Examination of Witnesses (Questions 1
- 19)
MONDAY 19 NOVEMBER 2001
MR NIGEL
CRISP AND
MR DAVID
FILLINGHAM
Chairman
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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