Annual accountability hearing with Monitor - Health Committee Contents

Written evidence from UNISON (MON 05)


1.1  UNISON is the largest public sector union with over 1.4 million members working across a range of public services that help and care for the most vulnerable in our society. In the health service, UNISON has 450,000 members employed across the NHS. We are pleased to have the opportunity to make a submission to the Health Committee in relation to its scrutiny of Monitor.

1.2  As a leading voice for health and social care staff, UNISON is instrumental in influencing policy at regional, national and international level. We work collaboratively with Government and other UK and international unions on health and social care issues, including areas of practice and care. UNISON also works closely with each of the health regulators to establish standards and policies in education and patient care. UNISON is a diverse organisation, enabling us to have a broad perspective of health and social care services. We are a key stakeholder and value the opportunity to participate in any attempts to improve patient care and public protection.

1.3  We hope that the Health Committee will take into account the weight of UNISON's views. We have sought to include information which we believe the committee will find helpful.


2.1  UNISON has serious concerns over the potential conflict of interest between the roles of Monitor and the Care Quality Commission (CQC). We believe there to be an inherent contradiction between the business model of Monitor and the quality care model of the CQC.

2.2  With the increased powers for Monitor proposed in the Health and Social Care Bill we believe this contradiction will increase further. In promoting competition and price driving service provision rather than quality we see that situations will arise where CQC and Monitor are in conflict with each other.

2.3  For example how would Monitor deal with a situation where a Trust's business plan was either just breaking even or in need of some remedial action based on the performance indicators set by Monitor yet the CQC's assessment identifies a need for investment to improve quality standards. Any further investment by the Trust could worsen the performance indicators set by Monitor and potentially warrant increased intervention yet by such investment could get a clean bill of health from CQC. How would Monitor resolve such conflicts?

2.4  Arguing that the market can provide solutions we believe does not hold water as evidenced by the introduction of competition and private contractors in the 1980's into cleaning in the NHS with price being the driving factor and the resultant reduction in quality and increase in hospital infection.

2.5  David Bennett, Chair of Monitor, has likened the NHS to utility companies and argued that it was ripe for dismemberment following the lead of the privatised utilities and railways. UNISON has real concerns over the "level playing field" that lays ahead for NHS Trusts when Mr Bennett clearly sees plurality of provider and competition as the means of providing NHS services. How does this sit with the provision of quality care?

2.6  We would argue that this view is further compounded by Mr Bennett quoted in the Times[30] as saying: "I think over time an amount of price competition will be appropriate," … "The question for us is, would we seek to force a degree of price competition? And we would have to be very careful about doing that because there is a risk to quality."

2.7  So risk to quality is clearly an issue and as stated earlier allowing competition and price to be the driving factors for services leads to reduced quality of service and increased risk to patient safety.

2.8  As a regulator what guarantees can Monitor provide to ensure that quality will take precedence over cost when its overall aim is focused on a business model and competition? How will Monitor use regulation to enforce quality over cost within health providers?

2.9  We believe using a business model, competition and price as the driving force for determining the provision of NHS services is too great a risk to quality care and patient safety. Light touch regulation further increases those risks. Evidence such as Mid-Staffs shows that organisations focusing on achieving their business plan and seeking to achieve Foundation status lose sight of quality and results in compromised care and patient safety.

2.10  Even with Monitor taking on board the recommendations of the Mid-Staffs enquiry earlier intervention still poses significant risks when competition and price is the prime driver for NHS services and quality secondary.

2.11  Since the Health Select Committee commenced the evidence session, the Future Forum reports have been published and on Monday the Department of Health (England) published the government response to this. However whilst the language has changed in relation to the role of Monitor we do not believe the over riding policy has changed and therefore remain concerned about the role of Monitor and its interface with the CQC.

2.12  We believe also there may be further valuable lessons to be gained from Robert Francis once the Mid Staffordshire inquiry has concluded. In particular the conflict of external regulation, and the implication of managing differing priorities relating to these reporting structures. Robert Francis said in his earlier report "if there is one lesson to be learnt, I suggest it is that people must always come before numbers"[31]

June 2011

30   In need of a spoonful of competition to revitalise NHS-The Times 25 February 2011. Back

31   Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 to March 2009 Volume 1, Robert Francis QC, London:The Stationery Office, February 2010. Back

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Prepared 14 September 2011