Select Committee on Public Accounts Minutes of Evidence


Examination of Witnesses (Questions 100-119)

NORTHERN IRELAND DEPARTMENT OF HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

2 NOVEMBER 2004

  Q100  Mr Jenkins: Let us get this one thing right. I constantly get fed up and very, very angry when people come before us and say, "This Report is not correct". Did you have a chance to speak to the staff of the Comptroller and Auditor General about this Report?

  Mr Gowdy: If I may—

  Q101  Mr Jenkins: I am talking to Dr Carson at the moment, please. Did you get a chance to speak to the staff when they had compiled this Report?

  Dr Carson: We did, yes.

  Q102  Mr Jenkins: Did you point out this fact to them?

  Dr Carson: Yes, we did.

  Q103  Mr Jenkins: They refused to take notice of it?

  Dr Carson: Pardon?

  Q104  Mr Jenkins: They refused to take notice of your observation?

  Dr Carson: I am not aware.

  Q105  Mr Jenkins: Did you pass the observation on to Mr Gowdy?

  Mr Gowdy: Dr Carson was not directly involved, he was in a different position when this Report was compiled. I can give you an indication of what has happened here. We have agreed fully with the Report, there is no question of us having any difference of view. What Dr Carson is reflecting is the practical experience now that we have got the Theatre Managers' Forum in place.

  Q106  Mr Jenkins: You recognise the importance that these reports must be correct.

  Mr Gowdy: Yes, indeed, absolutely.

  Q107  Mr Jenkins: Any observations you make afterwards are immaterial, we do not take them into account. In fact, if you make an announcement that this Report is wrong we challenge your contribution to it.

  Mr Gowdy: There is a full understanding of that.

  Q108  Mr Jenkins: When the Chairman started talking and going through this Report, I was not very happy with the Report and I was even more unhappy with your replies because the first thing you said about the amount of money was what a poor deprived area you have got, you have got all these problems, therefore you need the extra money. I could take you to any area of a large city in England that would make your deprivation look like paradise and they manage to get on with it and they manage to produce better figures than you do. Maybe the deprivation you are suffering in Northern Ireland is a deprivation brought about by inefficiency and poor management. I suggest the taxpayers in Northern Ireland do not get a good deal for their money, especially when you get reports like this. Maybe they are not vocal enough in forcing their replies on to you.

  Mr Gowdy: I would have to disagree with that.

  Q109  Mr Jenkins: You said you compared your set-up with hospitals on the mainland in England that were as bad or worse than this. Name them, please, with the operating theatre times.

  Mr Gowdy: We can send you a letter setting this out.[1] I do not have the names with me. It was a sample of 16 trusts and it was undertaken in the course of 2003-04. We can give you the names. What I was saying was that our outcome here at 64% utilisation matches that in England, so we are not out of kilter with what is happening elsewhere.

  Q110 Mr Jenkins: I want to know and, believe me, I will be following it up most seriously. If I could turn to page 69, and I may be reading this Report totally wrong, on the range of sessions cancelled in major specialities, is it right that 36% were cancelled in cardiac surgery?

  Mr Gowdy: In 2001-02 yes. The figure for 2003-04 is close to that, it was at 32% cancellations. What lies behind that is that patients for cardiac surgery are, as we were saying earlier, much frailer, much older and more likely to have conditions which would make them unfit or unsuitable for procedures.

  Q111  Mr Jenkins: No, no, no. Let us get this straight. When you are a patient in hospital, when you first go in you have a GP or a surgeon come and assess you. They do various checks on your blood flow and your heart and they see exactly if you are fit for surgery. If you are fit for surgery you are then booked in. They do not book you in and then come along at the last minute and check if you are fit for surgery. I might be wrong, it might be different in Northern Ireland, maybe it is totally different, but in hospitals in my part of the world they check us in before we go into surgery so we cannot have a cancellation because the patient at that stage is too frail unless you get a sudden failure of the patient as they move from the ward to the theatre itself. It can happen with a very old and frail person, but I would suggest it is not 36% of the time.

  Mr Gowdy: I had not quite finished the point I was trying to make. What we are dealing with here are much frailer patients. In some cases, after the clinical pre-assessment has been made some of them deteriorate and some of them actually die so there are sessions that are cancelled for those reasons. The most predominant reason, however, is that those older, frailer patients who are in the beds that are needed for intensive care after the operation are, in a sense, blocking those beds. They need the care and those beds cannot be freed up so the operations that were going to be carried out on the patients who were due for those sessions cannot be held and have to be cancelled. Is that right, Dr Carson?

  Dr Carson: Correct.

  Q112  Mr Jenkins: I just find it totally amazing, absolutely mind-boggling that you have got days on end—days on end—when a theatre is not being used because no-one has done an assessment on a patient before they have booked them into the system. Is that what you are telling me?

  Mr Gowdy: No, quite the opposite. What I am saying is that, yes, there are some patients who have been through the assessment process who are deemed fit but who subsequently deteriorate for varying reasons. With a very frail patient that can happen. The major reason is that the very frail patients who are in the intensive care beds cannot be taken out of those beds because their condition does not allow them to be moved to another area which is less intensively nursed and because those beds are not free it is not possible to carry out the procedure on patients who will then need those recovery facilities.

  Q113  Mr Jenkins: This only affects cardiac patients?

  Mr Gowdy: That is why cardiac patients are such a high proportion of the cancellations, as you can see from this table. It is the most sensitive area.

  Dr Carson: In Northern Ireland we have one cardiac surgical unit to cover the whole Province, it is a regional service. That unit has a fixed number of staffed intensive care beds. If a bed gets occupied by a patient who needs a prolonged length of stay, what the Secretary was trying to illustrate was that the age profile of the patients is getting older and the complexity and risks associated with the surgery is increasing. These patients are taking longer in the intensive care units and if a bed is occupied in the intensive care unit no surgeon is going to take the risk of operating on a patient without the necessary post-operative support in an intensive care unit.

  Q114  Mr Jenkins: Yes, I understand all that. Answer the question. The question was, how do you book somebody into a theatre and then say, "Oh my word, this person is not fit for an operation" and that amounts to 36% of your cancelled operations?

  Mr Gowdy: The sessions are arranged in advance. They are arranged ahead in time.

  Q115  Mr Jenkins: How far ahead?

  Dr Carson: The operating list for cardiac surgery is planned a week in advance.

  Q116  Mr Jenkins: Do you not think pre-assessment should be a bit closer if the cancellation rate is 36%? What pre-assessment do you do for these people?

  Dr Carson: The pre-assessment is largely done by nursing staff now with the assistance of the anaesthetist.

  Q117  Mr Jenkins: Page 104, please. There we have got reasons given for last minute case cancellations. Do you see the ranking order. 30% did not attend. Do you mean that you have got someone booked into the system and they just do not turn up?

  Mr Gowdy: We were focusing there on the cardiac surgery.

  Q118  Mr Jenkins: I take it for an operating theatre you do a pre-assessment for a patient. In my part of the world you go into hospital, the doctor checks your height, weight, blood pressure, et cetera, checks your pulse and books you in and then you turn up. Not many people do not turn up in my part of the world, to be honest. I find that such a high non turn-up rate. Do you do pre-assessments before patients appear?

  Mr Gowdy: Yes. Increasingly the hospitals in most specialties are now doing a pre-assessment.

  Q119  Mr Jenkins: When I go down this list I understand "bed occupied . . . shortage of intensive care", but it is this business about lack of anaesthetists. Sick leave is obviously an emergency, but when you get to annual leave and shortage of theatre staff so you cannot book an operating theatre, court appearances, study leave, annual leave, lack of equipment, all of these are situations that should be overcome quite rapidly to allow you to re-man and re-equip the theatres to book an appointment. Why are these reasons given for cancellations? These are reasons or indicators of poor management, are they not?

  Mr Gowdy: As I was saying to Mr Steinberg, these are issues that increasingly we have been focusing on as a result of this Report. This has been very helpful to us in determining those areas where it is possible to make a significant improvement by asking all of our trusts to manage the leave issues better.


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