Examination of Witnesses (Questions 320
THURSDAY 8 NOVEMBER 2001
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.
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
(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.
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 . .
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
(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
(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
(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.
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
(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 workforceand I have got
to say that one of the keys to this is effective working partnerships
with the trade unionswe 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 ofit 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
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
(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
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
(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.
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
(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.