Examination of Witnesses (Question Numbers
100-119)
MR RICHARD
GREGORY, MR
STEPHEN FIRN
AND DR
BILL MOYES
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 doI
am sure if all my clinicians were here they would back this upis
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 failuresbreaches
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
upthings like 18 weeks, MRSAinevitably 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 moneyit is not an
enormous amount of moneyand 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 areathat is
in the public and patient area, PPII 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
donewhen I say "we" I mean the executive, the
board, management and governorsis 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 membershipwhich
is only around 4500, which is not typical I do not think for Mental
Health Trustshave 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
sayscertainly what our constitution saysis 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 yearsreports
published and even one recently unpublished but some people know
what is in itsuggesting 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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