Examination of Witnesses (Questions 140-159)
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
Julia Drown
140. Have any of you in your contacts with officials
or in your application so far got a clearer idea about what these
other freedoms are besides the financial ones we have discussed?
Mr Jackson mentioned earlier that he was hoping for the freedom
not to have to do Modern Matrons but you are going to have
to do health and safety and I understand all the same information
is going to need to be sent in centrally. There is no indication
that is changing. Have you had any indications of what other sorts
of freedoms you might have?
(Ms Rogers) If you ask them for freedoms, they are
very chary because this is a very conservative way of working—I
mean that apolitically. It might sound naive, but there is the
freedom in the "how" you do something as opposed to
the "what". They are quite clear that we are stuck with
all the targets as before and that quite bothers me. If you had
a foundation community, you might go for a different target. Chris
might want more money on children's health improvement through
SureStart than six-month access time. You might let that float
a month and we cannot do that, those are a given. What David was
referring to was the kind of really tight bureaucracy we have.
If somebody said to David that they would like him to get quality
back into nursing, which has been neglected for 25 years—which
it has been; Philip Hunt said that recently—but they left
David to think how he would do it, it might have been better than
telling him he had to have a modern matron, which is immediately
offensive to the males in the profession and leads to all sorts
of peculiarities. Similarly, I want a better hospital food panel
and I am really quite passionate about it, because nutrition is
about healing. Again it got lost because it was dumped down on
people saying this is the menu, this is what you have to do. It
became Lloyd Grossman's menus and this is how you do it and the
NHS plates, as opposed to what it was really meant to be, which
was nutrition and healing and standards. When we are talking freedoms,
it sounds naive, but it is about how you are allowed to do it,
rather than what you are allowed to do.
141. Do you think you might be given the freedom
for the menus, for example.
(Ms Rogers) A bit of "how" rather than a
bit of "what".
142. The trouble is that a lot of the targets
are about the "how to".
(Ms Rogers) If they are and they do not change that,
this would be less and less interesting to us.
Jim Dowd
143. I want to look at motherhood and apple
pie for a moment, or as the department has it in their guide,
governance and constitution. Mr Jackson, you say that you would
look to secure at least 10,000 registered members from the local
community who would elect members to the board of governors. Where
on earth did this number come from? It fell from the sky surely?
(Mr Jackson) I do not think that will be a problem
at all. We serve the population of Bradford, which is over 400,000
people. We have over 4,000 members of staff, we have just short
of 500 active volunteers. Whenever we have had some kind of local
appeal the public in Bradford have come up trumps. There is enormous
interest in local hospitals and we said 10,000, but we would be
very disappointed if we did not get more than 15,000 members at
the first go. It is an act of faith. I cannot prove it, because
we have not done the work yet. There is a very real feeling locally
that that is a very achievable target.
144. Do you have no fears that these are going
to be the broadsheet readers of various kinds or the producers,
trade union members?
(Mr Jackson) I would not say broadsheet; this is Bradford.
I think if you are going for 10,000 to 15,000 people I would expect
that the 10,000 to 15,000 members we go for would reflect the
local community. Of course within that you are bound to get some
people with their own agendas to grind, but on the whole you get
people who are genuinely interested in health care, in the hospital,
in the future hospital services. I do not think the fringe are
going to cause a problem. We will have to see how this works out
in practice and will have to put a lot of work into trying to
make sure that does not happen.
145. Are you confident that it would not be
dominated by the producer interest rather than the user interest?
(Mr Jackson) The majority has to be from the general
public. A lot of staff will be very interested in the opportunity
to be in a position to vote for the board of governors and so
on. The framework which has been set and the way we will draft
the rule book for this will be to make sure that does not happen.
Let us be clear. I want a membership and a board of governors
who are interested in health care and interested in the welfare
of the hospital and interested in the hospital's role in the wider
health economy.
146. But you cannot ensure it does not happen,
because these people will be self-selecting.
(Mr Jackson) At the end of the day there is an element
of democracy here. Yes, of course you are right. I do believe
that there are large numbers of people who are genuinely interested
in the things I have described and these are the ones who will
come forward. I do not think it will attract a lot of people who
have other motives.
Andy Burnham
147. I take a different view. I agree. I think
there will be many people who will take a very close interest,
particularly we have seen it in areas where there is service reconfiguration
and people take an extremely close interest in what is going on
at the trust. There is one criticism which calls it a gimmick
and another criticism within the health service which sees it
as a way of GMB taking control of the hospital and everybody is
jumping to a different tune. Do people see any of those criticisms
as valid, or would they see, as I do, that it is a way of giving
you as health service professionals a different set of people
to be accountable to from the ones you are currently accountable
to, who are often faceless managers to the public going up the
NHS chain whom no-one ever sees. I would hope that it might change
your focus, so you are not looking up to Whitehall, you are looking
down into your local co-operation. I would think most people in
the NHS are slightly chary of that. They think the great unwashed
are going to start telling them what to do.
(Mr Jarrold) Of course there are people in the NHS
who have no experience of dealing with democracy. Since 1948,
there has never been a system of democratic elections in the NHS.
The only form of democracy we ever had—and that was extinguished—was
indirect democracy of councillors sitting on health authorities.
Even that was extinguished. We have to start not being afraid
of the people we serve. Every community has interest groups. Every
community has people whose judgements we may not agree with, but
that is what democracy is about. It is about time the NHS returned
to its democratic roots and they were democratic before 1948,
both in local authority hospitals and in voluntary hospitals which
attracted the sort of interest from their community which David
has been talking about. We must not be afraid of our patients,
our carers, our staff and the people we serve. If we are afraid
of them, we are dead in the water.
148. Do you think you will change that accountability,
the way you look for accountability? Do you think it will stop
people?
(Dr Rutter) It will change the shift in the "how",
but let us not forget that there are some quite hard national
targets on which we will be expected to continue to deliver. The
how will change very significantly; it will change some of the
"what". There will still be in the regulated system
we are operating in, some hard national targets which we will
clearly have to meet.
(Mr Dixon) I will probably sound like an old cynic,
but I do not believe there is this pent up demand for electoral
participation in the NHS. I have worked over a number of years
since I have been involved in the health service to try to engage
people and it is extremely hard work. The biggest audience I ever
saw at any meeting I have been involved in was when my health
authority was debating whether or not it was going to abandon
a very small contract for homeopathy worth about £50,000
a year. That was the only occasion on which we had a reasonable
turnout of people.
149. One of the things which to me has come
clearly out of this morning's session is that the London angle
may have a different perspective on foundation status than others.
(Mr Dixon) Yes, that is possible
Andy Burnham: I see a fine community with a
trust which is serving that community where they feel a sense
of loyalty that the more transient population of London perhaps
does not feel. What we might have teased out a bit is that it
might mean something different to a community where it is very—
Chairman
150. I have another perspective on this to put
to Mr Dixon. Over the years as an MP and prior to that as somebody
involved in local politics as a councillor, I have been involved
in numerous public consultation exercises with the health service.
The reason why the public have this attitude is that in every
one of those it was usually a closure or change of use, their
clearly argued view was completely ignored.
(Mr Dixon) Yes; consultation in the health service
has been a charade so far, I agree with that.
151. A joke; an absolute joke as you well know.
(Mr Dixon) It has been a charade and I am not convinced
that this is going to be a better way forward. The reason I say
that is that I do think there is a severe risk of "entryism".
There is no way I could get an electorate of 10,000 operating
in my part of the world and I think that is a fairly common view
in London. What I could get undoubtedly is the local Trots or
the Hampstead Heath Preservation Society putting up a decent showing,
or even the local Conservative Party or local Labour Party.
152. That is very interesting. The Secretary
of State has been accused of being a Trotskyist on the side.
(Mr Dixon) I think my local MP said he was a Maoist
rather than a Trotskyist: constant revolution. There is a real
danger that we shall spend an awful lot of time on the mechanics
of this without becoming more seriously accountable. The idea
that we do spend all our time facing Whitehall and not facing
our patients and the various other groups we deal with is a travesty.
We really do spend a lot of time trying to engage with users groups,
with patients, with local authorities. We really do do that.
Andy Burnham
153. Do you accept that it might mean something
different in Hartlepool or Bradford?
(Mr Dixon) I am sure they all do it as well. I can
only speak for what I found in London, not just central London
but outside London. We were merging two hospitals on the fringe
of London some years ago. We advertised it all over the place.
The biggest degree of participation we got was four people and
that was unfortunately typical. Whether or not this produces a
complete sea change, I do not know, but I am nervous about jumping
into it on the assumption that it will. We certainly need to engage
better, but will we? At the moment we are saying that foundation
trusts do not have to have a patients' forum. That seems to me
a rather strange thing to say. I would welcome a patients' forum,
but if I am going to be a foundation, I do not have to have one.
All right, I can have one, but it seems to me an odd way of structuring
this.
154. You would not need one if you had an involved
membership. You would not need a patients' forum.
(Mr Dixon) I think we probably would, because a patients'
forum is different from anything remotely resembling a stakeholder
council or anything else. It is very specific.
Jim Dowd
155. Is it not the case that the parallel was
trying to be drawn with co-operatives, but co-operatives literally,
by definition, only serve those who are members? The registered
members of any foundation trust will not be a cross section, I
suspect that will be the last thing it will be, it will just be
a random number of people and yet that institution has to provide
a service way beyond that number. We know the volatility of these
issues. Dr Taylor sits there as the manifestation and embodiment
of how volatile people are. It is only ever around the big monochromatic
issues of closure and all the rest of it. I should be amazed if
anywhere in the country you could go and get a public meeting
to agree to the closure of anything, a hospital notwithstanding.
Is it the PCT's responsibility to engage with the public? The
PCT has the obligation to provide comprehensive medical services
for people in its areas across the field, not just in the acute
sector. The acute trusts, foundation or otherwise, are simply
trying to claim the same people.
(Mrs Willis) It is really important that we have this
public involvement. I am not sitting here saying we have got it
cracked by any stretch of the imagination because it is quite
difficult. I go back to an earlier point which I just want to
make, which is that I think by having a lot of people involved
for NHS managers, we have to endorse everything Ken said. Where
it is becoming incredibly difficult is where you have succeeded
in having meaningful local democracy and they vehemently disagree
with national targets. I am not sure what we do at that point.
That is when it is either going to stand or fall.
Chairman
156. Do you see a clear conflict here?
(Mrs Willis) Potentially. I am quite clear that some
of our local targets and priorities, if you go out to talk to
local people, are not necessarily the same as those we are currently
putting in a massive amount of effort to access targets. We have
to engage the public and one of the ways to do it is not by doing
it separately by health. I made reference earlier to working with
local authorities. We are co-terminous with the local authority.
I sit on the local strategic partnership. We have area boards
underneath which have a lot of residents on them. There is the
health partnership under that. It is how we join across all the
public sectors and have meaningful public involvement. Years ago
we had a separate community consultation about areas and when
you consult the public they do not just tell you about one thing.
Who am I to talk? You probably get this in your surgeries every
week. You ask about health and they will talk about street litter
and kids hanging around on corners. When you do joined-up community
consultations, part of the trick for health is to stop seeing
yourself as separate. We are part of the community. There are
loads of avenues for getting more public involvement. I am not
saying it is cracked because one of the other local concerns is
this whole idea of how you get people voluntarily to come forward
generally and be involved. There is a massive potential, if we
stop looking at it in a health box and just look at it with partners.
Jim Dowd
157. You have seen the development in recent
times of PALS and patient forums and the commission for public
involvement. How does the translation system add to that or does
it detract from it, as Mr Dixon seemed to be intimating?
(Mr Jarrold) I do not think we can have too many ways
of involving the public. All of this is important. The NHS has
traditionally not been good at this and we have a lot to learn
from local authorities as to how we relate to the public and how
we engage with the public. I believe that we need everything the
commission for public and patient involvement will do, the expert
patient programme, programmes of the PCTs working with local authorities,
the new mechanisms in foundation trusts. We are starting from
a very low base in public and patient involvement. I am not concerned
about having too many mechanisms. We have a very long way to go
before that becomes a reality where patients both feel involved
in their own care and able to influence the planning and management
of local services. There is a long way to go.
158. Where is the clamour for this coming from?
I have never had a single person come to me and say they feel
disengaged from the local hospital. What I do get is a lot of
people saying to me that they had to wait three hours in casualty
or they have to wait six months to be treated. The only people
who talk about democratic deficits are the politicians and professionals.
A lot of people do not.
(Dr Rutter) The real issue of what we are trying to
move to is the situation where, instead of variation in health
care being determined by professional autonomy, it is actually
determined by patient choice. As a professional, it is very, very
powerful to have a patient in front of you who will challenge
you about the way you organise health care. That is much more
challenging and is much more profound than having individual commissioners
arguing the point. I have been the point between primary and secondary
care sometimes. There is a richness and a focus and a clarity
which comes with having patients involved in this process at whatever
level. On the point you were making earlier, what we must not
do is detract as PCTs from seeing this as our key prime responsibility.
Quite clearly it is and it is not just about engaging views, we
do need to address the needs of our population as well. Not all
demands are the same as the needs of the population. We have a
very high incidence of ischaemic heart disease and it would clearly
be quite wrong in Bradford not to address that as a key public
health issue despite what local residents may feel. There is a
silent majority which is clearly dying out there and we need to
address those issues. What we need to do is enter into a proper
adult relationship with our populace where this is about informing
people about the issues, giving them understanding, allowing them
to make informed decisions. What we have done so far in health
care, it seems to me, is that we have treated patients as children
for the majority of the time and they ought to be grateful for
what we give them.
(Ms Britton) What we are saying is that we acknowledge
we do not have this right at the moment and we will not quickly
get it right. We will continue to improve. What we are probably
going to have to do is to accept that we shall have to remain
very flexible about accepting the involvement and the input on
other people's terms. There will be patients who want to engage
and be involved when they are ill. There will be others who when
they are well will want to have an involvement. There will be
carer groups also which will want to choose when they wish to
be involved. There will be people who want to engage when we are
looking to develop services, there will be people who want to
engage when we might be changing and reducing their services.
We shall have to accept imperfection and almost infinite flexibility
and allow engagement on other people's terms and demonstrate that
to them as a method of communicating to them our commitment to
accept their views truly and listen to them. They will test us
and they will judge according to how they find us and that is
fair enough.
Julia Drown
159. How many of those here thinking of applying
for foundation status would apply if the financial regime were
the same and it was just a change in accountability and change
in governance arrangements? How many of you would be thinking
of applying?
(Mr Jackson) At the end of the day this is a package
and a lot of the detail is not clear yet. The financial arrangements
are changing with the financial flows. We are all working through
what that will mean in practice. My personal view is that the
financial flows approach will be very good for the NHS.
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