Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 223 - 239)




  223. Colleagues, can I welcome you to this session of the Committee. Can I apologise to our witnesses for the slight delay in starting this morning, and welcome you to the Committee; we appreciate your willingness to co-operate. Mr Weeks, it is good to see you again; you are nearly a member of the Committee at the moment, it is the second week running, I think, we have seen you. Could I ask you each briefly to introduce yourselves to the Committee, starting with Mr Rose?
  (Mr Rose) I am Norman Rose, Director-General of the Business Services Association. We represent 20 of the largest outsourcing contractors in the UK, and have a particular interest in PFI/PPP projects in the Health Service.
  (Mr McGuire) I am Steve McGuire. I am Divisional Director for Property and Support Services at The Leeds Teaching Hospitals Trust. I manage all non-clinical support services in the Trust.
  (Mr Turner) Phillip Turner, Director of Operations for Bradford Hospitals Trust, and I manage all the non-clinical support services, other than estates, within the Trust.

  (Mr Weeks) Stephen Weeks, National Officer, UNISON, with overall responsibility for PFI, market testing and relationships with private contractors.

  224. Can I begin by thanking you all for your written evidence to the Committee, which has been very helpful. And perhaps I could start by asking colleagues from Bradford and Leeds briefly to summarise your experiences and relationship with the private sector, because in some respects you are perhaps going in slightly different directions. Mr Turner, could you describe briefly your own experiences in Bradford, as they relate to the area this Committee is looking at?
  (Mr Turner) We have a history of contracting out services for soft FM, porters, domestics and catering services. This year, we took the decision, after competitively tendering the services, to bring all of those services back in-house. Up until, I think, two or three years ago, the relationship with the contractors, catering in particular, has been very good, but that started to deteriorate and the quality of service for us in Bradford started to deteriorate. So part of our rationale, when we were looking to retender the services, was clearly value for money, and the Evaluation Panel thought that the in-house bid was the best value for money, in the circumstances, for Bradford.

  225. So you did not feel that, within the contract you had, there was a way of addressing the problems that were occurring and affecting services?
  (Mr Turner) For portering and domestics, I think we moved a long way in addressing some of the issues. We had a very bad experience for catering, and I can only speak for Bradford, because that is my only experience; and one of the big issues for us in Bradford was, in a five-year contract we had five general managers, so the ability to have an ongoing dialogue about quality was very difficult because the faces around the table kept changing.

  226. So these were managers of the private company, the contractors, basically?
  (Mr Turner) Yes, and they managed the services on site; so they were the on-site general managers. And really it was those general managers that we had to work with and to influence in terms of quality, and because they were changing so often it just gave us a real problem in terms of what we could do to improve quality.

  227. Mr McGuire, obviously, you have heard of the experiences in Bradford. The background to where you are at, does it relate to the reconfiguration that has taken place in Leeds, as a whole, and the various medical changes that have gone on there?
  (Mr McGuire) Yes. I have two issues really. One, non PFI-related involvement with the private sector, which is patchy in Leeds, the Trust that I belong to now in Leeds has only been in existence for two or three years, so we are relatively new in terms of what the organisation can say about involvement with the private sector. The two former organisations in Leeds that merged together did have various levels of involvement with the private sector, I can only comment on my own, which was in the east of Leeds, the former St James's and Seacroft Trust, where we have tended to get involved with the private sector when we think the need arises. We never involved the private sector as part of the compulsory market testing initiative, we involved the private sector where we thought there was a particular need within the organisation, quality or service based and not necessarily to reduce costs. We have an outsourced contract at the moment at Seacroft Hospital in Leeds, which is a multi-disciplinary contract, a hotel services contract, with Initial/Rentokil; the reason for appointing Initial/Rentokil was on the basis of a reasonably longer-term partnership, rather than a couple of years. The contract was not awarded to the lowest bidder, it was awarded to the company on the basis of partnership and quality. And, as I mentioned in the memorandum of evidence, we have involvement within the estate functions, topping up in terms of coping with peaks and troughs in demand throughout the year. In terms of involvement with the private sector through PFI, none as yet, because the PFI project is very early in its development. The Trust exists because of the need to reconfigure services in Leeds, that was the purpose of merging the hospitals together in Leeds, and we are now going through the process of trying to deliver the capital schemes necessary to reconfigure the physical buildings in the city. The original intention was to deliver the reconfiguration in one scheme across Leeds, but due to cost inflation, the original estimate was very inaccurate, we have decided to deliver the reconfiguration strategy, the TRS, the Trust Reconfiguration Strategy, in a series of packages, and the first package is the creation of an oncology building at St James's. We have made the decision, in conjunction with the local trade unions, to not include facilities services in the PFI scheme at this stage, we will only include the hard FM on the maintenance services necessary to maintain that particular building and in no other part of the Trust. What we do intend to do, is this, soft services will be retained in-house, over the next couple of years, is to systematically work our way through both hard and soft FM, through some form of value testing, and then make a decision, in conjunction with the staff side, as to whether that particular service, or (batch our of) services, should be kept in-house, or potentially outsourced to private sector, but the decision will be made based on service need, quality and also consideration to value and cost.

  228. Presumably, your oncology unit was announced only quite recently?
  (Mr McGuire) It was within the last few weeks, that we have had outline business case approval.

  229. So you are at the stage of actually contractor. We will probably get on to PFI later on in more detail, but I am interested in what you have said. Do you feel a contractor would wear this idea of the way you are going to split the service provision? I am interested in what you have said about the split between hard and soft, etc.
  (Mr McGuire) The intelligence that we are receiving informally from the market-place at the moment is that they are more than amenable to work with us on that basis. We have actually organised a market-sounding day, for next week, to bring private sector in, just to discuss generally and informally the project and how private sector would see their involvement, for both sides to get a feel for what we think is possible, really.

  230. One of the issues that we picked up very strongly, or some of us picked up very strongly, on visits we did last week, you probably know we went to Durham and to Carlisle, which was very, very helpful, was a concern being expressed by, for example, ward sisters about the way they felt the current arrangements, both with PFI and with PPPs, meant that their ability to control their team was reduced. One of the ward sisters said to us, in a comment on the situation, she is sent quite regularly on what she regards as expensive courses on team leadership, but she said when she came back she only had part of a team on her ward to lead. Is that an issue that has affected Mr Turner, in Bradford, has it affected you at all, where you lose control, to some extent, of the overall services because of the relationships with contractors?
  (Mr Turner) I think you do lose control of the services, in a number of ways. Certainly, my concern around the National Plan, where we are trying to get people working on the wards to the modern matron, or to the senior sister charge nurse on the ward, the debates that I am having with nursing at the moment, is that they want the soft FM people to be part of the ward team, they are not bothered about having the budgets, but they actually want them to be part of the team. And the debates that I have had with nursing sisters, they said that in their experiences they have not felt that when they have had contractors on the ward they have actually felt they belong to the Trust, they work for somebody else, and they have found that difficult.

  231. Do you have any experience of one of the points that was made by one of the ward sisters at Carlisle, where their contract involves the cleaning staff, who are contract cleaners based on the ward, actually giving drinks to patients? And the initial idea was that that would be very helpful, to reduce the pressure on nursing staff. The experience has been that patients who should not have had drinks have been given them, so the ward sister now feels that she has got to supervise the cleaner to ensure that no inappropriate drinks are given. That is one example. Have you any concerns yourself about that kind of difficulty?
  (Mr Turner) We have got concerns around that; there are two concerns around that. One is about what you have identified, in terms of patients getting the wrong drink. The other issue for us is about this issue of domestic staff cleaning areas of the ward and then serving patients drinks; and it is a real issue. And one of the things for us at Bradford is we are looking at introducing the ward hostess, obviously where the ward hostess will not clean sanitary areas, they will clean food areas, and then—

  232. So you are saying they could have been cleaning the toilets and then giving the drinks out?
  (Mr Turner) Absolutely.

  233. But is there not something wrong there with the specifications, if that is happening, or are the specifications not being followed?
  (Mr Turner) I think the answer to that is yes, but I think it is the historical specifications that the NHS have had. My experience of specifications for cleaning services on wards is that the expectation is that the ward domestic will do everything, and clearly it has been demonstrated that they cannot do that in a proper way.

  Sandra Gidley: I just find this slightly bizarre. Perhaps it was noticeable that the women picked up on this, but we all say, at home, all the time, we clean the bathroom and then go and prepare food, but we wash our hands in-between, it is all a simple matter of training. We hear stories of nurses who handle a bed-pan and then handle food without washing hands. So it is a training issue, it has absolutely zilch to do with PFI, I am afraid. Perhaps you could comment on that? I just needed to get it out of my system, but perhaps Mr Turner would like to comment?


  234. Mr Weeks, as an alternative?
  (Mr Weeks) I am afraid I will have to respond to that. Obviously, in an ideal world where there was proper training, all procedures were followed and people had sufficient time to carry out all their duties, there would not be a problem, in principle, with people having a range of different duties, and in some places it does work effectively. But we have to look at the real situation on wards, and in many places the cleaners feel, and we can debate whether it is right or not, that they do not have sufficient time to do the job, in some places they feel that there is understaffing, and so on, and then corners are cut. So I am not saying that in principle it could never work, but it has been an area that has been reported to us as a cause of concern, because if corners are cut in that situation the consequences can be quite severe. I would not want to exaggerate the extent of it, but I would not want to dismiss the possibility either.
  (Mr McGuire) Before we move off this area, I just wanted to make a couple of points on this subject. In Leeds, we have tried to take a more innovative view to the configuration of support services. One, the ward sister anyway should have control of everything that goes on in the ward, and whether it is a contractor or in-house NHS staff she, or he, has direct supervision over the process and technically there should be no difference in terms of work process or risk.

  235. It should, technically; but certainly the message we got, loud and clear, was that there is a big, big difference.
  (Mr McGuire) I can only comment on the area that I manage. We have never involved private sector in that element. Which leads me to the second point. The principle that we have adopted outside of PFI, before PFI was created, our proposals currently, with future PFI, is that we will split services. The core business of the Health Service is clinical care, but in the non-care area, support services, there are core services and non-core. Core services, in our belief, are those which are delivered at ward level, as part of a ward team, and non-core services supplement that core delivery. We have proposed up to now, and probably would propose in the future, that only services of a non-core nature will be delivered by private sector as part of a PFI scheme.

  Chairman: Richard, do you want to come in on this?

  Dr Taylor: Only just to emphasise really what Mr McGuire has said. If you really have a ward cleaner, they are under the control of the sister, and the sister makes sure they wash their hands between cleaning the toilets and giving the drinks, or organises them.

  Chairman: I think the feeling of the ward sister that we spoke to who mentioned this was that she had enough on, without having to supervise things that were fairly basic commonsense, as far as she was concerned; that was the worry she had.

Dr Taylor

  236. I think this was the difference between the two systems. We saw it in Durham, where the ward teams were really working; so it can work and it should work, because it always did. I hate to go back to a few years ago, but it did.
  (Mr McGuire) I feel really strongly about this point, things that do not really matter; feeding patients is critical. There is still a lot of malnutrition around in the NHS, particularly amongst elderly people. Often, catering services at ward level are treated as Cinderella services by clinical staff, and it is really critical that they are taken more seriously, whether it is private sector or public sector, the feeding of patients and front-line care, just the principle of care, talking to people, is critical. Support services staff working in ward teams are very, very important people.


  237. Mr Rose, I have not brought you in so far, and you may want to comment on the general areas that we have touched on?
  (Mr Rose) I am happy to do so, Chairman. I think that Sandra Gidley hit the nail on the head, that the discussion so far is really nothing about PFI or the private sector, so far it has been about good hygiene and good practices. And certainly we in the private sector would never manage to get business, far less repeat business, if we did not abide by good practices, because we know whenever we go into a hospital we are under the spotlight. And we have very good experiences of working as part of a ward team, of helping to raise standards, and we certainly take a view that feeding patients and caring for patients is a critical function, it is the front-line function that we perform because we are there to help patients to have a more comfortable stay in hospital and to make sure that they get out well; we are not there simply to do a job because we are paid to do so. I cannot comment on any individual hospital, you can appreciate, it may be one of my member companies who does it, it may not, but, generally speaking, we believe we have a good relationship. We do not have problems with ward sisters, we work as teams. A lot of the issues do come down to local management, whether it is local management in hospital or local management at a sub-division on a ward, or a group of wards. And that is one of the issues we do have to address, because if there is a problem on either side, whether it be the public or the private sector, then communication breaks down, delivery breaks down, the standards go. And part of what we try to do, wherever we are, is to make sure that there are good relationships, and if something starts to go wrong to get in very quickly to stop it going wrong, because if it starts to slide it is very, very difficult to bring it back.

  238. So you do not think necessarily that this issue that Mr Turner highlighted, about having to deal with different managers from the contractual side, is necessarily common; and, secondly, the point that came over from one of the ward sisters that we met in Carlisle was her concern about not just the fact that she did not have a complete team, because the cleaner was not part of the team, but the individual cleaner on the ward frequently changed on a regular basis, so they did not get to know them, they did not work as a team, because they were virtually strangers, they did not how the person worked, the cleaner did not know the ward staff, and if you lack that kind of familiarity in a team doing a job on a ward you have got problems?
  (Mr Rose) Indeed. On the manager side, I find it surprising that there were so many changes, and we try not to have that; when we have someone on contract we like that person to be there for the whole of the contract. Equally, of course, we find that Trust managers change almost as frequently, and I am sure we will come on to that later on, in some instances, because they get promotion, they move on to another Trust, and we are trying to deal with somebody new. Talking about the cleaners, again, one would have to know what the circumstances of the contract were; sometimes it is simply that people move because they get more money, or they want to change their hours, or they want to be nearer home. Sometimes there will be changes because we are not satisfied with the staff and we do not believe that the ward is getting the service it deserves, and so we will move that staff member or get rid of that staff member in order that there is better service. But, generally speaking, whether it is at managerial or at operative level, we prefer to have a constant staff so that we can develop a relationship, we can build up a standard, and clearly we can do the job better as people get to know the environment in which they work, and therefore can produce better services, higher quality, indeed more efficient services because of familiarity.

Jim Dowd

  239. Just on that point; the question of cohesion between clinical and support services has always been an issue, the problems with domestics and portering services for ward sisters, they are as old as the Health Service itself, I do not think they are a particular aspect of PFI or contracting out. But can I just ask Mr Weeks, to start with. All public services, the Health Service pre-eminently, there are three key interests; one, the producer interest, which I am sure you represent adequately, the second is the user or the consumer, and the third, of course, is the taxpayer, the one who actually pays for the service in the broader community. Has not tendering really brought discipline and reduced costs in areas which were previously inefficient, thereby freeing resources, both for patient care and also ensuring the taxpayer actually gets a better deal out of their investment?
  (Mr Weeks) There are a number of questions within that question. I would just add a caveat at the beginning. Of course, we are the trade union largely concerned with the interests of the people who work in the Health Service, but the people who work in the Health Service work there because they care about the service they provide; we are not solely there and they do not ask us solely to represent their interests as employees, they are concerned about the quality of the service that they provide. Many of them are users of the service, all of them have families that use the service, and, of course, all of them are taxpayers. So just to add that, at the beginning, about where we are coming from. I think you have to separate out the issue of looking at costs and benchmarking from moving to contracting out. It is absolutely true, and UNISON does not oppose benchmarking at all, we co-operate with it, nationally and locally, that the process of benchmarking, which perhaps the original market testing was a catalyst for, has produced positive results in terms of looking at how services should be provided and moving costs down. We would have said, you could have done that in a different, in a much less brutal way, to be absolutely honest, particularly in the first phase, but that process is one that we welcome, engage with and work with, and local examples have been given already. We would say that contracting out itself may have reduced costs, but the extent to which it has is debatable, even the Department was not able to produce a reliable estimate of the extent to which it had overall, some individual Trusts could, but the Department as a whole was not able to do so when it carried out its review of market testing, but it came up with a range of estimates of between 5 and 10 per cent. We would say that some of that reduction in costs has come at the expense of the employees, and that, particularly from the point of view that those employees are the-lowest-paid workers in the Health Service, and historically have always been, that their interests have not been properly accommodated, was not a result of cost-cutting that we should welcome, that even if it reduced costs it was not the right way to do it, at the expense of some of the lowest-paid people in that service. Secondly, we think the way that the costs were estimated exaggerates the extent to which costs were reduced, because the impact, for example, on social security benefits of reducing wages for the lowest-paid people was never properly costed. So we would not dispute that costs have been reduced, we would dispute the extent of it.

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