Examination of Witnesses (Questions 360-379)
TUESDAY 4 MARCH 2003
RT HON
ALAN MILBURN
MP AND MR
ANDY MCKEON
360. So you are starting with a cap?
(Mr Milburn) The alternative to that is to do what
some advocate which is that we should have a free-for-all and
everybody should do it all at once—
361. Or you could start with a particular community.
(Mr Milburn)—which I think would have consequences
that would be pretty serious because you know as well as I do
that there are different starting points in the NHS, that is true.
Whether or not the star ratings are right, wrong or indifferent
does not really matter. The truth is that what the star ratings
have exposed is what everybody around this table and, incidently,
what every member of staff and probably every patient knows, which
is that some hospitals are really good, a few are poor and most
need to improve. There are different starting points and since
there are different starting points what we need to have is different
approaches because the ones that are doing well, honestly, I do
not need to worry about. The ones that are doing badly and that
pass across my desk every single day I worry about a lot. It is
not more freedom that they need, they need more help and support
to help them to improve, otherwise you are into sink or swim territory.
I am not sure you are advocating this, but I think the danger
of what some advocate, which is that we should just let anybody
go regardless of their performance, really would be sink or swim
territory and I am not prepared to sanction that. Why? What I
want to do is to make sure that the ones that are doing less well
get more help, more support and when you do that it works.
362. Did you consider looking at a health area
in which there might be some one star and three star trusts and
piloting at that level? The good reason for doing that is you
would not be accused of the elite charge. Secondly, given we know
things change over time, a three star hospital can become a one
star hospital, you get a change of management and the thing splits.
If the system is going to work it has to work to get through those
sort of problems too and so community ownership has got to be
able to work in what is seen as the poor performing trusts. Did
you consider looking at it in that way?
(Mr Milburn) What we have done is we have tried to
construct something that gives freedoms where it is appropriate
to do so.
363. So you did not consider doing it by geographical
area?
(Mr Milburn) Not by geographical area because in the
end the incentive has got to be on the individual organisation
to improve, but we have tried to recognise the reality of how
the NHS works at a local level, which is that the hospital is
not a little island, of course it is not, it has got to work alongside
the primary care trusts, it has got to work alongside the community
trusts, it has got to work alongside the local authority and,
most importantly of all, it has got to engage its staff. If you
are genuinely going to have services that are responsive to local
needs then it has got to engage better with the local community
and that means bringing the local community into the governance
structure.
Dr Taylor
364. Secretary of State, can I go back to some
of the comments you made to our Chairman. I was pleased to hear
that so far it is only expressions of interest you have received
from the 32 trusts. I would like a bit more detail about the consultation
that is going to go on locally because if it only involves staff
and patients in the community who are going to get the foundation
trusts it will be heavily loaded because, of course, they will
want it. Is it going to involve people in the community who are
in areas that are not going to get foundation trusts or have not
applied as yet because if it does not it is going to be a very
one-sided consultation?
(Mr Milburn) Yes. For example, in a sense I do not
want to say you have got to consult A, B, C and D because that
would be quite a difficult thing to do. I do not know Gloucestershire
terribly well so I do not know what the local organisations are.
Remember, these applications will come forward and I will have
to make a judgment on them. One of the judgments that I will be
seeking to make is who they have consulted. For example, you talk
about the consultation not just taking place inside the organisation
and I agree with that very much, I would be worried if in one
of our hospitals the staff were not on board for it. I think in
the end it is quite difficult to affect change unless people want
to go with it and they have to make judgments accordingly. We
would want to see evidence that the local commissioners, who in
the end hold the cash, the local primary care trusts and not just
one primary care trust but the PCTs who are commissioning services
from the prospective foundation trusts are happy with it and signed
up to it and if they are not then I will have to make a judgment
and I know that would be difficult. I think there are those organisations
and there are the local authorities and, as the Chairman quite
rightly said, MPs will have a view about it. There will be lots
and lots of patient organisations that will have a view and I
think should be consulted. I do not just mean the community health
council or successor bodies, I also mean the local Alzheimer's
Disease Society, Arthritis Care and all the other organisations
that are involved in this. I think we would want to see some demonstration
that consultation had taken place in a meaningful form and, secondly,
we would want to see what the results of those responses were
as that then allows me to make a judgment about whether this is
really just the sort of hospital that is off and going it alone
and so on, which would be one approach, or one that has taken
its local community and the people that it employs with it.
365. If you take Bradford as an example, that
has a lot of populated areas surrounding it that will not have
foundation hospitals. Will they be included in the consultation?
(Mr Milburn) I think it would be wise for Bradford
because the interesting thing about that one is that it is both
a district general hospital, which many are, but it also provides
subregional services. I do not know if that covers the Chairman's
area or not.
Chairman
366. It does.
(Mr Milburn) I think it would be perfectly reasonable
for it to ask other trusts nearby what their views are and, similarly,
the Huddersfield one because all of these organisations are fairly
cheek by jowl. I think we would want to have some evidence that
there had been consultation of that sort and to see what the results
of that have been.
Dr Taylor
367. I am glad to hear that. How do you decide
on the community for hospitals like Moorfields and the Marsden?
(Mr Milburn) That is more difficult, is it not, because
they are sort of tertiary centres. For example, I know that Moorfields
hospital, which serves London but obviously serves a wider specialist—
368. I was talking about the Marsden particularly.
(Mr Milburn) I know something about Moorfields and
less about the Marsden. Let me tell you about the centre that
I know something about. Moorfields has something like 50 primary
care trusts that contract with it, that is a hell of a lot and
yet not one of them is responsible for more than two per cent
of Moorfields' income. It would not be because it is a specialist
tertiary centre providing a very good range of services. They
have been thinking through the implications of that and I think
as part of their expression of interest they have begun to explore
some of this with us. In its governance structure, for example,
they would want to try to have that reflected. Clearly it would
be pretty difficult if they get to foundation trust status to
have 50 PCTs on the board and then the patients and the staff,
that is going to be one hell of a board and it is going to be
unmanageable. What they have been thinking about is having four
representative PCTs maybe elected from PCTs in London on the board
and then one PCT to represent the commission of PCTs outside of
London. They are in different positions and although we have been
criticised for this, that is why it is quite difficult to lay
down hard and fast rules, because your area is different from
mine, your hospital is different from mine and certainly the Marsden
and Moorfields are very very different because they are large
tertiary centres that really do not have a natural local constituency.
Their constituency of support I suppose are its patients and they
come from all over the country. You have got to have both in the
consultation period, which is what you are asking about, and also
in the proposed governance structure something that reflects that
and we would look at that. I cannot say to you these are the rules
because there are a different set of rules applying for the Marsden.
Andy Burnham
369. Going back to the Chairman's remarks, I
think something that probably unites most of us here and most
MPs generally is the fact that the NHS has never been particularly
good at listening to public opinion nor elected representatives
for that matter.
(Mr Milburn) Sometimes they are not very good at listening
to my opinion!
370. For me the democratic changes here are
the most attractive part of the foundation trust policy. You hear
it said that it is "window dressing" and in some ways
"window dressing" appeals to sceptical MPs. Would you
agree that it would be worse to do it in a token fashion than
not at all?
(Mr Milburn) Yes. Why is there concern about this?
There is concern about this because it is one hell of a big change.
Chairman
371. I do not think it is. What worries some
of us is I have sat in this inquiry listening to officials and
it took me back to ten years ago when I was listening to the same
sort of officials arguing for the internal market with the Conservatives,
the same words were being used. It is not that big a change. We
have had it before. Frankly, it did not work last time.
(Mr Milburn) With respect, it is and I will tell you
why. What Andy was asking about was the governance structure.
What we have had for 50 or more years in this country is one form
of governance over every hospital in the country and you are looking
at it, I govern the hospitals. In the end that is how it works
and every chief executive in the country is always looking over
their shoulder as to what the Secretary of State for Health will
do and this is a fundamental decision that we have to make about
how we want to structure health care in the modern world. I simply
do not believe it is going to be possible to continue to do that
for a whole variety of reasons. We have a small country, that
is true, but we have a country with huge differences and we have
just been talking about that in relation to specialist hospitals.
Your constituency is different from mine and it is different from
everybody else's around this table. Let me just finish this point
because it is absolutely at the nub of why we are doing this.
If you are going to have improvements in service and, crucially
in my view, if you are going to address what the NHS has singly
failed to do for 50 years, which is to narrow the health gap between
the poorest communities and the better off communities, then what
you have got to move out of is this idea that you can have one-size-fits-all,
top-down services decided by one person in Whitehall because it
will not work. What you have to have is local services that are
attune to the needs of the local community. Julia is quite right,
yes of course there have to be national standards. It is how you
calibrate the relationship between the national standards and
the local control that in my view will get you delivery, but the
idea that you can run a 1.3 million strong service from one office
in Whitehall, the Chinese Red Army tried to do that and the Indian
railways did, but it is not really appropriate for a modern, developed
21st century country trying to develop responsive services for
patients. Going back to your question, yes, it has to be for real.
We have got to relocate the ownership. The ownership has to be
housed in the local community. The accountability has to be to
the local community and in the end the only way of doing that
which will work and that is beyond "window dressing"
is by allowing fundamentally local members of the public for local
communities but also local members of staff because they are important
stakeholders, they have got to be given the opportunity of governing
the organisation.
Andy Burnham: I am reassured.
Dr Naysmith
372. Why not do it for primary care trusts then?
Why are you doing it for the elite?
(Mr Milburn) I do not know about your area, but my
primary care trust has just begun its work, it is a brand new
organisation. To be candid with you, I think what we want to do
over the course of the next few years is to get the balance right
between the standards that need to be in place so that there is
equity in the system and people feeling some ownership of the
agenda for change in the health service that fundamentally relies
upon the abilities of PCTs to commission services. I think we
have got to develop them as commissioning organisations. I think
it would be a fundamental mistake at this stage, although I do
not rule it out at all for the future, to put that bit of the
organisation through a further period of organisational upheaval
because I do not believe they are ready for it. They are new young
organisations that have barely begun their work. In time it might
be different, but that is not where we are at today. They have
barely come on line and they need to develop their ability to
commission services because unless they do we will not get good
value for money for taxpayers, we will not get improved choice
for patients and that is what I want to see happening.
Andy Burnham
373. I disagree with the Chairman in that I
think this is a huge change. It is reassuring to hear what you
said. If the people who own that hospital fundamentally disagree
with a proposal put forward by that trust about reconfiguration,
the nub of this, can those voting members overturn the decision
of a trust to reconfigure services in such a way that the public,
represented by the voting members, fundamentally disagree? Will
they have the power to change policy back in that way?
(Mr Milburn) I think the simple answer to that is
probably yes. The board of governors will have real powers. It
is not a tokenistic thing. You cannot have the board of governors
interfering in the day-to-day decisions of the hospital otherwise
the thing will never run. In my view you have got to have the
combination of a strong management team capable of getting on
and delivering the improvements in care that are required and
they should have the freedom to be able to do that. In a public
service there has to be accountability. It is how you get the
accountability.
374. I am not advocating that day-to-day decisions
should come up, but fundamental issues that would affect the future
of health care in that area should.
(Mr Milburn) Yes. For example, the governing body,
directly elected by the members of the foundation trust, would
be able to approve not just the annual report, the backward looking
report of what the trust has done over the previous year, but
also its forward plans for the forthcoming year, so there will
be real democracy, but no doubt that will cause all sorts of tensions.
You either have a view about democracy or you do not. Democracy
is not a perfect thing, but it is not bad as a principle for how
you run public services. This is the great irony of this debate
and I have never quite understood it. We are quite happy to say
we have democracy and local elections when it comes to deciding
leisure services or how the bins are emptied or social services,
Chairman.
Chairman
375. Some of us have argued that for the health
service as well.
(Mr Milburn) So why do we not have it for the local
health service? If you go and ask the public what they think is
the most important public service in this country, I bet they
do not say leisure centres, they are more likely to say health
centres.
Andy Burnham
376. I am happy it is not a paper exercise and
I think what you are saying is it is not just a way of shuffling
about bits of paper that do not really mean something, that is
great. If they are no longer looking up to Whitehall, they are
looking down to local elected representatives then that is a big
change in accountability. Do you think the NHS is ready for what
is a huge, traditionally insulated from public opinion, culture
shock of that sort?
(Mr Milburn) I think you have to migrate it down.
I think you are right, I think it was Margaret Jay, when she was
a health minister, who coined a great phase, which was that in
the NHS the term consultation really meant a period of time rather
than a meaningful exercise. I think every MP sat around this table
knows what I mean when I say that. This is where I disagree with
the Chairman because I think we have to relocate the ownership
so that the public are in charge of it. It will bring all sorts
of difficulties and we cannot leave the health service on its
own. We are working very closely with the New Economics Foundation
and they are people who have been very much involved with establishing
this sort of mutual approach and making it happen. We have commissioned
them to produce a source book for NHS organisations to draw on,
about how they can go about engaging with the public, how best
to do that. We are proposing that as part of the application process,
building on what I said earlier, that there will be a panel to
advise me on whether the governance structures that the perspective
foundation trust is proposing are appropriate and that panel will
probably include people like the Director of Patient Experience
that we have at the moment, Harry Cayton, who is seconded into
the Department from the Alzheimer's Disease Society. We may well
ask the Commission for Public and Patient Involvement to help
us with that. There are other organisations in and around the
NHS, but more broadly, I think you did take evidence from Dame
Pauline Greene, there are organisations of that sort who we would
go to both to advise us but also provide advice to the NHS as
to how we can go about this process of engagement because I think
it is true that all too often the NHS has not been strong on talking
and engaging with the local community and Richard might have something
to say about that as an example.
John Austin
377. You were saying about accountability and
local ownership and who would appoint the governors, but democracy
is not just about voting for somebody every five years, it is
about that engagement, that involvement, that accountability.
If that is the case, why are you proposing that the foundation
trusts would be exempt from the requirement to have a patient
and public involvement forum?
(Mr Milburn) It may well be that NHS foundation trusts
will choose to have a patient forum, but the reason why we did
this was to try to get the public and the patient's voice at the
heart of the health service. You will remember what Sir Ian Kennedy
said in his report into Bristol, which I thought was one of the
most telling phrases in the whole report, when he was commenting
on the fact that lots of people knew in Bristol that there was
a problem at the Royal Infirmary, the clinicians knew, the managers
knew, the only people who were not told were the patients, they
were not ever told and he made a very telling point, which is
that if we had the patient's voice at the health of the health
service rather than standing outside—
378. You are proposing that there is no requirement
to have a patient forum.
(Mr Milburn) Let me finish the point. Maybe that would
not have happened. That is why we put patient forums in place.
However, with foundation trust status we go way beyond patient
forums in at least two regards. First of all, it is the local
community who will elect the hospital governors, the patients
and the public will have a democratic mandate, which is not the
case with patient forums at all, so it is a much purer form of
democracy. If you want to put the patients at the heart of it
the best way is to let the patients decide that.
379. To have the election once every four or
five years does not ensure accountability.
(Mr Milburn) The second point is that whereas under
the proposals for NHS trusts patient forums would be able to appoint
one non- executive director, under these proposals the governing
body would be allowed to elect all non-executive directors. If
you want the patient's voice at the heart of the health service,
I have no problem with that at all. What I do not think is needed
is two replicated forms of patient involvement. It may well be
that individual NHS foundation trusts will decide that they want
to maintain patients forums, but that will be a matter for them
and not for me to decide.
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