Examination of Witnesses (Questions 40-59)
DEPARTMENT OF
HEALTH
3 NOVEMBER 2004
Q40 Mr Allan: The idea is that you call
it all an urgent care centre and if I want urgent care then I
go there and you will sort out whom I should actually go to see.
Professor Sir George Alberti:
It is not departmental policy yet, but I like the idea.
Q41 Mr Allan: In terms of the other form
of interaction, there is the GP booking system with which there
is a lot of unhappiness at the moment thanks to departmental targets
which mean that you quite often ring a GP now and get told that
if you want an appointment, you have got to ring on the day or
turn up on the day.
Sir Nigel Crisp: That is only
if they are implementing it inappropriately, because actually
what they should do, and what most of them do, is allow you to
turn up on the day for the actual appointment and you can also
book ahead as well. Some people have interpreted it as not needing
to book ahead. Both parts are departmental policy. We are very
clear about that. Having got the one bit right, which is that
you can get to see a GP within 48 hours, we are now dealing with,
the unintended consequence that some people dropped having an
appointment system.
Q42 Mr Allan: Do you have any evidence
of spillover to A&E? If I ring up and get told I just have
to turn up at my surgery, I may as well just turn up at the A&E,
because it is the same difference.
Sir Nigel Crisp: That is a question
which is around and came from St Thomas's, did it not? The figures
are not telling us that. Actually the increase in A&E is a
relatively small increase and if you think that 300 million people
use GPs and only 16 million people are using A&E, there is
no real evidence that significant numbers of those 300 million
are appearing in the figures.
Q43 Mr Allan: Do you have the figures
to show what the actual cost is of different patient route through?
We hear anecdotally, we are sitting here and we are assuming that
going to A&E is the worst thing you can do. But I do not know
that, because I do not know what it actually costs. I do not know
that it necessarily does cost more for somebody with a sprained
ankle to go to A&E rather than go to a doctor out-of-hours
service or go to any other kind of service.
Sir Nigel Crisp: We do have some
of those costs, but what we are trying to do is do this on the
basis of convenience to the patient at this stage. This Committee,
about two years ago, had the NHS Direct report in front of it,
which did actually attempt to cost the difference between NHS
Direct and A&E and to see those effects. We do look at those
figures. At the moment the primary issue is to try to make sure
that we are providing services out there at the convenience of
the patient and not trying to redirect them.
Professor Sir George Alberti:
We have some idea of the simple costs. It is £15 for a GP,
£25 for a walk-in centre and £60 for A&E. However,
if you have sprained your ankle where you need an x-ray, everything
gets swamped by the cost of the x-ray and any other investigation.
Those are the sorts of figures we are talking about, which suggest,
for example, that the walk-in centre is actually quite a cost
effective way of doing things.
Q44 Mr Allan: Is our basic assumption
that the person with a minor issue who calls an ambulance and
goes to A&E is the most expensive still a fairly safe assumption?
Professor Sir George Alberti:
Yes, and we are now with those people training our paramedics
to leave people at home more or to give them advice or take them
to the appropriate place, not automatically to A&E, which
was always the case in the past.
Q45 Mr Allan: Do you do any follow-up
with people who are using services inappropriately? It seems to
me that if somebody calls an ambulance and goes to A&E and
goes home again and they never hear from you again, the next time
they will call the ambulance and go to A&E. I am not aware
that anyone writes to them or gets in touch to say "You really
should not have done that".
Professor Sir George Alberti:
We are certainly auditing this with our emergency care practitioners
and to some extent the ambulance service. I am not sure the patients
get written to, although that would not be a bad idea and there
are big advertising campaigns, particularly by London Ambulance
Service, about appropriate use of service, which cuts that down.
Sir Nigel Crisp: That this is
not a taxi service.
Q46 Mr Allan: The people you want to
talk to are the ones who are actually using it as a taxi service.
Sir Nigel Crisp: May be should
take that one away.
Professor Sir George Alberti:
Yes, that is a good thought.
Q47 Chairman: The reference to benchmarking
and patients coming back is in paragraph 1.27 which you may wish
to refer to. It says here " . . . a small proportion of patients,
for example in review clinics and the lack of integrated patient
records means that it is not normally possible to track their
progress. You may want to comment on that. You also mentioned
the emergency care practitioner and that is mentioned in paragraph
3.15 which you can find on page 33 where you will see "Our
survey showed that . . . 22 ambulance trusts were in the process
of training emergency care practitioners, of which seven already
had trained staff in the role. We found varying levels of training
were provided". So there is a lack of consistency there as
well. I thought I would mention that in the light of Mr Allan's
questioning and you may like to comment on that now.
Professor Sir George Alberti:
We are now working very hard on getting some overall educational
standards for competence and skills, which could then be delivered
by local universities, but having a set curriculum for people
and that is beginning to come together. We have several hundred
ECPs now and many more on the way and these are two thirds to
three quarters paramedics and the other ones are nurses. What
they do is assess people and initiate treatment at home much more
or in a GP surgery, but they do not necessarily take that person
to hospital.
Chairman: And would you like to comment
on the lack of benchmarking which is dealt with in paragraph 1.27?
The patients cannot be sure they are getting consistently good
service because there is no follow-up, there is benchmarking,
there is no measurement.
Sir Nigel Crisp: As I read this,
there are two things here. The first one is that it is difficult
to track patients because we do not have an integrated patient
record system, which is true, but we are in the process of making
the changes which will mean that we will have one of those. In
terms of benchmarking of quality more generally in A&E, again
we have the Health Care Commission doing inspections against that
and we do have certain quality standards in A&E.
Professor Sir George Alberti:
Major new initiatives are happening there. The Audit Commission,
some part of CHI anyway, have just finished a comparison of fractured
neck of femur, paracetamol overdose and something else, three
common conditions, and they are now trying to set benchmarks.
We shall be developing a whole series of other indicators over
the next year to enable people to measure quality and patients.
Sir Nigel Crisp: The very general
point here is absolutely right, which is that in hospitals we
have tended to concentrate more on the specialist and the inpatient
services than in A&E and it is only in relatively recent years
with this relatively blunt target that we have made real improvements
in emergency care.
Chairman: I am sure we may want to come
back to that in our report.
Q48 Jon Cruddas: I get a weekly, what
they call, sitrep report from North East London Strategic Health
Authority. It is a brilliant weekly report about all these indicators
and how each hospital is dealing with them in terms of the four
hours. Our health authority, Barking, Havering and Redbridge,
has had some challenging issues.
Professor Sir George Alberti: "Challenging"
is a very good word.
Q49 Jon Cruddas: However, from these
reports over the last few weeks there have actually been some
quite dramatic changes. Talking to them, they generally point
to three factors which account for their relative under-performance.
First is the physical buildings issue and obviously a new hospital
is being planned and they say this will deal with this issue.
Second, is the relationship with other intermediary care, GPs
et cetera, to remove the chokepoints around A&E. I
will just deal with that point there. When you investigate that
further and you talk to the PCT about it, they say the problem
they have in terms of removing those chokepoints is this continuous
issue that they raise with me of under-capitation as regards PCT
funding. In the index and charts of the relative performance of
the health authorities, is there any correlation between under-capitation
as regards PCT funding, their ability to provide healthcare that
takes people out of going straight to A&E and the A&E
performance in reaching the targets designated by your department?
Sir Nigel Crisp: We do not have
that piece of information; I do not know. I should be surprised
if it were a straight correlation though, because I know of places
which are under capitation as much as in East London who are doing
well and of course your trust, as you say, is almost at the 98%
on the last week's figures that I have seen.
Q50 Jon Cruddas: The third element is
the sort of management system approaches within the health authority.
They are addressing them, partly with the new management system.
Sir Nigel Crisp: But you make
the wider point that some areas are under capitation and our Secretary
of State has recently said that he wants, in our next allocations,
to try to move people nearer to target.
Q51 Jon Cruddas: Well, funnily enough
that was my next question. Even though you do not have the data
to see whether or not there is or is not a correlation, would
you say intuitively that this sort of rings true? If the PCT does
not have enough money designated as the formulas devised by the
Department, in terms of their populations, therefore, everything
else being equal, they are not going to be able to provide enough
facilities to remove the pressure points around A&E and therefore
the relative performance of A&E in meeting targets designated
by the Department are more challenging than otherwise.
Sir Nigel Crisp: I would only
make two pedantic points. It depends how they spend their money.
I agree that if they have less money than the formula says they
can expect, then somewhere their services will not be as good
as if they had more money, but it may not be in A&E; it may
actually be in mental health or it may be in some other area.
I would only make that point.
Professor Sir George Alberti:
I could give half a dozen examples of low capitation areas which
have hit 98%.
Q52 Jon Cruddas: Ours does now actually;
in the last couple of weeks.
Professor Sir George Alberti:
It depends how you distribute your resource.
Sir Nigel Crisp: So there is a
local decision. Having said that, clearly if people are as far
under capitation as you are and in the North East of England,
then we want to try to move them towards capitation as fast as
we can.
Professor Sir George Alberti:
I would add that our team have spent a considerable amount of
time in the hospitals in your area and it is lovely to see things
improving.
Q53 Jon Cruddas: I was going to praise
the team because that was one of the key factors over the very
recent period in terms of the rate of change which is now being
recorded. I shall not push that any further because it is a self-evident
point that I am making about a priority. Presumably ceteris
paribus should be the capitation levels to ensure that PCTs
have the ability to help the acute sector in achieving these targets.
May I ask one other question? Given the increased demand on A&E,
do you model the projected demand on A&E? Do you have a peak
point in the future, given the trend increase in demand for up
to 16.5 million people a year? Do you have that?
Sir Nigel Crisp: We do not actually
have a model because there are so many variables here, unless
George is going to tell me otherwise. We are seeing the big increase
in NHS Direct, there has been a big increase in walk-in centres.
This is the point about having an urgent care network so that
people will make more use of it. We have just had this new contract,
which we are agreeing with pharmacists at the moment, which will
actually mean that people will be able to get more advice from
pharmacists. We know that six million people a day go into pharmacies.
This is a very good place for us to get minor ailments treated
and prevention as well. It is a bit too complicated to say that
we have a single model for all of that.
Q54 Jon Cruddas: Okay, so you do not
have an integrated model of these different variables where you
estimate their likely effects and therefore see the trend movement
in the number of accesses.
Sir Nigel Crisp: No.
Professor Sir George Alberti:
No, we do not and I am determined that the numbers should stop
rising through much better use of prevention and pre-emptive strikes,
particularly for older people and people with mental health problems
where I think we really could increase their wellbeing enormously
by some regular care before they get into a crisis situation.
Q55 Jon Cruddas: One more abstract point.
A few years ago when I started in this job, I quite often collided
with the notion that the demand is almost infinite and supply
almost creates its own demand. The better facilities you have,
the more demand you have, in terms of NHS Direct or whatever.
It seems to me that there is a philosophical shift going on in
terms of not having that as an underlying model, rather that this
is all manageable in the sense of you not working on this continuous
positive sum gain in terms of pressures on the system. Is that
a fair description of some of the changes?
Sir Nigel Crisp: It is complicated,
but one of the things we are trying to do is give people more
responsibility for their own health; which they already have of
course. That is why actually bringing things like the pharmacy
into play means you may actually be getting people to think about
health issues before they become health issues. That is where
the thrust of our policy is moving towards: to try to get in early
and be more preventative rather than worrying too much about the
fact that there is potentially an infinite demand at the other
end. Having said that, we know that there is still unmet need
and in areas like yours we know there is more need. Round different
parts of the country there is more unmet need for things like
cardiology interventions and so on in different parts of the country.
There is still quite a long way to go in what is very clearly,
we all agree, need rather than just people wanting.
Professor Sir George Alberti:
In chronic disease we have worked on rights and responsibilities
of patients in my own previous area of diabetes, so that there
are real responsibilities on the patient as well as rights to
good care, to access to good care. We need to expand that to the
whole public.
Jon Cruddas: I have to say that I thought
it was a very good report.
Q56 Mr Jenkins: Sir Nigel, when you read
this Report, how did you feel? How did you feel about the Report
itself? I know it is a very comprehensive Report and a good Report,
but how did you feel about it?
Sir Nigel Crisp: I was happy with
this Report; it gives an account of a good platform for moving
further forward.
Chairman: That is the same answer you
gave to the same question from Mr Jenkins last time.
Q57 Mr Jenkins: He is consistent, very
consistent.
Sir Nigel Crisp: I have a very
good briefing obviously.
Q58 Mr Jenkins: Any report which says
that in the A&E departments there has been a significant and
sustained improvement in waiting times and also improvement in
the environment for patients and staff and then goes on to say
that the reduction in total time spent in A&E does not appear
to have been at the expense of any other objectives and there
is evidence to suggest that reducing the patient time spent in
A&E has led to increased patient satisfaction, has to be a
good Report, as far as I am concerned. I think the Report has
highlighted what you probably knew about what the difficulties
are and it is an excellent Report. The people in the service should
be congratulated.
Sir Nigel Crisp: I think people
worked astonishingly hard on this actually and they have taken
the opportunity.
Q59 Mr Jenkins: I have met them and one
or two said "Will you ask him this?" so I agreed to
ask you one or two things. The four-hour wait is a bit of a problem.
Although I accept that there is a 2% leeway, you have to understand
that if somebody brings in a youngster and the youngster has fallen
over and cracked his head and they have brought him down, they
are quite comfortable, they have been treated and then they are
told that they have to be out in four hours, they say "I
would rather not. I would rather just leave the lad there. He
is not doing any harm. The parents are quite happy. I do not want
to admit him to hospital. I do not want to discharge him. I want
to leave him there because I want a bit longer to make sure that
nothing is going to go wrong". That is one. Then there is
the old-age pensioner who comes in, maybe an elderly, frail person
who is rambling a bit and you are not sure whether they fell over,
how much damage they have done to their head or whether it is
their general condition, so you want to put them into a holding
ward. The drunk who has come in after falling over, the mental
patient. You are probably going to tell me you do have, but why
do we not have a pool area where we can put these people? They
have been seen within four hours, have not been moved on for clinical
reasons, but they will not count against our four-hour time.
Professor Sir George Alberti:
We do, in a word.
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