Examination of witnesses (Questions 140
- 159)
THURSDAY 17 FEBRUARY 2000
MS GISELA
STUART, MS
DENISE PLATT,
CBE and MR ANDREW
CASH
140. That does not tie in with the answer that
you yourself gave in Hansard where you said "There
are no plans to provide additional money for winter pressures
in 1999/2000". Now you have just used a huge headline figure,
£1.9 billion is a huge amount of money. Yet, you said, on
2 December, that there was no additional money for winter pressure.
Do you stand by your statement now or was it what you said in
Hansard?
(Ms Stuart) There is a difference between money
being applied which is ring fenced or an overall increase in the
allocation to health authorities.
141. I understand the differences—
(Ms Stuart)—which is then used as part of the
winter planning groups because it goes across the whole board.
In 1997/98 and 1998/99 money was ring fenced specifically, here
it was part of the overall allocation to health authorities.
142. You see you said "... the 5.1 per
cent over and above the inflation increase in National Health
Service expenditure awarded by the Government is allowing health
authorities to plan more effectively for the health and social
needs of their populations, including the provision of services
throughout the winter". That is a little bit different from
this extra huge amount of money which is what I really wanted
to tie in with the pressures that you faced this winter?
(Ms Stuart) I think the real difference is that the
earlier lot of money was specifically ring fenced just to deal
with winter, whereas the extra allocation was for overall planning,
dealing with the overall period but also the year 2000 and the
sustainable changes. What is winter pressure? I think we need
to be quite clear what it is. It is how do we have in place systems
which deal with huge surges in demand, that is really the long
term gain of all this. That winter planning has to be seen in
planning for surges in demand, some of them expected, some of
them unexpected in a sense.
143. Specifically was there or was there not
any extra money to deal with the winter pressures?
(Ms Stuart) There was an overall increase in allocation
to the health authorities in England of £1.9 billion to allow
for the overall planning for that period. There was not, as in
previous years, at a later stage a separate pot of money labelled
"winter pressures" to deal with. It is very interesting
because actually in the service at around September/October, there
were grumbles going around saying "Was there going to be
extra money?" We made it very clear those kinds of labelled
pots of money called "winter pressures" were not going
to happen this year because it is long term sustainable changes
in service and funding thereafter.
Mr Burns: Minister, you said in one of your
answers to my colleague that waiting lists have come down by 50,000
in the last two and a half years, which of course everyone would
welcome because everyone wants to minimise the length and numbers
of people on waiting lists. We are all in agreement on that. Could
you explain to me though, whereas on inpatient waiting lists they
are, from your figures, coming down nationally, why is it, do
you think, that Mid Essex should so dramatically and consistently
in every month since March 1997 see their waiting lists far higher
than they were on that date? You heard the figures. The total
waiting list figure has gone up from 8,300 to 9,800 and something.
That is an increase. It has never gone below 9,300 since March
1997. Why is it that the number of people waiting 12 months or
more for hospital treatment has increased from 104 people in that
period to, I see the latest figures show a further increase to
11,023? Why do you think it is that trust or that area cannot
get its waiting list figures down below what they were whereas
the South Cheshire figures, we did see a total list, was below
the level in March 1997? Is it because historically under RAWT
and then with the fine tuning of the health allocation of funding
now that Mid Essex or North Essex in general has done less well
because when it was part of North East London the money was being
drained into the East End of London because of greater social
deprivation? What can the reason be? As a Government you seem
unable to influence the figures coming below that level whereas
in other parts of the country they may well be.
Chairman: Minister, could I just intervene to
say one of the interesting developments from the earlier session
was the question of whether we are comparing like with like. I
got the distinct impression that we are not necessarily recording
the same figures.
Mr Burns: That was on outpatient lists. These
figures are inpatients.
Chairman
144. Yes, it is a relevant point though, Simon,
whether we have got the proper comparison.
(Ms Stuart) There are two things I would like to say,
Chairman. One is I do not think this is the appropriate place
for me to try and make comparisons between two trusts whose chief
executives you had here and say "Why did one do it and another
did not do it?"
Mr Burns
145. I was just asking why it is that this trust
got the figures so high compared with March 1997 and they stubbornly
will not come down below those levels.
(Ms Stuart) I think that is a discussion which is
going to be had between the regional office and the chief executive
of that trust in terms of their management. Can I say overall
what we find when it comes to waiting lists. On the one hand there
is the pressure where more and more day cases are being done anyway
but also, which was identified earlier, in some areas the criteria
are different. Also, what I thought was interesting was what you
can do, quite apart from the quality of access, in the sheer management
of the list and booked admission systems, and the earlier evidence
you had about non attenders. What as a Government overall we are
doing, to provide the framework so that managers within their
areas can deal with that, is such as rolling out the booked admission
system and to provide extra money to deal with backlogs. In terms
of why your particular trust is not handling it, I think it is
probably a much more detailed discussion which they need to have
with their regional office. We put into place a sharing of good
practice.
146. It is all very interesting what you are
saying but you have not actually answered my question. I assume—given
you had advanced warning of this meeting and that you knew the
question of waiting lists would come out—that you will have
looked at Mid Essex's figures particularly as you knew that representatives
of the trust and health authority from that area were coming here.
I will try once again and just ask a very straight forward question.
Do you have any idea, have you given any thought or why do you
think that the figures in Mid Essex are higher and have always
been higher for inpatients waiting for treatment than they were
in March 1997?
(Ms Stuart) What I do know is that there are some
very detailed discussions going on between the hospitals and the
regional office to deal with that.
147. Can you help us by saying what you think
will happen to deal with those figures so that they will come
down below the level of March 1997?
(Ms Stuart) Chairman, I hope you will agree with me
that I think this probably is not the appropriate time and place
to deal with that issue.
148. Why?
(Ms Stuart) Because I do not think—and please
correct me if I am wrong—that a very specific trust's difficulty
in dealing with something merits a more than simple solution and
answer. We heard earlier on that in Mid Essex there have been
changes in the way they have been doing their admissions and there
have been improvements. The unit was opened around Christmas,
it is a long term issue to deal with it. These are ongoing negotiations
to deal with it and they will continue to go on.
149. I will briefly move on to outpatient waiting
lists and I will forget Mid Essex because, sadly, Mid Essex and
the rest of the country are all following the same trend. You
know that outpatient waiting lists of 13 weeks plus have gone
from a quarter of a million to half a million. Why do you think
that is?
(Ms Stuart) I think that there are two reasons for
what has been happening. On the outpatients there has been an
increase in activity, overall activity. For 1989-99 we completed
something like 42 million outpatient appointments and there have
been 170,000 more people who had their first outpatient appointment.
But, I think at 31 March 1999 they had gone down and now there
is an increase again. What the precise reason for this is a combination
of increased demand and at this very moment it has simply been
that there is more activity within the hospitals and it is a knock-on
effect.
Chairman
150. Minister, do you have any information collated
at a national level about the point that was made by the chairman
of the PCG from Essex that the interventions now, for example,
on opthalmics are at a lower level of disability than they used
to be? This was thrown in in the earlier session. Is this something
you can comment on? Is it something that is factual nationally
or is it a local issue?
(Ms Stuart) It may well be and I would be very happy
to go back and see if there is current data collected which we
could make available to the Committee.
151. Okay.
(Ms Stuart) I think we do know from anecdotal evidence
that there are differences but this is why with the introduction
of such things as the National Service Framework, the common standard
across the country, it is extremely important that we do get equal
care and equal access across the country which we have not had
so far.
Mr Gunnell
152. I would like to come back very briefly,
Minister, to the question of the ring fencing of monies. You explained
money was available but ring fenced monies were not specifically
available, they are in with the winter pressures money generally.
Have you had any feedback from trusts or health authorities on
any specific ways in which they deal with it or any which faced
difficulty in not having the ring fencing? Have there been any
good practice initiatives which have not been followed this year
because that ring fenced money was not available as such? I know
it was available overall but it was not labelled and ring fenced.
(Ms Stuart) What we found when we looked at that,
as far as I am aware, I am not aware of any form of feedback which
said they were not able to do things because the money was not
ring fenced. I think one of the reasons for that was because of
the way that the local winter planning group meetings were going
on all through the year, it was making sure that the plans were
robust and the funding for those plans were robust. As I understand
it, in the social services field, some of the money was much more
clearly allocated and as a result of that they have had very good
co-operation and very good examples of social services working
with the health authorities. I do think the way forward, and also
some of your witnesses said this, is to make sure that whatever
we put in place are sustainable systems which deliver year on
year. Therefore, it needs to be overall funding rather than late
in the day special pockets of money.
153. Yes. So as far as you know there were not
any initiatives which had been disbanded as a result of the change
which you would regret?
(Ms Stuart) I think what happened as a result of the
much earlier planning was a lot of things which they had done
in previous years were changed to be much more co-ordinated with
all the other systems. As I think I said earlier, one of the significant
changes this year was the much closer co-operation between the
GPs on the one hand and with the social services on the other,
but also there was real local ownership of those plans. Before
Christmas all the chief executives and all the directors of social
services and local PCGs and pharmacists signed up to the winter
guarantee pledge of what they would deliver to their local communities.
They were owned locally. Things may have been changing compared
with previous years but that should not be put down to saying
because the funding stream was different.
154. In other words, nothing that they really
wanted to do and they had done before was lost as a result of
any ring fencing?
(Ms Stuart) Not that I am aware of.
Chairman: Eileen just wants to come in on this.
Mrs Gordon
155. Yes, on this point, you say the plans were
robust and everything and obviously you monitored them very closely,
checked to make sure they were viable, etc.. What are you doing
post the millennium to analyse whether those plans were met and
where the problems were and how we can learn the lessons from
that?
(Ms Stuart) If I just focus on the overall areas where
looking at it it means looking ahead, I think we will fine tune
it. I think what happened as a result of this year, when you look
back, was not that we said we would do things differently but
probably we would just refine some of the things. One of the things
which we will certainly have some focus on is revisiting the issue
of the flu immunisation programme. Whilst there were high numbers
of vaccines offered, I think some 7.6 million were taken up which
is better than in any previous year, I would look at whether it
should not also be offered to social services staff, particularly
those working in the social care sector with the elderly. Also,
improving on the A&E modernisation programme to make sure
that all of them have effective admissions systems. There is tremendous
scope for working with much more detailed plans in terms of critical
care. One of the things at the moment is of the 200 trusts who
have got intensive care facilities, only two thirds have high
dependency units and, whilst there is some work going on to evaluate
that, I would certainly expect that number to go up. We are looking
again to further make sure there are out of hours services for
primary care. One of the biggest changes I think we will see next
year is that NHS Direct will be available through the whole country,
this year it is available to only two thirds of it. This will
help particularly on appropriate access. Those are some of the
areas which we are looking at at the moment.
Mr Gunnell
156. Coming on to the question of bed occupancy,
the NHS Confederation has said that the average bed occupancy
is 95 per cent. Do you have any figures on bed occupancy over
the period? What is the variation between the higher figures and
the lower figures you know of?
(Ms Stuart) The way bed occupancy figures are collected
is on an annual basis, so we do not have figures of bed occupancy
just over the winter period at the moment. I think the National
Inquiry has given us some very interesting figures. They say we
are talking about an annual level of 83 per cent but, of course,
if you talk to the trusts they will tell you that certainly in
many areas it is 95 per cent, and some of them it is even going
to 100. I think the long term way the National Bed Inquiry is
looking at that is bed occupancy itself is an important figure
but probably what in the long run is more significant is the actual
throughout rate. If we look at the throughput, particularly as
we have got more day care patients, particularly as we have got
such things as five day wards, the bed count happens at midnight
and you may have a bed which is empty at midnight but it will
have had two day cases during the day. If we look at what has
happened over the last few years in throughput, in the acute sector
that has increased from 1998-99 from 59.7 per cent to 60.2 per
cent so there has been an increase on the way it has been put
through. What I think is clear, and the National Bed Inquiry is
looking at, is that the decline in the number of total beds available
probably has gone far enough.
157. Have you had a look at the effects or have
you monitored the effects of bed occupancy on the flexibility
that hospitals can exercise in their work?
(Ms Stuart) Yes. Just looking around the hospitals
at the moment when you see where the bottlenecks have occurred.
158. Yes?
(Ms Stuart) In previous years there was a problem
with discharge so the patients were not moving through. Now with
that improved co-operation with social services there has not
been a problem with discharge but there has been a real surge
in people coming into A&E, emergency admissions and 999 calls.
Again, when you look at the different ways of how they are dealt
with, the medical admission unit assessments, GP units, it will
be the total number of beds but, also, discharge and we really
need to look at the way people come into A&E, given that there
is a year on year increase on A&E admissions of something
like 5.5 per cent.
Mr Gunnell
159. It is obvious you are looking at that on
the effect that it is having on creating an inflexible position
for hospitals. As you probably know I represent an outer London
area which with the previous government saw a massive reduction
in hospital beds due to a misinterpretation of the recommendations
in the Tomlinson Report. Leaving that aside, can I say how much
I welcome the Government's National Beds Inquiry. Since its publication
the Secretary of State has announced a variety of new intermediate
care services. I know what I understand by intermediate care because
I have a very successful unit in my constituency, with a much
better quality of care and more appropriate care than will be
provided by an expensive hospital bed, which is GP supervised,
nurse led, therapist led, et cetera. What do you mean by intermediate
care? You talked about building a bridge between hospital and
home, do you have any more detail available now for what is proposed?
Have you any idea of the cost and what other methods and plans
do you have to reduce occupancy rates in hospitals?
(Ms Stuart) If I can do two things, at this stage
I would like to bring in Denise Platt to give some good examples.
In terms of immediate care, as a result of the survey and the
consultation exercise going on, what is becoming quite clear,
particularly for a lot of elderly of patients, is they are given
a quite inappropriate choice between hospital and home. What is
the right thing to do may also vary between an urban area and
a rural area, the access and travel, and the kind of patient's
need. The health consultation that is going on at the moment is
aimed at two things in particular: patients do not stay in hospital
if they do not need to but also provide the support, preferably
at home, as much as they can. I think Denise Platt is able to
give us some examples of the things we are looking at.
(Ms Platt) You mentioned specific grants earlier.
From the Social Services' point of view the monies that came previously
at winter time in short bursts was very counterproductive, really,
because good schemes were started which could not be continued.
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