Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 1 - 19)




  1. Today we are looking at the Comptroller and Auditor General's report on Inpatient Admissions and Bed Management in NHS acute hospitals. Following on from our recent hearing on hospital acquired infection, this is another very important health issue. We all commended you last time, here we have you in your afterlife. A busy day today, I would imagine, given the news this morning of the Audit Commission Report.
  (Sir Alan Langlands) It has been a busy day, yes.

  2. I hope that this is at least an interesting end to it for you.
  (Sir Alan Langlands) I hope so too. Thank you, Chairman.

  3. The normal approach. The first thing I want do deal with is paragraphs 1.4 to 1.6 which point to the expansion in inpatient activity but also the increasing numbers of people waiting for outpatient consultations and the significant numbers waiting longer than your Patient's Charter standards. Why is this, and what are you doing to ensure that patients do not have to wait for long periods at any stage of the process of their assessment and treatment?
  (Sir Alan Langlands) Chairman, I think this is the blackest point in the report, the number of cancelled operations and waiting times in the NHS.

  4. I will come back to cancelled operations.
  (Sir Alan Langlands) Yes, I know. What we are doing is trying to enable the NHS to do more work and, as you can see from this report, we are doing substantially more work. I imagine that the waiting list targets and the length of time that people have to wait in general, not just for their operations, will reduce as the Government invests in the Health Service and as we change and improve the Health Service, I have no doubt about that. I have no doubt that we will hit the manifesto target that has been set by the Government, but in order to do that we are having to work extremely hard, or the people in the Health Service are having to work extremely hard (1) in coping, as the report sets out clearly, with the very significant increases in emergency admissions and (2) in coping with a vast increase in elective workload, eight per cent per annum in this report and that is only in relation to inpatients. The report does not really touch on day care where in the period of the study there was an 11 per cent increase. So overall more than a nine per cent increase in the number of operations last year. This is a huge drain on people working in the Health Service. I think it became clear during the winter that we have resource problems. I think the Government have responded to that in the Budget. The other thing this report does not mention very much is staffing and, of course, most of our money in the Health Service is spent on staffing. Essentially the central answer to your question is that we need to staff up to be able to do more work if we are to give people a more responsive service.

  5. Thank you. I know that nobody on this Committee would question at all the commitment of the Health Service staff in all of this, as you have highlighted. You talk about this year and the numbers, particularly cancellations, relate to 1998-99. My next point is about 1.11 to 1.14 which show that record numbers of patients had their operations cancelled, over 56,000 people in 1998-99, on the day they were due to take place, only cancellations on the day, in breach of the Patient's Charter again. In some trusts such cancellations totalled 8 per cent of planned operations which is an extraordinarily high number and even more patients had their operations cancelled on other days before the day of admission, which is not monitored. Why is it deemed acceptable for any patients to be cancelled once they have been given a date for their operation?
  (Sir Alan Langlands) I do not think it is acceptable but it is reality. One of the things I do is track the position of these things on a quarterly basis. Before I left today I looked at the last quarter of 1999-2000, in other words the quarter ending 31 December, and in that period of three months there were 1,350 cancellations more than there were in the same period last year, so roughly about 15,000 in that three month period. I also looked, during that period, at the number of emergency admissions and in that period there were 11,400 more emergency admissions. So what we have here is a direct trade-off between the elective workload of hospitals and the emergency workload of hospitals which used to be seasonal but, I must say, is flattening out a bit now. People have to make these difficult choices on a day to day basis. The other point that I would raise that came through very clearly in the Government's Beds Inquiry, and it is set out in this report as well, is there is a point where if bed occupancy in a hospital exceeds 85 per cent, the chances of not being able to cope with an elective workload on any particular day increases enormously. My answer is that the system is just running too hot, we are trying to do too much work given the available resources and, as I said in my earlier answer, that is a point we have to deal with.

  6. I certainly take that point on the 85 per cent, that is very clear. On the question of the National Beds Inquiry, which looked at the longer term requirement for hospital beds, how will the consultation process take account of the findings in this report that reducing delays in discharging patients and increasing the proportion of patients admitted on the same day as their operation would actually free up a significant number of beds?
  (Sir Alan Langlands) I think there has been good interaction between the NAO and the people doing the Beds Inquiry study and a lot of the findings from the Beds Inquiry are woven through this report. Clearly we will take account of, if you like, the additional insights, because this is essentially a synthesis of all that is going on in the service on admissions and managing beds and discharge, as we work through the NBI process. The way we are handling that process is that people are making written submissions but we are also having a number of regionally based discussion groups. Certainly the information I have from people leading them is that people in the Health Service are already referring to some aspects of this report as well. There is great consistency coming through the responses so far with the report. People are homing in on this notion of a health and social care partnership and feeling, as I think reading between the lines here the NAO feel too, that at the heart of this issue of bed management in the Health Service is improving services for older people. These messages are being taken on board. I think this report will influence future discussions and guidance about PFI schemes. I think it will influence discussions about workforce planning. My sense is that already the direction of travel is to try to sustain roughly the existing number of acute beds but to think about later investment and expansion in relation to intermediate care, community based care services for older people. I think that is the direction the service is taking and that is the direction the Government is taking.

  7. I will come back on the question of co-ordination of local systems in a moment but, before I do, one of the overwhelming feelings that came out of the report for me, as highlighted in 2.27 to 2.29, was the pivotal part that information management systems had in this whole exercise. I thought the case study of the excellent system at Shrewsbury was very indicative here. What are you doing to spread the use of systems such as the CALM system, as it is called, to the rest of the National Health Service? We have had letters and documents indicating that there are systemic limitations on the use of those sorts of systems in the Health Service.[1]

  (Sir Alan Langlands) I think there are but, let us be clear, it was we who identified the good practice that led to the Shrewsbury example. Indeed, we could cite other good information systems around the service, some of which are linked to the patient administration system, like Shrewsbury, some of which are stand alone. Over the Christmas holidays I saw in live action, if you like, a very good system in Aintree that not only was hospital based but linked to all of the other hospitals in Liverpool. I think people are increasingly finding ways of solving this problem. As far as we are concerned in the NHS Executive, we do not want the best to become the enemy of the good. There is the opportunity with existing systems and networks to build something that will work for the next two or three years but our longer term aim, as we have discussed here before, is fixed on network systems, an emphasis on supporting clinical care, and what we really want is a by-product of the work that is now going on on the electronic patient record, systems that throw out, if you like, as a by-product of patient care real time information on bed utilisation and the sort of time data that people need to support, not to plan beds two or three days in advance, or even 24 hours in advance, but well ahead of time so that work can be properly scheduled. I think we have got, if you like, a pragmatic short-term answer and a longer term game plan. We do encourage people to look at the Shrewsbury example. We have given them money to disseminate their practice across the service and a lot of people, as a result of this report and the award they were given, have visited the hospital and are putting in place their version of the system. Like all good ideas it comes from one person who struggles with these problems day by day. This piece of work is not some great management intervention from the centre, it is a frustrated urologist in Shrewsbury who thought "I have got to do something about this" and when people do that we have got to learn and disseminate that information.

  8. It is, of course, one of the things which will give you maybe a limited but rapid increase in capacity when it actually works.
  (Sir Alan Langlands) Yes.

  9. That is one thing that fits your current strategy. Paragraph 3.8 states that 2.2 million bed days are lost each year because of delays in discharging older people from hospital, and this is really the local co-ordination point that you raised yourself, and that costs the NHS about £1 million a day. How can you justify this? What do you foresee doing about it?
  (Sir Alan Langlands) We cannot justify it at all and we are trying to reduce these numbers. We are trying to reduce these delayed discharges by two courses of action. One, which is something within our own responsibility, is to sort out the internal systems in hospitals and make sure that, for example, pharmacy and transport systems can accommodate a different way of working in hospitals. The other thing, and I think the most difficult issue, is achieving co-operation across the boundary with social care because often the delay in a discharge is dependent on an assessment from health and social care professionals and a subsequent discharge either to a nursing home place or a residential home or maybe to the person's own home with a lot of support. We have measured that problem consistently. As things stand at the moment, before the extra money in the Budget, we have plans by 2003 to try to make a 30 per cent reduction in the number of delays and we are encouraging good practice and better ways of managing these things by an injection of £365 million over that three year period to try to encourage schemes across health and social care boundaries to make this work better. I just want to make one cautious comment in relation to this and that is that these are often difficult decisions for the people themselves and for families. I think this is an area where, in a sense, you have got to get the right balance between compassion and empiricism. This report is about empiricism. The compassion is to recognise that patients and their relatives and their carers need to be sometimes gently eased through this process. I do not think that by some very strict definition of delay we will ever get this figure to nothing but we do want to do much better and that is about investment and better joint working.

  10. We see the great exponent that you do have?
  (Sir Alan Langlands) It is pretty important.

  11. Absolutely, I take the point. That leads me to the last point. As you promote these best practices, how are you going to measure the extent to which they are taken up? How are you going to measure the balance that you just talked about? How are you going to know when it is right and know when they have done the right thing, and also know when they have not done the right thing?
  (Sir Alan Langlands) I do not have a worry about the whole of the report in this regard, because, not in any way to undermine it, but it does deal with the harsh numbers and the activity numbers and, of course, that is ideal because that is what it was for, but it does not deal with the qualitative aspect of service and it does not deal with some of the workforce issues that I think affect the quality of service. To get a complete picture of how you measure progress I think you need to understand the harsh numbers, and stuff that is in here, and you also have to understand the qualitative issues. We certainly will continue to measure against the parameters set out in this report. It gives us a good template. All of the data that is in here is essentially our data reinforced by European survey material, but we have also set up, not just now through the Audit Commission but through the Commission for Health Improvement, ways of measuring the qualitative aspects of health care, and we have also, for the first time, last year, launched, and have been working with, patient reaction and user surveys on how people feel that they have been treated in the Health Service and how the system has worked or not on their behalf. I think it is a combination of these harsh numbers, the qualitative information that comes from the Audit Commission, Commission for Health Improvement and the results of the patient survey that will allow us to know if we are making progress in a rounded sense.

  12. I would not be too cruel on the writers of the report, it seems to me that there are quite serious qualitative considerations involved in the cancellations. I believe that the report does pick out, in respect of people who have to do bed management, that it is a much more miserable existence when you are working hand to mouth trying to desperately find a bed for some very sick patient than when you have a well planned, ordered structure. I think that should be taken on board.
  (Sir Alan Langlands) I accept that. If you use numbers there is always going to be a threshold. If some old woman is being discharged after three weeks in hospital and she is declared medically fit for discharge on a Tuesday, but for some perfectly good reason she is discharged on a Thursday and feels better as a result of that experience and feels that the support systems are better in place at home, I do not think that is a bad trade off. I just want to counter some of the harshness of the numbers with that.

  Chairman: I think we all agree on that.

Mr Campbell

  13. Could I take you back to the question of occupancy levels? We are told that the number of general and acute beds fell between 1986 and 1997 by about 60,000 and as a result of that many hospitals are operating at something like 90 per cent occupancy levels. Just to be absolutely clear about this, to a lay person like myself that means that when there are a number of emergency admissions for any particular reason it is more difficult for hospitals to cope. That is right as a general principle, is it not?
  (Sir Alan Langlands) That is correct, yes.

  14. There is a lack of capacity for them to respond to that. Is there, in your view, a direct link there with the cancellation of elective surgery? Is there a direct correlation between the fall in the number of general and acute beds and the kind of problems which the report handles?
  (Sir Alan Langlands) I think we need to be a bit careful, because there are layers of detail here, but the fall in the number of acute beds that you mention is actually a fall in general and acute beds, and the biggest fall has been in general beds, which essentially, in this context, means beds for older people, if you like, geriatric beds. There has been a compensating increase in the nursing home sector during this period, but the real point that I want to make in relation to that is that the fall in the number of acute beds is very small. In the same period, 1993-94 to 1997-98 it is only just over 2,000. There is no doubt whatsoever that the tightness of bed numbers, the fact that we do not have well developed services for older people and the fact that hospitals are working at 85 per cent plus occupancy in many cases means that there is not enough slack in the system and it means that people are cancelled in favour of emergencies. When you are dealing, as we are, with very big numbers that can become quite a problem. The research that is cited in the NAO report, which I know of, actually goes on to say that not only is that a problem on the day that you confront it, but it can often take a big, complex hospital two or three weeks to come out of that problem and get back to normal. In other words, you get into this spiral of difficulty if you are not very careful.

  15. On the issue of general beds for older people, the report says that beds which had been specifically for older people fell by something like 20 per cent between 1993 and 1997-98 and yet, if I am right, something like two thirds of the people actually in hospital at any point in time are over the age of 65.
  (Sir Alan Langlands) That is right.

  16. Despite all you say about the opening of care homes and other facilities, have we, perhaps, been moving in this direction too quickly and getting rid of these beds?
  (Sir Alan Langlands) We may have been, because the two thirds number which you have quoted, if you were to take a census of all the general and acute beds in use in the NHS today, about two thirds of them would be filled with people over 65. We need to be careful, because many of these people would be in for short routine operations. Advances in surgery and anaesthesia means that people over 65 can be treated for straight forward conditions as you and I would be, so we just need to be a little bit careful. That group, the over 65s, are 16 per cent of the population, 36 per cent of the hospital admissions, 50 per cent of the increase that we have seen in general and acute services and occupying 66 per cent of the beds, so you do not have to be a rocket scientist to know that that is the problem that has to be dealt with. The provision and the pattern of services for older people is becoming the key issue in the Health Service and, given the implications for the Royal Commission for Long Term Care and all the rest of it, actually is one of the most difficult and urgent social policy issues that the Government has to deal with, and the Government is doing so in a systematic way ahead of the spending review in July, because whilst the Health Service funding was announced in the Budget last week, the issue of long term care and social services funding was not resolved. These are significant issues where the Department of Health are still in play and still being very clear about the difficulties that we have in that area.

  17. I want to lead on to that. The Chairman mentioned the 2.2 million bed days that are effectively lost to the community by beds being blocked predominantly by older people who, perhaps, cannot go home, or there is nowhere for them to go. How important are health authorities in encouraging the kind of cooperation and partnership which is necessary between hospitals and care providers to unblock that blockage? Is that the direction in which we ought to be going?
  (Sir Alan Langlands) Yes. I think everyone has got a part to play, but I do think health authorities are pivotal in that they are the people who are held responsible for assessing, if you like, the Health Service needs and the local population. They then sit at the centre of a web that has GPs and primary care teams, social services, the ambulance service, the secondary care services and the hospital services; they have relationships with all of them. Bringing that whole system of health and social care together in a way that is focused on the needs of individual patients and that does not put the administrative barriers that currently exist in the way of people being properly looked after, is the job that they are supposed to do, and it is a complicated job.

  18. Let me give a couple of examples, because I was very interested in what you had to say about good ideas and how they are often fairly simple, and on the ground it is important to push those good ideas. In my constituency I recently visited the Cedars where the local authority and NHS Trust together have provided nine beds for elderly patients, many of whom had fractures and would otherwise be kept in hospital but are actually going out to what is, in effect, an old folks home and getting excellent care and they are not blocking beds. Another example, and I understand that this is not exactly on the bed management issue, but my local accident and emergency department, which is using a triage system and software which is very similar to NHS Direct, superbly, is freeing doctors' time by making sure that they concentrate only on the real emergencies and giving qualitative treatment at the time. They are two good examples, but there is some frustration there amongst people working on the ground, I think, first of all, about funding and the speed with which funding can be made available to roll those good ideas out. There is also some frustration about spreading good practice and some concern that it is not seamless. When you move from the Health Service to Social Services there is definitely a seam there.
  (Sir Alan Langlands) Yes. Well, there is a seam. There is no getting away from that. I am saying you have got to have an integrated health and social services system that works for the patients.

  19. What about the speed of the Department of Health to react to initiatives that actually require funding to get off the ground and to roll it out?
  (Sir Alan Langlands) Just on the seam point, which I think is very important, while we are trying to be integrated we are, make no mistake, operating with two cheque books. I am not here as the accounting officer for every social services department in the country, so we are operating with two cheque books. On the point about getting the initiatives off the ground and the two examples that you cite, the nine beds at the Cedars, you will find examples like that all over the country. These are the sort of things that are being funded by the £365 million for the 2000-03 period that is being applied to that issue. On the A&E issue, we are spending, last year and this year, as the report says, £115 million trying to improve not just the surroundings in A&E departments, but the way that they work and the way they function. A number of people are experimenting with the NHS Direct protocol to deal with, if you like, lower dependency cases that people turn up to A&E departments with. We are all frustrated at the speed with which these things roll out, but I think what this report shows is that when we do have good ideas, as we have measured here between 1997 and 1999, you can see tangible progress, and in a big complex system which has, let us face it, been through quite a difficult financial period, that is pretty good. Hopefully, with more resources and more commitment to drive at these good practice issues, we will be able to do even better.

1   Note by Witness: See Evidence, pages 1-4 and Evidence, Appendix 3, pages 25-26. Back

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