Examination of Witnesses (Questions 60
- 79)
MONDAY 19 NOVEMBER 2001
MR NIGEL
CRISP AND
MR DAVID
FILLINGHAM
60. You mentioned earlier Norway and the fact
that as from January of this year in Norway people have a free
choice of hospital. The Telegraph reported the other day
that you will be able to have a choice if you have been waiting
more than 12 months. Is that right, that you will have a free
choice of hospital if you have been waiting for more than 12 months?
(Mr Crisp) Happily I am not here to speak on behalf
of the Telegraph or any other paper, but we are certainly,
as Mr Milburn has made clear, looking at how we can introduce
more choices in the system. There are some choices in the system
at the moment and we want to emphasise them and make it clear
that patients have more control in the ways I talked to Mr Steinberg
about earlier. Whether that particular report is accurate or not,
I do not know.
61. But you are the Chief Executive of the NHS.
(Mr Crisp) But not of the Daily Telegraph.
My interest is in looking at firming up exactly how we introduce
choice into the NHS.
62. Is it not possible we could have a free
choice of hospital throughout Britain without waiting 12 months
first of all?
(Mr Crisp) I think that would be highly desirable.
Let us be clear though that we are coming from a position which
is, as this report says—and this is what I am relying on,
I am not remotely complacent about it—unsatisfactory. We
need to make a lot of changes here and we need to increase activity,
increase staffing, improve the way we are doing things. Over that
period of time we will, I believe, get to a point where the patients
will be much more in control and where we should be able to look
at choices in the way you are talking about.
Chairman
63. Before I turn to the next member can I ask
a question of the Comptroller? It arose from an answer given by
Mr Crisp on paragraph 2.22, where Mr Crisp mentioned the very
low numbers who responded to the survey, 558 out of 20,000, and
Mr Crisp seemed to be suggesting that this threw into doubt the
validity of the conclusions reached. Would the Comptroller or
somebody from the National Audit Office like to comment on that?
(Sir John Bourn) The position on the figures, Chairman,
is that we got the fullest information we could in the time available
and we discussed it and the number of cases with the Department,
but we are not claiming that the figures meet the highest criteria
of the statistical profession. Nonetheless, we think they give
to the Committee a good indication of the thrust and the nature
of the issue.
64. But of course Mr Crisp has agreed this report,
so presumably you both agreed that although it is a low sample
it does have a real validity for our deliberations, otherwise
you should not have agreed the report.
(Mr Crisp) I intended to make the point, and am happy
to make it now, that this sample, 50 per cent of which is from
one speciality, is an indication that we have a problem. My point
was that it is not so it is a problem across all specialities
and there may be some other areas where this is not an issue,
so we need to treat it as a problem and identify it as a problem
and deal with it but there are some other aspects to take into
account as well. That is all I can say.
65. But if you had some further information
that this was giving us a wrong view of it, because of the other
specialities, you might share that with us in a note?
(Mr Crisp) Indeed, let me come back to you on that.
Geraint Davies
66. Turning to the point that has just been
made, in Croydon, which is my patch, it says that 52 per cent
of orthopaedic patients have to wait over six months, which sounds
appalling. At the same time, when I quizzed the Trust they said
to me between March 1997 and March 2001 there was a 13 per cent
overall reduction in inpatients and a 44 per cent reduction in
outpatients. How would you comment on that? Is that something
that underlines your earlier comments, namely this is very tightly
focussed on certain disciplines and we cannot infer it across
the board or is Croydon trying to pull the wool over my eyes?
(Mr Crisp) I have a briefing here from Mayday. I think
what they have illustrated to you is that they have focussed on
a set number of issues, they have actually made a significant
improvement in quite a lot of areas but I think they are also
recommending they have further to go and the capacity issues around
orthopaedics are significant, it is a very high number.
67. They have to try to make improvements but
I am only commenting on the point that has been made by the Chairman
of the C&AG that it appears in that case that we cannot infer
from specifics, in general they seem to be doing very well and
in specifics they seem to be doing very badly.
(Mr Crisp) I think that is right. I also think the
point there is that we have to look at this in each trust to understand
what is really going on.
68. There is trade-off, if one wanted to be
a statistical manipulator, working in the trust between producing
the overall numbers on the list and getting maybe a quarter of
patients and making them wait an extra six months, you keep a
certain section of people waiting an enormous amount of time and
you push through a lot more people and therefore reduce your overall
waiting list, is that a strategy you see adopted?
(Mr Crisp) I do not think it works like that. What
you need to do, what the chief executive needs to look at is to
understand the composition of people on their list and they need
to understand the people in each speciality by the clinical severity.
They need to make sure that people who are most clinically urgent
are got through quickest and even within a category the people
who have waited longest are dealt with first, sometimes it is
just as basic as that.
69. There is trade-off in there because even
if one went down the line that it has to be clinical importance
first then you would never treat anyone with an ingrown toe nail,
would you?
(Mr Crisp) On paragraph 2.21 of the Report there is
an important balance to be struck. There needs to be some flexibility
in the order in which patients are treated. We must not do it
too far the other way, but the point that is made here is that
on an operating list you know you are able to do two big cases
and three little ones.
70. If there is a little bit of space over I
can have my ingrown toe sorted out. The point I am making is that
unless you say that it is not the case that the more serious ailments
are dealt with then we are never going to deal with minor ailments,
other that in the five minutes at the end of your session.
(Mr Crisp) You can do it in a planned way, if you
look at the more serious ones and you conclude they need to be
done in the next four weeks or five weeks you can plan to do that,
but if you have the right strategy you can also plan to do the
people who have been waiting up to 12 months. You can actually
do it a planned way and manage to achieve getting clinical priority
right and also getting admission for the more minor cases.
71. The NHS plan pushes forward a more ambitious
target, you no longer have to wait more than six months by 2005.
Coming back to my ingrown toe nail, does that mean there is enormous
pressure suddenly to deal with large numbers of minor and relatively
trivial cases?
(Mr Crisp) We may put more capacity on to it, perhaps
I can give you another illustration, we do as a matter of practice
make sure that we get patients of clinical, with some minor exceptions,
importance, that does not mean to say we should not also plan
for the people who are less clinically important. I note that
the Royal Marsden, which specialises in cancer, seems to have
an average waiting least of seven weeks whereas the average waiting
time across the country as a whole is three months. You can see
we are putting resources in places where people have greater clinical
need, you have to do both.
72. You are not encouraging people where there
are longer waiting lists to go to the Royal Marsden?
(Mr Crisp) There may be some scope for that but currently
people will be referred to the Royal Marsden primarily based on
geography and clinical need.
73. If you did allow Mr Steinberg's suggestion
will find that the Royal Marsden waiting list is increasing again?
(Mr Crisp) I am sorry we have opened up the whole
question and debate of whether or not we should have an internal
market for this because you are assuming certain consequences
of doing that. I think there is scope for us to introduce choice
for patients in a controlled way and in looking at it we need
to make sure there are not negative effects that come out of it.
74. We would all agree with that. 46 per of
chief executives are said to have redefined the way they accounted
information in the year 1999/2000, of which nearly 90 per cent
said that meant a reduction in waiting lists. Are you finding
that a preoccupation inconsistent with other trusts and is this
going to be straightened out so that we do not have apples compared
with oranges?
(Mr Crisp) Yes, we are. Firstly, the definitions have
remained consistent through this period. It may be that people
may be looking at how those definitions have been applied in their
own hospitals.
75. It says in the Report, "redefined the
way it counted its inpatients and nearly halved it in one year",
the definitions have not remained the same.
(Mr Crisp) What you will find that that means, as
I understand, is that some procedures which have previously been
treated as inpatients have become outpatients, so that something
like an endoscopy or a cataract operation will have transferred
from an inpatient procedure to being an outpatient procedure.
That is because medical practice is changing. That is why that
is happening. We have kept the definition consistent through this
period and that will continue to happen, more and more people
will be treated as day patients who have previously been treated
as inpatients.
76. In terms of definitions this Report does
not include Accident & Emergency, pregnancy admissions or
anything like that, does it? From the point of view of inpatients
that does not include second or subsequent appointments, just
the first appointment.
(Mr Crisp) It does not.
77. There are limitations to this Report, are
there not? Tell me about the 1.5 million patients who are scheduled
to have a first appointment and the 13.7 million who do not turn
up, what are we doing about that?
(Mr Crisp) One very strong thing we are doing about
that is moving to a booked admission system. What I mean by that
is at the point at which it is decided that you need an operation
or an outpatients appointment—Mr Fillingham can explain
the system much more clearly - you will have the choice of a date
and you are able to be slotted into a diary.
78. It is extraordinary that we are only just
starting that. At one point I ran a travel business where people
telephoned and said, can we go on holiday on this particular date
in this particular place. You booked them, or not, they either
go somewhere else earlier on or later, there will always be trade-off
in booking appointments in the NHS. It is amazing to me that we
have waited this long for people to know when they have their
appointment rather than some time in six months. Is that not one
of the reasons why we get so many people not turning up, because
there is no clarity from the NHS when they are supposed to go
and if they do not turn up there is no sanction against them?
(Mr Crisp) In general I agree with you, which is why
we are introducing the booked admission system. Where we have
introduced this the evidence has shown that we are reducing the
number of people who do not attend. That is where we need to go.
By March 31 five million patients will be in the booking system,
so we are moving there.
79. Operating theatres are normally open between
8.30 and 5.30 normally, something like 40 per cent go over that.
What I do not understand is why they are not open 24 hours a day?
(Mr Crisp) Let me just pull out two points here, in
every acute hospital there will be some theatres that are because
of emergencies, we will have that continuation. In terms of planned
lists in general we are working a day that is between 8.30 and
5.30, as you say. The limiting factor there is other aspects of
capacity, most notably staffing, including surgeons and secondly
bed availability. Our theatres are not in general bottlenecks
for getting more people through.
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