Examination of Witnesses (Questions 20-39)
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
20. How will foundation trust status help in
this?
(Mr Dixon) We shall have to make sure that it does.
There is nothing intrinsically in it that does help. In some respects
the governance arrangements make it more difficult because if
we do everything at the behest of Camden Council, it may have
an impact on our bone marrow transplant programme which is a national
one. There are some dilemmas there which we have to face up to
and find solutions to.
21. Foundation trust status is not going to
make it easier to sort that out.
(Mr Dixon) It could make it easier if it enables us
to improve services generally and if it is positively regarded
by our staff. So far that appears to be the case. Directly speaking
the arrangements cause some problems rather than some solutions.
22. In my experience, staff look forward to
this freedom so it enables them to do more of the "exciting"
things they do and possibly not so much of the general services.
(Mr Dixon) That is a risk we have to manage.
Julia Drown
23. Mr Jarrold said that he would welcome some
element of democracy being introduced into the health service.
Would you and others welcome it if those people standing for the
governing body were standing under Conservative Party, Labour
Party, Liberal Party and it became a party-political governing
body, which it may well do?
(Mr Jarrold) Speaking personally, there is no way
that you can prevent that once you have a democratic situation.
24. No, you cannot.
(Mr Jarrold) In a democratic situation, where people
are organised in political parties, I see absolutely no reason
why that should not be the case. It would be a great pity however
if it excluded people who work for, say, Diabetes UK or the other
voluntary bodies who are very keen to participate in many of these
things and might feel excluded by a party-political ticket. My
own hope would be that if there is an element of organisation
around party politics, there will also be plenty of scope for
people to be involved who are carers and patients and involved
in organisations of that kind.
John Austin
25. Is not the logic of democratisation that
you make the commissioning democratic and not the providers? Is
not the first step to start with the commissioners?
(Ms Rogers) The commissioners will be on the boards
of governors. I do not want to take you backwards, but what is
in it for primary care trusts is very important. I sat down with
my own top team and the first question we asked was, "What's
in it for primary care trusts and the local population?".
If they do not like it they will not vote it in; it is as simple
as that. There is probably more in it than you would think. That
was another one of the three points I added to my slides recently
which surprised me. Within a legal situation for contracting,
that sounds really bad, that sounds as though it might really
favour the acute sector and we just go on getting bigger and more
and more like factories. Point number one: the commissioners are
in control of the flow. It is not like Sainsbury's. They lay down
a contract for what they want and I cannot just go mad and find
people on the streets and bring them in to operate on. They have
laid down a contract which has an explicit number of cases. As
a result of that, it will also force demand management. Demand
management does not have to be a horrible unethical thing but
it can be an extremely good thing whereby new ways of caring for
people at home are engaged in actively as a way of stopping this
expensive flow into hospitals. So the legal contract, if it is
laid down, which is quite expensive, would make more explicit
the need to go back and look carefully and thoughtfully about
whether you want people in hospital or whether you want different
models of care. It also needs remembering that the statutory duty
of partnership remains in this setup. I would expect to have Chris
and a few others on my board and if I suddenly woke up one morning
and went bonkers, which is the tendency of acute trusts it has
to be said, and thought I must go out and get loads of business,
they are there in effect saying to me that is not acceptable,
they are not approving the business plan, this is not what they
want to see. That is actually a bit more than they have available
to them right now.
Andy Burnham
26. May I come in and ask a question specifically
of our colleagues from the PCTs? We talked a bit about balance
of power, but I am very interested in the balance of resources
within the system. You are involved with PCTs in an area very
similar in character to the one I represent in terms of entrenched
health problems. I would argue that we need to give more health
resources, spend at the primary care level in preventative health.
Would it be difficult for you to pull money out of the acute sector?
It seems to me that there will be plenty of financial incentives
for the acute sector to make savings and then spend that money
within the acute sector. Do you think it will be hard to pull
money out of the system, if you have a foundation trust with which
you are primarily commissioning?
(Mrs Willis) It is where you have to look at some
of the other reforms around the service at the moment, certainly
the financial flows reforms, which would mean that there was not
as much activity being performed in an acute trust, that you would
actually pull out full cost. In a sense that reform will enable
us to move money round the service more easily.
27. That is very interesting. Just on that point
particularly. My understanding of what is being proposed is that
there will be a standard or national reference cost or reference
cost specific to your region, so the PCT would not have a great
deal of flexibility about that. I would say how many procedures
it wanted to commission. Then the incentive is all on the acute
side to undercut that cost and then keep the difference in the
acute sector. If the NHS as a whole gets better at doing things
more effectively, you cannot pull that money out and spend it
in primary care at community level, it would stay within the acute
sector. It does not help you pull money back down to that level.
Would you accept that?
(Mrs Willis) If there is a national tariff it could,
yes. In a sense what we are trying to do is work and work very
much at a clinical level with our consultant colleagues and nurses
in the trusts in agreed pathways of care to ensure that care is
provided in the most appropriate place. Ultimately what you will
do is only have patients having care in the acute sector which
cannot possibly be treated anywhere else in the primary or community
setting. I think what you are saying is right, but it depends
then where they are treated, as to whether that price is a fair
price.
(Dr Rutter) You have made a very valid point, which
is why it is crucial that under the financial flows arrangement
the HRG costings are very carefully developed and expanded so
that what you do not get is the trap you described, but what you
do get is increasing sophistication of HRG costing which allows
you to differentiate the different sorts of pathways you have
just explained. That is point number one. Point number two is
that I think there is a huge amount we can do jointly, working
together. It is not really in any acute trust's best interest
to assume that they can solve this problem by doing more and more
and more. In the partnerships we are developing, there is that
very stark realisation. What you are starting to see develop from
the work which has come out of the modernisation agency is looking
at the whole of the patient journey and making sure that the patient
is in the right place at the right time.
28. Within the guide to foundation trusts which
was published, there is a suggestion of a duty to act collaboratively
with other trusts. Are you suggesting that there should be a duty
to work with primary care and possibly the trust should perhaps
spend resources at that level? It should not simply be seeing
itself as separate from primary care.
(Dr Rutter) I think we should be moving to a situation
where we look at the patient journey and we invest money in the
right places in the patient journey. My sense is that over a number
of years the primary care trusts will become one of two animals:
either they will become commissioners or they will become providers
but it is going to be a very sophisticated job, for all the reasons
you have said, to be a very effective commissioner of health care.
29. How much will this depend on local relationships,
whether you get on well with Mr Jackson? How about an area where
there is not that meeting of minds? Do you see that potential
friction?
(Dr Rutter) We have trust discussions. The key to
me about this relationship, which is fundamental for the nation's
health, is it does put in place a degree of challenge, both to
primary care trusts in terms of properly commissioning care and
a degree of challenge into secondary care to deliver effectively
and efficiently what is asked of them, which is, in my view, one
of the reasons why we have had the "undelivery". We
have a system at the moment which is perfectly designed to ration
care by waiting list. That is what the system is perfectly designed
to do, because we have fudged those responsibilities. I think
we shall build a true partnership by being clear about our responsibilities
and trying to help each other to deliver our joint responsibilities.
Dr Naysmith
30. I want to explore for a minute or two, the
potential benefits of foundation status for primary care trusts
and mental health trusts. Since we have been talking about PCTs
I will just finish off with you. The question has sort of been
answered. Mrs Willis, what do you think the benefit would be of
turning primary care trusts into foundation trusts? Would you
see any benefit?
(Mrs Willis) Are you saying if PCTs could become foundation
trusts?
31. Yes, if they could apply for that status.
(Mrs Willis) Ultimately you would have more local
accountability than we currently have. That can only help in terms
of the local democracy. If we believe what is written down in
terms of releasing us from some central directives, then yes,
it would give you then more local freedoms to solve your local
issues in the most appropriate way.
32. That is what you are supposed to be doing
now anyway.
(Mrs Willis) We are.
33. The relationship between the acute trusts
and the primary care trust is supposed to be moving towards primary
care trusts being able to take local things into account.
(Mrs Willis) Yes. In reality an awful lot of central
requirements are placed upon primary care trusts and certainly
a lot of local people who have joined PCT boards as non-executive
directors do have a great sense of frustration that there are
so many national requirements. We are part of the National Health
Service, so it is a balance.
34. Would it help you to provide chiropody services
rather than heart transplant services, which is an issue where
I come from?
(Mrs Willis) The problem is that you need both, depending
on whatever you need at the time, do you not? That is the local
judgement call. In reality for us, we are part of a very big investment
programme to expand capacity for cardio-vascularisation. In a
sense that was almost a decision which was made three years ago
and we are still paying for that. In reality that is where the
vast majority of our money is going this year, yes, and not to
chiropody which might make the biggest difference.
35. So you think foundation trusts would make
a difference to that.
(Mrs Willis) If you were given the local freedom to
judge local health needs and use the resources to meet those needs
in the most suitable way locally, yes.
36. But actually acute trusts tend to have much
more power in terms of effect on the media and fund raising and
all sorts of things.
(Mrs Willis) One of the challenges for us is how we
improve awareness in the community of primary care and community
care, things like chiropody. It does not have quite the same media
impact as a heart bypass operation, but obviously the older population
is very interested in chiropody.
37. They are indeed.
(Mrs Willis) We have a key role to raise that awareness,
so that you have meaningful discussions locally about the local
needs. I think it would. In terms of your previous point about
starting with PCTs and more democracy, in some ways the structure
of PCTs means that we have more involvement already and we do
have a duty to involve public, patients and carers. We will have
patients' forums. Some of us work very closely with our local
community health councils and have them involved in all our work.
We do have non-executive directors who live locally and many of
us do have close links with our local authorities, close involvement
with the local strategic partnerships and we work very closely
with the community partnerships which are set up under that. In
one way PCTs have a lot of relationships in place, because of
the way we were constituted. Our executive committees give us
the front-line staff involvement that the acute trusts will get
through the government's arrangements for foundation trusts. In
some ways, we have more involvement in the way of the setup now
than perhaps acute trusts do because they were set up 10 or 12
years ago.
(Dr Rutter) We should be given the same opportunity
because we do not as yet properly empower clinicians in the health
service. Anything we can do down that journey of properly engaging
and properly empowering patients can only be a good thing. We
do all the things which have been described and I would not disagree
with anything Chris has said, but I do think this is still part
of the journey and we should be pressing as hard as we can to
engage patients.
38. May I bring in Ms Britton? What do you think
the benefits will be to your organisation?
(Ms Britton) I start from the point of view that a
large part of illness which exists is mental illness, not just
physical illness. A large part of health care which is delivered
is mental health care, not just physical health care. I think
that if foundation status is to be provided as a means of improving
care, then it should be a level playing field and mental health
organisations ought to have the option of considering its relevance
to them. I do think that we need to do some specific work looking
at applicability for organisations which provide mental health
and learning disability services. At the moment my view would
be that foundation status potentially offers us the next step
in the development of our relationship with our service users
and carers and our partner agencies in terms of the arrangements
which it presents to us for governance. If I think about most
mental health organisations like my own at the moment, they tend
to have become rather larger than they were, covering big geographical
areas in order to be able to have the critical mass to recruit
and develop high calibre clinical and managerial staff. What that
tends to mean is that we usually cover a number not only of primary
care trust areas, but local authority areas. At the moment my
governance arrangements at board level restrict me in terms of
quite how I can pull all these partner agencies in to develop
integrated services. As I read the guidance at the moment in terms
of foundation trusts, it would seem to offer me the opportunity
of developing much closer working relations with service users,
carers and their organisations in each of the six separate localities
where I work with different local authorities. I think that could
probably move us forward.
Dr Naysmith: I do not really understand that.
The mental health with which I am most involved, Avon and Wiltshire,
covers a huge area of the South West of England and getting all
these people together to act as stakeholders for this one organisation
is going to be more difficult.
Julia Drown
39. What is stopping you doing it now?
(Ms Britton) We do do it now in a variety of different
ways. What we do not do at the moment successfully is draw that
into the formal governance arrangements at board level. As I read
the guidance, under the new arrangements we shall be able to set
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