Examination of Witnesses (Questions 60
- 79)
WEDNESDAY 29 MARCH 2000
SIR ALAN
LANGLANDS
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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