Examination of witnesses (Questions 40
- 59)
THURSDAY 17 FEBRUARY 2000
MR STUART
GRAY, MR
EDDIE KINSELLA,
MR NEIL
LARGE, MR
ANDREW PIKE,
DR SHEILA
PESKETT, MR
NIGEL BEVERLEY
and DR PAUL
ZOLLINGER-READ
40. Mr Gray, do you want to respond to that
point?
(Mr Gray) I would agree with that. I think that we
are seeing such a change in the way we use the resources we have
and how we deploy staff, so there are bound to be changes where
the definition of patients as outpatients or inpatients or day
cases does change. With the pressure on inpatient facilities there
have been significant changes in the way we do procedures on an
outpatient basis.
41. You have slightly differed in your answers
from your colleague at the other end.
(Mr Gray) Yes.
42. When we look at figures nationally and we
break them down into local comparisons, here we have two different
local examples and possibly the classification of different patients
in different areas, so it makes it very hard for us nationally
to look at whether we are comparing like with like. Your answer,
Mr Gray, was somewhat different from the answer given earlier
from Essex.
(Mr Gray) Yes, and I think, Chairman, that one of
the things that is clear to us with the pressure on inpatient
facilities is that we are looking at doing things differently
in an outpatient setting using different staff in different ways
is the way that we are looking to tackle some of the pressure
in the system.
Dr Howard Stoate
43. You both said that there has been an increase
in outpatient waiting times to see a consultant. Can I ask you
about outpatient activity? Can you give me any figures for how
the activity of outpatients has changed? Have you seen more outpatients
in the last month to the same month a year previously, if you
see what I mean? What I am trying to get at is what your overall
level of outpatient activity is.
(Mr Gray) The increase we have seen in referrals across
South Cheshire, across all the trusts, is about a six per cent
increase year on year.
44. So you are producing an increase of six
per cent on your outpatient activity year on year?
(Mr Gray) In referrals, yes.
(Dr Zollinger-Read) What I would say is that referrals
have not gone up greatly, but the big issue around outpatients
for us is what are called other referrals. In the last quarter
of 1995/96 Mid Essex had approximately 3,000 other referrals.
Last year they had 6,000. There has been a phenomenal increase
in other referrals that we do not understand at present. The Eastern
Region as a whole had an increase of about 35 per cent, so although
GP referrals have not gone up we have this great influx of other
referrals into the system.
45. So you are saying that even while your outpatient
waiting times got longer you were putting more outpatients under
more pressure?
(Dr Zollinger-Read) I am saying that that is certainly
one part of it, yes.
Dr Brand
46. Could you define "other referrals"?
Where are they coming from?
(Dr Zollinger-Read) A number of referrals are-inter-consultant
referrals which clearly come around because of sub-specialisation,
and also people coming in through A&E, particularly around
orthopaedics.
(Dr Peskett) We have a specialist regional unit, Classic
Surgery and Burns. I take your point that we are not comparing
like with like. In urology we do an awful lot of procedures as
outpatient that in most other places would be done on a day case
basis.
Mr Burns
47. You were just saying that in Essex, for
example, your latest 13-week plus outpatient figure was 3,579.
What was it on the 31 March 1997?
(Dr Zollinger-Read) It was 555.
48. And it is now 3,579?
(Dr Zollinger-Read) Yes.
(Mr Gray) At the Countess it was 1,439.
49. Remind me what it is now?
(Mr Gray) It is now 2,167. There is one slight difference
here which is a one-off, and that is that in recent weeks we have
introduced a new information system that gives real time reporting
on outpatients which the old system did not. There was a one-off
increase of about 600 and that is what we have seen. We expected
it to happen and we have got to get it back down again, but that
is the reason why it is so inflated.
50. So you have got circumstances of a one-off
situation?
(Mr Gray) Yes, we have.
51. Mid Essex does not have a one-off situation,
so we have seen a substantial increase. There is a school of thought,
and I would be grateful to know whether you subscribe partly to
this or not, that, in order to help you relieve the pressures
on your inpatient waiting list figures to meet the government's
target and enhance the quality of care of patients, outpatient
lists are being allowed to balloon, in this case almost out of
control, so as to keep to your inpatient list so that more and
more people are having to wait in effect possibly longer to see
a consultant before they ever get on to the waiting list for treatment.
Is there any veracity in that?
(Dr Zollinger-Read) There certainly has been a substantial
growth and there are many local issues such as the siting of the
regional centres, such as the repatriation of some orthopaedics
work, such as the increasing age of our population. In the past
the level of disability that we operated on was not acceptable
and now we are beginning to operate on cataracts at a much lower
level of disability and certainly in orthopaedics and ophthalmology
we have an ageing population and I think that to some extent explains
the growth. The good news that I see, although we have had substantial
growth, is that although very little work here and nationally
has been done around outpatients we started to look at outpatients
in the mid to latter part of last year and there are clearly three
key areas around outpatients that we need to look at. The first
of those is around the way in which we book in outpatients because
we have significant cancellations, significant DNAs. That is because
I tell you that you have got an appointment and that is in about
four months' time. It may not be convenient and when it comes
around you have forgotten about it or you have got better. What
we need to do is to move ultimately to a direct booking but first
into a partial booking system whereby you come and see me and
I contact the hospital and they say, "You will be seen in
approximately three months' time. We will contact you nearer the
time. Please contact us." You set up a dedicated patient
switchboard and then when the patient rings up you offer them
an appointment in two to three weeks, it is convenient and they
turn up. It minimises cancellations and DNAs. The way we book,
the validation, we do need to reduce five per cent on national
patients but that system shows that you can go up to 20 per cent
if you clean up outpatient lists because patients have moved away,
patients no longer require treatment. That is good practice and
we are just starting to do that. Thirdly, and more importantly,
is re-engineering the agenda. What is outpatients? It is about
who does what best and where. It does not need to be a doctor.
It could be a nurse practitioner. We can re-engineer certain systems.
Action on cataracts is beginning to come along. There is also
work on orthopaedics. We are engaging in this national breakthrough
collaborative. When our numbers have gone up, and I think this
is partly a reflection of an ageing population, we are actively
engaged in solutions.
Chairman
52. On this issue of cataracts, and you mentioned
other problems as well, has this issue of intervention at a lesser
level of disability been quantifiable in any way either locally
or nationally? It is a very important point on the waiting times;
I appreciate that.
(Dr Zollinger-Read) I am not aware that we have quantified
it locally but I can only say anecdotally that when I started
in medicine, and that is about eight years ago, the standard reply
was, "It has not matured yet." Now any level of visual
disability is accepted as treatable.
Mr Burns
53. Can I ask one final question about ageing
populations in Mid Essex, given that I know the area reasonably
well? I can understand it in an area like the Tendring Peninsular
and maybe some of the other coastal areas, but I was unaware that
the Mid Essex part was noticeably an ageing population. Do you
have figures showing the proportion of population that is elderly
by your definition now compared to, say, 10 years ago?
(Dr Zollinger-Read) I do not with me, I am afraid,
no.
54. So what have you based your evidence on
of an ageing Mid Essex population?
(Mr Beverley) I have not got the figures broken down
to each locality of Essex, but you are right that the major proportion
of elderly people are concentrated in the coastal areas in Tendring,
but the catchment area of the Mid Essex Hospital group includes
not just Chelmsford but Maldon and parts of Braintree, and overall
in North Essex there is a large elderly population and a population
which is growing older, so I think the point is valid.
Mr Burns: I understand as a whole. I was thinking
in connection with Mid Essex. I would be interested if you could
send the Committee after today the proportion of the population
in Mid Essex of elderly by whatever definition you want for "elderly"
and what it was, say, 10 years ago.
Mr Amess
55. The government has set targets in a whole
range of areas. These targets have been set so that when the general
election is held next year obviously the government want to say
that these targets have been met. I am only too well aware of
the pressures that you in your own area of health are under to
meet the targets. Could both of you bodies first of all tell me
what targets you have been set in terms of these waiting lists?
(Dr Zollinger-Read) You want inpatients and outpatients?
56. Please.
(Dr Zollinger-Read) Do I need to spell out that the
inpatient target will be what we end up with in March 1999, which
for us is 9,034? We are trying to reduce the 12-month waiters
down to 104. The outpatient targets are, the four specialties
of ophthalmology, orthopaedics, dermatology, ENT. What we have
to reduce is the numbers waiting by 55 per cent from the September
1999 position, the aggregate of those four specialties below the
March 1997 position, and the other specialties, 13-week waiters,
10 per cent down on September 1999, also cardiac 13-week waiters,
35 per cent reduction on September 1999. For us in Mid Essex essentially
that means, if we look at the September 1999 position, the figure
was 4,175. We have to reduce it by 1,502 patients.
57. Best of luck. What is your target, Mr Large?
(Mr Large) In South Cheshire our target for 12-month
waiters at March 2000 and March 2001 is 14,447. We are currently
at 14,875 and we are still on target to achieve our target this
year. That is a reduction of 20 per cent on the waiting list over
the last three years. We are well on board with that target. In
terms of outpatient waiting targets, we have to reduce overall
by 35 per cent from September 1999, and that will take us to over
13-week waiters, 3,212, and that is a reduction of 1,700. Our
main specialties again are T&O(?), ENT, ophthalmology and
dermatology. We recognised last year that we had got a particular
waiting time for problems in dermatology, ENT and ophthalmology,
and we have already put initiatives in place from last September.
When the government earmarked the waiting list initiatives, we
targeted the high specialties where we were not going to hit the
targets we set ourselves, let alone the new targets. We are reasonably
optimistic that for the new targets for next year, March 2001,
we have already got plans in place to achieve those. Clearly some
of these initiatives take some time to work up so we will maybe
have a little bit of a six month—
58. Thank you. I think the Committee has got
the feel for the challenges that Essex has compared with the challenges
in Cheshire. I am very interested in the processes involved in
these targets. Can you very briefly and quickly tell me how these
targets are delivered to you as a group, having some insight into
the way management is? Do you suddenly get a letter through? Is
there a phone call from the Chairman? How are these targets delivered
and how are they filtered down to the staff that these targets
have to be met?
(Mr Pike) Obviously I am not at the trust yet, so
I will qualify my answer, but I can speak for my current organisation
at Southend, which obviously you know, Mr Amess. There are two
approaches. One is that a hospital clearly has to understand that
it can deliver the targets so these are not completely dictatorial,
that we have absolutely no choice, and it is important to say
that. I would certainly argue with region above if I felt that
the targets were completely unrealistic. There are two points
to make. One is that the inpatient day case target, apart from
the new drive to try and improve the 12-month wait position, has
not changed. Our targets have not been made harder. The 12-month
wait is new. What a hospital will do is engage in dialogue with
the region. There has to be some flexibility around the 12-month
target as to how much progress can be made over what time because
it is quite a challenge for Mid Essex, given the numbers you have
heard. One would look at the capacity in the hospital, discuss
with the clinicians as to what they could or could not do, and
then one would hope that one would have an accommodation and an
agreement with region. The difficulty with the targets is that
once you have agreed, as you know, waiting lists are dynamic features.
You have got a static number but it is a product of what comes
on and problems you may have in what comes off. There are all
sorts of things a hospital then has to contend with, from availability
of staff to surges in emergencies, and the key factor is referral
load from the primary GP referring to outpatients. If that is
relatively stable then the hospital is in a good position to know
that its plans can work.
59. When roughly were you given these targets?
(Mr Pike) These new targets were discussed at the
back end of last year and they were firmed up just around Christmas
time.
(Mr Kinsella) I would endorse what my colleague has
said but add to it. It is obviously an incremental process. To
a large extent it is not a surprise; it is building upon targets
which have occurred in the past, with the point we have made earlier
about a three-year improvement across Cheshire. It is also a question
of pragmatism, having regard to the different communities that
I referred to before in the different parts of the county, the
different projects, how well a particular trust has done, what
slack it has got, and what profiling can sensibly be done, and
building in a fallback position if there are exceptional circumstances.
Once we have signed up with the trusts and the PCGs we expect
them to deliver.
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