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Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 140 - 159)



  140. You are coming to my next question.
  (Mr Crisp) Actually if we tell people the date when they can come in at the point at which agreement is reached, by and large they come in, and we know there are improvements which can be made in that way.

  141. You have described this fully integrated booking system which you hope will be available by 2005, that is four years away—we fought the First World War in that time—why do you not just do what they do in Denmark, stick it on the internet so people can look? Although it might not be integrated in a nice management consultant way with bar charts, you are effectively letting the patients figure it out for themselves, if you give them the information.
  (Mr Crisp) That is a different thing from the booking system. The booking system is about booking appointments and so on. I take the point about providing more information and you will be aware the information being provided in a national newspaper today has been supported by the Department of Health. We see it as very important that we do get as much information as possible to the public because the people who will provide some of the dynamic for change here are the public.

  142. Absolutely. Are you going to put this information on the internet and, if so, how long will that take?
  (Mr Crisp) I am afraid my answer is still, we are looking at it, but that may be an interim step to what we are talking about here.

  143. Why do you not just do it?
  (Mr Crisp) I will take your advice. We will no doubt be able to report to the Committee in due course.

  144. Paragraph 2.36. Mr Davies made the point that a lot of chief executives have varied their definitions of what constitutes outpatient waiting lists and, surprise, surprise, in almost every case the number of outpatients fell, 88 per cent fell. I am right, am I not, that since 31 March 2000 outpatients have gone up by 80,000 and inpatients by 30,000?
  (Mr Crisp) This year, the long-waiting outpatients have gone up, you are right.

  145. Outpatients by 80,000 and inpatients by 30,000 between the end of March and end of June, yet this paragraph, 2.36, implies that people are managing their lists better and that the result is a reduction in the number of waiting lists.
  (Mr Crisp) The figures you have quoted are the three months figures. They are three months figures which have gone the wrong way and have gone against the trend of the last two years and need to be tackled. You are quite right, it has not gone away.

  146. Can I return to Scandinavia. The report mentions Norway where there is a choice of hospitals. Perhaps I can put the question more generally, and this again may be a question for Mr Fillingham, plainly there is a lot of good practice overseas, people generally have a perception that things are done better in many cases overseas than they are here. You often hear France, Germany, Scandinavia quoted. What are you doing in a systematic way to look at what is going on overseas and learn from it?
  (Mr Crisp) Again, if I may, that is not the total story. People from abroad come and visit us and look at the things we are doing, and things like our National Service Frameworks and the fact we have national standards are rated very highly by a lot of different countries.
  (Mr Fillingham) There is a considerable programme which includes research and development work to consider what is happening and looking at how that can be applied to the UK, but we also have strong links with other health care organisations not only in Europe but in the US, Australia and New Zealand as well. So there is a considerable amount of effort which goes into comparing notes and making sure we are adopting best practice, in just the kind of way you have suggested yourself.

  147. I would like to return to choice. Mr Crisp said that you were looking at introducing an element of choice for patients. I think most patients would regard that as a little understated. They are the people who are providing this £47,000 million you are using, and you are saying, "We are introducing an element of choice."
  (Mr Crisp) Over and above what is already there because patients are involved in their own care. If you think about what patients are saying to us about choice, they want to be involved in the decision-making about their own care, that is very important, and a lot of the work Mr Fillingham's agency is doing such as on cancer is actually about developing that patient-professional relationship, and there are choices in terms of care. There is generally more choice around in maternity care as well. We are talking about the relatively limited aspect of choice in acute hospitals when you have an elective case. I think there are arguments which Mr Milburn has spelt out as Secretary of State for why we now need to be looking at that and finding ways of improving the amount of choice which is in the system, but I do not have any announcement to make to this Committee, that is merely an up-date of where we are.

  148. Can I draw your attention to paragraph 3.21 which talks about effective discharge plans to ensure that admissions and operations are not cancelled due to beds being occupied by patients who should have been discharged. It goes on in paragraph 3.23 to say, "NHS acute trusts could use their knowledge of patterns of emergency admissions to help plan more effectively the number and type of inpatient admissions." My perception of my own constituency, and this is probably shared by colleagues, is that this is going in the other direction, that things are getting worse. Could you comment on the question of discharges and bed blocking and what steps you are trying to take to get round this?
  (Mr Crisp) There are several things to say. The first thing is that for the first time this year we asked health and social care jointly to produce for us a capacity plan, and this is a capacity plan which will not only deal with beds in acute hospitals but with the issue of residential homes and care homes and also with the amount of capability of social services departments to provide packages of care for people at home. So it is a full capacity plan. We got those in at the end of September so we could begin to analyse them and understand what the picture is looking like and, secondly, so we could get in to do what we are trying to do all the time now which is share good practice and make sure that one area learns from another. The second significant thing we have done in recognising the problems which are around the care home market and the residential home market in particular is provide an additional £300 million—£100 this year and £200 next year—to social services departments to develop plans for improving the position on bed blocking jointly with the Health Service, which is the first most important point, so they are not just a way of disappearing into the social services budget if you like. That money is recurring. That is important because it is not just a bit of sticking plaster this year, it is about a longer-term strategy.

  149. One more bite of the cherry, then I have to stop, you must have looked at the question of what it would cost to provide a guarantee, whether the threshold is three months, six months or nine months, you could say that either you would either provide the service yourself within that time to make a guarantee to the patient or if you could not you would find another way of having it done in the private sector or you would fly them off to Sweden or wherever it would be?
  (Mr Crisp) There has been debate around this and there is debate continuing. The one guarantee we are bringing in next year is the one that if your operation is cancelled we will either admit you again within 28 days or you can go to a hospital of your choice. That is how the words are written, maybe we are starting down that route.

Mr Jenkins

  150. Mr Crisp, I have been striking questions off as we have gone through some of the stuff and I will not go over it again. I see the list in front of us with regard to our own constituencies and our own local areas, it is rather illuminating insofar as I have one inpatient waiting six months or more for urology, and I have 23.6, and in the four areas I have 8.2, 6.1, 5.2 and 10.6. I have a better case than that, I can give you an instance of two people living opposite one another on the road where they both want the same operation, hip replacement, in their own hospital. They are in the same location, with the same surgeon and the same operation, one would have to wait for maybe up to three months and the other would have to wait 15 to 18 months due to the contract of the hospital health authority drawn up by this particular hospital, this is simply down to funding.
  (Mr Crisp) If it can be done—

  151. It is quite simple, it is what is called in terms of standard assessment, it is a weighted average, they put money together and they give authorities and areas different amounts of money to treat the population.
  (Mr Crisp) Your road has two health authorities, one on each side.

  152. That is right.
  (Mr Crisp) They will receive money as health authorities on the basis of the formula

  153. Yes.
  (Mr Crisp) That formula will be weighted for the age of the population, and so on, and they will then locally make the decision about the priorities that they need for categories of patients and there may be a difference between the two, except where we have a national policy which says they have to be the same.

  154. Yes. The formula is wrong quite simply because the formula was derived to produce the same level of service depending on the make-up of the population and it is simply not doing so. It produces extra waiting time and waiting lists in under funded areas.
  (Mr Crisp) There is a very extensive academic study going on at the moment which is due to report sometime soonish to advise us on how to create a formula that may be better, but it is not a simple answer. At the moment the formula is weighted towards areas of greater need and to some extent towards areas of greater cost.

  155. Here they are starting to show up with regard to extra waiting time, they have to suffer because of a lack of funding and they should be produced at the same hospital, producing roughly the same waiting times. If I can move on to one other thing, the doctor referrals, I have the impression it has being going up because doctors are making more referrals, would you say this is down to the public's expectation of being able to the treated for everything at any time and their right to go to a consultant or would you say that it is also being influenced by the medical insurance that doctors have to carry to cover that shift in risk?
  (Mr Crisp) The figure here shows it is going up. There is another thing, which is probably the strongest driver of that going up in some areas, which is that we introduced national standards. When you introduce national standards we then introduce the doctor's expectations of their referral patterns to hospitals. The people who were already referring at that high level do not refer any less and the people who refer less will refer more. We will gradually see as we introduce and drive through in some areas an increase. In other areas, Mr Fillingham gave an example, we will see less because they will be referred to physiotherapists straightaway, whereas sometimes it is up to the consultant. There are two different dynamics going on here, the quality one is a big one, the national standards one is a big driver.

  156. Not and insurance one?
  (Mr Crisp) I am not convinced how big a driver that is, it may influence people to follow the national standards.

  157. I notice one of things we have in our locality is A&E is going up by 9 per cent, apart from the ones turning up with cuts and bruises because they cannot see a doctor, because the system is not flexible enough. We have a situation with regard to doctors who open from 9 am to 4 pm, when most people are at work, and do not open in the evenings or at weekends, so people go down the hospital and once again they are involved in blocking the system up. What are you prepared to do about it?
  (Mr Crisp) The one about the people with the more minor injuries?

  158. Yes.
  (Mr Crisp) Again we have about three different programmes reflecting that, one is the introduction of minor injury units, which are nurse-led and designed specifically to deal with such issues. Having visited a number I am aware that they run to about 10 o' clock or 11 o'clock at night and at the weekends. The second one is, walk-in centres, again typically nurse-led and these are for people particularly in those areas where people are not registered with a doctor, where there is a high level of refugees, and so on. That is certainly happening. The third thing is that we have introduced NHS Direct so that people can ring up. Seven and half million people we think will use that this year, seven and a half million people will ring up to ask for advice from a nurse on their particular problem. It is the biggest call centre of its kind in the world, it is a very substantial increase. There are a lot of big things happening now and I think we will see more of that.

  159. Why then have A&Es gone up by 9 per cent?
  (Mr Crisp) I have seen two sets of figures. I have not seen the Staffordshire ones, overall A&E attendances have fallen slightly but admissions through A&E, ie the most serious patients, have gone up. It has only gone up by about 3 per cent. More serious cases seem to be coming in, which is a worry because we need to plan much more for them, it is much easier to deal with the less serious ones.

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