Select Committee on Public Accounts Minutes of Evidence


Examination of Witnesses (Questions 140 - 148)

WEDNESDAY 29 MARCH 2000

SIR ALAN LANGLANDS

  140. Let us take, then, over the 10- year period, the drop that has been referred to in beds from 200,000 to 138,000. A cut of 62,000 beds. How far was that the result of strategic objective decision making, and how far was it the effect of being coshed by the blunt instrument?
  (Sir Alan Langlands) I honestly cannot judge the numbers, but it is the point I was making earlier. It is a bit of both. There was a very good strategic decision in the early 90s to invest in day care with the advances of drugs and advances in minimal access surgery. A lot of money was poured into developing day care facilities, day theatres, staffing these places differently and encouraging new ways of working practice. Now 60 plus, pushing 70 per cent, of all the operations in this country that are carried out are being carried out on a day care basis perfectly efficiently and with the support of professional staff and patients. That was a wise strategic decision in the early 90s. There are other things where we do not lead, where we follow. There are changes in the length of stay. You used to have a cataract operation, you got lots of stitches and laid in bed. Now you get it quickly, and sometimes you get laser treatment. I gave the example earlier of gallbladder surgery, which has changed beyond all recognition. We took a scientific and technological advancement and made it work for us, and that allowed us to reduce beds and deploy money in different ways. I cannot give you figures, certainly not off the top of my head, although I am sure there are people who have looked at this, but some of it was just crude, "If we continue at this level of staffing and keep this ward open we are going to overspend by so much that we just cannot sustain it. Therefore, we are going to have to take what is a draconian action." There is no doubt that I have lived through periods where these sorts of decisions have been made.

  141. That is very interesting. Really is this cut the sum of a series of ad hoc decisions by the various trusts or health authorities around the country, or has there been any strategic guidance behind it?
  (Sir Alan Langlands) Until 1996 the regional health authorities, which were not always the authorities most favoured in this Committee, did take a strategic view of health provision in their regions. The regions were abolished in 1996. I think there was a period between 1994 and 1996, a sort of transition period, where with the efforts they put in to try to make the internal market work, there was some fragmentation in the sense that 418 trusts were taking individual strategic decisions, if you like, without any regional or national overlay. The pendulum has swung in favour of the planned approach again. That planned approach now is not about beds or having a particular hospital of a particular shape, a particular template, in each part of the country. The plan is now around very specific areas of the Health Service—cancer, coronary heart disease, mental health—with national service frameworks which set out national standards, clinical standards, which set out the right organisational model, the evidence based model, the thing that works best in health systems around the world. It sets out linkages with other specialists, so you say "here is the best way of providing coronary heart disease services, let us see if we can make that work, or a version of that work, across the country". There is a return to planning but it is planning, if you like, of clinical networks rather than of hospital buildings.

  142. Switching across, although it impinges on it, to the issue several of my colleagues have touched on, the 6,000 people over 75 per day who are in hospital and could actually be released. We are talking of over £350 million a year, so over one of our Comprehensive Spending Review periods a billion pounds will be lost. It is used but not used productively in a medical health sense. It costs that but it would probably cost the same to have people in there being treated. Coming back to this quandary that Mr Wardle and various people have touched on, that works out at about £1,200 per week per patient. That is vastly greater than the cost of keeping them in a nursing home, three to four times more expensive.
  (Sir Alan Langlands) Yes.

  143. Why is it that after all this time we still allow this utterly wasteful use of resources to continue instead of recognising the cost benefit advantages of providing alternative facilities such as those which Mr Campbell referred to? You said that it could be just as expensive to provide alternative facilities for some of these people but, frankly, it is hard to conceive of anything that would cost for most people £1,200 a week.
  (Sir Alan Langlands) I agree with that. You have got to qualify it a little bit in the sense that some hospitals do recognise that and try to run lower dependency wards with fewer staff and all the rest of it. I do take and accept your point. I think I would have two reactions. Again, we are dealing here with the divide between health and social care. One practical reaction, and I suspect it is right at the heart of Mr Campbell's example, is that in times of plenty the NHS subsidised Social Services budgets in order to buy, if you like, these cheaper alternatives. That is one. Two, in a planned way between now and 2003 the Government is spending £365 million, which is almost exactly a third of the sum you came to, to try to achieve change in the development of facilities at that health and social care boundary that might have the very effect that you suggest, which is that they provide both better and more cost-effective alternatives.

  144. I recognise that this does not lie at your door and this may be an unfair question, but it seems so glaringly obvious that the one is a gross under-use of resource as compared with the benefit of switching to the other. Why is it that this has not been addressed earlier?
  (Sir Alan Langlands) It is being addressed. It is being addressed in a spirit of reasonable co-operation between local governments and central government.

  145. That is where we are now. You have been in your present position and your position as Deputy since about 1993.
  (Sir Alan Langlands) I am about to make the point which I think is the very significant point here. There is no doubt that the tension in that relationship between national government and local government is much reduced when the predominant party of local government is one and the same party is in national government. There is no doubt that there was gamesmanship, blatant gamesmanship, between the local government of one party and national government of another party through a large part of the period you have mentioned. We experienced it and we were frustrated by it. There is a bit of politics in here as well that is significant.

  146. Yes, I am sure.
  (Sir Alan Langlands) The other point I would make, of course, is that local government have other quite legitimate priorities. Sometimes they have to throw up their hands and say "enough". Sometimes we in the Health Service have to say "enough". Local government often say to us "if only you could have intervened earlier. If only you could provide support at home for that person they would not have ended up in hospital in the first place", and that is legitimate as well.

  147. The current cliche« is joined-up Government. If you look at figure 25 on page 52 it is quite clear that the gulf between local government and central government has been almost unbridgeable. Looking at that table you find the percentage of older patients whose discharge was delayed ranges from 1 per cent to 81 per cent and in the case where it is 81 per cent of them waiting it is awaiting Social Services Directorate funding. If you look at the numbers in the second footnote, there were just three older patients delayed on discharge in Portsmouth, 188 in Cambridgeshire and in that case it was because Social Services Directorate funding was not available for nursing and home care. This is probably an unfair question but what hope is there of bridging this gap between the local decisions of one spending unit, an elected organisation, and the aspirations of an enormous national spending organisation such as yourselves?
  (Sir Alan Langlands) I think there is hope where there is money in the system to lubricate change and where there is consensus on both sides. We can provide them if it would be helpful to you. I am absolutely sure that when they arrive in a couple of months' time the annual figures for this year past compared with the year in the study will show a great improvement in that area because there has been a tremendous effort in the year. One of the things I am very keen to do at the moment is to be positive about the sort of support that we in the Health Service are getting from Social Services at the moment because I think they are doing vastly better than they have ever done to help us. It is not a lost cause but at the end of the day there are two chequebooks and two budgets and two finance directors who have got targets and deadlines to meet at the end of the financial year and I accept that does sometimes make life difficult.

Chairman

  148. Thank you, Sir Alan. A couple of points which it would be helpful to have notes on. One, I wonder if we could have a note on the Department's judgment of value for money of the Shrewsbury CALM system. The second one is you were asked, but did not answer, what is a sensible proportion that the rate of bed occupancy should be, 75 per cent, 80 per cent, higher, lower. I wonder if we can have a note on that[8].
  (Sir Alan Langlands) Can I just say one thing in response here if it helps answer the exam question. If the Committee feel there are papers that you have seen that we have not seen, that we could see, that would inform how best we can answer the question, I am very happy to take up the challenge.

  Chairman: Our Clerk will make arrangements for that. We know we have got you again so we will not go into another valedictory. It has been an extremely interesting session, thank you very much indeed.





8   Note: See Evidence, Appendix 1, page 22. Back


 
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