priority
has been given to emergency and critical care explicitly. But
trusts also have to manage their money properly because if they
do not, they cannot deliver services, and at the same time they
have to respond to public requirements as to standards and quality
and if the NHS were not doing that, then I think your constituents
would be trying to convince you that that is precisely what it
should be doing, so what we are trying to do is to balance all
of those things in a management system which does give priority
to emergency admissions, but also tries to keep the attention
of the NHS on other things which are critically important to success.
(Mr Griffiths) Could I say that this was a particular
concern of UHW and of course UHW in many ways is a unique institution
in Wales and it has got several regional specialties there. There
is the teaching component involved with the university medical
school and yes, I recognise that at the UHW perhaps they have
got more balls to juggle than elsewhere in the Health Service,
but I would hope that whilst they obviously recognise the difficulties
here, they are able to meet them to a very large degree and appear
to be doing so, and I would thank them for that.
48. Obviously this question arose from concerns expressed
by the two trusts, both of whom serve my constituency, so there
obviously is some concern that they perhaps do not feel they have
got enough.
(Mr Gregory) If it was not so difficult, it would
not be so interesting! That is the other thing to bear in mind.
49. The UHW Trust points out that having to cancel elective
surgery in order to admit emergencies does have quite an impact
because it obviously makes the waiting lists longer and makes
the hospital look inefficient. I can remember on many occasions
taking up the cases of people who had had their surgery cancelled,
as I am sure most MPs can, which causes a lot of misery and distress.
Also there is a loss of money because I think the UHW lost £250,000
that way, as it says in its submission, in 1996. What are your
views on that?
(Mr Griffiths) Yes, we recognise the fact that if
a hospital, because of the number of emergency admissions it receives,
has to cancel elective operations, then it loses money which had
been provided to do those operations. In this particular context
of course, this has led to the inequities of GP fundholders being
able to purchase, because they have the money to do it, from hospitals
extra surgery. Now, what we did in May when we came to office
was to say that where emergency activity across a health authority
runs ahead of plans and puts elective activity for non-fundholding
patients at risk, then fundholding budgets would be reassessed
and adjusted where this was appropriate to try and make up for
what in effect was a loss of funding for the health authority.
I will certainly look with some interest as this year draws to
a close to see what impact that has had upon helping places like
UHW cope with the loss of some of its elective surgery cases.
50. I think also the emergencies that UHW are dealing with
are often much more complex and again that has got financial consequences.
(Mr Griffiths) Yes.
(Mr Gregory) It should be said, just looking at the
future and trying to solve some of these problems, that if we
can implement the proposals in the very recent White Paper about
long-term agreements between health authorities and trusts, it
ought to provide a framework within which this can be handled,
not on the basis of a bilateral annual dog-fight about what the
volumes, quality and costs should be, but a rather more strategic
appreciation of what is needed over a number of years and within
a broad consensus about what are the health needs in the area
and how should health services be provided for them. So in terms
of trying to solve the problem, there is always going to be a
tension, in view of the degree to which we are requiring productivity
out of the system, between health authorities and trusts over
this issue, but the development of a longer-term way of managing
that ought to provide a more sensible basis upon which to try
to tackle it.
(Mr Griffiths) We are also meaning the Local Health
Groups, but the GP fundholding status will be abolished, but all
of those, if you like, more positive parts of GP fundholding which
give doctors a greater say in how care is developed both at the
primary and, what is more, at the acute level will help to deal
with some of these problems as well.
(Mr Williams) One of the first actions taken by the
Government after coming to office in May was also to develop proposals
for the provision of common waiting lists from the 1st April 1998
which will help to balance out the differential effect of elective
and emergency activity in different health authority areas and
between fundholders and non-fundholders and will help underpin
the development of long-term agreements which the White Paper
anticipates.
Mr Caton
51. In their submission, the NHS Confederation said that
they would like to see the exploration of the possibility in future
years of using resources "for specific purposes that cross
departmental boundaries", and they give the example of heating
vouchers for the elderly. Has the Department looked at this possibility
as it certainly seems to be in line with the more holistic approach
that you have certainly advocated today, Minister?
(Mr Griffiths) Certainly I would agree with you that
prevention is better than cure in this case and what we have got
to look at later on this year is that there will be a public consultation
document which will suggest a strategy to take account of the
sort of issue which you have just raised with me. Of course, whether
it will be able to be done in the very direct way that the NHS
Confederation suggests is something that we will have to look
at, but certainly we are aware of the fact that links between
housing and other possible health determinants are not sufficiently
well understood and we need to be able to make assessments about
that and what can be done. For example, in the current initiative
on the money being made available from previous capital receipts,
one of the priorities that we have put there is that of energy
conservation and there are already programmes going on of course.
But this would be another opportunity for housing authorities
to do more in improving conservation standards, particularly in
homes of pensioners and also of, from my constituency experience,
families with young children. Certainly I would be keen to follow
that agenda and we will be making some proposals for further research
on things like that as part of our new health strategy and something
will be out before the end of the spring for us to look at in
Wales. On top of that of course there is at the UK level the Comprehensive
Spending Review and that is looking at how scarce resources can
best be spent across programmes and departments and certainly,
as you have said at the end of that contribution, Martin, we are
very keen to adopt a holistic approach to these problems and we
look forward to more of that work to make better use of taxpayers'
money, whichever department it happens to be lodged with in the
Welsh Office.
Ms Lawrence
52. I assumed earlier by the way that when the Minister stated
that there will not be any more money for health next year, he
means an extra £9.5 million on top of Wales' share of the
£1.5 billion given by the Chancellor?
(Mr Griffiths) Yes, in the figures I gave, the £113.8
million extra includes the £60.2 million which was our share.
It includes that, plus we were able to find in the review of our
spending that when the Chancellor actually made that announcement,
since then the GDP deflator has changed a little and we were able
to find a little bit of extra money to put in to take account
of that, so that money is in the figure of £113.8 million.
(Mr Gregory) If I might just follow that up, with
your permission, it comes back to something Mr Ieuan Wyn Jones
was hinting at. We have to cash-manage the NHS every year and
that involves brokering agreements with health authorities and,
sometimes, the trusts about how they are to cope with financial
and other pressures on them. We will be doing that next year as
we have been doing it for the last few years. I have to say that
is becoming a more difficult issue to manage, as I think is self-evident
from just reading the newspapers and watching the television,
but although there will be more money in the system if it is needed
to cash-manage, that is not the same as putting money in for a
specific purpose like this.
53. The essence of my question really was more general, as
we are drawing to a reasonable close now, I think. You did mention
earlier the need to work together in a more focused way and Dr
Todd mentioned the necessity for co-operation between the key
players in dealing with emergency admissions. Also I noticed that
the University Hospital of Wales say that emergency admissions
should be considered in the wider context of all the changes being
made in the Health Service in Wales and not considered in isolation.
Do you feel that all these issues confirm that the demarcation
lines that have arisen within the Health Service over the last
few years have actually exacerbated the problems with emergency
admissions?
(Mr Griffiths) I suppose in one sense it would be
better for the previous administration to make judgments about
that. I think from our point of view what needs to be looked at
is what we are trying to do to make the provision of health services
and health care better in Wales and obviously in our White Paper
we are seeking to provide for better co-operation, particularly
through the Local Health Groups, in bringing together all the
NHS players and the local authorities and also, by the way, because
I think it was either Colin or Gill who laid some emphasis on
the work where voluntary bodies like Age Concern provide help
and care which contributes towards what is done in the Health
Service, there will also be an opportunity for those voluntary
groups to be involved in the decisions about the development of
health care locally, so, without wanting to comment about what
has happened in the past, I think it is very clear that we have
an agenda which is going to provide structures to make co-operation
much easier and we believe provide more effective health care.
Chairman
54. Finally, Minister, what impact is the reorganisation
of the NHS in Wales likely to have on emergency admissions?
(Mr Griffiths) Well, we believe, through our Local
Health Groups initiative, that it will help to deal with those
more effectively. I would also hope, setting that aside, that
everything else that is being done will help us to manage this
problem and I hope we will see better care in the community, people
able to move out of hospital quicker because there is that care
there for them, but I would not point to one part of our reorganisation
plans in particular; I would say that all we are doing in reorganisation
terms to provide a more effective service and to ensure that there
is more money available for health care along with all that we
can learn from the experiences of this winter will help us deal
with emergency admissions even better in the future.
Chairman: Thank you, Minister. Thank you for your help and
your hospitality.
|
