Examination of Witnesses (Questions 300-319)
ANN KEEN
MP AND MR
VERNON COAKER
MP
17 NOVEMBER 2008
Q300 Anne Main: That takes us neatly
back to the Chair's concordat—in which case it is not working,
is it?
Mr Coaker: It may not work in
particular circumstances in particular authorities and there may
be particular problems. Again, and I have been quite honest about
it, there are times when people say to me, and licensing laws
are another example about that, "Why can we not do that?",
and so on, and I say, "You can do that". Sometimes there
is a mismatch between what people can do and what they cannot
do.
Anne Main: The licensing was a
particular case when the guidances came out late.
Chair: Do not go down that route.
Q301 Anne Main: No, I am not going
down that route. They were waiting for you to give them guidance
and I think that is part of it. We have had numerous people telling
us that they do not think they can do this and if you are saying,
"Yes, they can do all of this stuff", I either suggest
that maybe they are totally misinformed or somehow the communication
from your Departments is bad but they do not know that.
Mr Coaker: I am saying that there
is certainly a need to improve communication between national
government and local government; in giving people not only the
knowledge as to what they can or cannot do but the confidence
to do that and the capacity to do that as well. All of those things
are important and that is why, with the new arrangements that
have been put in place, in particular since April of this year,
I think that we will see a considerable difference in what happens
locally and a build-up of both capacity and confidence.
Q302 Dr Pugh: Primary care trusts,
like local authorities, spend huge amounts of public money on
local priorities, and primary care trusts are looked at by LINks,
scrutinised by overview and scrutiny committees and have certain
obligations about consultation. But at the end of the day the
people on the primary care trust are people who get there by means
we know not quite how and the people who get on local authorities
have to be elected; so they have a definite vested interest in
pleasing the community that elects them. Primary care trust members
though would probably be more mindful of the institution that
appoints them. Why is there a difference?
Ann Keen: There is not. Again,
there is not anybody stopping anybody using a model similar to
the foundation trust of a hospital where they can be members.
There are two examples—
Q303 Dr Pugh: Wait—a foundation
trust is a provider body. It does not commission, it does not
have any resources. A local authority has resources; it spends
them. A PCT has resources; it spends them, but a PCT is constructed
on an entirely different model from a local authority whereby
none of the people on it is elected by anybody and those people
on it, if they wish to have a career on it, if they wish to go
further within the health world, please the people in the Health
Service rather than please the community, do they not?
Ann Keen: But equally back, with
respect, they can be on it, they can use a model where people
can be a member of a PCT, like what takes place at the moment
in—
Q304 Dr Pugh: If I may stop you there,
they can be if they go through an appointment process and satisfy
the people already on the PCT that they are a worthy person to
join them. They cannot, as you can in the local authority, simply
put their name on a nomination paper and see whether anybody votes
for them.
Ann Keen: A name on a nomination
paper directly elected again would be entirely up to the local
community as to how they do it because local representatives,
local councillors, for example, of course, can be on there, and
again, back to the overview and scrutiny committees, but I would
suggest—
Q305 Dr Pugh: You are deliberately
missing the point, are you not, because the fact of the matter
is that they can be on it? There are councillors on PCTs; I know
that. They get there because obviously people on the PCTs like
them or people in the Health Service like them and think they
will be useful members, but if, for example, an ordinary member
of the public wishes to represent their local community all they
need to do is write their name on a nomination paper and curry
favour with the electorate, try and get elected and, if they disappoint
the electorate, they will get unelected. You can be on a PCT forever,
can you not, while you are systematically displeasing the community?
Ann Keen: I am sure I am not deliberately
not answering you. What I am saying to you most definitely is
there are models where you, as a citizen, as part of that community,
can be very much involved with the PCT. You can form your own
PCT foundation trust area. You can sit with the commissioners.
In particular, world class commissioning is requiring the PCTs
to have a full day where it is scrutinised by the public[2],
by the local press, by councillors, by people like ourselves as
Members of Parliament. There are people that come from other organisations
that sit in and that is an annual check, which is absolutely essential,
that they have to have, along with the constitution which we have
publicly consulted on. That will very much make PCTs more transparent.
They cannot be directly elected to the PCT to have the power of
decision making financially because the power of the accountability
and the responsibility still remains very firmly with the Secretary
of State and Parliament, which is how it is.
Q306 Dr Pugh: On the business of devolving
power, PCTs in collaboration with local authorities can set local
health targets. That is a good thing, I think we agree. How do
you deal with the conflict that might exist between local targets
and national targets? For example, there may be a national target
about drug addiction but there may be very little sympathy for
spending local resources on that particular project. How are these
sorts of conflicts to be reconciled?
Ann Keen: They have to set out
objectives. PCTs have to set out a minimum of[3]
ten objectives that are agreed locally as to what will be their
areas of priority. That again is transparent and will be monitored
by overview and scrutiny committees and other such bodies. Should
they wish to change anything—for example, a change within
a reconfiguration of maybe maternity services or something in
that way—they have to be totally accountable to do that
and they have to publicly consult and they have to make it very
clear why they are changing a service or not adopting a service
which is a national priority.
Q307 Dr Pugh: What you are saying is
that they would be well advised to include important national
targets within their local targets but, if they do not and they
do not wish to, the mechanism would be for them to consult with
the public. If they could demonstrate that people locally knew
what they were doing and they were quite happy to neglect this
national target, the Department of Health presumably would say
that is okay?
Ann Keen: No. That is not what
I said. What I said was that the national target would be of such
an importance and we have very few national targets within the
Health Service that would affect the PCT. Those that will, some
of those will of course be mandatory and statutory. They have
to. If you could give me an example of what you are looking at,
you said on drug addiction and on drug misuse, I would expect
them to be working with all the statutory bodies within the local
community to make sure that that was not being ignored.
Q308 Dr Pugh: I can imagine in certain
areas that dealing with alcoholics might not be a major priority.
Ann Keen: They have to publish
their ten key objectives. Those key objectives have to be relevant
to the health needs of the community but also to the direction
that would be in the operating framework of the National Health
Service.
Q309 Jim Dobbin: This question might
not be very helpful to us today, but we are taking evidence from
local government and central government. We are talking about
constant change. There was a comment made in the previous evidence
session about not talking about structural change necessarily
but eventually that is what happens. Do you not think that the
system needs a period of stability? The professionals working
in the system for example do not always perform when they do not
feel secure in their roles or whatever they are doing. I just
feel, quite honestly, that we seem to have got into a constant
changing system. At some stage, somebody has to give whatever
system is introduced time to settle down.
Mr Coaker: I think that is fair
comment up to a point. The issue as I see it is that you change
not just for change's sake, but you change where it is appropriate
and where people believe that it will do something better. I am
sure the Committee, when it comes to its deliberations, will make
a series of recommendations about changes that it would like to
see happen which it thinks will benefit policing or benefit health
and so on. Anne Main's point about probation, for example. One
of the changes we are going to introduce is about making them
part of the CDRPs, making sure that they are a statutory partner
in that. That is a change. That is an involvement. You could say
that is an additional burden but it is actually something that
people want because of the issue around some of the points they
have got. It is not change that is the problem; it is where change
happens that people do not think is necessary. I think sometimes
change for change's sake is something that you hear. Where people
believe that it is addressing a problem or addressing something
that is wrong or has not worked, then I think people are fine
with that.
Q310 Anne Main: I would like to go
back to the same sort of theme as Dr Pugh about the need for directly
elected crime and policing representatives. We have directly elected
local councillors, often not on a very large mandate. There is
the concern, if you go down this route, you may have them elected
on even less of a mandate in a local election. Why are you doing
it? Why would you see the need to do it?
Mr Coaker: First of all, there
has been considerable evidence from the Casey Review, from what
Ronnie Flanagan said and, if you go back further, from the Lyons
Review about the need to address accountability with respect to
policing. We are perfectly happy with arrangements which exist
with respect to CDRPs where you have the involvement particularly
of local councillors and the big crime reduction community safety
agenda with respect to that. I think it is less clear with respect
to police authorities who obviously have a relationship with the
police and indeed with local authorities. If you actually look
at that, where is the accountability to the public with respect
to police authorities? From our perspective on it, the election
of crime and policing representatives would allow us to actually
ensure that there is a direct, electoral accountability between
the police authority and the public.
Anne Main: Is it not just adding
another whole layer of bureaucracy and indeed cost?
Q311 Chair: More to the point, why
is it okay in policing but not okay to have directly elected PCTs?
Mr Coaker: People make judgments
about where they think elections are appropriate or not. With
respect to the area that I have responsibility for, with respect
to the Home Office, we think the police authorities are something
where the injection of some direct accountability, some democratic
legitimacy, will be of benefit to the local community. In fact,
if you look at all of the political parties nationally, that is
what—
Q312 Chair: My question to Mrs Keen
then is why is that not useful as regards PCTs? Why should they
not be directly elected?
Ann Keen: Because we have already
said that they can participate. You can have a model of participation.
You have already elected representatives engaged with the public
at all times. If they want to be more involved they can be. The
present situation on the money that is spent and on the accountability
that is expected of us here is that the Secretary of State remains
accountable. Therefore, the difference is fairly obvious.
Q313 Anne Main: It does not appear
obvious to me and I was asking the question. The difference appears
to be that you think it is right in one place but not in the other.
I will move on. Back on the community deciding what it wants to
do—I am still very concerned about the whole cost of these
electoral policing representatives—should not a local community
agree safety targets and take primacy over national targets?
Mr Coaker: This is the distinction
that I am trying to make to the Committee. Before we go on to
targets, I think local councillors, local authorities, have a
very real role to play through the CDRPs with respect to the broad
community safety agenda, of which policing is a part. If you talk
about police authorities, that is a more general, policing specific
body. That is why we think that the injection of some democratic
accountability into them in a direct election way would be of
benefit. You will correct me if I get this wrong: in terms of
targets, Government has moved away now with respect to targets
and what happens locally. We will have one target which will be
a confidence target on a force area for individual police forces.
That will be the only target that we set nationally. Alongside
that will be the local area agreements which upper tier authorities
will negotiate with their partners to determine what in their
area, from the 196 performance indicators, are appropriate targets
for their area. They will come to an agreement and within that
are a significant number of crime and disorder and policing related
performance indicators.
Q314 Anne Main: Would your crime
and policing elected representatives go out with some sort of
little manifesto like we all do as elected representatives and
have different sets that the public would vote on? How do you
imagine this working?
Mr Coaker: With respect to Crime
and Disorder Reduction Partnerships, I think people understand
how they work. That is the local partnership which is dealing
not only with policing; it is dealing with respect to litter,
graffiti, housing and all of those issues that we all get. Separate
to that, I think what we are then talking about is the direct
election and the link between a police authority and the public.
That is where all the major political parties at the moment rest.
With respect to that, the operational independence of the police
remains but I think what people will then see is that they will
have people for whom policing and how their area is policed is
something for which they can be held accountable.
Q315 Sir Paul Beresford: London has
a directly elected Mayor who is seen by Londoners as being responsible
for the Metropolitan Police. That is democracy in action with
the police. Do you think it is good though that we should go down
this way? Should we apply it elsewhere? Do you think it has worked?
Mr Coaker: With respect, obviously
crime and policing representatives will not apply to London but
with respect to London we have a Mayor but there is also a police
authority. If you are asking me—
Q316 Sir Paul Beresford: Which he
chairs.
Mr Coaker: Which he chairs. If
you are asking me outside of London whether I think the abolition
of police authorities and the election of one person who is responsible
for the police force is an appropriate route forward, no I do
not.
Q317 Andrew George: I just wanted
to probe a little further, Mrs Keen, the question of PCTs being
locally accountable. You were saying earlier in answer to questions
from Dr Pugh that they were. Just taking examples of alternative
providers of medical services—independent treatment centres,
for example, centrally dictated policies within certain areas,
prescribing legislation, another example being the Pharmacies
White Paper—to what extent can local communities have a
genuine say in the way in which those services are provided?
Ann Keen: Very much on the commissioning
side. There are three specific areas that the PCTs have to look
at: safeguarding, competency and their commissioning. They have
to prove to us, to the public, in their PCT area that they have
a strategy on finance. They have to prove that they are competent
to manage that. All the minutes are published. Everything is accountable
to the local scrutiny committee which is made up of the local
authority. You cannot really have any sort of plan for your local
health service that is not known to the public. You cannot exclude
members of the public from attending meetings, contacting their
local representatives in any way that they wish to. All PCTs at
the moment are looking at models that they could involve people
in more. At the same time, taking Mr Dobbin's point, the NHS does
not need another reorganisation. It needs a period of stability,
particularly when we have had five years of the overview and scrutiny
and LINks are in their infancy and a constitution is being formed
that has very much involved the public, their rights. On the area
that does affect people which I have heard raised with me in many
debates, particularly debates in Westminster Hall, on the transparency
of the PCTs.
Q318 Andrew George: It has been transparent.
Perhaps the Berlin Wall has been taken down but instead what has
been put in place is a transparent totalitarian state, centrally
controlled.
Ann Keen: That is not happening
in Hounslow.
Q319 Andrew George: Let us take the
example of alternative providers of medical services. To what
extent was that a Whitehall-driven initiative which the PCTs had
to roll out in their own area? Independent treatment centres:
the 15 per cent target of planned surgery. All of these are centrally
dictated to the PCT. They may be transparent, you are arguing,
in the way in which they are delivering these policies but they
are certainly not decided locally, are they?
Ann Keen: Decisions to reduce
waiting lists were decided nationally when the Government was
elected that said it would do that. The fact that the PCTs have
delivered that has only pleased the local population. Their waiting
list times and their waiting times, whether in A&E or access
to medical services in a treatment centre—
Andrew George: That is a very
good example because a lot of surgeons tell me they did not have
a waiting list. They simply had a booking system, so there was
no waiting list at all. They were not allowed to do that. They
had to create a waiting list so, instead of addressing the problem
of there being a waiting list, they had to create one.
Chair: This is a health issue
which we are not responsible for. Most of us are thinking where
on earth are these surgeons.
2 Note by witness: It is not accurate to refer
to scrutiny "by the public" here. Back
3
Note by witness: It is not accurate to refer to "a
minimum of" here. Back
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