Examination of Witnesses (Questions 20
- 39)
WEDNESDAY 29 MARCH 2000
SIR ALAN
LANGLANDS
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
| 
