Examination of Witnesses (Questions 20-39)
SIR
NIGEL CRISP,
KCB, PROFESSOR ROGER
BOYLE, PROFESSOR
IAN PHILP
8 FEBRUARY 2006
Q20 Greg Clark: We know that in Australia,
for example, immediate access to scanning is something that is
very important in preventing death and disablement. Indeed, there
is a memorable phrase in the Report that time lost is brain lost.
One of the figures that truly astonished me in the Report is on
page 22, paragraph 1.18: "For patients who were registered
as requiring an urgent CT scan (within 30 minutes), only 30% actually
got the scan on the same day." That is the most shocking
statistic I have seen in these Reports.
Professor Philp: In 2001, there
was not evidence that an emergency response to stroke made a difference
compared to people getting access to a multidisciplinary stroke
service. There was a leading article published in The British
Medical Journal at that time that said as long as you had
an organised stroke service that had a multidisciplinary team
there were benefits but it was not clear whether the service should
focus on acute care or rehabilitation or both. The evidence for
the need for the emergency response to stroke emerged in 2004.
At that time, we established the Stroke Strategy Group whose principal
aim was to define what needed to be done to ensure that people
got rapid access to stroke services.
Q21 Greg Clark: In 2001 you had NSF
standards for strokes and standard five for stroke care was that
by April 2004 every general practice can identify people who have
had a stroke and is treating them according to protocols agreed
with specialist services. Yet, at page 16, table six of the Report,
despite this standard imposed in 2001 to be achieved by 2004,
agreed stroke protocols between acute and primary care were in
place in less than half of the cases. There is no excuse there
for not having had the best available medical evidence. It was
targeted. It was seen as important that GPs had good links with
acute hospitals and yet less than half of them had these protocols
in place.
Professor Philp: In the National
Service Framework there was a difference placed between the target
date which we wanted PCTs and local government to achieve, but
there was latitude to deliver the standards within the 10 year
programme of NSF implementation. Compared to what was a very complex
and detailed National Service Framework with a lot of recommendations,
those were seen as the absolute key priority.[2]
Q22 Greg Clark: Some are more important
than others?
Professor Philp: Yes. Some became
public service targets which were requirements therefore.
Q23 Greg Clark: Can I give you an
example of the effect of these targets on ordinary people? We
have had a publication sent to us by the Stroke Association and
there is a case study that is relayed in it, where there is a
lack of agreed protocols between primary and acute care. A lady
takes her husband to hospital. He has had a major stroke. It was
obviously a struggle as he was showing weakness down one side
of his body. After a wait in A&E, she was told his symptoms
were probably caused by drunkenness and sent home. Can you imagine
the distress caused to that patient by a target that was there,
designed to be a treatment, and it was decided unilaterally that
it was less important than some of the other targets?
Professor Philp: The evidence
was clear. The most important two targets were risk factor modification
around smoking and blood pressure control and on establishing
stroke services in all our acute hospitals, which we have now
achieved. It gives us the foundation upon which we can build the
effective emergency response. Furthermore, in terms of the staff
skills and knowledge, stroke as a medical sub-specialty was only
created in 2004, so we were starting from a low base.
Q24 Greg Clark: You had a target
that was set in 2001. Accepting that things did not happen as
they should have done, the Chairman referred to the Minister's
response to the NAO Report when it was published. Mr Byrne said
on the day of publication, 16 November, "We will take action
immediately by spreading examples of best practice." Here
is an example of best practice, protocols between primary care
and acute hospitals. Are protocols now in place in 100% of cases
between acute hospitals and primary care?
Sir Nigel Crisp: Part of doing
that was to appoint somebody to lead it.
Q25 Greg Clark: You knew what needed
to be done. That was identified in 2001. It had not been done
by 2004. The Minister said in November last year that immediately
this best practice would be spread. Has it happened immediately?
Professor Boyle: We have in our
stroke community the best centres in the world.
Q26 Greg Clark: Have those protocols
been established? It is a very clear question based on a very
clear figure in the NAO Report. It says that 49% of acute hospitals
had protocols agreed with primary care. This is identified as
important. The Minister said he would respond immediately. Is
that now something approaching 100% or has it not much changed?
Sir Nigel Crisp: To be fair, we
have appointed somebody to take the lead. We have a lot of people
engaged in working forward with this. We have a big conference
in two weeks' time to bring people together, including patients
and carers in particular, in order to make sure that we understand
exactly what the key issues are.
Q27 Greg Clark: I do not think it
is a question of understanding. It is very clear. My understanding
of immediate response to spreading best practice is not to convene
a conference but to make sure that those hospitals that do not
have those protocols in place put them in place. It is an example
of the sluggishness here that sometimes we make points that might
seem pedantic, but I think in this context, when people are dying
as a result of this, this is very serious. This is a shameful
situation in which targets and protocols have not been established
and ministers and officials said they would be established. During
the five years, Sir Nigel, that you have been the chief executive
of the NHS over 112,000 extra people have died as a result of
our practice being behind the Australian practice. At the same
time, it has cost us money. That gives me the utmost alarm.
Sir Nigel Crisp: I regard it as
extremely serious and an extremely important set of issues. I
also know that in those areas where we have given priority you
cannot give priority to everything at once, however much you may
wish to. You can imagine that we have patients' groups from all
kinds of different disease groups at our doors every day asking
to be given priority. The government has to make decisions. We
have made decisions; we have given priority; we have made real
improvements, saving lives that would not otherwise have been
saved because of the work of colleagues here. In terms of spreading
good practice, it is not a question of clicking one's fingers
and saying that you send a protocol out and tell people to do
things. The experience of getting good practice takes time because
it is about persuading professionals that this is the right way
to do it. Professionals need to be trained. It is about involving
huge numbers of people. It is not a simple exercise and we are
going about it in a way that we have proven works so that we now
have the best heart service in the world. We would expect to see
the improvements that the Chairman asked for in stroke over the
next few years as well.
Q28 Chairman: You will not have seen
the brief to Members from the National Audit Office. It tells
us in the fourth paragraph, "The Report demonstrates that
stroke has not received the attention that other major killers
have . . .". You made the point that you concentrated on
coronary heart disease but they tell us, ". . . there is
scope for considerably greater effectiveness even within the resources
available. In particular, value for money improvements should
come from reducing hospital stays (the average length of stay
in England is 28 days, compared with 11 days in Australia) . .
." This is a value for money Committee. It seems that even
with the resources available to you, because you are not getting
people into stroke units quickly enough, giving them a scan, getting
them the drugs, it is costing you more money in the long run than
if you did it properly. Is that a fair point?
Sir Nigel Crisp: I take the point.
We did not publish this precisely in November. I think it was
October but this is a best practice document about acute stroke.
It compares length of stay between various different hospitals.
It shows that that length of stay has come down four days in the
last year and a half. It shows the characteristics of a high performing
stroke system. I have not quite followed the logic of what you
were saying earlier, Mr Clark. I think this is probably what you
were talking about. This describes the characteristics that we
expect to see in a good stroke service and incidentally on hip
replacements, Caesarean sections and so on. The institute we use
is the NHS Institute for Innovation and Improvement, which is
precisely about spreading good practice around the NHS. I am happy
to provide copies of this to the Committee if that would be useful
but I totally recognise the value for money issues and I am pleased
to see that we have had a four day reduction in length of stay.
Q29 Jon Trickett: I want to go back
to the issue of scanners. We are investing as a country quite
heavily in scanners but when do you think most stroke incidents
take place during the 24 hour period?
Professor Boyle: They occur at
all times of the day and night. One of the problems is the patient
suffering the event recognising that that is happening. There
is an issue about raising awareness amongst the public about what
the symptoms are, which is why we are supporting the Stroke Association
in their vast campaign to recognise the symptoms.
Q30 Jon Trickett: When, during the
week, do you think they take place? Are they concentrated on the
five working days or do they occur at weekends as well?
Professor Boyle: Patients do not
choose the days.
Q31 Jon Trickett: There are seven
days in a week and 24 hours in a day. Strokes occur at night and
at weekends. That is a fairly obvious statement of fact and yet
the majority of the scanners only operate for nine hours a day
or less for five days a week and 80% of all scanners only operate
for nine hours or less on week days. What does a scanner cost?
Professor Boyle: A full installation
would cost about £1 million. That is not the issue. The physical
capacity is there. It is possible to get a scan in virtually every
hospital at any time of the day or night with a radiographer.
The point is how it is interpreted.
Q32 Jon Trickett: I only asked you
what it cost. I did not ask for a thesis on it. No other business
would invest £1 million in a piece of plant and only have
it operate for 40 hours a week when business really runs throughout
the whole of the week, does it not? There are 168 hours in a week
if my maths are correct. Why is it that they are only operating
for such a short period of time when there is a difference between
some kind of early diagnosis and effective action and not if one
is not put in front of a scanner very quickly?
Sir Nigel Crisp: Your point is
an entirely good one. The point that Professor Boyle is making
is that the equipment is there but we do not always have the staff.
What is hopeful for the future is the PAC system, the picture
archiving system, which means you can digitally do scans and send
them to the home of the radiologist who can then interpret them.
You may be aware that we are putting in such digital X-ray systems
around the country at the moment which will help unlock part of
that bottleneck, which is basically a people bottleneck.
Q33 Jon Trickett: Before we get on
to people who seem to be operating inside some sort of box rather
than in a way which is joined up and holistic, I want to ask you
about the management of the service. Paragraph 1.19 says that
the NAO were told that five times as many MRI scans and over twice
as many CT and Doppler scans could be achieved without compromising
necessary scans for other patients, simply by managerial change.
How can that be?
Professor Philp: I presume by
"managerial change" we mean organising the workforce
for reading the scans, because we know that the block is the 24/7
availability of appropriate staff to interpret the scans, which
is why we have been working with the diagnostics team and the
relevant colleges of physicians, radiologists and radiographers
to define what are the critical scans. It is a little bit complicated
because a scan done within three hours to exclude haemorrhage
and to get the absolute gold standard for door to needle time,
if you like, for thrombolysis will not produce a diagnosis of
an infarct and will miss some other things.
Q34 Jon Trickett: It is clear in
paragraph 1.17 that an early scan will distinguish between a clot
causing a stroke and a haemorrhage, which is an entirely different
thing and much more serious. I believe you must have assented
to this statement. What you are saying is, if managerial change
was brought about, including staffing and timing changes, you
could double immediately the number of scans which are available.
That is twice as many human beings getting in front of a scan
more rapidly than otherwise. Surely immediate action could be
taken in relation to that. There is no reason for delay at all.
Sir Nigel Crisp: I accept that
point about a reorganisation by management. It is about how you
run the whole process. You can do that which is why we did produce
these programmes which were about both quality and value for money
in five of the most important areas, including stroke, in order
to do the best practice stuff that we were talking about before.
Q35 Jon Trickett: It is a very complex
system in the NHS and decision making is devolved into all kinds
of different centres of management. Is there something you can
do to bring about immediate change in the management of the scanners
and the staff who support the scanners so that we can double the
number of people being scanned within the next six months?
Sir Nigel Crisp: I think that
is in these guidelines, is it not? I think the answer is probably,
yes.
Q36 Jon Trickett: I do not want to
be unfair to you because it is a complicated issue but can you
give us a note as to your objective to increase the productivity
of each scanner?
Sir Nigel Crisp: Yes, let me produce
a note.[3]
Q37 Jon Trickett: I was told in my local
hospital that there is a scanner being produced under the PFI
scheme. It is for ever breaking down because it is ancient now.
The contract which was signed by the PFI and the NHS precludes
other scanners being utilised or even other staff being employed.
Is that one of the problems, that we have a series of contracts
which are perversely precluding scanning episodes from taking
place and thereby slowing the system down? I was also told by
a senior consultant that this scanner is only available for eight
hours a day under the PFI contract.
Sir Nigel Crisp: Let me look at
that. If that is the case—and I find it a bit surprising—it
is certainly not widespread. Most scanners are NHS scanners within
NHS institutions in any case.[4]
Q38 Jon Trickett: The Committee would
be interested if there are such contracts. It has been around
for a long time.
Sir Nigel Crisp: Let me look at
it.
Q39 Jon Trickett: On clinical specialisation,
the difference between radiologists, consultants dealing with
strokes and radiographers, it appears to be the case that anybody
who is reasonably trained can interpret the results of a scan;
yet that seems to be one of the issues, the shortage of radiographers
and the fact that they do not work overnight and at weekends and
so on. Is that an issue and, if so, how can it be tackled?
Professor Boyle: Radiographers
do work at night and on weekends. In most hospitals, it will be
possible to get an acute scan done out of hours. The difficulty
is then having the person to interpret the scan. Also, it makes
the big assumption that the whole system is ready to respond to
the scan because only about 10% of patients maximum would be eligible
for the clot busting treatment which is the one that the Australian
system seems to be able to deliver.
2 Note by witness: Figure 4 of the NAO Report
shows that 73% of GPs had local protocols in place for rapid referral
and management of acute cases and 71% of GPs had local protocols
in place for rapid referral and management of minor cases. Back
3
Ev 18-19 Back
4
Ev 19 Back
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