Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 20 - 39)



  20. Why did 170,000 people fail to turn up in 1998-99 for their operation? Has the Department done any research as to why people failed to turn up?
  (Sir Alan Langlands) Again, there is a dreadful phrase which is used in relation to these people, which is "Did not attend", "DNA." If you are 70 years old and not feeling very well and not able to get to the hospital in the way that you thought you might be three or four months earlier when you had your out-patient appointment, you ring in and you do not go.

  The first point is I do not want to get into a position where we assume that the patients are confounding the system because there is often good reason for these delays. That is 170,000 on millions.

  21. How far is the Department actually looking at some of those issues and trying to address them?
  (Sir Alan Langlands) We have looked at them and there is mention in here of the National Patients Access Team who have been working on these very issues. We can see improvements. I think the case study in here from Birmingham Heartlands Hospital is a very good one. You can see it is often a very simple improvement if you just phone people two or three days in advance and remind them or drop them a card saying "you will remember you have a hospital appointment on X day, bring Y with you". Often when there is a delay between either a GP referral or someone attending the outpatient department, people do forget. That is the first thing to say. The second and, I think, more important thing to say is that the real way to deal with these issues is to improve the system of booking so that people are actually booking more at their discretion and in conjunction with the doctors concerned, booking with the outpatient department when they are in the GPs, booking their hospital operation when they are in the outpatient department, and then having a system that throws up two or three days ahead a reminder of these things. Imagine this is an electronic system. That is actually working in a number of parts of the country. We are funding 60 pilot schemes to help that process and all of these new systems are beginning to show improvements on the figure that you rightly identify as a fault in the system.

  22. Finally, when your successor seeks your advice on priorities, will you be saying that while there are clear signs of progress the reality is that for all sorts of reasons bed management has not been given the priority that it should have been given in the first place?
  (Sir Alan Langlands) I think in the last two or three years it has been given a priority and I think we are seeing real and tangible improvements. I would cite the new-ish ideas in here, like pre-admission assessments and admission on the day of an appointment. There are things where we can improve. I think of these things as I did about day surgery ten years ago. Ten years ago there was hardly any day surgery, now 60-plus per cent of the operations in the Health Service are handled on a day case basis. With the right investment in people, in new ways of doing things and in the facilities needed, there is no reason why we cannot take this practice and move it on over the next few years.

  Mr Campbell: Thank you.

  Chairman: Sir Alan, I know these are complex issues but can I ask you to be a little briefer in your answers.

Mr Griffiths

  23. Sir Alan, I think that all Members of Parliament have constituents whose operations have been cancelled by hospitals and it is a complaint that we all get. Why is this not taken more seriously?
  (Sir Alan Langlands) It is taken very seriously but, as I explained earlier, we are having to make difficult choices within constrained resources. Let me just repeat what I think is a very dramatic example. The number of cancellations in the last quarter up until New Year's Eve of 1999 increased from last year by 1,350 and in that same period the number of emergency admissions, ie things that were unstoppable, that just had to be done, increased by 11,400, nearly ten times as much.

  24. Tell me this, Sir Alan, on your own example here, and you mentioned the Shrewsbury project.
  (Sir Alan Langlands) Yes.

  25. Why did those emergencies not impact on Shrewsbury? Why did they handle the flu epidemic so well?
  (Sir Alan Langlands) They do impact. Through the system that we have been promoting and they have developed—

  26. We are going to come on to how it is being promoted.
  (Sir Alan Langlands) They are able to do better than some but there are other people doing equally well.

  27. What they are proving, it would seem to me, on your example is that where there is a crisis the cancellations do not shoot up as much as they might shoot up.
  (Sir Alan Langlands) I agree with that.

  28. Shrewsbury shows that they do not have to shoot up at all.
  (Sir Alan Langlands) They do shoot up a bit. I am sure if you look at their waiting list figures during December and January you will see—

  29. You are moving from waiting list figures to cancellations.
  (Sir Alan Langlands) That is the problem in this whole business, you punch the pillow in one spot and it bulges out here. You cannot have it all ways.

  30. You think it is bulging in Shrewsbury?
  (Sir Alan Langlands) Of course it will bulge. If their emergency workload goes up and they have got fixed facilities their elective workload will have gone down. They are very much cleverer at scheduling the workload but I can assure you during their very busiest periods their waiting lists will have gone up. Probably by now, like the whole of the rest of the NHS, they are getting them down again. You cannot have it all ways within fixed resources, that is the simple point I am trying to make here.

  31. About two hours ago I spoke to the gentleman you were commending so much and what he told me, and what he has also put in writing[2], is that when the hospital had to cope with that prolonged flu epidemic actually the median wait for cancelled patients was held steady at around two weeks. So we have an example there where the impact was not to shoot cancellations through the roof, in fact it did not have any impact.

  (Sir Alan Langlands) There will be other reasons for that, the number of people waiting. I do not want to criticise Shrewsbury, my goodness we have just given them an award for doing something very good.

  32. The NHS Beacon Award.
  (Sir Alan Langlands) I think they are doing an excellent job in Shrewsbury but I make the simple point that when resources are finite some people can use them to better effect than others, and they are doing that, but there is still a bulge somewhere in the system.

  33. Let us look at how valuable that experience is. They got a Beacon Award, but how good is your body at disseminating the ideas that lead to a Beacon Award and how have you done it in Shrewsbury's case?
  (Sir Alan Langlands) We have got a very good database of good practice with thousands of entries which is—I hate using the jargon—part of something called the NHS Learning Zone. People working in the NHS can electronically tap into examples of good practice and you will see all of the Beacon Awards there, not just in relation to waiting lists but in relation to employment practice and everything else. Shrewsbury will be there in lights so people can learn from that. That is the first thing to say. Secondly, we do have a National Patients Access Team. The leader of that team, who is a member of the advisory group here, is the person who arrived in my office, arrived in the Department of Health, and said "you have got to see what they are doing in Shrewsbury, it is excellent, we have got to support that". His team have been going around the country and finding people who are in difficulty, not able to resolve the problems that you have described as well as they are doing in Shrewsbury, and have been advising them on how they can develop such a system and improve things in their patch.

  34. Why do they have to develop the system, why can they not just take it from Shrewsbury?
  (Sir Alan Langlands) They can take a system but they might not have the same host system to plug it into. You cannot just lift these things and replicate them three or four hundred times around the NHS, I am afraid life is not as simple as that.

  35. Do you understand the consultant's—Andrew Hay's—frustration that a system that has taken him 12 years to develop and is proven and award winning is not being piloted elsewhere?
  (Sir Alan Langlands) It is wrong to say systems like that are not being piloted elsewhere.

  36. What is the closest one to it that you would commend him and us to look at?
  (Sir Alan Langlands) There is probably a good system in Heartlands and, if I remember, I think there is a system in Darlington or Durham, somewhere in the North East that I have seen.

  37. Are these pilots or have these sprung up independently?
  (Sir Alan Langlands) Some of them have sprung up independently. Andrew is one consultant in 26,000. I am sure he would be the first to recognise that his system is not going to work by magic just by plugging it into every hospital in the country. All the behaviourial issues that support that system, the way in which they are organised, the way in which they do things, have to be translated as well, it is not just a box of tricks.

  38. And the Emergency Services Advisory Team I understand did translate it. They looked at the problem of bed management after the 1997 problems, they completed a survey of all the bed management systems in the United Kingdom and recommended that the Shrewsbury system should be piloted in other hospitals and that has not been done, why not?
  (Sir Alan Langlands) I think it has been done.

  39. There is no think about it, just tell me the ones it is in. He does not know. Funny that the man who invented it does not know.
  (Sir Alan Langlands) As I understand it the man who invented it has been working with a firm who supply patient administration systems to the NHS and it is likely that people who have these patient administration systems, which is not the whole of the NHS, nor indeed the whole group in this study, will begin to develop that system. It is also the case that the NAO cite that there are other information systems around the Health Service in their report, they do not say Shrewsbury is the only place that has got it, and it is also the case that this report is absolutely peppered with examples where the position has improved between 1997, the ESAT Report, and 1999, the end period of this study. To suggest that somehow we are sitting on our hands, I think, is wrong.

2   Note: See Evidence, page 2; see also Evidence, Appendix 2, page 24; Evidence, Appendix 3, page 25. Back

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