Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 60 - 79)

MONDAY 12 MAY 2003


  Q60  Mr Gibb: Compared with the best private sector hospitals there is scope for improvement of about 20%.

  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 service?

  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 two titles?

  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 and safety?

  Sir Nigel Crisp: If you would like me to go through my accountables I am more than happy to do so.

  Q67  Mr Gibb: The answers could be short.

  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, would he?

  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 you?

  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 run?

  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 question.

  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 would not.

  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 to manage?

  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?

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