Examination of Witnesses (Questions 40
- 59)
MONDAY 19 NOVEMBER 2001
MR NIGEL
CRISP AND
MR DAVID
FILLINGHAM
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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