Examination of Witnesses (Questions 320-338)
TUESDAY 11 FEBRUARY 2003
DAME PAULINE
GREEN, PETER
HUNT, CLIFF
MILLS, MR
MARK SESNAN,
MS FIONA
CAMPBELL AND
MR DONALD
ROY
320. Have you seen an example of where a mutual
has become unbalanced? We have heard this word "entryism".
You hear people saying that people will register to a takeover
of the organisation. Is that a valid fear? I have heard someone
saying that hospitals will be run by the GMB, making an opposition
to this proposal. How real is that a threat? What kind of weight,
what kind of countermeasures, should be in place to stop that
happening? (Mr Mills) That is partly to do with the
design of the structure and what interest groups you recognise
and what limits you put on them, and then it is to do with how
the organisation is overseen and run. Doubtless many people are
aware of organisations which started off perhaps as a consumer
society or a retail society, where employees become predominant.
That can be addressed if you are starting off with a blank sheet
of paper. You can address that by saying, "It's important
that employees are represented on the board, therefore we'll say
that there can't be more than a third of the board who are employees
or connected to employees, and the balance of them will come from
other quarters." That prevents employees, in that example,
taking control. That, to my experience, works reasonably successfully.
I think where there are more stakeholders involved, the risks
of capture are reduced, and I think it then comes down to the
question of the policy that is put in place by the organisation
for who qualifies for membership; that where there are posts that
individuals are being nominated for in the democratic process,
again there are categories that are to be fulfilled, and if you
have reached the full complement of that category there cannot
be any more. So they can be written in and the organisation can
retain control over that. Were you also hinting at a demutualisation
threat as well?
321. I think some of the legislation that has
been passed or hopefully will be passed but is currently before
the House, presumably would almost make that impossible, I guess,
would it not? (Mr Mills) Yes.
322. It is 75% of the membership. It is hard
to imagine that, once set up, any foundation trust could muster
such a majority, is it not? (Mr Mills) Yes. I think
also that in establishing the foundation hospitals the legislation
can specifically prevent demutualisation in the way that happens
already. Housing bodies, registered social landlords, through
the relevant statutory provisions, cannot simply liberate the
assets. A similar thing should be done here.
Dr Taylor
323. Can I ask you for your views on the timescales?
Things are getting very tight. If the first wave is supposed to
be in by 2004, and we have to elect and we have to train these
representatives, should we be pushing for the first-wave trusts
to be trying to hold their elections with the May elections that
are coming up? However can this be fitted in by 2004? (Dame
Pauline Green) I think there is an issue around that, and
also that those trusts that are going to opt to apply for foundation
status need to begin to demonstrate their commitment to that wider
participation, by engaging with people, staff, users and other
groups to start working that up, because it does not happen overnight.
The evolution of the co-operative structures is bottom up, as
Mark was saying earlier on. That engagement needs to be demonstrated.
I would caution against the trust who last week apparently gave
evidence that they would take the money and run, because that
is not what a mutual structure is about.
324. In fact, we got an entirely different picture
from a large teaching hospital trust and the other groups who
were obviously looking after communities. (Dame Pauline
Green) Good.
325. What are your views on the training that
is necessary? How long will that take and how should it be organised? (Mr
Hunt) It is a very important and a very serious part of the
whole process. In terms of the timescale, if you think about it,
really we are not going to know until September which are the
hospitals that are likely to be the foundation trusts, so May
is too soon to do anything in practical terms. What those organisations
could do in the meantime is start to engage with training needs
that they will actually themselves be required to fulfil in running
the new government structures, but also in seeking to engage the
different constituencies in the new government structures. There
is a whole range of issues. They need, as I have already said
earlier, to talk to people who have already done this sort of
thing. There are a large number of mutual organisations in the
UK that have great experience of this and provide training in
great detail. They need to get on with that very quickly for this
to be successfully implemented.
326. Do you think that the three-star trusts
we have talked to are aware of this need? (Mr Hunt)
I think it is very early days.
327. I see a shake of the head. (Ms Campbell)
They have no idea of what is involved in real community engagement,
I do not think. I think it was pretty clear, from some of the
answers you received earlier from the group of people, that they
do not actually even know what the existing structures of public
involvement are, because they referred to PALS as if they were
patients' forums and things like that. So I really do not think
that by and large the trusts have a sense of what would be involved
and the kind of real engagement that their colleagues are talking
about. Can I make the additional point that I think it is terribly
important—and I think Mr Mills has also emphasised this—that
if the community are going to become involved, if foundation trusts
go ahead, they will need to have had some sort of a say in whether
they are set up or not, and you certainly cannot do that kind
of role, consultation and education process in the proposed timescale.
Dr Taylor: I think those are very important
messages which we take on board.
Chairman
328. Mr Sesnan, I think you wanted to say something? (Mr
Sesnan) There were two points I wanted to make. One was to
respond to that last point, but the previous one was where you
used the term "one person/one vote". For clarity, you
have to understand that you can have constituencies within the
board, if you like, so it could be one person/one vote, but you
can only vote for a certain number of people on the board. So
the staff would be one constituency, the users—patients—would
be one constituency, the administration of the nurses or however
you define the constituencies, and then you have one person/one
vote, therefore you get much more of a balance. It is very important
that that is built correctly in the first place. That kind of
takes us back to this other point about the delivery of the training
and everything else. In reality, this creature is going to be
forced. It is a forced birth, it is not going to be a natural
birth, because there is not out there necessarily even an understanding
of what we are trying to create here. I think we have to recognise
that. That is why I keep coming back to saying that there have
to be limited pilots at this point, and then we have to work with
experienced people to try to work out what kind of model can actually
work, and analyse what is good and what is bad. The customers—I
keep calling them "customers", the patients, the users
or whatever—do not know what they are going to vote and
stand for, so they are not going to go out and fill this form
in, are they, because it does not mean anything to them. Once
you have several hospitals operating and engaging in the community,
and people can see the difference that these things can make—and
I have no reason to assume they will not—it will become
a successful type thing in itself and everybody will want to get
on that bandwagon.
Andy Burnham
329. Have you heard of a scenario where the
leading officers of the organisation have been at odds with the
membership, so where the membership as a whole wanted to do something
differently that was being proposed by the senior staff and management?
Have you ever been in that situation at all? I can imagine a situation
in the Health Service where the perceived wisdom of providing
healthcare services conflicts with what the public want in terms
of services on their doorstep. Do you foresee that tension in
health? How would you reconcile it? (Mr Sesnan) When
you move these people to represent, they become directors at the
end of the day, company-law style directors of the company, therefore
they have to take responsibility for the effective governance,
efficiency, responsibility for the jobs of that organisation.
This is not just a consultation panel that you elect in a foundation
trust. These are the people who are going to be running that organisation
effectively. It has to trade properly, it has to be a business.
It is an employer. It spends £100 million of public money.
It was to work within certain legislative frameworks, National
Health Service delivery frameworks, all these things within it.
It is hugely important that the training that you are talking
about is given to those individuals, people who want to be elected,
people who are elected onto the board, so they know what they
are doing, they have support, they know how to get independent
advice to help them with the decision-making, but at the end of
the day they have to run that thing properly. So taking it back
to our organisation, any time there is potential conflict, it
has to be talked out, everybody has to understand what the implications
of it are. Turkeys do not vote for Christmas. We are not going
to end up with a board that is going to collapse the organisation.
People need to understand what the issues are. I have to say that
with the empowerment of people in that manner, it never ceases
to amaze me about the level of responsibility and intelligence
that comes with them. I am sure you find that with football as
well.
330. We always encourage supporters to play
a responsible part in things. It actually has gone away from the
old debates and the boards. I think that actually in the best
examples it has led to a much better understanding of the economics
of football and the pressures on football clubs, and you would
hope the same thing might happen in terms of public understanding
of the way the National Health Service is run. (Mr Sesnan)
But with the added issue that you are running a £100 million
business which is responsible for thousands of jobs and a huge
number of outputs, so there needs to be a desire to get calibre
in there, as well as training and support and everything else.
Dr Naysmith
331. I wanted to move to a different point and
ask Fiona Campbell something, because she has drawn our attention
to quite a lot of what she considers to be problems with the present
proposals for getting to social ownership of foundation trusts.
It is fair to say that you have said that, is it not? (Ms
Campbell) Yes.
332. There is one particular one I would like
your views on, and that is the suggestion that foundation trusts
might or might not have patients' forums and patient advice and
liaison services and so on. Leaving aside all the other problems,
do you think that would be a sensible situation? (Ms Campbell)
That they might not have them?
333. Yes. (Ms Campbell) One of the
reasons that the Government abolished community health councils
was that they were not seen as being independent of the NHS, and
they have set up patients' forums deliberately— (Mr
Roy) Will set up. (Ms Campbell) Yes, they are setting
up patients' forums deliberately not to be part of the NHS, but
to be an independent voice on behalf of the patients in relation
to what goes on within NHS trusts and so on. I think there is
an issue about external scrutiny on behalf of patients if foundation
trusts are set up. Some of that would be mitigated by the fact
that the individuals would be elected who are on the governing
boards, but still their responsibility would be to the interests
of the trusts, not necessarily to the interests of the population
as a whole. One sort of safeguard might be to commit the patients'
forums, under the umbrella of the primary care trust patients'
forum, as is going to be the case, to have that sort of oversight.
There are also various powers attached to patients' forums, like
powers to visit, powers to refer issues to the local authority,
of the scrutiny committee, that do not seem to be taken account
of in anything within the guidance. So I would think there needs
to be some sort of a locus for those kinds of powers, which at
the moment does not seem to exist in the guidance. (Dame
Pauline Green) Can I just draw your attention as well to the
fact that the patients' forums do actually offer the opportunity
for a constituency to be developed amongst the patients. They
are not mutually exclusive. There seems to be a view here that
you either have that or you have the other. I do not see why they
cannot be built on as a very positive evolution of participation
by patient groups, and in that sense be an active part of the
constituency of the trust.
Chairman
334. I do not think it is our view, I think
it is the Government's view. (Dame Pauline Green) Also
it is important to state the proposals as developed so far still
leave a lot to be evolved. There is a lot of work to be done on
putting flesh on the bones. I think that certainly people like
us who are engaged in the process are very keen to put our comments
in. The evolution of these participatory groups is one very clear
message we would like to give.
John Austin
335. I think we may have dealt with most of
my questions. The Democratic Health Network has said the proposal
is essentially fundamentally flawed and that other examples of
democracy and accountability have not been explored. Clearly local
authority scrutiny committees and, some would say, the CHCs were
a form of accountability, although not perhaps addressing the
democratic deficit in the management and control of the organisation.
Does anyone who is critical of the foundation trusts proposal
have an alternative model for addressing the democratic deficit
and introducing accountability? (Ms Campbell) We would
say that certainly there is a democratic deficit and we totally
accept that and there needs to be increased democracy. What we
would like to see is elections to the boards of primary care trusts
at least in the first instance and perhaps to other NHS trusts
as well. The reason we would like to see elections to the boards
of primary care trusts from the electorate served by those trusts
is, as I said to Dr Taylor, because they look across the whole
health care system and they join up health and social care and
the primary, secondary community and so on. There is an important
educational role I think for people from communities who are elected
on to the boards of primary care trusts to come to understand
that whole systems approach and the social model of health and
all of those other things which the Government is promoting in
its other policies in, very importantly, tackling health inequalities
by looking at the social and economic causes of ill health. Those
are the sorts of things you get discussed in primary care trusts
particularly because they have involvement in all the different
health sectors. I do not think there is any reason why boards
of PCTs should not be elected. At the moment there is a majority
of appointed lay people on the boards of PCTs. I am a non-executive
director of my local primary care trust in Lambeth and I feel
rather uncomfortable about that role because I am not elected.
I feel I should be accountable to the local people but actually
I am told I am not. I feel what I should be trying to do is speak
on behalf of the local groups, yet I do not have any mandate to
do that. There is a rather uncomfortable role for a lot of people
already who are on the boards of NHS bodies and that could, without
a lot of difficulty, be changed into a hugely increased democracy
and those people could work, as colleagues have said, with the
patients forums to try and make genuine the commitment to representation
of communities and to introduce lots of the aspects that have
already been described as going on with the co-operative model.
336. Can I ask Pauline Green if she would agree,
notwithstanding the views about whether foundation trusts are
desirable or not for the hospital sector, with Fiona Campbell's
suggestion that if we are looking at democratising the National
Health Service the first place to start should be with the PCTs
as the commissioners rather than the providers of services? (Dame
Pauline Green) We had a discussion about this a bit earlier
actually; we touched on it. I am in favour of this sort of model
applying to PCTs, I do not have any problem with that. It is a
matter of where you start. Clearly the Government has decided
it is the best of the performing hospital trusts. Where do you
start? We could as easily have started with PCTs but we would
like to see an extension of it. We hope it is going to be a successful
model and of course we have a very strong interest in making sure,
if it is going to be a mutual structure, it is successful. As
I said earlier, we would feel the cold draught if it does not
work as part of the mutual sector. If it is going to be introduced
it has to work and we would want to help it work and we would
hope it would then be extended. (Mr Sesnan) I am not
an expert on health but it seems to me we are talking about two
different things here. One is democratisation, which is a laudable
thing, and the other one is better management of hospitals. This
process is supposed to be about the better management of hospitals
and looking at ways of better managing hospitals. I think we probably
need both of these things but clearly the Government thinking
is that some hospitals are very good, some are not so good and
others not good at all, and most customers, patients, would think
like that, and what we are trying to do is raise the game. What
we are asking is, what models are out there to help us get better
management of hospitals. The mutual model in public services is
being experimented with because it retains the public sector ethos
and enables all these other ingredients to happen. I do not care
whether the PCTs go yet or not, but I do not think that should
destabilise trying to get better management of hospitals.
Dr Taylor: I know we are not supposed to make
comments but I would want to make one comment because I have to
disagree with Fiona's reason why CHCs were abolished. I am sure
they were abolished because some of them were causing much too
much trouble.
Jim Dowd: And others were not causing any.
Dr Taylor
337. Or not causing any, yes. The argument which
has been put to us is that the best form of accountability to
patients could come from allowing them to vote with their feet
and go to other commissioners. I do not think that is going to
be the case in the rural areas we have talked to, in the North
East and East Anglia, but do you think that could be a risk in
London where it is relatively easy to move, that it is a way of
allowing patients to vote by moving away? (Dame Pauline
Green) It begs the question whether it is easy to move in
London. Having lived here for 30 years I have to say it is not
that simple. People still prefer their local hospital to which
they can walk.
338. Certainly they do outside London. (Dame
Pauline Green) Inside London too, I am sure about that, being
a Londoner. (Mr Roy) I am afraid that does not agree
with my experience in Wandsworth. We have encountered a number
of instances, some justified and some not, of people choosing
to vote with their feet where they felt a particular department
at a particular hospital had acquired a certain reputation. I
think that is a risk and I think there is a risk generally in
the London area about introducing further degrees of distinction,
partly because it has been misunderstood and partly because the
current system of funding and adjustment for market forces within
London is producing major distortions. That will of course go
by April 2005 when the common tariff for acute services comes
in, but in the meantime there will be a real risk possibly of
decisions made which will set up foundation trusts in London being
distorted by what is an inappropriate structure of funding at
the moment.
Chairman: Do any of my colleagues have any further
questions? If not, can I thank our witnesses for a very interesting
session. We are sorry it has gone on so long but we do value your
contribution. Thank you very much.
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