SIR NIGEL CRISP KCB AND MR HUGH TAYLOR CB

THURSDAY 30 JANUARY 2003

  900. It said managers. The figure they used was that there was a 28% increase in managers. What is your view of the increase?
  (Sir Nigel Crisp) Well, first I would like to know whether there was that increase or not. The figures that I have got here tell me that there are 26,285 NHS managers. Is that the figure that you are referring to?

  901. This is between 1996 and 2001.
  (Sir Nigel Crisp) The figure moved between those years by 2,000 which seems to me to be about 10%. I am sorry, I have not got your figure of 28%, but may I make two points though. Firstly, actually we do need good management in the system which spends £1 million every ten minutes. We need to make sure that we are actually controlling that properly, do we not? These are relatively small numbers overall in the wider context and during the period of 1998-2001, the percentage of the NHS budget which went on management reduced.

  902. In terms of the NHS Plan, a claim was made that an additional 10,000 doctors are needed to deliver the Plan and you are looking for an extra 2,000 by the year 2004. Is that correct?
  (Sir Nigel Crisp) No. Let me just find the figure. This is one of the targets that I referred to.

  903. While you are looking for that, may I just give another gentle reminder that we are not the Health Select Committee, but this is related to targets, I think, so we are still on legitimate territory.
  (Sir Nigel Crisp) I have not quite found the target, but the figure we are looking for is 10,000 and I just need to check the date by which we are saying 10,000. I think the point you may be making is we are saying of that, it was going to be 2,000 GPs and the others were consultants.

  That is the only 2,000 figure I can think was being referred to.

  904. Okay, I accept that 2,000 GPs by 2004 is the target, but where are we just now on that figure?
  (Sir Nigel Crisp) Not doing as well as we should.

  905. That is not what I am asking. What number are we at?
  (Sir Nigel Crisp) Sorry, I do not know. I have not actually got it in front of me, but the figure, as I recall it, is that we are not on track at the moment to hit that which is why we are doing some remedial action right now to move forward.

  906. How far do you think we are off track?
  (Sir Nigel Crisp) I think that we are 300 short at March.

  907. We have taken evidence and a number of people have said that the targets create clinical distortion in the trusts. What do you say to that?
  (Sir Nigel Crisp) Most of this conversation is about waiting list targets, is it not, of which there are only about five, bearing in mind that there are an awful lot of targets here that are absolutely clinical and it is very important that you remember that in this context, so I think you are talking about waiting list targets. Again we have looked at this and let me say what I just said to the Public Accounts Committee which is that clearly it is possible that that happens and clearly there is evidence that that has happened in a number of cases. However, firstly, it does not need to happen, and we have got some very clear guidance about how you manage waiting lists which show that you can actually make sure you are treating the most urgent people first, but that you are treating everyone within every category in order that they actually arrive on the waiting lists, and, secondly, where there are examples of that, we look at them and we see what are the reasons as to why it may have happened.

  908. I am interested that you mentioned that reply then. I read an article about two weeks ago of a surgeon who was brought in on a Saturday and finished up doing varicose veins the whole day. How can that be about clinical priorities?
  (Sir Nigel Crisp) It is slightly difficult for me to comment on an article that I have not seen, but probably those patients needed treating.

  909. As urgently as hips or knees or whatever?
  (Sir Nigel Crisp) Well, it would not be the same surgeon who did hips and knees and varicose veins.

  910. So that would be a priority, you think, doing varicose veins?
  (Sir Nigel Crisp) The point is that we actually have a commitment to people in this country to deliver health services and the health services that they need, and if you have got varicose veins, that is pretty important to you. Now, what we have is a system for making sure that we put the most resources we can against the highest priority. Occasionally that will slip, occasionally that will move, but our commitment to giving priority is the answer to your colleague about coronary heart disease, that we have harder targets on coronary heart disease, so actually we are saying that it is more important that you get coronary heart disease fixed than it is to get varicose veins fixed. The fact that a surgeon came in and treated a lot of varicose vein patients on a Saturday, I suspect, was a jolly good thing. I am sure the patients thought so.

  911. Is there not a fundamental contradiction between targets as used, understood and promoted by politicians and targets as a way of improving service in that for politicians targets have to be met? If it is not, it is a failure, so they get called to account, they lose elections and they are headlines in newspapers and so on. Actually a lot of the evidence we have taken has told us that there is a purpose of targets in the world of service delivery where it is not necessary that they all should be met, but they should be achievable and they should be ambitious, and we should accept along the way that quite a lot of them will not be met. Now, you mentioned that a lot of the 62 targets are clinical, so are you saying that the others are political?
  (Sir Nigel Crisp) No, I was making the difference between access and things that are obviously clinical. There are some other targets here which you would not say were clinical which are actually about patients' experiences, about single-sex wards, those sorts of things which in a way you cannot say are clinical, so I am making that distinction. I do not think any of these targets are political, but these are all about service improvement in one way or another. Improving waiting times is a service improvement, improving the way we treat heart patients is a service improvement, reducing people being in mixed-sex wards is a service improvement, all of those.

  912. How many of the 62 that you have got do you feel at the bottom line are the ones you have to meet in order to satisfy your political masters? Which are the ones that fall into that category?
  (Sir Nigel Crisp) I think all of them.

  913. All of them?
  (Sir Nigel Crisp) This has been refined down and our intention is to hit these targets. We would not have set them unless we intended to hit them.

  914. If I can revert back one step, we have been told time and time again in evidence that that is just simply unrealistic, that the essence of good target-setting is that they should be ambitious, but you should accept that you are not going to be able to achieve all of your targets. You said that to satisfy your political masters you have to achieve all of your targets. Does that mean that the targets you have set are not sufficiently ambitious?
  (Sir Nigel Crisp) No, it does not. What I am telling you is that we should aim to hit them all, which I think is the same thing as you are saying.

  915. That is different from what you said a moment ago.
  (Sir Nigel Crisp) I think it is the same thing as you are saying. We should be aiming and committed to hitting these targets everywhere and at all times and that is what we should be doing. I think the point you are making is a slightly different point, but I do not see that it is incompatible. We may or may not achieve all 62, but we should certainly aim to do so.

  916. The point I am making really is that targets in business, if you like, if you are in a private-sector business, in the business of service delivery, you would not face the pressure of every time a target is not reached that it is a headline in a newspaper, "Government failure, NHS failure to reach target on hip replacements" or whatever it is. That would not happen and, therefore, targets can be developed in private-sector business to do the job that targets are supposed to do, namely to drive service improvement and to produce better results. However, for you in the public sector, you face a completely different pressure. The pressure that you face and that politicians face is that unless the targets are met, you will get a hammering and, therefore, you cannot afford not to hit those 62 targets or your political masters cannot afford for you not to hit those 62 targets. That is why I am questioning whether or not you would be prepared to say that the targets you set would equate with the sorts of targets which would be set for service improvement in a business organisation.
  (Sir Nigel Crisp) Well, I am not sure that I can make that comment. I do obviously entirely understand the fact that we work in a political and media spotlight, as we can see it at the moment and, therefore, people will always be scrutinising NHS performance. It seems right to me though that we should have some markers for doing that.

  917. I know you are not commenting on the individual case and I accept that, but is that not exactly the atmosphere within which you work that produces the article about Ian Perkin in The Observer of Sunday 26 January 2003 written by Jo Revill, the health editor, where she says, "It lifted the lid on what he claims is the culture of deception now endemic in the NHS". Is there a culture of deception driven by the culture of targets endemic in the NHS at the moment?
  (Sir Nigel Crisp) Certainly not.

  918. There is not a culture of deception at all?
  (Sir Nigel Crisp) There will be instances. There will be instances of all kinds of things happening, but the vast, vast majority of senior managers, managers in the NHS, senior clinicians, are honest, well-motivated people who are absolutely determined to be doing the best for their patients and the public, and that is right and as it should be.

  919. You see, in another article on the same day in The Observer, Ian Perkin, commenting on the same case, and again it is the general principles, not the individual case that I am referring to, said in that article, "We need to replace the targets culture with a system of intelligent accountability".
  (Sir Nigel Crisp) Can I widen this because obviously I cannot possibly talk about an individual case and a particular set of allegations for which there is no evidence produced. Let's actually think about another bit of the NHS which is fantastically important, and which you may or may not be aware about, which is the whole service improvement movement we have got going on. I do not know whether anyone has talked to you about the primary care target of making sure that people see their GP within 48 hours, a very important thing for your constituents, I have no doubt at all, so that is a target, but having a target is not the answer to everything. What we have got is a very charismatic GP and a group of people working around him who, over the last 18 months, has ensured that in 40% of the practices in this country you can now do precisely what I am talking about, and that has been about spreading good practice, it has been about innovation, it has been about learning. We have a real culture of innovation and excitement and learning around that whole bit of process. We had last year something of the order of 120,000 people through service improvement programmes in the NHS. We are starting to create precisely that culture of enterprise, innovation and change that we need to have.