Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 120 - 139)



  120. Into their contracts, yes.
  (Sir Alan Langlands) And into their contracts. If they abuse their right to undertake private practice in any way they can be held accountable and there have been one or two recent and dramatic cases where that has happened.

  121. I must say, Sir Alan, I do not object at all to the principle of private care for those who want it, I just wonder to what extent it dovetails neatly into the management of all this.
  (Sir Alan Langlands) I think it is very important, and a lot of people do not recognise that the vast majority of elective surgery that is undertaken in the private sector is undertaken by people who are contracted to work in the NHS. This has to be taken into account when one is thinking about flexing the relationships across that boundary.

  122. Can we go on to bed management. Appendix 5 is interesting in this Report and from page 41 on to paragraph 2.19. There have been a number of questions from colleagues on this. You said that it is very important that bed management has the support and endorsement of senior management, which seems thoroughly sensible. What is the profile of the bed management star? Who is doing this job? Where have they come from within the NHS to do this job?
  (Sir Alan Langlands) Some of the key ingredients are that they have to be knowledgeable across the whole range of activity, they have to understand the dynamics of the hospital, the emergency care, elective care, critical care. In the main they will be people from a nursing background and they will often have been very senior nurses in a particular trust or hospital, because the other key ingredient here is trust, and senior experienced people with judgment, rather than someone who can just push buttons on a machine, are people who are valued in that role.

  123. Is that why only 8 per cent of the hospitals seem to make use of an integrated computer support system? One would have thought there was a standard there that could be offered right round the NHS. Are you saying that the kind of people that have the skills and the qualities that you have spoken about may think they can do this by interpersonal relationships with people, rather than by relying on their laptop?
  (Sir Alan Langlands) I think that was the early attitude, but I think these people are now often becoming highly skilled at using innovation systems as well, and often have back-up staff.

  124. Are you not surprised that only 8 per cent of hospitals seem to have a system like that?
  (Sir Alan Langlands) I expect that number to increase very significantly.

  125. We are not talking big costs in terms of software, are we?
  (Sir Alan Langlands) The costs were put in earlier. I cannot remember what they were, but they were quoted earlier in this hearing.

  126. 150,000 I hear.
  (Sir Alan Langlands) There is significant investment, but it might be worthwhile. You have got to have both. There is no point in having an information system that is perfect and a bunch of people who do not know how to interpret intelligently the information and use it in discussion with their colleagues.

  127. I understand that. We have talked about the fall in the number of beds and you have highlighted the obvious reasons—survey, increase in day surgery and changes in clinical practises. Why do people hear about beds in corridors at hospitals across the country? Why does that arise? In most of the hospital envelopes, the bricks and mortar, there has been a shrinkage in the number of beds. We have all heard of empty wards because that is not needed any more in terms of physical space as the number of beds reduce, but how come we get the phenomenon of beds in corridors?
  (Sir Alan Langlands) You do not hear stories of beds in corridors, you hear stories of trollies in corridors.

  128. People lying prone in corridors.
  (Sir Alan Langlands) That is an issue of concern and one that is being tackled. It is not sufficient to say in that same hospital there might be an empty ward, therefore, instead of being in the corridor—

  129. Is this to do with staffing very largely?
  (Sir Alan Langlands) That is precisely my point. What you need is staffed wards, not empty wards.

  130. Can we move to delays in discharge, which a number of colleagues have touched on? It says in the Report that this costs £1 million per day. The Report talks about where the delays come from and you have mentioned social services several times, residential care homes and so on. If there is £1 million per day swilling around there, is there not some way of extracting that from the system and ear-marking that to take forward the kinds of initiatives that you have spoken about in terms of residential care for the elderly in particular? Who is taking the lead in this?
  (Sir Alan Langlands) It is not swilling around because people are not being properly looked after.

  131. I accept the challenge to the description.
  (Sir Alan Langlands) The alternative services need to be funded as well, so what we are looking at is not £1 million per day in an organisation which spends—

  132. Are you saying that it is dangerous to use that statistic as an illustration?
  (Sir Alan Langlands) I am not saying it is dangerous, I am putting it in some sort of perspective. The point is that the £1 million is not a net figure, because alternative services would need to be provided, and sometimes these can be just as expensive but perhaps closer to what the patient actually needs.

  133. That has not answered my question. Who is taking the lead in terms of the across-the-line residential care?
  (Sir Alan Langlands) The people who have that responsibility are the people in health authorities.

  134. Did I hear you say, "Not me, gov"?
  (Sir Alan Langlands) Anyone who imagines that you can run the whole of the NHS from Whitehall—

  135. Do not get prickly, Sir Alan, I am asking you a perfectly straightforward question. Listening to your earlier answers, there was clearly a benefit, you were persuading us, in trying to do more, particularly for the elderly with residential care. It would benefit the National Health Service and it would benefit the taxpayer. Start back from there and now tell me, with that genial smile of yours, who takes the initiative?
  (Sir Alan Langlands) The people who are responsible are health authorities, social services departments and NHS trusts. It is their responsibility to provide services to their local population.

  136. What part do you play in that?
  (Sir Alan Langlands) We provide three important things from the Department of Health. We provide some clear statements and priorities—and the Secretary of State has been very clear about the need for investment in this area—we provide money through the resource allocation process and we provide a means of disseminating good practice and encouraging people, where we have identified good practice, to take it up. Everyone has their part to play, as I think is set out in one of the annexes to this report, in making that very complex change happen.

  Mr Wardle: Thank you, Chairman. I think Sir Alan has finished with my questions on a note that makes for the perfect Whitehall memo.

Mr Williams

  137. I suspect I see signs of you getting a bit demobbed and I am hopeful that you are in a mood to bare your soul and indulge in the usual thing when you are out with the lads the night before you are about to go back to civilian life and look back over your period in the Health Service, which has been a very long spell, since 1974. Looking at the problems that we are discussing today, are there any watersheds, errors or decisions to which you would point at and say, "Well, in a way they made this situation virtually inevitable"?
  (Sir Alan Langlands) I would not describe them as errors.

  138. Decisions then.
  (Sir Alan Langlands) Yes. I think, and Mr Steinberg referred to it earlier, the notion that over endless years you can squeeze out efficiency savings in the NHS is one that needs to be challenged. I am not saying by that that the NHS operates to optimum efficiency, it clearly does not, but successive year by year blunt instrument reductions do have a very demoralising effect on people working in the service and have led to some of the decisions that have reduced the bed numbers. What I think I am interested in, and what I have been arguing today, is finding the right balance between that quite legitimate discussion, the discussions about the quality of care and the discussion about the life of the staff and how the staff who work in the NHS feel. I guess that would be a concern. I do not think there is a sustainable position. I did a little exercise when I read the newspapers a couple of weeks ago, which was full of the Longbridge material, and it was talking about productivity in the United Kingdom manufacturing industry set against European comparisons. If you do that exercise for the NHS, we are highly productive. That is a good thing, and it masks all sorts of difficulties and idiosyncrasies that we often discuss at this Committee, but it is not a descriptor of the quality of care and it is not a descriptor of the pressures and difficulties that staff in the NHS face in their working lives. I think getting that rounded picture is very important.

  139. In opposition we constantly criticised, what you described as a blunt instrument, the arbitrary presumption that you can go on making efficiency gain after efficiency gain. In order to educate our colleagues from the Treasury, who are here—and one of them is also sharing your mood of ready to jump off ship, I understand—do we have available to us alternative, more sophisticated ways in which we could secure efficiency gains without risking cutting to the bone with what are effectively financial cuts?
  (Sir Alan Langlands) The Treasury are becoming very enlightened on this matter, but we have been working with the Treasury over the last couple of years on something called performance assessment framework, which does take a more rounded view of performance. It tries to take account of the sort of rudimentary signs of health outcomes, it tries to take account of the patient's experience, but it does take in some of these harder edged measures of efficiency that we have discussed here from time to time. I think there is quite a strong sense building up in the relationship between the Treasury and the Department of Health that there is an intelligent way of handling this that would be good for the Health Service and good for the taxpayer. That is what we are working on at the moment and we will continue to do so.

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