Examination of Witnesses (Questions 264-279)
TUESDAY 11 FEBRUARY 2003
DAME PAULINE
GREEN, PETER
HUNT, CLIFF
MILLS, MR
MARK SESNAN,
MS FIONA
CAMPBELL AND
MR DONALD
ROY
Chairman
264. Can I welcome our second group of witnesses
and say that we are rather late in starting this session. Can
I thank you for being willing to come to the Committee and thank
those who have submitted evidence, which has been very interesting
and useful. Can I begin by asking each of you to briefly introduce
yourselves to the Committee and say who you represent.
(Ms Campbell) I am Fiona Campbell, I
represent the Democratic Health Network, which was set up by the
Local Government Information Unit in 1999 to provide policy advice
and information specifically to local government but also to health
organisations about closer partnership work between health and
local government and also to promote the democratic role of local
government in health. I think it may be of particular interest
to this Committee that we have been working with the Department
of Health and with local authorities on developing the new local
authority role in scrutinising health and health services, that
is relevant to what you are talking about today.
265. Mr Roy, a veteran of this Committee. (Mr
Roy) Indeed, Chairman. I was reading the minutes of a previous
meeting and what you said to me at the end where I think you indicated
that you were not entirely clear whether I would still be round
in 2002. Though no doubt it would be presumptuous to speculate
as to how much longer I am going to be round I am very glad to
be here again now, it being 2003. I am Donald Roy, I am one of
the two vice chairs of the Association of Community Health Councils
for England and Wales. In light of some of the declarations of
interest made about an hour ago I should mention I also happen
to be a paid up member of the Cooperative Party, although I do
not think it will necessarily affect any of the evidence that
I give on behalf of the Association for Community Health Councils
for England and Wales. The general background is that we are a
national, unincorporated association and we are directed by CHCs,
which I probably do not, in the light of the great knowledge and
experience of your Committee, really need to say much more. (Mr
Sesnan) I am Mark Sesnan, I am the Chief Officer of Greenwich
Leisure Limited, we are a trust that operates thirty-two public
leisure centres in partnership with 5 London boroughs. We are
a not-for-profit social enterprise and we were established in
1993. Prior to that we worked for Greenwich Council. We were established
under the Industrial, Public Society for the Benefit of Community
Rules. We have stakeholders involved and are lead by staff working
alongside councillors, customers and trade union representatives. (Dame
Pauline Green) My name is Pauline Green:, I am the Chief Executive
of the apex organisation for Co-operatives in the United Kingdom.
A week ago the Co-operative Union changed its name to become Co-operatives
UK, which reflects the fact that it is now much more inclusive
of all sorts of co-operatives, we represent consumer co-ops, worker
co-ops, housing co-ops, credit unions, employee owned businesses,
and so forth. We provide a range of services to our members, constitutional,
performance monitoring, both commercial and social and indeed
good governance. We are also the body charged with seeking innovation
in the co-operative sector. We are looking for new models of co-operation
and have been engaged in a whole range of second generation or
new-wave co-operatives. (Mr Hunt) My name is Peter
Hunt and I the Director of a relatively new think tank called
Mutuo, it has been established by the recognised mutual sector
in the United Kingdom, co-operative societies, friendly societies,
building societies and mutual insurers. Its purpose is to promote
the value of mutual ownership and in particular to look at a range
of new applications for mutuality relevant to this session today
in terms of public services in particular. I should also I am
the General Secretary of the Co-operative Party and this is probably
the best attended party meeting I have been to in some time! (Mr
Mills) I am Cliff Mills, I am a partner of Cobbetts Solicitors
in Manchester and Leeds. I think we have established some preeminence
in providing legal services to co-operatives and mutual organisations.
I have a background working with and for company, both plcs and
private companies and I have spent most of the last 10 years working
with mutual and co-operative organisations. I am not a member
of any Co-operative Society but I advise a number of the leading
societies on constitutional matters. As well as acting for societies,
including Co-operatives United Kingdom, I work with the wider
mutual sector, particularly through Mutuo, developing new alternative
structures for community ownership and mutual ownership, particularly
in public services, social housing, child care. We have also worked
in the utility sector ,and we designed the constitution for Supporters
Direct.
266. Thank you very much. Can I begin by asking
you a question about the governance element of foundation trusts.
I think there is a feeling among a number of parliamentary colleagues
who have reservations about the wider impact of the freedoms being
offered to foundation trusts. The governance element was introduced,
in a sense, as an afterthought, and some would say as a sweetener,
in respect of opponents of the wider principles. I was interested
to see from this week's Co-op News, which I read avidly,
an article by the previous Secretary of State for Health in which
he says, "Supporters of the co-operative principle should
be aware of being used as a human shield for a bad, unpopular
idea". Dame Pauline, are you being used as a human shield? (Dame
Pauline Green) Certainly not. There is no greater treasure
for the co-operative movement than to be party to and help to
support community engagement in public services. Community engagement
is where we come from, it is our genesis and we think that if
this is the Government's proposal, and it is, and if they are
going to go forward with this, and it appears they are, then we
have 160 years of cumulated experience and in-depth knowledge,
particularly on governance issues. My organisation, as I have
already says, looks after good governance across the co-operative
movement, then we think we have something to add and to give and
to offer to this debate. Governance and membership participation
and the empowerment of people and engagement with people is a
critical part of this proposal. Listening to your earlier witnesses
I can tell you that we have some very good researched evidence
from the co-operative movement in Italy and Japan that where you
have that community engagement in the health care provision it
actually leads to a better, healthy locality and to lower morbidity
rates. We think there is very good evidence and experience within
the co-op movement.
267. With the greatest respect to your aims
and objectives I am sure many of you round this table feel that
you are effectively being used in the context of the foundation
trusts? (Dame Pauline Green) I think clearly we need
to see that if this is going to be a mutual foundation trust then
it needs to encapsulate and incorporate all of the best elements
of mutuality. Clearly that is an issue that we have a strong,
vested interest in. If it does not work properly and work as we
believe mutual should and indeed according to the principles for
us of international co-operation, and it is very clear in terms
of democracy and participation and open and voluntary membership,
if it does not work on that basis there would be concerns.We have
a vested interest in making sure that it does because if there
is a problem with it then we would feel that cold draught as part
of a mutual sector. We can recognise the concerns that we believe
that we have something to offer to make sure that those can be
mitigated.
268. Do you not think there is something a little
divisive between on the one hand the freedoms, which certainly
for some of us smack very much of the internal market and competition,
and on the other the mutuality co-operation ethos that is being
put forward on the governance side? Divisive is the wrong word,
contradictory. (Dame Pauline Green) I do not think
so. The essence of the proposal and where we would see our contribution
is to engage with the community to make sure their priorities
and their concerns are taken into account in establishing priorities
for a particular institution. That is clearly an extension of
their rights, their involvement and their engagement in it. For
us that goes for staff, users, community groups, local authorities,
across the range. I think that it is that balance of community
interest that is critical to getting the priorities for the institution
right. I can understand where you are coming from but we think
that that is a non-sequitur, it does not follow that will be the
issue.
Julia Drown
269. The proposals at the moment are both together
and the worry is that allowing just some trusts to have a different
call on capital gives them a first call on capital. In the co-operative
movement you might feel, fine, if you were just responsible for
the people and the health care round that trust but is there not
an issue there that it is not a co-operative thought, policy or
principle to allow one section of a population to have access
to financial resources that another does not? Is that not where
you could be being pulled in to support a proposal that is not
a co-operative proposal? (Dame Pauline Green) Well,
once again if it is going to be extended, if it is going to be
that sort, we would hope that it is going to spread across the
piece, as it were, but obviously you have to start somewhere.
270. And you are happy starting with the three-star
trusts? (Dame Pauline Green) Well, I think we recognise,
I certainly do, the comments made by the earlier witnesses that
you do have to start somewhere and it is probably as wise to start
with those that are performing well and which have the capacity,
therefore, to perhaps develop the innovation that is needed and
to deal with the in-depth participation. If you are going to bring
community groups into active participation and engagement with
the hospital and with the structure of the trust, what you have
to do is spend a lot of time and a lot of energy in working with
local people, in developing the community structures that empower
all sections of the community, and that is a question which was
raised earlier. That is a big effort and if you have a hospital
that is still working on its care standards, and they always all
have to, but if they obviously have been perceived to have some
weaknesses, I think it is probably appropriate to start with the
ones that are perceived to be working the best. I accept as you
do that it is not ideal, but I gather it is the intention to move
to all of them in time.
271. That is still not clear. Would you prefer
for it to be looked at on a geographical basis? (Dame Pauline
Green) I think it is right that the best-performing hospitals
actually act, if you like, as a pilot for the remainder.
272. So you think there is the potential that
this might not work, that the mutual model will only work with
those sort of similar, successful trusts? (Dame Pauline
Green) Not at all. I think what is happening actually is that
if it is going to go with a group to start with, that is actually
probably quite sensible because, as we know, things develop and
good practice is always a matter of progression and evolution
and I think we would want to see that happening. Once again I
think it is best if those hospitals which are performing best
are enabled and empowered to begin the process with the others
still working on their healthcare facilities, working on that
with the intention of moving along that line later.
273. The issue of more patient involvement,
more community empowerment is a bit like freedom in that it sounds
great and nobody would oppose it, but how would this link to the
ownership issue and do you really believe that people do not feel
like they own their local hospital and will this filling a form
really mean they will somehow get to feel more involved than,
for example, if the patient forms are developed across the country? (Dame
Pauline Green) Well, I think the fact is that people now feel
they have paid for their hospitals, but I do not know that they
feel that they own them. I think what is being suggested and where
we come into this debate is that we have long experience of active
engagement with people in sometimes very, very major organisations.
274. And do people need to own that? They need
the piece of paper saying, "I have got my £1 liability"
if it goes over? Do they need that in order to be engaged? (Dame
Pauline Green) Well, it is not just having a bit of paper
that says you are the owner, but it is actually engaging. It is
actually having the facilities—
275. Can you not engage if you do not have ownership? (Dame
Pauline Green) Well, at the present moment I think it is very
limited and we are not just talking about putting people on the
board of governors. As far as I am concerned and as far as the
co-operative movement would be concerned, it is actually about
working up the active participation on the ground. That is quite
different from anything else.
276. And you only work up that active participation
on the ground if you own it? (Dame Pauline Green) I
think ownership is a very important issue and I think people do
not feel a sense of ownership. I think they feel a sense that
they are paying for the service, but they are not actually having
a real say in how it is run and how it works.
Dr Naysmith
277. It is an interesting point there that people,
even if they are not members of the group that is running the
hospital, they still own it because they are still paying taxes
and they are still citizens, so how does that work out? Why should
one group of citizens get more benefit than another group just
because they sign a form? (Dame Pauline Green) Well,
you know as a good co-operator the principles of co-operation,
open and voluntary membership, and I do not think you force people
to take part, but you encourage them and you actively try to work
up the participation and that is certainly where our experience
takes us. We have got through in over 160 years the ups and downs,
so we know how to do it and how not to do it because obviously
in 160 years you have cycles in your success and dynamism and
clearly we have gone through that, so I think there are ways,
very clear ways in which we have got experience and evidence of
what works in activating local participation and what does not. (Mr
Mills) The comment was made that we already own it, which
is true in the sense that as citizens and taxpayers it belongs
to through the State, but the ownership is somewhat remote if
our only ability to have any influence is via a general election.
If we have an ability to take part on a much more local basis,
if we can attend meetings locally, receive information about our
own organisation, express our views, nominate people and elect
people, all these things can help to create a greater participation
and involvement. Certainly working in other sectors which I have
been involved with, the idea of the need to own a share and feel
that it is an organisation in which you are included is important
psychologically. The obvious example is in social housing where
tenants who are in houses which are owned by a remote housing
association do not feel that they own them or that they are their
houses, but that they are somebody else's. By moving to an organisation
in which they can be a member, a shareholder, it is closer and
they can have a direct participation.
Jim Dowd
278. But where mutuals and co-operatives are
most effective is clearly where they have got people engaged in
active membership and there is a direct link between the benefits
of the co-operative and mutuality and those involved in it. That
will not be the case in foundation hospitals. A layer of people,
I suspect wholly unrepresentative, will occupy the position you
have outlined, but the vast majority of people will not and yet
the vast majority of the rest of the population will still have
an interest in the services provided by that hospital. (Mr
Mills) I think the answer to that comes down to how you design
the structure and the constitution of the organisation. If you
simply rely on a self-selecting system, then yes. The models we
have designed do not do that. They positively impose an obligation
on the board or the governors, in this case, actively to develop
the membership to engage people, to identify the relevant geographic
communities or particular groups of people that are important
and may be excluded or left out and to develop ways of engaging
them and establishing their aspirations and needs and then working
out how to meet those aspirations and needs and positively writing
into the constitution a requirement that at the annual meeting
the board must report back to the membership at large what they
have done in identifying those groups, in identifying their aspirations
and seeing if they can meet them. I think that the modern models
which are being developed are precisely aimed at meeting what
would otherwise be a problem, I would agree.
279. Is that not the role of the PCT because
they are there to provide a comprehensive range of services for
the whole population in their area. The acute sector is still
further. Why should it just apply to hospitals and not any other
activity across the healthcare field other than the fact that
simply you are reinforcing an institution? (Mr Mills)
I am of the general view that has been expressed by a number of
people that this is an approach which could be adopted much more
widely and that if you set out with the idea of doing it altogether,
that would be great, but there are certain practical problems
with that. Although I agree that in a way foundation hospitals
are, if you like, more like secondary providers or federal organisations
which are supplying services to primary care trusts, as we know
from the earlier witnesses, a number of them or all of them are
significantly involved with their local communities and if there
is an accident and emergency unit or a labour ward, if there are
services which are being used directly by the communities, then
I would not go so far as to say that it is inappropriate for them
to go into direct community ownership because there are a lot
of people working there and there are a lot of people using that
facility.
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