Examination of Witnesses (Questions 60-79)
20 MAY 2004
RT HON
JOHN HUTTON
MP, MR JOHN
BACON, MS
ANN STEPHENSON
AND MR
GORDON HEXTALL
CB
Q60 John Austin: Yes, but to represent
the interests of patients. Is it not right that patients should
know who the representatives are?
Mr Hutton: Yes, but let us be
clear. We are not talking about people who have been elected in
a public electoral system who then discharge important responsibilities
and statutory functions which this House has decided. We may not
be comparing like with like. I agree with you, my very strong
impulse in all of these things is that this information should
be public. There may be some issue around the Data Protection
Act; I am not familiar with the Data Protection Act.
Q61 Chairman: Would you be willing to
look at this one?
Mr Hutton: Yes.
Q62 Chairman: Community Health Council
members were publicly known and I think John Austin has raised
a very important point. I should be grateful if you would have
a look at that.
Mr Hutton: I shall certainly look
at that issue and come back to you, but I have expressed a view
about that.
Q63 Jim Dowd: Back to the constituencies
of foundation trusts. To what degree do the trusts' applicants
dictate their own constituency? I was thinking in particular of
my experience in South East London when King's and St Thomas's
and Guy's were pursuing theirs. They essentially divvied it up:
King's restricted themselves to Lambeth, Guy's and St Thomas's
restricted themselves to Southwark and a number of my constituents
use both but were not actually included in the process. I think
it was Alan who said they were looking at a four- to five-year
programme for all trusts to achieve foundation status. What work
are you undertaking to achieve that? Is that still the objective?
Mr Hutton: Yes, it is. I shall
come back to that in a second, but in relation to the first part
of your question, ultimately the constitutional arrangements,
including where the constituency maps and boundaries are drawn,
are part of the application process and the approval process for
the office of the independent regulator. He has to be satisfied
about that. There is a difference in the public constituency between
patients and residents. It may well be the case in relation to
your constituents that they might not qualify under the residence-based
constituency boundaries for Guy's and St Thomas's, but might well
qualify if they have used Guy's and St Thomas's as a patient.
They will obviously be eligible through that route. They will
have a say in the management of that new foundation trust. Essentially
this is a local issue. It is dealt with by the regulator ultimately
who has to sign off the arrangements for the constitution. In
relation to the wider roll-out of NHS foundation trusts, it is
our ambition to ensure that every acute trust, every mental health
trust has the opportunity of becoming an NHS foundation trust
over the next four- or five-year period, yes. We are looking forward
to a very substantial wave 1A round with another 36 trusts in
the frame, depending obviously on the result of the decisions
the regulator makes in relation to the second batch of wave one
applicants. We could be looking at 60 NHS foundation trusts from
the first batch and that is a very substantial tranche of acute
trusts going through that process; maybe one third. We have some
very important policy decisions to make in relation to how we
would get to the wider goal of every NHS being in a position to
apply for foundation trust status; probably the most important
decision we will need to make in that regard is whether we retain
the three-star rating requirement, which currently is the passport
into NHS foundation trust status. Those are decisions which ministers
and the Secretary of State have to make at some point in the near
future, as to whether we maintain that as a requirement or whether
there should not be another set of criteria which we would use.
That decision has not been made yet.
Q64 Mr Amess: The minister has not asked
for my assistance in explaining the Basildon and Thurrock turnout,
but I am going to respond, simply to say that in my time as the
Member of Parliament the hospital was always very popular, very
few complaints about it. I think that built-in apathy is a factor.
I do think the fact that anyone over the age of 12 living in Essex
can become a member is something, considering that Simon and I
are both Essex Members, we shall have to look at and we shall
take your advice and talk to the regulator about how this came
about. It does seem absolutely crackers to me that this is possible.
Moving on. Royal Devon and Exeter hospitals achieved a 56% turnout
with about 9,000 people engaging in this process. They feel that
to make the situation really accountable and meaningful they are
suggesting that they should have a membership of between 30,000
and 40,000. In the first wave of foundation trusts the membership
seems to be about 2,000. Is this something which worries you?
Do you think this is a realistic aim, to get 30,000 to 40,000
members? How does the department think it might be achieved?
Mr Hutton: It is very difficult
to say. In relation to individual NHS foundation trusts, they
are best placed to form a view about what their potential membership
is likely to be. They will know their local community much better
than I do. If that is the objective of Devon and Exeter, that
is a fantastic objective to have set for themselves because that
really would be a significant public engagement. We have set the
foundation trusts up to provide a vehicle to achieve that. Whether
it is achievable or not will depend on the effort and contributions
which are put into that at a local level. They have set themselves
a fantastically worthy objective and I wish them every success
in doing that.
Q65 Mr Amess: We all want to see much
more involvement but this is the broader issue of participation
generally. Is the department able to put in any extra resources
to try to encourage more participation at a local level or is
it something we just cannot afford to do at the moment, given
the constraints?
Mr Hutton: Some effort is going
into this through the Commission for Patient and Public Involvement
and other agencies and it is a very important objective, not just
for foundation trusts but for primary care trusts as well to be
involved in this wider effort of securing maximum public engagement
in the affairs of the NHS. We have provided some additional resources
for the first wave of NHS foundation trusts; they all got about
£250,000 each to help them with the preparations and plans
for foundation trust status. We are not providing any further
financial assistance directly to the first wave of NHS foundation
trusts for that purpose, but we need to continue to keep this
whole area under review. The policy is partly designed, one of
its principal pillars, for more active local engagement and where
there is a NHS foundation trust which is willing to push the barriers,
to go as far as they can on that and have active community-wide
recruitment and training for membership, that is a fantastic thing
and that will reinvigorate support for public services not undermine
them.
Q66 Mr Amess: The other point I wanted
to touch on was payment by result. Basildon and Thurrock already
have foundation status; they are very, very pleased about it.
Southend has now applied; I am supporting their application, given
that this is an area you know extremely well, although it is not
your decision, to me it would make a nonsense if they did not
also get status for obvious reasons. I really wanted to touch
on the core argument, the crux of the argument about foundation
status, because the reputation of a hospital is all-important.
It is very likely that once a hospital acquires foundation status,
that is going to be the green light as the place to go, they are
going to be the premier hospital. Are you in any way anxious that
will have an adverse effect on other hospitals in the area? Do
you think that will impact on the workforce and on resources generally?
Even though the government's aspiration is eventually, I assume,
for everyone to achieve foundation status, there is going to be
a huge gap between that happening and, as we are all on life's
journey and we all want help now, it is going to be a bit tough
if you are in the area which is suffering as a result of a particular
hospital getting the green light and attracting everyone, more
money, more staff, etcetera, yet your local hospital is not going
to be able to offer such a good service.
Mr Hutton: Am I concerned about
it? Yes, obviously. Anyone who occupied my job would be. There
are two basic flaws, if I might suggest, in the premise there
that it is only foundation trust status which suddenly acts as
this magnet for people to come and work there. Remember; at the
moment of being in a position where you can apply you have already
established your credibility as an excellent and outstanding institution
and people will know that. The reality across the NHS now is that
in our own constituencies and various parts of Britain we know
that there are very substantial competition and pull factors based
precisely around these sorts of issues and that has always been
so in the NHS. My own view is that foundation trust status is
not going to affect that issue per se. It is something
we obviously have to keep very carefully under review. The whole
point and purpose of NHS foundation trusts is to improve the quality
of care we provide to our patients. It is not to undermine the
quality and care that the NHS provides. We want to make absolutely
sure that is not what happens. Remember; there are a few other
basic assumptions here which we need to be clear about. Agenda
for Change is going to apply in all of the NHS foundation trusts.
That is a very important guarantor of stability and continuity
around workforce and human resource issues. I do not want to see
unfair competition for staff; that would be damaging to the NHS.
However, in the NHS workforce and in the NHS as we know it there
is always going to be competition for qualified staff. That per
se is not a bad thing; in fact it is a healthy thing. What
we have to make sure is that we do not lose sight of our overall
objective, which is to improve the quality of care in every NHS
trust, whether it is a foundation trust or not. That is why there
are additional resources going into the hospital improvement programme,
to make sure that we improve the quality of care everywhere in
the NHS and not just in the NHS foundation trusts. At the end
of the day, we all talk to staff in the NHS and one of the things
which is very clear is that there is very strong loyalty to one's
own hospital and one's own trust and that is a very admirable
and important thing we should try to preserve. There is also a
very strong sense of achievement and result for staff when they
see the quality of care they are providing improving and it is
improving. In my humble view those are probably the more important
issues for NHS staff in deciding where they want to work than
whether their trust is a foundation trust or not. There will be
common terms and conditions across the NHS. That is absolutely
taken as read. It is issues to do with quality, reward and loyalty
which determine ultimately where people work in the NHS. I personally
do not believe that it will depend on whether they are working
for an NHS foundation trust or not.
Q67 Mr Amess: I should just like to take
you up on one important point which you made about keeping the
effect under review. This is not directed towards you, but health
ministers do come and go. It does occur to me that even though
you have held the position for a long time, there will be another
minister in place later. Given that there are all sorts of arguments
about how Parliament is allowed to scrutinise these matters, I
hope that it is not going to be the case that we are going to
have endless adjournment debates when individual members start
complaining because things are happening in their area regarding
their hospitals. Is there built into all this any mechanism whereby
there will be after a period an annual statement to Parliament?
Will there be an opportunity for us to scrutinise the real effect
on the health economy with disclosures? I know this is a very
complicated area and this is at the embryonic stage, but it does
worry me how Members of Parliament will be able to scrutinise
the real effects of how the policy is working in practice.
Mr Hutton: Members of Parliament
will be able to scrutinise the Secretary of State in the normal
way through debates and questions. The office of the independent
regulator will produce an annual report to Parliament which can
be the subject of parliamentary debate. The office of the independent
regulator is subject to the jurisdiction of this Select Committee,
so I am sure the Select Committee will want to question Bill Moyes
(Chairman of the Office of the Independent Regulator) at some
time about how he is setting about his job. It is actually very
important in the context of all this to accept that in setting
up the office of the independent regulator, we tried to strengthen
parliamentary accountability and not weaken it. The regulator
is accountable to this House, not to me and not to the Secretary
of State. I think there are opportunities there for the sort of
scrutiny you have suggested would be right and proper and we have
to reflect that in the legislation itself.
Q68 Mr Bradley: Going back to electorates,
I have raised in the past and you have used the term on a number
of occasions "the local community", where there is a
specialist hospital such as Christie's in Manchester which serves
not only the North West but the whole of the country. In a previous
Parliamentary Answer you said to me that the electorate is likely
to be, and I accept the regulator has the ultimate responsibility,
anyone who has been treated at the hospital in the last five years
or their relatives wherever they are now in this country or in
the world. Do you still feel that is an appropriate electorate
for a specialist hospital like that, or do you have any views
about how that might be limited, if for no other reason than just
the pure bureaucracy of setting up a register of that sort of
magnitude.
Mr Hutton: I am not sure that
the reference to having been treated within the last five years
is actually in the legislation. I would need to check that. I
think that is simply an indicative feel about that. That is broadly
where we should be in all of this. The specialist hospitals like
Moorfields, like Christie's are in a unique position, Royal Marsden
and others. That is very much how they have set about their definition
of membership: to focus on the patient constituency as the important
electorate. That is the sensible course for them to follow. I
hope all of these issues in relation to Christie's or others can
be agreed and settled locally as to what the proper parameters
for the electorate should be and ultimately the regulator has
to cast the final eye on whether the arrangements are robust enough.
We have to do it right, minimise bureaucracy, not undermine the
principle. One of the principal objectives is to widen the democratic
input into the NHS and the specialist hospitals are in a unique
position, a uniquely difficult position.
Q69 Dr Taylor: Going back to the question
of review, my memory is that one of the hard-won concessions from
the Secretary of State himself was that there would be an independent
review after the first wave. We were all confused, because in
fact he lumped together first and second waves and called them
1A and 1B. You have implied that all will be foundation trusts
in four to five years. Are we going to wait for this review which
was promised after waves 1A and 1B?
Mr Hutton: Yes, the Secretary
of State will not be referring any applications to the regulator
from the autumn of this year to the autumn of next year.
Q70 Dr Taylor: I thought this was more
a review of the function of the whole system.
Mr Hutton: Yes, and during that
period the Health Care Commission will be carrying out a review
of the arrangements in relation to NHS foundation trusts, under
section 54, I think, of the legislation.
Q71 Dr Taylor: So it is the Health Care
Commission which will do it.
Mr Hutton: Yes.
Q72 Dr Taylor: The government will wait
for the result of that before going on to waves three, four and
five or whatever.
Mr Hutton: Yes.
Q73 Chairman: One assumes that the Commission
will be charged with looking at the impact on the wider health
economy and not just the direct specifics.
Mr Hutton: Yes; yes.
Q74 Chairman: It is going to be a wider
look at the whole issue.
Mr Hutton: Yes, it has to.
Chairman: We have done an hour on foundation
trusts and we have to move on sadly. Siobhain wants to lead in
on reconfiguration of services.
Q75 Siobhain McDonagh: I have become
increasingly concerned and I am pleased it has come after foundation
hospitals, because, as I have said before, I hope the foundation
hospitals will give the opportunity for people in my constituency
to be represented on the local hospital board, because the systems
which exist at the moment do not allow them to be. It is looking
at reconfiguration which I imagine will gather speed all around
the country with the European directive on junior doctors' working
hours and with pushes from the Royal College. In my own area,
Epsom and St Helier are looking at changing where the acute hospital
is. To my alarm, I discovered that even though those areas are
very contrasting, as you probably know, they are not required
to take any notice of the fact that two thirds of the patients
of that trust actually live around the St Helier estate, that
that is the area of greatest ill health, that the local population
relies on it for skill level, for employment, that it has the
best transport links, that the ethnic communities in the area
live around the hospital currently, that the A&E and maternity
services, if they are moved, could lead to St George's having
its A&E closed because of the displacement of patients and,
on the positive side, that the Epsom end of that area has the
highest levels of private health insurance possibly in the country
and the greatest access to more hospitals in the Surrey area.
I should just like to ask what you consider are the criteria they
should consider when looking at reconfiguration?
Mr Hutton: They should look at
all of those things. It would be incomprehensible to me if, in
moving forward with some of those concerns, the local primary
care trust, which has the primary responsibility for conducting
these consultations, does not make proper reflection on all of
those facts and take them properly into account. What I am not
going to do at this time, because no decisions have been made
about any of those issues you have referred to, I am not going
to express a preference or a view about any of those issues but
we have made guidance clear to the NHS about how they should set
about handling local consultations. I am sure the Committee has
a copy of that. It is called Keeping the NHS Local. We
expect primary care trusts to pay full attention to the guidelines
around how to handle a consultation in taking a particular proposal
forward. It is very, very important. My objective as a minister
is to try to make sure at all times in all parts of the country
that there is a maximum local accessibility for NHS services.
That is a really important objective which we should set for ourselves.
Q76 Siobhain McDonagh: Would you agree
that accessibility means different things to different people
and people start at a very different point in being able to access
services? It is my concern that when we talk about health inequalities,
we often say—this is only anecdotal—the new hospitals,
the new services, tend to be in the more affluent end of catchment
areas. I appreciate that section 11 of the Health and Social Care
Act 2001 places a duty on the NHS to involve and consult patients
and the public, but how should they actually do this? Those who
are more organised, more articulate get to be the loudest and
to say most. It is your methods of consultation which will include
people or not.
Mr Hutton: Yes, I agree with that.
This is why we have taken another very long and careful look at
the whole of the arrangements for trying to involve patients in
the work of the local NHS and patients' forums are one example
of that where we have tried to strengthen the opportunities for
patients to get involved. The era of having consultations by convening
meetings in windy village halls is over. People will not go to
that. Anyone in the NHS who constructs a consultation process
around that type of assumption is not going to be consulting with
the public properly. To be fair to the NHS, we have moved away
from that perspective and that view towards consultation. We have
literally to approach this as a modern and much more effective
way and reach audiences and particularly groups in our communities
and our constituencies who historically have never ever been asked
their opinion about anything. That is a very, very important thing
which we have said to the NHS they must look at. With great respect,
there are huge amounts of activity all the time around this in
the NHS and what we have tried to do is not say to every PCT that
they have to do X, Y and Z, because that is a very, very difficult
and a wasteful thing for us to try to do. We have tried to set
out the framework and then we have the SHAs overseeing that and
ultimately we now have the overview and scrutiny committees of
local authorities which are a very important extra voice for local
communities in all of this. We are just trying to fashion a better,
more democratic process around all these consultations. Is there
a perfect way of doing it? Maybe. Have we found that yet? No.
We are working very hard to try to improve the input of local
people into decision-making across the NHS and I hope the NHS
locally will do the right thing in relation to any reconfiguration
in your constituency. Ultimately you have the opportunity as a
Member of Parliament to raise your concerns with ministers, with
the Secretary of State and directly with local NHS management.
I am pretty sure that you will not be shy in coming forward with
your views about that.
Q77 Dr Taylor: You know that I welcomed
the document Keeping the NHS Local wholeheartedly and I
have also welcomed the work you have done on the European Working
Time Directive to try to avoid down-gradings and closures in various
places. What I want to explore is the connection between overview
and scrutiny committees and the independent reconfiguration panel.
Every time we ask a minister about a local affair, the minister,
quite understandably, always says with devolution that it is nothing
to do with him, these are local decisions. Here you are going
exactly against that, because the person who decides whether the
overview and scrutiny committee can refer to the independent regulator's
panel is the Secretary of State, unless, hopefully, I am wrong
and overview and scrutiny committees can refer direct to the independent
reconfiguration panel.
Mr Hutton: No. The overview and
scrutiny committee can refer an objected reconfiguration to the
Secretary of State and then the Secretary of State can ask the
national reconfiguration panel to have a look at it. Ultimately,
in those kinds of contested issues, it is the Secretary of State
who makes the final decision. If the change is being proposed
by the PCT, it is the Secretary of State who will make the final
decision. It is sensible in those circumstances to involve the
national reconfiguration panel through the offices of the Secretary
of State.
Q78 Dr Taylor: So this really is a complete
paradox to evolution in this one really crucial issue.
Mr Hutton: To be honest, I do
not think it is a paradox, given that ultimately the buck stops
with the Secretary of State. We want as many of these decisions
to be made locally as possible, but if there is no agreement locally
about what the right course of action should be, then it is difficult
to avoid the conclusion that the Secretary of State or Ministers
will have to make a decision, because ultimately it is ministers
who are accountable for the National Health Service.
Q79 Dr Taylor: What I am bothered about
is when the disagreement locally cannot get across to the minister,
so he does not feel the strength of opinion that really means
it is absolutely essential for something to go to the independent
panel.
Mr Hutton: To be honest, your
constituency is one very good example of that. That did get across
to ministers; maybe too late, but it did get across.
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