Examination of Witnesses (Questions 80
WEDNESDAY 29 MARCH 2000
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
(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.
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
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
(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 sectorsmaybe
not just social services, but the voluntary sector and the private
care sectorand 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 million7
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: They all are.
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
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
7 7 Note by Witness: The figure was, in fact, sixty
million, not six million. Back