Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 80 - 99)



  80. Has any estimate been made of the cost to the Health Service of those 170,000 failed operations? I accept your view that in the vast majority of those cases there is very good reason why that has happened. Is there any estimate of what that is costing and how you can save money from changes in practice?
  (Sir Alan Langlands) I do not have an estimated cost. The way we can, not save money, but make the best use of the money that is being spent, is to make sure that people turn up when they are supposed to. We have got to help people to do that and that is my task.

  81. Can I ask you one final question? In the report it talks about the need for, in particular, single sex wards and wards where there are specialty beds available. One of the issues that comes back to me as a Member of Parliament is where those sort of qualifications are breached because of the pressure on beds. How widespread is that and is it something that the Health Service is looking at to see whether they can improve practice?
  (Sir Alan Langlands) I think it is pretty widespread, or has been, but it is getting much better. We do have very clear targets to essentially eliminate mixed sex wards. I would say that two things are happening that are significant, one is that there is some physical rejigging going on to split wards up in different ways and create bathrooms et cetera. We talked about some of these information systems earlier and people are using these sort of real time information systems to schedule and profile patients into particular beds so that in a full bed day you can have a system that allows you to make sure that there are going to be four women there or four men there on a particular day. Good information, good management and some physical rejigging of the available facilities is what is going on at the moment.

Mr Gardiner

  82. I hesitate to suggest that you are making as many come backs as Frank Sinatra. It is very good to see you again and it is nice to know that you are living proof that the NHS has managed to effect resurrection as well. Can I just begin by asking you why occupancy rates are charted at midnight? I ask that in the light of paragraph 2.14, which makes it clear that at other times of day, for various reasons related to admissions and discharges and the consultant's rounds and so on, occupancy rates are substantially higher.
  (Sir Alan Langlands) This is where the old forces of conservatism kick in. They are counted at midnight because that is the way they have always been counted. That is the tradition but, of course, that tradition is based on the notion that that is the most stable point of the day. Having said that, I think clinical practice is changing at such a speed that maybe there is a case for looking at that. Certainly being measured at that time is not, as the report suggests and as the previous questions have suggested, going to pick up the point of peak pressure, which is more likely to be in the early afternoon, just after lunch time to 1 o'clock, where the morning effort meets the afternoon effort, meets the bulge from GPs' surgeries and meets the traditional bulge in emergency admissions from A&E departments. That is the critical point in hospitals now. The maximum pressure, if you like, tends to be between 1 o'clock in the afternoon and 5 o'clock in the evening. If you measured occupancy at that point—

  83. You would get a substantially higher figure.
  (Sir Alan Langlands) You would find there is greater pressure. People would not be in beds because there are only a limited number of beds there, but you would find them in other parts of the hospital.

  84. So the way of measuring it at the moment is actually giving us an under-estimate or a rosier picture of bed availability than is perhaps justified?
  (Sir Alan Langlands) I think the best thing I can say for the way of measuring it, given that it has always been done that way, is that we have a clear trend that we can see occupancy rates over time. It is giving us a rosy picture if we then try to convert the measure of occupancy into a measure of pressure. I accept that.

  85. Picking up on what Mr Steinberg was talking to you about earlier about beds and the National Beds Inquiry that was mentioned, what would you say a sensible level of occupancy would be? It seems to me that in our discussions this afternoon you actually made a case, perhaps against what one might have suspected, for saying, "Look, there do need to be these times of day when the nurses have less pressure and they are not having to cope with high pressure needs of patients", and in a sense you seem to be making a plea for, perhaps, slowing down the process.
  (Sir Alan Langlands) You can read it that way. The other thing you could say is that I made a case for having more nurses, which is the strategy we are adopting, and I think most are valid responses to the problem I have described. The average occupancy across the country is 81 per cent and there is somewhere between 80 and 85 that makes life bearable in the way that we run things at the moment. I guess that is where we should be pitching.

  86. That, of course, is on our slightly rosier figures, 81 to 85 by midnight assessment?
  (Sir Alan Langlands) Then you get into what I think is a much more interesting discussion about pressures in hospitals and the quality of care and staffing levels and the whole experience that patients have, rather than just trying to measure through-put and occupancy numbers. I think that is a very difficult assessment. There is absolutely no doubt whatsoever that the search for ever greater through-put has put a strain on staff which is not sustainable and, therefore, there will have to be more staff.

  87. Can I just pick up on the point that has been made by the NHS Confederation, who point out that the National Beds Inquiry talks of the correlation between successful bed management and the quality and access to acute care, namely the acute trust with access to well resourced alternatives being less likely to have problems with bed management. They contrast that with the approach that has been taken by the NAO where the acute sector has been looked at in isolation and the approach of this report which advocates a more intensive micro-management of the acute bed system. Do you believe that there is tension between what this Report has been pressing for on issues of micro-management and the National Beds Inquiry?
  (Sir Alan Langlands) I do not think there is a tension, but I think the NHS Confederation has a valid point, because what essentially they are dealing with here are two balancing acts. The first balancing act is the one that is described in this Report. It is balancing emergency workload, elective workload and, I would argue, critical care, which has not been mentioned this evening. The Report, I think, gives us a very good lead on how to improve the management of acute hospital activity and tackle these things in a sensible and straightforward way. It is not even comprehensive in relation to the whole hospital activity, because there is very little mentioned of day care in this Report. The other balancing act which we have touched on a lot tonight is much more interesting, I think, and much more difficult, and that is the balancing act between acute hospitals and the rest of the system, primary care, community support and the sort of intermediate care options that the Government has been talking about. That is the point that the Confederation are making. You have really got to think this issue through a whole system basis. You cannot take a partial look at it without getting yourself into a position where you intervene in one spot and you may create a problem elsewhere. That does not make this Report invalid because it gives us a whole lot of recommendations that we can act on and we can make better use of resources by acting on them. There is a much more significant and wider discussion here that I think is teased out in the National Beds Inquiry, and is certainly being teased out by people who are responding to it and who are experiencing this on a day-to-day basis.

  88. Picking up what you said in the discussion that we have had about discharge and social services and the liaison with local authorities on that, do you not think that it is a shame that 30 per cent of NHS trusts are still not employing discharge coordinators?
  (Sir Alan Langlands) Yes, I think it is, because I think link people work in the NHS. Good systems of chronic disease management work because there is a diabetic nurse that can join the hospital to the GPs and if there is a nurse or someone from the social services department working in a hospital who builds working day-to-day links with people in other sectors—maybe not just social services, but the voluntary sector and the private care sector—and in an active way manages these relationships, gets to know the people, builds trust and can call on them in times of trouble, that usually leads to practical problems being resolved in a commonsense way. I think if you get the right people and the right attitudes you can make a lot of things work.

  89. I am just trying to pick up on a few other areas where, perhaps, best practice is not as widespread as it might be. 28 per cent of consultants estimate the likely length of stay and there is only 24 per cent of consultants who estimate the length of time they expect someone to be in theatre. These seem obvious gaps in the system, but by providing that information management flows would be a lot smoother and a lot better.

  I suppose really my question is given the Government's 60 million that the Secretary of State announced yesterday, how is that 60 million that is supposed to be about the dissemination of best practice, the dissemination of these good ideas, and many of them have been highlighted in the report, going to be used to get those various pieces of best practice filtered down throughout the whole system?
  (Sir Alan Langlands) I suspect not just in relation to the six million[7]7 but part of the 660 million announced yesterday, in relation to some of the balance of extra money that is going to be given to the Health Service, I think we will see much clearer attempts than we have done before to incentivise people to adopt good practice and, if you like, to reward the uptake of good practice and a challenge financially in the failure to take up good practice. We have a number of discussions going on with Ministers at the moment about how we can make that work in a practical way that is fair and that avoids any perverse incentive and all the rest of it, that can actually take up the challenge of using this money by encouraging best practice. The whole question of incentive structures is something that we are looking at at the moment.

  90. Can I just pursue that with you. You have raised the issue of financial incentives here. Certainly in recent conversations with health care workers in my own constituency who came into the House the other day for a reception we spent a lot of time talking about the stresses that there are on GPs and primary care groups and the sense in which clinical governance and the drive for dissemination of best practice was imposing an incredible pressure upon doctors, such that they felt one more initiative and they would not be able to cope. Do you think that it is simply a matter of incentivising GPs and primary care groups? Certainly the people I spoke to desperately want to be following best practice but the actual demands of the process at the moment and the setting up of protocols and so on are really quite tremendous, are they not?
  (Sir Alan Langlands) They are onerous, it is a whole new territory. Money is not the only thing that incentivises people in the Health Service. For people in the Health Service their main incentive is doing a good job for their patients, that is what they want to do. The trouble is when the pressure is on and people, with justification, are demanding a 24 hour service, some of the things that you might do in other sectors are not so obvious or available. If John Lewis want to introduce a new system of customer care they close down on a Tuesday morning to retrain their staff. That is not so easy, particularly in your GP example, when people are distributed over dozens of practices in your local area. Unless people have time to assimilate these new ideas and work them through on their own terms and are supported perhaps by money or persons to do the clerical work associated with the systems, money to support the development of systems, it just will not happen. Therefore, if the target is to improve the quality assurance, as the Government's target is, you might then have to step back a little bit and say "in order to do that we are going to have to compromise on throughput and productivity, we need a brand new product here". That is the way it is going. With a bit more money in the system we will see investment in these development activities because they have got to work. The notion that you can have a static distribution curve of competence or quality in the Health Service and you are not constantly trying to move it to the right is not one that can be accepted.

  91. Can I ask you one final question. Why do you not keep data on operations that are cancelled prior to admission? Why do you not keep data on operations that are cancelled on medical grounds? It seems to me that they are a genuine part of the distress to patients that could be avoided.
  (Sir Alan Langlands) An explicit decision was made by previous Ministers in relation to the Patient's Charter to deal with this single issue of non-medical cancellations on the day. I accept there is a case, and we are trying to understand more about that, but we are dealing with millions of transactions. These patients, millions of patients, are not a homogenous group. There will be very precise medical reasons why a particular operation is cancelled. It might be to do with being unable to cope with an anaesthetic, it might be to do with a justifiably conservative approach to treating that person where they say "he is really a bit better, I do not think we will risk an operation at this point". These are very fine judgments that certainly cannot be taken remotely from the relationship between patients and their doctors or the nurses who are looking after them.

  92. That would not apply to prior cancellations.
  (Sir Alan Langlands) My question is then if we did collect all of that data, what would we do with it? The important thing is that people locally understand these issues and begin to question them, "is there something wrong with my practice that I keep having to cancel this" or "my colleague seems to have more success in dealing with this sort of patient". That is at the heart of the Government's medical audit and all of these other things. If we tried to do these things from Whitehall I suspect that we would get into terrible trouble.


  93. A reminder on brevity, Sir Alan.
  (Sir Alan Langlands) These are very interesting issues, Chairman.

  Chairman: They all are.

Mr Wardle

  94. Sir Alan, hail and farewell act two or three. By the time you have been sitting as Vice Chancellor in Dundee, the little bit of extra money you have talked about will have been spent and you will be able to reflect on whether the strong indications of progress that you have talked about have materialised. We shall see. I hope they do. Can we stick with cancelled operations. Is there a difference in the analysis of these things between cancelled and postponed? If something does not happen on the appointed day is that a cancellation even if it happens the following week?
  (Sir Alan Langlands) That is referred to as a cancellation and then the challenge is to ensure that person is given another date for admission within a month of the day of cancellation.

  95. But if they are that is still a cancellation so far as the statistics are concerned?
  (Sir Alan Langlands) So far as the 56,000 figure in this report is concerned, yes.

  96. What was the recent experience immediately after the millennium holiday put down by many trusts to an outbreak of the flu, although that is an annual occurrence? Was there a surge in cancellations as you have just defined it?
  (Sir Alan Langlands) There would be. I quoted the quarter three figures earlier, the quarter four figures will show a similar—

  97. You do not have any figures for that yet?
  (Sir Alan Langlands) I do have them.

  98. You cannot tell me what the trend was?
  (Sir Alan Langlands) I do have the January and the February figures but I am not going to tell you what they are because the Government has not announced them. The trend in January was a slight increase in—

  99. What do you mean by "slight"?
  (Sir Alan Langlands) More than last year by roughly the figure that I quoted earlier which is somewhere between 800 and 1,200.

7   7 Note by Witness: The figure was, in fact, sixty million, not six million. Back

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