Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 1 - 19)




  1. Good afternoon, ladies and gentlemen, and welcome to the Committee of Public Accounts. We welcome today Mr Crisp. Perhaps you would introduce your colleague.

  (Mr Crisp) Can I introduce Mr Andrew Foster who is the Director of Human Resources for the NHS and Department of Health.

  2. Thank you. Today, of course, we are talking about an issue which is of enormous importance, namely, inappropriate adjustments to NHS waiting lists. Perhaps I can just introduce a few topics so that my colleagues can go through them in more detail if they wish. I want to start off by talking about the extent of inappropriate adjustments. If you turn to page 5, paragraph 12, Mr Crisp, you will see that only five of the nine cases of misstatement were spotted by the NHS's own systems. How then do you know that this is not just the tip of the iceberg?
  (Mr Crisp) Can I, first of all, say that, as you have said, this is an extremely serious issue and one we take extremely seriously and one we have taken seriously for some time as well. The history of this is that when we identified the first one of these, which did indeed come about because of it being raised externally to the NHS, we first of all in London and then across the country drew the attention of Chief Executives to the issue about the number of patients on suspended waiting lists, so that we were therefore deliberately wishing to check with them whether other people had been doing what had been happening in Redbridge. We followed that up and we follow that through regular monitoring. As a result of that and the raising of awareness in this issue in the NHS, a number of other cases have become apparent which have now been looked at by the Audit Office. We have now gone further than that. We are formally introducing triggers at the point at which we want to review with individual trusts whether their waiting lists are being properly managed and they will be the sort of things that are identified in the National Audit Office Report—where we have got a suspended waiting list of more than ten per cent, where we have got very long waiting lists or where we have got concerns about waiting lists. In addition to that, what we have done is we have now, as you know, written to the Audit Commission to ask them to introduce a series of spot checks which we are in the process of agreeing how that will happen, and at a later stage in the meeting perhaps I can expand.

  3. You mentioned this point about triggers which is very interesting. If I now refer you to paragraph 3 of the Report on page 3, you will see that there are 13 trusts mentioned in that paragraph. How have you assured yourself that there has not been manipulation in the case of these 13 trusts?
  (Mr Crisp) Again on the basis of what I just said, most of those 13 had passed the trigger points that we already had in place so we had already been undertaking reviews with those cases.

  4. What have you found?
  (Mr Crisp) We have not yet found any inappropriate manipulation in the ones that we have looked at. All have now been contacted. There are some things that require a degree of explanation. Could I take an example with you and talk it through, would that be reasonable at this point?

  5. Yes, thank you.
  (Mr Crisp) One of the trusts, which is the trust with the highest number of suspensions in the country (which is not on the National Audit Office list simply because it does not have long waiters) is the one that has the highest number of suspensions, at 700, which is about the same as other trusts which have that level of throughput of patients, but because it has concentrated very hard on its waiting lists and therefore it has a much smaller waiting list, the proportion of suspensions is what you might expect from a trust of that size but they show up as a much higher percentage. So you will find there are perfectly legitimate reasons why there are anomalies in suspensions and I could give you some other examples as well.

  6. You have not yet, despite the fact that these are trusts that there might be a problem in because of the trigger mechanism that appears to come up, found any problems. Does this lead you to believe that perhaps this is less of a problem in the NHS than we might have feared or do you want to share any views you have from your initial enquiries about the nature of this problem throughout the NHS?
  (Mr Crisp) It is significant for the patients involved—and I think none of us should under-estimate the fact that for the approximately 6,000 (which was the best estimate that the NAO Report picked out) this is a very serious matter. I do think from our review of it that a) it is at the margins of activity, it is small percentages of what is happening and b) and perhaps I can make this as a very strong point, we are moving to a much more open system about information in the NHS and that has got a number of points, one directly relevant to your inquiry on waiting lists when we were last in this room together. We will be publishing from the new financial year waiting times by individual consultants on the Internet and by individual hospitals. That will pick up a point made particularly by Mr Steinberg about that information not being available. We will also be moving to booked admissions. This means that it will be that much more easy for patients to check themselves that we are handling their administration appropriately.

  7. But you are setting ever more challenging targets.
  (Mr Crisp) They are more challenging targets, indeed that is right.

  8. Are you not worried that this will put further pressure on Chief Executives?
  (Mr Crisp) I have no doubt that the targets are stretching but the vast amount of evidence shows they can be achieved without resort to anything inappropriate, whether it is changing waiting lists or anything else, and we have seen that throughout the country. I do recognise, and it is important that we should all recognise in looking at this, that the targets for waiting lists are challenging, and rightly so because people in this country want us to bring down waiting lists. I also think when you look at these trusts you will see a number of them are run by very good people where they have a number of other difficulties as well as the ones that are described here. People are working under pressure in the NHS but that is no reason to resort to the sort of practices which are highlighted in some cases here.

  9. Are you confident that the spot checks that you have referred to will be a sufficient counterbalance to distorted figures and do you think that you should have introduced some kind of formal external annual validation for key NHS performance indicators?
  (Mr Crisp) If I pursue the second part of the question first which is further about openness, we are making much more information available to patients, as I have said. We have now got much better systems for whistle blowing so that individuals can draw this to our attention internally. We are now putting in place an independent inspection system through the Commission for Health Improvement and we have said, and we will be saying, that they will be having a much bigger role in publishing information so that information will be coming much more from an independent source on NHS activity.

  10. But not yet formal external annual validation for key performance indicators?
  (Mr Crisp) If the information is being pushed by someone like the Commission for Health Improvement then they will need to satisfy themselves. Your last Report said that the level of data quality of waiting lists was probably satisfactory and that it was probably appropriate that we did not put much more resource into making them absolutely precisely accurate, and that there was a trade-off to be drawn between the amount of expenditure on doing that and getting the absolute accuracy of the figures. This is live management information. I personally think the biggest safeguard is when patients can look at the Internet or get somebody to look for them on the Internet and see the waiting time for that individual consultant is of the order of three months, or whatever it is, and can also have a booked appointment so they can see how they rate, and giving patients information is probably the single biggest safeguard we can bring.

  11. Other colleagues can pursue questions on the extent of inappropriate adjustment. I now want to ask you questions about how the investigations into the adjustments were handled. At the end of the day, despite investigations into these irregularities, no one was dismissed, the process in some cases was clearly inadequate, many of those accused complain about its quality and fairness. What are you doing to ensure that, in future, investigations are undertaken quickly, professionally and fairly?
  (Mr Crisp) Again, I am sure we will cover some of this. I do accept that some of the investigations in hindsight were not satisfactory. In fact, what took so long in a number of cases was the decision-making and preparation for disciplinary action outside the investigation, although some of the investigations were good. What we are doing is putting in place a standard format for investigations of this sort and we will be introducing that just as soon as we can.

  12. Others can ask further questions on that. The last area I want to deal with you of course concerns the disciplinary action taken and the compensation payments that were made, which I am sure you were expecting us to ask you about. If you look at page 9 and if you refer to paragraphs 28 and 29, you will see that individuals there were subject to these inquiries, they resigned during the process, they were then re-employed within the NHS and the NHS apparently cannot pursue disciplinary action against them. This seems to an outsider to be an extraordinary state of affairs. How can this be?
  (Mr Crisp) That happened in some cases, not in all cases.

  13. I accept that.
  (Mr Crisp) And the information is described there. We also want to take action to prevent that happening in future and what we are doing specifically around the guidelines by bringing them up to the force of direction around some of the issues to do with termination of contracts and so on, we can talk about in more detail in a moment. I think the other strong point here is that we are introducing a Management Code of Conduct so that if somebody is adjudged to have broken that Management Code of Conduct in one setting as a manager of the NHS, they should not be employed as a manager anywhere else in the NHS. That does not exist yet. It is a recommendation of the Bristol Royal Infirmary inquiry and it is one we are bringing in and we are taking steps to do that. The point at the moment is that different NHS organisations are different employers and they have the right to employ people. We will be introducing this new arrangement whereby senior managers, or managers, in the NHS will be expected to conform with the Code of Conduct.

  14. That is the problem, that you are currently dealing with a number of different trusts and your powers are somewhat limited. I take it that answer means that there is now going to be a framework within the NHS to allow continued action against staff who move around? That is what I take your answer as meaning.
  (Mr Crisp) Yes, on the management issues specifically, just as there is on other professional issues.

  15. Right. Coming out from this Report it is clear that NHS trusts , or some of them, do not have the skills to handle these complex disciplinary cases. Do you think that there should be an NHS Litigation Authority?
  (Mr Crisp) You mean specifically internally for dealing with disciplinary issues?

  16. Yes, an expert group to deal with these sorts of problems?
  (Mr Crisp) The way that we are moving in the NHS is to actually give more freedom and more responsibility to local organisations. What I think there should be is perhaps clearer guidance and a clearer framework and perhaps more support for people to do that. Sometimes we ask relatively inexperienced people, some of those non-executives, to take big and difficult decisions and I think this Report does raise the question as to whether we always give them enough support. What we are not going to do though is renationalise managers' contracts within this and make it a national system, we are going the other way.

  17. The thing which will really shock colleagues and other people outside is that four senior managers who left received payouts totalling £260,000 even though they were allegedly involved in these irregularities. What are you doing about this state of affairs?
  (Mr Crisp) Can I firstly say that in one of those the agreed termination happened before the irregularities were found, so it is actually two cases involving three managers. What we are doing about precisely that is we are making it clear firstly by bringing guidance up to the force of instruction in regard to how you terminate a contract, secondly we are making it absolutely clear to people that we expect them to go through a disciplinary procedure in these cases and that it is not appropriate where the integrity of the organisation, and therefore indeed the integrity of the NHS, is called into question that we do those sort of compromise agreements in future.

  18. The last question I want to you ask you about, which again is a matter which irritates this Committee and we have raised it on many previous occasions, is that compensation agreements have confidentiality clauses which we do not think is acceptable in the public sector. What is your guidance about such clauses and what are you going to do to ensure that they are not used again?
  (Mr Crisp) May I make two points. Firstly, this is one of the issues where our guidance, which fits in with your views, is guidance at this stage and we will add to it the force of direction to make sure that happens. I can talk you through again, either now or in response to one of your colleagues, what actually happened in one or two of the individual cases.

  Chairman: I have no doubt this will come up again. I will now pass over to Alan Williams.

Mr Williams

  19. Thank you, Chairman. Mr Crisp, you are relatively new to this particular role. I have been on this Committee over 12 years and I find this the most sickening report I have seen in that 12 years. Would you agree that it is the lowest form of cynicism for managers to protect their own backs and their own jobs at the risk of extending and aggravating the suffering of patients waiting for treatment?
  (Mr Crisp) I too find some of the things in this Report shocking where what you have described is the case. Let us be clear that we all have the right to expect better standards from NHS managers and in general we get them.

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