Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 40 - 59)



  40. The question really is whether the ESAT recommendations were carried out in respect of their commending the Shrewsbury system which has won your Beacon Award and which now the National Audit Office commends two years later.
  (Sir Alan Langlands) Okay, but—

  41. I can tell you what the consultant told me earlier and that is that the scheme is not being piloted elsewhere, there is no indication that it will be piloted elsewhere. What I would like is an assurance from you today that you will look at how to pilot that in four or five other areas.
  (Sir Alan Langlands) I am perfectly happy to concede, as I have done in signing off this report, that improving information systems is a key objective in improving bed management. I cited earlier in discussion with the Chairman a system in Aintree that spans the whole of Liverpool which is very different in nature in terms of workload from Shrewsbury which is working perfectly well for the people there. The people there do not want the Shrewsbury system airlifted in against their will. They have developed their own system which works with the rest of their hospitals in a way that allows them to manage their very complex workload. To suggest that these things can be dictated from the centre of a big complex organisation is fallacious.

  42. Is that not the advantage of piloting schemes?
  (Sir Alan Langlands) We are piloting schemes, we are piloting all sorts of things, but that does not mean to say that we are engaged in cookbook management, trying something in one place and insisting that it has to work everywhere else.

  43. What we have got in Shrewsbury is a system which is as good as an airline booking system where cancellations are brought down to a minimum. We have got a system that is being looked at by the Cardiff Business School, which of course advises car manufacturers and other companies of state of the art production, your Liverpool system, where else is that one being tried out?
  (Sir Alan Langlands) Where else is it being tried out?

  44. Yes.
  (Sir Alan Langlands) It does not matter where it is being tried out, it works in Liverpool. The people there are standing in the operating theatres and on the wards singing its praises, it works for them. It has allowed them to work through this winter in a way that would have been unimaginable two years ago.

  45. How do you get the Liverpool and the Shrewsbury systems into other areas?
  (Sir Alan Langlands) You tell people about them, you allow them to visit. You allow them to think about these things in their own terms and you allow them to either, as they might do in some cases, pick them off the shelf or in other cases to develop their own systems. You can have diversity and still get a result, that is my first point. My second point is you used the term "airline booking system", the Government is funding 60 pilot schemes on outpatient booking.

  46. Outpatient booking systems are different.
  (Sir Alan Langlands) No, they are not. Booking people in from an outpatient department to a hospital on a particular day, profiling work, scheduling that work, scheduling the theatre time and doing all of these things is exactly what they are doing in Shrewsbury. I am merely arguing that there is more than one way to skin a cat.

  47. What you are also suggesting is that the way to do this is by saying "here are some good examples, off you go, we hope you will do it", but I do not think the Prime Minister would have had a summit this morning if he did not feel there was some resistance to spreading some of the best practices which this NAO report suggests and which I do not think followed dramatically from the previous report that we talked about, the 1998 report.
  (Sir Alan Langlands) I do not want to criticise the system, but there is not one silver bullet that solves the problems of the whole of the NHS. The Prime Minister is well aware of, because I have discussed with him in detail, the progress that is being made in the 60 out-patient pilots and booking pilots, the so-called airline schemes that you suggest. He is very supportive of what is going on there. He was hearing directly about them not so long ago from the people who are providing them. He understands exactly what we are doing and is very supportive of the efforts that are being made through the Learning Network, through the use of reports like this and the Audit Commission Report to provide good practice in the Health Service. He knows, because we have discussed it, that sometimes that needs top management. He knows that it needs learning from others, because you do not just change the behaviour of a million people working in the Health Service by telling them what to do. He knows it needs expertise from the specialist teams who have been supporting people to make these changes. This is complex change, that is all I am saying.

  48. I think that it would be good to have examples from you of what pilot work is going on on this and what groups of hospitals are sharing similar pilot systems. You have given us stand alone examples and I do not call them pilots.
  (Sir Alan Langlands) I have given you an example from Aintree and I can give you details of the six day pilot booking systems[3] and you can think about them and look at them in detail. They are well written up and they have been properly evaluated. This is a professional process of trying to achieve change in a very complex area[4].

Mr Steinberg

  49. I am going to argue this on Old Labour lines and support the Prime Minister and the Chancellor of Exchequer when basically and fundamentally the problem is lack of resources and the only way to resolve that is to increase resources. Mr Campbell touched on it when he said that beds had fallen from something like 200,000 in 1986 to 138,000 in 1997, which is a loss of 62,000 beds. For 13 to 14 years, Mr Langlands, I have gone to my health authority and they have told me each year that they have had to have efficiency cuts and cost improvements of 3 per cent a year. If that is not a case where we have seen a reduction in beds, then I do not know what is. If those efficiency cuts and cost improvements had not actually been requested, would we be needing this report this afternoon?
  (Sir Alan Langlands) I think you have a good point. I think there is an absolutely clear and proven case that the Health Service needed a lot more money and it needed more money on a sustained basis.

  50. Why did you not say that two years ago?
  (Sir Alan Langlands) No one has argued stronger and harder for more resources than I have for the NHS, that is the first point. The second point, however, is that I do not think you can just wish away all of these reductions on that basis. More than 60 per cent of all the operations that take place per year—3.5 million—are now happening on a day case basis. That does not mean that we need the same number of beds that we used to. I think there are swings and roundabouts in this discussion. I accept your point about resources. My focal point in this is about services for older people and stretching the elastic of acute services to cope with these tougher and tougher waiting list targets, but there is another side to the argument and practice has changed as well.

  51. I actually think that you substantiate my argument when you argue the way that you are arguing, because if you are saying that 60 per cent of operations now take place on a day basis, if the beds had not been taken away in the first place there would have been plenty of beds for those people who had to go into hospital and could not have day surgery, you would not have the situation that you have now. In the 70s you had something like 70 per cent occupancy of beds and now you have something like 90 per cent occupancy of beds where there is absolutely no slack at all. What you are saying is that if the progress has been made in terms of day operations, then you would still have the occupancy of, perhaps, less than 70 per cent with those particular beds and, therefore, you would not have the problems you have today?
  (Sir Alan Langlands) I agree with that, but if I was sitting here with the bed occupancy rate across the NHS of 65 per cent and the PAC was doing its job and looking at the international comparisons, you would be saying that I am wasting public money and that the NHS has too many beds. You cannot operate at 65 per cent, just as you cannot operate at 95 per cent effectively. I am accepting that you have a point, but there is another side to the story. If you wanted a gallbladder operation 10 years ago, you were in hospital for 11 days. My next door neighbours, getting their gallbladder operations in the last few months, have been in hospital for five and half days. There are changes in practice that you have to take into your equation.

  52. Absolutely, but perhaps if that had taken place over a period of 10 years rather than 20 years, and it had not been 3 per cent a year but one and half per cent a year, then you could have had a situation where beds would have been reduced but not to the extent they are being reduced now and we would not have the problems that we have today.
  (Sir Alan Langlands) That may be true in part.

  53. Can we move on to the PFI schemes? How many beds have actually been lost because of PFI schemes?
  (Sir Alan Langlands) I am afraid I do not know the answer to that question. We may have used that number in the Dartford and Gravesham survey. I can certainly give you the number if that will be helpful[5].

  54. It is argued that the number of beds have not actually been reduced by PFI schemes, and it has been argued that health managers and independent experts actually make the judgment on how many beds there should be in hospitals, but we all know—particularly in the one that I was involved with—that the financial consortium was calling the tune and it was basically saying, "You have so many beds, and if you do not have that amount of beds, which is a reduction, then there will be no scheme." We have seen a reduction, I suspect, because of the financial issues rather than the actual need in these PFI schemes.
  (Sir Alan Langlands) We may have done, but I sat here not so long ago with the managers for Dartford and Gravesham and they said, "Yes, of course we are seeing a reduction in the number of beds", but the woman from the health authority was also able to tell you about all the other community based schemes that they were developing to support that very group of patients that I am worried about, all of the people that spend time, perhaps sometimes unnecessarily, in acute hospitals. Again, this is not always a black and white argument, but we can give you the numbers.

  55. It will be interesting to know how many PFI schemes have gone ahead on reduced numbers and how many PFI schemes would not have gone ahead if the managers and the so-called experts had not agreed to reduce the bed numbers, but I suppose that is impossible to tell us?
  (Sir Alan Langlands) I can give you the numbers, but we are talking today about the importance of a whole system. You also need to know, if the numbers are reduced, whether or not there has been compensating increase in other services to make good that shortfall in numbers. We can give you as much information as we have.

  56. This report is an excellent report, as it always is by the National Audit Office, but I have got the impression that it was a bit of a red herring really, because it was solving the problem as it is now. I must get back to the fact that there should never have been a problem there in the first place. We have seen bed numbers falling by 2 per cent every year since 1980 and admissions rising by 3.5 per cent every year since then. It is so obvious what is happening, and the report seems to deal with how you fiddle around with the management of beds and have bed managers and God knows what else, when at the end of the day what you really need is more beds. You would not need a bed manager if there were more beds, would you?
  (Sir Alan Langlands) I think we might need more services, and I think we might need more services particularly for older people, but I do not think they necessarily need to be based in expensive acute hospitals. The sort of pattern and the numbers that you described are the sort of things that have been happening in other developed countries in the acute sector. I think some of them have been smarter at compensating for that by developing a wider range of community based and home based services. These are often services that against the mighty battalions of big hospitals do not get much of a shout when it comes to tough resource allocation decisions or when monies are short. You can sometimes see these services being eroded. I think that penny has dropped and the need to invest in that area is something that is now being looked at in a very serious way, more serious than I can remember.

  57. That is fair enough. When I read the report I got the impression of a bed manager scuttling around looking for a bed somewhere, if not in his own hospital, in another hospital, and I thought to myself that just typifies the fact that there has not been enough resources. Thankfully, the Government has now decided that there will be enough resources, so possibly we will not have those problems again. Can I move on to something which is totally different, and it is on the periphery of the report really? It is page 75. It is a hobby-horse of mine that I have had now for quite a while. I have written to the Secretary of State, I have talked to doctors about it and I have talked to the local trusts, but nobody will listen to me at all, and I am hoping that you will listen this afternoon. It is to do with waiting times for out-patients and consultations. It started when I got a constituent who came to me with quite serious problems. His eyes were streaming and he could not see. He said to me, "I have got an appointment with the consultant in 26 weeks' time." I said, "Good God, 26 weeks? You are going to have a problem with 26 weeks looking like that. You should really see a doctor." What I said was, "Leave it to me and I will have a look at the list." I have had these lists for the hospital consultants for nearly 13 years. The Chairman, Peter Carr, of the old Regional Health Authority in Newcastle used to issues these lists and he used to say, "Don't tell anybody I am doing it." Now you can get them. It is no longer a secret.
  (Sir Alan Langlands) Freedom of information.

  58. Anybody can have them. I went back to the list and I noticed that this gentleman had been sent to a specific consultant in a hospital in Durham and if he had gone to a hospital two or three miles the other way he could have seen a consultant in about 10 weeks. I said, "Go back to your doctor and demand to go to that hospital." He went back and I had a letter two or three weeks later saying, "Thank you very much. Fantastic news, I went back to my doctor and the doctor has now sent me to Sunderland Eye Infirmary and I am going in nine weeks, rather than 26 weeks." I then got the most disgraceful letter from the doctor telling me that I had destroyed the patient/doctor relationship and I should mind my own business. I wrote back and said, "I have not destroyed the relationship, you destroyed the relationship by not giving the person the truth in the first place." The point that I am trying to make is that if you look at these lists, and I am not going to take you through them, if you take general surgery in Durham, Mr Herring in Dryburn Hospital has a waiting list of 44 weeks whilst Mr Mason at Shotley Bridge hospital, which is in spitting distance, but the same trust, has a waiting list of nine weeks. You have another situation in ENT, Miss Heaton of Dryburn has a 20 week waiting list and Mr Cameron at Shotley Bridge has a four week waiting list. The worst one is a gentleman who wrote to me and had to wait 90 weeks to see a neurologist at Dryburn Hospital. I told him to go back to his doctor—by the way, the same doctor—and demand to go the RVI in Newcastle, and could be in in 13 weeks. 90 weeks to 13 weeks. Why is it that doctors and trusts seem to insist that everybody sees the same consultant when you have other consultants in the same hospital, in the same trusts, with no waiting list at all? If you were to send half the people from one consultant who has a 44 week waiting list down to the one that has got no waiting list, you halve the list. Nobody does anything about it.
  (Sir Alan Langlands) It is very difficult to defend such a strong point, but—

  59. It happens in Durham and it is happening all over the country.
  (Sir Alan Langlands) Might I just make one point? There are instances where people have very long waits where they are waiting for the one person in the area who has a particular expertise, a highly specialist skill, might be the only person in the region, maybe the only person in the country, I do not know, and I can think of examples of that. The point you make is a fair one. My answer is that sort of information is available to GPs.

3   Note by Witness: There is a sixty pilot booking system, not a six day pilot booking system. Back

4   Note: See Evidence, Appendix 1, page 22 and Appendix 2, page 24. Back

5   Note: See Evidence, Appendix 1, page 22. Back

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