Examination of Witnesses (Questions 300-319)
MR NIGEL
EDWARDS, MR
DAVID STOUT
AND DR
BRIAN FISHER
22 FEBRUARY 2007
Q300 Dr Naysmith: Dr Fisher?
Dr Fisher: I would agree with
that. I think what you are asking is, should LINks be involved
in individual consultation level issues, so in terms of Choose
and Book for someone who chooses their hospital it usually happens
within a consultation and does LINks have an impact on that right
kind of intimate level.
Q301 Dr Naysmith: Should it have?
Dr Fisher: I would, I suppose,
see it as mainly about collective approaches, so I think it would
have less impact on that. On the other hand, there are some things
that we know make for better outcomes, shared decision-making
between doctors and patients, record access we think is going
to be very important in the future, so there are a number of key
things that really matter at an individual level. I suppose I
have not really thought it through in a great deal of detail but
LINks should be saying, "We would expect patients to come
away from practices feeling that they have been part of a discussion,
shared decision-making. We would expect patients to have access
to all their data when they want it", and that is to some
degree part of the questionnaires that practices fill in at the
moment. There are ways of gathering that data, although it is
not terribly easy, but I would not see it as the main job of LINks.
I think they could be saying, "This is the degree of standard
that we would expect locally", and they could check on it
from time to time but that would not be the main focus of their
work.
Q302 Dr Taylor: I have one or two
questions about the consultation process when you are talking
about major service changes and hospital reconfigurations. From
the manager's point of view how useful are consultations?
Mr Stout: A consultation on its
own, if you have not done before it, is almost certainly not going
to be very useful at all because it is often too late by the time
you have got to that stage. So I think a formal consultation,
consultation with a big "c", so to speak, needs to be
the product of quite a lot of initial discussions and dialogue
and involvement leading up to it. Seeing consultation as a stand-alone
process is unlikely to be very successful and is indeed quite
likely to cause difficulty. For me, when there is a formal requirement
to do consultation, it is absolutely reasonable and right that
you should build on a process that has gone on before.
Q303 Dr Taylor: And who should you
involve in the pre-consultation?
Mr Stout: Everyone who has an
interest, within reason, obviously. It sounds a bit idealistic.
Q304 Dr Taylor: Do forums or LINks
or whatever have an absolutely key role in that?
Mr Stout: I believe so, yes. This
goes back to my commissioning process, that is the strategy in
the commissioning process if you like. In devising your strategy
I would expect there to have been dialogue, involvement, whatever
the right verb is, with the local community in developing that
strategy.
Q305 Dr Taylor: During the Deficits
report we heard that it is very difficult for trusts because if
they have to make certain economies they have to make certain
reconfigurations so they have to go into a consultation process
to achieve the end they need because they have to make the economy.
Mr Edwards: There is an issue
here in which the system that has been set up, the so-called reform
system with payment by results and foundation trusts and a range
of new providers, does require a level of agility and speed of
adjustment which is somewhat at odds with the consultation arrangements.
We are saying to people, "Please behave in a highly responsive
and rapid way". This leads us onto a very interesting problem
with a definition of the word "significant" in the Bill.
If I am producing the same level of healthcare but I am managing
to do it with fewer beds is that significant, because you might
well argue that you should judge me by what I am producing rather
than the means of production? You do not ask a factory how many
units it produces. You ask, "Does this product do what I
want?". There is a bit of an issue here where we have a collision
of a wish to involve people, as David says, in strategy and when
you are thinking of things when you perhaps have time and space
to create that strategy this is not a problem, but if we have
a much more fast-moving world in which people have to respond
to choice—if all of your orthopaedic patients decide to
go to the hospital down the road for their operation of choice,
in a sense there is a very interesting question about to what
extent you need to consult because actually the patient has already
told you very clearly what they think of your orthopaedic service.
You may want to consult about any changes that you then need to
make to other services around that as a consequence of that and
you may want to talk to the public about whether as a public they
are happy to see that, but to think that you would be asking people
to run a service which had no patients for a considerable period
of time is something that I think some of our members would wrestle
with and say, "Well, actually, we are consulting people who
have already told us what they think in no uncertain terms".
Q306 Dr Taylor: So, going back to
the word "significant", should we be trying to change
it, delete it, or what word should we put in instead?
Mr Edwards: I think "significant"
will do and maybe it is the guidance that is the issue here and
it might be helpful to have some worked case studies. I know the
civil servants have wrestled with this too. I am afraid that even
raiding the thesaurus there was no immediately obvious better
word. From our point of view, "significant" must relate
to a change in patient experience or convenience, so saying that
I produce the same amount of healthcare but I have moved from
Grantham to Lincoln would count as significant if it makes a big
impact on patients, but if you change the GP practice between
one practice and another or between a GP practice and a private
company, for example, as we have seen recently in north east Derbyshire,
as long as the same experience is there that probably does not
count as significant. It is a really quite slippery concept and
I think we may run into trouble with it as time goes on, but we
are, whatever happens, stuck with this collision of policies in
which there is rapid change required and there is a need to consult
the public and I think people will need some help thinking that
through.
Dr Fisher: There are two points
here. Section 11 says you should be involving people in everything.
I have never quite understood where the "significant"
idea comes from because we should (not that anybody does) be involving
people at all levels in a much broader way, so that is one point.
In South East London we are involved in a very large reconfiguration
that is going to continue for a while. I think that for the first
time we are developing quite good consultation around this. The
thinking has been going on for a year before it has gone out to
the public but there are enormous amounts of decisions still to
be made. What I think is interesting about it is that in our patch
we are faced with serious financial issues and that is being made
absolutely clear to the population, and what we are discussing
is how we manage that, and that is absolutely right. That seems
to me just so and it is very hard and we have to do it together.
Q307 Dr Taylor: With the Government
talking about devolution and local decision-making is there pressure
from the Department of Health for reconfigurations that will save
money and perhaps at the same improve things? Is there pressure
or is devolution real?
Mr Edwards: I am not aware of
any direct pressure. The pressures to reconfigure come from a
variety of sources and the department is not really one of them.
You will be familiar with the Working Time Directive and changes
in medicine. That is a very interesting question. My experience
of reconfigurations, which is perhaps another debate, is that
they very rarely save money. They may prevent the need to spend
more and they may release some resources but they are often being
done for reasons not directly connected to financial pressures.
I think actually think there has been some department nervousness
over reconfigurations over the last five or six years. To some
extent we have had a bit of grant cropping recently, partly because
of that. Far from it really. The incentives for the department
are actually rather the reverse. They would rather have less noise
than more.
Q308 Dr Taylor: Changes to the consultation
process: you have already said it is vital to start them before
the formal consultation. Are there any other improvements you
could offer?
Mr Stout: The key thing on consultation
and on engagement generally, is being clear what you are engaging
on, being very clear what is poor consultation and what is not
and not pretending. That is the thing that irritates people most,
when they have gone through a whole exercise, taken personal time
to contribute to it and then discovered that they did not really
have any say whatsoever because that was off limits. I think the
general rule of doing these things properly is being as clear
as you possibly can be about what it is that you are willing to
talk about and what is beyond the power of the consultation, if
you see what I mean.
Q309 Dr Taylor: Brian said we were
getting better at listening and not necessarily better at acting
on the results of what we have heard. Is there any chance that
we could improve on acting on what we have heard at pre-consultation?
Mr Stout: Yes, and I suppose to
some extent you can judge that by the effectiveness of the consultation
after the pre-consultation phase, if you like. We should be able
detect whether those sorts of improvements have been made. Can
we get better at it? Yes. Does that mean we respond to every single
point made? No, you are never going to do that, are you? Consultation
is not about responding positively to every single comment because
that is usually impossible, but having the transparency to demonstrate
that you have listened and fed back your rationale for the decisions
you are making I think again is part of doing it well. It is not
just listening, noting the comments and then making your decision.
It is listening, noting the comments, responding to the points
and then making your decision. It is fulfilling that whole cycle.
Q310 Dr Taylor: Transparency, honesty
and no spin?
Mr Stout: Yes.
Q311 Chairman: Given that the consultation
process has been gone through down at local level where it should
be with PPIfs or whatever we have in future, are you happy that
the department or politicians in the department have a right to
intervene at a late stage in this process?
Mr Edwards: They clearly have
a right by virtue of where they are.
Q312 Chairman: Should they have a
right?
Mr Edwards: I think the rules
that Richard just laid out are probably quite good ones to apply
right the way up and down the system as well. There have been
some examples where sometimes those interventions have seemed
to run quite counter to both logic and local opinion and, therefore,
I think we should be asking whoever does intervene to be willing
to be held to account for the same tests about is it fair, is
it logical, is it transparent and is there no spin, which I think
were your words, Richard. That seems to me to be a sensible test
to apply. It is quite difficult. There needs to be some arbiter
in the system. Sometimes, however much consultation you do, however
much involvement you have, it is quite likely that in some cases
people will still be substantially dissatisfied with the decision
that you find yourself having to take and I think some referral
up the system is the expectation one has of working in a system
that is funded by the taxpayer.
Q313 Chairman: An expectation?
Mr Edwards: I think so.
Q314 Chairman: Because it has been
around, but you have also said that it can be illogical from the
point of view of the reconfiguration.
Mr Edwards: I think that is for
the independent panel.
Q315 Chairman: I do not want to put
you on the spot, Nigel. Could you send us an example of where
you believe it has been illogical and maybe the Committee can
comment on whether it is an expectation and should remain one?
Mr Edwards: I will.
Q316 Chairman: Brian, do you have
a view on this?
Dr Fisher: I am not quite sure
what you are asking. If you are asking can you keep politics out
of local decisions the answer is no, I do not think so.
Q317 Chairman: Local decisions have
been taken by all these stakeholders in these local decisions
but the current system has a right, if it wants it to be triggered
by an individual, to intervene in the decision of that consultation
process.
Mr Stout: I think that right comes
in when it has been challenged generally, does it not?
Q318 Chairman: If you are going to
close a hospital ward in Rotherham I would expect I would get
to know about it. There is one about to be closed, for very good
reason, which I wholly support, but if I did not I would have
the right to have a say-so as a representative. Should I have
a further right than that as a politician? Should I have the right
to influence somebody who has a right to intervene in this process
at a late stage and send it to an independent panel? That is two
rights.
Dr Fisher: Yes, two rights do
not make a wrong.
Q319 Chairman: Does it make a right?
Is it right?
Mr Stout: You were talking about
yourself as a constituency MP in the first instance and then you
were talking about the Secretary of State in the latter.
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