Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 60 - 79)



  60. When I asked the GP he said he did not have time to look through the lists.
  (Sir Alan Langlands) That information is available to GPs. I can envisage a day, and maybe it is not too far off, when that information will be publicly available.

  61. It is.
  (Sir Alan Langlands) Publicly available, not really if an old regional chairman has given it to you.

  62. I said the regional chairman gave me this information 13 years ago but now it is free to anyone who wants it, you just phone NHS Direct and you get it.
  (Sir Alan Langlands) There you go.

  63. Why do the doctors not get it?
  (Sir Alan Langlands) The doctors do get it. I am absolutely sure that your GP has got it and uses it and I am absolutely sure that the GP you referred to, and GPs in general, will be confronted with patients who not only have information about waiting times but information about their clinical condition and say "this is what I want to happen and this is who I want to see".

  64. As one of your last deeds as the Chief Executive, I do not know how you would do it, would you try to impress upon doctors that there are consultants, for example in cardiology in Durham, Dr Cave, Dryburn, 16 weeks waiting time to see him and in the same hospital, down the corridor, Dr Terry, no waiting list at all, and yet people have been asked to wait 16 weeks simply because the doctor says "you must see Dr Cave". If he said "there is Dr Cave and Dr Terry, one has 16 weeks, one has no waiting list at all, who would you like to go to?", I know what I would say.
  (Sir Alan Langlands) I agree with you. I think that doctors should use that information. Without introducing a discordant note I would argue that GP fundholders did precisely that and it was not popular. They used that information and they used it aggressively and they backed it with money and the services for part of the population improved as a consequence.

  65. The doctor who told me off was a fundholder.
  (Sir Alan Langlands) There you go, maybe he was not a very good one.

  Chairman: Mr Steinberg is now down to zero minutes.

  Mr Steinberg: As usual.

Mr Love

  66. Good afternoon, Sir Alan. It is very nice to welcome you back so soon after I wished you goodbye at the last meeting. Perhaps you can tell us when your actual last meeting is and then we can wish you well on your future appointment at Dundee.
  (Sir Alan Langlands) I am afraid I am in your hands on that one.

  67. You should not have said that. On page seven of the report, talking about occupancy levels, the report indicates, and you talked about it earlier on, that any level above "85 per cent can expect to have regular shortages and periodic bed crises". I know you have signed this report but in your view is that 85 per cent an accurate figure?
  (Sir Alan Langlands) It is a figure that people in the Health Service use and it is borne out by experience. I do not have the reference, it is probably in the bibliography here. There is some quite good research that backs that figure and I assume the NAO drew on that research. There is good data that supports that point, yes.

  68. You will be aware of the concern that has been expressed in the past about measuring that occupancy level at midnight rather than at another time during the day.
  (Sir Alan Langlands) Yes.

  69. Would you recognise that by doing that the figures may well be under-estimating the true level of bed occupancy and, taking up the point Mr Steinberg was mentioning earlier, in fact the efficiency savings have gone much further than perhaps would be desired?
  (Sir Alan Langlands) They may be an under-representation—again, I hate to use the jargon—but the jargon in the report talks about improving efficiency by having what are referred to as admissions lounges and discharge lounges, ie that people can be assessed and made ready for their operation in something that is not a bed and they can wait in something that is not a bed to be taken home. So there is often on a very busy day, especially with lots of routine operations rather than complex things, a situation, if you take it to this extreme, where there is someone in the admissions lounge, someone in the discharge lounge and someone in the bed, in other words three people in one bed. The report says that is good practice but it is an indicator of how productive the system has to be to cope. I made a point earlier about staffing and the importance of that. It may be a good thing to have a discharge lounge, to have people in comfortable surroundings before they go home, but there is a point post-operative or just before discharge where the patient is not terribly dependent and when that patient is not terribly dependent they do not need as much care and attention from the nurses on the wards, so they have a bit of a breathing space, if you like. If these people who are whipped in and whipped out and constantly going through the beds are people of high dependency, the staff do not have breathing spaces. I think that is a crucial issue. In terms of thinking about reductions that have resulted from efficiency savings, I do not necessarily always want to count that in terms of bed numbers because I can explain these away by changes in practice, more day care and all the rest of it. I do count it and I do see it when I go round the Health Service in terms of pressure on staff. Undoubtedly these reductions and these changes in practice and this desire to achieve ever greater throughput in the system has affected the workload of the staff and has created a situation where some people, to put it bluntly, are just having to work too hard. If we are going to make an intervention to ease this position, the intervention in my book should be about improving staffing levels and it should be about resolving the problem we discussed earlier in relation to older people.

  70. Can I sum all that up by saying on the balance of judgment, rather than having these improved information systems that are talked about in this report, you think that perhaps the problem is more fundamental and it is to do with bed numbers, staffing and other issues?
  (Sir Alan Langlands) Yes. I think there are fundamental problems in the Health Service that are to do with staffing and bed numbers, particularly in relation to older people, which hopefully now we are in a position to resolve, but I do not want to sit here and say "and, therefore, discharge lounges or innovative schemes from Shrewsbury or recommendations from the NAO on bed management are bad things". I think we have to make the best use of what we have got.

  71. I understand that but the reality is this Committee is charged with finding value for money and I want to come back to finding out whether some of those things are value for money. I want to ask you about the Beds Inquiry and it is on page 36. This really arises from what you said earlier. Right at the foot of the page it says "A key issue in the Inquiry has been assessing the future need for acute hospital beds by older people, and the scope for alternative models of care, including the further development of community and intermediate care services". You touched on that earlier on, but what does that mean?
  (Sir Alan Langlands) What does it mean? It could mean—

  72. You talked about it in terms of a partnership earlier on, is that what you are talking about?
  (Sir Alan Langlands) It could mean putting together groupings of health and social care professionals who can support people in their home. It could mean that highly skilled health professionals could visit people at home post-operatively and look after them. It could mean creating teams of occupational therapists and physiotherapists at a local level who would help people through their period of rehabilitation.

  73. I think you have illustrated that. I am sorry to interrupt you but I know my Chairman will be knocking on my door in just a few moments and I would like to move on. You mentioned earlier on about your target of a 30 per cent reduction through the £365 million programme of partnerships. The point that raised in my mind is in effect it is the Health Service subsidising Social Services because of lack of adequate provision through local government. You talked about the seam. You talked with Mr Campbell quite a lot about the seam between the Health Service and Social Services. Is that seam in exactly the right place or should that seam be removed somewhere else? Should the part of the work that is currently done by Social Services actually be done by the Health Service?
  (Sir Alan Langlands) Or vice versa some people say. No matter where you draw the boundary you are going to have a division.

  74. I understand that but could we draw the boundary more effectively to deal with the problems currently in the Health Service?
  (Sir Alan Langlands) We could certainly lay down some ground rules that avoid the nonsense of having people in health authorities and local authorities having a spat over who is going to fund a daily visit to someone to help them with getting dressed in the morning and being bathed properly and all the rest of it. I think that in 2000-01 that is an absolute nonsense. Taking a harder look at that and shifting the boundary between health and social care has one huge political elephant trap and that is that Social Services departments and local government have the ability to charge and the NHS is free at the point of delivery. If you redraw the boundary you can be accused of one of two things, either unloading NHS costs on to local government or creating a tension in lodging that charges should be introduced for certain parts of NHS care. I think that would be very difficult. What I would argue for is commonsense. The other thing we have got to be very careful about is that it is other things that happen in local government that affect social care budgets rather than anything that happens in the Health Service. If the Government has a priority in favour of education, Social Services' budgets might suffer and, therefore, the Health Service picks up the backlash of that. It is a very difficult balancing act and it varies in a hundred places around the country about where these lines are drawn.

  75. That is the problem that has happened in my local area and I know in many others. The word "partnership" is not one that can be used too much with the Health Service and Social Services.
  (Sir Alan Langlands) I think that has improved enormously.

  76. I believe you are right, that has improved greatly but there is still a long way to go and it may well be that a different boundary may be a more appropriate approach to that. I want to come on to this issue about whether the developments in IT were good value for money. I do not know whether you know the local situation in Shrewsbury but, since we have talked about that, to what extent would you say that the good practice in Shrewsbury is due to the excellent IT system, or is it that they have got excellent Social Services and aftercare for elderly people?
  (Sir Alan Langlands) I think it is probably a mixture of things. I do think that it is a good initiative. I have probably revealed pretty comprehensively already that I do not know enough about Shrewsbury, so let us not go down that track again.

  77. According to a letter that we have received the cost of introducing the Shrewsbury system is 450K with an annual cost further on of 110K. Would you say that is good value for money[6]?

  (Sir Alan Langlands) I do not know. You have got information that I have not got. If you give it to me and if I have the advantage of speaking to the consultant concerned two hours before the meeting I will come back and give you a considered answer. It is a bit of a one-sided discussion, I am afraid, when you have got information that I have not got.

  78. I would ask you for a note on that but perhaps that is not appropriate at this time.

  79. The report talks about the number of patients who do not turn up for their operations. This was brought home to me very vividly when I was asked to go and speak to my local hospital. The major issue that all of the consultants raised with me—I was there to adopt a high power policy on health matters—was people not turning up for either consultations or, indeed, at operation stage. They see that as a major problem within the service and a major inefficiency. You mentioned earlier that you had been doing some work, if that evidence is coming back to you why has more research not been done into the reason why this happens? I certainly do not want to suggest for one minute that this is not a sensitive issue and a difficult one, but are there ways in which you could improve that situation?
  (Sir Alan Langlands) Sensitivity is a part of this. There is a lot of practical work going on to try to improve on that situation and there is a balance to be struck between some of the rights and responsibilities here. I think it is fundamentally wrong to blame the patients. Equally, I think it is fundamentally wrong to say that patients do not have a responsibility. If you and I were going for a hospital appointment, 99,000 times out of 100,000 we would know that we have got to go. There may be good reason for that. If not, we have found that ways of reminding people help enormously, that explanatory leaflets help people enormously and there is a lot of good practical information and good practice that we know we could extend into other parts of the Health Service. We are trying to do that.

6   Note: See Evidence, page 2 and Evidence, pages 3-4. Back

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