Examination of Witnesses (Questions 1-19)
NORTHERN IRELAND
DEPARTMENT OF
HEALTH, SOCIAL
SERVICES AND
PUBLIC SAFETY
2 NOVEMBER 2004
Q1 Chairman: Good morning, ladies and
gentlemen. Welcome to the Committee of Public Accounts of the
United Kingdom. We are here, and we are delighted to be here,
at Stormont in view of the fact that the Northern Ireland Assembly
is currently suspended but we very much hope that this will be
our last visit here because we very much look forward to the resumption
of what I understand to have been an excellent Northern Ireland
committee. I think this will be a very interesting hearing for
us and we are much looking forward to it. We have got two very
interesting subjects. The first is the use of operating theatres
in the Northern Ireland Health and Personal Social Services. We
are joined by witnesses from the Northern Ireland Department of
Health, Social Services and Public Safety. Our first witness is
Mr Clive Gowdy, who is Permanent Secretary and Accounting Officer.
You are very welcome. Would you like to introduce your two colleagues,
please?
Mr Gowdy: On this side I have
Mr Andrew Hamilton, who is Deputy Secretary in the Department,
and on my left-hand side, Dr Ian Carson, who is Deputy Chief Medical
Officer.
Q2 Chairman: Thank you very much.
We look to this Report with concern because we understand that
spending on acute health services in Northern Ireland has been
higher than any other region in the United Kingdom, apart from
Scotland. These services are provided by 21 acute hospitals which,
between them, have a total of 109 operating theatres, serving
a population of some 1.7 million. It seems to us that this is
a relatively generous provision and we would like to determine
this morning why performance has not been better. Perhaps I could
start by asking, Mr Gowdy, if you could please look at figure
eight in the Comptroller and Auditor General's Report, which you
can find on page 66. You will see there that 37% of available
weekday physical theatre capacity is not being used and yet we
also understand that Northern Ireland has the longest hospital
waiting lists in the United Kingdom. How can you explain then
the co-existence of long waiting lists with substantial spare
physical theatre capacity?
Mr Gowdy: Chairman, if I might
make a point prior to picking up on your introductory remarks.
Yes, we do have higher per capita spend on health here
in Northern Ireland than in England. That is a reflection of the
high levels of need we have. We have higher levels of morbidity,
higher levels of disability and higher levels of deprivation,
all of which are associated with higher levels of need for health
and social services. That is by way of context. In terms of the
utilisation of our theatres, we would certainly accept that the
point that is being made in this Report is one that we need to
take very seriously. It is important that we should seek to get
the greatest productivity and greatest efficiency out of the use
of our theatres, but there are a number of points that I am sure
the Committee would find helpful by way of explanation. In terms
of our use of theatres, we are comparable with what is happening
elsewhere in the United Kingdom. Our pattern of use of theatres
matches the pattern of use in the rest of the United Kingdom.
In fact, our current utilisation figure, which has now risen to
64%, matches exactly a sample of trusts that we have compared
ourselves with in England. We are not wildly out of kilter with
the rest of the UK. I think it is also important to make the point
that this figure of 63% utilisation actually masks a number of
different things. It is an overall average for all theatres that
are used in Northern Ireland. As I am sure the Committee will
appreciate, theatres are used for different purposes and in different
places. One point to make is that a number of theatres are dedicated
for emergency use and have to be kept ready for those emergencies
and they are counted in these figures. It is also the case that
a number of theatres are used for speciality procedures, such
as obstetrics, some used for particular cancer operations, and
virtually by definition their utilisation rate is significantly
lower. We also have a number of theatres which are in rural hospitals
and the catchment area for those rural hospitals and the throughput
of cases is substantially lower.
Q3 Chairman: I must stop you there
because in our Committee, as you know, Members do like to have
short answers because they are time limited. The fact remains
that you—or perhaps you do not—have the longest waiting
lists in the United Kingdom, is that right?
Mr Gowdy: We have the longest
waiting lists.
Q4 Chairman: You have the longest
waiting lists in the United Kingdom, yet 37% of available weekday
physical theatre capacity is not being used. You have given us
a number of excuses but what we would like to now know from you
is how you are going to meet the needs of the population of Northern
Ireland, who are presently suffering from the longest waiting
lists in the United Kingdom, by resolving this problem.
Mr Gowdy: We have taken very seriously
the recommendations that have been made in the Audit Office Report
and we have been working with our trusts to ensure that they take
all the measures that are needed. As the Report indicates, there
are various dimensions to this: the management of theatres, the
introduction of theatre information systems, and putting as much
as we can into utilising the theatres effectively. What we have
been able to achieve through this is a system which is functioning
better than it was at the time of the Report. All of the recommendations,
with one or two exceptions, have now been fully implemented and
we expect all of the recommendations to be in place by the end
of—
Q5 Chairman: We will stop you there
because we often get this answer but what we would like to know
is why we had to wait for an NAO Report for these recommendations
to be carried out. Can you please turn to figure nine on page
68 which deals with the actual use of planned sessions in Northern
Ireland's largest hospital trust, the Royal Group of Hospitals
Trust? You will see there that the Royal Group of Hospitals Trust
were below the Bevan target of 90% of sessions cancelled. I take
it that this is an agreed Report and, therefore, this figure is
accepted. Why are so many sessions cancelled in this and other
trusts?
Mr Gowdy: The figure you are looking
at is 835?
Q6 Chairman: Yes, that is right.
Mr Gowdy: There are a number of
reasons. I will try to keep my answers as brief as possible. Certainly
we are seeing a number of very frail patients being dealt with
whose condition can alter quite quickly.
Q7 Chairman: And that explains this
level of cancellation?
Mr Gowdy: No, it does not. It
is one of the factors that we have to take into account. There
are also issues around the availability of staff to run the sessions.
There are various reasons why they would not be available.
Q8 Chairman: Are you monitoring this
to ensure that they are good reasons that are being given?
Mr Gowdy: Yes. We are doing two
things. We are asking each of the trusts to take responsibility
for managing the throughput of cases in their theatres and to
do what they can to increase the utilisation. We are taking an
overall monitoring look at how those trusts are doing that and
what their outcomes are.
Q9 Chairman: I think other Members
will want to come back on this. I am sure you know this Report
very well and if you look at Part 4 of the Report—I would
like to have a general answer—has your Department defined
and agreed with trusts a common set of performance measures for
the use of operating theatres so we can get some idea of what
is happening around the Province? What theatre utilisation targets
have been set for hospitals?
Mr Gowdy: We are introducing within
the next 12 months a new theatre management information system
which will be a common computerised system across all of our trusts.
That will give us a common, consistent information base on which
to compare the performance of each and all of the trusts. Also,
we are expecting each of the trusts to report to us on the implementation—we
have been doing this at six monthly intervals—of the recommendations
made in the Audit Office Report plus in some of the other documents
that we have issued to them from other bodies we have been dealing
with in terms of theatre use.
Q10 Chairman: My last question relates
to understaffing. This is dealt with in paragraphs 5.17 to 5.47
of the Comptroller and Auditor General's Report which you can
find on pages 91 to 97. There is concern, is there not, about
the level of consultant and nursing understaffing? Could you please
explain to us what the reasons behind this are and what actions
you are taking to rectify the situation.
Mr Gowdy: There are a couple of
reasons which it is quite important to explain. One is that we
did lose quite a lot of our capacity in the 1990s as a result
of a reduction in our base line. A number of posts disappeared
as a result of that and a number of beds were taken out of the
system as well. What we have found is that the levels of demand
have been rising to such an extent that we now need to rebuild
our capacity and that is in terms of beds, nursing and medical
staff. We have done a number of things to try to correct this.
One is that extra medical student places have been put into effect
into at Queen's University Medical School. Similarly, we have
taken action to increase very substantially the number of nursing
students from 480 in the late 1990s through to the current figure
of 750 per year. Also, we have been recruiting extensively in
places outside the UK, notably the Philippines and India, to increase
the number of nursing staff available to us. Theatre nurses in
particular have been a problem area for us and we have been correcting
that problem, but we still have some vacancies to address there.
Chairman: Thank you very much for those
answers. Mr Curry?
Q11 Mr Curry: Mr Gowdy, if you look
at the various tables there are lots of discrepancies between
the performances of the trusts. Which is your best trust?
Mr Gowdy: All of our trusts are
performing to high levels of utilisation against the planned sessions.
Our planned sessions in theatre use are those for which the trusts
are funded. As you can see from the tables, there is a very high
degree of utilisation against those planned sessions. We think
that our trusts are getting as much as they can with the level
of funding that we have been able to give them.
Q12 Mr Curry: Which is the best one?
In all theatres of life—operating theatres—some are
good, some are bad and some are indifferent. Somebody must be
at the top of the league table. If I am a journalist coming from
the United States and I want to do a really good story about health
care in Northern Ireland, where would you point me? Where would
you like me to go to really get the best story?
Mr Gowdy: I am not trying to be
evasive. I think that in this case what we have is a range of
hospitals doing different things, they have got different case
mixes, they have got different contexts within which they operate,
some are rural, some are urban, some have a very wide span of
specialities, others are narrower, and it is very difficult to
make the sort of comparison that you are inviting me to make.
From talking to all of our trusts, I believe that they treat very
seriously the need to get the greatest efficiency out of their
theatres but the circumstances differ.
Q13 Mr Curry: Which trust has got
the greatest degree of surgeon absenteeism or sickness? Could
you draw a league table on that?
Mr Gowdy: If I may, I will let
Dr Carson say something about this because he has been involved
quite closely in this.
Q14 Mr Curry: There is a remarkable
phrase in the Report talking about surgeons not turning up, you
see.
Mr Gowdy: It fluctuates from time
to time in different areas. We have had some problems in terms
of being able to recruit and retain enough anaesthetic consultants
and other medical staff. Dr Carson may be able to say more about
this.
Dr Carson: Thank you. The utilisation
of our scheduled theatres across the Province is running at 95%
at the moment. In fact, there are five trusts in which there have
been no cancellations whatsoever of scheduled operating sessions
and they are running at 100% utilisation of the scheduled capacity.
As the Secretary has said, the perceived under-performance in
certain organisations is influenced by a variety of factors. There
are several factors that influence why an operating list gets
cancelled, not just the absence of a surgeon on leave or whatever,
there have got to be other services in place to enable an operation
to take place. Principally, and increasingly over recent years,
it has been the use and availability of intensive care and critical
care capacity.
Q15 Mr Curry: I appreciate all that,
but on pages 66 and 68 there just happen to be two tables. One
is called "Actual Use of Theatre Capacity" and one is
"Actual Use of Scheduled Sessions". I accept that is
2001-02 and things may well have moved on since then, but the
fact is that sessions held as a percentage of sessions available
run from 82% down to, say, 50%, because below that there are special
factors at work obviously, and sessions held as a percentage of
sessions intended go from 108% down to 76%. With all the factors
brought together there are some people doing better than others,
are there not?
Dr Carson: There is no doubt that
there are individual variations in performance.
Q16 Mr Curry: There are good ones
and less good ones.
Dr Carson: Yes. Having hinted
to the Committee that performance has improved, not only since
the Audit Office Report but since a variety of good guidance and
practice has been shared with the service and the introduction
of effective Theatre User Committees and good communication between
trust managers and the staff who run and organise theatres, the
performance has improved and is continuing to improve.
Q17 Mr Curry: I am going to leave
consultants to the tender care of Mr Steinberg; I should hate
to deprive him of one of his favourite topics. Can we look at
cardiac surgery at the Royal Victoria? I think you have said already
the Report says that the number of operations has gone down because
older and sicker patients are being treated, that means more intensive
care, that means fewer admissions so there are fewer operations
and there is a catch-22 in operation. Surely this must be true
of every large hospital in the known world, is it not? There is
nothing unique to Northern Ireland about this, medical advances
are making it possible to treat older and sicker patients. Is
this phenomenon happening everywhere or is it particularly pronounced
here?
Dr Carson: No, it is happening
throughout the UK in relation to cardiac surgery. We do have an
ageing population. We have had very significant advances in cardiology
with interventions at the early stage of heart disease which means
that the patients who are coming forward for cardiac surgery now
are older and sicker and may well be at end stage of cardiovascular
disease. It is a sicker population requiring much more intervention
in the post-operative intensive care period.
Q18 Mr Curry: There are other factors
which you admitted as well, that perhaps there were not enough
staff, no cover when surgeons were on holiday, the record keeping
was not particularly sophisticated, there was no fast tracking.
Demography is against you on this, is it not? Does this mean this
is always going to happen? What do you do to buck demography on
this as people are getting older and more doddery and medical
advances are increasing? Are you not going to be running faster
to keep still on this one, as it were? How do you break out of
that cycle?
Mr Gowdy: I think it is important
to say that the nature of the treatment afforded to those with
cardiac conditions has been changing. It is no longer the case
that most people would go for a coronary artery bypass graft.
Percutaneous interventions, stenting and angioplasty are much
more prevalent. We are seeing a very substantial growth in those.
In the year 2003-04 we had 1,600 of these percutaneous interventions
and we expect to see that rise to just under 2,000 in the current
year. The balance is changing away from bypass surgery. We are
now able to treat patients with a range of different interventions,
cardiological interventions, as well as surgery. If I may say,
we are getting the waiting lists on cardiac surgery very substantially
reduced. We have made use of facilities outside Northern Ireland
and that has helped us to deal with some of the cases that could
be transferred elsewhere, while dealing with the most difficult
cases within the Royal Hospital.
Q19 Mr Curry: The key is what, the
key is the technology, is that what you are saying, or is the
key the management?
Mr Gowdy: It is advances in the
care of cardiac patients. There are a range of interventions now
available, including the use of statins and other drug treatments,
as well as using stents to open the arteries. These sorts of things
are now becoming much more prevalent and are usually treated on
a day case basis. This is an easier and quicker way of dealing
with some of these problems. Not every patient is suitable for
it, of course, so we still need to have some cardiac surgery but
the balance is changing substantially although the overall numbers
we are treating are much greater.
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