Examination of Witnesses (Questions 80-99)
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
80. Initially the PCTs would enter into a three-year
contract with the foundation trust. The Secretary of State talked
about guaranteeing that funding for seven years. Where goes the
control and the choice then?
(Mr Jackson) This is the detail which we are not clear
about yet. My understanding is that it may be for three years.
Three years is not a very long time in the lifetime of a hospital
and the fear of losing a substantial amount of income is a very
real anxiety to the hospital. I have to say I do not think we
are coming from that point at all. What most hospitals want is
to be the hospital of choice for their community. Hospitals do
actually feel part of the local community and want to be part
of the local community.
John Austin: As long as they do not have a man
in a monkey suit who has been elected by the people, or Camden
Council interfering.
Dr Taylor
81. I want Mr Dixon please to expand on how
taking patients away will allow a poor performing trust to improve?
I am looking at the actual star ratings. The one you must be referring
to has scored precisely seven out of 30 on inpatients' satisfaction
and one out of five on a staff opinion survey. Surely this sort
of place somehow has to improve or close. I do not understand
how taking patients away will allow it to improve.
(Mr Dixon) From the practical point of view that hospital
cannot close because we need the facility and we need it to be
there to serve the patients in that locality. Taking off some
of the immediate pressure in terms of relieving their waiting
lists, may enable them to start to address some of their longer
term problems. It is a trust I know, because I used to be chairman
of the health authority in that area. It is not all bad by any
means, but it needs some relief from the constant pressure of
waiting lists, or emergencies and everything else, to enable them
to sit back and concentrate on the things they need to do to address
it. They are not going to do that without outside help.
82. Dr Rutter, how realistic is it to take patients
away from the low performing ones? You are obviously in a position
where you can. There are probably many PCTs which only have one
hospital which is not doing very well to which they can refer.
What sanctions do they have?
(Dr Rutter) I think the whole issue of poor performance
is much more complex than this discussion. What we have been talking
about is one of the measures of quality which is about access
or timeliness, but there are many more factors. There is efficiency,
there is effectiveness, there is patient centredness, which we
have mentioned. These are actually quite critical. I had to have
my own hip replaced two years ago and what was much more critical
for me, was having the right implant by somebody who was just
doing that sort of procedure. That was much more critical than
whether I waited one month or two months or three months. The
real issue and the exciting thing, it seems to me, about choice
initiative, is that it does offer patients the real opportunity
with their true advocate, which is the primary care physician,
the GP, to make real informed choice about the whole issue of
quality and the quality of care they may receive. Engaged in that
sort of debate, you will have some people who will choose to move
because they want to go more quickly: others will choose to wait
because they perceive the quality of care in other ways is worth
waiting for.
Andy Burnham
83. We touched on staffing issues a second ago,
but perhaps I could just focus a bit more on the effects of foundation
status on workforce issues in any given locality. The government
have said that foundation trusts will have freedoms with regard
to rewards for staff. It is fair to say we would assume that would
be non-paid rewards but also possibly pay rewards as well. May
I ask Mr Jackson first how he thinks trust will implement those
freedoms? Firstly, what do you think those freedoms might be?
Secondly, how would you personally choose to implement them?
(Mr Jackson) I really do not know what the freedoms
will be because at the moment we have freedom to pay staff what
we think is appropriate and it is being used on a very limited
basis. My own experience is that trusts have not set out to poach
staff from other organisations aggressively by offering higher
pay. There are very good reasons why they should not do that.
The reasons are that they cannot afford to on the whole. If they
started doing that, they would soon have pressure from their commissioners
to stop. I do not know what the new freedoms will be, because
we already have these freedoms, but we use them very sparingly.
I do disagree with my colleague Mr Dixon, because I think if we
were unable in exceptional circumstances to offer some variation
in national terms and conditions of pay and so on, it would be
very hard to operate successfully.
84. I cannot remember where we heard, perhaps
from the Audit Commission, about the Bill for agency staff, particularly
in London. It is extremely high. Do you think foundation trusts
would look at what they are spending on agencies and try to reduce
that by being a bit more aggressive in taking staff from the local
organisations?
(Mr Dixon) The London context is a peculiar one because
we are all relatively close together, therefore people can move
from St Mary's to Guy's and St Thomas's to my trust relatively
easily. We are a special case. The sort of freedoms which are
being outlined in Agenda for Change are very sensible;
that does give us a bit more flexibility. I certainly would not
want to remove all the flexibility we currently have. What I would
not wish to do is to risk setting off a wage spiral in an area
where there are shortages so that you finish up with the same
level of people employed at a 20% higher price.
85. Even though you may apply for foundation
status, you would actually like your freedoms with regard to staff
being prescribed in some way.
(Mr Dixon) Yes.
86. So you could not go beyond.
(Mr Dixon) I am probably more prescriptive than most
chief executives. Most chief executives will always find a good
reason why they need to do something exceptional; chairmen are
perhaps a little more cautious.
(Mr Jackson) We have to say, with the financial flow
schemes and national tariff prices, do not run away with the idea
that there will be lots of money available to pay people above
the odds. I think that would be a very powerful constraint on
what trusts can offer.
(Mr Dixon) May I just contradict that for one second?
My trust happens to have low reference costs. It has low reference
costs because of the way in which the funds flow system appears
to work. I think we would have the freedom to up the ante on staff
pay without busting the reference costs. This is the risk area.
Dr Naysmith: A very interesting thing has just
happened. Mr Dixon, who has the ability to do it is saying he
does want to do it. Mr Jackson, who thinks he does not have much
ability to do it, says he is going to do it. How does that pan
out for the rest of you?
Mr Burns
87. Mr Dixon said he thought London had special
circumstances and he did not anticipate that within London there
would be much poaching. What about the Home County circle around
London? As you may know, the police had significant problems with
people living in southern Essex, Buckinghamshire, etcetera, preferring
to go into London and the same could potentially happen for NHS
staff to a more significant degree than it does now. Do you think
that is a problem, even if it will not be a problem within the
London hospitals so much?
(Mr Dixon) I can see no reason why it should be any
different from the problems the police are currently having. If
you pay staff £5,000 a year more in central London and give
them free transport, they will move there from Surrey and Essex
in exactly the same way as they move towards the Metropolitan
Police Force. It will not be any different. It is simple economics
in my book.
Andy Burnham
88. Going back to the question, may I ask Ms
Rogers how she thinks this may fit with the Agenda for Change
package? The BMA have said that foundation status may start to
unravel that package before it has been introduced. Do you see
trusts using that as a base line and being able to vary it upwards
if appropriate?
(Ms Rogers) I am a bit where David is at. We have
all had bad experiences in the past where we set up a wage spiral.
I do not interpret Agenda for Change, so far as I understand
it, as individual bungs being given to people. Where we have done
that in the past, as most of us as trust chief executives did
in the heady days of the trust movement, we got trouble at the
ranch, because one particular doctor was then in effect valued
more highly by me. A whole load of really irritable other doctors
were then putting in wages claims or you did attract from another
trust and then personal relationships with another trust quite
near by were hugely damaged. The whole thing was really awful.
The way I interpret Agenda for Change I do not think foundation
trust status will mar it at all. It is a start and it is the start
of a process which you can clearly do without being a foundation
trust under Agenda for Change.
89. Is your view then not that the three-star
trusts which may be going for foundation status are probably those
which have a well-thought-through wage structure anyway? They
are not the ones who have perhaps made those mistakes which you
indicated, where they have perhaps paid over the odds and then
regretted it?
(Ms Rogers) They should have a well-developed pay
structure. I am not saying we have; let us be honest about that.
They should have and they certainly will have to in order to get
through. They will have to prove they can control pay and know
what they are doing. The kind of thing my trust has done—and
I suspect David's and others, because they are good trusts round
here—is that they have already thought their way through
some of those issues. The kind of thing we are thought to be quite
good at is changing practice. We are a pilot site for this kind
of thing. I have radiographers working where radiologists used
to. The more exciting part of Agenda for Change and a foundation
trust is getting new beasts, so at long last we can get a different
kind of person who is a physio and an OT combined as opposed to
these rigid structures which we have. People are rewarded for
their competence rising and rising and rising, not given an individual
bung of £30,000 because they could not be found anywhere
else and everybody else is like this about it. I do not see foundation
trust status as a barrier to it. It is clearly an enhancement
because you are going to get on quicker in theory. You will be
an early implementer, but frankly all trusts will be looking in
the same way now at rewarding competence and changing the kind
of beast we are growing.
90. Do you think foundation trusts may start
to attract people at different stages of their career? We have
heard just before how work may gravitate towards the foundation
possibly away from other non-three-star trusts. Is it possible
that people with families may start to gravitate to trusts where
the workload is lower? Could you see that? Not a two-tier workforce
but just different kinds of jobs and different organisations.
(Ms Rogers) Different kinds of jobs would be really
attractive. Different ways of treating your staff would be really
attractive. I am not just being pious here, but when you treat
your staff well . . . For example, there is a very good preceptorship
programme in my trust and it made a huge difference in the recent
past in terms of attracting from the local pool because youngsters
coming off the training scheme, would be well looked after and
not stuck on nights and left on their own. Of course money makes
a difference; I do know local trusts who are doing rather better
on breast screening and their retention of radiographers because
they are paying a bit more, but I do not think that is the whole
thing at all. Moira's trust had a brilliant report in CHI about
morale of staff. I just thought "Wow". If I were a member
of staff, I would wish to go to a trust which had that. This is
why I think the staff survey, as well as the patient survey, is
so key. That is one of the good things which the three stars do
give you. There are two wild cards: one is the patient view and
one is the staff view. If you get them wrong, you are out of it
as well and that is quite a safeguard.
Sandra Gidley
91. May I just follow up on Agenda for Change?
The early implementers have been sites where the staff have been
very much involved, yet my understanding is that the Department
of Health guide states that foundation trusts will be encouraged
to be second wave implementers. Are we not missing something there
in that the staff may necessarily not have the same engagement
in the process?
(Ms Rogers) I am just guessing. I think most three-star
trusts are pretty engaged. We wanted to be an early implementer
and put in for it. From my point of view, because we did not get
to be an early implementer, it would give me the chance to get
on and do it faster. You would not find many three-star trusts
around, where this whole staff survey thing is so important, where
they were not trying to get ahead on changing practice, already
well ahead on engagement with their staff and talking to their
staff. I am not sure I am answering your question, but I am saying
that I just think three stars are naturally going to go into Agenda
for Change. I should be stunned if there were too many three-star
trusts around—this is the point of being a three-star trust,
is it not?—which were just stunned by Agenda for Change
and got it plonked down when the staff were unengaged?
Sandra Gidley: Possibly, but there were clearly
some three-star trusts which had a less favourable staff rating
than others.
Julia Drown
92. Finally on pay, to get over this concern
that a foundation trust might upset the other local trusts in
terms of the local health economy, would you all support a formal
signing off of any differences from Agenda for Change by
your neighbouring trusts, should you be foundation trusts or if
you are the neighbouring trust? Would you all think that was a
reasonable idea? If not, why not?
(Mr Patten) At the application stage of the first
wave of Agenda for Change we applied as a health community.
All the trusts and all the PCTs and Moira's trust applied as a
health community to say that we work in a network in Durham and
Teeside and both the patients and the staff are in it. We are
all part of that whole organisation. Yes, staff do move between
trusts and patients do as well, but only at the margins. We think
it is important for us as a health community to develop that staff
relationship.
93. Would it not be an important safeguard for
you, that if your neighbouring trust became a foundation trust
and decided it wanted to start paying 10 per cent extra to every
nurse, you could have an opportunity formally to sign off, saying
you did not think it was a good idea?
(Mr Patten) I know Joan would not do that because
she could not afford it. We would develop that jointly.
94. If you were in London they might be able
to afford it.
(Mr Patten) I am not in London, so I cannot answer
the question.
(Mr Jackson) I cannot speak for London but I have
to say I think it would be a daft idea, for this reason. I remember
the 1970s and 1980s where we were rigidly controlled by the Whitley
system. It was simply not possible to have flexibility at local
level and that created all sorts of problems in managing a service.
To have another regulation which says before you agree a minor
change for a particular member of staff in particular circumstances
you have to get all your colleagues in the community to sign it
off, is just overkill frankly. I come back to what I said at the
beginning. It really is not in anybody's interests to engage in
inflationary practices. It is not what we want to do. It is not
good for us. I do not think it will be a problem in practice.
(Ms Britton) I would support that. Our experience
locally has demonstrated to us that when we work together we succeed
together. Experience may be different in different parts of the
country, but it would be not only unnecessary, it would be a backward
step for us. We have co-operated where we have had some sticky
HR issues and we have demonstrated in fact that we can support
each other and all benefit from that. That would be the approach
we would continue to take. It is that collaboration built on experience,
sometimes bitter experience of doing things differently and finding
that it works to nobody's advantage. Sometimes you have to go
through that to come to the point of collaboration.
(Ms Rogers) One tiny paradoxical but I think really
exciting thing is that we do not compete locally about the money.
There are already some differences but when you can do variable
things—and this is what staff want to hear, is it not?—you
are competing almost on niceness. Each trust has a scheme. My
staff side approached me and asked why I did not have one, so
we have a scheme that after 25 years in the service you get a
month's sabbatical, and the consultant's contract is just about
to do the same. Twice in a row now my staff have received a day
off for getting through the winter and doing well on stars. In
some ways it is more about emulating best practice on what we
do to one another than emulating worst practice on how we are
raising the cost of salaries.
Dr Naysmith
95. That costs money too, does it not? If people
take sabbaticals, it costs money.
(Ms Rogers) It costs invisibly. It is much more invisible
in the system. As with a day off agreed by individual discretion,
it can be done invisibly, yet it has a huge bonus effect.
(Mr Patten) It does cost money but it is a lot less
than recruiting new staff, training them and inducting them. Retention
of staff is so important in this.
Julia Drown
96. Moving on to financial freedoms, it is clear
from what you have been saying in your evidence that one of the
reasons some trusts are keen on becoming foundation trusts is
to have more access to capital. We have had statements saying
it is nearly impossible to access capital and that is frustrating
efforts to improve and increase services. Would you think it was
justified only to allow some trusts to have that access to capital,
given that overall the NHS pot is not increasing?
(Mr Jackson) My view on this is very simple. The present
arrangements are holding back the development of services.
97. Holding back the development of services
only in three-star trusts or in all trusts?
(Mr Jackson) They are holding it back right across
the board; there is this problem of accessing capital. I do not
know from a national level how you free this up. I can understand
the Treasury's anxieties. What I do know is that if it is not
freed up, then the NHS is not going to progress at the speed we
all want. Where I am coming from is that I cannot solve the problem
for everybody else, but if there is an opportunity for Bradford
to be able to move forward on this, without damaging anybody else,
then it is an opportunity we would want to grab. That is probably
where most prospective foundation hospitals are coming from.
98. If it is from the same capital pot and you
are being given first call on it, are you not necessarily damaging
others because you are having first call on the same capital?
(Mr Jackson) It is not clear that it will be from
the same capital pot and that is part of the detail we do not
know yet. If, as I understand is a possibility, we could actually
access money from the public and the private sector—
99. But it is still all counted within the same
pot.
(Mr Jackson) This is part of the detail we do not
know about. If we could access money in that way, then it would
be a very substantial benefit.
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