Examination of Witnesses (Questions 60
MONDAY 12 MAY 2003
Q60 Mr Gibb: Compared with the best
private sector hospitals there is scope for improvement of about
Sir Nigel Crisp: I have no doubt
there is scope for improvement, and that is what we are trying
to do with the NHS.
Q61 Mr Gibb: What would you say the
productivity gap is if it is not 20%?
Sir Nigel Crisp: The private sector
in general in health care does not do the same things as we do,
so it is difficult to compare.
Q62 Mr Gibb: The average within the
health service is how much worse than the best within the health
Sir Nigel Crisp: I think these
global figures do not make a lot of sense. On particular procedures,
and let me take one, which is the productivity in day surgery,
we know that the best performers here are over 75% and we know
the spread goes down to 60%, that is the gap on day surgery. I
think you have to take processes that are tiring and look at how
you can increase productively or the use of public money. I do
not think there is a particular gap.
Q63 Mr Gibb: That is what certain
health sectors are saying.
Sir Nigel Crisp: Some. I think
others may say different things.
Q64 Mr Gibb: This is a kind of snapshot
example of one particular area that does seem to be going particularly
well. Could you say why you have two titles, why are you Chief
Executive of the NHS and the Permanent Secretary? Why do you have
Sir Nigel Crisp: There were originally
two jobs, one is I am head of the Department and the other is
I am head of the NHS.
Q65 Mr Gibb: How does head of the
NHS work? In what way are you Chief Executive of the NHS?
Sir Nigel Crisp: I am happy to
explain it, Mr Chairman.
Q66 Mr Gibb: I am trying to understand
how Sir Nigel Crisp, who is before us, is exercising his duty
as manager of the NHS with regard to this particular area of health
Sir Nigel Crisp: If you would
like me to go through my accountables I am more than happy to
Q67 Mr Gibb: The answers could be
Sir Nigel Crisp: The people in
the NHS are accountable managerially to me for the performance
of their organisations.
Q68 Mr Gibb: The local manager of
an NHS trust would be accountable via another manager to you,
Sir Nigel Crisp: In general, yes.
Q69 Mr Gibb: What does that mean?
Sir Nigel Crisp: Because there
is a chair and a chief executive of a local trust it is a little
bit more complex.
Q70 Mr Gibb: That is why I am asking
why you are here answering about this when I thought the people
that are running these trusts were not accountable to you, they
were accountable to the NHS, the local boards, the 600 boards,
but not to you?
Sir Nigel Crisp: Both the chair
and the chief executive are accountable at the time this Report
was written to local regional directors, who are in turn accountable
to me. There is a clear line of responsibility.
Q71 Mr Gibb: Who is accountable to
Sir Nigel Crisp: The regional
director. The people who are accountable to the regional director
are the chairs and chief executives of the various organisations
Q72 Mr Gibb: They are not accountable
to the local board?
Sir Nigel Crisp: The chairman
and the chief executive of the local organisation are accountable
to me for the performance of their organisation, through me to
the Secretary of State.
Q73 Mr Gibb: The local people have
no say then in terms of the way the hospitals and the trusts are
Sir Nigel Crisp: That is not true.
I do not know what point is being made here.
Q74 Mr Gibb: I am finding out information.
Sir Nigel Crisp: Would it be helpful
if we sent you a note?
Mr Gibb: No, it would not really, I would
quite like to spend my time the way I would like to spend it subject
to the Chairman's rules.
Q75 Chairman: If you can help please
do. Mr Gibb is perfectly entitled to ask you, I will try and elucidate
what he is asking, if for instance a nurse slips on a vinyl floor
and a very large sum of compensation is rewarded it is of some
interest to this Committee to know what the line of responsibility
is, is it the board which is responsible both for the nurse slipping
in the first place and the large sum of money, is it the regional
director or is it ultimately you? That is a perfectly justifiable
Sir Nigel Crisp: In that precise
consequence it is the responsibility of the trust to actually
handle compensation issues and to deal with their employee. It
is my responsibility through the regional director to hold the
trust to account for its overall performance, which may include
how it has handled that particular case, but in general it probably
Q76 Mr Gibb: If are you not happy
with that particular instance what can you do about it?
Sir Nigel Crisp: We can take it
up with the regional director and we can take it up with the chairman
and the chief executive. What we can do, as we have done in response
to other advice from this Committee, is issue guidance to the
NHS on what they should do and on occasion to issue direction.
Q77 Mr Gibb: This is my concern,
I think you manage like that. If you look to page 44, Appendix
2, here is a list of things you have done in managing the NHS
through this very centralised pyramid structure, you direct the
regional directors, they direct the NHS chief executives but what
you seem to be doing is in 1995 you issue guidance, in June '97
recommendations, in November '97 guidance for managers, in April
'98 guidance, in March '98 guidance for managers, in April 1998
targets, in October 1999 targets. The way you manage this is very
unusual in terms of the way large, private sector organisations
run things. You manage guidance, which you seem to issue every
few weeks, and recommendations and targets but you do not seem
Sir Nigel Crisp: This is a very
much a snapshot, this is a list of guidance pulled together, this
is not the only thing we do.
Q78 Mr Gibb: Tell me some of the
things that does involve?
Sir Nigel Crisp: We are involved
in making appointments. We have done a lot of thinking about what
you need to do centrally when running a very large organisation,
you need to keep your hands on a number of things, which includes
major investments. We make decisions about major investments,
major appointments, we make decisions about the organisation's
structure and we hold people to account against their key targets
Q79 Mr Gibb: Targets?
Sir Nigel Crisp: Not against every
detail. You shown me a large organisation that does not have targets?