Examination of Witnesses (Questions 180-199)
TUESDAY 11 FEBRUARY 2003
MR DOUGLAS
PATTISSON, MS
KAREN BELL,
MR MALCOLM
STAMP AND
MR CHRIS
BANKS
Mr Burns
180. I thought I heard Dr Taylor say that you
only had one star on delayed discharge. If I heard your answer
correctly, you said that you thought there was nothing structurally
wrong with your work in social services; there were other areas
where you had to look at how to improve the problem. (Mr
Banks) I said that the Change Agency reviewed the process
and the way we work with social services in primary care and did
not feel that they could fault that terribly much. I suggested
that there might be structural issues around the growth in the
population of Cambridgeshire, the availability of residential
and nursing homes, that were not helping the situation.
181. If you were to seek foundation status,
do you think that part of your performance record would hinder
you? (Mr Banks) That remains to be seen because in
order to become foundation trusts we have to get three stars next
year.
182. Or do you think that you would be able
to enhance your opportunities to get three stars so as to enhance
your opportunities to seek foundation status if social services
were fined for the delayed discharge problem? (Mr Banks)
I understood the inquiry was about foundation trusts.
183. It is. (Mr Banks) We have gone
on record as saying that we tend to work very closely with social
services anyway.
184. What about seeking foundation status and
your record? Do you think it will be enhanced by your record on
delayed discharge improving if social services were to be fined? (Mr
Banks) I am not sure that it would be.
185. That is basically a no, is it not? (Mr
Banks) It is a do not know. We are working very closely with
our colleagues in other sectors and fining is something that may
or may not be introduced next year. It does not change the ethos
that we are working under as partners in our local community.
The object is to try and reduce delayed discharge because that
is, in effect, a patient who is in the wrong place and not necessarily
getting the right care. That is important.
Julia Drown
186. On the wider health issues, we have had
evidence from others saying that they feel the new model will
enable people to feel like they own their hospital more and that
it could lead to people having more responsibility for their own
health because they feel they might get more involved in terms
of taking responsibility for their diet and exercise or self-diagnosis,
for example. Do you feel that local people do not feel like they
have any ownership of your trusts at the moment and that this
might be a way of getting patients that come to you to take more
responsibility for their diet or exercise and issues like self-diagnosis?
Do you think that is a possible advantage of foundation trust
status? (Mr Pattisson) The hospital I am responsible
for has a very strong bond with its local community. Many of the
people who work there also live locally. Most of the residents
who live locally look to Hinchingbrooke Hospital for their treatment,
whether it is to have a baby or through the A&E department.
One of the advantages of having a board of governors in a foundation
trust would be to strengthen that link and make it more structured,
to put people who have an interest in the hospital on the board
as part of the overseeing and decision making processes at a high
level. For the staff it would for the first time put the staff
very much in a position where they had some direct influence and
a role. Extending that to whether people will improve their diet
may be a bit of a long hop but the more the community and its
staff come together to take an interest in health matters and
their local hospital the better. There would undoubtedly be some
spin-offs. Whether it will be in how many pieces of fruit people
eat a day, I do not know.
Mr Amess
187. My questions are directed towards morale
and the star rating system. I have strong views about the star
rating system but unfortunately I am not sitting where you are
this afternoon. Last week's witnesses felt very much that the
idea of foundation trust status would be a real incentive for
improvement. One of the witnesses also described how morale at
his trust had dramatically improved when they were given three
stars so, as you can imagine, Mr Pattisson, I would like you to
share with the Committee what morale is like in terms of your
particular hospital. (Mr Pattisson) As the Committee
I am sure will be aware Hinchingbrooke Hospital was given zero
stars last year in the NHS performance ratings on the back of
a critical CHI report. That was the first time that the Commission
for Health Improvement's reviews had been weighed in the star
ratings process. The Commission for Health Improvement were asked
to bring forward the trust's clinical governance review by the
Trust's Board because the Board had concerns about issues around
quality and governance. I do not think it was altogether a surprise
to the board that the trust ended up with a zero star rating,
although we were not clear how the CHAI report would be weighed
in the star ratings. That is the background. Plainly when the
trust was awarded zero stars, that was not something that was
warmly welcomed by the staff. Many people took it as a description
of the hospital that they did not feel fitted with their day to
day working experience. Having talked to the staff—we have
done a great deal of work developing an action plan and addressing
all the issues which are all around improving patient care, which
is absolutely a fundamental part of our strategy and what we are
there to do—people now acknowledge and recognise that the
criticisms that were levelled were justified and needed to be
dealt with. Whilst we had a bit of a dip last July, the morale
in the hospital now is much better. Plainly it will be much improved
if next July we improve our star ratings which we are fundamentally
committed to. In terms of a general comment on the star ratings,
my personal belief is it is a good system. For sure there are
refinements that could be made and the system is being reviewed
as we speak but it says very clearly to the staff and people who
live locally and others in the NHS community how our hospital
rates against other local hospitals. It sets out a challenge for
us to improve our star ratings and to be up alongside others who
have better star ratings.
188. I do not want to put you in a difficult
position. I want you to pretend that there is no one else in the
room. When you were given zero star rating—and we all know
how staff talk, particularly consultants—did any of the
consultants share with you their surprise that they worked at
other hospitals and they had a view about the other hospital and
they said, "For goodness' sake; our hospital is better than
theirs and yet they have a higher star rating because their chief
executive knows how to contrive things to meet the criteria"?
Pretending that there is no one else in the room, was there any
of that? (Mr Pattisson) I do not recall a conversation
along those lines, even in the sanctity of this room. Some consultants
did have views about it and over half our consultants work in
other hospitals, so we are very well connected with other hospitals.
When the ins and outs of the star ratings were made clear, how
the judgments were made, the scores which we achieved on all the
various headings—and there are five in total—it became
clear to people that we had not achieved where we should have
achieved on the CHI report. We had done extremely well on our
waiting time targets and on our patient focus indicators, on our
clinical indicators, on our capacity and capability indicators.
There is a lot to be very proud of. It was the CHI report that
was the key issue. I have spent a lot of my time explaining that
to people and getting people to buy into the issues that we needed
to address. I think people were anxious about it. Nobody wants
to be labelled as zero stars, do they? The challenge for us is
to get out of zero stars and improve our performance.
189. Your hospital is clearly one where they
do not gossip a lot with your good self. Mr Stamp, our analysis
shows us that nearly two-thirds of three star trusts had a lower
star rating in the previous year and the majority of trusts had
a different rating in 2001 and 2000. What are your views on the
appropriateness of using this system as a means of achieving foundation
status? (Mr Stamp) The star rating system is generally
well received in the health service. There was a recognition that
some form of measurement, given the amount of performance measurement
that was starting to take place and has continued since, would
be useful as a bench mark within the service. In terms of the
star rating system being used as an entry into the first wave
of foundation trusts, I think it is perfectly reasonable given
that it has been said that the best performing should be allowed
to see what additional freedoms can be built on to provide even
further excellence. That is well supported.
190. I can understand you saying that because
for two years you had three star rating but how general do you
think your view is? You must talk to other colleagues at other
hospitals. (Mr Stamp) Occasionally. If you take Hinchingbrooke
and Peterborough and ourselves and West Suffolk as well, when
we first received the documentation in November about foundation
trusts, we got everybody together including community health councils,
the trade unions, the local authorities, county councils and so
on and talked through our potential interest in making a preliminary
application. We did that, I hope, with some support from the room
and after the meeting as well. We do complement each other. We
have established clinical networks with neurology and radiology.
We are looking at pathology. We work closely on accident and emergency
and so forth. We do not see that the relationship with a no star,
a one star or a two star is any less important than dealing with
other three stars, but I think it is a reasonable policy issue
to say that the three stars should be allowed to go forward in
the first wave. As we have heard more recently, this is the way
in which the NHS is going to go in total so that it is a first
step.
191. I can understand everything you are saying
but say suddenly next year you got a zero star rating. I just
wonder if you would be making the same points. I can see why you
are an advocate and an enthusiast, but I wondered if, in the reverse
situation, you would be quite so keen. (Mr Stamp) I
think I would. As an NHS family, we know what we have to deal
with. We know that the future is about working together, whatever
label we might have. It is about clinical networks that I have
already started to describe. We have similar arrangements with
Peterborough as well. We know that is the pattern for the future
so whether I have none, one or three tomorrow I would be sitting
here saying the same thing.
Dr Naysmith
192. You are a major teaching hospital? (Mr
Stamp) Yes.
193. I think you said something like 6,000 staff
versus Mr Pattisson's 2,000. Is it fair to judge an institution
by the original star measurement that is doing such a different
job with so many different stakeholders and many other things? (Mr
Stamp) In terms of the measures that are laid down in terms
of the key nine followed up by the other 26 or whatever it is,
they are fairly consistent measures. We will always have the argument
about case mix complexity and so on but the measures that are
there, in terms of those key nine, are reasonable as proxies across
different sorts of trusts. What is not to be lost within that
is that we work very keenly together and, at the end of the day,
we may well be a major teaching hospital with a fantastic research
record and reputation but we are also a very important district
general hospital for the people of Cambridge and we never forget
that either.
194. That is a very important point. I come
across people at Bristol Medical School who say that they do not
recognise their hospital as being a zero star hospital because
of all the terrific things that go on in the medical school, associated
with high technology medicine. (Mr Stamp) We have good
engagement with our staff and good communication for which we
have been recognised, both in terms of awards and as a general
feeling within our staff and trade unions. That is why we can
confidently have such open, proactive discussions with them and
others in our community about preliminary applications for foundation
trusts. I think there is a sense that Addenbrookes is a very close
community, despite being a very big teaching hospital, and it
does have a very good engagement with its staff and with the people
it serves. They do see the relevance of a four hour trolley wait
and having a brain research centre on the scale that we have.
That connection, which is nothing to do with three stars, has
been going for decades and I think it is very important.
195. I realise you are a three star trust. Part
of my question should have been directed towards Mr Pattisson.
Being a zero star trust is a very difficult position to be in,
especially if you have had more stars than that not very long
before. How do you deal with that with your staff? (Mr
Pattisson) It requires a great deal of communication and we
put a great deal of effort into explaining how the system works.
196. How do you communicate that to 2,000 people? (Mr
Pattisson) With a variety of messages. We did a huge amount
of face to face briefing. We used normal instruments of communication,
e-mail and news letters, open sessions taking in night staff as
well as day staff, and we have run a series of workshops. We have
had good support from the Modernisation Agency to help us deliver
the plans that we have developed to get back on track. The key
point in all of this is some objective assessment of performance,
whether it is on the quality of the care or the quantity of the
care you provide. There are some basic minimum standards and within
the NHS locally and within the NHS nationally I think there is
a great desire to improve standards and to do better for patients.
There is huge commitment to make sure that patients with cancer
get seen within two weeks, that no one waits more than four hours
on a trolley and that patients get into an outpatient clinic as
soon as they can.
197. It has been said that having CHI involved
would improve matters. People who criticise the star ratings system
have said, "If only we had a better measure, we would do
better in the system." With you, it worked the other way
round. Is that because you think the star ratings are concentrating
on the wrong things and you have taken your eye off the ball?
CHI was concentrating on the star ratings and the other things
were carrying on without too much interest being taken in them. (Mr
Pattisson) The star rating system includes wherever a report
has been conducted so that is weighed in the balance in everybody's
rating.
198. It has not been up to now. (Mr Pattisson)
No; it has been up to now.
199. The first time it happened you went down. (Mr
Pattisson) That is correct. The reason why the Board invited
CHI to bring forward the clinical governance review within a programme
of four to five years is because the Board had concerns about
some aspects of the quality of care and the quality of service
that were being provided. The Board was justified in its view.
The report that came through was critical. We have addressed those
issues. We are confident that we will improve our star rating
and improve the confidence in the locality in our hospital and
our position within the NHS in general.
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