Examination of Witnesses (Questions 60
- 79)
MONDAY 14 JANUARY 2002
MR NIGEL
CRISP AND
MR ANDREW
FOSTER
60. So why do some consultants have extra long
waiting lists? I can understand that some consultants get many
more referrals but why else do some consultants have these huge
waiting lists?
(Mr Crisp) It can be a whole mix of issues including,
as you said, some people have a particular reputation for shoulders
or whatever it is. It can be that in some cases we have not got
enough consultants in that speciality in that area. It can be
in some cases because of management issues either for the trust
or for the individual consultant.
61. Is it because consultants do not do enough
work?
(Mr Crisp) In some cases that might be true but in
general our view is that consultants do more than they are contracted
to do across the NHS as a whole. There will be some exceptions
in any fairly large group.
62. Have you ever checked with consultants who
have really long lists how much private work they do?
(Mr Crisp) Some of that work has been done through
a number of different studies. There is no direct pattern, which
is the obvious question.
63. I am not sure about that. I am not going
to give you information because that would be unfair but a certain
Chief Executive of a trust told me that he experienced in the
job that he has at the present time and in the one previously
consultants that he could not handle, he could not manage, because
they were a law unto themselves. They decided how much work they
would do, they decided how much private work they would do and
they were not prepared to help the system and they had long lists.
(Mr Crisp) I think there are two points here. The
first one you make, which is actually managing hospitals, managing
professional people within a setting like a hospital, is very
difficult and there can be some cases where precisely what you
describe is true. These are difficult jobs that people are doing
and most of these trusts, if you look at them, are not only suffering
from a particular issue like a waiting list fiddle of some sort,
they have also got other points they are trying to deal with.
64. So is there any mechanism to have a look,
where you have lists of 12 months or longer, at those particular
consultants who have those lists? Are they monitored to see how
much work they actually do?
(Mr Crisp) There are two things. Firstly, can I just
go back to our conversation of three months ago when you asked
me about two consultants at the same hospital having different
waiting times for outpatients. We will in future publish that
on the Internet so the patients can see that. That is in direct
response to—
65. That is after five years. Will doctors also
be given that explanation so that a doctor cannot say to me "I
have not got time to look and see how long lists are, I just refer
to the hospital"?
(Mr Crisp) GPs already have that information, as we
had the discussion in October.
66. Will you ensure that GPs use that information?
(Mr Crisp) I think, and I said it earlier, that the
biggest method for making sure this gets better is giving patients
more power and more information and when patients have that information
it will be better. To go back to your particular point about do
we look to see if it is the consultant who is at fault, what we
do where we have waiting list problems of whatever sort, and some
of them may be about long waiters or particular problems, is in
general we will ask one of our NPAT teams—National Patient
Access Teams—to look and to identify the problems. What
we tend to find is they are a mix of things, they are not just
one thing. They are not just a difficult consultant, if that was
your hypothesis, there may be a whole mix of different things.
67. It will be interesting to have a look at
the 13 trusts who meet the criteria of ten per cent of patients
who are suspended and more than two per cent of patients waiting
more than 12 months, which is on page three, to monitor and see
how much work they do.
(Mr Crisp) Particularly on the 13, that is not something
that we are doing to look at the 13 in isolation from others,
that is a particular group of 13 which the NAO has suggested.
However, consultant workload is one of the issues that we do look
at. Can I again bring in Mr Foster on this because he has got
some direct experience.
(Mr Foster) I would like to make the general point
that the information we have is that the vast majority of consultants,
as Mr Crisp has said, actually work significantly in excess of
their contractual obligations, and it is very unfortunate that—
68. Absolutely, but it is a very small minority
we are talking about here anyway.
(Mr Foster) Absolutely and I would not want the vast
majority to be tarred by some of these allegations about a relatively
small number of individuals.
69. But you agree that there are these relatively
small numbers of people?
(Mr Foster) There are anecdotal instances of a few
individuals, yes, indeed there are. What I would say in answer
to your general question is first of all we are in the process
of negotiating a new consultant contract and the Government has
announced proposals to take more direct control of consultants'
working week to remove some of the distinctions of the 1948 contract
that have left certain areas ambiguous, so we will have a much
clearer control, allied to a much more sophisticated information
system where we will be able to gather increasingly more sophisticated
information about consultants' workload and as we become reassured
by the robustness of that information increasingly publish it.
So that is part of the same drift of making the information available
to patients so that it is transparent for all.
70. What about the consultant who invites a
patient in for an operation, the patient goes in the evening beforehand
and is woken at six o'clock in the morning for the operation,
the consultant then comes in and says "I have not got the
parts to do the operation", it is a hip operation, "go
and see your MP and tell him"? Why was the patient called
in in the first place if he knew that the parts were not there
the night before?
(Mr Crisp) I think we cannot answer the individual
occasion.
71. No, of course not, I would not expect you
to. This is what worries me greatly about some of the statistics
and some of the attitudes coming from some of our consultants
frankly. I will move on. Why do people have to wait 12 months?
If a manager is doing his job properly, or a consultant, and they
see the lists are over 12 months long, why do they not do something
about it, why do they allow it to go on for 12 months? It just
seems common sense to me that the hospital would see there is
a waiting list of 12 months and say "we have got to do something
about it". Why do they not? It is no good saying because
they are short of that particular speciality.
(Mr Crisp) I think the biggest single issue is capacity.
72. Why do they not—what is the word—hive
it off to another trust?
(Mr Crisp) As you are aware, that is what we are doing.
As you will be aware, we are introducing at some point for next
year for coronary heart disease patients in the first place the
option if they have waited six months of going somewhere else
to help drive down this waiting list. The single bottleneck on
that is having the capacity elsewhere for people to go to because
whilst some hospitals have got very short waiting lists we have
still got too many that are 12 months. We need to bring the whole
thing down and that means more capacity, and more capacity is
coming but it will take time.
73. Let me move off that point now, we have
got a bit bogged down. Page four, paragraph seven, here we are
told, this was the fiddling that went on, ". . . the adjustments
were made in the context of pressure on trusts and particularly
Chief Executives to meet key departmental targets." How much
credence is there for that excuse?
(Mr Crisp) The wording here is very carefully worded,
it is in the context of pressure, it is in the context of a lot
of different things, if I may put it like that.
74. Was it pressure or just plain cheating?
(Mr Crisp) There is no evidence that it was pressure
because if it was then everybody would be doing it, would they
not?
75. That is my point.
(Mr Crisp) Pressure is no excuse for doing these sorts
of things. Just to take the point further, other trusts when have
they have got 18 month waiters have come and told us, they have
held up their hands and been honest, and that is why this should
not slur everybody.
76. You have anticipated the question I was
going to ask. If the majority of trusts were able to achieve the
Government targets, why were these trusts not able to? If they
knew that they could not meet these targets, why did they not
do something about it, why did they not come and report it?
(Mr Crisp) To be entirely fair, some of these trusts
had a range of difficulties and problems that they were trying
to deal with and individuals within the system presumably, and
I can only say presumably, felt that their only option was in
some way to cheat to make it better. They may have thought they
were doing that in the interest of I do not know what, I have
no insight into it.
77. What role does the Government have in dealing
with the cheats?
(Mr Crisp) I think our role, and I am speaking here
as a Chief Executive rather than Government in that sense, is
where we discover that something is going wrong we act as quickly
as we can to put it right. I take a degree of comfort that in
every one of these cases the first thing that happened was the
patients' welfare was taken into account. I do think it is important
that Government sets up the sort of arrangements that you have
obviously got that exposes this problem so that we can tackle
it. Those are the things that I think are right for us to be handling
centrally.
78. The Report clearly states that perhaps pressure
was the reason and that the targets may have been too severe but
my understanding, if you read the Report, is that the targets
are going to be even more severe, are they not? The targets are
not 12 months now but are six months.
(Mr Crisp) They were 18, then they will be 15 and
then they will be 12 and so on. I do not accept that pressure
was the reason and I did not think you accepted that pressure
was the reason.
79. No.
(Mr Crisp) I think pressure is part of the context
but these are difficult jobs and that is why we have good people
on the whole managing these organisations, and good non-executives.
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