Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 1 - 19)




  1. Good afternoon, welcome to the Committee of Public Accounts and welcome to Mr Crisp once again.
  (Mr Crisp) Thank you, Mr Chairman.

  2. This afternoon we are looking at the Comptroller and Auditor General's report on Inpatient and Outpatient Waiting in the NHS. Would you like to introduce your colleague, Mr Crisp?
  (Mr Crisp) Could I introduce Mr Fillingham, who is the recently appointed director of the Modernisation Agency, which is that bit of the Department which is focused on driving forward change and spreading good practice. I have brought him along with me because this is a topic of considerable importance in the light of this report.

  3. Thank you very much. We last reported on this subject in November 1995 and we recommended that the NHS measure the total time a patient waits for treatment. Why has this not happened?
  (Mr Crisp) We have looked at this on a number of different occasions. What we have done is actually go for a two-part process effectively. The first one is to say that for most patients with most conditions going for an outpatient appointment does not necessarily result in an inpatient appointment, and indeed, putting it the other way round, for many people who are admitted they do not necessarily come through an outpatient route, therefore for performance management purposes it seemed sensible for us to measure those two elements. That is in general. However, on specific cases, where it is clear there is a co-ordinated patient pathway, if you like, through the system, we are specifically measuring time from urgent referral to treatment, and we are bringing in some new targets around cancer, coming in in December this year, and we are bringing in a target of one month for time between urgent referral and treatment for children's cancer, bringing in the same thing for two months for breast cancer and so on. So for those conditions where we think it is appropriate to do that, that is precisely what we are doing, but in general we are going for the two separate indicators.

  4. I am glad you mentioned cancer because that begs the question, if you are doing it for cancer why not do it for a wider range of conditions?
  (Mr Crisp) I think over time we will do that in those areas where we have got National Service Frameworks, and for example in coronary heart disease we will be looking at the total wait and so on, but in the generality of cases that is not the case. People go to outpatients, it is not known they will be going on for inpatient operations, and, as I said before, a number of people coming in for inpatient operations will not necessarily come in through the outpatient route.

  5. I now refer you to the variations in the average patient wait for treatment. If you look at Figure 7 on page 12, you will see there are very wide variations. Why is this the case and what are you going to do about it?
  (Mr Crisp) There are three issues here in terms of variations. One is simply capacity, and the history of capacity, and if you look at some of those areas, and I take an example like, having mentioned it already, coronary heart disease, the facilities available for treating coronary heart disease are much greater in the south of the country than in the north. That is something we have to change and indeed we are in the process of changing. So the first issue is the capacity constraints in some parts of the country. The second issue is about effectively the management of the systems and the focus within the systems, and we know that some hospitals can do this far better than others, they can move people through the system far better than others, and that is precisely why this report focuses on the fact we need to make sure we identify through active research the lessons why some people do it better and make sure we spread those good practices, which is the role of the Modernisation Agency.

  6. But you accept it must be one of your objectives to overcome these disparities, otherwise you are going to get more publicity about postcode lottery, are you not?
  (Mr Crisp) I think it is very important we do. As I say, the particular discrepancy I have just referred to between the north and the south is something which is particularly important.

  7. But it is not just between north and south, there are discrepancies between areas which are very adjacent. For instance, let us take one example close to me, in the Lincolnshire Area Health Authority, 24.6 people per thousand of the population are on an inpatient waiting list compared to 19.1 in South Humber, just over the border. So it is not just between north and south, is it? Perhaps you could explain that variation?
  (Mr Crisp) That is why I say it is multi-factorial, it depends on a number of different things. One is the capacity, and that may apply in those two hospitals which are being referred to, which I do not know in detail, historically one may have greater capacity than the other, and therefore that needs to be tackled. The second one is, one may have some better practices in terms of bringing in people in terms of running the whole system, and that too needs to be examined. It is the combination of the two things together.

  8. You will be trying to disseminate best practice, for instance, in that particular example I have just referred to?
  (Mr Crisp) I do not know the particular example but very clearly we have produced two things. Firstly, the National Service Frameworks for the major diseases, such as coronary heart disease and cancer, which are identifying the levels of treatment which are needed in different areas, if there is a capacity issue in your part of the country, in either cancer or coronary heart disease, it ought to be picked up through those frameworks and planned for. Secondly, we have a whole battery of ways, a number of which are illustrated in this document, in which we spread good practice, including at one level sending out documents and making work books available to people, but on the second basis perhaps more strongly sending in teams to help and support people make change where that is necessary.

  9. Another important difficulty that the report shows up is dealt with on page 18, paragraph 2.22, and this lists a number of cases where people requiring urgent surgery have had to wait while patients with more routine surgery are treated in order to meet waiting list targets. Do you agree this is wrong and what are you going to do to prevent it?
  (Mr Crisp) Yes, we do agree that is wrong, and the Department of Health has consistently said it is important we do not have this happening. Let me say two things. The first is, if the waiting list system is run effectively, this need not happen. Indeed the report itself points out that you can run the systems in a way which allows you to make sure that you put patients in order of clinical priority and then in each category you take the patients who have been waiting longest, and the report itself points out there will be times for example on a theatre list where you have a bit of space at the end of the list where you can take two or three minor cases which may be less important cases to balance up the major cases. So there are ways of doing this. We are clear, again, about the importance of disseminating that good practice. The second point I would make is that this is a relatively brief survey of a number of consultants only in specific specialities, it is not either our policy nor is it as widespread as this might imply I think. Let me give you two examples. Firstly, we have driven up rates of coronary bypass surgery faster than we have driven up activity in other areas, so we are concentrating resources on some of the most important areas. Secondly, if you look at the lists and analyse them, you will see that we are continuing to admit the same proportion of people who have waited three months as those who have been waiting longer. The point being, we are giving the same priority to the different parts of the list now as we have been doing over the last few years.

  10. But is it not going to become even more a problem for you because the Government has set very ambitious targets to try and reduce waiting times, I think15 months by next March, six months by 2005, and could this not introduce even more potential distortions?
  (Mr Crisp) Not if we actually manage the system appropriately. We have examples around the country, as this report again shows, of people who have been managing to do that. The sort of accusations you have talked about will not be coming in, for example, from Dorset, which features largely in this report, and those sort of areas, who have much smoother systems it seems to me of bringing patients into hospital. So the models show we can do it, the key is to make sure everyone involved, the clinicians as well as the managers, buy into this process and make it happen.

  11. Let me then just spend a moment talking about good practice and how this can be spread around the country. On page 23, paragraphs 3.2 and 3.3, we can see there is good practical advice available to chief executives on how to manage waiting lists. Can you give us a flavour of what are the main obstacles to spreading good practice and what are you doing to improve matters?
  (Mr Crisp) Let me give an outline answer to that and then it may be appropriate if I brought in Mr Fillingham to make it more precise, if that is okay. There are obstacles and the main obstacle is the one of history, if you like, on the basis that we have done it this way for years within this particular setting and therefore what are the incentives to change. We know among the incentives to change there is providing people with information, but that does not always work. The most effective incentive to change, it seems to me, for a surgeon working in a particular area, say eye surgery, is to see what surgeons are doing elsewhere within that speciality, and that is why we have programmes like the Action on Cataracts, which is precisely about bringing together the clinicians working on cataracts around the country so they can learn from each other. Doctors will learn from doctors and managers from managers, and that is the most effective way it seems to me to spread it.
  (Mr Fillingham) The report actually refers to the National Patients Access Team and from April of this year that is now part of the Modernisation Agency and we have added to the National Patients Access Team a number of other teams who are working with front line clinicians to help make change happen across the NHS. As Nigel Crisp has said, that is not easy in a very large and complex organisation but we are beginning to see some successes coming through. There are three strands to what we are doing. The first is a series of national programmes to make sure we do reduce variation, we do get consistently good practice right across the NHS, Action on Cataracts, Action on ENT, Action on Orthopaedics, for example, and we have a Cancer Services Collaborative which focuses on front line clinical staff working together to resolve the problems and difficulties. Set alongside that is intensive support for those organisations who are in the most difficulty, and we have a visiting support team which can visit trusts in Lincolnshire, in Southampton, in other areas right across the country, to bring to them examples of good practice elsewhere, and to bring to them skills they may not have had before. The third and final strand, which is very important, is that the new NHS Leadership Centre is part of the Modernisation Agency and if a lot of the change is to happen it is about really good leaders, and that is not just about managers and chief executives, it is about operational managers everywhere and crucially about clinical leaders. If there is one single big thing which helps get best practice transferred across the NHS, it is very strong clinical involvement from clinicians.

  12. Let me take one example of good practice, it is mentioned on pages 25 to 26, which is the case of doctors making referrals to consultants. If they refer to a particular consultant who may be heavily overloaded that can cause difficulties, but if they just write a "Dear Doctor" letter that is much easier on the system. So that is one example. What are you doing to spread around that example of good practice?
  (Mr Crisp) The point there is that doctors traditionally have not liked the "Dear Doctor" letter, there is a resistance to that.

  13. Why?
  (Mr Crisp) If I think of hospitals where I have worked, the issue has been about developing the relationship between the primary care doctor, the GP, and the hospital consultant, and therefore people see them as "their patients" coming into the system, and they are part of that referral relationship. We have had to move on from that for a number of conditions, for the reasons you have talked about, and that would be precisely one of the things which would be tackled within the sort of processes which David Fillingham has talked about, and there would be agreement about for what conditions it would be appropriate to do that, because it may not be appropriate for every condition if, for example, some people were more specialised than others.

  14. Do you want to say a word about that, Mr Fillingham?
  (Mr Fillingham) The involvement of GPs is absolutely crucial to the kind of programmes the Agency is running, so Cancer Collaborative, the Heart Disease Collaborative, have GPs very much as part of those teams, because from a patient's point of view it is the whole process, the whole patient journey they want to see improved from first going to the GP with a problem, right through to that problem being resolved and them hopefully being well again. That is the whole pathway we have to manage effectively. We have a number of programmes running with general practitioners looking at how we improve referral processes, how we improve the monitoring of that patient journey, and we are starting to see some quite considerable successes.

  15. One last question from me before I turn to colleagues, what are you doing to provide better information and more information on likely admission dates?
  (Mr Crisp) At the moment, there are two or three things. There is the College of Health to whom we provide information which they then are able to provide to patients when patients approach the body. Secondly, we provide a certain amount of information retrospectively around waiting times and so on, which is available on the internet across the whole of the country. Thirdly, we provide specific information to GPs, so GPs should have the information available to them of waiting times for an outpatient or inpatient appointment within their local hospitals. However, that is not good enough, and again there are some interesting examples in here from Norway and Sweden where that latter information being provided to GPs is actually provided much more widely to patients, and the GP and patient can look at it together. We are looking at the feasibility of doing that. Certainly, we know we can do that by 2005 when we have the fully integrated booking system, which is referred to in here, but the question is whether or not we can bring it forward, and that is what we are looking at at the moment.

Mr Steinberg

  16. I am going to choose some of the points the Chairman has raised and a few other ones. Based on the number of constituency cases which I have had over the years, going back I suppose 15 years now, I came to the conclusion a long time ago that one of the biggest problems in the Health Service is the doctors and the consultants themselves. I think they cause most of the problems, frankly. Vast resources have been put into the system over the last two or three years, I think it says at the beginning £737 million, and this has shown some results but there are still problems. Why are the problems still there when considerable sums of money have been put in?
  (Mr Crisp) Because it takes a long time. That in some ways is a trivial answer but maybe we can contextualise it a bit. In your local hospitals, you will have a number of clinicians who certainly are the leaders locally, who have been doing their work in a particular way over a number of years, and they have been brought up and educated and trained—

  17. Exactly, so they will not change their practices. They have had practices for 20, 25 years, and they will not change the way they work.
  (Mr Crisp) That may be true for some people, but I think the important thing is actually we have also, if you like, left those people working in those areas without actually coming and working alongside them and making sure we introduce them to some of the changes which have been going on in recent years. The sort of things we are doing through the Modernisation Agency, where we are bringing the consultants who work in cataract surgery together with the other consultants who work in that field, to look at how they manage their lists and so on, is I think very important. The other point I would make, before I go down on the record as implying doctors are stuck in the mud and do not change—

  18. If you had said that originally, I would have given you more respect, because that is the situation, is it not?
  (Mr Crisp)— is that it seems to me doctors are very good at moving on in clinical practice, what they are less good at is some of the management practice issues which they may not see as being as important as we do.

  19. On page 8, paragraph 1.13 and I think it is mentioned in paragraph 1.21 as well, it tells us about how consultants have a contract with the NHS. Tell us a little more about the consultants' contracts which specifies their workload et cetera, because that impacts tremendously on the lists, does it not?
  (Mr Crisp) It can do but a consultant contract is, and I suspect you know they are being renegotiated at the moment—

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