Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 320 - 339)



  320. You would never agree completely?
  (Mr Weeks) No. Obviously, there has been some discussion in Leeds about where you make the definition of core and non-core, and you would expect us maybe to disagree around that; but I would say we have worked on a partnership basis with both of those Trusts.

  Dr Taylor: Because I am absolutely delighted that the NHS seems to have gone full circle. Those of us of about my age will remember being on health authorities in the 1980s, when privatisation of cleaning services was introduced, and we had a tremendous battle to make the managers accept anything other than the lowest tender; and now we are back to realising that quality issues count and that in-house services can win, on occasions. So it is full circle. I am delighted.

John Austin

  321. It is a question I wanted to raise in relation to an answer which Mr Rose gave, about the renegotiation of contracts and about the balance of power in those negotiations. Clearly, if there is a renegotiation of the contract that the Trust has signed up to, it seems that the power is in the hands of the contractor in those negotiations. And, in response to Doug Naysmith's question about Glasgow, you were saying renegotiation does not always result in higher costs. I assume, if there are higher costs, as a result of a renegotiated contract, those higher costs will be passed on to the Trust. If, as you say, there could be lower costs, is there any guarantee that lower costs in a renegotiated contract would necessarily be passed to the Trust, or would they increase the profits of the contractor?
  (Mr Rose) As I said, Chairman, at the beginning, we do not have the upper hand in any renegotiation; the Trust is the client and the clients have the upper hand in all negotiation because the clients have set the contract and its specification, and it is only if the client agrees to change that and is convinced that it is a good thing to change it that there will be any movement at all. And that is not a non-partnership view, every partnership with a senior partner has to make things happen, and so we work very closely, but it has to be agreed by the client or we cannot do it. In relation to cost, if the cost is lower then we are paid less, that is the bottom line; it is not we are paid the same amount but we spend less, if there is such a reduction it can be guaranteed that the Trust will reduce the amount of money they pay us, and that is what we would want to happen.

  322. Is that a self-denying ordinance on your part?
  (Mr Rose) No, it is a mark of efficiency and innovation, and we welcome it. If we can do it for less, without sacrificing quality, we are happy to do so, because we are still making a return on it, but we are benefiting the end users, whether they be staff or patients.

Andy Burnham

  323. Just turning to specifically employment issues, and really focusing on this issue about day-to-day on the ward, I hope I am not putting words into your mouth, but what we seem to have got from Mr Weeks, Mr Turner and Mr McGuire is that the ward sister having direct control and directly managing everybody on the ward seems to be the preferred way of doing things; although we have got some experience, I think, from Carlisle that that does not happen and it still leaves demarcation disputes going on. So I think you may all favour that model. But can I ask Mr Rose, do you favour that model, where all staff are directly managed by the NHS, who are on the ward?
  (Mr Rose) We have experience of both, and we are happy to work as part of a team, where the ward sister, whatever she may be called, or he may be called, has overall control, presuming that person has been properly trained and has the management experience and the knowledge to be able to evaluate what we are doing.


  324. Which system do you favour, was the question?
  (Mr Rose) We favour horses for courses; we like both. We do not want to have a ward divided against itself, we are there as part of a team, we are an outsourced team of workers, most of whom have come from the NHS, who are still working in the NHS but are working under our management, we want to work in conjunction with the clinical management of the NHS, and at ward level also. So we want a team level where we are part of it, but if it is agreed by the hospital that the ward sister will have the overall control of that area then our only concern is that that person has been trained in relation to all the services which are being provided, and has an objective evaluation and an ability to evaluate objectively the services we are providing, rather than simply looking at it and thinking, it doesn't appear to me to be . . .

Andy Burnham

  325. You say you favour horses for courses, but if you know the sister is in charge, ultimately, there is going to be a sense of command in that ward, and that I think is quite important for how patients feel things are running on the ward. And is there not the potential that when she, or he, does not have that direct control, while the team might work well, there is a potential it might not, and that she, or he, may be spending some of their time having a running battle with whoever it is? And in terms of the other model, they are in control and everyone knows where they stand. While the model you say you do not like could work well, it has that other side to it, does it not?
  (Mr Rose) It has exactly the same potential where you have directly employed staff, if the ward sister happens not to get on with the staff who are providing the services in the ward. We are there to provide services and to manage them, along with the clients, and it is very easy, and there are many instances showing how successful it is, very easy to work with the ward sister, who has control, as long as it is clearly stated that that is the control the person has, and this is how we slot in. Where problems arise is where it is not clearly stated who is in control, or what duties and responsibilities people have, and in the grey area in the middle we come together like badly meshed cogs, and occasionally there is a great scrunch and, if we took that analogy on, the gear-box begins to break up.


  326. Mr Turner, you were shaking your head at one point; it is probably unfair to put on record that you were shaking your head, but could you indicate what you were shaking your head at?
  (Mr Turner) It is this issue of, I firmly believe that the ward sister should manage the ward domestic, and the emphasis is on the word "manage". If that ward sister wants technical advice about cleaning, she does not have to be trained in that, she has a department that will give her that technical advice. So the strategy that we work towards is that the domestic on the ward is part of the ward team; if there is a professional problem around cleaning standards, she has people in the Trust, and indeed the Cleaning Standards Framework has said there has to be a qualified domestic manager working in each of the Trusts. Her role, or his role, is the management of that person, not the professional issues surrounding cleaning; because, with the best will in the world, they cannot know everything about everything.
  (Mr McGuire) With respect, I glanced across at Dr Taylor and we smiled at each other, there is a degree of lack of understanding about the ward sister's role. It is nationally accepted practice within the NHS that the ward sister is in charge of the team on the ward, it is not a preference, it is national practice, and goes back to the days when we had the matron.

  327. They are coming back, are they not?
  (Mr McGuire) There is generally, in our field, unanimous support for the introduction of the modern matron, or whatever we choose to call that post. But just a point of clarification. We are not excluding contractors from the ward team in Leeds because we do not want contractors on the ward; the reason that we have chosen at this stage to propose that we retain that, as we consider, core function in-house is that we want it re-engineered and changed, the function of that ward team. We have got a chronic nurse shortage in the country; what we should be doing is getting people in as domestic people and grow them through the ward team until eventually they become nurses; you can do that with private sector, but it will be very complex. What I would choose to do is handle private sector involvement separately from the development of people through the ward team, and, ultimately, in ten years' time perhaps, have a professional, or semi-professional, ancillary team that within it could grow its own people into nurses.

  328. So you see progression?
  (Mr McGuire) I do, yes.

  329. That is a very interesting point you are making, really.
  (Mr McGuire) One of the things that we have engineered into the proposal in Leeds is that there will be job progression, and we will not call people cleaners, and personally I would like to see generic workers but we will call them support workers, and then there will be a clinical support worker and then there will be the nurse; we will not recruit nurses in the future, we will grow our own nurses.

Andy Burnham

  330. Has that inhibited the development of such a system, the development of such a progression, as you state?
  (Mr McGuire) It is impossible at the moment.


  331. Why is it impossible, on the basis of a contractual issue?
  (Mr McGuire) No, it is nothing to do with contractors. In my opinion, it matters not a jot whether we have private contractors or NHS staff working on the ward. I concur with the views of my colleagues, it is how it is managed. We have all got experience of successful relationships with private sector, and unsuccessful relationships with private sector; the partnership is essential. But as long as we maintain an ancillary workforce and the shackles that are around that ancillary workforce—and I have got to say that one of the keys to this is effective working partnerships with the trade unions—we will not be able to create job progression and a more professional and better rewarded ancillary, of the future, workforce.

  332. Can I just ask you, to be sure I understand what you are saying, if we have a situation where, I mentioned earlier on, in Carlisle, the ward sister tells me that the cleaner changes every other day and is not part of the team because of the contract, you are saying, in a sense, perhaps, or I am assuming, that will inhibit the kind of personal development, which I think you have talked about, which I would value very much. We have got an interest in ensuring that there is appropriate staffing in the NHS, and recruitment, and I think getting that career progression is brilliant and it is a great idea, it is how it should be, but you are saying at the moment that cannot happen. And what I would like to know is how can we assist that to happen, because I think you have picked up on a point that is very, very important?
  (Mr McGuire) I am not sure how you can assist that to happen, but I think it is important that—

  333. What can be done that would enable that process to happen, not just in your area but elsewhere?
  (Mr McGuire) I think it is important for this Committee to have an objective view of the use of private sector in the NHS. We have talked about the need to sort of—it is almost as if, go in hard from the very beginning on penalties for private sector contracts, we cannot let these people run amok through the NHS. But let us start off by looking at proper, effective working relationships and not necessarily penalising from the start.

Andy Burnham

  334. But are you giving in your whip hand from the beginning though, (—inaudible—)
  (Mr McGuire) I would rather keep out of the whip hand.

  335. Ultimately, that is your reserve power?
  (Mr McGuire) Ultimately, you can have that, but if you start with that in the first—

  Andy Burnham: If a private company feels that you are never going to use it, are you not giving too much ground? I am only suggesting, I am interested to hear what you say.


  336. Mr Turner, do you want to come in on this one?
  (Mr Turner) Chairman, yes. You asked about how the Committee could help in the centre. Steve is talking about his vision for Leeds, and I support that vision of the support worker working on the ward, but there is no national incentive for us to do that, there is no national initiative; so other hospitals up and down the country may not want to do that. And I share with Steve, the only way that we are actually going to break the shackles of the ancillary workers is by giving them a career progression. I was talking to the chief nurse last week about ward housekeepers, and she is very clear where ward housekeepers will come from; they will initially start to come from these people that we progress through different posts so they get different experience, and from ward housekeeping, because they are NVQ Level 3, the jump into nurse training is very small.

  Chairman: I think you are seeing us putting more national thinking on this. One of the reasons for a Select Committee is that we can sometimes pick up ideas of the kind you are talking about and do something about it, so we welcome that point.

Julia Drown

  337. Our staffing inquiry did pick up that point about calling them nursing assistants.
  (Mr Weeks) And it may not be advertised as widely as it should be, but there is, in fact, national thinking on this, as part of the Agenda for Change discussions about a new pay, job evaluation, grading system for the NHS, which is obviously addressing a wide variety of issues. That issue has been quite central, and there is a great degree of consensus at national level between the Department, the employers and the trade unions about that approach for the support workforce, rather than the ancillary workforce, of the future. Obviously, there is no final agreement yet, because there are many issues to be addressed, not least funding, but that approach there is a consensus around.


  338. So, presumably, you would broadly support the philosophy that Mr McGuire has set out, from your own point of view?
  (Mr Weeks) I would. We would differ about the extent of the impact and the relationships in the use of private contractors, and our firm view is you would not able to achieve that where those staff are employed by the private sector, and, for a range of reasons. I will not go into that.

  Chairman: That was the point I was making, in a sense, about the situation at Carlisle, with the sister whose cleaner is nothing to do with the ward, because I could not see that progression happening.

John Austin

  339. I was going to say, does not that apply across the board with all the services? The one you were talking about earlier, the Glasgow Royal Infirmary, clearly says that the improvements were brought about by a negotiated agreement with the trade unions, with a proper career path and graded opportunities. So does not that go to the heart of all the services that are provided, that there needs to be that valuing of staff and career opportunities?
  (Mr Rose) Chairman, I must agree entirely. And I do not agree with my colleagues that the use of private contractors would stop any of that career progression, we welcome it, and, in fact, my own member companies have a very clear policy on developing individuals, both in multi-skilling them and developing their career from where they are to where they might be. And, indeed, the former chief executive of one of my members had an HND in catering and ended up running the largest contract catering company in the world, because he was given a chance by someone to move on, he took it; he is a Yorkshireman, so you will be delighted at that. And that is what we want to do. We do not want to set ourselves apart, Chairman, we work very closely with all the public sector trade unions, we like to work with our public sector clients. We believe that career progression is an essential, if staff are going to feel that they are valued. And we accept that the shortage of nursing staff needs to be addressed; if this is a way to deal with it, we are happy to look at it. I sit on an NHS staff task force, alongside UNISON and the Trusts, looking at ancillary workers, how we can improve the footprint, how we can improve career progression; it is an essential. And we hope that in the private sector we have got something to bring to the table on this from our experience across multinational activities of member companies, and we hope we can bring that into the NHS and help that process.

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