Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 40 - 59)



  40. Presumably the number of people waiting 18 months is not very many, is it?
  (Mr Crisp) 200 or 300.

  41. Exactly, so why are they waiting 18 months?
  (Mr Crisp) Specifically on the 18 months, about two-thirds of them are tonsillectomies and adenoidectomies where we have had a particular problem in dealing with those patients in the course of this year. So there are about two-thirds who are there for a very, very specific reason. On top of that, there are a few people who have slipped through the system for whatever reason. We should not have any.

  42. Why can you not say to someone who has had to wait 18 months, "Come in and we will do that operation now"?
  (Mr Crisp) These really are anomalies. We actually have at the moment something of the order of 8,000 who are over 15 months, and the number who are over 18 months is a very small number and they are there for very specific reasons, but they should not be there.

  43. Let's move on quickly and get on to the part I really want to get to. This is the topic I raised in this Committee a year ago probably, 18 months ago, I have written to ministers about it, I have written to the Chairman of the Health Select Committee and—I am going to take the credit—I think it is in this report because of me, to be quite honest. It is to do with GP referrals and trust lists.
  (Mr Crisp) Can you show me where?

  44. Paragraphs 3.12, 3.13 and 3.14. The Chairman touched on it. When I said that the consultants were to blame and the doctors were to blame I came to that conclusion because of constituency cases. I had a constituency case where a gentleman came to see me in my surgery, his eyes were streaming with tears and he was complaining that he had to wait 15, 16, 17 weeks to see a consultant. I said to him, "Did the doctor give you an opportunity to go somewhere else?", he said, "No, that was never given as an alternative." This was a Saturday and I said, "Go back to your doctor on Monday morning, tell your doctor you do not want to see the consultant she has told you, you want to see another consultant, I have the lists in my office, I will look up the lists and I will ring you up over the weekend." I found out that the North Durham Hospital was 15, 16, 17 weeks, but at Sunderland it was three or four weeks. He went back to the doctor on Monday and told the doctor and she said, "Who has told you this?" He explained and she said, "You have to go to North Durham", he said, "I don't want to, I have been told I can be seen quicker somewhere else". He insisted and he was sent to the hospital in Sunderland in three weeks, and two or days after he wrote me a letter saying "Thank you very much indeed." I then got a letter from the doctor telling me to mind my own business, that I had destroyed patient/doctor trust. I wrote back and said, "No, it wasn't me who betrayed the trust, you betrayed it because you did not give him the information in the first place." That was one case. There are other cases where doctors refer patients to a consultant in a specific hospital—and the Chairman has mentioned this. I have some examples here which I got this morning. In North Durham, for ENT the longest waiting list is 13 weeks, the shortest is six weeks. That is not a very bad example. In ophthalmology, 32 weeks for one consultant in the hospital, another consultant in the same hospital, nine weeks. So the list could be virtually halved if there was a system of pooling where the doctor referred to the hospital pool for ophthalmology rather than to a specific consultant, yet they will not do this. When I asked my doctor why he did not do this he said he did not have the time to do it. That is in the same trust. Take gynaecology, for example, in North Durham you have to wait 42, 33 and 33 weeks to see the consultants, in Sunderland, which is ten minutes down the road, five weeks, eight weeks, nine weeks, 11 weeks. So why are those consultants not used by different doctors? All they have to do is look at the list, see where the shortest list is and send their patients to those hospitals. Why are consultants and doctors stuck 100 years ago where they are not prepared to manoeuvre at all to help the patients?
  (Mr Crisp) Let me deal with the two issues separately. Firstly, the one about the GP deciding whether or not to refer to the person in the local hospital who had the shortest waiting list. They have that information at the moment, what we are saying, and what I said to the Chairman earlier, is we want to make sure that information is also available to the patient because there may be some reason for going to the person with the longest waiting list. They may be a particular sub-specialist in that particular speciality.

  45. Or the doctor plays golf with the consultant.
  (Mr Crisp) I think that is not relevant.

  46. I think it is very relevant.
  (Mr Crisp) It certainly would not be relevant when the patient has got that information as well. I do think it is right for us to be in that position and you will have heard our Secretary of State saying that. On the second one, where people are referred to North Durham Hospital rather than to Sunderland Hospital, the health authority which has responsibility for planning for the care and paying for the care of people within that area has chosen to do that. They may choose to do it differently in the following year and send patients to Sunderland rather than to North Durham, however that is a local choice, but again you will have heard the Secretary of State talking about how it would be important to try and introduce some choice within the system, because the point you make is a very strong one.

  47. Do you accept that if the system was to change so that GPs referred not to specific consultants but to pools or to different trusts where the lists were much shorter, the people having to wait would considerably reduce without another penny being spent?
  (Mr Crisp) The two issues are separate. The first one about the pool, in general we think that is the right way to go unless there is a sub-speciality reason—if the guy you are referring to is good on shoulders and not knees. That sort of issue.

  48. I accept that.
  (Mr Crisp) The second point is these are powerful arguments, we need to look at them and work out how to do it practically. You will be aware that was where the Health Service was a few years ago to a significant extent in terms of running the internal market. Now we are looking at how we ought to manage the introduction of some choice without going down the same route as before.

Mr Gibb

  49. I want to go back to the Chairman's question regarding paragraph 2.22. You gave a measured answer talking about balancing positions and so on. If you read the paragraph it is really quite damning, it says that nearly 52 per cent of consultants said they are working to meet NHS waiting list targets which meant that they had to treat patients in a different order than their clinical priority indicated. That is a very damning thing to say, and you talk about balancing positions and priorities as a response to that. Have any consultants been disciplined by their professional body as a result of taking these kind of decisions?
  (Mr Crisp) Let me explain the reply. This helpfully tells me there are 20,000 consultants working in the NHS, I said 17 to 20,000. You will notice that they interviewed 558, and you should be aware that half of those were in trauma or orthopaedics, so this is a very selected group of consultants you are talking about. That is just by way of background and there may be some particular issues in some specialities and not in others. That may be more likely to be the case there than it would have been in heart surgery, for example. Your second point, has anyone been disciplined to do this, I am not aware of anyone being disciplined for doing this. Where issues have arisen or have come to the attention of the Department, clearly we have intervened and made sure they are not repeated.

  50. Do you think it is ethical for a consultant to cave in to pressure from management to deprioritise somebody they believe in their professional judgment should take priority over another patient?
  (Mr Crisp) If it were that black and white and if we were absolutely clear, but if you just look at this information here, this is asking consultants if that has ever happened and giving a few examples which—because we do not know what they are—we have not actually had a chance to look at properly. If a doctor believes that he or she is being ethically compromised by something they are meant to be doing, then they need to raise that with their managers, they need to decide how to handle that. We are very clear, we do not want clinical standards or priorities to be interrupted.

  51. So do you think it is not happening?
  (Mr Crisp) It may be happening in some individual cases.

  52. Do you not know?
  (Mr Crisp) One hears allegations from time to time and where those are investigated, if there is a problem, it is made sure it is stopped.

  53. Do you agree with Martin Taylor, who said before another Select Committee, the Public Administration Select Committee last week, that the NHS targets such as waiting lists are essentially political targets? He said that he did not blame ministers, it was the natural consequence of excessive promises made in the past and a kind of national hysteria. He went on to say that if you have one key target and subordinate all else to that, things will go wrong, "it is a dangerous trap which we fall into". Are we falling into that trap?
  (Mr Crisp) No, I do not believe we are. The first thing which has to be said, whether there are political issues here or not you will be better able to judge, but there are patient issues here. When we talk to patients, the single biggest issue which they raise every time is waiting, and it is not just waiting for admission to hospital, it is waiting for access to a GP, it is waiting within the Service. This is a very important patient issue. Secondly, it is not our only target. In fact, we normally get accused of having too many targets. We have very clear targets around cancer, coronary heart disease and so on, which are enormously important, and around emergency care. So this is not the only target we have, but it is one which for patients is important.

  54. I am slightly alarmed by your complacency. We have the NAO Report saying there is something going on here, we have people like Martin Taylor saying there is something funny going on here, but you are saying as far as you are aware there is nothing funny going on?
  (Mr Crisp) I am sorry if I am being complacent because this is serious, as I hope I said at the beginning, not least because we have issued so much guidance on it. The other thing, and this brings me back to what we are doing in the future, is you can tell people to do things or you can tell people not to do things, but how do you make sure it happens. One of the things we need to do is to help people manage their waiting lists better and that takes us back to the issues of good practice, and again we have issued some very clear guidance around how to handle that.

  55. There have been some recent falls in the waiting lists but there have also been some increases in the waiting times at the wrong end, between 12 and 17 months. For example, in the last quarter I have figures for, inpatient waiting lists have gone up from 41,000 to 46,000. Are we seeing falls in inpatient and outpatient waiting lists at the expense of longer waiting times? Is it like squeezing jelly, you push it in one place and it comes out somewhere else?
  (Mr Crisp) You are referring to the quarter on quarter change, are you not?

  56. Yes.
  (Mr Crisp) Whereas actually, if you take a year on year change, you will see the 12 month-plus waiters are coming down. At the moment they are 44,670. Is that the figure you have for 12 month-waiters at the end of September?

  57. It is a similar figure to the one I have.
  (Mr Crisp) Whereas a year ago it was 51,000. The year before that it was 50,000. We are trying to squeeze that down. At the end of this financial year I am expecting that figure to be about 25,000.

  58. So it is not just coming out somewhere else? You do not see an extension of waiting times as a consequence of targeting waiting lists?
  (Mr Crisp) Sorry, the point I should have made is that we have actually changed our policy in the last few months to make it clear we are concentrating on waiting times, not pure numbers on the list. But we do need to increase activity to get those waiting times down. Waiting times are the important issue.

  59. On a general issue, how do you think that health policy should be changed to cope with ever-improving advances in medical science?
  (Mr Crisp) I think I am here to talk about implementation rather than speculate about health policy.

  Chairman: I should say we should not get too much into policy.

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