SIR NIGEL CRISP KCB AND MR HUGH TAYLOR CB

THURSDAY 30 JANUARY 2003

  880. So what is the difference between the targets you have been trying to hit and the two you have missed? Are you taking the two you have missed and trying to hit them after April?
  (Sir Nigel Crisp) We have slightly changed one. One was to ensure that 75% of patients receive thrombolytic drugs after the time that they arrive in the hospital, so a very specific clinical target. It is a very important one and it is part of the fact that many more lives are being saved at the moment around heart attacks. We have actually changed that target. We missed it, but we have actually changed it so that it is a target about whether they receive thrombolysis within 60 minutes of calling for professional help, so we have not just taken the time from when they arrive in hospital, but we have actually recognised that the target is now 60 minutes from the time they call for professional help and that is on the basis of people talking to us and saying, "Actually that's an even better target", and also recognising that ambulance services now have people on board many of them who are capable of giving thrombolysis.

  881. Are you going to put your neck on the line with these new targets? Are you going to resign if they are not met?
  (Sir Nigel Crisp) No.

  882. You are the guy at the top, you are a civil servant, so are you going to say sorry? How far are you going to put your neck on the line with this?
  (Sir Nigel Crisp) I am accountable for delivering the best Health Service that we can against this set of targets and with this money. I will be held to account in the normal and the usual way. One does not need facile threats of resignation to describe the commitment and determination of people like me or my senior people to delivering these targets.

  883. Well, it is interesting, that, because Ian Perkin has just been sacked from his job because he allegedly refused to fiddle the waiting list figures. Are people being bullied in the National Health Service to hit the targets? It is suggested that a colleague had asked him that there should be no cancelled operations in one week and in fact he knew there had been 28.
  (Sir Nigel Crisp) Well, obviously I am not going to make any comments at all about something that is going through an industrial tribunal.

  884. Do you think people are being bullied to hit the figures?
  (Sir Nigel Crisp) No, I do not. I think undoubtedly there are instances where things are happening because again, and I think you have explored this with other people, you cannot control behaviour across an enormous, huge organisation, so I obviously would not say that there are not instances of bullying around. There is no need to bully. I can show you many, many examples around the NHS of people who are operating their organisations extremely effectively, where people are very committed and are delivering.

  885. We went to Bristol to talk to people and we had people from the NHS who came to talk to us. Time and time again we were told that they were being bullied to achieve targets. You are setting 62 targets from April onwards and you have said, "We're going to hit those targets", but how are you going to ensure that people are not bullied? I am not saying it does or does not happen, but we are being told that it happens, so how are you going to stop it?
  (Sir Nigel Crisp) Well, referring to your colleague's earlier question, this is tough, this is difficult and there will be instances where there will be behaviour that we do not condone. Let's be clear that that will happen in some cases. This is an organisation with a million people working in it. What we need to do is to make sure that where that happens or where there are reports of that happening, we investigate them. This again is a world where lots of people can say lots of things and can make lots of allegations which need to be tested. We need to look at them and we need to make sure that they do not happen again and that can be done in a whole series of different ways.

  886. If you come across people you realise are bullying because they have got to hit these targets, what will you do to managers?
  (Sir Nigel Crisp) Well, you will perhaps have seen that there is a code of conduct—

  887. Which you brought out.
  (Sir Nigel Crisp)—for managers which sets out the standards of behaviour that we expect. I cannot remember the exact words in there, but there is something about respect and respect for working with people within it. It is for the individual employers, ie, the trust boards or the health authority boards or whatever actually to deal with breaches of that and with allegations about that.

  888. What if they are doing the bullying?
  (Sir Nigel Crisp) If that were the case, then we have a whistle-blowing system which can be used.

  889. You certainly do. The Observer and a few other papers, they are very good at it, I will admit. The papers are marvellous at it. Can I ask why we are suddenly starting to lose, it seems to me, an awful lot of consultants? Are they feeling they have had enough of the Service and perhaps time for early retirement has come, "Let's just step back because we are just under too much pressure to sort out targets and it is alleged that people are saying we are hitting targets when we are not"? Have they just had enough?
  (Sir Nigel Crisp) No. I think you are referring to a recent report which said something like the number of early retirements went up from 400 to 490 or something like that.

  890. It is a 23% rise.
  (Sir Nigel Crisp) It is in that sort of order, from 400 and something to 490 or something like that. I cannot remember the figures, but it is that sort of order. That is disappointing and clearly each individual will be making their own individual decision around that. What we have introduced in a number of areas is incentives for people to stay and what we also are seeing very clearly with consultants is that there is a continuing increase overall, net loss and net gain.

  891. The reason there is going to be a gain is that you have cut down the time it takes to train them and you are bringing in people from other countries obviously. It is tinkering as opposed to mending.
  (Sir Nigel Crisp) Well, your definition of "tinkering" and mine may be very different. Shall I say that we have gone from 5,000 medical students a year to 7,000, which, as you will observe, is a 40% increase in medical school places.

  892. We are talking about consultants.
  (Sir Nigel Crisp) Actually we have then also, and this again is a major strategic change, we have changed the medical training so that we can bring in people from different backgrounds and we have shortened it in a lot of cases. These are major strategic decisions designed precisely to increase the number of consultants and GPs in the country. These are big decisions and I find it very surprising if you describe them as "tinkering".

  893. The tinkering is that you are losing senior consultants at a rate at which you are going to find it very hard to keep up with if this continues. Why are they going? What does your analysis say as to why these people are leaving?
  (Sir Nigel Crisp) But actually your figures are wrong because whilst retirements may have increased from 403 to 497, during the same period the number of consultants increased overall by 3,130. That seems to me like we are going in the right direction. I am sorry that any individuals decide to retire early. There will be myriad reasons for it and in some cases it will undoubtedly be about pressure. We need to make sure that we understand, that we have, where we can, interviews with people and look at the issues and try and resolve them. We need to do all of those things, but don't let's pretend that anything is happening at the moment other than the number of consultants in the system are going up, that we have big, strong mechanisms in the system which will drive that number up even further and that it is important that we also bring in people from abroad, where we can, to fill gaps that we need to fill. We are trying to run a health service here.

  894. When the Audit Commission did its recent report on what you might call morale and motivation in the public sector, one of its findings was that the whole target culture was one of the reasons why people were getting out. Is that something you recognise?
  (Sir Nigel Crisp) Well, I said earlier that actually over the last year we have been listening to what people have been saying, we have been listening to people's worries and so on because actually what they were saying was more than that, was it not? It was about a much bigger set of burdens, it was about monitoring, it was about having to report on things, it was about having to fill in lots of plans, it was about all of those things and that is precisely why we have done a lot of work to reduce all of those things, so I do recognise that you can have a big bureaucratic burden on top of the process. What we need to have is the minimum burden compatible with our accountability for delivering change for this big increase in money.

  895. Do you have interviews with clinicians who leave the Service to ask why they are getting out?
  (Sir Nigel Crisp) Not personally.

  896. Does the Service do that?
  (Sir Nigel Crisp) There is a fair amount of work, I think, particularly around GPs where some of the same things are evident to make sure that we understand those reasons and that is why in a certain number of places we have put in some financial incentives to keep people working longer or indeed we have looked at whether there are things we can do to actually change the job in the last few years.

  897. Would it not be sensible to talk to those people who are leaving to find out why they are leaving?
  (Sir Nigel Crisp) Yes, I agree with you.

  898. That would seem to be just a good management system.
  (Sir Nigel Crisp) We have done that with GPs, but, I have to say, I do not absolutely know whether we have done that with consultants, but I will take the point away.

  899. In October 2002 Health Which reported a 28% increase in NHS managers. How do you explain that?
  (Sir Nigel Crisp) I do not think I have seen that figure. Were they talking about managers or were they talking about a bigger group of people? Could you give me the numbers?