Examination of Witnesses (Questions 120
- 139)
WEDNESDAY 29 MARCH 2000
SIR ALAN
LANGLANDS
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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