Examination of Witnesses (Questions 160-179)
NORTHERN IRELAND
DEPARTMENT OF
HEALTH, SOCIAL
SERVICES AND
PUBLIC SAFETY
2 NOVEMBER 2004
Q160 Mr Curry: What sort of time?
Dr Carson: I am sure there is
a whole spectrum. For example, patients for elective orthopaedic
surgery are probably told six months in advance and that in itself
creates a problem.
Q161 Mr Curry: In the cardiac unit
then, if it is a week in advance presumably nothing should be
cancelled because of study leave or annual leave?
Dr Carson: Correct.
Q162 Mr Curry: Because presumably
that is predictable.
Dr Carson: It is a small unit,
five surgeons, six or seven anaesthetists in the unit. That information
is well known within the theatre management team. The major factor
for cancelled lists and non-availability of an operating theatre
is the fact that intensive care capacity is already full with
patients in it and those patients are not scheduled for surgery.
Q163 Mr Curry: I am looking down
this list and, as Mr Jenkins said, if people do not turn up you
cannot do anything about that. If a bed is occupied by an emergency
you cannot do anything about that. In sector after sector we look
at ways in which sick leave can be reduced and better managed,
so I do not think you should take that as an absolute given. A
lack of anaesthetists is common right throughout the NHS across
the United Kingdom. Things like study leave and holidays and things
like that presumably should be programmed well enough in advance,
or noted well enough in advance, so that rescheduling can take
place so there are not cancellations. What are your targets for
that? You said, Mr Gowdy, that this was one of the prime areas
where you felt management intervention could improve things. Have
you got some sort of targets here which you could share with us?
Mr Gowdy: In terms of?
Q164 Mr Curry: In terms of reducing
those rankings. What would you like to get cancellations due to
holidays down to? The whole world seems to spend so much time
being retrained that nobody seems to turn up for a job now.
Mr Gowdy: We have not set specific
targets for this. We regard that as a local management responsibility.
Q165 Mr Curry: Have you asked local
management to set targets?
Mr Gowdy: We have not asked them
to set targets as such but we have asked them to look very carefully
at the reasons why these planned sessions, for all of the reasons
that are here—
Mr Hamilton: I would like to emphasise
the point that we have placed a requirement on all trusts to implement
in full the recommendations of this Report and that would include
tightening up on the control of leave. The other issue that I
would want to emphasise here so that there is no misunderstanding
is that the cancellations that we are talking about impact upon
the utilisation of the funded sessions. The Bevan report suggested
90% is the target and at the time of the report we were operating
at 94%. We have checked again and we have increased that to 95%.
The scope for improvement is between 95% and 100% of utilisation.
Q166 Mr Curry: Even if you do not
set specific targets it is bench markable, is it not?
Mr Hamilton: It is.
Q167 Mr Curry: It seems to me the
central issue is this: you said "We cannot use our theatres
more than seven hours a day, five days a week because (a) we cannot
fund it and (b) we cannot staff it". If British Airways only
used its aeroplanes seven hours a day and five days a week British
Airways would be bankrupt. That is true of many businesses. The
funding in Northern Ireland is the highest outside Scotland and
the United Kingdom and your waiting lists are the longest. These
bits of the geometry do not seem to fit together. How is it that
with the highest funding, except Scotland, you still do not seem
to be able to get the utilisation out of the equipment, and there
is very, very high tech kit there, a return on the assets which
is obtainable in parts of the United Kingdom at much lower levels
of funding? What is the heart of this problem?
Mr Gowdy: The heart of this problem
is the waiting list issue and the use of theatres is not the single
critical dimension. It requires us to have a system that operates
in its entirety right through from the efficiency of the GP and
the primary care folk out in the community through the hospital
system and back out into the community where people need nursing
and residential care. We have to provide funding against all of
those elements and with the levels of need we have got, our funding
has to be higher to allow us to do more of those things. What
we are trying to do is to make the whole system work more efficiently.
As part of this, we fully accept that we should be driving and
striving to increase the utilisation of our theatres and we have
made some modest progress.
Chairman: I think that is enough, thank
you very much. That question was brilliantly put, very direct,
and the answer was just a complete load of waffle as far as I
am concerned. Mr Allan?
Q168 Mr Allan: I would like to take
us straight on from there. Mr Gowdy, you are responsible for health
and social services, as you say the whole thing into residential
care. Why do we have as one of the highest ranking reasons for
last minute case cancellations "Beds occupied by outstanding
dischargers"? You are responsible for getting them into residential
homes, are you not?
Mr Gowdy: Yes, we are. The provision
out there in the community is the determining factor in getting
patients out of those beds. There are a number of issues that
come into play there, one of which is patient choice because people
do not want to be moved to a far part of the Province, they want
to be near their home where their relatives are. We need to build
up provision. Our provision is largely the independent sector
and the decisions that are made by the private sector are matters
that we can influence only to some extent. Certainly we have been
doing as much as we can to put in place additional community care
packages to try and get these folk out into the community. We
need to look after the patients in any part of the system, we
cannot just abandon people and push them out of the hospital setting.
Q169 Mr Allan: You are not pushing
them out, you are taking them out. In England and Wales we get
told the problem is that you have got the health service here
and social services there and they are separate funding streams
and they are uncoordinated. We should be able to expect you to
do better, should we not, because you are doing it all?
Mr Gowdy: Yes, we are, although,
as I say, a lot of the—
Q170 Mr Allan: You do not seem to
be doing it better.
Mr Gowdy: The residential home
sector is very largely run by the independent care providers.
Q171 Mr Allan: Presumably you have
got the funding.
Mr Gowdy: It is a decision for
them where they place their homes.
Q172 Mr Allan: You have got the big
block contracts.
Mr Gowdy: We try to influence
those things.
Q173 Mr Allan: You could shape the
market.
Mr Gowdy: We try very hard to
influence those things. We are looking at some alternative ways
of dealing with it. An acute hospital bed is the most expensive.
We are looking at putting in place intermediate care provision
so that we can step those patients down from the expensive hospital
sector into something less expensive, even if we have not got
the residential home in place for them.
Mr Hamilton: We have been investing
in the community as well as in the acute service in order to deal
with the total demand for patient flows through the hospital.
We have increased the number of community care packages from 15,000
in March 2000 up to 19,000 in March 2004. Some of these can cost
between £15,000 and £20,000 a year. The issue for the
service is what is the balance in terms of deploying those funds?
Should all of those funds be used to sort out the delayed discharges
issue? Yes, one could say that is one way forward but there are
also people at risk living in the community and some of those
resources have to be devoted to maintaining people safely in the
community otherwise further down the track there is an exacerbation
of their position.
Q174 Mr Allan: You are telling us
that having health and social services together presents other
problems of competing priorities as in our English and Welsh system
of having them separate?
Mr Gowdy: Yes.
Q175 Mr Allan: Still it is all yours
and you cannot blame anyone else if people are in hospital who
should not be in hospital, who should be back in the community.
Mr Gowdy: We do not have the organisational
barriers that exist elsewhere.
Q176 Mr Steinberg: I just want to
clear up a couple of points that have been part of the discussion.
Twice it was said that the reason why the theatre was being used
so little was because it was a cancer hospital. Can you explain
that. Because it is a cancer hospital, why should that do less
work than another hospital?
Dr Carson: This particular hospital
is a radiotherapy and cancer treatment unit. Cancer surgery is
not carried out in that hospital. That "operating theatre"
is used for placement of radium implants under anaesthesia, no
surgery is actually carried out. There are only one or two patients
a week accessing that operating theatre.
Q177 Mr Steinberg: It is being utilised
totally by the people who need it, nobody has to wait?
Dr Carson: Nobody has to wait.
It is only used for one or two procedures. No cancer surgery is
carried out in that hospital.
Q178 Mr Steinberg: Could it be?
Dr Carson: No.
Q179 Mr Steinberg: Could it be used
for surgery?
Dr Carson: No, because there is
no back-up, recovery, intensive care, high dependency support.
It is not an acute hospital. None of the other supporting infrastructure
that is necessary to carry out surgery is available in that hospital,
it is a stand alone site, not on an acute hospital site, and it
would be unsafe.
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