Examination of Witnesses (Questions 1-19)
THURSDAY 6 FEBRUARY 2003
MS JOAN
ROGERS, MR
NIK PATTEN,
MS MOIRA
BRITTON, MRS
CHRIS WILLIS,
MR KEN
JARROLD CBE, MR
DAVID JACKSON,
DR IAN
RUTTER OBE AND
MR PETER
DIXON
Chairman
1. May I welcome you to this session of the
Health Committee. We are sorry you are rather squashed together
but we are hoping to develop some dialogue between you and I recognise
that there may be some different perspectives on this issue from
a number of you. Could we begin by each of you introducing yourself
to the Committee and perhaps summarising where you are at in terms
of your organisation or agency in respect of the foundation concept?
(Mr Jackson) My name is David Jackson.
I am the Chief Executive of Bradford Hospitals. We are at the
position at the moment where we believe that the foundation trust
model offers the promise of enabling us to provide better services
for patients, greater opportunities for staff, more dynamic and
response to relations with our partners and so on. Of course,
we are not sure how the concept will develop as it works its way
through the legislative process. We think it offers a promise
and we want to keep a very open mind and make our decision when
we are more certain.
(Mr Dixon) My name is Peter Dixon. I am the Chairman
of University College London Hospitals. My board has reached the
decision that it will make a preliminary application. It has done
so with some reservations. We believe that the devil really is
in the detail with this process. We have considerable reservations
around governance issues, particularly as they impact on the large
teaching hospitals. We have concerns over the issue of payment
being freed up in such a way that it could create pay spirals.
We have concerns about the lack of knowledge that we all have
over the new funds flow arrangements and the way in which they
will develop, with the need for some form of interim financial
arrangements for a considerable time until it is clear how those
bed down. We do feel that there are possibilities of this enabling
us to produce better services for patients and therefore at this
stage we have said that we shall submit a preliminary application
but it does have some caveats.
(Mr Patten) My name is Nik Patten, I am Bill Murray's
Deputy. I am Deputy Chief Executive of South Tees Hospitals NHS
Trust. Although we believe that the foundation trusts will bring
considerable benefits to the local population, we are not pursuing
an application at the first phase. We are busy at the moment opening
a new PFI hospital and a merger last April and are unsure yet
of the consultation process for a tertiary hospital and how we
involve people across a wide population in the local management
of the trust.
(Dr Rutter) I am Dr Ian Rutter. I am a practising
GP. I am also Chief Executive of North Bradford Primary Care Trust.
We discussed this at a broad level and are in broad support of
the principles but, like previous speakers, the devil is not just
in the national detail, but in the local detail as well. We are
particularly keen to understand the details relating to the sorts
of contracting arrangements which will exist between PCTs and
acute trusts and also governance arrangements and the local ownership,
which are key issues for us. We believe they could either make
it very, very successful or actually something which does not
succeed. In broad principle, we think it will make substantial
benefits, on the understanding that it is linked and is part of
the wider changes which are happening in the health service at
the moment around patient choice, financial flows, etcetera.
(Mrs Willis) I am the Chief Executive of North Tees
Primary Care Trust. Our local district general hospital has made
a preliminary application. We have not yet had a discussion at
board level, but we have certainly had discussions with our colleagues
involving key players, lay chairmen, PEC chair and others. We
are in support in broad principle of the expression of interest
and I would endorse a lot of the points which have been made in
terms of the devil being in the detail and how you actually use
the guidance to bring about the benefits it is meant to be bringing.
(Ms Rogers) I am Joan Rogers, I am the Chief Executive
at North Tees and Hartlepool, actually two local district general
hospitals. We are just about to express interest and, as everybody
has said so far, it is to find out more about what it actually
contains. It has been quite a surprise. I tried to go round quite
a few local people recently, including PCTs and others, and there
is a huge amount of support. The staff side were almost immediately
supportive of this concept, on the grounds that it gave them status,
which they want, in a hospital in the North East and it gave them
a kite mark badge for quality. It has been quite surprising to
have been pushed from below by my own staff side, which includes
medical staff who are sceptical but supportive as well. That is
quite unusual; you tend to lead from the front. I have to say
the board is probably more sceptical and anxious than the staff
side, who actually said at one point, "Don't leave is as
long as has happened on other occasions". The reservations
I have, in running a twin site hospital, purely for us running
twin sites, are that it can be intensely parochial: you make changes
and one town does not like them or the other one does not. The
board of governors, which is necessarily, and rightly, made up
of local people, could understand your issues fully, be really
on board with you, but has the potential to split into two camps
and lead the board to division. That does worry me. The second
caveat the board has about it is simply whether the freedoms are
enough worthwhile to make this governance change meaningful. It
is much the same as others have said, but the degree of support
has been quite surprising.
(Mr Jarrold) I am Ken Jarrold. I am Chief Executive
of County Durham and Tees Valley Strategic Health Authority. I
guess I am here for two reasons: first, because I am a member
of the health community in which Joan works and Joan is an applicant
for foundation status. I am also here because I am a long-standing
supporter of shifting the balance of power to the lowest possible
level in the NHS. I believe that foundation status offers a real
prospect of doing that.
(Ms Britton) My name is Moira Britton and I am the
Chief Executive of the Tees and North East Yorkshire NHS Trust.
We are a trust providing mental health and learning disability
services. Currently foundation status is not available to mental
health and learning disability trusts like mine and we have not
therefore taken a position as a trust. However, together with
a group of other mental health and learning disability trust chief
executives across the country, we are very keen to start to do
some work to try to assess what the appropriateness may be of
foundation status for an organisation such as mine, providing
a very different set of services to some of those which my colleagues
have mentioned.
2. May I begin by asking a general question
as to the origins of this idea? I am very much struck by having
two people from Bradford in front of me because in 1991 under
the chairmanship of Sir Nicholas Winterton I recall sitting on
the Health Committee examining Dr Mark Baker and my friend Rodney
Walker from Bradford on exactly the same sort of issues, at that
stage proposed by a Conservative government. It is no coincidence
that we are in the Thatcher room this morning. I make a serious
point. Where has this idea come from in terms of the way you read
it at the chalk face? Has it emerged from genuine pressure among
what people call stakeholders? Has it come from below? Or is it
being imposed from central government and you as servants of central
government are responding in various ways, some very positive,
some less so, to what is a government initiative? Perhaps Bradford
would like to begin because you are expressing an interest at
this stage.
(Mr Jackson) I do not know the answer to your question
about where the idea has come from.
3. Has it come from you? Have you pushed this
as an issue before this was floated, before the NHS Plan were
you saying you needed these freedoms, you needed to be able to
recruit differently, reward staff differently, innovate in a way
you cannot do now and were you held back?
(Mr Jackson) Yes; that is not to say that we were
proposing foundation hospitals, which is an idea which did not
occur to us. Most of us have been saying for a very long time
that the bureaucracy under which we operate has a very stifling
effect, which feeds its way into delivery of services to patients
in a negative way, that the increasing centralisation of decision
making in the Department of Health has a deleterious effect on
how we work in the local situation because it does not take account
of legitimate differences between health communities and it discourages
people from using initiative and innovating and making opportunities.
I would say that we are responding to a government idea, a national
idea, which seems to offer the prospect of freeing up the NHS
which we then think we can exploit in the best possible sense
to benefit patients, staff and partners.
Julia Drown
4. I presume what you are referring to there
as centralisation is the target setting.
(Mr Jackson) Not just the target setting.
5. Could you say a bit more about that because
most of that is still going to apply to foundation trust? What
exactly are the problems?
(Mr Jackson) I do not have any problem with the principle
of targets. The problem has been that there are too many of them
and often they are contradictory. I am thinking in terms of the
actual micro-management of the NHS, so that at a local level you
simply do not bother to take an initiative because you think probably,
in a month or two months' time there will be a central directive
which will simply undermine what you have done locally. I could
give a whole range of examples.
6. Could you just give us one or two because
most of the supposedly central directives from the Secretary of
State, as I understand it, are not the directives you are going
to be freed from?
(Mr Jackson) Not many trusts will automatically assume
that Modern Matrons were necessarily the appropriate way
of managing their organisation; an idea worth considering but
there was no opportunity to decide whether this was right in the
local circumstance. That is an idea which has considerable implications
in organisational terms and in cost terms. That is just an example.
7. Are you confident you are going to be freed
from that?
(Mr Jackson) My understanding is that the Secretary
of State has promised to remove his powers of direction.
8. Yes, but I am not sure that is a direction.
(Mr Jackson) Of course in my view the government will
continue to influence the NHS very directly through the commissioning
process, but I think it unlikely that a government would say you
must have a particular form of management organisation at the
lowest level in the organisation and use the commissioning process
to enforce that. I am quite clear that the control will not go,
but there will be less micro-management. That is the prospect
on offer. Of course if that does not materialise, then many of
us will say it is perhaps not an idea which is worth pursuing.
Chairman
9. Do any of the other witnesses want to respond
to the general point I opened with?
(Mr Jarrold) The reason that many of us are enthusiastic
about this is that it is part of a very long journey which we
have been on. Some of us remember the 1974 reorganisation which
sucked power up the structures of the NHS and away from the hospitals
at local level. I prepared some evidence for the Royal Commission
in the 1970s which argued for power to be restored to people at
hospital level. We got an element of that in the 1982 reform under
Patients First. General management under the Griffiths
recommendations took us further down the road. The trust movement,
which again many of us welcomed, took us further down that road.
Certainly for me foundation status is a logical next step in that
process which I very strongly support.
10. What is the end result going to be of that?
I have had passed to me a quotation from yourself in Health
Service Journal where you were reported as telling a recent
health service conference that the NHS as we know it is over and
in ten years people will be paying for their own health care,
that it will only be free for people who cannot pay. Do you see
foundations as a step in that direction? If that is the endgame,
then presumably you are arguing for foundations. Some of us who
are slightly worried about foundations might say that this is
the connection to a scenario we are not entirely happy about.
Is that quote accurate?
(Mr Jarrold) You must always allow for the influence
of the sub-editors in these things, as I am sure you do. What
I would say about that is that I certainly do strongly believe
that the NHS is going to be a very different NHS. It is going
to be a NHS defined by values, by standards, by regulation, by
inspection, by an element of public funding and not necessarily
by public provision. Really what I was trying to get across in
a very stark way, because it is important for these messages to
be understood by many people, is that it is going to be a very,
very different NHS. That is one line of argument. There are many
other issues which I assume the Committee are not going to investigate
today about why we might ultimately have a system in which at
least some members of the public were contributing from their
own resources to their health care. That is not directly linked
to the issue of foundation hospitals.
11. It is an area which we should like to look
at, but it is possibly not the appropriate time to do it. Let
me look at in another way. You introduced yourself as a stakeholder
within the area your colleagues are involved in. One of the issues
which some of us are superficially attracted to is the devolutionary
aspect of this, the genuinely local public governance which many
of us have favoured for a long, long time. In the process of these
expressions of interest, would it not have made more sense to
have gone for establishing that governance model first and then
working out whether, when you have your stakeholders, your local
communities, they felt collectively that it was a good idea. Would
that not have been a better way forward rather than putting the
cart before the horse?
(Mr Jarrold) Sure. Joan is the applicant, so she may
well want to address that, but may I say something very briefly
to start with. I am certainly attracted by the governance arrangements,
because I believe that some element of democracy, however limited,
is long overdue in the NHS. I remember the days when we had substantial
numbers of councillors of right on health authorities and HMCs
and I very much enjoyed working with them.
Chairman: There are some around this table.
John Austin
12. Mr Clarke removed us.
(Mr Jarrold) Yes, he had a rather different notion
of these things. I certainly believe in that. What is actually
happening—and Joan can say more about this—is that,
because the precise model of governance has been left to applicants,
a lot of discussion is going on at local level with stakeholders
in order to define what should be said in the application. A discussion
is going on locally.
(Ms Rogers) That is a real paradox. I have just added
three sub-sections to some slides I have been putting on for local
groups of people and that is a real paradox. It sounds crazy but
it is true. Usually in the health service we go out and we have
a product to sell,"I'm going to change arthroplasty. I have
to move cancer services", a thing I have just been doing.
Local people often think you are a complete charlatan because
it is all stitched up and the consultation is about a product
you have to sell. The really amazing thing in this is precisely
because it is not all nailed down. I felt quite nervous going
out with a content free zone and wondering what I had to tell
local people. It has actually worked extraordinarily well. You
have no product to sell and are able to say that if we do not
like this collectively we are not going to do it. You can work
through the business plan and the due diligence and you can see
it with us publicly. There is enough to talk about. They can understand
the gist of things. You do not have just nothing but you have
a point where you can say that the constitution is something to
work through with the local social services and others. For the
first time ever I have actually found a paradox: not having a
known product and feeling confident about it has really worked
in my favour. So far stakeholders are not violently anti, they
are just interested and they want to input and that has been much
better than the usual "Here's this thing I've got, answer
against it if you dare" sort of attitude.
13. How are you defining stakeholders? The difficulty
for me is that I could argue I am a stakeholder in the Bradford
situation. I am only 15 miles down the road and what they do will
impact upon me. We are going to come onto this later on and I
am probably pre-empting somebody else's question, but it strikes
me that it would have made more sense to have this stakeholder
governance concept developed before the decision was made to move
on the foundation route? Dr Rutter, do you want to come in? You
were broadly supportive of Mr Jackson.
(Dr Rutter) Yes. For the reasons Ken has given, we
are very strongly supportive in principle and we have seen this
as a long journey of which this is just a part. As crucial to
us as the governance arrangements is the framework under which
we commission care and the rules which properly govern that and
the concern that we will not move as quickly as we would wish
to see in terms of being very clear about cost and volume contracts,
being very clear about moving to the financial flows arrangements.
It seems to me that if we can move quickly into the financial
flows arrangements, we will get rid of a lot of the unnecessary
squabbling which may exist between us. The definition of role
within the health care economy would be much clearer. For far
too long we have actually blamed the acute trusts for not delivering
waiting list targets, for not delivering on a whole range of issues,
when it is a whole health economy problem where the demand generated
by primary care is just as important as the efficiency of the
supply you are delivering and much more crucial is the flow between
primary and secondary care. The real gain to be made here, which
is the quantum leap, is for the first time really starting to
embed and sustain a lot of the work which has been done with the
modernisation agency in terms of patient mapping and patient flow
and the patient being the centre and in control of their experience
into the mainstream of how we manage the health service.
14. You have not quite answered the question
I put to you. Why have I as a stakeholder in West Yorkshire not
been engaged with your big idea? Clearly what you do will impact
upon me and my constituents and my PCT and my acute trust.
(Dr Rutter) My understanding and reading of this is
that there is a timetable of a journey in which people have to
express an interest and that timetable is quite a tight timetable
and therefore what you do is put yourself on the starting line
and that then buys you the time to engage people like yourself,
David and others as proper stakeholders. If you do not get to
the starting line, then you cannot even begin the process.
15. Some of us would say the starting line should
begin in here with legislation and we are not at that stage yet.
There is a little way to go.
(Mr Jackson) You may well be not only a stakeholder
but somebody eligible to be on our board of governors and a member
of the foundation trust if we go that far. It would depend. Many
of your constituents would have been ex patients of Bradford Hospitals.
The more interesting question is whether the effect of becoming
a foundation trust in Bradford would have a deleterious effect
on the surrounding area or not. My guess is that if it has a beneficial
effect, then there would not be that much concern about it.
16. In a sense I am trespassing on questions
my colleagues may want to ask. My question was in the context
of why we are not going for this governance agenda first before
we move onto the next stage. You might say that the government
have not put it that way. It would seem to me that if we genuinely
seriously are talking about engagement with the community, then
that should have been the first step which should have been taken
to determine whether people who are your customers felt it was
good idea.
(Mr Jackson) What we are saying to you is that the
process of developing both preliminary and a second stage application
involves considerable consultation with the community. As Joan
said, if, during that process, we got the message that nobody
was really interested in this, then we would not be wanting to
go ahead with it.
17. Let me come at it another way round and
then move on. The direction of travel of government policy has
been very much towards primary care. Many of us who have looked
at the health service over years and years and years have felt
the dominance of the hospital sector, the acute sector, has meant
we have failed to develop so much of the potential of our NHS
so the direction of travel has been PCGs, PCTs, giving people
like you, Dr Rutter, more freedoms to drive forward change, in
my view in a very effective way. Why all of a sudden have we drawn
back from that and put the policy emphasis on the acute secondary
sector when the policy direction of travel has been in a fundamentally
different direction? If we believe in this wider concept, why
have we not said you are a PCT and you are going to be a foundation
PCT and if we did it for the acute sector that would come later
on?
(Dr Rutter) My understanding is that they have mooted
the idea of foundation PCTs. I would strongly welcome them. The
point you have made is well made.
18. Why have we not started with that? Bearing
in mind that we are emphasising primary care and giving you all
sorts of freedoms and you are in the driving seat, certainly with
the commissioning process now, surely the obvious starting point
would be you?
(Dr Rutter) The answer is that if we see this in the
wider concept of what all the reforms are about, this is still
in line with empowering the NHS, not just down to primary care
level, but empowering it at the patient level. That is why I said
earlier that the crucial issue is around the commissioning arrangements
which are forged between PCTs and these new foundation hospitals.
If they are properly in place and are correct, then it will give
us, as PCTs, the sort of continued control about shaping the services
we wish to see for our population. If we do not have that in place,
then this will be a monumental disaster.
(Mr Dixon) May I answer that from a slightly different
angle? I am obviously representing a large acute trust and I am
well aware that the primary care trusts around us are very concerned
about the fact that they have a rogue elephant in their midst.
In a sense it is not for us to explain the logic of the proposals.
What we can do is explain why we think there may be benefits for
our particular organisations. One of the things my organisation
is going to have to work at very, very carefully in London—and
the same applies to the other big London teaching hospitals and
we have all discussed it together—is how we continue to
deliver services in a way which is integrated, in a way which
is sensible and in a way which actually cuts across some of the
independence which we are now being given. In a sense the question
is not for us. We have to go on collaborating, we have to go on
convincing our primary care commissioners that we will be collaborative,
despite some of the rhetoric.
Dr Naysmith
19. I have some experience of the relationship
between teaching hospitals, university hospitals and the communities
round about. It has been my experience that no matter all the
wonderful things happening on the university side, the teaching
side, sometimes communities are left behind in terms of the ordinary
everyday district hospital service. Is this going to make any
difference to that? I could see it making a difference the wrong
way unless we empower primary care trusts as well.
(Mr Dixon) There has always been a balancing act there
which is difficult. Some organisations have been better at it
than others. My organisation has not been particularly good at
it in the past, but we are putting a lot more effort into it.
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