Examination of Witnesses (Questions 380-399)
TUESDAY 4 MARCH 2003
RT HON
ALAN MILBURN
MP AND MR
ANDY MCKEON
380. You have established a Commission for Patient
and Public Involvement in Health. Their view is very clearly that
your exemption for the requirement to have that forum will be
a serious threat to the integrity of the new system for involving
the public.
(Mr Milburn) I do not see how people can argue with
that.
381. This is the commission you have established.
(Mr Milburn) I cannot speak for the commission because
it is an independent organisation. My views are that the public
are going to get an opportunity. The public has never been able
to have in your constituency and in mine the opportunity to choose
to become members of the local NHS foundation trust with the right
of directly electing themselves or their fellows to a governing
position. The public will be at the heart of it.
382. Not a self-selecting group.
(Mr Milburn) Not an election. I think elections tend
not to be self-selecting as some of us sometimes have found. The
people out there will be doing the electing. It will be the public
who will be deciding who is on the governing body. Just one further
safeguard to be slightly more consensual as far as the commission's
position is concerned which is this, even if an NHS foundation
trust decides that it does not want to have its own patient forum—and
it may well decide that, I do not know, that will be a matter
for them—nonetheless, there will still be obligations, for
example, to the local PCT patient forum. The local PCT patient
forum will have a wide remit, we went through all of this in the
committee on the Bill, on the Floor of the House, the Chairman
put down amendments and so did others, we had a long discussion
about how best this will work and if there are patients that the
PCT is referring to the local hospital then the local PCT patient
forum will continue to have the right to assess and inspect the
services that are being provided to those patients.
Chairman
383. We spent a lot of parliamentary time looking
at the governance issue. We have established the NHS Appointments
Commission, the Commission for Patient and Public Involvement,
as Mr Austin has mentioned, the patients' forum. Some of us throughout
this period have argued for democratic models of governance. Are
you saying in a sense that you are accepting that argument?
(Mr Milburn) Yes.
384. So the principle is established then?
(Mr Milburn) The principle is established.
385. So in a sense these are temporary measures,
the ones that we have voted on recently?
(Mr Milburn) On patient forums?
386. Yes.
(Mr Milburn) I think it would be for the individual
patient trust to decide. It may well be that they will value having
a second opinion, but they will have a very important first opinion
which will come from the body drawn from both the patients and
the public. I accept your first point absolutely, that democratisation
of the health service, which many of us have been concerned about
for very many years, and the democratic gulf between local communities
and local health services is something that we have got to bridge
because otherwise I do not think we are going to get services
that are going to be terribly responsive.
Sandra Gidley
387. There has been a lot of talk about the
public electing the governing body. You said earlier that it is
very difficult to say who the stakeholders are for any particular
hospital. I am at a loss to understand how you are going to bring
forward a system in which everybody, for example, in my local
hospital, Southampton General, will have a say and not just the
people who live in the Southampton area. You mentioned the Moorfields
hospital earlier and that does not have an actual community. Who
decides for a hospital like that? It sounds very good to talk
the talk, but how are you going to make it work in practice?
(Mr Milburn) I think the guide sets that out and presumably
you have read it, which is it is true, Richard made the point
earlier, Moorfields and Marsden are in a different position from
my local hospital. My local hospital serves the people in the
local areas and yours may too, I cannot speak for it. Moorfields
and Marsden serve a national constituency, people go there from
all over the country and in some cases from all over the world
and in the case of the Marsden, it is a very very fine institution
indeed. If I try to lay down hard and fast guidelines and said
this has got to be the constituency, I am afraid we are back to
the lowest common denominator approach that simply will not capture
the fact that different hospitals are in different positions.
That is why in the guide we said that there are basically some
ground rules but individual foundation trusts will have to make
some decisions about how best they think the governance will work.
In the case of a tertiary centre like the Marsden or some of the
orthopaedic centres that we have or the cardio-thoracic centre
in the north-west, their constituency as such is not really the
local community because by and large they are not providing services
to it, they are largely providing services to people throughout
the country. So their constituency is their patients and the best
way of securing public involvement in their governing structure
is through the patients' constituency.
388. But you are not having a patient forum.
(Mr Milburn) The patient forum, with respect, is a
committee. Okay, I know we are all terribly fixated with committees
in here and we think the best way of organising democracy is to
establish yet another committee. I believe in the democratic principle,
we all agree with it. We all think local authorities are very
fine organisations and we accept diversity when it comes to local
authority provision. I am prepared to see people elected to represent
the oversight of particular local authority services, bins, leisure
centres, all of these things, but we find it difficult to accept
that for the health service and I do not understand why.
389. At least we can define the local authority.
This is much more difficult.
(Mr Milburn) Yes, it is difficult, absolutely, democracy
is a difficult thing, but that is precisely why there are no hard
and fast constituency boundaries that we lay down. However, the
rules are very very simple in the end, that is for most organisations—and
tertiary centres are quite different and there are only a handful
of them in any case—it is extremely straightforward and
that is that if there is a facility provided by an NHS trust in
a local authority area the people in that local authority area
as a minimum have the right to become members of the foundation
trust. It may well be that the foundation trust itself will decide
that there are people from outside the local authority area in
which its hospitals are based that it wants to grant a mandate
to, in which case that is fine. So those people plus the patients
who have used the hospital over the course of the last three years
are the democratic constituency from which the members will be
drawn and the members will then elect the hospital governors.
As you will know because you will have read the guide, there are
two further groups on the governing body. The first are the people
elected by the staff. Why? Because every piece of evidence, whether
it is from the public sector or the private sector, for any organisation
in the world tells you one thing, that if you are going to get
improvement in services, then you have got to engage and involve
members of staff. When I go and talk, and you must find exactly
the same thing, in the Health Service, they have an absolute desire
to be involved and to try to improve their services and actually
they are terribly frustrated that they do not have a seat at the
table and are always being told what to do. Now, if you can involve
them, I think there is a very good chance that you can get improvements
in services, notwithstanding the dilemmas that Andy Burnham raised,
which is that once you bring people in, then they have a say.
Sometimes it is difficult because there will be tensions, but
I think in the end it is far better to bring people inside the
tent and engage them with the dilemmas that NHS hospital managers
have to deal with every single day than simply keeping them outside
because the consequence of that is what we had for decades where
local communities do feel divorced, sadly, from their local hospitals
and their local health services, and the final constituency of
course are the local primary care trusts. Now, we are flexible,
as the guide says. If, for example, the foundation trust decides
that it wants to co-opt people from local social services, it
will get a thumbs-up from me. That is fine. I think that will
be a great thing. If it wants to have people represented from
the local universities if it is a teaching hospital, that is absolutely
fine, but in the end the local hospital provides the local service
to the local community and, in my view, it is the local community
that should have the say over how the hospital is run. It should
be the local community that does that and the best way of doing
that, the best means by which we translate that thought from theory
into practice is through the democratic principle of people being
elected.
John Austin
390. Would the primary care trust not be the
point to start?
(Mr Milburn) That may well happen in time, John, but
I tell you, I think the most destabilising thing right now—
Mr Burns
391. Can I move on then to your experience of
your investigations of what happens in certain European countries
which you have given us an annex for. Beforehand, I just wanted
to relate that to the English experience because you have spoken
on many occasions and during the course of the last hour on the
benefits of foundation trusts, foundation status and the whole
concept for the Health Service. Given your enthusiasm for what
you perceive as benefits, could you explain why almost a quarter
of the Parliamentary Labour Party have signed a motion disagreeing
with you?
(Mr Milburn) Well, I did not really sign it—
392. No, I know you did not.
(Mr Milburn)—so it is not really for me to say,
is it? You would not expect me to either.
393. Why do you think that such a significant—
(Mr Milburn) Frankly that is the best piece of news
I have had all morning.
394. Why do you think that such a significant
part of your Party do not support your proposal?
(Mr Milburn) Because I think there are some concerns,
as I said earlier to the Chairman. I think the fundamental concern,
and there will be a variety of concerns about any new policy,
particularly when it marks a break from the past, as I think this
does, but the principal concern that constituency MPs will have,
and they will not just be Labour MPs, but they will be people
across the piece, they will worry that somehow or other their
local hospital which they are very attached to for perfectly good
reasons, we all are, we are all involved in one way, shape or
form with our local hospital, is somehow going to be at a disadvantage.
What I am saying to you is that that is not the policy, that is
not the policy of the Government. The policy of the Government
is extremely straightforward. We want to see—
395. You are—
(Mr Milburn) Let me finish it for the record because
you have asked me a question and I am determined to give you an
answer.
396. You are not really answering the question;
you are giving the Government's policy.
(Mr Milburn) No, I am answering the question by telling
you what the Government's policy is as distinct from what you
might read about occasionally and it is always better, I find,
to hear it from the horse's mouth. Do you not? That is presumably
why I am here.
397. Well, not if it is done by you sometimes.
(Mr Milburn) Because otherwise you could get one of
the newspapers to sit here and no doubt they could tell you what
they thought I thought, but in the end it is probably far better
that you ask me.
398. Okay. Well, can I ask the next question
then because we are losing time.
(Mr Milburn) No, you cannot because I have not finished
on the last one yet. The Government's policy is extremely straightforward,
and that is that we want to see NHS foundation trust policy, we
want to see NHS foundation trust status available as an opportunity
to every NHS hospital and, providing we get the right policies
in place to raise standards and make improvements happen, there
is absolutely no reason, within a four or five-year period, why
every NHS trust should not be an NHS foundation trust. That is
the Government's policy.
399. I am glad you gave me the Government's
policy. What is the Chancellor of the Exchequer's policy on it?
(Mr Milburn) The same; it is the Government's policy.
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