Examination of Witnesses (Questions 160
- 179)
MONDAY 29 OCTOBER 2001
MR STEPHEN
WEEKS, MR
ROBIN MOSS,
MR DAVID
PRICE, MRS
JAN LEMMON
AND MRS
PATRICIA BOTTRILL
160. This is not what I am asking. What I am
asking is specifically we have been informed that the reason for
the drop in numbers over the sequence is directly as a result
of bed reviews that took place that had nothing to do with any
form of capital financing but as a result of the changes in medicine,
of day surgery and an increase in bed throughput. Are you saying
that is wrong?
(Mr Moss) I think it is a very, very complicated question.
We think that PFI and the costs associated with PFI have a major
role, along with capital charging, in determining the number of
beds that could be built. There are a number of very highly suspect
assumptions made about the way in which the bed plans or the bed
model was constructed. In 1996-97 in the full business case the
assumption was made, contrary to what had been in the outline
business case, that in the year 2000 the number of inpatient admissions
would be the same as in 1996-97. That is a rather surprising assumption,
given that the outline business case had assumed that there would
be a nine per cent increase by the year 2000 was reached. The
implication of that is that the number of beds in the hospital
was tailored to the financial equation, not to health needs
Julia Drown
161. Are you saying it would have made the public
sector comparator cheaper?
(Mr Price) The analysis is that the annual cost of
debt finance arrangements, and PFI is just debt finance, depends
on the value of the assets that you are getting, that obviously
follows. I think what Mr Mason and Mr Flook were suggesting was
basically two things, that PFI did not increase the asset value,
there was not a separate PFI effect that made the asset more expensive
and Mr Flook also said that any new hospital was going to be more
expensive than the hospital that it replaced. I think both those
points are questionable. The point that Mr Flook made, that any
new hospital is more expensive is very difficult to understand
because the capital charges on the existing Dryburn are paid at
replacement cost. It is not obvious that the replacement hospital
should have a higher asset value. The problem with arguing that
the PFI has no separate effect, which was Mr Mason's point, is
that we can see that there are separate charges that arise simply
from PFI. There are two ways you can see this, you can see that
the PFI affected the total capital cost. The total capital cost
for Dryburn was around £86 million, £18.2 million of
that was financing costs, that is 21 per cent. Financing costs
do not occur in public sector procurement. I heard it suggested
that they do and I have heard it suggested that they should but
there is no cash cost in public sector procurement that is equivalent
to that £18.2 million. Your total capital cost is therefore
inflated by this distinct PFI effect and it is very difficult
to see how you can then argue that the public sector option is
going to be the same costs. The second way that the PFI increases
the cost is that if you have a total capital cost that has to
be repaid over the life of the contract, over the 30 years. That
is repaid in the annual fee and the availability fee. If you translate
the total capital cost into an availability fee then two other
PFI effects kick in, one is the higher cost of borrowing, because
the borrowed sum has to be replaced and we know PFI has a higher
costs of borrowing and we know too there is an equity share of
minimum 10 per cent in the total capital cost. I do not know what
the rate of return was on the Dryburn, I understand it was 18.5
per cent, and the cost of borrowing is 6.5 per cent—these
figures are subject to confirmation—these show these are
distinct PFI effects, one on total capital costs and the other
on the annual costs of repayment. We can say then that PFI of
itself, apart from the debt finance model, which obviously has
an effect if it increases the value of an asset, has a revenues
pressure and that will be expressed through bed modelling.
162. Is that all put into the model when they
are checking it against the public sector comparator?
(Mr Price) When you get to the public sector you are
starting to talk about value-for-money. When we are talking about
bed numbers we are talking about affordability, not value-for-money.
Value-for-money is not about cash, it is not about affordability.
The PFI factor on beds is about the cash in the system, where
the money goes. If it is going to pay for the increased cost of
PFI, which means something like 16 per cent of your income has
to pay for capital, where it is normally only eight per cent that
has to pay for capital, then that money must come from another
part of the budget. I do not understand what Mr Flook is saying
that they were funded for that affordability gap. According to
the full business case no extra revenue, apart from the smoothing
mechanism, was coming in. It is an interesting point he makes
and since I do not have data after the full business case it would
be interesting to see it. The PFI model does not presuppose extra
revenue support.
Andy Burnham
163. I would like to turn to our colleagues
in the RCN and just ask about the design and construction of the
hospital. Before we came here we all read stories about the litany
of problems in the hospital, during the early days it was too
unbearably hot, ambulances not being able to turn around, no hot
water and all of these things. Certainly one of the things I have
taken away this afternoon, talking to possibly your members on
the wards this afternoon, is that they were over blown, all those
stories, people wanted, for whatever reason, to cite it as a failure.
Is that fair or do you think some of the technical problems, and
clearly there were technical problems, are they more deep seated
or are they just the small things you get in any hospital? Are
the staff happy with the working conditions they have?
(Mrs Lemmon) The things happened. The heat was intolerable
in the middle of the summer. Problems did occur which I think
should have been preempted, they should have been seen before
they happened. However things seem to have settled down. On the
whole I think most people are reasonably happy in general with
the way that the hospital is set out and the technical specifications
of it. There are problems. There are still specific problems which
should have been addressed before the hospital opened. Things
like doors which are not electronically operate, so if you are
taking a patient to and from theatre you are actually having to
hold doors open. You will see a lot of them, I do not know if
you noticed, a lot of the doors which are marked fire doors are
kept open. The reason for that is because they do not stay open
and if you pass through with a wheelchair or a trolley the patient's
arm or limbs can get knocked.
164. The Chief Executive referred to a feedback
groups or focus groups in terms of the experience of staff, are
they working? Do you feel there is an opportunity to say where
you want to see improvements, that these doors need to be made
automatic?
(Mrs Lemmon) There has been the opportunity, we have
had meetings where we have been able to come and talk to members
of the executive board and express our concerns. How quickly those
problems have been resolved gives me some concern. We still have
seen no movement on the problem with the doors. The heating situation,
I hope, will be resolved next year when we can open windows when
the demolition work is over.
165. From what you are saying, am I right to
infer, the failures, the technical problems and the teething problems
in the hospital they were not because it was PFI financed hospital,
they were the kind of things you would get when you transfer services
from one site to another and in fact the quality of service is
actually quite good.
(Mrs Lemmon) I take that with a pinch of salt, I think.
Aspects of how the hospital has been set up give me cause for
concern. I think in general the staff feel that possibly their
needs were put towards the bottom of the pile when it came to
designing the wards, et cetera. Our changing facilities are abysmal,
absolutely abysmal. The toilet facilities, one toilet, unisex
toilet, per 33 bed ward for staff use I do not think is acceptable.
We have sitting rooms which we did not have before and we have
staff rest rooms which we did not have before but we have a whole
floor where we have four 33 bed wards and all of the female staff—and
bear in mind we are talking female to male ratios are something
like 90 per cent to 10 per cent—are getting changed in a
room possibly quarter the size of this room, which I do not think
is acceptable. Things like that should have been addressed. Whether
it is to do with PFI or to do with bad building design in the
first place I really do not know. I feel that emphasis has been
put on the public phase, if you like, and not enough emphasise
has been put on giving staff facilities.
166. That does not quite tally with what we
heard from colleagues on the ward. The three people I spoke to
they were pleasantly surprised and were happy with their work
environment.
(Mrs Lemmon) When you are talking comparisons, where
we have worked for the last however many years, compared to that
it is a world of difference, a world of difference. There are
aspects I think that more concern should have been taken towards
looking after the staff. It is fabulous to have a rest room, we
never had a rest room for staff. It is nice working facilities,
it is airy, it is light but there are things which I think should
have been addressed. We are supposed to be working in patient
focussed care and all your services are supposed to be ward centred
so you do not have to leave the ward any more than is necessary.
Systems were put in place, such as the pneumatic tube system,
which is a pneumatic tube feed. I do not know if anybody experienced
that system working through the night, the noise is unbelievable
because it goes up in to the roof, shoots along the roof. Any
patient in a side room need forget about sleeping because the
racket is unbelievable. The pneumatic tube system is not working
terribly well because if you put a blood sample in it it is haemolysed
by the time it gets to the lab. Urine samples explode in it. We
have now been told if we take a blood sample from a patient let
it sit for an hour before we send it to the lab, that rather defeats
the object of immediate care. Things like the buzzer system, which
is fine, every patient has a buzzer, a call system set up to attract
the nurse's attention and a light system to indicate where help
is needed. However, although on the control panel it says there
is a mute facility on it for through the night there is not a
mute facility that works through the night. Through the night
if you are on a ward, as I am, with orthopaedic patients who are
bed bound and who need to buzz for help through the night the
noise goes on continuously all night. If one person gets woken
up, the next person is awake and also buzzes and it is a continuous
system. The opportunities for rest for the patients is somewhat
limited. The call system, I think, could do with a bit of adjustment.
167. If there was a patient survey what would
that be showing now in terms of satisfaction with the quality
of things?
(Mrs Lemmon) I think on the whole patients are reasonably
happy with what they have. They came in, however, because of the
bad publicity with a different idea. As the nurses on the wards
we had a problem initially because of the adverse publicity for
the hospital and people came into the building expecting problems.
We had to reassure them they would not have to pay for vases,
they would not have to pay £30 for a porter to take them
to the theatre. All of these rumours came long. You could hear
patients coming along the corridor going, "I do not like
this. You can see where they spent the money. That is not up to
scratch", and they were expecting a bad experience. It is
not just on the ward, as nurses on the ward we had an uphill struggle
to assure them and to make sure that their experience was not
a bad experience. That is something that we are overcoming now,
I think. We have been working for a while and patients more often
are going home with a good experience. I think it is down to the
staff on the ground that make the hospital works. We have overcome
the difficulties, we expected snags and problems, it is a new
building, we could not expect anything else, but there are aspects
of it which should have had a little bit more careful consideration
and a bit more input from the staff on the ground.
Chairman
168. I was going to ask you, what involvement
did you have? A criticism that has been of some of the new schemes
has persuaded the government to ask Prince Charles to come along
to assist and one or two of us felt that people like you might
not want that, what involvement did you and your colleagues in
UNISON and GMB have, people working on the design stage of the
practical issues of the kind you talked about.
(Mrs Lemmon) We were allowed to see initially the
two last designs that were put forward as potentials for the new
hospital. I do not think at that stage I can remember being asked
our opinions on which one we preferred. In the end I got the impression
the design that looked good got picked.
169. Are we talking about big models?
(Mrs Lemmon) Yes. We got a look at the big picture
and we were told how it would work, the triangular wards, et cetera.
Once the design had been picked we were informed how it would
work on the triangular ward system. Patient focus care, I am not
sure if that came first or after. I do not know if that was planned
because of the hospital or that was planned and the hospital took
it on board. As to the day-to-day running of things I know that
some of the sisters, some of the ward managers were asked for
input. I do know that certainly some of their input was not taken
up. I know that some of the ward managers asked for the wards
to be a bit smaller than 33 beds, but obviously that was never
on the cards because it was designed specifically that way. Little
nitty gritty things, I have had a sister who came down from Shortley
Bridge to open up the new plastics unit and she did not have a
linen cupboard. Obviously the input for the day-to-day running
of things was not as much as I feel it could have been.
170. Do our colleagues from UNISON have anything
to add?
(Mr Weeks) Obviously in any transition everyone accepts
there will be teething trouble and problems arising from building.
The proponents of PFI, forgetting that one of the main arguments
of PFI is it would produce a step-change upwards in design and
although there would be some transitional problems you would not
get the type of problems you traditionally have within NHS design.
When making an overall assessment of whether it is the move to
a new building or impact of PFI or design that should be borne
in mind in the general assessment. We were promised by the advocates
of this approach by integrating design and delivery this would
change the traditional experience in the NHS.
(Mr Moss) Very quickly, the question was asked, was
there a PFI effect in terms of design? Very definitely at one
stage there was. During the famed affordability crisis, when the
whole project went dead for many months, the outcome of the affordability
crisis was that instead of having 50 per cent single beds you
ended up with a figure of 25 per cent, I stand to be corrected
on the figure.
171. Single rooms you mean, not single beds!
(Mr Moss) Single bedded rooms and one of the triangular
units went west. Unfortunately all the PFI projects I have seen
all seem to have sewage coming up, this hospital was no exception.
Of course there are teething problems. The design faults are a
mixture I think of cost cutting, corner cutting and sheer bad
design, and you could pick out things. Cost cutting, the lack
of changing rooms, one changing room for three wards; three nurses
to share one locker; the fact there are no linen cupboards, the
fact that soiled linen has to be dragged through clean areas to
be put into soiled linen cupboards; what about the lack of air
conditioning. You will go to the Carlisle and you will hear the
same story there, people baking in the hospitals. It is a state
of the art hospital why does it not have air conditioning. You
have fire doors, the doors that were being referred to by my colleague
earlier on, why do we not have doors that automatically open instead
of going through the rigmarole the nurses and porters and other
staff have in terms of when they are wheeling patients on trolleys
and chairs. These things are not just pure design faults, I think
they are evidence of cost cutting.
Dr Naysmith
172. I was going to ask a question or two about
the reduction in bed numbers that obviously took place over that
10 years. We have probably dealt with that for the moment, though
I am sure we will take it up else where. The Royal College of
Nursing in its evidence suggested that because there had been
a reduction in bed numbers there was higher throughput levels,
do you think that is related to the fact that there is a smaller
number of beds in the hospital.
(Mrs Lemmon) It has to be related to that. We have
got use to the idea of the quicker, sicker patient, it is not
anything specifically to do with PFI it is do with getting to
grips with waiting list numbers, you know getting people through
the door and out the door again. The pressures on ward staff have
increased substantially in recent years because of that. As was
said when I came into the meeting earlier about the actuality
of patients going home so much quicker means that you have a lot
more pressure when you are working on the wards.
173. Some people would argue that standards
have changed and it is better nowadays to get some patients home
earlier rather than spending 10 days in hospital, but you do not
buy that?
(Mrs Lemmon) Possibly. In some situations I can see
that patients probably are better at home, however the downside
of it is that you have staff who are now working at extreme levels
of pressure, who never get any respite, who never have the opportunity
to have a patient who needs minimal care, if you like.
174. What you are really saying is you think
it would be a good idea to keep people in hospital not making
demands on the hospital?
(Mrs Lemmon) I am not saying that. It has to be recognised
that the pressures on staff and the workload has shot up.
175. I am sure that is right. Nurse nowadays
work extremely hard and I understand that.
(Mrs Lemmon) Going back to what I was saying before,
if do not look after your staff, if you do not give the staff
the impression that they are being cared for and they are a high
priority in the situation we are in then staff will not continue
to work in that situation.
176. Are you suggesting there has been a decrease
in the quality of care?
(Mrs Lemmon) I do not think there has been a decrease
in the quality of care. What you have got are the people who remain,
the people who say in the acute nursing service are the people
who are very dedicated, very skilled and who can offer you the
most. The people who come out of the situation are those who cannot
cope with the pressures and who feels their skills would be best
applied else where. The ones who are left are the people who can
give you absolute, top return for your money, if you like.
(Mrs Bottrill) I want to come in on this issue about
bed reductions and PFI. I think it is very difficult to link bed
reductions totally to PFI. We have actually given evidence that
in the smaller PFI schemes, where there was an opportunity for
community services to develop alongside the scheme, you have a
working situation. It is when you have the larger schemes, with
the corresponding bed reduction numbers and you have not got the
back up system outside the acute hospitals. I have worked for
24 years in an acute hospital, I understand about changing patient
services, doing things faster, doing it in a day instead of a
week, I have been part of it. In fact we now do have the patients
in the larger hospitals who are highly dependent and there is
nowhere else to put them. You therefore get the inappropriate
boarding out of medical patients in the middle of an orthopaedic
ward or a surgical patient in a gynaecology ward, it is going
on all over the place, that is unacceptable to a professional
nurse to try and have that case mix shift after shift after shift.
It is rather like asking an accountant to go and do a bit of admin
work in the personnel department, they will be able to do some
minimum things, they will not be able to carry out the task appropriately
because it is not their chosen speciality. That is where the quicker
throughput will have a demoralising effect on the nurses.
177. I know nationally the recruitment and retention
of nurses is severe, how severe is it within this area?
(Mrs Lemmon) I can only give you instances of our
actual experience. If we advertise in the Trust for a D grade
staff nurse to work in the acute sector we are lucky if we get
one or two applicants. If you advertise for a team assistant you
will get upward of 50 applicants. I think that indicates there
is a lack of qualified staff available. In order to get people
into the job you have to give them decent working facilities.
It is bad enough having the pressures of the actual job but if
you then do not support with ancillary support, decent changing
facilities, whatever, then nurses will look elsewhere. That happens.
I have had colleagues who have spoken to me and said, "I
thought about coming to work in your hospital but I have better
facilities up the road, I will go there". They have open
choice.
Chairman
178. Going back to the original beds issue and
the wider arrangements for social services care or whatever. Mrs
Bottrill, you implied that smaller schemes could be what we term
whole districting, I have quite a large scheme in my area and
we have initial approvement by the government, and that is a whole
district scheme that is looking at primary care, intermediary
care, you seem to imply that this could only happen with a smaller
scheme, why could it not happen with larger schemes
(Mrs Bottrill) I think if there is a smaller scheme—and
our evidence is based particularly on mental health patients—if
you look at the scheme, at the build, at the service and look
at the service delivery and everything that needs to be in place
then you have a greater chance, in our experience, of delivering
on that. As it escalates up to a larger scheme some things just
seem to fall off people's thinking and I think that is where we
now have fragmented services and you have not got the appropriate
number of intermediate care beds to pick up the patients who are
having major operations in this hospital today. If you started
looking at processes and then build the process round the patient
you might have had a better chance of matching the two. You have
a design ethos here but the functionality went out the window
when people started to design the building. I think it is an issue
that people have also tried to rationalise services in this area
as well and that has confused the clinical staff as to exactly
what is the fault of a functional building and what is the rationalisation
of services.
179. Mr Price, from your study do you want comment
on that general point? Have you looked at various schemes?
(Mr Price) If I can make two comments, one is that
there is that affordability problem again. In looking at the acute
sector PFI one of the routes that has been very frequently taken
with PFI is bringing in money from other parts of the health care
system to bail the acute sector PFI out. One of the places where
it comes from is community sector investment. You have this paradox
of a new hospital, a smaller hospital dependent on greater post
acute or sub acute care and you have a withdrawal investment from
the sub acute sector. That is a paradox. I do not know whether
this happened in Dryburn but plain community investment had not
taken place. The bed blocking here suggests that the community
schemes was not in place with the acute scheme. The other point
I would make very briefly is there is a hypothesis that underlines
all this, there has been a steady unrelenting and constant increase
in the efficiencies of inpatient management, that is to say a
higher occupancy rate, higher throughout rates and shorter length
of stay. The problem with that assumption is the efficiency gain
is meant to have made room for PFI, your health care spending
would go further if you increased efficiency and you could make
room for the higher costs. The problem with it, and it has been
shown by the National Bed Inquiry, is that the efficiencies have
pretty well tailed off since the mid 1990s. In other words, the
bottom line there is that you have a capital finance strategy
that is at odds with your health care needs assessment and that
is a very serious problem.
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