2013 accountability hearing with Monitor - Health Committee Contents

6  Monitor as an organisation

108. The Health and Social Care Act 2012 expanded Monitor's role considerably, and as the Committee argued in its report of last year's accountability hearing, Monitor's role is complex and demanding; the BMA describe Monitor's role as "exceptionally challenging".[110] To meet these challenges, it is important that Monitor has sufficient staffing and expertise, underpinned by robust internal structures. The RCN highlight the importance of Monitor retaining an open approach to evaluation and learning over time:

    The RCN would like to again highlight that much will be proven by how all elements under Monitor's remit, including pricing, their advice on mergers, commissioning the Trust Special Administrator for FTs under the failure regime etc, will work together. This will either help or hinder the ability of the NHS to deliver safe, high quality care and stay within a challenging budget.The RCN urges an open attitude for agencies such as Monitor to evaluate their approach and to work with others on making improvements in the best interests of patients.[111]

109. As part of this year's annual accountability process, the Committee posed the question "what does success look like for Monitor?" and asked what measures it currently used to monitor its own performance. Monitor responded as follows:

    We are fundamentally concerned with ensuring that the health sector works well for patients and that overall the NHS is delivering better care, more efficiently.Our role in ensuring foundation trusts are well governed and in regulating the sector from an economic perspective means that we are at the heart of delivering many of the changes and improvements that are needed.In particular we have set ourselves the following high level objectives:

      In Assessment, to make significant progress, working with the Trust Development Authority, to ensure all public providers achieve the minimum standard needed to become a foundation trust;

      In Provider Regulation, to ensure that the majority of foundation trusts are providing high quality care on a sustainable basis in a way that supports commissioners to deliver the best possible outcomes with the money available to them.Where trusts have difficulty in achieving this, to resolve issues swiftly in support of commissioners' objectives;

      In Pricing, to ensure that the system does not act as a barrier to change but incentivises quality and efficiency improvementsas well as rewards providers that deliver good quality care; and

      In Co-operation and Competition, to apply the rules relating toProcurement, Patient Choice and Competition to help commissioners deliver better care for their local populations and to help ensure the merger regime works for the overall benefit of patients.

    We are currently defining a set of more detailed and specific outcomes against which we can measure our performance in the coming year.This will be published as part of our Business Plan for 2014/15.This will form the basis of a more comprehensive performance measurement framework which we will develop later in 2014.

    This performance framework will take account of our new roles and responsibilities, some of which come into force in April 2014.The new framework will use a range of performance measures to track the progress and success in achieving our goals.We are also assessing whether to commission an evaluation of the impact of our work on patients.[112]

110. The Committee welcomes Monitor's plans to develop more detailed and specific outcomes against which it can measure its own performance, and a more comprehensive performance measurement framework, and we will consider progress against these outcomes as part of our next accountability review with Monitor. The Committee believes that its two recommendations set out in Paragraph 107 will facilitate these developments.

111. The Department of Health report that Monitor has been working to recruit new staff and diversify its skills base. Monitor's staff base has increased from around 160 in March 2012 to nearly 300 by March 2013. It is predicted to increase further to around 420 by March 2014.[113]Monitor provided the following breakdown of staff by function area:


    Provider regulation-78

    Sector development-80

    Co-operation and competition - 29


    Executive Office-4

    Legal services-25

    Patient and clinical engagement-0

    Strategic communications-28

    Organisation transformation-20

112. The RCN raised concern in its written evidence about whether "appropriate clinical advice is sought and applied as Monitor continues to refine their approach to their new responsibilities" and argued for a formal role for nurse representation to ensure effective clinical advice is supplied throughout all levels of the organisation.[114] Monitor reported in its written evidence that:

    All Executive Directors have been appointed, except for the Medical Director (whose appointment awaits government approval). This has delayed recruitment to the ten-strong Patient and Clinical Engagement team.

    We do recognise the importance to the organisation of people with a clinical background. A total of four clinicians have been recruited to our teams working in Co-operation and Competition, and Policy. Additionally, we have seconded five quality governance associates from the NHS.[115]

113. When questioned further about this, Dr Bennett said:

    One of the things that I am very clear about is that, although we draw heavily on external experts for advice on clinical aspects of much of what we do, we need more people with clinical backgrounds inside Monitor. My starting point for that is to appoint a medical director to run the unit that you mention. I have had a problem in that I know who I want to appoint and have known for many months, but I have had a problem getting the terms and conditions of that appointment agreed. That is why that unit is not yet established.[116]

114. Dr Bennett expanded on the importance of clinical engagement:

    On clinical engagement, we need a number of in?house clinical experts like the medical director and then I want them to reach out to clinical experts across the NHS, including the royal colleges, for example, and there are two things that they need to do for us. One is to bring genuine specific technical knowledge, clinical knowledge, to our decision making, and we have touched on those sorts of issues several times in the course of this afternoon. The second thing I want them to do, which at the moment mostly I and one or two other colleagues are doing, is to reach out to the clinicians as important stakeholders for all the things that need to happen in the NHS... I want to do this more often, more regularly, on a broader base, so that we can establish strong ties with the clinicians in the health sector.[117]

115. In follow up information received by the Committee on 24th January, Monitor provided an update on recruitment:

    Monitor has been recruiting over the past 12 months to allow us to undertake our new regulatory responsibilities.Great care has been taken to ensure that we recruit people with the right skills and expertise to ensure that we fulfil our core function of protecting and promoting the interests of patients.In addition to recruitment, where we will continue to enhance our resourcing strategy, we have developed a core set of internal training courses as part a commitment to provide staff with ongoing learning and development.We will continue to recruit as our new activities get underway; we will be working with the Department of Health to ensure that recruitment to business critical senior roles requiring a salary over a threshold set by the Department can be progressed quickly without detriment to our business operation.

    The Committee specifically asked about recruitment to the position of Medical Director.We have only just been able to conclude discussions with the Department of Health about remuneration for this position-we can now progress this apace.Delay in recruitment to this post has led to a delay in recruiting to the Patient and Clinical Engagement team; we are now initiating recruitment for an interim resource to support the Medical Director.However, because it is important to have people with a clinical background in the organisation we have already recruited four clinicians to work in our Co-operation and Competition and Policy teams.We also have five quality governance associates seconded to us from the NHS.

    We have recently recruited an Enquiries Director to work within the Co-operation and Competition team to help us develop our capacity for providing informal advice to the sector.Sector engagement specialists will also be recruited to work across our functions to ensure as full an understanding as possible.We will discuss with the Department our requirements for any further recruitment to the Co-operation and Competition team as the need arises.[118]

116. It is essential that an organisation with such a central and crucial role as Monitor has appropriate clinical input. The Committee was frustrated to learn that the Department of Health delayed the appointment of a Medical Director for several months due to an argument about appropriate pay levels.The Committee regards this as an absurd distortion of priorities and strongly supports the formation of a fully staffed Patient and Clinical Engagement Team within Monitor at the earliest possible date.

110   British Medical Association (AMO 0003), para 1


111   Royal College of Nursing (AMO 0006), para 6.1 Back

112   Monitor supplementary information, para 4.1 Back

113   Department of Health (AMO 0002), para 7 Back

114   Royal College of Nursing (AMO 0006), para 3.4 Back

115   Monitor (AMO 0010), para 8.5-8.6 Back

116   Q109 Back

117   Q111 Back

118   Monitor supplementary information (AMO 0013), para 4.2 Back

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Prepared 26 March 2014