Examination of Witnesses (Questions 180
- 199)
THURSDAY 1 DECEMBER 2005
SIR NIGEL
CRISP, MR
JOHN BACON,
MR RICHARD
DOUGLAS AND
MR ANDREW
FOSTER
Q180 Dr Naysmith: Would you agree
that this is a bit worrying, because all you are doing is opening
up the opportunity for my colleagues on the right and left over
there who may not want to support the Government in these targets
to start attacking you about having fiddled the targets. It makes
it very suspicious. I am sorry Paul, you would not do that!
Sir Nigel Crisp: May I make two
points? We actually do have some experience of this. What Mr Bacon
is saying is we do not have the total picture, but we do have
some experience because last year, as you may recall, we had two
cancer targets which were from initial engagement to treatment
for children and for testicular cancer, and that period had to
be four weeks, and that has been achieved. At the moment, as again
you probably know, we have got targets for cancer again over a
30-day period and a 62-day period, so there is some learning going
in the system around this as well, but it is important that we
go out to consultation on this definition precisely for the reason
you say, so that the definition is clear, upfront and there will
not be any discussion about the definition once it is settled.
Q181 Dr Naysmith: If you can, will
you let us have that information, please?
Sir Nigel Crisp: Yes.
Q182 Dr Taylor: Do you have any feel
for the number of trusts that might be keeping clandestine waiting
lists to go onto the waiting lists so these people do not appear
on the failed target list?
Sir Nigel Crisp: Let me come back
again to the point on the Audit Commission. We have Audit Commission
spot-checks to actually go and investigate. They see about 50
trusts a year, and we have not found any like that at all if we
are talking about our current waiting definitions for out-patient
and for in-patients.
Q183 Dr Taylor: Surely those hidden
waiting lists could be hidden even from the Audit Commission?
Sir Nigel Crisp: If you know of
one, let us know.
Q184 Dr Taylor: I know of several.
Sir Nigel Crisp: Let us check
that you have got your definition right. Can I make a point here,
which I think is an important one? Many trusts, when they put
you onto the waiting list, say, "We will contact you again
in due course to agree a date with you". Some people mistake
that for them not going on the waiting list until they are contacted,
when they go on the waiting list at that first point. That may
answer your point.
Q185 Dr Taylor: So they go onto the
waiting list when they get that letter that says, "We cannot
give you an appointment yet"?
Sir Nigel Crisp: "We cannot
give you an appointment date yet", is what the letter actually
says, and they go onto the waiting list at that point.
Q186 Dr Taylor: Would not it not
be reassuring for them to know that they were put onto the waiting
list: because the ones who are coming to me do not know that they
are?
Sir Nigel Crisp: I think there
is a very good point there which I am sure many people get right,
but maybe just as a result of this conversation we will ask people
to say, "We have now put you on the waiting list and we will
confirm the date afterwards", because this is where, when
other people have raised this with me and I have looked at it,
that is actually what is happening. They go on the waiting list
and there is a very precise definition about when they get on
the waiting list.
Q187 Mr Burstow: Very briefly, in
terms of this issue of diagnostics, whilst accepting you have
yet to start a formal collection of data, presumably in terms
of modelling this and getting some grip of the nature of the problem
you have got to grapple with to achieve the 18-week wait, you
have done some individual data collections to start to try and
gather some information. Can you confirm that you have collected
data on that basis?
Mr Bacon: We did two things in
thinking about this. One was to look at what one might call the
normative utilisation. So, you have got a given population, how
many MRIs, or whatever, you would expect to see in a population
of that size, and in asking the service to plan for this target
we asked them to say what their rate would be, and, if it was
not close to the normative level, we went back and asked them
to plan for more. As far as you were able to predict how many
of various types of diagnostic procedures the population is likely
to need, we did careful research, we produced that normative number
and that is what the service has planned for. What we have started
to do is to look now at particular diagnostic procedures, and,
as you know, there are many types of diagnostic procedures some
of which result in an in-patient episode some of which are the
episode themselves, so it is quite a complicated area. That is
why we need the rules straight, we need the definitions clear
and why we need to build this database, but it is building from,
we would confess, a low base because this is not an area where
we have collected data in the past.
Q188 Mr Burstow: Certainly when this
has been the subject of some exchanges on the floor of the House,
the previous Secretary of State seemed to be able to draw on some
data which suggested that there was within the Department some
information about diagnostic waiting times. It will be useful
if that information could be shared with the Committee.
Mr Bacon: We have done some work
to look at this in a research sense, but this is by no means comprehensive,
this is looking at individual geographies for individual diagnostics,
but to the extent we have got it, I am sure we will be happy to
share it with you.
Q189 Mr Burstow: Have you looked
at utilisation rates of the equipment?
Mr Bacon: We are beginning to
look at that, particularly in planning for what diagnostic facilities
individual organisations would need to deliver the target. One
of the things they will be looking at, and we asked them to look
at, was the utilisation rate of particularly the major pieces
of equipment; and we do know that our utilisation rates can be
substantially improved, because if you look at the performance
of the best against the worst, if I can use that word, there are
significant differences. One of the things that Sir Nigel referred
to earlier, which is his work around high impact changes, is to
look at how you organise say an imaging service to ensure that
facility can be used more intensively and, therefore, we can achieve
these targets through not just growth in the service but more
intensive use of the service we have got.
Q190 Charlotte Atkins: Turning now
to NHS reorganisation, can you tell us, on the basis of the polls
on PCT reorganisation submitted by the SHAs but also based on
deliberations of the External Review Panel, what will be the costs
of this reorganisation?
Sir Nigel Crisp: I do not think
we can yet do that, because part of what you are asking about
there presumably is redundancy, for example.
Q191 Charlotte Atkins: Indeed.
Sir Nigel Crisp: We do not yet
have a complete picture on what that is going to be; so we do
not have a cost on that.
Q192 Charlotte Atkins: You mean because
the external panel is still considering the proposals from the
SHAs or what?
Mr Bacon: No, what we have done
yesterday, and I had understood we had written to MPs individually,
or our ministerial team had.
Q193 Charlotte Atkins: I am sorry;
I cannot quite hear you?
Mr Bacon: I had understood that
we had written to MPs about this—whether you have yet received
the letters or not, I think they were sent out yesterday—announcing
the deliberations of the external panel, and I have now written
to SHAs telling them that we have agreed that they can go on to
consult, and in the letters that I have sent I have said on what
proposals they can consult.
Charlotte Atkins: I have not seen my
letter yet.
Q194 Dr Naysmith: They only arrived
yesterday.
Mr Bacon: They were signed and
sent yesterday, whichever method you get your mail.
Q195 Charlotte Atkins: Every MP has
a different method and I have not seen it yet, but that is not
really the issue. What I am looking for is what you estimate to
be the overall costs given that redundancies will be affected?
Mr Bacon: We would not pretend
that there will not be redundancies, there will in this process.
One of the reasons we cannot be specific is because, as you will
see when you get individual letters and as you see the growing
position, health authorities will be consulting on a variety of
options, and in some parts of the country the number of PCTs that
will emerge after public consultation and after ministerial decision
could be significantly different depending on what the outcome
of that process is, and that will, of course, affect the amount
of redundancy costs.
Q196 Charlotte Atkins: I certainly
hope they will be significantly different, if I can talk personally,
but having said that, the exercise is expected to ensure £250
million in savings, as I understand it?
Mr Foster: Yes.
Q197 Charlotte Atkins: So, in addition
to the costs, which will have to be recouped, there is also the
issue of the savings which are already on the drawing board, if
you want?
Sir Nigel Crisp: That is absolutely
right, there will be an upfront cost, and that will need to be
repaid from the first bit of the savings, but, as I say, there
will be an upfront cost and there will be savings year on year
on year of at least £250 million. What we have asked health
authorities to do is to tell us how they will recover that £250
million. What we cannot do yet is to get an accurate picture on
the upfront cost simply for the reasons that Mr Bacon has said,
that we do not know exactly what the configuration will be, but
that is something that we will get.
Q198 Charlotte Atkins: I am sure
you must have some sort of estimate of what it might be. You must
have two or three scenarios. We are being told that PCTs may be
reduced by two-thirds from 300 odd to about 100, so you must have
some sort of ideas, after all, this a financially driven exercise,
is it not?
Sir Nigel Crisp: No, it is not
a financially driven exercise. I understand you have had a hearing
on this anyway in which I am sure it was made very clear that
we are trying both to improve commissioning and, secondly, actually
deal with the issue, as, again, I think maybe in your own area,
we already had a number of PCTs with joint management, and with
47 around the place it was quite clear that we needed to, and
we have been holding back mergers for a long time, so those are
the reasons. People can make all kinds of rough estimates if they
work out how many staff 250 million might represent, but then
it is terribly difficult to get an accurate picture because you
do not know how many staff maybe leaving anyway or what the turnover
is or what the redundancy costs will be. The redundancy costs
will clearly be the big one, and until we get a clearer fix on
where these are we will not know these numbers and I do not think
I should speculate.
Q199 Charlotte Atkins: You are saying
that it is not a financially driven exercise, but when I met my
local SHA leaders and they put forward a proposal which was unacceptable
to my constituents, when I suggested an alternative I was told,
having been told originally that was not financially driven, that
actually that was not any good because that would leave the SHA
a million pounds adrift. Mr Nicholson was very clear that therefore
what I was suggesting was not acceptable because it was a million
pounds too little in terms of savings.
Sir Nigel Crisp: We are maybe
using language differently here. I do not mean to be pedantic
about this. Clearly, we have got to deliver the savings as well,
but that is not the purpose of the exercise. The purpose of the
exercise is to develop good and effective commissioning around
the country and to deal with these questions of mergers that have
been coming up. There is a financial constraint and people do,
indeed, have specific financial envelopes they have got to work
within.
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