Select Committee on Health Minutes of Evidence

Examination of Witnesses (Question Numbers 100-119)


3 JULY 2008

  Q100  Sandra Gidley: Stephen, have you managed to do any better?

  Mr Firn: I cannot comment in relation to Richard, obviously. I mentioned a few of the initiatives earlier. What I think I can confidently say we have been able to do—I am sure if all my clinicians were here they would back this up—is innovate locally to do the types of services that we were providing better, to increase access and to improve quality. I think we can show we have done that from our patient survey; we can show we have done that around expanding psychological therapies and indeed our governors said that in their submissions. As we said before, we are hindered by two things, one is having this block contract so that there are no means for a Mental Health Trust to do something really exciting and innovating with the money following the patient; it has to be a commissioning decision and the commissioners have to say "Yes, we will fund that". At the moment we are still in this position where we have a lack of clarity around how Darzi will actually play out in the way that services are delivered in local areas and it will be different in local areas. In terms of innovating into major service change, not yet. However, I think that the fact that we have Foundation Trusts and the fact that Foundation Trusts have the surpluses or the cash balances that we talked about will be a critical element of making things like Darzi happen. As I have said, we are already engaged in discussions around things like polyclinics et cetera. We are not quite there yet in terms of major service change.

  Q101  Sandra Gidley: Dr Moyes, from Monitor's perspective do you have any mechanisms to identify innovation? If so, how would you evaluate what is going on and maybe spread best practice which is something the health service does not do well in any area?

  Dr Moyes: I do not see that as Monitor's role. I think the Healthcare Commission and the Care Quality Commission are the bodies that ought to be interested in how clinical care is delivered and how it might be improved. We do try to keep Monitor focussed on particular areas and I have not so far seen Monitor as having a role in analysing innovative models of care and spreading best practice.

  Q102  Sandra Gidley: So it is not something you even have any desire to do.

  Dr Moyes: I think if we started to do that we would be easily open to the criticism that we were allowing our mission to creep and regulations were coming overburdensome. I am always very conscious of those things and I do try to keep Monitor focussed on the things that I think we were set up to do.

  Q103  Sandra Gidley: Moving on, in your draft annual report you state that "as the financial stability and strength of the sector has grown, increasingly the issues are different kinds of service failures—breaches of national waiting time targets and more recently failures to secure sustained reductions in the rate of MRSA infections". Is it perhaps possible that improved financial performance is being gained at the expense of quality?

  Dr Moyes: I do not think there is any evidence to demonstrate that. I think in the early days of Foundation Trusts the focus was very much on the financial performance but more recently, as deadlines for targets have come up—things like 18 weeks, MRSA—inevitably Foundation Trusts and our own focus has switched to ask questions about whether these things are or are not going to be delivered. As we list in the draft annual report that you have we have tackled this year a number of financial issues in Foundation Trusts but I think we have spent more time on non-financial issues than we have one financial issues, reflecting the kinds of problems that are emerging.

  Q104  Sandra Gidley: You have the flexibility in-built to do that, it is just the way the systems work.

  Dr Moyes: Yes.

  Mr Gregory: To give you an example, without any pressure from Monitor or anybody else we were concerned back at the beginning of 2007 about our C.diff rates and as a board and as a Council of Governors we were determined to do something about it. We spent half a million pounds of hard earned revenue gain so directly impacting our bottom line on a whole range of measures that achieved over the next 12 months a very dramatic reduction in our C.diff rates, 53% down. We did not need to do that; we were absolutely determined to get hold of that issue and I have always said that it is the quality of what we do that is the most important thing. Finance enables you to make decisions; it is not going to be the key determinant and driver at Chesterfield Royal, it is about the quality of what we do and that has to be the priority. Going forward I think we all need to focus on the opportunities that we have just been talking about recently about how we can carry on doing that.

  Q105  Dr Taylor: I am just wondering if it is coincidence that we have two of the very best Foundation Trusts here because looking at the glorious technicolour diagrams at the back Chesterfield is green all the way across for governance risk ratings and number five all the way across for financial risk. Oxleas is likewise green all the way across and steady fours for financial risk. I wonder if that was coincidence or by design. There are 25 trusts who governance risk ratings have remained for the last year at either amber or red and when we did our first report on Foundation Trusts we were worried that there were going to be adequate incentives in place to ensure that trusts improve or even maintain high levels of performance. Are there incentives to improve or maintain when we are talking about quality particularly?

  Dr Moyes: I think there are, Dr Taylor. I cannot really speak for Primary Care Trusts and how they monitor performance against the contract, but I think Monitor's compliance system and its focus not just on finance but also on governance does provide very real pressures on the Foundation Trusts to first of all recognise that they have problems, so go and find the problem in the trust; the board has to self-certify to us when they provide their annual plan and then every quarter whether or not they are delivering national standards and targets. That means that we expect the board to know what their performance is and to forecast their performance so there is a pressure to look ahead as well as just to tell us what is happening today. Foundation Trusts know that if they have a persistent problem and it is obvious that they are not tackling it, that Monitor will intervene, initially informally but if that does not produce a result then we will use our formal powers. I think Foundation Trusts are extremely conscious that we do have very, very tough powers and we can use them.

  Q106  Dr Taylor: What happens if a trust remains on red for a long time?

  Dr Moyes: If a trust remains on red for more than two quarters we would certainly call in the board. By that stage we probably would have concluded that they were in significant breach of their authorisation. We would try to establish whether the board understood the nature of the problem or not. If we had any doubts about that we would commission advisors to work with the organisation to make sure that we were tackling the right problem. We are very unwilling to go for quick fixes; we try to find out what is the real nature of this problem: is it the quality of the board? Is it the quality of the management? It is something about clinical quality? We try to get an advisory team in depending on the nature of the problem to describe to us the true nature of the problem. We have done that with five organisations in relation to MRSA. Having done that we make a judgment as to whether we think the hospital can or cannot, with the existing board and the existing team, solve its problems. If we think that they can then we make sure there is an action plan in place. We meet them monthly; we tend to want monthly reports against the action plan to try to make sure that they are delivering. If we came to the conclusion that the board or the management team or a combination of the two simply could not solve this problem then we would use our powers, if necessary to remove the board or the chief executive or the clinical director and find people who could solve the problems. That is an option we try not to use very often.

  Q107  Dr Taylor: So you would remove the board before banishing them from the elite of Foundation Trusts.

  Dr Moyes: We cannot do that. Once they are Foundation Trusts they are authorised forever; that is the legislation. The idea of withdrawing the authorisation and handing them back to the secretary of state is not an option.

  Q108  Dr Taylor: One of our witnesses in the first session did say that he thought there were financial instruments to drive quality, for example that the commissioners could pay more for high quality services than for lower quality. I think one of you said you could use the power of commissioning to improve services.

  Dr Moyes: Lord Darzi has recommended a system of paying for performance and a pilot scheme has been run in the Northwest using a model developed in America by Premier Healthcare to have a very small pot of money—it is not an enormous amount of money—and to use that small pot of money to reward trusts (not just Foundation Trusts, but all trusts) for delivering above and beyond the minimum contracted levels. I think the pilot in the Northwest has been held to be a successful pilot and Lord Darzi has recommended that it is adopted as a feature of the tariff going forward, which we would certainly support; we think it is a good idea.

  Q109  Dr Taylor: Did you approve of Cheltenham giving all their staff a bonus of £100 for their achievements?

  Dr Moyes: It is not for me to approve or disapprove but personally I think it is not a bad thing. I think the staff worked extremely hard and it was justified, but it is not a matter that comes to me at all.

  Q110  Dr Stoate: I would like to talk about governance and democratic accountability. Richard, there has not been much evidence that we have seen on the costs of governance and accountability but some figures have put it around about £200,000. How much does it cost to run your governance arrangements?

  Mr Gregory: The costs of running our membership, our public events, the newsletters, the elections and a whole range of associated things, the Chesterfield Royal is about £200,000 a year.

  Q111  Dr Stoate: Is that good value for money?

  Mr Gregory: Yes, I think it is very good value for money. I think we have to be careful long term about the targets that are given to us on total membership because every election, for example, costs about £35,000. If we have a catchment area of 375,000 I dread to think what it would cost to actually mail out to all 375,000 residents in North Derbyshire. There would be cost implications if it went to the end of the extreme. What we are looking for really in engagement; we are looking for a two way relationship so that is going to be more costly.

  Q112  Dr Stoate: Can you explain what specific things your governors and your membership have added to your trust that you were not able to do beforehand? Can you give us examples?

  Mr Gregory: I would be delighted to. I think if I give you the specifics of area—that is in the public and patient area, PPI—I could tell you an awful lot about what we have done to try to make our governance more effective. It was a concern of mine when I arrived that the model was thin on good principles and on detail. What we have done—when I say "we" I mean the executive, the board, management and governors—is to give far more of an effective role for the governors within the Trust. One key output or example of that is our PPI arrangements. The governors have their own PPI Committee and they have the ability to look at all aspects of our patient care. That means mystery shopping type visits to the wards, evidence based checking system on whether it is cleaner, whether the food is good enough, whether the levels of care are good enough. This is a properly documented Committee where the board asks for the executive to not be defensive but to make sure that we are doing this to add value to the system. I am absolutely delighted with the way our executive has engaged with this. It is a positive, internal, constructive challenge and we would not have got that any other way. They are putting pressure on the system all the time. Our cleaning regime has changed; we are spending more on it. We are doing things in a different way; we have brought housekeepers back onto the wards, we have re-introduced matrons; we are looking at bringing our food sourcing into the locality rather than importing it from South Wales. We are doing a lot of things on all aspects of patient care. We would be doing them anyway to a degree but absolutely hand on heart I think we are doing them harder and faster because of the pressure that the governors are exerting on the system. We have only been running that for about 18 months and it is paying off a lot of rewards. I think the focus is on quality that Alan Johnson, Lord Darzi, Bill and David Nicholson have spoken about on many occasions over the last six months; I think we are into a new regime of focussing really hard on quality, not just on waiting time reductions and infection control rates, but really about the quality of everything we do. That is absolutely our mandate at Chesterfield.

  Q113  Dr Stoate: Stephen, are there any specific challenges in terms of governance for a Mental Health Trust or is it broadly the same picture?

  Mr Firn: It is more of a challenge. As I said before, even though we had a user council the fact that we now have governors with these formal roles, at every three monthly meeting I am on my feet for about an hour and a half taking questions principally from the public and patient governors about all aspects of the organisation. This is challenging enough but the Council of Governors is really a critical grilling and they really do hold us to account.

  Q114  Dr Stoate: Does it improve the way you do things?

  Mr Firn: Absolutely. It is in the forefront of our minds: "What are our governors going to think about this? What are they going to think about our staff survey? What are they going to think about our patient survey? What are they going to think about this serious or untoward incident?" So it is there now, it is right in front of us. They also do site visits like in Richard's trust and if we do have a serious incident, such as a suicide or very, very occasionally a homicide, then they will sit on the inquiry panel and they will be a full member of that inquiry panel and will give their views and judgments alongside the professionals. So there is that clear feedback. I think the real challenge for mental health is that whilst we have a very active set of governors it is building a large membership and that is a real challenge because most of our membership—which is only around 4500, which is not typical I do not think for Mental Health Trusts—have some contact with the organisation or family or friends. If you want to get people interested in a mental health organisation you should tell them you want to build something in their local area; that is often the only reason why they get very agitated and involved, otherwise if things are seen to be going fine it is very hard to get people interested. That is our biggest challenge I think, engaging with a wider membership. One of the things we wanted to do as a Foundation Trust is to actually start to make mental health something people discuss, know about and talk about it in the way we talk about other health problems. That is the challenge.

  Q115  Dr Naysmith: Stephen, what happens if you and your team find yourselves in disagreement with what the governors and members want? Has it ever happened?

  Mr Firn: There has not been a major disagreement, no. This has come up mainly around our annual plan in which we agree our priorities and we have to agree where we are going to invest our surpluses, so they are actually involved in making decisions about money. I think what the legislation says—certainly what our constitution says—is that the governors are required to take a view. They have asked me directly what that means and I have said that if they do not agree with something we are saying we will invest in or if we are refusing to do something that they think is very important, then we have a serious problem and I would be very silly to ignore them, given the powers they have.

  Q116  Dr Naysmith: So you talk them round.

  Mr Firn: We have not had major problems. One of the things we were worried about that has not come up is that we would have people who had completely off the wall views, but most people's concerns are the same as ours: what are we doing to support patients' care and improve things like psychological therapies? The agenda is similar, they just challenge and hold us to account.

  Q117  Dr Naysmith: The question I want to ask you, Bill, is that this year for the first time you mentioned in your annual report that you are going to offer guidance to governors in the discharge of their key responsibilities. There has been a lot of evidence over the last two or three years—reports published and even one recently unpublished but some people know what is in it—suggesting that governors are very confused sometimes about their roles. Why has it taken you so long to offer this guidance?

  Dr Moyes: We wanted to let the system settle down. It is a new approach and it is not something that we came to with a recipe book that said that we know exactly what governors are going to do and this is how they should do it. We thought it was very important that governors and members had a chance to think for themselves a bit. We did a survey of governors earlier this year; that gave us some useful information. We got Ipsos MORI to do the work for us. We held a series of four regional events where we invited governors in; we had about 100 to 150 at each one. That gave us quite a lot of intelligence about the issues that they faced. I think the conclusion we reached was that there is actually quite a lot going on but governors have some very specific statutory duties but not always a very clear idea of how those duties should be discharged. They appoint the chair, they appoint the non-executives, they approve the terms at which a chief executive is appointed; they appoint the auditors, they receive the audit report, those kinds of things. One can infer that from that Parliament probably intended them to have some basis for making the appointments, so some kind of performance assessment process. We think probably the time has come where we understand enough the issues that governors face and the questions they have to start expressing some views about what would be very good practice and what might not be such good practice. That is where we are heading at the moment.

  Q118  Dr Naysmith: Are you going to take it to some of the lower performers in this area and start with them first?

  Dr Moyes: What we are going to do is to write from our experience and from the experience of other people and it think it is a guide to best practice; I do not really have it in my head yet because we are just starting work but I think it is a guide to best practice. It certainly will be something we will consult on. Then we hope out of that will come a consensus, purely in relation to the statutory functions of governors, what is a good way to do the job and what are the things we should discourage governors from doing. I think the other thing that we will try and bring out is that the board of directors have to support the governors to discharge their statutory duties. It is not two separate camps; there are a lot of things the board has to do and we want to make sure the board recognises this.

  Mr Gregory: There is a national association for governors, the FTN, which works very closely with the governors on a national and a regional basis. The chairs do spend a lot of time encouraging governors to meet with each other and talk with each other, so there is a lot of best practice developing. We are on a journey and I think the journey as new trusts are authorised, the more mature trusts are offering facilities and help and the FTN does a great job doing that and we do an awful lot of it in Chesterfield.

  Q119  Dr Taylor: Going back to Monitor and Dr Moyes, it has been suggested to us that your organisation's success is very closely tied to Foundation Trusts' success and that therefore you may have an interest in being something of a cheerleader for Foundation Trusts in general, emphasising the good points rather than necessarily focussing on those towards the bottom of the tables. How would you respond to that?

  Dr Moyes: I think in our early days Monitor wanted to establish in people's minds that this was a system that could be made to work and work well. However, I think if you talk to hospitals like Bradford or UCLH or some of the more recent hospitals where we have intervened either formally or informally they would say that when we are not happy our unhappiness is extremely apparent and that they are expected to make us happy. I think overall we are very conscious of the issue and we are trying very hard not to be a cheerleader. We try very hard to be a constructive regulator and to let the Foundation Trust Network do the cheerleading because that is their role.

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