Examination of Witnesses (Questions 60-79)
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
60. That is extra financial help, is it not?
(Mr Jarrold) Of course it is, but you have to have
some element of incentive. What you have to look at in all of
these things is the balance between equity and incentives. I think
the balance which has been struck between incentives and safeguards
is a good balance. If you have no incentive, it is very difficult
to improve performance. If on the other hand you have no safeguards,
you do have a risk of two-tierism. It is a question of finding
the balance between the two.
61. Do you not think managers have an incentive
to improve patient care because they want to improve patient care?
(Mr Jarrold) Of course they do, but human nature being
what it is, surely we have discovered that people need more incentive
than simply a commitment to improve things. It has been our experience,
has it, not of large services that unless they are provided with
incentives, we do not get the standards of improvement they are
seeking? It is a very important issue in human behaviour.
(Dr Rutter) My responsibility is that I do think the
three-star system at the present time is fundamentally flawed,
it is too blunt an instrument. Even my Autocar rates cars
out of ten, ten stars not three stars. The issue is that if you
are already a three-star trust you sit back and rest on your laurels.
The whole principle should be that we should all be trying to
improve performance all of the time. My sense is that if you had
a number of two-star trusts here you might get some people who
felt quite aggrieved that they really just missed the three-star
status and now it has such significance to them that they feel
quite aggrieved about it. The point Kevin made about CHI being
more involved in this process is perfectly valid and appropriate,
but there will be some grievance across the nation and that this
is a very blunt instrument.
Andy Burnham
62. Do you think that sense of grievance is
more likely to make them work harder to get three-star status,
or do you think it is more likely to make them demoralised?
(Dr Rutter) It is going to help people to work, but
redefining the system a little bit and modifying and improving
it, in which CHI will be much more involved, is fundamental. If
it were up to me, I would want to increase the number of stars
so nobody in the country had three stars, nobody had ten stars.
What you would actually be talking about would be a range.
63. I put to you though that the people, once
they have got over their initial sense of anger, irritation, whatever,
then work hard to get it next year. I would say that is the experience
of star rating so far. Do you not agree with that?
(Dr Rutter) Yes.
(Mr Patten) My argument is from the point of view
of being a two-star trust at the Middlesborough end of the patch.
We missed it very marginally last year; our inpatient data was
very, very good but our forms in two areas were slightly off the
leading pace which has been set by trusts like Joan's. We were
disappointed that we did not get three stars and our incentive
is to be a three-star trust and our incentive is to be a foundation
trust. Having failed last year marginally, we want to achieve
that three-star status.
64. It has energised you rather than demoralised
you.
(Mr Patten) Yes, that is true.
Sandra Gidley
65. We are talking about whether the star system
is right or wrong, but fundamentally the star system looks at
a very narrow range of indicators, which can change according
to government whim at the moment. It is not really the incentive
you say because the goalposts can change from year to year. Does
everybody feel that the star system is the right one? Should it
be broader in some way?
(Ms Rogers) There is just one thing I should like
to say about the stars. I am not sitting here smugly because I
have gained three stars three years in a row. I do think it can
be a disincentive, because it is not all about working harder.
Without being loyal because Nik is sitting here as well, it is
a fact that a tertiary centre would find it harder to attain three
stars. At some point it would not matter how hard they were working,
for example if they could not recruit plastic surgeons, which
they cannot right now, they are not going to hit that waiting
list. That is where it gets demoralising. As a three-star trust
myself, the staff are amazingly worked up about the status and
I dread the day somebody dies in a mountaineering accident or
something similar, as doctors tend to, and the next thing is your
service is cut and you have lost your stars. That is the only
thing which worries me. It is not only about hard work: some of
it is about the inescapable problems the NHS has and that can
be very demoralising.
Julia Drown
66. Even some nursery schools are phasing out
the idea of having the star ratings for their pupils because of
the effect it has on the ones which are not at the top. It just
seems to me very surprising that when we are thinking about developing
trusts and giving managers a push, we need to have this ten-star
rating so they can all be working on this little chart and whether
they can get up the chart. Are you seriously telling me that managers
in the health service and clinicians in the health service are
not inspired and motivated enough just to deliver best services
for patients? As I go round the NHS what I see is incredible commitment
from people throughout the health service who do not need anything
else. What they want to do is deliver the best for their patients.
They do not need to have a little chart to look at and to move
one step up.
(Mr Jackson) The star rating system at the moment
has many imperfections and I am not going to sit here and try
to defend it. What I would say is that the vast majority of people
who work in the NHS are highly motivated and self-motivated, but
I can tell you that when we became a three-star trust—and
I was very cynical about the whole process—the atmosphere
in the hospital changed and people felt that they had been recognised
for the hard work and motivation and commitment and it had a very
tangible beneficial effect. I acknowledge that causes problems
elsewhere and I say again that it is a system full of imperfections,
but the recognition that it gives a hospital and its staff has
a very positive effect.
Mr Burns
67. Have you or anyone else had any experience
of a hospital where they have lost a star and gone down a rating?
I wonder there whether that energises them to get back to their
levels or whether they all get so demoralised they say "Stuff
this for a lark" and the whole thing slides. I do not know,
I was just wondering whether anyone had any experience.
(Mr Jackson) All I can say is that we are certainly
very keen to retain three-star status and working very hard to
do that.
(Mr Dixon) As far as we were concerned, we were concerned
that the CHI inspection would make us lose a star and we all worked
very hard to make sure it did not happen. It is a genuine incentive,
there is no doubt about it. I agree 100% with that. There is also
the little matter of £1 million which all three-star trusts
are given, which was hugely motivating. You get £1 million
of additional capital and no strings. Wonderful. That enables
you to do a number of specific things. You make a big play of
it. It is great. Do not underestimate the benefits you get from
three stars.
Dr Naysmith
68. What do you say to some consultants who
said to me that the star system means that clinical freedom is
interfered with and you are working to meet targets and not necessarily
providing the best clinical care?
(Mr Jackson) I do not accept that at all.
69. Do you mean it does not happen?
(Mr Jackson) It does not happen, no.
John Austin
70. While all this process of major structural
reforms and commissioning of performance management is settling
in, a number of doubts have been expressed about the capacity
of PCTs and the strategic health authorities to manage this new
set of organisations. Are you concerned that there may be imbalances
between foundation trusts and PCTs in terms of management negotiating
skills?
(Mrs Willis) That certainly is a matter of concern
to PCTs. However, in terms of the development of foundation trusts,
we are very keen to see the proposed equal development of the
PCTs to work with foundation trusts which is in the guidance and
we have highlighted it in our memorandum; that will be absolutely
crucial. In terms of what will be proposed, we would need additional
support and advice to develop the skills.
(Dr Rutter) PCTs are at different stages of development.
Some of us have been in existence for two years, some have been
in existence for much shorter periods of time than that. There
is a real need to ensure that the PCTs in a particular area of
a foundation trust are given the support and the capability to
commission care from their foundation trust. It will depend on
the locality and the use of the PCT as to whether they are capable
of doing that.
71. How is this to be done? Clearly these trusts,
which are recognised as high performing, are increasingly going
to be staffed by more and more experienced managers and they will
have greater access to information about activity, cost of services.
What happens when there is a different set of priorities between
that trust and the PCT in terms of meeting the needs of the local
community?
(Dr Rutter) The situation we are in is that we are,
very much as part of pursuing the patient programme, mapping patient
journeys and working collaboratively to establish the best way
to treat patients with particular problems. Our commitment is
that we are funding the interventions which come out of those
patient journeys, whether they be in primary care or secondary
care, jointly. That seems to me to be a much more effective way
of developing commissioning than having a bun fight about activity
and money in the past, which did not actually really address the
issues of equality and the patient's perspective. It does mean
that at the PCT level we do have to be very certain about the
level of activity we require, be able to manage the flow of patients
through those journeys and it does require an increased degree
of sophistication which has not existed through PCG and early
PCT commissioning.
72. One of the things I think we have seen in
education is that once a school is labelled as a failing school,
teachers do not want to teach there and parents do not want to
send their children there. They go into a spiral of decline and
are very difficult to turn round. Proposals for enhanced patient
choice almost certainly will lead to additional demands for treatment
at what are seen as the successful foundation hospitals. In Durham,
for example, particular groups of patients from the west of the
county might want to seek treatment at the foundation hospitals
in Sunderland or Teeside rather than going to their local hospitals
in Durham and Bishop Auckland. Could this not have some destabilising
effect on the latter hospitals, making it more difficult for them
to aspire to or achieve three-star status? Is this not going to
change the whole determination of hospital development in an area?
(Mr Jarrold) I do not believe so. To give just the
local examples, the new County Durham and Darlington Acute Services
Trust, which has just been created, was created from two trusts,
the South Durham Trust, which was a three-star trust, and the
North Durham Trust, which was a two-star trust. I have every expectation
that under the leadership of the new trust, the whole trust will
be a three-star trust before long. The South Durham Trust in particular,
but North Durham is improving rapidly, have very good waiting
times and it is most unlikely that patients from that area will
be seeking care further away, because the waiting times are very
good. Clearly they do go to South Tees for the specialist treatments
they need to have there, but that is absolutely fine. As a local
health community, we are not in the position of having somebody
who is a no-star trust and somebody who is a three-star trust.
All our trusts are very close together in terms of performance.
I do not think that will be an issue locally.
73. May I bring in Mr Dixon and ask him whether
he would like to comment on that in relation to the London scene,
where perhaps it is easier for people to exercise patient choice
in which hospitals they go to?
(Mr Dixon) As far as my trust is concerned, we are
anticipating that more people will want to use our trust. That
is very much an institutional view rather than a system view shall
I say. We have one no-star trust which is not a long way away
from us. I am aware that they are having difficulties in filling
vacancies. They are also having difficulty in meeting their waiting
lists; the waiting list is still there, so patients are not yet
voting with their feet. I would anticipate that we shall actually
be taking patients from that hospital. In doing that, it is possible
that we shall enable them to improve, strangely enough. In that
particular set of circumstances, it may not be a problem. It does
become a problem if that trust does not turn round.
Chairman
74. John used the analogy of education. You
do not see that the same situation as John described, in terms
of a failing school, will happen to those "failing"
hospitals.
(Mr Dixon) London is a difficult case anyway because
of the shortages all over the place. I do think we need to have
measures in place to make sure that the more successful hospitals
cannot poach staff by just paying them more money. That has to
be a control. You cannot rely on a duty of participation or co-operation
or any such thing. It will not work.
75. Basically you are attacking the whole concept
that the schools have had.
(Mr Dixon) No, I am not.
76. In the notes of guidance issued this issue
has been addressed very clearly. You are saying that the duty
of co-operation which is on the table at the moment will not work.
(Mr Dixon) I believe that will not be sufficient,
in the context of London particularly, where recruitment issues
are around a lot more than just money. People want to come and
work in my trust, because it is a good place to be. There will
undoubtedly be temptations at some point to add money to the other
good things. I do not think we should be allowed that freedom,
because it is potentially dangerous. In terms of the London issues,
I think we should be restricted.
John Austin
77. I was referring earlier to patients exercising
choice and deciding where to go. Do you think there is also a
possible danger that foundation trusts themselves could be selective
about the patients they treat? Could this not bring in perhaps
age-based rationing or socially selective access to treatments?
Could the foundation hospitals perhaps, being in this privileged
position of being able to choose their patients, achieve higher
levels of throughput by treating a carefully selected mix of patients,
leaving the rest to the two-star and one-star and no-star hospitals
and therefore adding to their difficulties?
(Dr Rutter) From the commissioning point of view,
we have a very substantial budget, which means we are in a position
to exercise some significant control. It would not be something
we would be prepared to tolerate. The whole of our commissioning
contract would be based on a broad approach to care across a wide
range of issues which will fulfil the needs of our population.
78. Do you think you will have adequate powers
to do that?
(Dr Rutter) We would be potentially spending many
millions of pounds. As long as we are quite careful and have contracts
which are based on an individual specialty basis and identify
quite clearly what we are potentially commissioning, then we can
make sure that does not happen. If you just have a situation of
a broad block contract, then there is always the potential for
that to happen. This is why it is imperative that quite detailed
contracts and the financial flows are introduced alongside this
initiative. With regard to patient choice, for many years as a
TPP we ran a system, admittedly with only 30,000 patients, where
nobody waited more than three months for any element of elective
care. What we did systematically was that if somebody tripped
beyond that time in the NHS, we moved them. It is quite surprising
how many people choose not to move if they are actually given
a choice. Geography is fundamentally important to patients and
they often prefer to stay and go locally rather than have the
opportunity to be seen more quickly but have to travel some distance.
That was certainly our experience.
(Mrs Willis) The only thing I would add to that is
that one of the biggest problems we have in the acute sector is
capacity. What you would be trying to do as commissioners is develop
high quality capacity in all providers, not just foundation trusts,
because they would not be able to meet everybody's needs. It is
in our shared interests as commissioners to make sure that all
of your local hospitals improve and meet targets.
(Mr Jackson) You have to think about this from the
point of view of the foundation hospital and what it wants to
do. This notion that a foundation hospital wants to suck in patients
from the whole wide world is nonsense. Most hospitals and certainly
my own wants to be the hospital of choice for Bradford and in
certain specialist areas for a slightly wider area. We do not
want to pull in patients from the whole of West Yorkshire, for
very good reasons.
79. But if you can be selective about the patients
you take in, you can improve your performance, can you not?
(Mr Jackson) I was just going to say that there are
very good reasons why we would not want to pull in a lot of patients
from the surrounding areas. It is in fact not in our interests
to do it. We do not have the capacity and ability to do that without
providing a worse service locally. At the end of the day, over
90% of our income is coming from the three Bradford primary care
trusts. I support Ian's point very strongly. That is where the
control will be. If we were to try to be selective, we would very
soon be in serious difficulty with our commissioners.
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