Examination of Witnesses (Questions 40-59)
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
40. Why can you not do that under the arrangements
now?
(Ms Britton) Because at the moment we have a board
with chair and non executives appointed in a very different way
and with limited numbers. It is prescribed unto us how we do that
at trust board level.
41. How often do you take a vote at your trust
board?
(Ms Britton) We do not take a vote very often at all.
42. So you could co-opt them there. There is
nothing to stop you inviting other people to attend your trust
board meetings, is there?
(Ms Britton) And we do invite people to come. As far
as the users and carers are concerned, they would regard the arrangement
of having sub-sets of our board of governors at locality level
as being a very significant step forward.
Dr Naysmith
43. How much would that cost in terms of staff
time? Have you thought about that?
(Ms Britton) No. No, we have not looked at that. We
have not yet been in a position, we have not been given the option
of foundation status for organisations like ours. We shall benefit
in some senses from the phasing of foundation status. We shall
be able to learn from some of these hearings which others are
going through in terms of how it is being applied to them and
we will make good use of that time. We need to be sure that it
will work for mental health and learning disability services.
44. As you say, some of the arrangements are
still a bit vague about what is likely to happen. Now and currently,
with what is proposed, patients' forums and so on, there is probably
more chance of ordinary people influencing a board like yours
than there would be under some forms of foundation trusts which
are being suggested.
(Ms Britton) I do not think it needs to be one or
the other. The more opportunity we can provide for a whole range
of people to be involved, the better and that would be the position
we would take and look to use as foundation status. We believe
it would give us that opportunity to bring more people in and
more people by locality, particularly interested in the agenda
around their particular part of the service in their locality.
45. What relations do you currently have with
local authorities, particularly with social services which would
be improved or made worse possibly by foundation trusts? What
do you think would happen to that?
(Ms Britton) At the moment, I do not believe they
would be made worse. We have good relationships, we work with
six different local authorities, so we have six different sets
of relationships. We have six different sets of arrangements for
integrating our services and for working together. I repeat what
I said before: this will formalise it at the most senior level
and draw more people into the opportunity to be involved. That
would be a significant benefit and would be perceived to be a
benefit by those local authorities in terms of their opportunities
to sit round the formal table with us and work with us on integrated
service developments.
Chairman
46. May I press you on the issue of stakeholders?
I do not like the term: there must be a better term. It is one
I do not use regularly but you all seem to use it so I will use
it. How do you define your stakeholders in terms of this social
ownership model of foundation trusts? I am wrestling to work out
how you as a mental health trust, who have emphasised, and in
my view quite rightly, the user element of this, so you are clearly
personally committed to engagement with users in developing a
social ownership model, then look at the nature of mental health
services and work out where you would start to draw together a
coherent structure for the social ownership of your trust if it
became a foundation. Presumably you have people using your service
who may be all over the place. One assumes you probably have some
in Rampton and Ashworth and in and out of prisons. If it is not
going to be tokenistic and you are sincere in what you are arguing
for, how are you going to do it?
(Ms Britton) In common with all other NHS trusts we
draw patients from a range of areas and cover a range of services,
so it is not easy for any trust moving to foundation status. In
terms of my particular organisation, I would start from the point
that I deal with six discrete localities and they are all different
and they are six different local authority areas. I would look
for appropriate arrangements in each of those localities and I
would certainly look to involve established user and care organisations
with whom we are working and look to the patients' forums to advise
us about how we might draw users and carers in beyond the organisations
I have mentioned. Clearly I would also look to work with our local
authority colleagues, our colleagues in the voluntary sector.
In mental health we would have a very broad range of partners;
that is the nature of the work we do and that is the potential
benefit of having the opportunity of the flexible approach to
the governance arrangements, to be able to talk that through,
tease that through locality by locality and come to a view about
what will best suit the needs of that locality. I do not underestimate
the difficulty of that; it is quite complex.
(Mr Jarrold) I just want to support what Moira was
saying. It is a completely different dynamic. At the moment your
chairmen and non-executives are appointed by an appointments commission
and if you bring other people into the decision making, as indeed
Moira does, they are not part of the governance. Under foundation
hospitals you could have whatever local discussions you decided
to have; users, carers, people who work in the services, local
authority people, could all be members of the foundation trust.
They would elect the board of governors, the board of governors
would elect the chairmen and the non-executives. That is a direct
involvement in a way which is completely impossible under the
present arrangements.
47. But you do not have to have the wider "freedoms".
You could do that with any element of the health service and many
of us have argued for that concept for years. Why are we confusing
two very distinct elements here? I think there might be some deliberate
confusion. I am not saying you are, but one or two people seem
to be.
(Mr Jarrold) I am grateful for that, Chairman. At
the moment you simply cannot introduce any element of the kind
you describe into trust board appointments. You cannot do that.
Julia Drown
48. Of course you cannot override the Secretary
of State and say you would rather appoint those instead. You could
encourage those people to apply, but that is a few people, the
five non-executives you have around the trust board, and those
are the people who get paid the money. Sure, but, if your non-executives
are engaged with the agenda, I would not expect them to object
to you bringing in other people to that trust board and a lot
of people would like to be able to sit around the table and take
part in that discussion.
(Mr Jarrold) And they do. But it is completely different
because they depend on an invitation to be there; they have no
right to be there, they have no voting rights, none of those.
49. No, they do not, except, if it were your
trust board policy, it could give them a right to do so.
(Mr Jarrold) You could not give them voting rights
on the trust board.
50. No, but you could give them the right to
sit there and given no votes take place at Ms Britton's trust,
not having the vote does not make much difference.
(Mr Jarrold) I think you will find that if you are
a user of mental health services, it would feel very different
to be invited along, not as a member of the trust board on the
one hand and on the other hand to be a member of your foundation
trust, to have equal rights with everybody else, to be able to
vote for the board of governors, to know that there is a possibility
that you might be on the board of governors and that you might
then be elected as a chairman or a non-executive. That is a completely
different feel to being an invited person, attending a trust board
at the behest of the chief executive.
51. But you have not even taken the stage one
to get them invited there to start off with.
(Mr Jarrold) To me it feels different, is all I can
say. If I were a user it would feel different to me.
Dr Taylor
52. May I go back with rather a broad question,
aimed really at Mr Jarrold? As a chief executive of a strategic
health authority obviously you have a wide range of trusts under
you. It is very obvious, from hearing all of the things which
have been said so far, that people who have a chance of getting
foundation status are extremely enthusiastic about it because
it does offer a lot, particularly the freedoms and the public
involvement which I am sure we are all in favour of. What about
the others? You must have a lot of people who do not have a chance
to get foundation status. What is their reaction? If we had a
row of them here, what would they be saying?
(Mr Jarrold) I have five NHS trusts directly in my
patch. None of them is less than a two-star trust. They all aspire
to being three-star trusts and they can all see the possibility
of this status. I would want to work very closely with them all,
to ensure that they got to three-star status, so that they were
eligible. Certainly we would hope when that was the case, the
mental health trusts, as Moira has said, would also be eligible.
I believe that ultimately the way forward is for the PCTs, social
services, the strategic health authority and the trusts to work
together to achieve three-star status for all the trusts on the
patch and to enable them all to proceed. We have two two-star
trusts and one three-star trust and they must speak for themselves,
but I believe that they aspire to this status of three stars and
that would give them the entry gate to foundation status.
53. May I go on to some points about the star
rating system as it exists at the moment? Just looking at the
trusts we have here, I see two of them have had their star ratings
confirmed by CHAI, because North Tees and Bradford have both had
significant strengths from CHAI, which is very, very reassuring.
A lot of us have very great doubts about the star rating system
as it happens at the moment, unless backed up by CHAI. The other
thing I feel is not taken into account nearly enough is the inpatient
survey. I am delighted to see that South Tees, the two-star trust,
got 27 out of 30 on the inpatient survey, which is about the highest
possible; the others were about 19, 20 and 22. This is not taken
into account. Are star ratings the right way of choosing the first
people to try the foundation system? Should it not have been a
whole area of the health economy doing it so that there would
not be the potential gains for some and the potential losses for
others, which we will come onto later?
(Mr Jarrold) There are two different questions there.
The first is about the star rating system itself. I would agree
with you, except for the fact that the star ratings are now being
taken over by CHAI and they will be responsible for star ratings
in future. I feel a lot more comfortable knowing that is going
to be the case, because they will be independent of government
and they will be taking into account a wider range of factors.
If that were not going to be the case, I would agree with you.
Given that it is the case, I feel much more comfortable. That
is on the issue of how the star ratings are arrived at. In terms
of the health community as a whole, it would be very difficult
to give a star rating to a health community. You provide a much
greater incentive if you relate that to individual organisations.
54. I was not really meaning give them a star.
I was meaning pick out a local area, whatever stars it has or
does not have and work through the system for the whole area.
(Mr Jarrold) That is exactly what we have been discussing,
including with our social service colleagues and are hoping to
do exactly that. We believe that performance is a whole-system
issue and that we should be working, PCT/Social Services and the
strategic health authority and the trust together on performance.
If you look at the public service agreements for local authorities
and for health, there are so many of the health targets which
are dependent on local authority work and a number of the local
authority targets which are dependent on the health contributions.
We certainly want to behave in that way locally in improving performance.
That is our objective.
(Mr Patten) Yes, we aspire to three-star status. From
a tertiary and teaching hospital point of view it is clearly important
that we work not just with our primary care trusts in the local
area; you are right about the schizophrenic nature of tertiary
and district general services. We also need to look at DGHs where
the patients go through. Trying to capture all the patients and
all the staff is very difficult for a tertiary hospital. It is
very important that we do work with the DGH and the PCT so that
patients do flow through in the right way. I agree with Ian, that
we must get down to the individual patient journey and that is
where PCTs need to have a stakeholder involvement, because tertiary
centres and acute trusts cannot continue to treat patients in
the same way they have been doing it for years and achieve all
the NHS plans. This is all connected. We need to find out how
we can treat patients in a better way. Some of those will be in
primary care; that has to be noted and done. PCTs will need their
patient and stakeholder involvement to design their patient flows
in their areas in the same way as we will in acute trusts. This
is connected and the health community approach, if it were acceptable,
would be the right way to do it. Our performance very much depends
on the performance of the DGHs and the PCTs.
55. It is ever so encouraging to hear Mr Jarrold
say he is going to combine everybody together, all foundation
trusts in the area. I think I should like to move up there very,
very quickly.
(Mr Dixon) First of all with regard to non-executives
and chairmen, we do not come from Mars. There is an appointments
commission, which I think has done some useful work. It is a shame
that the work the appointments commission has been doing, in making
sure that, as far as the non-executive elements of boards are
concerned, they are fit for purpose and locally accountable, is
good and there is a risk that we will lose that. I can be replaced
by the man in the monkey suit who may well do a perfectly good
job through an elective process, but there is an alternative route.
In throwing out the appointments commission process there is possibly
a baby with the bath water issue there. The other point I would
make is that the enthusiasm which some of my colleagues are showing,
is not necessarily shared by all three-star trusts. I had a discussion
with the chairmen of all the three-star trusts in London recently.
We got together because of our concerns rather than our enthusiasm.
A number of us have made preliminary applications. We see that
there are potentially advantages in this, but our approach is
not an enthusiastic one. It would be a mistake for the Committee
to get the impression that it is. I am quite sure it is in some
locations, but the London three-star trusts are unenthusiastic.
They may well go forward but they see quite a number of problems
which need to be resolved in order to make it attractive. We are
obviously trying to influence the powers that be to move some
of the problems we see.
Mr Burns
56. There has been a criticism that foundation
hospitals will create a two-tier system. Would one of the ways
of getting round that be to allow all hospitals from the outset
to seek foundation status? Is there any reason from the NHS's
point of view why that would not be possible or a sensible thing
to do from the outset?
(Mr Jarrold) You do have to provide an element of
incentive for people to improve their performance; it is important.
If you make this available from the start to everybody, you would
remove some of that element of incentive. It is important for
trusts who are one-star trusts and no-star trusts to feel that
there is something to be gained by improving their performance
and moving towards foundation status. I believe that is an important
consideration. In terms of two tiers, and as we have argued in
our evidence, we do not think that is a significant issue. Whether
you are a foundation hospital or an NHS trust, the vast majority
of your income will come from PCTs and PCTs have the same amount
of money to spend on NHS trusts as they have on foundation trusts,
with the coming in of the national tariffs, the prices will be
fixed for both kinds of organisation. There are many safeguards
in the system which work against two-tierism, but I personally
believe that incentives are important.
John Austin
57. If this new system is geared to provide
the incentives to drive up standards, why does it only drive up
standards for those hospitals who are already performing and not
drive them up for those which are not?
(Mr Jarrold) The incentive is: if you want these freedoms,
you have to improve your performance. That is where the incentive
lies. You cannot get through the entry gate until you are a three-star
trust. It is yet another incentive for people to improve their
performance.
58. Is it not going to become more difficult
to become a three-star trust for those which are not a three-star
trust when they have this favoured foundation trust in their area?
(Mr Jarrold) I believe that the safeguards, which
we have set out in our memorandum, are very, very comprehensive
and that the fundamental safeguard is the funding safeguard and
tariff safeguard. That is the fundamental. A foundation hospital
will not have in the main, in terms of its regulated income, sources
of income which are different to NHS trusts.
Julia Drown
59. Except it would be able to keep any surplus,
whereas the others will not.
(Mr Jarrold) Indeed.
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