Examination of Witnesses (Questions 140
- 151)
MONDAY 29 OCTOBER 2001
CLLR KEVIN
EARLEY, MR
STEVEN MASON,
MR ANTHONY
RABIN, MR
MIKE ARCHBOLD,
MR JEFF
THORNTON AND
MR JOHN
FLOOK
140. It has been suggested because of the costs
the Trust faces now in terms of its payment to the contractor
that that does not enable you to fully staff all of the beds in
the hospital, something like only 350 are staffed, is that correct?
(Mr Mason) That is not correct. I have to say in fairness
when you look at the full business case there was assumptions
made in the full business case that there was a level of occupancy
of 70 per cent when the hospital opened. That clearly is not the
case, obviously it is significantly higher than that. We did carry
out a review of all nursing establishments and we are now at the
sort of mid range use in the district audit comparative analysis.
We have looked at this on a number of occasions in a fairly detailed
internal review and also sought opinions externally in terms of
what would be the correct level of staff and the wards are staffed
on the levels of occupancy they are currently experiencing. It
is fair to say the full business case did assume staffing of occupancy
levels of 70 per cent.
141. What is the current occupancy level? We
know you had trouble with bed shortages over the summer?
(Mr Mason) At midnight we are running at levels of
occupancy of 90 per cent, which is in excess of the recent bed
review, which suggested it should be running at 82.5 per cent
and during the day we can run at over 100 per cent.
142. Given that you had that during the summer
does this suggest with winter pressures coming on there is cause
for concern and occupancy levels are not leaving you with a great
deal of scope.
(Mr Mason) I am concerned at the occupancy
levels because I think there is enough evidence to suggest if
a hospital is operating at very high levels of occupancy you have
very limited amounts of flexibility and that does tend to lead
to more cancellations on the day of surgery, obviously there are
concerns round that but there is not really the distinction between
summer and winter we often talk about. If you look at general
medicine it tends to be pressurised for eleven months of the year
and it is often only in August or September, which might be connected
with the holiday season, where it tends to noticeably drop. We
tend to have one or two months in the winter that tend do have
spikes of activity. We are now closely working with the social
services department locally and primary care groups about trying
to put extra capacity from late November onwards to try and put
more beds into the system so that we have some flexibility to
deal with that type of activity. Obviously we would like to be
running at the 82.5 per cent level that is recommended in the
recent report if at all possible. The key to that might not necessarily
be more beds within the hospital, it might be eliminating the
problem of delayed discharges.
(Mr Flook) The Health Authority were very supportive
of the independent studies into the cost base of the Trust and
the clinical service performance for the simple reason we were
anxious not to put the Trust in the position of signing up to
something that could not be delivered. In the circumstances that
existed at the time the outcome of those independent reports was
that these things were achievable and that the changes in working
practice in the hospital, these clinical standards, were achievable.
Whether they are still relevant I think is a point that Steven
is moving on to at the end in answer to another of your questions
and, yes, a lot has moved round since the time we had those independent
reports.
143. Are you victims of changing philosophy
generally the Health Service?
(Mr Flook) There are a lot of dynamics constantly
moving round in the Health Service and some of those have not
moved the right way since this was done.
Chairman
144. One of those dynamics may be the concept
of intermediate care, it is a very old concept in a sense but
it seems to have been revived for some reason recently. Presumably
your bed blocking problem is long-standing, what assumptions were
made about the role of social services when you began to look
at your bed numbers? Were the local authority involved in discussing
how you make provision in the scheme for assisting them? Was there
any discussion? Were they involved in the project?
(Mr Mason) When the business case was developed the
configuration of services within North Durham was different than
it is now and it will change again next year because there has
been at lot of organisational change. The business case itself
did focus very much on acute hospital perspectives in terms of
delivery of health care. Within the business case there was an
assumption that community services would be developed to the tune
of £1.5 million per annum to support the reduction in the
beds. It is fair to say there was an investment of about £1.5
million, some of that has gone to improve the existing infrastructure
of where the services are delivered. About £850,000 of that
money is round the development, for example at Shortley Bridge.
That is not adding to the quantum of services available but improves
services provided. We commissioned an intermediate to care strategy
and we now have people signed up to that within social services
and primary care and within the Trust to work together to improve
that. With the benefit of hindsight it would be nicer to have
had it earlier. We are working through that within terms of how
we manage.
(Cllr Earley) We should have thought about issues
at the beginning, the more pressure put on hospitals the more
you put on the social services. They are queueing up at the door
to get out. If you are putting more pressure on social services
to perform the more you use hospital at home, you are sending
people at home when you have occupancy rates of 118 per cent.
They are sick people who need a lot of nursing time. The people
who are in and out for surgery, who used to spend ten days, you
do not have those taking up hospital beds, you have somebody else
sick who needs attention. That is a day-to-day human story for
your staff. You have to bear that in mind when you are upping
your efficiency.
145. Presumably you are on the social services
authority?
(Cllr Earley) I am on the district authority.
146. Would you say if the social service authority
had been more involved with the scheme initially the arrangements
might be some what different to what we have?
(Cllr Earley) There you get very focussed. I think
you need to get down a bit in the bunker and see the price. As
John was saying, 30 years without any significant investment.
All of the things we talk about, getting design right and all
of the business information and developing relationships that
does fill the horizon a bit. If we look at it a bit broader, things
are changing, we have made some good inroads with our friends
at Kenby Hall and there is a lot of stuff that will come in which
will help, and the extra money that the government is putting
into bed blocking.
Andy Burnham
147. There have been reports because of bed
capacity complaints, are you considering a partnership with Nuffield
hospitals and if that is the case how would that arrangement work?
(Mr Mason) We are considering a number of options.
We are busy reviewing the hospital design internally to look at
some areas that are not as well utilised and if they cannot be
made better use of by changing them. For example, there is an
area within theatres for second stage recovery which could convert
into additional beds, we are examining the feasibility of that.
We are looking at the feasibility of an extension, not just to
provide some extra capacity but also to look at the provision
of service. I think most people realise there is quite a difference
between where we are now and the accommodation that is available
within the new hospital. We have looked potentially at whether
that could be with the private sector, such as Nuffield, or another
private provider or whether we could do it ourselves. We are looking
at a number of options as to whether we are going to have an extension
with our partners in terms of a PFI extension or whether we would
not put it up as a publicly funded extension, but again you get
back to is the money available centrally. To have a publicly fund
extension you have to look at what represents best value. We are
at the very earlier stages of doing the business case and that
will be submitted to the primary care groups and then on to the
regional office for consideration. One of reasons we need to look
at extra capacity is the NHS plan has set very challenging targets
for waiting times. If we are going to achieve those standards
it undoubtedly true that we are going to have to have some extra
capacity as well as a further review of working practices. Also
within Durham the elderly population is projected to increase
quite dramatically over the next 10 years. Obviously we need to
build that in and plan for the future. In many ways that comes
back to my earlier point, the health service has not traditionally
been very good at planning ahead, you tend to get a new facility
to cope with the existing service configuration. I think it is
inevitable whether it was a PFI or a publically funded hospital
we will be look at some form of extension in the future. If we
are doing that now because we have the local Modernisation Review
that is focussing everyone's mind.
(Cllr Earley) The other thing we mentioned a couple
of years ago was whether the elective surgical unit would be a
way of using existing resources to get more people through. It
is going to be a £67 million PFI general hospital and if
you want to make some use of it then it may be there to be used
as an elective surgical unit for orthopaedics or whatever.
(Mr Flook) In the light of NHS plan and the National
Bed Review the Health Authority has recently started a complete
comprehensive review of acute sector bed need and utilisation
across the county and that will have implications for this hospital
we are sat in at the moment, Darlington Memorial and Bishop Auckland
Hospitals.
Dr Naysmith
148. A question that comes up on the back of
all that, and which you talked about a lot, is getting involved
in the design and so on. There have been suggestions from think
tanks that the contractor could take on provision of all the hospital
services, including clinical services, I am not advocating that,
but that would mean the Trust would not need to be involved in
the design of a hospital like this. Maybe we should ask the representative
of Balfour Beatty, after you have commented, Mr Mason, on that.
(Mr Mason) I am aware that the idea has been suggested
but I have not studied any documents in detail to say how that
would work. It is theoretically possible to contract it out to
the management of a local health care facility. I think we need
to look at it very carefully because management of a Trust is
a very complicated business and I think the private would have
to look at the relevant risk associated with that before they
would make a commercial decision about whether it was worthwhile.
I am aware of the proposal. It is possible but I think the devil
would be in the detail really.
(Mr Rabin) I can respond by saying that Balfour Beatty
have no plans to be involved in that area—
149. You must have considered.
(Mr Rabin) A very simple reason. That which we do
as subcontractors here, either in terms of building the hospital
or providing the service as we do, is part of our bread and butter
existence. We believe that it is a natural and logical extension
of activity. We do not provide clinical services as part of our
bread and butter activity and therein lies the fundamental and
essential distinction.
John Austin
150. Are there any private beds in the new hospital?
(Mr Mason) There are not at the current time. It is
part of the review I referred to earlier to look at the provision
of some private beds but not a significant number.
Dr Taylor
151. The term "affordability gap"
has been coined by some of the critics of the private finance
initiative, I would like to know how you answer that? The figures
that are given are that from the Trust's own accounts only seven
per cent of income is available to pay for capital and the amount
you are having to pay is obviously a great deal more than that
seven per cent. Are those figures wrong? Do you have the amount
to pay? Is there an affordability gap? How much money do you get
from the government as smoothing funds that are given to ease
the gap?
(Mr Flook) I have been associated with major capital
schemes for 30 years now in this region, the Freeman Hospital,
the Memorial Hospital, Northallerton and North Tees. Every new
hospital costs extra to run. When capital was a free good the
extra cost was primarily about additional clinical staff and services,
that was the climate at the time, and it was a genuine development
of services for people when they got a new hospital. Those days
have past partly because people started to abuse it and it got
discredited. Capital is no longer a free good and the reason why
additional costs are incurred when you replace old building with
new buildings is because there is a financing cost to capital,
it has to be paid. There is no affordability gap, as such, because
in the full business case the Health Authority took it into consideration,
decided it was affordable, it was worth paying, the money was
put aside and the Trust has been funded to cover that.
Chairman: Can I thank you for your participation.
I wonder if it might be possible for you to remain with us because
there are areas where we may wish to come back to you arising
from the next group of witness. We hope to conclude not long after
5 o'clock, so we hope it will not be too long. Thank you very
much.
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