Examination of Witnesses (Questions 20-39)
DEPARTMENT OF
HEALTH
3 NOVEMBER 2004
Q20 Jon Trickett: I am told that across
the three hospitals in the trust which covers my constituency,
there are very different patterns of referral. There is a difference
in culture maybe between the populations, but possibly also between
the GPs. There are three PCTs there. Would it not be advisable
actually to do some work, since the cost pressures, really engendered
perhaps by GP practice, on some hospitals are greater than others,
given the fact that there is more of a propensity among some populations
to use A&Es than others, perhaps for cultural reasons, but
partly determined by the GPs.
Sir Nigel Crisp: In most A&Es
people come in themselves, but there are GP referrals as well.
What I would hope, and I can find out, is that in the particular
location you are talking about that piece of work has been done
locally, but we have not done that piece of work nationally that
I am aware of.
Q21 Jon Trickett: Is it not a key piece
of management information? If it can happen within Wakefield,
just within one district, then across the national presumably
there are huge differences?
Sir Nigel Crisp: What we know
nationally is that there are variations and that is why we are
actually saying that the local system has to be designed to meet
the local need and that is why, for example, in areas where a
lot of people are not registered with GPs, there is a high turnover
of people, which is probably not true in Wakefield.
Q22 Jon Trickett: No, I do not think
it is.
Sir Nigel Crisp: You need a different
sort of service than some other areas.
The Committee suspended from 4.05pm to
4.10pm for a division in the House
Q23 Jon Trickett: If you
would like to respond, then I want to ask about the financial
pressures.
Sir Nigel Crisp: May I ask Sir
George to answer, particularly on the Wakefield PCTs.
Professor Sir George Alberti:
I have visited your constituency and the trust and PCTs therein
and I should say that we have been giving quite a lot of specific
support to the health economy there. One of your PCTs has set
up a primary care emergency type thing, and that is what is happening
in different places where there are more pressures from general
practice for primary care type patients, Sunderland is another
good example, Newcastle the same, where they have a primary care
emergency centre at the front door of one of the hospitals. I
just come back to you on what is permissible with consultants.
You should not be allowed to be a Type 1 A&E department if
you have no consultants at all and that might be something I could
follow up with you afterwards.
Q24 Jon Trickett: In private correspondence.
Professor Sir George Alberti:
I should be delighted.
Q25 Jon Trickett: I just wanted to pursue
this hospitalisation as opposed to "GPisation", if there
is such a word. The consequence of the kind of practice which
appears to be going on is that the PCT may well be benefiting
financially at the expense of the hospital, since the hospital
bearing more of the cost of treating patients and more people
are presenting rather than going to the GP with minor injuries.
I notice in paragraph 2.27 that a significant number of trusts
are not being funded to the expectations outlined there. Maybe
you could reflect, rather than try to answer now, on the point
I am making about this variation and the differential impact,
unless you have anything particular to say about it now.
Sir Nigel Crisp: Where we know
there is a particular issue, as there is in Wakefield, because
I think the performance is in the low 90s, is it not, then we
send in people to help work through the issues and they have to
be across primary care as well as secondary care. We can come
back to you on the particular Wakefield issues.
Professor Sir George Alberti:
We are putting a lot of focus now on the whole system, getting
them to work together through the networks.
Q26 Jon Trickett: I do not want to bore
the Committee with Wakefield. I think there is a generic issue
which I am raising and perhaps we can have a private correspondence
about the Wakefield situation. On the question of paragraph 2.27
which is talking about the staffing ratios, is there a minimum
point at which an A&E simply cannot function, I mean a number
of patient visits a year? Is there some number where you can say
that simply will not sustain an A&E because it is too small?
Sir Nigel Crisp: We do not have
an actual number on that.
Professor Sir George Alberti:
No, we do not have a number, although once you are below the,
you have about 30-35,000 a year, it becomes difficult then to
justify fully staffing with all the rotas you need et cetera
for a type 1 department.
Q27 Jon Trickett: Can I just ask some
other questions which relate to sparcity of population? In the
event that there are long distances between one hospital and another,
one is reliant to some extent on ambulance services in terms of
treating patients in A&E. How far is an holistic approach
taken to that process of A&E and its inter-relationship with
the ambulance service and, again using mine as an example, WYMAS
in West Yorkshire is not very good at all in meeting your targets.
So here we have an additional problem which is probably a national
issue as well.
Professor Sir George Alberti:
May I say very strongly that we take this into account. At the
back of this, our next steps, that is starting now, and some have
already started, are very much to get the whole health economy
of that region to work closely together, to do the planning and
work out what is needed for your local population. It is absolutely
key that that goes on and I have talked to your ambulance service
as well and we are encouraging them to work closely with the acute
trust and the PCT and the mental health trust and the other partners
in that. It is very much on the cards and we are doing our best
to promote that.
Q28 Mr Allan: Starting again with a local
question. I scanned the league tables and was rather depressed
to find Sheffield Teaching Hospital's NHS trust at the bottom
of the table, only meeting 83.7% of patients going through within
the four hours according to the tables we have been given.
Sir Nigel Crisp: That is not the
figure I have. Sorry, that was Quarter 2 last year.
Q29 Mr Allan: That was Quarter 2 last
year, but they are all miserable: 81.7%, 80.1%. It is a miserable
performance, is it not?
Sir Nigel Crisp: The last quarter
we published, which was the first quarter of this financial year
up to June is 92.4%.
Q30 Mr Allan: So they have made a sudden
leap up.
Sir Nigel Crisp: They have made
a 10% leap.
Q31 Mr Allan: In terms of the old ones,
targets, my understanding is that they were a three-star trust
which has become foundation status. I am just curious about the
apparent disparity between a complete failure to meet the target
and—
Sir Nigel Crisp: The target was
on milestones and I think the figure you are looking at is the
figure which is about 15 months old. It was a 90% target in April
this year and is going to be a 98% target in December this year.
Q32 Mr Allan: My last one was 2004-05,
Quarter 1.
Sir Nigel Crisp: The figures should
be—
Q33 Mr Allan: That was 83.7%.
Professor Sir George Alberti:
That is Type 1 only. Sheffield has a very big walk-in centre and
a minor injury unit associated with the acute trust, so Type 1
are getting the really major stuff there, but Type 3, the walk-in
centre, is getting the less serious. Between them it works out
at 92.4%.
Q34 Mr Allan: Very poor at the serious
stuff, but much, much better at the minor stuff.
Professor Sir George Alberti:
Not very poor, but under a lot of pressure. Put this in the context
two years ago: you took your rucksack with you if you went into
A&E in those days.
Q35 Mr Allan: That is helpful. That was
the local point, now to move on to the more generic issues. May
I ask about the NHS Direct role and whether in the gateways described
in Table 1 on page 4 the vision is that if I want a service, no
matter what kind of service, the first point of contact will be
NHS Direct, that I ring the NHS number, or are we going to maintain
a number for the GP co-operative, a number for the A&E units,
separate numbers?
Professor Sir George Alberti:
I am passionate about simple local access and having a navigator
to help someone through the system to get to the right place as
quickly as possible. We are now talking with NHSD and the out-of-hours
people and the ambulance service about how to handle that initial
contact.
Q36 Mr Allan: So it is one number.
Professor Sir George Alberti:
One number.
Sir Nigel Crisp: One number gets
you into the whole system. Whether it is NHS Direct that takes
the first call or is a later call in the system is something that
we have still got to work out.
Q37 Mr Allan: At the moment it is a patchwork.
I could be in one place and I could be calling NHS Direct because
that is a pilot area for that. I could be in another place calling
the GP co-op.
Sir Nigel Crisp: Yes. We want,
as it says on that page, the patient to make a single call which
actually gets you into whichever bit of the system you need to
get into.
Q38 Mr Allan: And there is no suggestion
that that in itself is not a problem, that people who do not like
those kinds of call pathways will just turn up at A&E.
Professor Sir George Alberti:
I am sure some of them will continue to turn up at A&E or
at this bigger network of walk-in centres that we will have, or
maybe at the GP. What we need to do, first of all, is to have
a good public education policy here, bringing people along with
what is available to them; the more contact they have, the more
they will know; also, not to say anything is inappropriate but
to provide services which our patients want.
Sir Nigel Crisp: We have made
quite a big philosophical point here, which is actually that we
want to treat the patient where they turn up as well. We used
to talk about educating them to go to the right place, but actually
they are going to turn up. If they turn up in the pharmacy, we
need them to be looked after in the pharmacy and be redirected
if necessary, but not to be told off for turning up in the pharmacy
if I can put it like that.
Q39 Mr Allan: Are you going to do anything
to reduce the confusion? I am thinking again of Sheffield. If
I am sick, I want to see a doctor, I do not care whether you call
it a secondary or a primary care doctor. At the moment in Sheffield,
I have a minor injuries unit, a walk-in centre, an A&E and
for a lot of people, it is very confusing just to work through
that and walk-in sounds funny, it does not sound quite right.
Professor Sir George Alberti:
I personally would be renaming them, but I shall have to adhere
to advice from my senior.
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