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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