Examination of Witnesses (Questions 360-379)
MR KEN
JONES AND
MS JO
WEBBER
17 NOVEMBER 2008
Q360 Andrew George: If PCTs were
entirely democratically elected, how different would services
be, do you think?
Ms Webber: It is very difficult
to say because what we have is a combination now of national—I
hate to use the word "targets"; we are supposed to be
moving away from targets, but they still feel like targets—
Q361 Anne Main: They still are.
Ms Webber: --- and locally decided
priorities. You are still going to have that mix because there
are some things where the general public feel that they need that
national consistency. If you look at things like waiting times
and some of the other issues around the recent stuff on top-ups,
what is allowed and what is not allowed, the public want a national
consistency. There is always a balance in some areas between that
national framework within which the public want the NHS services
provided and the degree of local flexibility that you need to
actually meet the needs of some local communities in the most
effective way.
Q362 Chair: When you say the public
want consistency, we have inconsistency at the moment. We have
much longer waiting lists than Scotland and Wales because they
have chosen a different model of health delivery. That is an expression
of the democratic voice of people in Wales and Scotland. Why is
it not possible on, let us say, a regional English level, that
people in the north east should decide they do not mind waiting
and they would prefer more preventative health work?
Ms Webber: Within England there
is a lot of evidence that people want that national consistency.
They want local flexibility. They want both. They want national
consistency and local flexibility. That is absolutely fine, but
that is the sort of environment in which we are working. If you
look at the top-up issues recently, the huge issue around topping
up treatment was around not having an England-wide consistency
about how that was done, people wanting national criteria or at
least a national framework within which local decision making
could be used.
Q363 Andrew George: There are two
potential areas of difference. One is that greater local accountability
might result—this is presumably what the Government may
fear—in a different quality of person going on to the PCT
and therefore a lesser quality or a different quality decision
taking. The other is that the lines of accountability are rather
inconvenient. In other words, a locally accountable person will
be playing to an entirely different audience to a PCT appointee
who would be presumably accountable to diktats from the centre.
Is that the reason why you think things will be different, because
of where they believe their lines like accountability are?
Ms Webber: People within PCTs
at the moment have a huge variety of accountabilities, both nationally
and locally. There are the national target accountabilities. There
are local target accountabilities. There is the role of overview
and scrutiny and there is the new duty to involve. There is the
ability for local people to make their voices heard through local
petitioning. There is a variety of other mechanisms such as the
annual patient survey for people to make their views very well
heard about what they feel about their local health services.
Q364 Andrew George: If you do not
mind me saying so, these are merely peripheral issues of consultation
and the ability for people to have a say. In terms of making decisions,
in answer to the original question—how different would services
be?—you were intimating that they would be different if
people were locally accountable. They might resist some of the
national targets being imposed on them. Is that the main difference
you think there would be?
Ms Webber: I think there might
be more ability within the system to say locally we will strike
out and have our own way of delivering this, but I think you would
still need national frameworks because you still need people to
feel that the services, particularly in certain areas—stroke
care or cardiovascular disease or diabetes care or dementia—do
need to be within a nationally consistent model. I think your
point about quality is well made. One of the risks around this
is how do you ensure the quality of services when you have very
much more local accountability.
Q365 Andrew George: You have set
quite a store on consultation but can you give an example where
local scrutiny has resulted in any real, significant change in
the way services are delivered? That might also apply to Mr Jones.
Ms Webber: I do not know off the
top of my head, without consulting. I am quite happy to go back
and find the individual examples.
Q366 Chair: That would be helpful.
Ms Webber: I think there are some
issues. For instance, if you look at the next stage review, the
Darzi Review, that came out in June/July this year, one of the
key points there was to ensure that local processes were part
of this whole system so that it was a local, whole systems approach
to the way in which health services were delivered. Decisions
about how reconfiguration might be necessary locally were taken
within the context of local authority needs and local, strategic
needs assessments. There is a whole process there that is still
under way at the moment to ensure that that sort of local accountability
is there.
Mr Jones: I have been around this
probably too long. I remember first working for Clive Betts's
authority some years ago and I have seen the culture of local
and central government change from my service perspective, not
always for the better. I have seen some of the changes, which
were properly driven on efficiency grounds, take away some of
the vigour of agencies and produce a lot of inefficiency, cost
and bureaucracy. What we are hearing now from ministers is very
welcome if it can be delivered because I think there is a need
to recalibrate the relationship between local and central and
to get away from the position where ministers now feel they are
accountable for every tactical failure and sometimes success that
happens out there, be it in health or policing. I think that is
just not a good place to be. I think the Government's job is to
make sure that agencies like ours are properly structured, led
and funded and then hold those people who lead those agencies
fully to account for what goes right and wrong within them, but
we have got ourselves into a position where the public think otherwise.
We have found that incredibly disempowering over the last decade
or so. We hear all these changes and the ones the minister was
speaking about earlier, but I think delivery is going to be very
difficult because it challenges cultures in Whitehall and local
government. Frankly, this is a massive change under way here and
it does not suit a lot of people. On behalf of the public, it
has to be driven through. I think we will then need to accept
there might be some postcode differences. In return for that accountability
goes the responsibility for that at local level. Other countries
do not have a problem with this but we seem to have a media and
a political culture that has introduced quite a lot of weakness.
Our organisations are not as organic and resilient as they were.
One of the dangers of concentrating on this is that you produce
vulnerability and what the military would call single points of
failure as opposed to the diversity that used to be out there,
which I think was move innovative and better served the public.
Q367 Chair: What about the answer
to Mr George's question about whether you have an example where
scrutiny at a local level has altered these services?
Mr Jones: I can think of lots
of examples. Operating within the culture we have now, where accountability
has shifted upwards, it is almost an inevitability that if something
goes wrong in an agency for which locally there is not clear accountability,
an inspector or regulator is sent in. It will generate the change
necessary.
Q368 Chair: I am thinking about local
authority scrutiny of the local police service where it has then
resulted in change in service delivery.
Mr Jones: There are stronger and
stronger links at basic command unit level with local government
through those scrutiny operations. I cannot give you the evidence
today but I am fairly confident because we are all operating within
frameworks which, provided they are given sufficient impetus and
sometimes funds, will generate the right outcome.
Q369 Chair: If there is an example
and you find it afterwards, can you let us know?
Mr Jones: I will.
Q370 Anne Main: Could I just take
you back to the postcode lottery? Would you agree that, if the
postcode lottery has been determined by those who occupy the postcode,
they see it slightly differently than if they have had it imposed
on their postcode by on high?
Mr Jones: Absolutely, up to a
point. The point at which perhaps Government has a responsibility
which it cannot step back from is if a locality decided on a service
provision which put people at harm or at risk and for which I
think the state has to have some responsibility. Up to a point,
I agree with you. I think we should all be grown up enough to
make our choices and pay for them locally and live with the consequences.
Somebody somewhere has to say, "That is insufficient. That
puts children at risk" or what have you and somebody will
have to step in and make sure there is a minimum standard or a
threshold standard below which differences in delivery will not
occur.
Q371 Anne Main: Why were police authorities
only relatively recently asking to be super merged into large
areas?
Mr Jones: It was driven by us
as policing professionals rather than police authorities. Police
authorities were very much against the majority.
Q372 Anne Main: Why did you wish
to do that then?
Mr Jones: Operationally, there
were clear scale economies. We were sensing diminishing funding.
Q373 Anne Main: That was one of the
criticisms of it?
Mr Jones: The main driver was
it was operationally efficient.
Q374 Anne Main: How locally accountable?
Mr Jones: That is one of the challenges
and that is one of the things that unpicked it because people
already felt some forces were—
Q375 Anne Main: Why are you arguing
for localism but you are in favour of that?
Mr Jones: Because I think you
can find a way of having your cake and eating it. You can have
greater answerability at local level and we are doing that now
through local neighbourhood policing, where local priorities will
be agreed sometimes on a street level and people can be held to
account for that; but local people, in my experience, will never
vote for investment in counterterrorism, homicide investigation,
information systems, helicopters, etc. If you are giving people
the appropriate capacity to deal with the things that matter to
them most locally, it is absolutely right and proper that somebody
somewhere—and it has to be the state—has to say that
there is a threshold which cannot be dropped below in respect
of homicide investigators, counterterrorism units, what have you.
Local people, bless them, rarely get sighted on that layer of
policing. We have presented a model of policing to the public,
a Dixonian model, which is over-simplified. It is about bobbies
on the beat and their front police station counter. It was when
I joined but sadly it is no longer.
Q376 Mr Betts: We are looking at
maybe some fundamental changes. We had a discussion with ministers
a few minutes ago. If you are going to introduce some real changes,
it is about giving power, responsibility and accountability to
locally elected representatives. Would you feel comfortable with
a model where local councillors had the responsibility to commission
neighbourhood policing or health services at local level instead
of the current arrangements through the PCT?
Ms Webber: What we would be comfortable
with is, to a certain extent, what we have already. It sounds
like it is a bit of a cop out. It is not meant to be. The health
and wellbeing services, the preventative end, the end which is
very much within the dual purview of the PCT and the local authority,
the amount of joint commissioning that goes on in those areas
should be increased to the level where you can run services that
feel to the individual out there receiving them that they are
receiving something which is joined up, seamless and works for
them. For that, you need to have that very close working relationship
that enables you to really know what the needs are in a local
area and to really be able to be quite innovative about where
the funding comes from to deliver the services. I think there
are some health services that are very specialist. This is probably
going to get a difficult response. Health services might not want
to get involved in waste disposal for local authorities. Maybe
local authorities might not want to get involved in commissioning
very specialist, heavy end, regional or national specialty services
where you need an awful lot of very good professional knowledge
of a very small but very high usage group of people to make the
decisions.
Q377 Chair: PCTs currently commission.
Ms Webber: No.
Q378 Mr Betts: I was talking about
PCTs.
Ms Webber: I think you are absolutely
right. There are some services that we should be joint commissioning.
Q379 Mr Betts: Why does it have to
be joint? How is it that we have to have appointed people by some
faceless commission called an appointments commission to determine
who sits on a PCT, to determine how health money is spent at local
level? Why cannot that be done by elected representatives?
Ms Webber: Ipsos MORI did some
polling for us with people, asking them who they would like to
make decisions about their local health services for them locally.
The information we got back from that polling was that local people
would rather clinicians, people with knowledge of health, made
those decisions.
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