House of Commons Health Committee

Appointment of the Chair of the NHS Commissioning Board

Eleventh Report of Session 2010–12

Oral evidence

Ordered by the House of Commons to be printed 18 October 2011

HC 1562-II Published on 28 March 2012 by authority of the House of Commons London: The Stationery Office Limited £4.00 2 Appointment of the Chair of the NHS Commissioning Board

The Health Committee

The Health Committee is appointed by the House of Commons to examine the expenditure, administration, and policy of the Department of Health and its associated bodies.

Membership Rt Hon Stephen Dorrell MP (Conservative, Charnwood) (Chair)1 Rosie Cooper MP (Labour, West Lancashire) Yvonne Fovargue MP (Labour, Makerfield) Andrew George MP (Liberal Democrat, St Ives) Grahame M. Morris MP (Labour, Easington) Dr Daniel Poulter MP (Conservative, Central Suffolk and North Ipswich) Mr Virendra Sharma MP (Labour, Ealing Southall) Chris Skidmore MP (Conservative, Kingswood) David Tredinnick MP (Conservative, Bosworth) Valerie Vaz MP (Labour, Walsall South) Dr Sarah Wollaston MP (Conservative, Totnes)

Powers The Committee is one of the departmental select committees, the powers of which are set out in House of Commons Standing Orders, principally in SO No 152. These are available on the Internet via www.parliament.uk.

Publications The Reports and evidence of the Committee are published by The Stationery Office by Order of the House. All publications of the Committee (including press notices) are on the Internet at www.parliament.uk/healthcom.

The Reports of the Committee, the formal minutes relating to that report, oral evidence taken and some or all written evidence are available in printed volume(s).

Additional written evidence may be published on the internet only.

Committee staff The staff of the Committee are David Lloyd (Clerk), Sara Howe (Second Clerk), David Turner (Committee Specialist), Steve Clarke (Committee Specialist), Frances Allingham (Senior Committee Assistant), and Ronnie Jefferson (Committee Assistant).

Contacts All correspondence should be addressed to the Clerk of the Health Committee, House of Commons, 7 Millbank, London SW1P 3JA. The telephone number for general enquiries is 020 7219 5466. The Committee’s email address is [email protected]

1 Mr Stephen Dorrell was elected as the Chair of the Committee on 9 June 2010, in accordance with Standing Order No. 122B (see House of Commons Votes and Proceedings, 10 June 2010).

Health Committee: Evidence Ev 1

Oral evidence

Taken before the Health Committee on Tuesday 18 October 2011

Members present: Mr Stephen Dorrell (Chair)

Rosie Cooper Dr Daniel Poulter Andrew George Mr Virendra Sharma Grahame M Morris Dr Sarah Wollaston ______

Examination of Witness

Witness: Professor Malcolm Grant CBE, Prospective Chair of the NHS Commissioning Board, gave evidence.

Q1 Chair: Professor Grant, you are very welcome to how it works, not in the committee rooms of the Committee. Congratulations on securing the Westminster but in the general practices of this Secretary of State’s nomination to what is going to country. A second one is being the president of a be a very important post in the Health Service going university with a fantastic health and medical sciences forward. We are clearly going to have an open school and a very strong relationship with key London discussion with all the Members of the Committee, hospitals, which has grown quite dramatically in the but I would like to open by saying that you obviously eight years in which I have held this job. This has saw an advertisement in a newspaper and thought, given birth to UCL Partners, a unique academic health “That is a job I would be interested in doing.” An sciences centre in which I have been very closely interesting way to get the discussion going is to involved since its inception. understand why you reached that conclusion and what In a sense, although I am only a lawyer, I have been it was that attracted you to the job, and hopefully able to engage with the NHS through Partners to see still does. what is happening and what can be achieved. One Professor Grant: It certainly does, Chairman, and example by which I have been totally enthralled is the thank you for the opportunity to appear before the handling of acute stroke in London. Relatively simple Committee this morning. The processes of recruiting service reconfigurations—unthreatening and to major public sector jobs are never quite as strategically carried through—have led to a reduction straightforward as you have suggested. The approach in mortality from the national average of 22% to 10% did come to me originally from head-hunters. in this part of London. That opens the eyes of all of Head-hunters, as you know, were retained by the us to the opportunities that one can bring to the NHS Secretary of State for this post. Then various siren if it is led much more by strategy than crisis. That voices were spread around me to try to lead me to this seems to me to be the opportunity that the Board destination, but it has been a long and difficult provides. journey. It is not an obvious course for anybody who is enjoying their present job to head off along. I am Q3 Chair: We will no doubt come on to that as the here today because there is a serious job to be done session continues. How does this relate to your and I hope you find that my background and interests relationship with UCL? Clearly you have a full-time are sufficient to allow the Committee to endorse that executive post there and this is a pretty challenging nomination. post. How do you anticipate balancing those? Professor Grant: I hope to be able to do both jobs at Q2 Chair: At the heart of the question was not just once. What makes that possible is the very strong was it in response to an advertisement or a support I have had from senior colleagues at UCL, head-hunter approach, but what is the pitch that you which I will explain. made to yourself to think that someone with the I have a very strong senior management team, five background that you have has value to add? What is vice-provosts, who work directly to me, and 10 deans the value that you are seeking to add to this process, of the different faculties. A large component of what given the nature of the beast that you are taking on? we do is life and medical sciences, probably about Professor Grant: I start with something that is not a 60% of UCL’s activity. The enthusiasm that has been value to add but rather a quality and a value that is shown by my colleagues for my undertaking this role shared by everybody in this room, which is passion has been quite humbling. Their expression of a about the NHS. It is one of the greatest institutions willingness to support me intellectually and also to this country has. The path that has been mapped out substitute for me from time to time on formal in the Bill is one that contains a wide variety of engagements at UCL and to allow me to free up the opportunities and risks. time has been the key thing that has made it possible One of my great associations with the NHS is by for me to consider doing it, coupled with securing the virtue of having been married to a GP for the last 37 approval of the UCL Council to our proceeding in years, which has given me a remarkable insight as to this way. Ev 2 Health Committee: Evidence

18 October 2011 Professor Malcolm Grant CBE

Recently I announced to the UCL Council that I executive and vice versa. The governance role needs would seek to stand down from my job in two years’ to be sufficient and focused to allow the executive time. That will have given me 10 years in the role, team a clear structure within which to operate. which I assure you is quite an endurance feat The second part—thinking over the role in the 100 nowadays for a vice-chancellor. That allows me to hours since my nomination was announced—seems to consider how to match my final two years at UCL me to engage with a much wider community. The against the growing demands of this job over the Chairman has to be engaging with the Royal Colleges, coming two years and then, of course, beyond. the clinical community across the country and with the other big beasts in the NHS landscape, such as Q4 Chair: The advertisement suggested that the NICE, the CQC and Monitor. It is critical to ensure higher time commitment to this job will be in the early that we overcome some of the inherent fragmentation period rather than the later period. Do you agree that presently exists across the NHS and get much with that? clearer ideas about where collaboration and Professor Grant: No, I do not. It is completely co-operation are going to be essential and, ultimately, impossible to forecast it at this stage. The one simple where accountability lies. That seems to be the maxim is that the work will grow to fill the time transformational change from where we are at the available. Would you like me to trace through how I moment to what the new Board must be able to see it developing over the coming two years? deliver. Chair: Indeed. Chair: I do not want to monopolise the questions, so Professor Grant: The first major task is to recruit the perhaps I will turn to Grahame because the point on other members of the Board. The proposal is that the accountability that you ended on is probably where Board should be small, probably no more than 10. Grahame would like to pick you up. The majority should be non-executive members. That requires the recruitment of five other non-executive Q5 Grahame Morris: Professor Grant, can you members. The minority will be executive members share your thoughts with the Committee in relation with David Nicholson, who is the Chief Executive, to governance and accountability, in particular in the and three others. For the non-executive members I context of the changes that are envisaged in the Health would be very keen to ensure that we recruited some and Social Care Bill that is currently in the House of of the most able and independently-minded people we Lords, in respect of the Secretary of State’s can find. This Board is not going to do anything unless responsibilities? Is he in effect delegating or it is visibly independent and strong-minded. We abrogating his responsibilities for the NHS? Is he should be able to complete that process of passing the buck to you and the NHS appointment by, let us say, January. In the meantime, Commissioning Board? there is an enormous amount of work to be done at a Professor Grant: I would not put it in either of those management level in terms of devising the systems ways, but let me try another way of expressing it. The and the processes that will take us through the Bill is still in the House of Lords and the House of transition. From April 2012 a Special Health Lords Constitution Committee has raised some Authority which will have been created at the end of questions about this very point. They will, I know, be this month will assume some limited statutory reviewed very closely in the Lords. As the Bill responsibilities for patient safety. From September currently stands, you have to look at clause 1, which 2012 it will take on the statutory responsibility for retains the Secretary of State’s responsibility for authorising the clinical commissioning groups. From delivering a comprehensive National Health Service April 2013 it will become fully operational. At that in this country, and at clause 20. I have to say, by the stage, the clinical commissioning groups will also way, that the Bill is completely unintelligible. become fully operational. There is a build-up of responsibility over that period, and from April 2013 Q6 Grahame Morris: The Secretary of State is the job will no doubt be particularly demanding. delegating that responsibility to you, is he not? What head-hunters and job describers can never fully Professor Grant: No, I am coming to that. The reason predict are two things. One is what is the relationship I say this is that clause 20 inserts clauses 13A to between the Chair and the Executive team? The other 13Z(1) in the National Health Service Act 2006. You is what needs to be done that goes well beyond the have to try to read the two at once and then forecast strict terms of the job description but is essential to what will happen in subordinate legislation. Let us make it work. summarise what clause 20 does. It requires the Let me deal with the first one. It is absolutely critical Secretary of State to prepare a mandate for the Board. to be clear about the difference between governance That mandate sets out the Secretary of State’s and management. David Nicholson will have objectives for the Board and also its future financial responsibility for managing the Board. The Board will arrangements. The mandate should not be for a single have responsibility for governing. I am sorry that the year but for two years, and possibly three years if word “Board” gets used ambiguously in this context, we are going to have the Board running properly and as I think this Committee has pointed out in the past. strategically. The mandate needs to be discussed with The governance role risks tripping over its shoelaces the Board before it is published. It needs to be laid if the governors spend too much of their time doing before Parliament and it is a public, clear document, the governance. I am very strongly against full-time which, for the first time, establishes accountability. chairmen. I have seen too many instances of full-time In so far as the matter is within the mandate of the chairmen confusing themselves with the chief Board, it is not within the jurisdiction of the Secretary Health Committee: Evidence Ev 3

18 October 2011 Professor Malcolm Grant CBE of State, except that he has power to revise the responsibility for developing the relationships mandate with the consent of the Board or he may between primary and secondary care, and other revise it in exceptional circumstances. I am sure we services such as radiotherapy, to satisfy themselves need that clause. That is only going to happen, is it that they have the best deal. If the CCGs are the not, when there has been a break-down of purse-holders for the future, then their ability to effect relationship? If he cannot revise it with the change is dramatic. Commissioning Board, then he is going to need to move to the “exceptional circumstances” clause. Q8 Grahame Morris: Are you accountable for that? What that does is effect an extraordinary As a Member of Parliament, living in a region that transformation of responsibility within the NHS. You has the seventh highest incidence of newly-diagnosed used the words “abrogate” or “delegate”. It is not cancer and the worst access, I cannot hold the “delegate”. It is passing over the responsibility and Secretary to State to account now, other than through then allowing the Secretary of State, through the the biennial mandate to Parliament. Can I hold you mandate, to hold the Board accountable against the accountable as the Chair of the NHS Commissioning objectives that have been set for it. It is then for the Board? Board, through its relationship with the clinical Professor Grant: Let us break down your question commissioning groups, to hold them accountable for because you talk of incidence as well as treatment. the objectives that are set for them. It allows us, for Incidence is an extremely important public health the first time, the possibility of tracking accountability matter. Incidence is often a consequence of failure to and responsibility through a system and, what I would present in a timely manner with symptoms. Incidence see as being the prize to fight for, restoring to the is also a consequence of lifestyle choices. We are NHS the stability that it needs away from day-to-day spending £2.7 billion a year on the disease political interference in its priorities. You may worry consequences of smoking in this country. There are about the ultimate political accountability. It remains 1.1 million admissions to hospital on alcohol-related secure, but it requires a Secretary of State to define incidents. We have the other enormous public health upfront what he or she wants the Board to be epidemic of obesity where we are seeing between 5% accountable for and to hold the Board accountable and 6% of the NHS budget going on obesity-related for it. conditions such as type 2 diabetes. If you start by I should have mentioned one other final provision talking about incidence, it highlights the need for this which is in the Bill. The Secretary of State can amend whole thing to be much more joined up around public a mandate after a general election. That may satisfy health, health education, self-care and presentation in some concerns about dramatic changing of priorities. the first instance. In so far as the treatment of cancer is concerned, once there has been a presentation and Q7 Grahame Morris: Can I follow up on that? I am diagnosis, it is very much now for the CCGs in the grateful for that because your view that the Secretary hands of GPs through these consortia to ensure they of State is transferring power to the NHS are getting the best possible service from their Commissioning Board is very illuminating. I am glad secondary providers. If they are not, it is their you have shared that with us. I know that you are not responsibility to ensure that that service improves. in post yet and your background does not give you a detailed knowledge of individual services, but you did Q9 Grahame Morris: give an example in your opening remarks about stroke How will you performance services in London and how you see the NHS manage the clinical commissioning groups and the Commissioning Board as strategically planning rather other commissioners who are responsible for £100 than fire fighting and reacting to crises. In respect of billion worth of taxpayers’ money? What happens if some of the other issues that need to be addressed, for they are underperforming? How are you going to hold example disparities, health inequalities and access to them to account? radiotherapy services, in the north of England we have Professor Grant: That is a very difficult question. The one of the 28 Cancer Networks and ours is the worst simple answer is that there are several levers and the performing in terms of access to radiotherapy CCGs will have a variety of different starting points. services. What role would the NHS Commissioning Come April 2013, there will be some that are up and Board play in addressing such disparities? ready to go and some which will have command of a Professor Grant: Over the period through to population which is quite significant, up to 600,000, September next year, as I see it, the NHS for example, and with good experience. Others, I Commissioning Board is going to be working very expect, will not be ready to go by April 2013. That closely with the clinical commissioning groups trying commissioning will need, in the meantime, to be done to develop this understanding of what commissioning for them by the Board. The levers that are available truly means. We are not starting from a blank sheet of are various, but they will require close relationships paper. Many of these are now working with Pathfinder with the Board. They can include performance status within PCTs. Commissioning is not only buying management. They can include engagement with the a service. Commissioning is planning it, thinking clinical senates that are proposed to be established so about it, buying it, funding it, monitoring it and that we can bring multi-disciplinary opinion and revising it. For an activity such as the Cancer guidance in geographical areas to bear upon particular Network, it requires the CCGs to think about issues as you have described. But, remember, we are pathways and networks for handling particular at the early stages of a journey here. What I do not illnesses and conditions. It requires them to take local want to be this morning is prescriptive in relation to a Ev 4 Health Committee: Evidence

18 October 2011 Professor Malcolm Grant CBE whole new approach to commissioning healthcare in country know what a PCT is or have a clue what a this country. clinical commissioning group is? Rosie Cooper: They know where their hospital is. Q10 Chair: There is an old saying: “When Professor Grant: I would say, of the latter, that it is everybody is responsible, nobody is responsible.” It in the low thousands. was striking in your answer to Grahame’s questions that you listed a whole series of people who are Q14 Rosie Cooper: They absolutely know where certainly engaged, but where does the buck stop? that medical service is delivered. They know where Professor Grant: The buck stops with those who are their local hospital is. spending the money. Professor Grant: Exactly. Rosie Cooper: You. Professor Grant: That is a very good point. It is a bit Q15 Rosie Cooper: Will you and your Board be able like health and safety, is it not? Each of you secure to sustain the public opposition which will come back the level below where the responsibility goes, but in down to you as a Board personally? How will you be this, remember, the role of the Commissioning Board accountable for those decisions made by the power is to devolve the budget to the CCGs, and the CCGs you have given in terms of accountability? are those who are empowered to get best value for Professor Grant: To consider that question, the power money and quality healthcare from those devolved we have given is a power to take decisions and to be budgets. held responsible for them. Our job as a Board is to try to ensure that there is a comprehensive network of Q11 Chair: Devolution implies a decision. Who CCGs across the country financed and empowered to makes the decision? get value for money for their provision of health Professor Grant: Do you mean the decision as to services to patients. What they cannot do, as so often funding or as to quality? happens in the NHS at the moment, is to keep pushing that accountability back up the chain. We need to Q12 Chair: I mean the decision to accept that a make sure that CCGs—these are the GPs, after all, commissioning group is capable of delivering what who are being empowered—have the responsibility to the taxpayer wants for their pound. take these decisions. If they are dissatisfied with what Professor Grant: That is the Commissioning Board. happens in a hospital they need to deal with it and not As I see it—and, please, I am in early days yet—it is simply complain to a Secretary of State who no longer going to be an immensely active process of has this responsibility, nor to the Commissioning consultation and discussion over the coming 12 Board which has given them the responsibility, but to months, up to September next year and then through complain to the hospital and get it sorted, and, if it is to the formal process of authorisation, which goes not sorted, to use their commissioning power to ensure from September through to the following April. We that it is. That seems to me to be a fundamental will all be struggling to get away from the old Nye change of responsibility and accountability under the Bevan aphorism that if a bed pan drops in St Thomas’ Bill. Hospital it reverberates down the corridors of Whitehall. Q16 Rosie Cooper: I think you are due a shock, but, Grahame Morris: It is Tredegar actually. ergo, what you are in essence saying to the great Professor Grant: Thank you, but it is not the way for British public is that they will no longer have any the future and it never has, realistically, been the way power. Their view will not be heard. for the past. People who spend the money have to take Professor Grant: No; I think you have misunderstood the responsibility. 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— Q13 Rosie Cooper: Grahame has asked the question I was going to ask, but I am really struck that in your Q17 Rosie Cooper: You have not described your evidence so far you never once mentioned patients in passion for the NHS. reality and your accountability to the people. If you Professor Grant: Can I finish that one? I would very are going to authorise CCGs and you are going to much like to be able to ensure, as we develop this, organise that commissioning, surely you must be that we get away from running the NHS on the basis accountable. Earlier you talked about passion for the of “shock, shock, crisis, crisis” and that there is a NHS. As well as about accountability to the people, more measured view, which is to do with one, two other than being married to a GP and having a medical and three-year improvements in the quality of health school, what have you done that involves you in any and in patient satisfaction in this country. That has to way that demonstrates that passion about the NHS? be the long-term strategic aim. We cannot do that by Professor Grant: Let me deal with the first question. all the time passing accountability and blame up It should have been implicit—and I should have made through different parts of the system. The Chairman’s it clearer—when I was talking about the mandate that initial view is absolutely right. If you have too many it is all about outcomes. The mandate has to be people who are accountable, nobody is accountable. specified in terms of those five domains of outcomes Rosie Cooper: That is where we are. prepared by NICE. As you will recall, they all revolve Professor Grant: Good. around patients. The whole point of the NHS is not Rosie Cooper: Nobody is accountable. around structures, which is where most of the debate has been on this Bill. How many people in this Q18 Chair: What about your passion for the NHS? Health Committee: Evidence Ev 5

18 October 2011 Professor Malcolm Grant CBE

Professor Grant: Come on, what do you want me to you have already referred to, is to look at integration say? Doesn’t everybody have passion for the NHS? I and how these pathways work for patients? Secondly, love the expression that Peter Hennessy used in the you mentioned the issue of public health—a very House of Lords, which was that this was probably important issue with, obviously, the huge problems we the greatest institutionalised altruism that this or any have with alcohol and smoking-related morbidity— country has ever seen. Look at the outcomes of the but, of course, public health is going to remain with NHS against the investment that goes into it. They are the Secretary of State. How are you going to manage not perfect, but, by God, they are one of the best in that tension? If you feel that inadequate emphasis is the world. Anybody who can look at that without being placed on prevention, how will you interact to feeling some sense of passion for it is— push that the other way? Professor Grant: I still find this a puzzle. This is one Q19 Rosie Cooper: I asked about the demonstration of the most difficult things to pull off. Public health of that passion. and certainly health inequalities are absolutely Professor Grant: I find it difficult to demonstrate appalling. Much of the work that has been done by because I am not a patient of the NHS. My passion my colleague Michael Marmot at UCL has touched for it, therefore, comes through my institutional on exactly this issue. The relationship is one which is involvement with some of London’s leading hospitals. going to have to be worked on and will evolve over We have people working in our hospitals who are time. One of the roles of the Chairman of the Board saving lives on a daily basis. We have people who will have to be drawing together these other are developing research. We have a team working in organisations with responsibility for health. I Moorfields that I am really optimistic will come up suspect—and I am still young and naïve in this—that with a stem-cell approach to curing blindness. How there is far too much silo operating going on. I know a fantastic is that? You cannot stand back coldly and little about local government. I have chaired the Local say, “Gosh, that is very nice, but it doesn’t matter to Government Commission for England and I know me.” It matters to all of us. some of the problems which come from trying to organise health and social care through local Q20 Rosie Cooper: Forgive me, but as chairman of government and the interface that exists with the a hospital, when I interviewed for non-executive NHS. posts, one of the questions would be about What are we going to do? We are going to have to demonstrating involvement, knowledge and real depth make extensive use of the Health and Wellbeing of getting involved with the NHS. You have described Boards to tie together public health concerns with the a passion for the NHS, but I don’t know whether you work of the CCGs. We will have to have much more are showing any. I suppose what I am really saying is you were head-hunted for the job, but have you had integrated care by taking pathways and trying to work any contact with Ministers or people in the out how we can deliver them, not only through the Department of Health, and were they involved in CCGs but also with other partners and providers. helping you draft the answers to the questions at all? Remember this includes charities as much as anybody Professor Grant: What was that, I am sorry? else. It also includes private providers. One thing that Rosie Cooper: I mean the questions that were posed I have only learned in recent days is the extent to to you by the Committee. which psychiatric services, for example, are bought in Professor Grant: Yes. I was assisted in drafting the through private providers. 80% of The Priory’s work answers to those. I have, as you might have expected, is for the NHS. spent a lot of time briefing myself. I do not take The question for my concern is how we get the best briefings for an appearance in a Select Committee choice for patients as mediated by GPs. How do we except on issues about which I cannot find the get it on pathways as opposed to patients being told answers elsewhere. that their needs have to conform to the requirements of each specialty with which they are dealing? There Q21 Rosie Cooper: But they helped you. Had you are quite fundamental problems at the moment with met with Ministers before your appointment? the tariff systems and with the hospitals benefiting Professor Grant: I have met Andrew Lansley, I think, from a patient making six visits as opposed to one on three occasions in my life. where there is an integrated care arrangement for overseeing all of the multiple problems from which Q22 Rosie Cooper: You have met Andrew Lansley. they suffer. You have not met with Ministers before this appointment. Q24 Dr Poulter: I have a couple of questions picking Professor Grant: No. up on what we started off with earlier. You clearly have a very strong record of public service in what Q23 Dr Wollaston: Professor Grant, could I return you have done at UCL. You obviously train medical to two points you have already touched on? The first students, so you have an understanding of medicine, is the balance between integration versus choice and in my view, from that. You were talking about the competition. One of the statements we hear is that the importance of not micromanaging things, which I Board will lead at national level the delivery of more think a lot of us would agree with, and having choice and control for patients. Are you concerned long-term reconfiguration or long-term plans and that you may be being asked to deliver a mandate for strategies. Could you outline what you have done at something when in fact your natural instinct, which UCL in that sort of vein? Ev 6 Health Committee: Evidence

18 October 2011 Professor Malcolm Grant CBE

Professor Grant: When I arrived in UCL, which was worked quite well. There are other parts where they eight years ago, I wrote a Green Paper for the future have suffered from clinical leadership, perhaps from of UCL. I consulted on it. It became a White Paper. weak management and high levels of staff turnover. It then defined the strategy for the institution for the That fragility, of course, is enhanced at a time when next five years. I have done it twice since. We have reform is in the air. The weaknesses are exacerbated published this month the latest White Paper for UCL. as we come through to the new model, but the new It helps you immensely to understand where you are model is different. going with an institution, if you are able to agree with One of the things the Board is going to have to think your colleagues what the medium and long-term aims very hard about is what the governance structure is are and how you are going to be able to get there. for clinical commissioning groups. What is the mix You do not do this in any institution by command going to be between what will appear in subordinate and control. You have to do it in an institution like a legislation and in the authorisation? We need quite university by setting out an intellectual case that clear basic arrangements because there is a huge people will buy and setting out steps that will allow amount of public money going through the groups. As you to get there. That has been my experience at UCL. a consequence of the principles and the part about In many ways, it is reflected in what the institution autonomy and lack of bureaucracy, we need to be able has been able to achieve over that period. to give CCGs the opportunity to do things their way. It is a very difficult balance to strike between trying Q25 Dr Poulter: It has always been a strong to pin them down, which we must do for financial institution, but certainly its position has strengthened accountability, and energising and stimulating them in in a number of fields over that time. Thank you for a way which will allow them to perform to their that. It would be very much that approach, you have highest levels. said already, that you would be taking towards the NHS, looking at the bigger picture and the longer Q27 Andrew George: Professor Grant, I want to term, if you are trying to take a lot of the knee-jerk follow up on the question asked by Dr Wollaston. You politics out of things in how you would be acknowledged in what you said about public health commissioning services. that tension existed and the fact that you do not have Professor Grant: Absolutely. It starts with the control or responsibility for public health within the mandate. The Board has to play a powerful role in NHS Commissioning Board. I am not suggesting that setting up the mandate. We may need to think about at this stage you should indicate that you believe you the outcomes framework because, at the moment, know how to resolve tensions, but do you although it is specified at a high level, not all of the acknowledge that there are a number of tensions domains are fully filled. Setting the high-level within the role that you will be playing and the role outcomes, objectives and then costing them and of the NHS Commissioning Board, the first being in getting a realistic balance between objective and cost relation to the point made by Dr Wollaston about more into the mandate will be part 1. But I would love to choice for patients against also ensuring that the see a mandate that, although it was issued on an architecture is cohesive and co-ordinated? In your annual basis and was reported on, on an annual basis, brief you do not necessarily acknowledge that there is did not change significantly year on year. If you have a tension. The political debate here is underscoring agreed medium-term objectives, you should not be that. Would you acknowledge that there is a tension tearing them up at the end of the first year and starting between those two objectives? with a fresh set the following year. That, to my mind, The second question is on the issue of, as you say, is the model for the Board for the future. your role in relation to the governance issues and the role of GPs. As you are married to a GP, you will be Q26 Dr Poulter: Finally, there is the issue we have well aware of some tensions possibly with GPs. That talked a little bit about, which is accountability at the question is with regard to your role in commissioning local level, local commissioning boards and the clinical commissioning groups but also accountability. There are concerns being flagged up commissioning GP practices—micromanaging, in a by Members of the Committee about accountability— sense, individual GP practices. Do you see the role of that at the moment PCTs are very unaccountable on a the GPs being financially driven at the GP practice local level and lack, crucially, clinical leadership in level and how that relates to their role in many cases. I would like to clarify your position. commissioning services, some of which they may be There is a model in Cumbria where GPs have begun providing themselves? to lead on developing services and that has benefited Finally, there is the whole theme of being strategic, patients, with reduced waiting times and improved as you said you wanted to be, but also having to be integration of services locally. You believe that the responsible for micromanagement as well at a local local commissioning board should be very much at level, individual GP practices, dentists and community the heart of that, that the responsibility lies at a local pharmacies and so on. Do you acknowledge those level, it should be led by local commissioners and it tensions or do you think that those kinds of tensions should be those people who are holding to account can be easily resolved? local hospitals and helping to integrate services Professor Grant: No, I do not. I acknowledge all of locally. That is very much how you see things. those tensions and think their resolution is going to be Professor Grant: That is exactly right. The experience immensely difficult. We are not going to end up with with PCTs has been quite mixed. I know there are a perfect health system at the end of this. This is a some parts of country where people think PCTs have long-term process that we are entering upon. First of Health Committee: Evidence Ev 7

18 October 2011 Professor Malcolm Grant CBE all, the relationship between public health and the certainly the commentators on the system, there is not Board is absolutely fundamental if you want to deliver an understanding yet of the extent to which the way a set of health outcomes for the nation as a whole. care is delivered has to change if demand is going to Those health outcomes are very much related to health be met within the resources available. Do you inequalities and to what I was saying before in answer recognise that and what do you think is the role of the to an earlier question about people presenting with Commissioning Board in leading that process? It is a symptoms at a sufficiently early stage for them to be literally unprecedented process of change able to take advantage of early interventions. That is management, and that is seldom utopian. going to require co-ordinated action, which is Professor Grant: No, it is not. I have read your impossible to prescribe in legislation. It simply reports on this and would have to say that I agree with requires the bodies to work more closely together. the conclusion that you can only deliver the Nicholson Your second point was about commissioning GPs challenge through this fresh approach to themselves. It is very early stage work in progress, commissioning. It is a double hammer being applied but it is quite complicated. Trying to work out the at the same time within the NHS. For this reason you allocative formulae for the future with a more flexible need a Commissioning Board which will have strong approach to doctors’ lists and the change in residential appointments to it, taking a clear line. There is nothing requirements, for example, is quite problematic. A wrong with being visionary or utopian if that sets the significant amount of the Board’s budget, around £20 ultimate goal. The real problem is the behavioural billion, will go into commissioning primary care. Of changes that are needed to steer away from traditional course, there is experience to build on—this is not models of integration and patient care into what will entirely fresh activity—but there is a tension that I be more cost- effective, we hope, for the future. We recognise immediately, which is the relationship must remember also that part of the ultimate goal, part between getting that right and then getting the role of of the Nicholson challenge, is the ability to reapply the GPs and their participation in the consortia and the £20 billion or so which comes out of that the clinical commissioning groups right also. I am challenge into the new problems of health: for sorry, but I have forgotten your third question. example, long-term care on a scale that we have not yet seen. Q28 Andrew George: The first one, which was touched on by Dr Wollaston, was as to choice and Q31 Chair: Do you think it is accurate to integration. We have both mentioned it and you have characterise one of the problems facing the Health not, as yet, given a clear indication of the fact that Service as that the structures exist in a form that is you believe there is a tension there. determined by yesterday’s pattern of demand and that Professor Grant: Yes, I hope I have said that there is what is now required is to change the structures to a tension between those two. The simple answer is to meet tomorrow’s pattern of demand, which is likely say that, again, it is back for the clinical to be fundamentally different? If that is true, is that commissioning groups to develop their own not a huge challenge? approaches to integration and to ensure that patient Professor Grant: Yes. You have put it much more choice is exercised with appropriate guidance from the eloquently than I had, but that is true and it is a huge GP within that structure. challenge. The patterns of demand will be quite different. Q29 Andrew George: The final one was micromanagement versus being nationally strategic. Q32 Chair: In this new system, who owns the Professor Grant: Yes. What a wonderful tension. responsibility for delivering that change? Andrew George: Lovely tension. Professor Grant: It is an activity which is owned at Professor Grant: I do not think there is a glib answer the level of the Commissioning Board but working to that or to any of these questions. My natural with the clinical commissioning groups to try to instinct—and I am sure most people’s—is to empower transform existing patterns of behaviour, and in a and devolve responsibility and let people do what they harsh financial climate that will compel practitioners are better able to do. You and I cannot run a GP to confront difficult choices which, at the moment, are practice from Westminster or Whitehall, and yet we capable of being eluded. have to have put in place the necessary safeguards to ensure that it does not all trip up over itself. That is Q33 Chair: I will have one more go and then turn to going to have to work out through a series of Grahame. I think you used the words “support exemplars and discussions over the next year. commissioning groups.” Human nature is such that, when there is a soft option available, they usually Q30 Chair: What strikes me about this discussion so choose it. Who is going to close off the soft options? far is that it all seems quite utopian. We are describing Professor Grant: That is, again, the balance between Elysian Fields that we would all like to live in. One the Board and the groups. All of this is going to have of the things the Committee has sought to do since we to be worked out, and it would be foolish for me to were established is draw attention to what we call the try and give you strong and clear answers today. I am Nicholson challenge; what the Health Service faces is not clear in my own mind how far we are advanced a period of unprecedented change not of the with the existing commissioning arrangements across bureaucratic structures but of the way care is the country in preparation for these very significant delivered. You have used the word “integration,” but changes. There is, after all, only 18 months before the the danger must be that within the system, and majority of CCGs assume full statutory responsibility. Ev 8 Health Committee: Evidence

18 October 2011 Professor Malcolm Grant CBE

Q34 Grahame Morris: My questions follow on from consensus, then it would come to the Board in that, and you have touched on some of the tensions exceptional circumstances. There is an independent between the NHS Commissioning Board and the local reconfiguration panel—which I think was brought in clinical commissioning groups. The NHS on Chase Farm—that could advise the Board, and, I Commissioning Board will authorise them so that they suspect, in truly exceptional circumstances it may are fit and proper organisations to commission even end up on the Secretary of State’s desk. The services. When, if ever, do you envisage the NHS strong wish of the Board—and I am sure of any Commissioning Board would intervene in the event of Secretary of State—would be to drive that failure by the clinical commissioning groups? I will responsibility down to where it belongs. If service share with you some evidence that was presented to reconfiguration is needed because the present service the Committee. As you are aware, we have published is not meeting the needs of patients as mediated two reports on commissioning, but the Nuffield Trust through the CCG, that needs to be addressed at local presented a study that they had done in North America level. where there was ample evidence of the main reasons for the failure of clinical commissioning groups being Q37 Grahame Morris: I fully appreciate that and I financial underperformance—overspending their do not want to labour the point, but the nature of the budget. Are they the circumstances in which you unpopularity of such tough decisions is that when the would see the NHS Commissioning Board intervening local decision-making processes—the scrutiny or are there other circumstances as well? committee and the Health and Wellbeing Board—look Professor Grant: This is very early stages. Certainly, at it, they may say, “No, we want to retain a local financial propriety and financial discipline has to be at service in a local hospital.” You, as you have already the heart of the clinical commissioning groups and, indicated, Professor Grant, are taking a strategic look for that reason, will need to be written into the at these issues. In those circumstances, are you saying, governance arrangements. There will need to be a when the local commissioners cannot agree to service chief executive or an accountable officer for each reconfigurations, that you as the NHS Commissioning clinical commissioning group who will have that clear Board will step in and take the decision for them? responsibility. In so far as clinical failure is concerned, Professor Grant: Can I tell you that nothing would it is going to be a balance between intervention by appal me more? I do not think the Board wants, any the Board, by CQC and by other agencies who have more than Secretaries of States do, to get involved responsibility across the whole piece, depending on in local service reconfiguration. Responsibility has to where the failure is. Is it in secondary care, long-term continue to be pushed down to where it is, but, if it care, social services or is it within general practice? reaches an impasse, then some way needs to be found The levers and the models of intervention will be of resolving that. variable according to the nature of the circumstances. Your underlying point is the important one, which is Q38 Rosie Cooper: My view is that each and every that the Board is going to have to ensure that it has one of those decisions will reach that impasse. The the intelligence flow to be able to detect failure Board that you described before of a chairman and coming through at any time. five non-executives is the current model of trust boards in the NHS. Very important and core to that is Q35 Grahame Morris: Can I ask a supplementary to the relationship between the chair and the chief that? Professor Grant, do you envisage that the NHS executive. How do you envisage your relationship as Commissioning Board is likely to intervene where Chair of the Commissioning Board with the Chief commissioners fail to effectively reconfigure a Executive and what is the single most important tool service? There is a huge debate and controversy over that you as Chair-elect would have to hold the Chief the Chase Farm reconfiguration of accident and Executive of the Board to account? emergency services, and in my area the Professor Grant: It is difficult to answer the first part reconfiguration of an A and E facility and of your question without personalising it, and that is downgrading of services to a walk-in treatment centre. undesirable. You have in the present Chief Executive Because the politicians have already said we are somebody of extraordinary experience, with a lifetime stepping away from that, is this the kind of of employment within the NHS. He knows his job. circumstance where the NHS Commissioning Board The job of the Chair is to ensure that he and the will show some muscle and intervene? executive team are working within the new Professor Grant: If it has come to the Board, then all framework, which is a different framework from the the local arrangements have failed. old one. In my experience, both as a chairman and as a chief executive, ultimately it boils down to personal Q36 Grahame Morris: I am asking you about the relationships. Is there a trust and respect between the failure regime in a sense. two parties which allows them to be clear about where Professor Grant: Service reconfiguration is the most the responsibility of each starts and finishes? Is there difficult thing in the NHS and is always a hugely an ability to deal with differences of opinion? There controversial issue, as you mentioned with Chase will be? Those differences of opinion need to be dealt Farm. However, the responsibility under the new with, addressed and sorted out. arrangement, as I understand it, is that this will rest in the first instance with the clinical commissioning Q39 Rosie Cooper: What is the most important tool? groups, but there is a process of consultation and Professor Grant: Let me finish this because the Chair, engagement with other groups. Should that not reach as you have pointed out, is not the sole non-executive Health Committee: Evidence Ev 9

18 October 2011 Professor Malcolm Grant CBE member of the Board. There will be five others in Board and the Board assigns responsibility to CCGs. addition to the Chair. The relationship is not only We will have a transparency that I think we have not between the Chair and the Chief Executive. It is had before. between the other members of the Board as well. The way I would see this—and the Chairman is going to Q43 Rosie Cooper: Given the policy intention to accuse me again of being utopian—is that the Board delay and reduce management while moving away works as a team. from central top-down performance management, why Rosie Cooper: He will not be on his own. does the Board need regional arms? Professor Grant: Thank you. By that, I mean the Professor Grant: The Board cannot do everything executive and the non-executive members work as a located in London and Leeds. You are leading me in team. a long direction, for somebody who is 100 hours into the job. As I see it, the Board will not be establishing Q40 Rosie Cooper: Given the Board’s power, can its any formal structures between the Board and the executive be effectively held to account by a CCGs. It will, of course, have staff deployed part-time Chair? regionally so that they are closer to the CCGs and Professor Grant: Do you think a full-time Chair better able to do the very things that you would have would be more effective at holding people to account? us do. I do not think it is the question of time that the Chair puts into the job. It is the question of the personal Q44 Dr Wollaston: You mentioned earlier—and I qualities both of the Chair and the Chief Executive. quite agree—that we need to get away from the “shock, shock, crisis, crisis” response to the NHS and Q41 Rosie Cooper: Absolutely. That goes on in think more strategically, but, inevitably, somebody every hospital in the country. You did not answer the will have to be responsible and comment on events as question I posed to you first, which was: what is the they arise. Today, for example, take the Parliamentary single most important tool that you can use to hold Health Service Ombudsman Ann Abraham’s report the Chief Executive to account? into the variability of GPs in their response, say, to Professor Grant: I expect it would be the normal tools striking patients off their lists. Who do you feel should in which targets and objectives were set for the year respond to these sorts of reports and crises that arise and there was performance management of the Chief in the NHS or issues that need addressing urgently? Executive by the Chair. Should that be the NHS Commissioning Board, through you, or should that be the Secretary of State? Q42 Rosie Cooper: In that case I would like to go Where would you see that role? on and ask you this. The White Paper stated that the Professor Grant: I have to say that I am still puzzling Commissioning Board would be “free from this one through. I thought Ann Abraham’s report was day-to-day political interference”. You have described quite telling this morning, as was the CQC report what you see as the optimum relationship between the recently on the lack of dignity and respect accorded Board and the Chief Executive. How do you see that to elderly and infirm patients. It is no longer going to relationship between the Board and Ministers and do be the case that the Secretary of State is wheeled in you think “free from political interference” means free front of the TV cameras. Responsibility has to go back from political accountability? to where it is. It has to go back to within those Professor Grant: There is a big difference between hospitals. Who is the chief nurse? Who is the medical interference and accountability. Accountability is director or where is the CEO? something which, in the Bill, is to be maintained through the mandate. The accountability is for Q45 Dr Wollaston: Can I stop you there? Take, for delivering what the Board has been told to deliver. example, Ann Abraham’s report today, which is That is accountability, which is to a large extent ex saying that there are a handful of GP practices across post: “Look, this is what we have achieved.” The the country with unacceptable practice in the way they Board’s annual report goes to Parliament, and it is a are removing patients from lists. Are you saying that clear and transparent responsibility. That differs from those individual GPs should be accountable? day-to-day political interference, and that is Professor Grant: Yes, they should. something that the Board would have to be resolute to resist. This is not a statement about any particular Q46 Dr Wollaston: Who should be responsible for, Secretary of State, but there is a strong temptation for as you say, facing the TV cameras and saying, “How a Secretary of State to reach into the NHS to try and are we going to get a grip on this variation in GP push buttons, pull levers and turn knobs. That is not practices?” Ultimately, GPs are going to be the new model. You may ask what the role of the commissioned directly by the NHS Commissioning Secretary of State is under this new model and how Board. the Secretary of State responds to constituency Professor Grant: Yes, that is true. concern about the operation of the NHS. Again, the answer lies in my answer to your earlier question, Q47 Dr Wollaston: That is the accountability, which is where responsibility ends up. The Secretary ultimately. of State has the overall accountability for the Professor Grant: In that case, it would need to be, I provision of a comprehensive National Health Service assume, the Board, but I am still anxious to ensure in this country. Under this measure, he assigns, that there is a clear chain of responsibility and that through a mandate, responsibility for delivery to the there is not accountability at too many levels. You Ev 10 Health Committee: Evidence

18 October 2011 Professor Malcolm Grant CBE have to push it back. The accountability for the Professor Grant: Yes. How long do we have? specific actions rests with the GPs themselves. The Chair: As long as it takes. I am afraid there is no accountability for the climate, if you like, and the defence there. rules under which they operate, will rest with the Professor Grant: I was dreading that was going to be authorisation, which they have from the Board. Some your answer. The relationship with the CCGs is of the instances that she cited were breaches not of through the authorisation that they have from the rules but of BMA guidance, which is a slightly Board with clear accountability. I keep coming back different position from that of a formal operating to this, but we do need, over the next 18 months, to structure. be absolutely clear about what this means. Among the population at large, nobody knows what Q48 Dr Wollaston: The trouble is that people can commissioning is. Patients want a system that gives slip through the net. The public do not want to see the them access to the highest quality care and with NHS Commissioning Board saying, “It is not us. It is accountability for default. down to these individual GPs.” Of course it is, and they ultimately take responsibility for poor practice Q51 Chair: I completely agree with that, but it that is completely divorced from guidelines, but comes back to Sarah’s question, does it not? If Ann people will want somebody to account for how it is Abraham reports that there is some aspect of the going to be changed. system—or, indeed, the CQC and a number of others, Professor Grant: That is the question. It is not and it may even be this Committee occasionally—that accounting for what has gone wrong but how it will is not as it should be, arguing that there is no change, and in that case it will be a question of accountability other than the CCG means that there is whether what has been breached is something which nobody going to appear in the television studio. The was in the authorisation from the Board. Can I say public is going to become even more fogged as to that this is all going to be very messy? what is going on than they are at the moment. Chair: Life tends to be messy. Professor Grant: I wonder about the test of the Professor Grant: Yes, but it is messy already. It is effectiveness of a system by who appears in the going to be messy as we go through a very complex television studio. There are two questions, as I said transitional programme. What we hope for is a earlier. One is, “Where is the fault and who is sharper, more transparent and more accountable responsible for the fault?” The answer to that is with system at the end. If I am dewy-eyed for believing each of those GPs. The second question is, “What is that that is achievable, you must not confirm my the systemic issue and how is that changed for the appointment to the role. future?” The answer to that, so far as GP conduct is concerned, must be with those who commission the Q49 Chair: Can I test, for a second, this proposition, GPs, which is the Board. In so far as secondary care that one of the effects of the new structures is to is concerned, the answer must be with those who introduce—and, it is sometimes implied, for the first commission the secondary care, which is the CCG. I time—a delegated management structure, and may be oversimplifying this. previously with dropped bed pans there was no defence mechanism between the individual nurse and Q52 Chair: I do not think you are, but, for systemic the Secretary of State because that is not how it was accountability in a national health system, the CCG or is under the current statute? Responsibilities are that conducts the local commissioning process has to defined in statute for trust boards, for PCTs and for be accountable through someone, which is presumably special health authorities. To what extent are the new the Commissioning Board. structures different from the existing structures in Professor Grant: Yes. The question goes back to your terms of the extent to which the statute defines a very early observation that, the more who are delegated responsibility? I entirely agree with you that accountable, the fewer are actually accountable. good management requires people to have defined responsibilities and to be accountable for the way they Q53 Rosie Cooper: Will you be the person doing carry them out. I absolutely agree with that, but I do “Panorama”? not see this Bill as creating different delegated Professor Grant: I said this job was full of risks and statutory structures, or structures that are different in probably that ends up being one of them. form, from the ones that already exist. Rosie Cooper: You will be accountable to the people Professor Grant: That is right, up to a point. In my via the press but not via structures. It is unbelievable. understanding of it, one of the critical differences is Chair: That is a statement rather than a question. the transfer of financial responsibility to the CCGs and their obligation to hold the secondary providers to Q54 Dr Poulter: I want to come back to the point account. you made quite well about the fact that devolving responsibility to local commissioning boards will Q50 Chair: How is that different from the statutory mean that local GPs and other healthcare professionals responsibility that rests on a PCT? will take ownership of services. There is a strong Professor Grant: Because this is not the PCT. I am argument for that. There will need to be some national sorry—we are getting into acronym soup. The CCGs guidance and framework as to how it will work. are being established on a different basis from the Accepting that the demands and healthcare challenges PCTs. in Easington may be different from central Suffolk Chair: Discuss. and north Ipswich—or indeed may be different in Health Committee: Evidence Ev 11

18 October 2011 Professor Malcolm Grant CBE

Ipswich from central Suffolk, for example—and the professionals on the ground about the quality of particular challenges and local factors that may affect services being delivered by a particular what commissioning groups will look at, how do you commissioning group, what powers would you envisage the overarching guidance and framework envisage, at a national level, you would have to either from the National Commissioning Board filtering intervene or act to change what is happening? down to a local level? Professor Grant: As I said in my answer to Mr Morris Professor Grant: This is very early days and it still earlier, it seems to me that there is a variety of levers has to be worked out. that can be used. First of all, you need to have the intelligence as to what is going on, which may come, Q55 Dr Poulter: You talked earlier about the service as you suggest, through reports from others or may reconfiguration and those sorts of things. Would it be come through the relationship between the CCG and along the lines of saying, “Over a defined period of the staff of the Commissioning Board at the regional time we would envisage that healthcare challenges are level. Our role, as I would foresee it on the dealing with an ageing population and healthcare Commissioning Board, is to work always in support inequalities, and we would envisage your local and improvement of clinical commissioning groups framework to reflect that in how you are delivering across the country. services in generic terms”? Professor Grant: There are two aspects to it. One is Q58 Dr Wollaston: Professor Grant, you have made the financial allocation, which I anticipate would it clear that it is not your role to be involved in the continue to be done with advice from the advisory micromanagement of the Health Service. How committee on resource allocation, which does look at available will you be to respond to concerns raised by demographic differences across the country. The other individual CCGs as the whole culture and basis of one around service provision is going to depend very the new NHS is established? For example, one of the much on the maturity of what exists there now. You concerns that I am consistently hearing from CCGs is have some very large groups already which are quite that they need to know their management allowance significantly moving into commissioning with in order to be able to become established and make populations of up to 600,000 where you can spread plans properly. What position will you be in to risk much more effectively. For some types of persuade the Board to make decisions if you are commissioning you can be very effective with small approached by CCGs with issues like that, for populations and with other types of commissioning example? you need large populations. I would also imagine that, Professor Grant: I understand that there will be an with smaller commissioning groups, there may be announcement about the management allowance fairly mergers or partnerships which would allow them to soon. I hope that that one can be addressed. In this develop an effective programme across a broader area. job you have to be eyes and ears, you have to be As I say, these are conversations that are yet to responsive and able to engage with a broader commence. community. In my present job—and I have nothing like the size of community you have in the NHS—my Q56 Dr Poulter: I have one follow-up on that. You inbox is never empty of people wishing to draw things talked a lot about GPs in terms of the local to my attention, some of which require my personal commissioning. In terms of clinical commissioning it attention, others of which can be relayed to is a lot broader than that, particularly if we are looking responsible members of the executive staff to resolve. at that sort of service reconfiguration. You mentioned To be the Chairman of this Board does require some silos earlier—the Chairman mentioned them as well— visibility to those involved in the NHS across the and breaking down a lot of them and the institutions country. that exist in the NHS is probably fundamental if we are going to reconfigure services and deal with Q59 Dr Wollaston: In other words, you will do the tomorrow’s NHS and tomorrow’s patients. Would you best you can to be available to listen to those concerns see it as your role and that of the Commissioning and represent them. Board’s to facilitate and put across national Professor Grant: Yes. The prospect of the inbox is frameworks for local commissioning that would overwhelming. enable that? Chair: You are right. Professor Grant: Yes. I see that as one of the central tasks. The landscape still, after the Bill, is quite Q60 Rosie Cooper: I have two final questions, if I confusing where different bodies relate to each other, may. One is to go back into more of the detail about but probably the Board, with its very significant the failure regime. Would you be concerned if that financial responsibilities, has to ensure that all the failure regime allowed providers to apply to the others are engaged with it. That is going to require a financial regulator Monitor for a higher-than-tariff lot of hard work through advocacy and sharing payment for services without the consent of their objectives. commissioner? Professor Grant: I am sorry, but I would not want to Q57 Dr Poulter: I have one last question which was give you an off-the-cuff answer about that. I do not mentioned earlier. If it was felt at the end of a defined sufficiently understand that regime. period of service delivery that there were very real concerns being expressed and passed up by Members Q61 Rosie Cooper: Fine. There is a facility in the of Parliament, patient groups or by other healthcare current proposals where providers can go to Monitor Ev 12 Health Committee: Evidence

18 October 2011 Professor Malcolm Grant CBE and say they cannot provide the service for that price appointments, I understand head-hunters have been at and Monitor can consider it. Perhaps you could take work, but I have had no communication because I am away that thought: “Should that be allowed? If so, not the Chairman of the Board. what would happen?” and, “If not, why not?” Chair: I understand. I will leave that and go to a personal question. In describing your boards, you said it was important to Q64 Dr Wollaston: I have one final question. As the be independent and strong-minded. Could you Bill passes through the House of Lords, are there any describe a time in your career when you have held a changes you would like to see that you feel would position or a view or fought your corner in the light make your job easier? of strong opposition and shown yourself to be Professor Grant: I would like to think that through. independent and strong-minded all the way to the end There might be changes that would make it more of the argument? difficult. Professor Grant: This is starting to sound like a job interview. Q65 Dr Wollaston: Could you elaborate on what those would be? Q62 Rosie Cooper: Forgive me, but you have said Professor Grant: Looking at the concerns of the today that you have been 100 hours in the job and I Lords about the relationship between the Secretary of thought I was coming to a pre-appointment hearing— State and the Board, I would wish to keep a very close so, yes. Funnily enough, that is what the eye on that because, frankly, if it ends up with the accountability is about, the bit you are struggling with Secretary of State having revived powers of direction right through this. to the Board, then you need civil servants to run it. Professor Grant: Thank you very much. The Dr Wollaston: Thank you. substantive answer to your question I would say was in my experience in chairing the Government’s Q66 Grahame Morris: You mentioned how Agricultural and Environment Biotechnology important it is for commissioners to look at the Commission, in particular in relation to GM crops, evidence base, and you also made some reference to which I did for five years. It was a time of dealing your admiration for Professor Sir Michael Marmot, with a Government which was not a good client of a who is based at UCL. What are your views about the commission that it had set up and in which, at that cuts in the public health observatories? Surely that is time, in a single Department there were two Ministers the resource which should inform our policy choices with diametrically opposed views on the substantive of redesigning services. issue which we were addressing. We had a Professor Grant: I am sorry, but I am not going to commission which had on it 20 people. It ranged from get drawn into what is a political arena and which I the chairman of Greenpeace UK through to do not think is relevant to my views about the work representatives of the seeds and biotechnology of the Board. industry. The prospects of getting consensus on that commission were very low. We got it, and we had to Q67 Grahame Morris: You mentioned the be very clear with Ministers that this was a consensus importance of evidence on which to make decisions. and that if we were to conduct on their behalf the Are the PHOs not one of the key organisations that public debate they wanted they were to have to fund compile evidence on which action plans are based? it adequately. That is one instance from my Professor Grant: Yes, but — background of undertaking a public service against a highly complex and controversial set of factors across Q68 Grahame Morris: You must have an opinion the country and with a rather shaky level of on that. Government support. Professor Grant: I do, and I think evidence is absolutely critical. Q63 Chair: Can I ask you a formal, mechanistic question? At the beginning of the session you said Q69 Grahame Morris: What do you think about the you felt that the non-executive board should have five 30% cuts in their funding this year? members and then there would be the executive team Professor Grant: I am sorry, but, Chairman, do I— as well. Looking at the balance of the non-executive Chair: I think you have given the answer. Virendra members, do you think it is relevant that some of wants to come in. those people have Health Service backgrounds, would you welcome a weight of the non-executives being Q70 Mr Sharma: Thank you. I apologise for from outside an NHS background, or do you not think arriving late. When I arrived you mentioned the time that is necessarily relevant? commitment and whether there is a full-time or Professor Grant: I do not think it is a sine qua non, part-time chair makes no difference, but certainly if but I would very much like to see strong clinical you have a very clear vision and system in place you representation. This is about clinical change and I can work. There is one other very sensitive point would like clinical input on the Board. You would which it may not be easy for you to answer because have it from the executive end as well as the it is not of your making, and I do not want you to feel non-executive end. Clinicians are well able to uncomfortable on this point, but I think it is important understand and articulate the challenges and to be to ask. You will be expected to answer the question forceful advocates and ambassadors across the as to whether the salary of £63,000 a year is country for the work of the Board. As to other reasonable or is quite high. If you are working four Health Committee: Evidence Ev 13

18 October 2011 Professor Malcolm Grant CBE days a month, one day a week, it works out at £1,312 assume it is one that is followed by every Member of per day. How are you going to justify it when the this Committee. question is asked, or how would you respond to that? Mr Sharma: Thank you. Professor Grant: The answer is simple. Throughout Chair: That is a straightforward answer. Thank you my time at UCL I have accepted a number of external for that. I do not think there are any other questions appointments which carry remuneration. My from the Committee. Thank you very much for invariable practice has been to have that remuneration coming this morning. paid directly to UCL and not to take a penny of it. Professor Grant: Thank you for your time. That is a fundamental facet of public office, and I Chair: Thank you.

Printed in the United Kingdom by The Stationery Office Limited 03/2012 019573 19585 Distributed by TSO (The Stationery Office) and available from:

Online www.tsoshop.co.uk

Mail, Telephone, Fax & E-mail TSO PO Box 29, Norwich NR3 1GN General enquiries 0870 600 5522 Order through the Parliamentary Hotline Lo-call 0845 7 023474 Fax orders: 0870 600 5533 Email: [email protected] Textphone: 0870 240 3701

The Parliamentary Bookshop 12 Bridge Street, Parliament Square London SW1A 2JX Telephone orders: 020 7219 3890 General enquiries: 020 7219 3890 Fax orders: 020 7219 3866 Email: [email protected] Internet: http://www.bookshop.parliament.uk

TSO@Blackwell and other Accredited Agents © Parliamentary Copyright House of Commons 2012 PEFC/16-33-622 This publication may be reproduced under the terms of the Open Parliament Licence, which is published at www.parliament.uk/site-information/copyright/