Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 80 - 99)



  80. Tell me about bed availability and bed blocking, it is the case that some people in the nursing home industry say had there is almost a shortage of nursing homes, particularly in London and the southeast, and people are selling up and going into residential homes, normal people who do not need support, and in fact the cost of beds in nursing homes is appreciably less than the NHS. Do we have the numbers wrong, should we invest more in nursing homes and less in marginal beds in the NHS?
  (Mr Crisp) This is taking us into another hugely big and important topic.

  81. It does impact on waiting lists.
  (Mr Crisp) But it is not quite exactly as you describe it. We have this year about the same number of people delayed in hospital by lack of a transfer to nursing homes as we have had in previous years.

  82. Too many.
  (Mr Crisp) Too many. We need to understand why and what we can do about it, because it is not just as simple as putting up the price of nursing homes or creating new ones. There is a whole series of interventions we need to put in place. You are quite right, when we have people in hospitals who do not need to be in hospital, we cannot put people in hospital who do need to be in hospital. So it is all part of a much bigger system.

  83. What I am getting at in simple terms is that the cost of an extra bed in the NHS is the same as the cost of two beds in the nursing home sector, so clearly at the margin you start shifting resources.
  (Mr Crisp) But if you have also worked in the airline industry, you will know the marginal cost of a seat in the airline industry is pretty small, and if we shift two people out of Mayday Hospital and put them in nursing homes, we will only release the marginal cost in Mayday and it is not as big as the cost of putting them all in nursing homes for the next three years, which is the average length of stay people have in nursing homes.

  84. These people do end up in nursing homes, so it is a question of when they go in.
  (Mr Crisp) But they go in through a properly planned and funded stream. It is not as simple as saying, "You can take the marginal cost out of hospital", which is by and large smaller than the cost of introducing a new residential bed.

  85. Actually the marginal cost of acquiring an extra bed and not using it but buying it is more than the average cost, is it not?
  (Mr Crisp) We can open this up for a longer discussion.

  86. I will move on. A comment I made the last time you appeared before us was something along the lines that various royal colleges were saying that because of recent cases of negligence claims have been successful against doctors, and doctors are reluctant to rush through very large numbers of patients they are diagnosing in case they make a mistake, and because of that the Royal College of Surgeons, the Royal College of Physicians, the Royal College of Ophthalmology and indeed Urology and Orthopaedics as well, as I understand it, are recommending that they look at 15 minutes per patient, or 20 minutes for a new patient, 10 minutes for a follow-up. Given that is quite a lot more than currently they take to see these, does that not mean there will be an increase in waiting lists, other things being equal, although I realise more money is going in? Secondly, that the average cost would go up? In other words, because there is more pressure and more concern even though there is more money, we are going to see costs rising and the waiting list erosion is going to be less than we might have hoped.
  (Mr Crisp) You are quite right that royal colleges and others are seeking to introduce new standards which would have that effect, but that is not the end of the story. We are also engaged in discussions with the royal colleges about whether we can do things differently, because that is assuming we run things exactly as we have run them to date, and maybe we can do things in different ways perhaps with different groups of staff doing different jobs and so on. So that is a pressure but one we have to make sure does not have the effect you are talking about.

  87. If we are not to put more pressure on them and not increase the amount of time per patient, what will we do? Give them more legal protection?
  (Mr Crisp) You can see a whole series of things which are happening in the NHS where we are doing things differently, so the anaesthetist may be seeing them at a particular time of day, we may be bringing them in in the morning rather than overnight. There are lots of other things we can do to increase throughput, if you like, in terms of the number of patients going through the system which are not purely dependent on that point. We can do things differently.

  88. Finally, is your general view that things are getting better although there is room for improvement?
  (Mr Crisp) Yes. There is a big underlying infrastructure renewal happening at the moment. There is a lot of learning, a lot of spreading of good practice, some very good things going on through the programmes of the Modernisation Agency, but it is taking time to come through.

Mr Osborne

  89. Mr Crisp, you said earlier to members of this Committee that waiting times are the important issue, and I would agree with you. Do you think it was a mistake for the NHS to target waiting lists instead of waiting times for four years?
  (Mr Crisp) I think again that was actually a policy decision which it does not seem to me I should be commenting on. There is an advantage, however, in the argument of targeting waiting lists as well, which is we need to bring them down overall because if we are going to get the waiting times down to an appropriate point we need to have reduced our waiting lists to do that.


  90. That is a policy issue.
  (Mr Crisp) Yes.

Mr Osborne

  91. Do you agree with the King's Fund which says that national waiting list targets divert attention away from the issue which matter most to patients, by focusing simply on the number of people waiting for treatment after seeing a hospital consultant, and that the list ignores the time people are waiting and the severity of their need?
  (Mr Crisp) I did say earlier that the policy as it stands at the moment within the Department is that we are focusing very much on waiting times and specifically on reducing waiting times for the most seriously ill patients.

  Mr Osborne: So you do not agree with the Chairman of the BMA Consultants Committee who said that the waiting list issue had distorted clinical priority and denied care to people in most acute medical need, that the NHS must end its obsession with numbers on lists and focus on patients in greatest need?


  92. You can answer that or not as you wish, Mr Crisp.
  (Mr Crisp) Let me make the point that I have recently written to the chairman of the BMA setting out where money is being spent within the NHS and how we are targeting long waiters. I think I have already answered the point in that we have put within our overall policies, our deliberate attention on the most seriously ill people.

Mr Osborne

  93. If I could turn to the NAO survey at paragraph 2.22, which we have already discussed, and I take your point about the sample, I was slightly surprised to hear you say that you did not think this was particularly widespread due to the sample and the kind of consultants who had been interviewed. Can you give me some indication of how widespread you think it was at the time the report was put together that some consultants were distorting clinical priorities?
  (Mr Crisp) The first answer is not enough to distort the overall figures, because if I look over this period the number of patients who have been admitted within three months of waiting has stayed broadly level. That would indicate we are giving the same level of priority as we always have done to those people who have the most difficult clinical conditions. So not enough to show up in those figures, otherwise we would have seen a trend in the under three months coming down as a proportion, would we not?

  94. A large number of organisations, the BMA, the King's Fund and so on have said the same thing. The chief executive of the Nuffield Orthopaedic Centre said that "the name of the game is to get numbers off the list" (Electronic Telegraph, 15/11/98) so it is going to be more beneficial to focus on the cheaper procedures and that by deploying such a process he successfully cut 400 patients off the list in four months. Surely all these signals must be coming into the Permanent Secretary's office that consultants around the country are distorting clinical priorities?
  (Mr Crisp) This report entirely fairly says we have issued guidance and instructions on this many times, we have also invested money in the high profile and important procedures such as coronary heart disease, and if you start to look at the figures on a widespread basis you will actually see that does not appear to be happening. There may be quite a lot anecdotal cases, and I have no doubt there are specific instances where that will happen, and I have also no doubt that people can see incentives in making that happen, just as you have described the chief executive of the Nuffield Orthopaedic Centre did. That does not mean to say it is widespread. Where we come across that as an issue we need to do something about it and make sure it is not continuing to happen, but I am not complacent about it.

  95. You conceded there are specific instances and specific incentives, do you think it is possible that anyone has died because they were not treated with the degree of clinical need they should have been because someone was trying to meet a target?
  (Mr Crisp) I would have no way of knowing that. Nobody has brought that sort of case to my attention.

  96. No one has brought it to your attention?
  (Mr Crisp) No. My point is undoubtedly in a service which sees 5½ million elective patients on an annual basis there will be some instances where there will have been some distortion of clinical priorities, but not at a level which is enough to distort the overall figures and show there is a real pattern of this happening.

  97. There was an interview in which Peter Wilde, a heart specialist at the Bristol Royal Infirmary, said of the 20 patients on his heart operating waiting list who had died in the past six months: "If those patients, who had been classified as urgent, had been operated on within a month we would have saved half of them." (Daily Telegraph 1/3/00)
  (Mr Crisp) I cannot comment on that particular example, I am not sure if that is the same thing.

  98. He was attacking the waiting list targets.
  (Mr Crisp) He was not implying that instead he had been asked to operate on people of a lower priority. I do not know the particular quotation, I do not think I can frankly comment on it.

  99. Can I turn to outpatient lists? Do you think it is possible that the pressure to reduce inpatient lists resulted in a surge on the outpatients list?
  (Mr Crisp) I think there are some figures here which I am desperately trying to find.

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