Examination of Witnesses (Questions 81-101)
MR DAVE GALLIGAN, MS EIRLYS WARRINGTON, MS LIZ HEWETT AND MR GREG WALKER
MONDAY 17 JUNE 2002
81. I am sorry for the delay in starting but that is perfectly normal in my committee. Feel free not to be intimidated by the process of the Committee; that is the way it has to work under the rules of the House of Commons. Although your words may be taken down, they may not be used in evidence against you! This is really an evidence-gathering session. We want to make sure that the NHS Act for Wales becomes an Act and works properly. We are trying to work with the Assembly as far as we can and as far as our Standing Orders allow. We have an Assembly Member sitting in as some of us sat in on the Assembly Committee. We have one person we were not expecting but we always welcome them. Perhaps, David, you would like to start off and introduce yourself.
(Mr Galligan) I am Dave Galligan, Unison's Head of Health in Wales. My colleagues are all from the Royal College of Nursing and I am sure they can speak for themselves.
(Ms Warrington) Good afternoon. My name is Eirlys Warrington and I am Chairman of the Welsh Board of the Royal College of Nursing. First of all, could I thank you for inviting us to give evidence to the Select Committee on the draft NHS Wales Bill. This is an important Bill with proposals that will influence several aspects of NHS plans for Wales. The Bill will set up Health Professions Wales, which will act as a supervisory body for all the health professions in Wales including nurses, midwives and health visitors. RCN members will therefore have a direct interest in the content of the Bill. On my right is Liz Hewett, Chief Executive and Board Secretary to the Royal College of Nursing Wales, and Greg Walker, our policy adviser. Thank you very much, Chairman.
Chairman: Thank you very much. If we can start with Dr Francis.
82. Good afternoon. This is a general question really. Leaving aside for a moment the three specific issues covered in the draft Bill, are there any general observations either or both of you, ie, the Union on or RCNW, would wish to make concerning the draft Bill and the procedures that are being used?
(Mr Galligan) From Unison's position we welcome the opportunity to go through this pre-legislative scrutiny. It a new departure for us and anything that improves the consultative process is certainly something we would support and endorse. The whole process, as far as we can view it, seems to be a lot more transparent than perhaps other things that have gone in the past. That has got to be a plus in terms of extending the democratic mandate. We welcome the opportunity to try to express our views and influence the process. Whether it has any influence or not, we will judge in the fullness of time.
83. I notice in RCNW's evidence to us that you make some interesting constitutional points.
(Ms Hewett) You are absolutely right, as we say in our written evidence, we are pleased that the Bill has been published in draft form. We too welcome the new approach. We think that is very healthy and gives an open and transparent approach to consultation on what is a very important Bill for us in Wales. I think the fact that interested parties have had this opportunity to comment is very welcome and very healthy. Of course, we would hope that this would now be the model by which Welsh Bills and Welsh clauses in England and Wales Bills will be treated from here on. We would certainly look forward to partaking in that. As to parliamentary procedures, as we have made reference to in our written submission we have stated that we would favour a standing committee at committee stage which is as broad as possible and includes as many Welsh MPs as is practicable, recognising the onus of responsibility that you already carry as MPs anyway.
84. Would you say it is too prescriptive or not prescriptive enough at the moment?
(Ms Hewett) The Bill in general terms? What we are seeking to gain from this is something that is prescriptive enough in a broad sense but allows the detail to be discussed locally in Wales and for the Welsh Assembly to have secondary and legislative powers to enable principles to be enacted. We would not be looking for a lot of detail, we would be looking for broad brush principles to allow the Assembly to move those on.
85. Is Unison and the RCNW expecting to be consulted on draft Regulations at an early stage?
(Mr Galligan) We would welcome the opportunity to be consulted on legislation as it affects our members at any stage and the earlier the better. It is a new departure and it is a new approach that we can only judge as the influence that we seek to bear comes to fruition. If it affects our members we would certainly want to be involved and try and shape the legislation as much as we can.
(Ms Hewett) Obviously the earlier the better we on behalf of our members are involved. I think it is also fair to say that there is very little to do with health that does not affect nurses, who are obviously our primary interest in this respect, and therefore not only would we hope to be consulted but I think in the spirit of openness and transparency we would expect to be consulted.
86. Both Unison and the Royal College of Nurses Wales seem to back all the proposed legislation while raising some detailed queries, a number of which we are going to explore in a few minutes. The AWCHC: how do you think it can or should function? Can it be given responsibility for CHCs?
(Ms Hewett) We have given consideration to this. Firstly, we would not want necessarily to see that there is primary legislation, as I think I have probably given in response to my previous question, of any great detail. We are of the view, though, that there is a need for an association, if you like an over-arching body to oversee the work of which we are supportive of community health councils in Wales. However, what we do feeland I was listening to your earlier debate and I am not looking to go back into the detail of thatfrom our own work with community health councils locally and at an all-Wales level is that their current powers and roles are challenged by their current level of resources. If they are to extend and expand their work and their powers in the future then the resources have got to follow that expectation.
(Mr Galligan) One would try not to add to what has already been said but in some respects the unified role that it presents gives a unified voice to the CHCs in Wales. With that voice you have to judge whether the responsibility that it can deliver can be supported with any powers on behalf of the Association. It really is something that needs a bit more teeth and certainly a lot more fleshing out. I am not going to add to the debate about finances because we could argue every one of these clauses on finances.
87. Secondly, the CHC staff: who do you think should employ, deploy and pay them?
(Mr Galligan) Unison represents a significant number of the CHC staff. The existing arrangement is that they are simply bolted on as part of the health authorities and whilst it is under discussion at the moment where they should move to post 1 April 2003, the reality is that it continues to expose the fault lines in Wales that were caused by the abolition of the Common Services Authority. Ever since that was abolished in 1999 we have been bolting on a multiplicity of agencies and groups on to various trusts around Wales, none of which sit particularly comfortably. I think the (?) Trust more resembles the Common Services Authority than the old authority did in itself. Notwithstanding that, they have to be given a home and they have to have some relationship both with the service and the Assembly. We believe they should be part of the service but in a hands-off, arm's lengths role simply managed through one of the trusts. In that context we have no particular feelings which trust they should be bolted onto but certainly they need to be part of the service even at arm's length rather than part of the Assembly which might prejudice how people might view their role.
(Ms Hewett) Again not wanting to get into repetition because a lot of what I would want to say has already been said, it is an issue that warrants further consultations once the draft Bill has completed its passage. We would certainly look for the CHCs to retain some degree of independence and therefore more of an arm's length approach to their role in overseeing National Health services and patients who use those services. At a minimum a service level agreement between an organisation which may be called the Association of CHCs in Wales and the Service and the Assembly would be satisfactory, but I think the more independence and the greater the arm's length the better and the more robust their ability is to complete the task in hand.
88. Continuing on the role and structure of CHCs, what about CHC membership: how should it be different from local health board membership? Should your members, for instance, be on CHCs?
(Mr Galligan) In some respects our members will be on CHCs through other bodies or as members of local authorities or voluntary sector interests or interests in the community. The reality is that CHC membership does need to be reflective and representative of the community they serve. I do not think that is always the case at the present time and we welcome, as we said in our submission, the proposals to at least pay particular attention to making sure that they are representative of their communities. How you do that I suppose poses a question. Open advertisement is obviously one way. Local authorities will continue to have a role on there, although we do perhaps consider there may be some tensions between local authority members on CHCs and local authority members on local health boards who may be pursuing different avenues on certain issues. The reality is that independent representative voices are what are required and that requires a broader brush approach than is perhaps adopted at the present time. I am loath to use the terminology but there is an awful lot of the usual suspects sitting on all the same bodies.
89. Before the Royal College of Nursing comes in, in your submission you specifically say that every effort needs to be made to gain representation for groups and communities that are traditionally excluded or disaffected from involvement in public bodies. Who had you in mind when you were writing that?
(Mr Galligan) I am particularly conscious in the larger urban environments of a significant number of ethnic community people such as within Cardiff who I do not feel are properly represented in my understanding of the composition of the CHC. I believe that is by accident. It is simply about getting people to engage in a process. In some respects perhaps it is the fact that CHCs have not been seen to be viewed in all sectors as the voice of patients. They have gone through a number of transformations over the years. It would be unfair to say that they are not representative in every community but every CHC would need to look at its own composition. Somebody needs to look at it objectively and see whether it is representative of that local community. It is a broad brush treatment for what is probably not a broad brush problem.
(Ms Hewett) I think clearly many of our members would in their own personal right be or could be members of CHCs so in that respect they are there. Whether we want to be the nominating body to create membership on a future CHC, I think is debatable. We do not find it the best idea to compare local health boards with CHCs because we believe that the two bodies serve quite different functions and therefore have different roles and responsibilities. The adage that form follows function is probably the best one and therefore when you understand the remit, role, format, responsibility and function of the body, then the membership of that body should reflect exactly that. So whilst we are very pleased that we have seen nurses going to be appointed to the executive of a local health board, I am not convinced that they need to necessarily be there in their own right on the community health council. They can be there in a personal way and bring a diverse range of skills to the work of CHCs but not necessarily because they are a nurse. I would be very dubious about the rationale behind why you would want a nurse in that respect and tokenism is something that we would find it hard to live with.
90. There is that consumer/deliverer dichotomy. At the moment CHCs are consumer organisations and as organisations you represent people delivering that service.
(Ms Hewett) I think it is fair to say as well that in our experience of being nurses and talking to nurses and talking to our members, nurses and CHCs generally work very well together and have a mutual respect and understanding of each other's roles. If it is not broken, we are not sure there is a need to fix it.
91. Generic advocacy services: do you think CHCs are the right organisations for this? Indeed, are there any realistic alternatives?
(Mr Galligan) There are other organisations and we have debated that here this afternoon. We would suggest how you allocate 12 postswhich I think is the figure that is being proposedamongst 22 instantly creates a problem whilst there is going to be some shared services among the CHCs. If advocacy is to be taken seriously, it needs to be supported and funded appropriately and the advocacy demands could be different in different CHC areas as a consequence. It again needs to be judged a little more ambitiously and in the light of a little more evidence rather than as we seem to have done which is plucked a figure of 12 out of the air. We have 12 because that is what currently sits in the existing arrangement. Advocacy is something under a great deal of discussion at the moment and the value of it cannot be underestimated. I believe the CHC is the natural home of advocacy. Whilst we are not enamoured of the viewpoint of calling them Patients' Cymru, the issue is that advocacy in this context is going to be a key element within that. We do not think this sits comfortably anywhere else than in CHCs if they are going to represented.
(Ms Hewett) I think it is fair to say that advocacy is there is some sense now. What we want to see is much stronger advocacy services made available. We would see the inception of generic advocacy services as complementing the advocacy services that already exist, albeit we believe they are completely under-resourced and therefore under-utilised. However, to undertake advocacy properly and to have benefit to those for whom you are advocating, it needs to be as independent as possible otherwise vested interests will clearly be factored in and that is not proper advocacy we would suggest. We do not have a difficulty with the idea of CHCs providing that service but again we are back to the resources debate which has been well articulated here already this afternoon so I will not go over it. We would be sympathetic to that, therefore it is our suggestion within our written submission that we would support the idea that CHCs could be the lead commissioning body for advocacy services. We would factor in the fact that we would be looking for consistency for all people across Wales. We do not have a difficulty if it is CHCs but given the practicalities and realities of where they are and where they might be, they might want to be the commissioner and the lead.
92. There are a number of voluntary bodies providing advocacy for patients, particularly for those with mental health problems at the moment. Do you think it is an either/or or do you think the voluntary or statutory bodies can complement each other?
(Ms Hewett) It is complementary. The pure theorists amongst the world would say patients should be able to choose their own advocate literally by name but by service as well. We have to be careful about not prescribing who one's advocate or one cohort of patient's advocate is or which service that is. Your point is well-made that there are already some very good advocacy services around who, let's face it, progressed the services from something they were to where they are now. There is just a lot more to be done. It has to be complementary and therefore I do not think you should just ditch and dump the current advocacy services that are available, especially where they are working well and properly, for the sake of reinventing something which is new, needs resourcing and is an adventure, let's face it, because it is not an easy undertaking to be an advocate either for an individual or for a group of patients.
93. The last question on CHCs, and it overlaps on other things, concerns scrutiny. You represent many NHS employees in Wales. Do you have any fears that we might end up with too much or insufficiently co-ordinated scrutiny stopping your members getting on with their jobs?
(Ms Hewett) I have had that fear for some years and it does not alter each day. In fact, it probably gets worse in as much as the high level of scrutiny that is now invested into the service is appropriate and right, particularly, we would suggest, around clinical standards, professional conduct and financial probity. What we are absolutely clear about as well is the inordinate amount of time that our membersnurses, midwives and health visitorsare having to spend on form-filling and measuring and returning forms on time and, therefore, there is an inordinate amount of additional appointments to administrative and managerial posts in the service as well. We believe that the down side to that is that that is not necessarily the best use of scarce resources.
(Mr Galligan) We do not have a different view to that. Enough needs to be judged as enough, but it is considered to be burdensome in the clinical environment at the moment.
(Ms Hewett) Basically taking nurses and others away from looking after the needs of patients and doing the job that this country's taxpayers have invested in training people to do that job.
(Mr Galligan) At a cost.
(Ms Hewett) Absolutely.
94. Does Wales really need the proposed Wales Centre for Health. In your submission you come down in favour of it but you have a number of reservations?
(Mr Galligan) We come out broadly in favour of it because it has been discussed for a long time, since 1998 as we understand it. The issue is not seeing it in isolation but working in collaboration with others. We are mindful of the changes going on with the abolition of health authorities and the public health responsibilities that are going to transfer as a consequence of the abolition of health authorities and the creation of the Health Protection Agency, which will also have a role in respect of how the Wales Centre for Health will work. It is a cautious welcome but we would like to see a little more evidence on what the expectations are rather than the need for it. The reality is that it has been around a long time and a lot of people are waiting for it to be delivered, but it is a cautious welcome.
95. Your reservations in your paper revolve around resources, staff and whether it is taking those away from direct delivery of health services.
(Mr Galligan) if it is a new body it needs to be funded and resourced accordingly, not requiring funding spread from everywhere else within the service to accommodate it. The reality is that new ideas and new initiatives need new funding, not using the existing funding which is usually to the detriment of patient care somewhere down the line, and arguments on the cost of administration and bureaucracy. It really is such a new area for us that we would like to comment, perhaps having given it a little more time to work as to whether or not we view it more favourably than what we have said in our presentation.
(Ms Hewett) We have also welcomed the concept of a Centre for Health. Again, the concept has been around since 1998 and we would like to see it come to fruition, although I concur with the idea that we still need to know a bit more detail and meat on the bones of exactly what such a body would do, even with the demise of health authorities, which is imminent now. The opportunity that is provided by the concept of a Wales Centre for Health is that we could move into a new model of how public health is viewed and that is it is no longer the domain of one health care professional and it should be therefore be quite clearly a multi-professional approach to public health, and that would certainly be progressive and modernise the concept of public health. That is what we would be seeking.
96. The RCN in its submission refers to the possible transfer of staff. What sort of guarantees do you seek in that area?
(Ms Hewett) We are quite clear on that. We would seek and we are looking for a public assurance from the Minister for Health and Social Services in the Assembly that TUPE will be invoked and used if staff are transferred from existing entities that maybe would meet their demise in the future to such an entity as the Centre for Health. We are quite clear on what we want and what we are seeking.
97. Do you have a vision as to the connection between the newly agreed National Public Health Service and the Wales Centre for Health and how they are going to interact?
(Ms Hewett) It has to be a close relationship and it has to be one that is complementary, not one that duplicates but recognises that the Centre for Health is primarily there to conduct research and analysis rather than to provide public health services directly, which will be the role, as we understand it, of the new NPHS, so we would expect complementary working recognising that each has a role to play, but there are subtle differences between those roles. Again, I would stress the importance, as I see it, of a new multi-professional approach to public health not a single or uni-professional approach to public health, which has traditionally been the case.
(Mr Galligan) I would not dispute that view.
98. If the Welsh Centre for Health is to represent the wider public interest in public health, do you think its statutory terms of reference should be broadened?
(Mr Galligan) I really have not got a view on it. Unison has not taken a considerable view on it beyond what we have said in the submission. I would be stabbing in the dark to try to respond to that.
(Ms Hewett) We have taken the view that at the moment it feels appropriate. I think it would be tempting to include a lengthy list of functions in the Bill, but we also can see that that would not be necessarily helpful in the final analysis. We think it is more appropriate that the specific functions be set up by order of the National Assembly. That is back to my earlier comment that we are looking for broad brush principles and details to be enacted locally.
99. If we can turn now to Health Professions Wales with a series of questions. What do you see as HPW's role in relation to staff groups such as health care assistants? Is RCNW's concern on page 5 of its memorandum that any Code of Conduct should be UK-wide?
(Ms Hewett) The Royal College of Nursing UK has as yet to produce a position statement, and that is because we are still waiting for the outcome of the consultation by the Department of Health on the future of regulation of health care assistants. What I am happy to give you is a more personal perspective as the current appointee to the Nursing and Midwifery Council and that is on a personal level I believe that the Regulations should be UK-wide if it were to be forthcoming.
(Mr Galligan) Unison has long argued that the issue of a Code of Conduct for health care assistants does need to be universal UK-wide. It has actively campaigned for a long time for a register of health care assistants in this context to make the field more professional. We use the term "health care assistants" but I notice that the document talks of "health care support workers". Health care assistants and their registration have long been something that Unison has campaigned for.
100. Does the HPW have the resources to do what it should do? Unison doubts it.
(Mr Galligan) Unison doubts it very much. It does appear that HPW has taken on a role of additional functions that was not its responsibility before, working to a wider group than previously it did, and the Welsh National Board for Nursing Midwifery and Health Visiting has expanded its role. I do not see significant evidence that it has expanded its resource base to accommodate that. I remain to be corrected on that point but it does appear to me that if you expand an organisation's responsibilities significantly you do need to support that and resource it accordingly, whether that is during its current status living within the Assembly before it eventually moves out as an Assembly sponsored public body. Things will be a little different, as we understand it, and its responsibilities have been enlarged b a significant degree. I am not aware there has been a sufficient level of funding to accommodate that.
(Ms Hewett) I cannot sensibly add to what has already been said without repeating.
101. RCNW questions the power under clause 4(4) for the Assembly to give directions to HPW. Does that mean less autonomy than for example the old Welsh National Board had?
(Ms Hewett) We have taken the view we believe there are too many powers of direction for the Assembly in the Bill and we believe that HPW should be operated again at arm's length from the Assembly and should not been seen simply as a creature of the Assembly. The provision in clause 4(4)"in exercising any function, Health Professions Wales must comply with any direction given by the Assembly"we find far too controlling and not necessarily the most helpful way to move things forward. We would prefer to see a wording that included "HPW should have to have regard to directions by the Minister" rather than the stronger "must comply" injunction as is set out in the current clause, and we believe that that would better provide for the role and function of Health Professional Wales in Wales and for Wales.
Chairman: I think that is it. Thank you very much for coming and thank you for the written submissions as well. Although we have passed the formal limit for any written submissions, by all means put them in because we want to get this right. Once again, thank you very much for coming.