Examination of Witnesses (Question Numbers
40-59)
DR MARK
EXWORTHY, MR
JOHN CARRIER
AND MR
KEITH PALMER
3 JULY 2008
Q40 Mr Bone: Following on from Lee's
question, is it more like internal politics within this very large
organisation that Foundation Trusts see themselves as something
above the rest and the others think they really do not want to
cooperate with them; they are a grammar school and we are a secondary
modern. Is it that sort of thing you are worried about?
Dr Exworthy: I probably would
not put it like that. Foundation Trusts have a duty of partnership
but that clearly gives them quite a wide latitude of how they
interpret that. Many of the rules under which they are now operating
are much more explicit, so legally binding contracts, payment
by results. They are very much more of a higher profile, more
explicit, more overt and so clearly they are thinking in terms
of managing their risks accordingly.
Q41 Mr Bone: John, earlier on in
your evidence you actually said that you thought it had encouraged
better working between partners. Could you just say a bit more
about that?
Mr Carrier: Since shifting the
balance some years ago which emphasises the cultural change that
would have to come about, there is no doubt that the large hospitals,
especially teaching hospitals, could see that commissioners were
going to be important because their income is going to come from
commissioners. I think other things which are difficult to quantify
are also important, which are relationships: knowing people, meeting
at networks, meeting at the oversight scrutiny committees, exchanging
ideas, being invited to seminars and goodbye parties; all those
sorts of networking, gossipy things do help to get the feel. As
Wellington once said, you look to the wit and spleen of the person
to understand who they are. That does help collaboration and I
think it also goes beyond that and gives you the idea that whether
it is a Foundation Trust or a non-Foundation Trust there is complementarity
here, they are both on the side of the patient. For the Foundation
Trusts with very high reputations, with teaching responsibilities
and medical students, there is another dimension here which is
extremely important because they have an intellectual critical
mass which they want to defend as well. We want that to get into
the service. So there is a whole debate in London about academic
health science centres and we have been invited to discuss those
and that is interesting. The last president of the Royal College
of Physicians but one, myself and the chief executive and the
chairman of what is now the Camden and Islington Foundation Trust
also had discussions with the Foundation Trusts about the easy
and quick reception of people with mental illness who are brought
in under section 135 and how that could be improved in the middle
of London. That seems to be working. So there are changes but
it does very much depend as much on relationships and understanding
of each other and not simply on the economy issue. I think it
is a health community as well as a health economy. We are not
against the economic and financial issues but other things are
just as important.
Q42 Mr Bone: Mr Palmer, I think you
have seen this from both sides, Foundation Trust and non-Foundation
Trust. Would you say that there is any evidence that Foundation
Trust hospitals are better at collaborating with the private sector
than non-Foundation Trust?
Mr Palmer: If I may I will answer
that as well as whether they are any better at collaborating within
the NHS because I have, as you say, seen it from both points of
view. I do not think that the tensions in the system about service
re-design and cross-organisations makes very much difference whether
they are Foundation Trusts involved or not. I am now at Barts
and the London; we are a high performing, financially in surplus
major teaching hospital trying to do re-configuration with clinically
less high-performing, financially very troubled DGHs. I think
that situation creates enormous tensions in trying to do things
that are good for patients that the losers will sign off on and
losers will usually the district general hospitals. I see that
exactly the same in the Northeast where we do not have Foundation
Trusts as it was in the Southeast where they have the same issues.
I think they are inherent in service re-design and the way that
payment by results works more than whether you are engaging with
a Foundation Trust or not. On the private sector, my answer would
be exactly the same. There are inherent difficulties in the NHS
dealing with the private sector; I do not think it makes very
much difference except there are a few more legal powers to do
it in Foundation Trusts but that does not make it any easier actually.
Q43 Dr Stoate: I am going to be the
Committee Rottweiler for a moment or two and have a go at Mark
now. We are talking in theory about primary care in the NHS and
yet we are seeing Foundation Trusts which are gaining huge amounts
of power and control over the local health economy. What evidence
is there that Foundation Trusts have in any way facilitated the
move of resources and services into the community away from themselves?
Dr Exworthy: Foundation Trusts
were initially acute trusts and have been extended into mental
health trusts and there is the potential to move into community
foundation trusts so there is a pathway if you like in which that
Foundation Trust status is moving. Given my earlier comments about
their self interest, they have a clear interest in looking at
acute care. Having said that, I think there are some areas where
they are moving into primary care and that is either a function
of other partners in the local health communityso re-configuration
across organisational boundaries (clinical networks might be one
example)but there might be other areas, particularly outside
the bigger cities, where the Foundation Trust as it were dominates
the area so that in a sense they become the provider across many
towns and villages that they encompass. There might be a degree
of difference and ability of moving outside their traditional
remit for Foundation Trusts to enter into those primary care pathways.
Q44 Dr Stoate: Is it not happening?
Dr Exworthy: Not at the moment.
I think there are discussions and areas of debate in which they
are thinking about that but have not actually moved in that direction.
Q45 Dr Stoate: Given that the Government's
line is for a primary care led NHS do you think it was a wise
move to set up Foundation Trusts in the first place? You are going
to have Foundation and Primary Care Trusts.
Dr Exworthy: I think that is difficult
if PCTs are commissioning on the basis of government allocations
and financial allocations. There were some suggestions at the
outset of Foundation Trusts that perhaps we should talk about
a foundation community so rather than giving it to each individual
organisation it would be given to a network of organisations.
That obviously did not happen but that would be a very different
model than setting it up with each individual, as it were, in
competition with others.
Q46 Dr Stoate: You are saying there
is no evidence whatsoever that we are moving from the current
situation of hospital dominated care into a primary led care as
a result of Foundation Trusts.
Dr Exworthy: I think a lot of
the rhetoric about primary care led NHS is still to be realised,
but I think there are steps in that direction. Clearly Foundation
Trusts have been put in the position that they are going to try
to shape that agenda in each health community.
Q47 Dr Stoate: Given their self interest
are they helping or hindering that process?
Dr Exworthy: I think they are
helping and they might be in a good position to do that because
they might be able to coordinate many of these primary secondary
care networks.
Q48 Dr Stoate: Why could the PCTs
not have done that? Why are we leaving it to Foundation Trusts
to do that with their self interest? Why did we not set it up
in the way that PCTs lead that process?
Dr Exworthy: A lot of Primary
Care Trusts areand perhaps should beleading that
process. Clearly it makes a difference when one of your partner
organisationsyour providersis a Foundation Trust
because that sets up a potential tension and a potential resistance
to shifting your money, especially under the PbR system which
sets up different incentives for the PCT and the FTs.
Q49 Dr Stoate: I am still trying
to get a straight answer; is that a hindrance or a help in that
case?
Dr Exworthy: For shifting to the
primary care led NHS? I would probably say it is a hindrance on
balance but I think that balance might be shifting.
Q50 Chairman: Have you got a view
on that, John?
Mr Carrier: I think it is shifting
and I think it is shifting because the language now differs. The
patient pathway/patient journey is an important idea; there is
a pathway in and a pathway out. Some services are also clearly
negotiated to come out of hospital and back into the Primary Care
Trust (dermatology is an example and diabetes is an example).
There is also quite a good discussion going on stimulated by the
polyclinic, for example there is a discussion between the Camden
Primary Care Trust and University College Hospital about the location
of four GP practices on the ground floor alongside an urgent care
centre, alongside an A&E department, alongside out-patient
services. Whether this comes off depends on consultation and whether
it is financially feasible, but there are four surgeries round
about that are not DDA compliant and it would be very interesting
to see if we can get an integrated centre out of that. The Foundation
Trust is certainly interested in discussing this with us. I do
not think that could have happened before although, to be fair,
the Royal Free too is talking about collaboration with local integrated
care centres and so on. Coming back for one second to something
said earlier, I think one man's silo may be another man's professional
division of labour and although you may want to defend a silo
you may also want to defend your professional division of labour
which is what you have been brought up on, what your skill is,
what your competence is, what your knowledge is and what your
values are. I think silo as a pejorative term does not really
fit here. I think people will defend what they hold out to be
good but I think there are gaps here which people are crossing
and talking to each other. That is very, very important whether
you are a Foundation Trust or not. I think Primary Care Trust
is included now because commissioning is extremely important.
We have shed our provider service; it is now an autonomous provider
organisation and they will have to do what others do in that situation.
We are purely commissioning. We have a budget of well over £400
million of which £52 million goes to UC, £58 to the
Royal Free (both 2008-09) and we are financially in balance so
we are not at the moment strapped for cash and we have taken advantage
of the increase year on year.
Q51 Dr Stoate: I understand what
you are saying, it is just that my philosophy has always been
that we should look at a health community where we spend large
amounts of public money hopefully to the public good and anything
that causes artificial divisions and effectively barriers to that
happening I like to examine. It seems to me, just to step back,
that locking money up when that money could be used and freed
up for patient care seems to be a barrier rather than a help.
I am just trying to tease that issue out.
Mr Carrier: I see the point but
my feeling also is that accountability is important, that the
more pluralistic and the more multi-services there are, the more
difficult it may be to see when things go wrong, who is accountable
and where the money is actually being spent. I think there is
a case for and against.
Q52 Dr Taylor: I welcome what John
says because you are obviously beginning to bridge the purchase
and provider split.
Mr Carrier: I hope so.
Q53 Dr Taylor: That is absolutely
brilliant. Keith, I want to know about the costs of the Foundation
Trust application process. I have to declare an interest because
on Saturday I am going to a consultation meeting in my own Trust
about doing it. What does it cost to apply?
Mr Palmer: I think the major cost
is difficult to put a money value on because it is a huge effort
that the whole organisation has to go through to get itself prepared.
There is a very structured process that Monitor runs; there are
very high standards in terms of compliance with their requirements
and I would say at Guys and St Thomas's it caused us at least
12 months to take our eye off the ball; not take our eye off the
ball because actually you cannot do that because you cannot become
a Foundation Trust if you slip from meeting all the targets. People
had to work much, much harder simply to get through an additional
major agenda which is the Foundation Trust application process.
The monetary cost is mostly measured in terms of the recurrent
costs of running the membership. You have a membership; it is
not the elections, they are not very expensive, but you have to
communicate with them, you have to produce publications quite
properly and circulate them to potentially tens of thousands of
people. Those sorts of running costs are material but they are
measured in hundreds of thousands rather than millions. The front
end cost is really measured in the time and energy that staff
have to put in; the actual cash on the table is not that great.
Q54 Dr Taylor: Have there been any
specific challenges for your trust particularly that you have
had to face other than just getting the finances and the quality
right?
Mr Palmer: In becoming a Foundation
Trust?
Q55 Dr Taylor: Yes.
Mr Palmer: I think that with hindsight
the first wavers have got a relatively easy ride. Some of the
follow-on trustspeople like King'swere referred
back three or four times and there were major costs in terms of
doing extra work and re-submitting that were not immaterial. For
my rust at that time we sailed through.
Q56 Dr Taylor: Do you think there
are any major challenges to you at the moment?
Mr Palmer: The major challenge
for Guys and St Thomas's is to use the surpluses effectively.
There is a major push to contribute to service improvement in
southeast London outside the narrow ambit of Lambeth and Southwark
and the reason they have to spend their surpluses if because that
is capital which will be needed to bring about service improvements
which have yet to be both agreed and consulted on, so it is simply
a timing problem. The challenge for Guys and St Thomas's is to
become an academic health sciences centre of international repute
and to contribute to service redesign across southeast London.
Q57 Dr Naysmith: This is a question
for Mr Carrier because, as well as the acute Foundation Trust
in your patch, you have a smaller mental health Foundation Trust
as well. I just wondered what are the important management issues
this has generated.
Mr Carrier: There is a much smaller
commissioning budgetjust over £40 million a yearand
it is much more difficult in a way because that trust has very
deep relationships with two particular boroughs in London, Camden
and Islington, with two local authorities and some very challenging
users who are well organised into user groups and put a lot of
pressure on that trust. I meet the chairman oftenin fact
I am meeting with him this Fridayand he is a very near
neighbour, but we do not have half as much contact even though
we are in the same building as we do with University College Hospital
or the Royal Free or the Whittington. We do have regular meetings
and mental health issues often come up on our agenda but it is
not an issue in the same way that our relationship with University
College is.
Q58 Dr Naysmith: What about relationships
with the local authority because of mental health issues?
Mr Carrier: We have joint commissioning
under section 31 of the act. We share senior managers between
local authority and our trust. A lot of it has to do with mental
health and obviously children and families, but the relationship
is a good relationship and we often come into criticism because
the local authorityas it has donewishes to close
the day centre and turn it into what they call a recovery centre.
My trust then gets the flack in a sense and we have to explain
that we are not responsible; we fund it but we would support what
is going on having examined the case because we obviously jointly
employ the senior managers.
Q59 Dr Naysmith: Would that cause
a problem between you and the council if they were proposing to
close something?
Mr Carrier: It is not a problem;
it is a question of asking them to account for the policy and
to make sure that my board agrees with it. The joint commissioner
sits on my board and the senior officers from the local authority
are members of our partnership board and attend our board and
have papers on it. There is a good partnership working with the
local authority. We find some of the scrutiny committees rather
tense and difficult but they are doing a job.
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