SIR NIGEL CRISP KCB AND MR HUGH TAYLOR CB

THURSDAY 30 JANUARY 2003

  860. In NHS terms, how soon is "soon"?
  (Sir Nigel Crisp) Two weeks, I am reliably informed.

  861. It will appear in February?
  (Sir Nigel Crisp) I would be happy to say February.

  862. Will it still be called the autumn report?
  (Sir Nigel Crisp) We will make sure that it is cross-referenced so that it can be identified as the autumn report.

  863. That is very helpful. Could I ask you a couple of other things very quickly? In terms of the validation of performance data, and this is always a big issue as to whether we can actually make all this stuff stack up, the suggestion has come that the new inspectorate, CHI, should have this role in the external validation of these performance data inside the Health Service. Can you confirm that in fact that is the role that CHI is going to have?
  (Sir Nigel Crisp) Amongst other things, yes. The point about having an external inspector is its independence and that it will be reporting on the validity of performance, yes.

  864. Queries have been raised in the Public Accounts Committee recently about the fiddling of figures. It is said that it was crucial that CHI should be able to have this validating role to make sure that all that is stopped. Is that going to happen?
  (Sir Nigel Crisp) What we have said, and indeed I was there, to the Public Accounts Committee is that CHI, as the external inspector, will be doing just that and in the short term, as you may also be aware, partly in response to that Committee, I decided to ask the Audit Commission to review the validity of waiting list figures specifically. We take this issue extremely seriously.

  865. So from now on questions of fiddling figures, the nature of the integrity of the reporting of data is all going to be taken care of by the new arrangements?
  (Sir Nigel Crisp) Let me just be clear that they are not in place yet, but they will be be in place and the intention is to do precisely that, so when they are reporting on performance in the NHS, they will be putting their mark against the validity of the be information.

  866. Let me just ask you about this recent report about alleged problems in meeting the key 2005 waiting time. In terms of the targets you are working to and the key waiting time targets, my understanding is that the Government is saying that it is on target to meet its interim target of the 12-month wait by 2003, but the leaked memorandum from Michael Barber, the head of the Delivery Unit, allegedly says that the Government is not on course to meet its 2005 target of the six-month wait and indeed the quote is, "Meeting the 2005 target will require a different approach which is not yet tested". Could you tell us whether this is so and what a different approach might be?
  (Sir Nigel Crisp) Well, let's firstly say that yes, I am confident that we will hit this year's interim targets on progress to having very short waiting times indeed and let's be clear that six months may be the target in 2005, but we should have the ambition of removing all unnecessary waiting in the NHS. This is the route that we are going down. The point that I think allegedly is made is that this gets harder as you reduce the waiting times further and, therefore, you have to make sure that you have the capacity in the system and the methods for doing it. It is a big enterprise, it is a difficult enterprise, it is one we are committed to doing, it is one we have the pieces in place to make happen and I have no doubt at all that we will make it happen.

  867. So, as far as you are concerned, despite the warning shot across the bow from the head of the Delivery Unit, you are firmly on target still for the 2005 six-month waiting target?
  (Sir Nigel Crisp) I do not regard that as a warning shot. I regard that as a perfectly sensible statement that this is a very difficult task that requires an enormous number of people in the NHS, the dedicated, good people in the NHS who are working to provide good services for patients, and it is also absolutely true that the NHS needs to change in order to make sure that it delivers on these targets. The sort of example I would give you is the well-publicised example in Peterborough where for cataract surgery, for example, the whole system has changed so that it is the opticians in the high street, as it were, who are able to refer patients directly on to the operating list, cutting out a whole series of processes and thereby reducing the amount of time that people are waiting. Now, that does mean that we need to look at, restructure and redesign the way in which we deliver services to do this. That is absolutely right and that is the big challenge, but it is happening. We have got lots of examples and I merely pull out the Peterborough one as I suspect people may be aware of it.

  868. I do not want to explore particular cases, but it is very useful to have that. Broadly what you are saying is that the kind of methods that have been used to achieve interim targets may have to be at least supplemented by other methods to achieve the 2005 target?
  (Sir Nigel Crisp) Well, the way I have described it before, and I described it in that report, is that mostly these achievements have been done by the sheer hard work, determination and commitment of the people working. We need to do it smarter. The way I think it is at the moment is 80% perspiration, if I can put it like that, and 20% modernisation, but we need to turn it the other way around and we need to change our services in order really to deliver.

  869. I must say, I am uncomfortable with some of the language. I think there is a spectrum of words from "standards" going through "monitoring", "performance management" to "targets" and when I get to "targets", my hackles rise and I feel uncomfortable. From our experience of speaking to people who work in hospitals, they feel uncomfortable with this idea of targets as well, and at the lowest level indeed we have been told by some staff when they are in private and away from their managers that they feel pressurised and bullied because of the imposition of targets and the effect it has at their level. Do you think that morale is to an extent damaged by this kind of regime?
  (Sir Nigel Crisp) Can I firstly say that I think part of the confusion here is because these words are all a bit slippery. They can slide into each other and that is why I think it is so important that we are trying to be absolutely precise about what we are telling the Service we want for the next three years and that is the purpose of the document published in October, I think it was. On the particular point, you see, there is a tension here and let me give you an example, perhaps anticipating a further question, as it were, of where a target has clearly delivered a benefit and the one I would take is on cardiac surgery. Now, we do not want people to wait a long time for cardiac surgery and we have actually got targets in cardiac surgery that are ahead of other waiting times. We have driven that very hard and right now we have got virtually nobody who is waiting more than nine months on cardiac surgery. Now that, I have no doubt has come about because of the real focus and the resources, both those two things together, that we are dealing with in terms of cardiac surgery. The other point is that sometimes that is uncomfortable for people. Before the NHS Plan, we did a survey of the public and a survey of staff as to what they thought needed to change. Top of the public's list was reduced waiting times. It was, I think, number five on the staff's list. Some of the things we are doing people do not see as being as important as maybe the public do. This is uncomfortable and this is difficult. We are trying to make really big change here. I am very sensitive to the issues that you talk about and we have got to get that balance right of moving people on in the direction we need to move without damaging them, but it is difficult.

  870. I appreciate the point, but might it be that one of the reasons why the staff perhaps do not put waiting times as high is because the pressures on them on a daily basis are too high? Is it not really about decades of under-resourcing?
  (Sir Nigel Crisp) Well, I think there is a very clear position here which is that we are coming from a situation where as a health service we are not comparing well enough with our European neighbours, we are not doing well enough. We are coming from behind the game, we know that, in a number of areas and we are clear about that. We have now got the opportunity and the determination to get to the same level and even better. We are aspiring to be world class. Now to move from where we are to where we are going is much tougher than just staying in the same position, so it is tough, it will be difficult. People in the Health Service do understand that, but from time to time pressures will get too much in some places and we need to keep managing that, but it is a very difficult task to get from behind the game to get ahead of the game.

  871. Do you try to put pressure on the Government and your masters, or all of our masters really, to recognise the under-resourcing of Britain's National Health Service because if you compare Britain and France, for example, the difference in spending amounts to over £40 million per Parliamentary constituency every year, just on health. Germany spends even more than France on health and they do not have the problems with waiting times that we have. They have more beds, they have more doctors and nurses, they have more scanners, they have more everything. In a sense it is your job to tell the Government, "Yes, we will make the NHS as efficient as possible, but you have got to provide the resources".
  (Sir Nigel Crisp) Frankly, I think those discussions were held a year or so ago and we are now in a position where we have got very substantial resources coming into the NHS, a very big commitment over the next five years which will take us into the same area as the European average, depending on how that moves over that time. We have now got the resources coming in. Frankly, the issue right now is down to the NHS to make sure that we deliver against that. I think we are moving in that direction. Can I also just say in parallel of course that I hear lots of comparisons with the continent and they are not always in favour of the continent. There are a number of areas where the British Health Service is ahead of some other parts of the world.

  872. There seems to be a germ at the heart of government seeking to fragment the Health Service, to divide it, to move towards privatisation, with competing providers—in their terminology, to create a market inside the Health Service, to drive us towards an American system of health service provision. America has a health service which is grotesquely inefficient and does not serve a high proportion of the poorest people in society. Is there any debate at your level about these proposed changes?
  (Sir Nigel Crisp) Firstly, may I say that I share your critique of America, but this is not where we are going. The direction in this country is very clearly set out in all our policy documents, which is that the money coming into the Health Service is coming in through the public purse and that within that it is the responsibility of the NHS to secure the highest-quality services for all its people with particular reference to those who are most disadvantaged in the system, a very clear set of values, very value-driven within that. We need to secure care in one way which works best. I think your last witness was saying that there is not a hard-and-fast line between public and private, or I think he was saying that, I would certainly say that, and do remember that a vast proportion of the NHS at the moment is delivered by self-employed contractors called GPS who are under a clear contractual arrangement with the Government. 90% of healthcare takes place in primary care. There are possibilities that we can actually use and involve a whole range of different organisations in delivering the services to the standard, to the quality, monitored in the way your Chairman indicated across the country. This is a national health service.

  873. I would just give a gentle reminder to all of us that although this is all very fascinating, we are not actually the Health Select Committee!
  (Sir Nigel Crisp) I had wondered actually.

  874. How many targets did you miss last year?
  (Sir Nigel Crisp) I am afraid I cannot give you a number on that.

  875. Give me a guesstimate, go on.
  (Sir Nigel Crisp) Of the sort of ten or twelve major targets, I think we probably hit nine or ten of them and the misses were by relatively small numbers.

  876. How many standards did you miss? As to the interface between standard and target, is a standard more difficult than a target? Do you decide, "Well, let's turn this into a target, it's a bit easier"?
  (Sir Nigel Crisp) My point about standards was the sort of sloppiness of the language that is around some of this. The sort of standard that I am talking about is that if you have a heart attack, what is the standard of care in terms of what is the professionalism and background of the doctor and nurse, what is the understanding of best medical practice around in terms of whether you get thrombolysis as opposed to whether you get other sorts of treatments and so on. It is all those kind of things which is a professional body of work. Now, I do not think there is any way in which we can say, "Did we miss standards?" because standards are just things you are applying all the time as professionals who are doing a hard job.

  877. But this whole thing is a shambles, is it not?
  (Sir Nigel Crisp) What whole thing?

  878. The targeting system and standards. You have come up, within an NHS which is moving forward, with 62 more targets starting some time in April. So far it has been a shambles. You thought, "Oh, we had better make some changes here. We'll start again. We'll wipe the slate clean. We've got another 62, so we'll wrap them in", so you have got 62 coming up. How many standards are you trying to set? Are you looking at standards as a number or are you just saying, "Well, we can't do it, so we're not going to think about it"?
  (Sir Nigel Crisp) Let's make a couple of points. Firstly, I think there is an awful lot of misinformation around. If you look at our targets, and I do not know whether you have looked at our targets in your inquiry, but you might want to, you will find that there is remarkable consistency between last year's targets, the year before's targets and the targets we are setting for the future. By and large, there is enormous consistency in the targets. We have refined them in some cases, we have gone from a target of waiting list numbers to a target of waiting times and so on on the basis of advice, so we have moved forward. This is consistent and it is showing how it works. The answer to your earlier question is that I believe we missed two targets.

  879. So up to April this year when you start again, a clean slate—
  (Sir Nigel Crisp) It is not a clean slate, but a continuation.