Examination of Witnesses (Questions 1
- 19)
MONDAY 29 JANUARY 2001
MR NIGEL
CRISP AND
MR MARTIN
GORHAM
Chairman
1. Good afternoon. This afternoon we are taking
evidence on the National Audit Office Report on the National Blood
Service. We have giving evidence Mr Nigel Crisp, the new Permanent
Secretary, Department of Health and the Chief Executive of the
NHS. Two heavy burdens, Mr Crisp.
(Mr Crisp) Indeed.
2. And Mr Martin Gorham, the Chief Executive
of the National Blood Authority. Welcome to both of you.
(Mr Gorham) Thank you.
3. Now, Mr Crisp, I welcome you on your first
appearance before this Committee as Accounting Officer. I suspect
we are scheduled to see you a number of times in the coming months.
We will come to be old friends. Let me perhaps start with an easy
question for you.
(Mr Crisp) Thank you.
4. That is to say as one who has recently taken
up his post as Permanent Secretary at the Department of Health
and as Chief Executive of the NHS Executive, and with your experience
of the NHS in London, can you give us an overall view of the performance
of the National Blood Service and what key aspects do you hope
to improve?
(Mr Crisp) Right. Well, let me start with my initial
impression on taking up office is that the Service has actually
come a long way since the crisis of the 1990s, and I think this
very helpful Report shows that. Indeed, I think as somebody coming
into post as an Accounting Officer, to have this sort of Report
which has gone into the detail around the Service is very helpful.
I have also had a chance to go and look at one of the services
as part of the Blood Service. I have been previously to other
bases before hand. I must say I have been impressed by the professionalism,
by the attention to detail, by the standards that are in place
and by the commitment. I think the Blood Service has come a long
way since those days. I have also been impressed, however, by
the fact that there is no room for complacency here, particularly
in terms of the public safety issues and particularly in terms
of the fact that there is actually an awful lot of detailed work
still to be done. I think what this Report is telling me and what
my observations are telling me is that the broad thrust is right,
we are getting the policies in place but there is a lot of detailed
work to do to make sure that we are absolutely where we want to
be.
5. You will probably find me a little less sympathetic
than the Report, but we will see as we go on.
(Mr Crisp) Indeed.
6. Let me turn to Mr Gorham. This is your first
time as well, is it not?
(Mr Gorham) It is indeed, Chairman, yes.
7. I will try and give you the paragraph indicators.
I will start with paragraph 1.25 which identifies two initiatives
that are aimed at improving the use of blood in hospitals: the
National Blood Service's National Blood Stocks Project and the
Chief Medical Officer's `Better Blood Transfusion'. Can you tell
the Committee how successful these have been in reducing wastage
of blood within hospitals and improving the way it is used?
(Mr Gorham) Yes, Chairman. We have seen a reduction
in the wastage in blood. In fact, if I can refer you to table
number 7, there is a table which shows wastage. We have actually
seen a further reduction of about 0.4 per cent in wastage since
that table was prepared. We think that is probably partly based
on the Blood Stocks Project but I think it would be ambitious
to try and get a direct relationship. The particular strength
of the Blood Stocks Project has been to bring the NBS and a number
of hospitals together, to work together, again doing some very
detailed work. It set up a scheme, a daily check on stock levels
and wastage and enabled hospitals to compare their performance
with other hospitals' performance. As a result we had 67 per cent
of hospitals reporting changes, either reductions in blood stocks
or other changes in practice. We have now recruited 123 hospitals
to the Blood Stocks Management Scheme which, if you like, is the
successor to the Blood Stocks Project. That is going to be partially
web based so it is going to be much easier to do information exchanges.
Again, we think that is going a long way to building links between
our Service and the NHS hospitals we serve. In terms of Better
Blood Transfusion, obviously that has encouraged the development
of transfusion committees in hospitals and the figure reported
in here, we have a very high level of attendance to that. We have
developed our own services to give better support to that in two
ways. We have developed our hospital liaison function, which is
to work very directly with hospitals, and we have also developed
the organisation of our medical staff in such a way that they
give better specialist advice to hospitals. So we think it is
laying some very important building blocks in terms of taking
us forward and bringing expertise and influence on blood usage
in hospitals.
8. Thank you for that. Others will no doubt
come in on it. My only passing comment is that in my part of the
world the National Blood Stocks Project was thought to be stud
farms. Clearly some of the Committee Members do not understand
the reference so I will let them work it out. The next question
relates to figure 17 on page 25. This is a part, I have to say,
where I am a little sterner in my view than perhaps the Report
reflects because I am a would-be blood donor myself. What it shows
is that existing donors stop giving blood at a rate of around
200,000 a year. Can you tell the Committee what action the National
Blood Service is taking to reduce that rate of loss?
(Mr Gorham) Yes. I think the context of this is that
we have had to do a number of things to improve blood safety which,
frankly, have not made life easier for donors. Clearly in particular
the concern about the possibility of variant CJD being transmitted
by blood led to a number of actions which actually makes the whole
donation process longer. So we have had more safety checks, we
have had the donor questionnaire. We have had more staggered operating
procedures. We actually have a more complicated process all the
way through. We extended our core computer system—Pulse—into
the donor area. All of that frankly slowed the Service down. What
we are now trying to do is to take steps to speed it up again
without in any way compromising the safety. We have a whole set
of initiatives that we have been preparing and we are going to
be undertaking over the next year. Probably the most important
is a review of the whole donor process which we are doing right
across the country because, as I am sure you will have gleaned
from the Report, practices vary in detail quite a bit in different
parts of the country. If we are going to carry through change
we have got to take the staff with us, they have got to see that
it is taking account of their local practice. So we are doing
a very major review of that. We are looking at the whole issue
of session opening times and whether sessions are in the right
place at the right time. We have a long historical record, maybe
we have not moved things like that on as quickly as we might have
done. That is another important aspect. We are looking at whether
we can get more volunteers supporting the Service. A few years
ago there was a lot of volunteer support, it is now quite patchy
and we think if we could recapture that local connection that
could very helpfully allow us to speed things up again. I think
those are the major things that we are looking at in the short
term. They will take time to work through because carrying through
changes has got to be done against a context of maintaining safety
all the time.
9. I understand that. I am pleased to hear that
you are reviewing session opening times and hopefully it will
deliver some improvements. I have to say, however, and it is very
dangerous to judge from anecdotal experience, but experience of
being kept waiting a very long time, not for any apparent reason,
or even having an appointment and turning up and them saying "join
the end of the queue" is not very clever and does not arise
out of safety measures from CJD or changes in the approach, it
is just poor management.
(Mr Gorham) Yes. We have been piloting appointment
schemes and in some ways we have found it very helpful but it
is not a panacea. What we have discovered is some donors do—
10. Not if it does not work it is not a panacea.
(Mr Gorham) We certainly have some work to do. On
some sessions we simply have not got it right and we are working
to get it right. Some donors do not want appointments, they value
the ability to drop in. What we have found is that it is very
difficult to have a system which is a mixture of appointments
and drop-ins, that does not work well. The other problem we have
had is that our donor IT system does not enable us to use technology
to offer donors the ability to change their appointments and that
is a service that donors can expect and are right to expect. Until
we have sorted out the technology to enable us to do that we simply
are not going to be able to offer a robust appointments system
of the sort donors want and we want to give them.
11. Just to press on, paragraph 3.6 tells us
that in 1999-2000, 40 per cent of those who enroled as donors
failed to give blood. Are the reasons the same and what are you
going to do about it if they are not?
(Mr Gorham) What we have discovered, again, from the
work we have done is stating an intention to give blood and actually
giving blood are two separate stages. I think in the past we have
tended to think that people will automatically move on and that
is clearly not the case. What we are now doing is being very much
more active in going back to people who enroled much more quickly
and offering them appointments. We have now developed a video
to send to newly enroled donors which, again, encourages them
to come forward. That is a very new initiative and we do not yet
know whether it will work. From our survey work we did discover
that if you did not invite people to an appointment within one
to two months they were highly unlikely to turn up, so we have
changed the whole way in which we react to newly enroled donors
to try to get a better conversion rate.
12. That is helpful. The National Audit Office's
survey of the public and complaints from donors, as summarised
at paragraph 3.14, indicated that the waiting time during donor
sessions is a major problem. You have already talked a little
bit about that but what are you doing to improve services to donors
to minimise the time they have to wait?
(Mr Gorham) Really the initiatives that I have been
describing are aimed at trying to reduce waiting time.
13. Are you measuring waiting time?
(Mr Gorham) Yes, we do measure waiting time. It remains
the biggest matter of complaint and it is the issue that we have
to crack if we are going to continue to attract and retain new
donors, which is why we have got such a wide range of initiatives
to try to deal with it. I do not like waiting and I can understand
other people not liking waiting.
14. It may not be a matter of not liking waiting.
If somebody is coming along in their lunchtime, it is not a question
of liking or not liking, and they have got an appointment somewhere
else they cannot do it.
(Mr Gorham) I think that goes right back to the issue
that some people want appointments and some people do not. If
you go down into a rural area it is almost like a community event.
My attitude still is people should not have to wait. If they choose
to stay on afterwards because they are there with their friends
that is fine, but we should not be making people wait. Until we
sort that out we have got a real problem. I think the other thing
that has had an impact on this is our tv advertising in particular
has been very successful in bringing people forward to donate
but it tends to have quite an immediate effect so we then get
some very overloaded sessions and that has undoubtedly had an
impact on this and made it worse.
15. Thank you for that, Mr Gorham. I will come
back to you at the end of the session but I will turn to Mr Crisp
now, if I may, and give you a rest. Mr Crisp, we have seen press
coverage of the Department's recent decision to require the use
of disposable instruments in some operations because of the risk
that sterilisation equipment will not be effective in removing
things like the CJD prion presumably. Paragraphs 1.20 and 1.22
set out the measures put in place to reduce the theoretical risk
of transmission of variant CJD through transfusion. Does the Department
have any plans to reduce the risk further?
(Mr Crisp) I think there are perhaps two points to
make here. The first one is, as I understand it, all instruments
that are to be used for taking blood are disposable, so we are
not in that bit of the territory. There is a question that is
raised around the use of fresh frozen plasma and that is an issue
which is seriously being looked at right now. We are taking it
through the normal processes, taking advice from the appropriate
committee, which is the Microbiological Safety of Blood and Tissues
for Transplantation Committee. We are literally at the point of
looking at that now.
16. Is that likely to come to a conclusion in
the very near future?
(Mr Crisp) I would think it would come to a conclusion
pretty soon.
17. Could you let us have a note if it is before
we publish?[1]
(Mr Crisp) Indeed.
18. That would be helpful, thank you. Finally
to you, Mr Gorham again, a question I forgot: what action have
you taken to secure the widespread adoption of best practice and
make full use of internal cost comparisons, as recommended in
paragraph 13?
(Mr Gorham) In a sense those are two separate questions,
Chairman.
19. They are related.
(Mr Gorham) They are related certainly. In terms of
best practice, the reason why we decided we had to adopt a genuinely
national structure was because we did not think it was possible
to get best practice throughout the Service unless the management
lines cut through the Service in that way. That in no way conflicts
with our belief that we are trying to offer local services within
a national framework. We are conducting major reviews in all of
our operational departments at the moment looking at current practice,
practice variations and best practice, and over the next months
we will be moving services towards those best practices. I suspect
it is going to take quite a time to get there because we are looking
at it against the background of very significant historical variations.
In terms of costings, we have not enjoyed comparable cost bases
in the different parts of the services. The three zonal costing
systems actually had significant variations. We are taking the
first real step in putting that right in this year's budgeting
where we are moving things to common definitions and a common
set of costings. I think we need a year's experience before we
can say those are really robust but certainly we are determined
to get to the position where we can make meaningful cost comparisons
because, in the first instance, we actually think that is a more
important approach to benchmarking than trying to move some international
comparisons where you have got some quite significant variations,
which is difficult to get out of the way, whereas with our own
internal variations we have a sort out.
Chairman: Thank you. Let us widen the issue
out. Mr David Rendel first.
1 Note: See Evidence, Appendix 2, page 3 (PAC
2000-01/157). Back
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