The below quotes are extracts from NHS Commissioning Board chair Professor Malcolm Grant's pre-confirmation health select committee appearance. The whole (uncorrected) transcript follows below.
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“This is not an obvious course for anyone who is enjoying their current job to head off on. I’m here today because I think there’s a serious job to be done”
“I start with … passion for the NHS. I think this is one of the greatest institutions this country has”
“One of my great associations with the NHS is by virtue of having been married to a GP for the last 37 years, which has given me a remarkable insight in how it actually work not in the committee rooms of Westminster but in the general practices of this country”
“For the NHS to be led more by strategy than by crisis ... it seems to me is the opportunity the Board provides”
“I hope to be able to do both of the jobs at once (UCL provost and NHSCB chair), and what makes that possible has been the very strong support I’ve had from senior colleagues at UCL … the key thing – coupled with securing the approval of the UCL Council – that’s made it possible for me to consider doing it. I should make clear that I recently announced to UCL Council that I will seek to stand down in two years time. That will have given me ten years in the job, which is, I can assure you, quite an endurace feat nowadays for a vice-chancellor. That allows me to consider how to match the demands of my final two years at UCL against the growing demands of this job over the coming two years and then of course beyond”.
“This Board’s not going to do anything unless it is visibly independent and strong-minded”.
“It’s absolutely critical to be clear about the difference between governance and management. DN will have responsibility for managing the Board. The board will have responsibility for governing … I’m very strongly against full-time chairmen – I’ve seen too many instances of full-time chairmen confusing themselves with the chief executive and vice versa”.
“The critical thing is to ensure that we overcome some of the inherent fragmentation that presently exists across the NHS, with much clearer ideas about where collaboration and co-operation are going to be essential – and ultimately, where accountability lies”
“I have to say that the Bill is completely unintelligible”.
"The buck stops with those who are spending the money".
"Look at the outcomes of the NHS against what goes into it: they're not perfect but by God they're among the best in the world".
"There is a fundamental change in accountability and responsibility in the NHS".
"I suspect there's quite a lot of silo-working going on in the NHS".
"As a consequence of the principles in the Bill of autonomy, we need to allow CCGs to do things their way".
"Taking a long-term view for the NHS depends on the mandate; the Board has to take a powerful role in setting up the mandate. We need to set objectives, cost them and get realistic balance in mandate ... we would then like the mandate not to change significantly year-on-year".
"This is not going to end up with a perfect heath system. We're entering on a long-term process".
UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 1562-I
HOUSE OF COMMONS ORAL EVIDENCE TAKEN BEFORE THE HEALTH COMMITTEE
PRE-APPOINTMENT HEARING FOR CHAIR OF THE NHS COMMISSIONING BOARD
Evidence heard in Public TUESDAY 18 OCTOBER 2011 PROFESSOR MALCOLM GRANT CBE
USE OF THE TRANSCRIPT
Questions 1- 70
1. This is an uncorrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee, and copies have been made available by the Vote Office for the use of Members and others.
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Oral Evidence Taken before the Health Committee on Tuesday 18 October 2011 Members present: Stephen Dorrell (Chair) Rosie Cooper Andrew George Grahame M Morris
Dr Daniel Poulter Mr Virendra Sharma Dr Sarah Wollaston
Examination of Witness Witness: Professor Malcolm Grant CBE, Prospective Chair of the NHS Commissioning Board, gave evidence.
Chair: Professor Grant, you are very welcome to the Committee. Congratulations on securing the Secretary of State’s nomination to what is going to be a very important post in the Health Service going forward. We are clearly going to have an open discussion with all the Members of the Committee, but I would like to open by saying that you obviously saw an advertisement in a newspaper and thought, “That is a job I would be interested in doing.” An interesting way to get the discussion going is to understand why you reached that conclusion and what it was that attracted you to the job, and hopefully still does.
Professor Grant: It certainly does, Chairman, and thank you for the opportunity to appear before the Committee this morning. The processes of recruiting to major public sector jobs are never quite as straightforward as you have suggested. The approach did come to me originally from head-hunters. Head-hunters, as you know, were retained by the Secretary of State for this post. Then various siren voices were spread around me to try to lead me to this destination, but it has been a long and difficult journey. It is not an obvious course for anybody who is enjoying their present job to head off along. I am here today because there is a serious job to be done and I hope you find that my background and interests are sufficient to allow the Committee to endorse that nomination.
Chair: At the heart of the question was not just was it in response to an advertisement or a head-hunter approach, but what is the pitch that you made to yourself to think that someone with the background that you have has value to add? What is the value that you are seeking to add to this process, given the nature of the beast that you are taking on?
Professor Grant: I start with something that is not a value to add but rather a quality and a value that is shared by everybody in this room, which is passion about the NHS. It is one of the greatest institutions this country has. The path that has been mapped out in the Bill is one that contains a wide variety of opportunities and risks.
One of my great associations with the NHS is by virtue of having been married to a GP for the last 37 years, which has given me a remarkable insight as to how it works, not in the committee rooms of Westminster but in the general practices of this country. A second one is being the president of a university with a fantastic health and medical sciences school and a very strong relationship with key London hospitals, which has grown quite dramatically in the eight years in which I have held this job. This has given birth to UCL Partners, a unique academic health sciences centre in which I have been very closely involved since its inception.
In a sense, although I am only a lawyer, I have been able to engage with the NHS through Partners to see what is happening and what can be achieved. One example by which I have been totally enthralled is the handling of acute stroke in London. Relatively simple service reconfigurations—unthreatening and strategically carried through—have led to a reduction in mortality from the national average of 22% to 10% in this part of London. That opens the eyes of all of us to the opportunities that one can bring to the NHS if it is led much more by strategy than crisis. That seems to me to be the opportunity that the Board provides.
Chair: We will no doubt come on to that as the session continues. How does this relate to your relationship with UCL? Clearly you have a full-time executive post there and this is a pretty challenging post. How do you anticipate balancing those?
Professor Grant: I hope to be able to do both jobs at once. What makes that possible is the very strong support I have had from senior colleagues at UCL, which I will explain.
I have a very strong senior management team, five vice-provosts, who work directly to me, and 10 deans of the different faculties. A large component of what we do is life and medical sciences, probably about 60% of UCL’s activity. The enthusiasm that has been shown by my colleagues for my undertaking this role has been quite humbling. Their expression of a willingness to support me intellectually and also to substitute for me from time to time on formal engagements at UCL and to allow me to free up the time has been the key thing that has made it possible for me to consider doing it, coupled with securing the approval of the UCL Council to our proceeding in this way.
Recently I announced to the UCL Council that I would seek to stand down from my job in two years’ time. That will have given me 10 years in the role, which I assure you is quite an endurance feat nowadays for a vice-chancellor. That allows me to consider how to match my final two years at UCL against the growing demands of this job over the coming two years and then, of course, beyond.
Chair: The advertisement suggested that the higher time commitment to this job will be in the early period rather than the later period. Do you agree with that?
Professor Grant: No, I do not. It is completely impossible to forecast it at this stage. The one simple maxim is that the work will grow to fill the time available. Would you like me to trace through how I see it developing over the coming two years?
Professor Grant: The first major task is to recruit the other members of the Board. The proposal is that the Board should be small, probably no more than 10. The majority should be non-executive members. That requires the recruitment of five other non-executive members. The minority will be executive members with David Nicholson, who is the Chief Executive, and three others. For the non-executive members I would be very keen to ensure that we recruited some of the most able and independently-minded people we can find. This Board is not going to do anything unless it is visibly independent and strong-minded. We should be able to complete that process of appointment by, let us say, January. In the meantime, there is an enormous amount of work to be done at a management level in terms of devising the systems and the processes that will take us through the transition. From April 2012 a Special Health Authority which will have been created at the end of this month will
assume some limited statutory responsibilities for patient safety. From September 2012 it will take on the statutory responsibility for authorising the clinical commissioning groups.
From April 2013 it will become fully operational. At that stage, the clinical commissioning groups will also become fully operational. There is a build-up of responsibility over that period, and from April 2013 the job will no doubt be particularly demanding.
What head-hunters and job describers can never fully predict are two things. One is what is the relationship between the Chair and the Executive team? The other is what needs to be done that goes well beyond the strict terms of the job description but is essential to make it work.
Let me deal with the first one. It is absolutely critical to be clear about the difference between governance and management. David Nicholson will have responsibility for managing the Board. The Board will have responsibility for governing. I am sorry that the word “Board” gets used ambiguously in this context, as I think this Committee has pointed out in the past. The governance role risks tripping over its shoelaces if the governors spend too much of their time doing the governance. I am very strongly against full-time chairmen. I have seen too many instances of full-time chairmen confusing themselves with the chief executive and vice versa. The governance role needs to be sufficient and focused to allow the executive team a clear structure within which to operate.
The second part—thinking over the role in the 100 hours since my nomination was announced—seems to me to engage with a much wider community. The Chairman has to be engaging with the Royal Colleges, the clinical community across the country and with the other big beasts in the NHS landscape, such as NICE, the CQC and Monitor. It is critical to ensure that we overcome some of the inherent fragmentation that presently exists across the NHS and get much clearer ideas about where collaboration and co-operation are going to be essential and, ultimately, where accountability lies. That seems to be the transformational change from where we are at the moment to what the new Board must be able to deliver.
Chair: I do not want to monopolise the questions, so perhaps I will turn to Grahame because the point on accountability that you ended on is probably where Grahame would like to pick you up.
Grahame Morris: Professor Grant, can you share your thoughts with the Committee in relation to governance and accountability, in particular in the context of the changes that are envisaged in the Health and Social Care Bill that is currently in the House of Lords, in respect of the Secretary of State’s responsibilities? Is he in effect delegating or abrogating his responsibilities for the NHS? Is he passing the buck to you and the NHS Commissioning Board?
Professor Grant: I would not put it in either of those ways, but let me try another way of expressing it. The Bill is still in the House of Lords and the House of Lords Constitution Committee has raised some questions about this very point. They will, I know, be reviewed very closely in the Lords. As the Bill currently stands, you have to look at clause 1, which retains the Secretary of State’s responsibility for delivering a comprehensive National Health Service in this country, and at clause 20. I have to say, by the way, that the Bill is completely unintelligible.
Grahame Morris: The Secretary of State is delegating that responsibility to you, is he not?
Professor Grant: No, I am coming to that. The reason I say this is that clause 20 inserts clauses 13A to 13Z(1) in the National Health Service Act 2006. You have to try to read the two at once and then forecast what will happen in subordinate legislation. Let us
summarise what clause 20 does. It requires the Secretary of State to prepare a mandate for the Board. That mandate sets out the Secretary of State’s objectives for the Board and also its future financial arrangements. The mandate should not be for a single year but for two years, and possibly three years if we are going to have the Board running properly and strategically.
The mandate needs to be discussed with the Board before it is published. It needs to be laid before Parliament and it is a public, clear document, which, for the first time, establishes accountability.
In so far as the matter is within the mandate of the Board, it is not within the jurisdiction of the Secretary of State, except that he has power to revise the mandate with the consent of the Board or he may revise it in exceptional circumstances. I am sure we need that clause. That is only going to happen, is it not, when there has been a break-down of relationship? If he cannot revise it with the Commissioning Board, then he is going to need to move to the “exceptional circumstances” clause.
What that does is effect an extraordinary transformation of responsibility within the NHS.
You used the words “abrogate” or “delegate”. It is not “delegate”. It is passing over the responsibility and then allowing the Secretary of State, through the mandate, to hold the Board accountable against the objectives that have been set for it. It is then for the Board, through its relationship with the clinical commissioning groups, to hold them accountable for the objectives that are set for them. It allows us, for the first time, the possibility of tracking accountability and responsibility through a system and, what I would see as being the prize to fight for, restoring to the NHS the stability that it needs away from day-to-day political interference in its priorities. You may worry about the ultimate political accountability. It remains secure, but it requires a Secretary of State to define upfront what he or she wants the Board to be accountable for and to hold the Board accountable for it.
I should have mentioned one other final provision which is in the Bill. The Secretary of State can amend a mandate after a general election. That may satisfy some concerns about dramatic changing of priorities.
Grahame Morris: Can I follow up on that? I am grateful for that because your view that the Secretary of State is transferring power to the NHS Commissioning Board is very illuminating. I am glad you have shared that with us. I know that you are not in post yet and your background does not give you a detailed knowledge of individual services, but you did give an example in your opening remarks about stroke services in London and how you see the NHS Commissioning Board as strategically planning rather than fire fighting and reacting to crises. In respect of some of the other issues that need to be addressed, for example disparities, health inequalities and access to radiotherapy services, in the north of England we have one of the 28 Cancer Networks and ours is the worst performing in terms of access to radiotherapy services. What role would the NHS Commissioning Board play in addressing such disparities?
Professor Grant: Over the period through to September next year, as I see it, the NHS Commissioning Board is going to be working very closely with the clinical commissioning groups trying to develop this understanding of what commissioning truly means. We are not starting from a blank sheet of paper. Many of these are now working with Pathfinder status within PCTs. Commissioning is not only buying a service. Commissioning is planning it, thinking about it, buying it, funding it, monitoring it and revising it. For an activity such as the Cancer Network, it requires the CCGs to think about pathways and networks for handling particular illnesses and conditions. It requires them to take local responsibility for developing the relationships between primary and secondary care, and other services such as radiotherapy, to satisfy themselves that they have the best deal. If the CCGs are the purse-holders for the future, then their ability to effect change is dramatic.
Grahame Morris: Are you accountable for that? As a Member of Parliament, living in a region that has the seventh highest incidence of newly-diagnosed cancer and the worst access, I cannot hold the Secretary to State to account now, other than through the biennial mandate to Parliament. Can I hold you accountable as the Chair of the NHS Commissioning Board?
Professor Grant: Let us break down your question because you talk of incidence as well as treatment. Incidence is an extremely important public health matter. Incidence is often a consequence of failure to present in a timely manner with symptoms. Incidence is also a consequence of lifestyle choices.
We are spending £2.7 billion a year on the disease consequences of smoking in this country. There are 1.1 million admissions to hospital on alcohol-related incidents. We have the other enormous public health epidemic of obesity where we are seeing between 5% and 6% of the NHS budget going on obesity-related conditions such as type 2 diabetes. If you start by talking about incidence, it highlights the need for this whole thing to be much more joined up around public health, health education, self-care and presentation in the first instance. In so far as the treatment of cancer is concerned, once there has been a presentation and diagnosis, it is very much now for the CCGs in the hands of GPs through these consortia to ensure they are getting the best possible service from their secondary providers. If they are not, it is their responsibility to ensure that that service improves.
Grahame Morris: How will you performance manage the clinical commissioning groups and the other commissioners who are responsible for £100 billion worth of taxpayers’ money? What happens if they are underperforming? How are you going to hold them to account?
Professor Grant: That is a very difficult question. The simple answer is that there are several levers and the CCGs will have a variety of different starting points. Come April 2013, there will be some that are up and ready to go and some which will have command of a population which is quite significant, up to 600,000, for example, and with good experience. Others, I expect, will not be ready to go by April 2013. That commissioning will need, in the meantime, to be done for them by the Board. The levers that are available are various, but they will require close relationships with the Board. They can include performance management. They can include engagement with the clinical senates that are proposed to be established so that we can bring multi-disciplinary opinion and guidance in geographical areas to bear upon particular issues as you have described. But, remember, we are at the early stages of a journey here. What I do not want to be this morning is prescriptive in relation to a whole new approach to commissioning healthcare in this country.
Chair: There is an old saying: “When everybody is responsible, nobody is responsible.” It was striking in your answer to Grahame’s questions that you listed a whole series of people who are certainly engaged, but where does the buck stop?
Professor Grant: The buck stops with those who are spending the money.
Rosie Cooper: You.
Professor Grant: That is a very good point. It is a bit like health and safety, is it not?
Each of you secure the level below where the responsibility goes, but in this, remember, the role of the Commissioning Board is to devolve the budget to the CCGs, and the CCGs are those who are empowered to get best value for money and quality healthcare from those devolved budgets.
Chair: Devolution implies a decision. Who makes the decision?
Professor Grant: Do you mean the decision as to funding or as to quality?
Chair: I mean the decision to accept that a commissioning group is capable of delivering what the taxpayer wants for their pound.
Professor Grant: That is the Commissioning Board. As I see it—and, please, I am in early days yet—it is going to be an immensely active process of consultation and discussion over the coming 12 months, up to September next year and then through to the formal process of authorisation, which goes from September through to the following April. We will all be struggling to get away from the old Nye Bevan aphorism that if a bed pan drops in St Thomas’ Hospital it reverberates down the corridors of Whitehall.
Grahame Morris: It is Tredegar actually.
Professor Grant: Thank you, but it is not the way for the future and it never has, realistically, been the way for the past. People who spend the money have to take the responsibility.
Rosie Cooper: Grahame has asked the question I was going to ask, but I am really struck that in your evidence so far you never once mentioned patients in reality and your accountability to the people. If you are going to authorise CCGs and you are going to organise that commissioning, surely you must be accountable. Earlier you talked about passion for the NHS. As well as about accountability to the people, other than being married to a GP and having a medical school, what have you done that involves you in any way that demonstrates that passion about the NHS?
Professor Grant: Let me deal with the first question. It should have been implicit— and I should have made it clearer—when I was talking about the mandate that it is all about outcomes. The mandate has to be specified in terms of those five domains of outcomes prepared by NICE. As you will recall, they all revolve around patients. The whole point of the NHS is not around structures, which is where most of the debate has been on this Bill. How many people in this country know what a PCT is or have a clue what a clinical commissioning group is?
Rosie Cooper: They know where their hospital is.
Professor Grant: I would say, of the latter, that it is in the low thousands.
Rosie Cooper: They absolutely know where that medical service is delivered. They know where their local hospital is.
Professor Grant: Exactly.
Rosie Cooper: Will you and your Board be able to sustain the public opposition which will come back down to you as a Board personally? How will you be accountable for those decisions made by the power you have given in terms of accountability?
Professor Grant: To consider that question, the power we have given is a power to take decisions and to be held responsible for them. Our job as a Board is to try to ensure that there is a comprehensive network of CCGs across the country financed and empowered to get value for money for their provision of health services to patients. What they cannot do, as so often happens in the NHS at the moment, is to keep pushing that accountability back up the chain. We need to make sure that CCGs—these are the GPs, after all, who are being empowered—have the responsibility to take these decisions. If they are dissatisfied with what happens in a hospital they need to deal with it and not simply complain to a Secretary of State who no longer has this responsibility, nor to the Commissioning Board which has given them the responsibility, but to complain to the hospital and get it sorted, and, if it is not sorted, to use their commissioning power to ensure that it is. That seems to me to be a fundamental change of responsibility and accountability under the Bill.
Rosie Cooper: I think you are due a shock, but, ergo, what you are in essence saying to the great British public is that they will no longer have any power. Their view will not be heard.
Professor Grant: No; I think you have misunderstood that. I know I am due for a shock. I am due for a shock a day in a job like this, but let us not get away from—
Rosie Cooper: You have not described your passion for the NHS.
Professor Grant: Can I finish that one? I would very much like to be able to ensure, as we develop this, that we get away from running the NHS on the basis of “shock, shock, crisis, crisis” and that there is a more measured view, which is to do with one, two and three-year improvements in the quality of health and in patient satisfaction in this country. That has to be the long-term strategic aim. We cannot do that by all the time passing accountability and blame up through different parts of the system. The Chairman’s initial view is absolutely right. If you have too many people who are accountable, nobody is accountable.
Rosie Cooper: That is where we are.
Professor Grant: Good.
Rosie Cooper: Nobody is accountable.
Chair: What about your passion for the NHS?
Professor Grant: Come on, what do you want me to say? Doesn’t everybody have passion for the NHS? I love the expression that Peter Hennessy used in the House of Lords, which was that this was probably the greatest institutionalised altruism that this or any country has ever seen. Look at the outcomes of the NHS against the investment that goes into it. They are not perfect, but, by God, they are one of the best in the world. Anybody who can look at that without feeling some sense of passion for it is—
Rosie Cooper: I asked about the demonstration of that passion.
Professor Grant: I find it difficult to demonstrate because I am not a patient of the NHS. My passion for it, therefore, comes through my institutional involvement with some of London’s leading hospitals. We have people working in our hospitals who are saving lives on a daily basis. We have people who are developing research. We have a team working in Moorfields that I am really optimistic will come up with a stem-cell approach to curing blindness. How fantastic is that? You cannot stand back coldly and say, “Gosh, that is very nice, but it doesn’t matter to me.” It matters to all of us.
Rosie Cooper: Forgive me, but as chairman of a hospital, when I interviewed for non-executive posts, one of the questions would be about demonstrating involvement, knowledge and real depth of getting involved with the NHS. You have described a passion for the NHS, but I don’t know whether you are showing any. I suppose what I am really saying is you were head-hunted for the job, but have you had any contact with Ministers or people in the Department of Health, and were they involved in helping you draft the answers to the questions at all?
Professor Grant: What was that, I am sorry?
Rosie Cooper: I mean the questions that were posed to you by the Committee.
Professor Grant: Yes. I was assisted in drafting the answers to those. I have, as you might have expected, spent a lot of time briefing myself. I do not take briefings for an appearance in a Select Committee except on issues about which I cannot find the answers elsewhere.
Rosie Cooper: But they helped you. Had you met with Ministers before your appointment?
Professor Grant: I have met Andrew Lansley, I think, on three occasions in my life.
Rosie Cooper: You have met Andrew Lansley. You have not met with Ministers before this appointment.
Professor Grant: No.
Dr Wollaston: Professor Grant, could I return to two points you have already touched on? The first is the balance between integration versus choice and competition. One of the statements we hear is that the Board will lead at national level the delivery of more choice and control for patients. Are you concerned that you may be being asked to deliver a mandate for something when in fact your natural instinct, which you have already referred to, is to look at integration and how these pathways work for patients? Secondly, you mentioned the issue of public health—a very important issue with, obviously, the huge problems we have with alcohol and smoking-related morbidity—but, of course, public health is going to remain with the Secretary of State. How are you going to manage that tension? If you feel that inadequate emphasis is being placed on prevention, how will you interact to push that the other way?
Professor Grant: I still find this a puzzle. This is one of the most difficult things to pull off. Public health and certainly health inequalities are absolutely appalling. Much of the work that has been done by my colleague Michael Marmot at UCL has touched on exactly this issue.
The relationship is one which is going to have to be worked on and will evolve over time. One of the roles of the Chairman of the Board will have to be drawing together these other organisations with responsibility for health. I suspect—and I am still young and naïve in this—that there is far too much silo operating going on. I know a little about local government. I have chaired the Local Government Commission for England and I know some of the problems which come from trying to organise health and social care through local government and the interface that exists with the NHS.
What are we going to do? We are going to have to make extensive use of the Health and Wellbeing Boards to tie together public health concerns with the work of the CCGs. We will have to have much more integrated care by taking pathways and trying to work out how we can deliver them, not only through the CCGs but also with other partners and providers. Remember this includes charities as much as anybody else. It also includes private providers.
One thing that I have only learned in recent days is the extent to which psychiatric services, for example, are bought in through private providers. 80% of The Priory’s work is for the NHS.
The question for my concern is how we get the best choice for patients as mediated by GPs. How do we get it on pathways as opposed to patients being told that their needs have to conform to the requirements of each specialty with which they are dealing? There are quite fundamental problems at the moment with the tariff systems and with the hospitals benefiting from a patient making six visits as opposed to one where there is an integrated care arrangement for overseeing all of the multiple problems from which they suffer.
Dr Poulter: I have a couple of questions picking up on what we started off with earlier. You clearly have a very strong record of public service in what you have done at UCL. You obviously train medical students, so you have an understanding of medicine, in my view, from that. You were talking about the importance of not micromanaging things, which I think a lot of us would agree with, and having long-term reconfiguration or long-term plans and strategies. Could you outline what you have done at UCL in that sort of vein?
Professor Grant: When I arrived in UCL, which was eight years ago, I wrote a Green Paper for the future of UCL. I consulted on it. It became a White Paper. It then defined the strategy for the institution for the next five years. I have done it twice since. We have published this month the latest White Paper for UCL. It helps you immensely to understand where you are going with an institution, if you are able to agree with your colleagues what the medium and long-term aims are and how you are going to be able to get there. You do not do this in any institution by command and control. You have to do it in an institution like a university by setting out an intellectual case that people will buy and setting out steps that will allow you to get there. That has been my experience at UCL. In many ways, it is reflected in what the institution has been able to achieve over that period.
Dr Poulter: It has always been a strong institution, but certainly its position has strengthened in a number of fields over that time. Thank you for that. It would be very much that approach, you have said already, that you would be taking towards the NHS, looking at the bigger picture and the longer term, if you are trying to take a lot of the knee-jerk politics out of things in how you would be commissioning services.
Professor Grant: Absolutely. It starts with the mandate. The Board has to play a powerful role in setting up the mandate. We may need to think about the outcomes framework because, at the moment, although it is specified at a high level, not all of the domains are fully filled. Setting the high-level outcomes, objectives and then costing them and getting a realistic balance between objective and cost into the mandate will be part 1. But I would love to see a mandate that, although it was issued on an annual basis and was reported on, on an annual basis, did not change significantly year on year. If you have agreed medium-term objectives, you should not be tearing them up at the end of the first year and starting with a fresh set the following year. That, to my mind, is the model for the Board for the future.
Dr Poulter: Finally, there is the issue we have talked a little bit about, which is accountability at the local level, local commissioning boards and accountability. There are concerns being flagged up by Members of the Committee about accountability—that at the moment PCTs are very unaccountable on a local level and lack, crucially, clinical leadership in many cases. I would like to clarify your position. There is a model in Cumbria where GPs have begun to lead on developing services and that has benefited patients, with reduced waiting times and improved integration of services locally. You believe that the local commissioning board should be very much at the heart of that, that the responsibility lies at a local level, it should be led by local commissioners and it should be those people who are holding to account local hospitals and helping to integrate services locally. That is very much how you see things.
Professor Grant: That is exactly right. The experience with PCTs has been quite mixed. I know there are some parts of country where people think PCTs have worked quite well. There are other parts where they have suffered from clinical leadership, perhaps from weak management and high levels of staff turnover. That fragility, of course, is enhanced at a time when reform is in the air. The weaknesses are exacerbated as we come through to the new model, but the new model is different.
One of the things the Board is going to have to think very hard about is what the governance structure is for clinical commissioning groups. What is the mix going to be between what will appear in subordinate legislation and in the authorisation? We need quite clear basic arrangements because there is a huge amount of public money going through the groups.
As a consequence of the principles and the part about autonomy and lack of bureaucracy, we need to be able to give CCGs the opportunity to do things their way. It is a very difficult balance to strike between trying to pin them down, which we must do for financial accountability, and energising and stimulating them in a way which will allow them to perform to their highest levels.
Andrew George: Professor Grant, I want to follow up on the question asked by Dr Wollaston. You acknowledged in what you said about public health that tension existed and the fact that you do not have control or responsibility for public health within the NHS Commissioning Board. I am not suggesting that at this stage you should indicate that you believe you know how to resolve tensions, but do you acknowledge that there are a number of tensions within the role that you will be playing and the role of the NHS Commissioning Board, the first being in relation to the point made by Dr Wollaston about more choice for patients against also ensuring that the architecture is cohesive and co-ordinated? In your brief you do not necessarily acknowledge that there is a tension. The political debate here is underscoring that. Would you acknowledge that there is a tension between those two objectives?
The second question is on the issue of, as you say, your role in relation to the governance issues and the role of GPs. As you are married to a GP, you will be well aware of some tensions possibly with GPs. That question is with regard to your role in commissioning the clinical commissioning groups but also commissioning GP practices—micromanaging, in a sense, individual GP practices. Do you see the role of the GPs being financially driven at the GP practice level and how that relates to their role in commissioning services, some of which they may be providing themselves?
Finally, there is the whole theme of being strategic, as you said you wanted to be, but also having to be responsible for micromanagement as well at a local level, individual GP practices, dentists and community pharmacies and so on. Do you acknowledge those tensions or do you think that those kinds of tensions can be easily resolved?
Professor Grant: No, I do not. I acknowledge all of those tensions and think their resolution is going to be immensely difficult. We are not going to end up with a perfect health system at the end of this. This is a long-term process that we are entering upon.
First of all, the relationship between public health and the Board is absolutely fundamental if you want to deliver a set of health outcomes for the nation as a whole. Those health outcomes are very much related to health inequalities and to what I was saying before in answer to an earlier question about people presenting with symptoms at a sufficiently early stage for them to be able to take advantage of early interventions. That is going to require co-ordinated action, which is impossible to prescribe in legislation. It simply requires the bodies to work more closely together.
Your second point was about commissioning GPs themselves. It is very early stage work in progress, but it is quite complicated. Trying to work out the allocative formulae for the future with a more flexible approach to doctors’ lists and the change in residential requirements, for example, is quite problematic. A significant amount of the Board’s budget, around £20 billion, will go into commissioning primary care. Of course, there is experience to build on—this is not entirely fresh activity—but there is a tension that I recognise immediately, which is the relationship between getting that right and then getting the role of the GPs and their participation in the consortia and the clinical commissioning groups right also. I am sorry, but I have forgotten your third question.
Andrew George: The first one, which was touched on by Dr Wollaston, was as to choice and integration. We have both mentioned it and you have not, as yet, given a clear indication of the fact that you believe there is a tension there.
Professor Grant: Yes, I hope I have said that there is a tension between those two. The simple answer is to say that, again, it is back for the clinical commissioning groups to develop their own approaches to integration and to ensure that patient choice is exercised with appropriate guidance from the GP within that structure.
Andrew George: The final one was micromanagement versus being nationally strategic.
Professor Grant: Yes. What a wonderful tension.
Andrew George: Lovely tension.
Professor Grant: I do not think there is a glib answer to that or to any of these questions. My natural instinct—and I am sure most people’s—is to empower and devolve responsibility and let people do what they are better able to do. You and I cannot run a GP practice from Westminster or Whitehall, and yet we have to have put in place the necessary safeguards to ensure that it does not all trip up over itself. That is going to have to work out through a series of exemplars and discussions over the next year.
Chair: What strikes me about this discussion so far is that it all seems quite utopian. We are describing Elysian Fields that we would all like to live in. One of the things the Committee has sought to do since we were established is draw attention to what we call the Nicholson challenge; what the Health Service faces is a period of unprecedented change not of the bureaucratic structures but of the way care is delivered. You have used the word “integration,” but the danger must be that within the system, and certainly the commentators on the system, there is not an understanding yet of the extent to which the way care is delivered has to change if demand is going to be met within the resources available. Do you recognise that and what do you think is the role of the Commissioning Board in leading that process? It is a literally unprecedented process of change management, and that is seldom utopian.
Professor Grant: No, it is not. I have read your reports on this and would have to say that I agree with the conclusion that you can only deliver the Nicholson challenge through this fresh approach to commissioning. It is a double hammer being applied at the same time within the NHS. For this reason you need a Commissioning Board which will have strong appointments to it, taking a clear line. There is nothing wrong with being visionary or utopian if that sets the ultimate goal. The real problem is the behavioural changes that are needed to steer away from traditional models of integration and patient care into what will be more cost- effective, we hope, for the future. We must remember also that part of the ultimate goal, part of the Nicholson challenge, is the ability to reapply the £20 billion or so which comes out of that challenge into the new problems of health: for example, long-term care on a scale that we have not yet seen.
Chair: Do you think it is accurate to characterise one of the problems facing the Health Service as that the structures exist in a form that is determined by yesterday’s pattern of demand and that what is now required is to change the structures to meet tomorrow’s pattern of demand, which is likely to be fundamentally different? If that is true, is that not a huge challenge?
Professor Grant: Yes. You have put it much more eloquently than I had, but that is true and it is a huge challenge. The patterns of demand will be quite different.
Chair: In this new system, who owns the responsibility for delivering that change?
Professor Grant: It is an activity which is owned at the level of the Commissioning Board but working with the clinical commissioning groups to try to transform existing patterns of behaviour, and in a harsh financial climate that will compel practitioners to confront difficult choices which, at the moment, are capable of being eluded.
Chair: I will have one more go and then turn to Grahame. I think you used the words “support commissioning groups.” Human nature is such that, when there is a soft option available, they usually choose it. Who is going to close off the soft options?
Professor Grant: That is, again, the balance between the Board and the groups. All of this is going to have to be worked out, and it would be foolish for me to try and give you strong and clear answers today. I am not clear in my own mind how far we are advanced with the existing commissioning arrangements across the country in preparation for these very significant changes. There is, after all, only 18 months before the majority of CCGs assume full statutory responsibility.
Grahame Morris: My questions follow on from that, and you have touched on some of the tensions between the NHS Commissioning Board and the local clinical commissioning groups. The NHS Commissioning Board will authorise them so that they are fit and proper organisations to commission services. When, if ever, do you envisage the NHS Commissioning Board would intervene in the event of failure by the clinical commissioning groups? I will share with you some evidence that was presented to the Committee. As you are aware, we have published two reports on commissioning, but the Nuffield Trust presented a study that they had done in North America where there was ample evidence of the main reasons for the failure of clinical commissioning groups being financial underperformance— overspending their budget. Are they the circumstances in which you would see the NHS Commissioning Board intervening or are there other circumstances as well?
Professor Grant: This is very early stages. Certainly, financial propriety and financial discipline has to be at the heart of the clinical commissioning groups and, for that reason, will need to be written into the governance arrangements. There will need to be a chief executive or an accountable officer for each clinical commissioning group who will have that clear responsibility. In so far as clinical failure is concerned, it is going to be a balance between intervention by the Board, by CQC and by other agencies who have responsibility across the whole piece, depending on where the failure is. Is it in secondary care, long-term care, social services or is it within general practice? The levers and the models of intervention will be variable according to the nature of the circumstances. Your underlying point is the important one, which is that the Board is going to have to ensure that it has the intelligence flow to be able to detect failure coming through at any time.
Grahame Morris: Can I ask a supplementary to that? Professor Grant, do you envisage that the NHS Commissioning Board is likely to intervene where commissioners fail to effectively reconfigure a service? There is a huge debate and controversy over the Chase Farm reconfiguration of accident and emergency services, and in my area the reconfiguration of an A and E facility and downgrading of services to a walk-in treatment centre. Because the politicians have already said we are stepping away from that, is this the kind of circumstance where the NHS Commissioning Board will show some muscle and intervene?
Professor Grant: If it has come to the Board, then all the local arrangements have
Grahame Morris: I am asking you about the failure regime in a sense.
Professor Grant: Service reconfiguration is the most difficult thing in the NHS and is always a hugely controversial issue, as you mentioned with Chase Farm. However, the responsibility under the new arrangement, as I understand it, is that this will rest in the first instance with the clinical commissioning groups, but there is a process of consultation and engagement with other groups. Should that not reach consensus, then it would come to the Board in exceptional circumstances. There is an independent reconfiguration panel—which I think was brought in on Chase Farm—that could advise the Board, and, I suspect, in truly exceptional circumstances it may even end up on the Secretary of State’s desk. The strong wish of the Board—and I am sure of any Secretary of State—would be to drive that responsibility down to where it belongs. If service reconfiguration is needed because the present service is not meeting the needs of patients as mediated through the CCG, that needs to be addressed at local level.
Grahame Morris: I fully appreciate that and I do not want to labour the point, but the nature of the unpopularity of such tough decisions is that when the local decision-making processes—the scrutiny committee and the Health and Wellbeing Board— look at it, they may say, “No, we want to retain a local service in a local hospital.” You, as you have already indicated, Professor Grant, are taking a strategic look at these issues. In those circumstances, are you saying, when the local commissioners cannot agree to service reconfigurations, that you as the NHS Commissioning Board will step in and take the decision for them?
Professor Grant: Can I tell you that nothing would appal me more? I do not think the Board wants, any more than Secretaries of States do, to get involved in local service reconfiguration. Responsibility has to continue to be pushed down to where it is, but, if it reaches an impasse, then some way needs to be found of resolving that.
Rosie Cooper: My view is that each and every one of those decisions will reach that impasse. The Board that you described before of a chairman and five non-executives is the current model of trust boards in the NHS. Very important and core to that is the relationship between the chair and the chief executive. How do you envisage your relationship as Chair of the Commissioning Board with the Chief Executive and what is the single most important tool that you as Chair-elect would have to hold the Chief Executive of the Board to account?
Professor Grant: It is difficult to answer the first part of your question without personalising it, and that is undesirable. You have in the present Chief Executive somebody of extraordinary experience, with a lifetime of employment within the NHS. He knows his job.
The job of the Chair is to ensure that he and the executive team are working within the new framework, which is a different framework from the old one. In my experience, both as a chairman and as a chief executive, ultimately it boils down to personal relationships. Is there a trust and respect between the two parties which allows them to be clear about where the responsibility of each starts and finishes? Is there an ability to deal with differences of opinion? There will be? Those differences of opinion need to be dealt with, addressed and sorted out.
Rosie Cooper: What is the most important tool?
Professor Grant: Let me finish this because the Chair, as you have pointed out, is not the sole non-executive member of the Board. There will be five others in addition to the Chair. The relationship is not only between the Chair and the Chief Executive. It is between the other members of the Board as well. The way I would see this—and the Chairman is going to accuse me again of being utopian—is that the Board works as a team.
Rosie Cooper: He will not be on his own.
Professor Grant: Thank you. By that, I mean the executive and the non-executive members work as a team.
Rosie Cooper: Given the Board’s power, can its executive be effectively held to account by a part-time Chair?
Professor Grant: Do you think a full-time Chair would be more effective at holding people to account? I do not think it is the question of time that the Chair puts into the job. It is the question of the personal qualities both of the Chair and the Chief Executive.
Rosie Cooper: Absolutely. That goes on in every hospital in the country. You did not answer the question I posed to you first, which was: what is the single most important tool that you can use to hold the Chief Executive to account?
Professor Grant: I expect it would be the normal tools in which targets and objectives were set for the year and there was performance management of the Chief Executive by the Chair.
Rosie Cooper: In that case I would like to go on and ask you this. The White Paper stated that the Commissioning Board would be “free from day-to-day political interference”. You have described what you see as the optimum relationship between the Board and the Chief Executive. How do you see that relationship between the Board and Ministers and do you think “free from political interference” means free from political accountability?
Professor Grant: There is a big difference between interference and accountability. Accountability is something which, in the Bill, is to be maintained through the mandate. The accountability is for delivering what the Board has been told to deliver. That is accountability, which is to a large extent ex post: “Look, this is what we have achieved.” The Board’s annual report goes to Parliament, and it is a clear and transparent responsibility. That differs from day-to-day political interference, and that is something that the Board would have to be resolute to resist. This is not a statement about any particular Secretary of State, but there is a strong temptation for a Secretary of State to reach into the NHS to try and push buttons, pull levers and turn knobs. That is not the new model. You may ask what the role of the Secretary of State is under this new model and how the Secretary of State responds to constituency concern about the operation of the NHS. Again, the answer lies in my answer to your earlier question, which is where responsibility ends up. The Secretary of State has the overall accountability for the provision of a comprehensive National Health Service in this country. Under this measure, he assigns, through a mandate, responsibility for delivery to the Board and the Board assigns responsibility to CCGs. We will have a transparency that I think we have not had before.
Rosie Cooper: Given the policy intention to delay and reduce management while moving away from central top-down performance management, why does the Board need regional arms?
Professor Grant: The Board cannot do everything located in London and Leeds. You are leading me in a long direction, for somebody who is 100 hours into the job. As I see it, the Board will not be establishing any formal structures between the Board and the CCGs. It will, of course, have staff deployed regionally so that they are closer to the CCGs and better able to do the very things that you would have us do.
Dr Wollaston: You mentioned earlier—and I quite agree—that we need to get away from the “shock, shock, crisis, crisis” response to the NHS and think more strategically, but, inevitably, somebody will have to be responsible and comment on events as they arise. Today, for example, take the Parliamentary Health Service Ombudsman Ann Abraham’s report into the variability of GPs in their response, say, to striking patients off their lists. Who do you feel should respond to these sorts of reports and crises that arise in the NHS or issues that need addressing urgently? Should that be the NHS Commissioning Board, through you, or should that be the Secretary of State? Where would you see that role?
Professor Grant: I have to say that I am still puzzling this one through. I thought Ann Abraham’s report was quite telling this morning, as was the CQC report recently on the lack of dignity and respect accorded to elderly and infirm patients. It is no longer going to be the case that the Secretary of State is wheeled in front of the TV cameras. Responsibility has to go back to where it is. It has to go back to within those hospitals. Who is the chief nurse? Who is the medical director or where is the CEO?
Dr Wollaston: Can I stop you there? Take, for example, Ann Abraham’s report today, which is saying that there are a handful of GP practices across the country with unacceptable practice in the way they are removing patients from lists. Are you saying that those individual GPs should be accountable?
Professor Grant: Yes, they should.
Dr Wollaston: Who should be responsible for, as you say, facing the TV cameras and saying, “How are we going to get a grip on this variation in GP practices?” Ultimately, GPs are going to be commissioned directly by the NHS Commissioning Board.
Professor Grant: Yes, that is true.
Dr Wollaston: That is the accountability, ultimately.
Professor Grant: In that case, it would need to be, I assume, the Board, but I am still anxious to ensure that there is a clear chain of responsibility and that there is not accountability at too many levels. You have to push it back. The accountability for the specific actions rests with the GPs themselves. The accountability for the climate, if you like, and the rules under which they operate, will rest with the authorisation, which they have from the Board. Some of the instances that she cited were breaches not of rules but of BMA guidance, which is a slightly different position from that of a formal operating structure.
Dr Wollaston: The trouble is that people can slip through the net. The public do not want to see the NHS Commissioning Board saying, “It is not us. It is down to these individual GPs.” Of course it is, and they ultimately take responsibility for poor practice that is completely divorced from guidelines, but people will want somebody to account for how it is going to be changed.
Professor Grant: That is the question. It is not accounting for what has gone wrong but how it will change, and in that case it will be a question of whether what has been breached is something which was in the authorisation from the Board. Can I say that this is all going to be very messy?
Chair: Life tends to be messy.
Professor Grant: Yes, but it is messy already. It is going to be messy as we go through a very complex transitional programme. What we hope for is a sharper, more transparent and more accountable system at the end. If I am dewy-eyed for believing that that is achievable, you must not confirm my appointment to the role.
Chair: Can I test, for a second, this proposition, that one of the effects of the new structures is to introduce—and, it is sometimes implied, for the first time—a delegated management structure, and previously with dropped bed pans there was no defence mechanism between the individual nurse and the Secretary of State because that is not how it was or is under the current statute? Responsibilities are defined in statute for trust boards, for PCTs and for special health authorities. To what extent are the new structures different from the existing structures in terms of the extent to which the statute defines a delegated responsibility? I entirely agree with you that good management requires people to have defined responsibilities and to be accountable for the way they carry them out. I absolutely agree with that, but I do not see this Bill as creating different delegated statutory structures, or structures that are different in form, from the ones that already exist.
Professor Grant: That is right, up to a point. In my understanding of it, one of the critical differences is the transfer of financial responsibility to the CCGs and their obligation to hold the secondary providers to account.
Chair: How is that different from the statutory responsibility that rests on a
Professor Grant: Because this is not the PCT. I am sorry—we are getting into acronym soup. The CCGs are being established on a different basis from the PCTs.
Professor Grant: Yes. How long do we have?
Chair: As long as it takes. I am afraid there is no defence there.
Professor Grant: I was dreading that was going to be your answer. The relationship with the CCGs is through the authorisation that they have from the Board with clear accountability. I keep coming back to this, but we do need, over the next 18 months, to be absolutely clear about what this means. Among the population at large, nobody knows what commissioning is. Patients want a system that gives them access to the highest quality care and with accountability for default.
Chair: I completely agree with that, but it comes back to Sarah’s question, does it not? If Ann Abraham reports that there is some aspect of the system—or, indeed, the CQC and a number of others, and it may even be this Committee occasionally—that is not as it should be, arguing that there is no accountability other than the CCG means that there is nobody going to appear in the television studio. The public is going to become even more fogged as to what is going on than they are at the moment.
Professor Grant: I wonder about the test of the effectiveness of a system by who appears in the television studio. There are two questions, as I said earlier. One is, “Where is the fault and who is responsible for the fault?” The answer to that is with each of those GPs. The second question is, “What is the systemic issue and how is that changed for the future?” The answer to that, so far as GP conduct is concerned, must be with those who commission the GPs, which is the Board. In so far as secondary care is concerned, the answer must be with those who commission the secondary care, which is the CCG. I may be oversimplifying this.
Chair: I do not think you are, but, for systemic accountability in a national health system, the CCG that conducts the local commissioning process has to be accountable through someone, which is presumably the Commissioning Board.
Professor Grant: Yes. The question goes back to your very early observation that, the more who are accountable, the fewer are actually accountable.
Rosie Cooper: Will you be the person doing “Panorama”?
Professor Grant: I said this job was full of risks and probably that ends up being one of them.
Rosie Cooper: You will be accountable to the people via the press but not via structures. It is unbelievable.
Chair: That is a statement rather than a question.
Dr Poulter: I want to come back to the point you made quite well about the fact that devolving responsibility to local commissioning boards will mean that local GPs and other healthcare professionals will take ownership of services. There is a strong argument for that.
There will need to be some national guidance and framework as to how it will work. Accepting that the demands and healthcare challenges in Easington may be different from central Suffolk and north Ipswich—or indeed may be different in Ipswich from central Suffolk, for example—and the particular challenges and local factors that may affect what commissioning groups will look at, how do you envisage the overarching guidance and framework from the National Commissioning Board filtering down to a local level?
Professor Grant: This is very early days and it still has to be worked out.
Dr Poulter: You talked earlier about the service reconfiguration and those sorts of things. Would it be along the lines of saying, “Over a defined period of time we would envisage that healthcare challenges are dealing with an ageing population and healthcare inequalities, and we would envisage your local framework to reflect that in how you are delivering services in generic terms”?
Professor Grant: There are two aspects to it. One is the financial allocation, which I anticipate would continue to be done with advice from the advisory committee on resource allocation, which does look at demographic differences across the country. The other one around service provision is going to depend very much on the maturity of what exists there now. You have some very large groups already which are quite significantly moving into commissioning with populations of up to 600,000 where you can spread risk much more effectively. For some types of commissioning you can be very effective with small populations and with other types of commissioning you need large populations. I would also imagine that, with smaller commissioning groups, there may be mergers or partnerships which would allow them to develop an effective programme across a broader area. As I say, these are conversations that are yet to commence.
Dr Poulter: I have one follow-up on that. You talked a lot about GPs in terms of the local commissioning. In terms of clinical commissioning it is a lot broader than that, particularly if we are looking at that sort of service reconfiguration. You mentioned silos earlier—the Chairman mentioned them as well—and breaking down a lot of them and the institutions that exist in the NHS is probably fundamental if we are going to reconfigure services and deal with tomorrow’s NHS and tomorrow’s patients. Would you see it as your role and that of the Commissioning Board’s to facilitate and put across national frameworks for local commissioning that would enable that?
Professor Grant: Yes. I see that as one of the central tasks. The landscape still, after the Bill, is quite confusing where different bodies relate to each other, but probably the Board, with its very significant financial responsibilities, has to ensure that all the others are engaged with it. That is going to require a lot of hard work through advocacy and sharing objectives.
Dr Poulter: I have one last question which was mentioned earlier. If it was felt at the end of a defined period of service delivery that there were very real concerns being expressed and passed up by Members of Parliament, patient groups or by other healthcare professionals on the ground about the quality of services being delivered by a particular commissioning group, what powers would you envisage, at a national level, you would have to either intervene or act to change what is happening?
Professor Grant: As I said in my answer to Mr Morris earlier, it seems to me that there is a variety of levers that can be used. First of all, you need to have the intelligence as to what is going on, which may come, as you suggest, through reports from others or may come through the relationship between the CCG and the staff of the Commissioning Board at the regional level. Our role, as I would foresee it on the Commissioning Board, is to work always in support and improvement of clinical commissioning groups across the country.
Dr Wollaston: Professor Grant, you have made it clear that it is not your role to be involved in the micromanagement of the Health Service. How available will you be to respond to concerns raised by individual CCGs as the whole culture and basis of the new NHS is established? For example, one of the concerns that I am consistently hearing from CCGs is that they need to know their management allowance in order to be able to become established and make plans properly. What position will you be in to persuade the Board to make decisions if you are approached by CCGs with issues like that, for example?
Professor Grant: I understand that there will be an announcement about the management allowance fairly soon. I hope that that one can be addressed. In this job you have to be eyes and ears, you have to be responsive and able to engage with a broader community. In my present job—and I have nothing like the size of community you have in the NHS—my inbox is never empty of people wishing to draw things to my attention, some of which require my personal attention, others of which can be relayed to responsible members of the executive staff to resolve. To be the Chairman of this Board does require some visibility to those involved in the NHS across the country.
Dr Wollaston: In other words, you will do the best you can to be available to listen to those concerns and represent them.
Professor Grant: Yes. The prospect of the inbox is overwhelming.
Chair: You are right.
Rosie Cooper: I have two final questions, if I may. One is to go back into more of the detail about the failure regime. Would you be concerned if that failure regime allowed providers to apply to the financial regulator Monitor for a higher-than-tariff payment for services without the consent of their commissioner?
Professor Grant: I am sorry, but I would not want to give you an off-the-cuff answer about that. I do not sufficiently understand that regime.
Rosie Cooper: Fine. There is a facility in the current proposals where providers can go to Monitor and say they cannot provide the service for that price and Monitor can consider it. Perhaps you could take away that thought: “Should that be allowed? If so, what would happen?” and, “If not, why not?”
I will leave that and go to a personal question. In describing your boards, you said it was important to be independent and strong-minded. Could you describe a time in your career when you have held a position or a view or fought your corner in the light of strong opposition and shown yourself to be independent and strong-minded all the way to the end of the argument?
Professor Grant: This is starting to sound like a job interview.
Rosie Cooper: Forgive me, but you have said today that you have been 100 hours in the job and I thought I was coming to a pre-appointment hearing—so, yes. Funnily enough, that is what the accountability is about, the bit you are struggling with right through this.
Professor Grant: Thank you very much. The substantive answer to your question I would say was in my experience in chairing the Government’s Agricultural and Environment Biotechnology Commission, in particular in relation to GM crops, which I did for five years. It was a time of dealing with a Government which was not a good client of a commission that it had set up and in which, at that time, in a single Department there were two Ministers with diametrically opposed views on the substantive issue which we were addressing. We had a commission which had on it 20 people. It ranged from the chairman of Greenpeace UK through to representatives of the seeds and biotechnology industry. The prospects of getting consensus on that commission were very low. We got it, and we had to be very clear with Ministers that this was a consensus and that if we were to conduct on their behalf the public debate they wanted they were to have to fund it adequately. That is one instance from my background of undertaking a public service against a highly complex and controversial set of factors across the country and with a rather shaky level of Government support.
Chair: Can I ask you a formal, mechanistic question? At the beginning of the session you said you felt that the non-executive board should have five members and then there would be the executive team as well. Looking at the balance of the non-executive members, do you think it is relevant that some of those people have Health Service backgrounds, would you welcome a weight of the non-executives being from outside an NHS background, or do you not think that is necessarily relevant?
Professor Grant: I do not think it is a sine qua non, but I would very much like to see strong clinical representation. This is about clinical change and I would like clinical input on the Board. You would have it from the executive end as well as the non-executive end. Clinicians are well able to understand and articulate the challenges and to be forceful advocates and ambassadors across the country for the work of the Board. As to other appointments, I understand head-hunters have been at work, but I have had no communication because I am not the Chairman of the Board.
Chair: I understand.
Dr Wollaston: I have one final question. As the Bill passes through the House of Lords, are there any changes you would like to see that you feel would make your job easier?
Professor Grant: I would like to think that through. There might be changes that would make it more difficult.
Dr Wollaston: Could you elaborate on what those would be?
Professor Grant: Looking at the concerns of the Lords about the relationship between the Secretary of State and the Board, I would wish to keep a very close eye on that because, frankly, if it ends up with the Secretary of State having revived powers of direction to the Board, then you need civil servants to run it.
Dr Wollaston: Thank you.
Grahame Morris: You mentioned how important it is for commissioners to look at the evidence base, and you also made some reference to your admiration for Professor Sir Michael Marmot, who is based at UCL. What are your views about the cuts in the public health observatories? Surely that is the resource which should inform our policy choices of redesigning services.
Professor Grant: I am sorry, but I am not going to get drawn into what is a political arena and which I do not think is relevant to my views about the work of the Board.
Grahame Morris: You mentioned the importance of evidence on which to make decisions. Are the PHOs not one of the key organisations that compile evidence on which action plans are based?
Professor Grant: Yes, but —
Grahame Morris: You must have an opinion on that.
Professor Grant: I do, and I think evidence is absolutely critical.
Grahame Morris: What do you think about the 30% cuts in their funding this
Professor Grant: I am sorry, but, Chairman, do I— Chair: I think you have given the answer. Virendra wants to come in.
Q70 Mr Sharma: Thank you. I apologise for arriving late. When I arrived you mentioned the time commitment and whether there is a full-time or part-time chair makes no difference, but certainly if you have a very clear vision and system in place you can work. There is one other very sensitive point which it may not be easy for you to answer because it is not of your making, and I do not want you to feel uncomfortable on this point, but I think it is important to ask. You will be expected to answer the question as to whether the salary of £63,000 a year is reasonable or is quite high. If you are working four days a month, one day a week, it works out at £1,312 per day. How are you going to justify it when the question is asked, or how would you respond to that?
Professor Grant: The answer is simple. Throughout my time at UCL I have accepted a number of external appointments which carry remuneration. My invariable practice has been to have that remuneration paid directly to UCL and not to take a penny of it. That is a fundamental facet of public office, and I assume it is one that is followed by every Member of this Committee.
Mr Sharma: Thank you.
Chair: That is a straightforward answer. Thank you for that. I do not think there are any other questions from the Committee. Thank you very much for coming this morning.
Professor Grant: Thank you for your time.
Chair: Thank you.
The below quotes are extracts from NHS Commissioning Board chair Professor Malcolm Grant's pre-confirmation health select committee appearance. The whole (uncorrected) transcript follows below.