Health policy debate
1 June to 15 June 2004
This summary does not usually comment on public health, stories relating to diet, alcohol, smoking and the like; it concentrates instead on the politics of health policy. But some of the discussion relating to the recent push on public health is worth noting because of the philosophical and political divide it highlights within the Labour party.
John Reid’s comments at a Labour party event indicated his view, in common with other new-Labour-libertarians, that choice is paramount and people need information to make their own mind up – they should not be dictated to. He said the middle classes were obsessed with giving instruction to people from lower socio-economic. "I just do not think the worst problem on our sink estates by any means is smoking" [1].
John O’Farrell joined the debate in The Guardian. While ‘John Reid does have a point, ‘it is easy to pontificate when your life is in control…easy to see the damage that people do to themselves and others when you are not totally demoralised and exhausted, [but]…the bottom line is that passive smoking causes cancer. Smokers don't have the right to inflict that upon others. The government should follow the example of the Irish and push through an outright ban in public places. They'd be saving thousands of lives; what more motivation can MPs possibly want? And when they stagger home claiming that they've been working late at the Commons, there won't be a stink of smoke betraying the fact that they've been in the pub all evening’ [2].
Reid later said he had been acting as “devil’s advocate” and was encouraging the audience to see the debate from all angles [3].
Workforce
The Guardian’s political editor, Michael White, wrote about a conversation he had with David Hinchliffe after his Health Committee’s report on obesity - commendably White found Hinchcliffe walking his dog in the morning - he had ‘already taken 4,987 steps’: “that’s half my daily quota”.
Hinchcliffe wanted to press a point not highlighted in coverage of his report: ‘where are the public health professionals in the debate?’ A previous health and social services secretary, Sir Keith Joseph, ‘shoved local medical officers of health, once famous figures, into health authorities in the 1974 reforms. Even inside PCTs they remain marginalized in the NHS structure’. White says, ‘It’s time to make them famous again’ [4].
The following week, White returned to the public health theme, reporting that the previous week’s article had elicited a ‘note from Politics of Health Group co-chair Dr Alex Scott-Samuel, accusing Labour of gradually walking away from a sound agenda for public health since 1997. Scott-Samuel says, “A change of direction is urgently required; the department [of health] needs to break out of its silo mentality and engage with the more joined-up and progressive policies of other departments in areas such as neighbourhood renewal”. If the direction within the DH cannot change, ‘public health must be moved to a genuinely cross-cutting set up like the Cabinet Office’ [5].
Dispensing public health
The DH announced it has signed a contract with four organisations to enhance the role of pharmacists in public health. The organisations are Pharmacy HealthLink, The Royal Pharmaceutical Society of Great Britain, the Faculty of Public Health and the UK Public Health Association.
‘The consortium will work with pharmacists to come up with recommendations on how much wider their public health role could be and to establish what support and extra facilities they would need. Any recommendations will then feed into the new contractual arrangements currently being reviewed by the NHS Confederation, which represents health service managers, on behalf of the DoH’.
Pharmacy HealthLink’s chief executive said: "These are clear interventions that are really easy to carry out in a pharmacy." However, she made clear pharmacists would not necessarily be obliged to undertake them and that any extra responsibilities should be clearly rewarded along the lines of the new GP contract, which has rewards for work in specific clinical areas [6].
Minister of State for Health Rosie Winterton said, “To date, pharmacists have been a major untapped resource for health improvement. The track record of community pharmacists in areas such as stopping smoking, sexual health advice and substance misuse is evidence of how integral they are to tackling public health issues.
“But we would like pharmacists do even more and get involved in aspects of care such as checking people's blood pressure and even measuring blood glucose levels” [7].
Dentists heckle Rosie Winterton
‘Around 200 dentists gathered to quiz the minister over NHS funding, staff shortages and changes to the way dental services are commissioned at the conference of local dental committees in London. There were jeers and laughter from the audience as Ms Winterton repeatedly promised to make announcements "shortly", adding: "Let me reassure you that we will work this out."
‘From April next year, all primary care trusts (PCTs) in England will take over the £1.2bn budget and commissioning of dental services from central government. This will mean PCTs will either have contracts with dentists to provide dental care or will provide the services themselves. The plans will also see dentists receiving a fee per patient rather than a fee per treatment they carry out, which Ms Winterton said would let them focus more on quality of care’.
Dentists are concerned that new finance systems for dental services are being rushed through, and that funding for dentistry is not increasing at the same rate as other areas of the NHS.
Dr Lester Ellman, chairman of the General Dental Practice Committee, voiced disappointment at the lack of progress that had been made in allaying dentists' fears over the changes. "I have to be honest with you and say that our discussions with the government have been disappointing. "It is a matter of great personal sadness to me that in more than a year's talking with the Department of Health we are effectively little further forward than we were at the start" [8].
Agenda for change implementation delayed
More problems for the government over workforce contracts came with the postponement of the implementation date for Agenda for Change. The complex pay system will not now be rolled out until unions have agreed the system, following ballots of their members.
The results of the ballots will depend on the experiences of 12 pilots where there have been problems. Staff in one (the North East ambulance service trust) are preparing to take industrial action, objecting to unpaid breaks when staff are still be on-call and the regrading of many positions. ‘A ban on overtime working and cover for public events (such as football matches) will start next week after a 94% vote in favour of action by Unison members’.
A joint statement signed by lead negotiators Paul Marks, the staff representative secretary, and the NHS' acting head of pay, Mike Evershed, sets a new December 1 implementation date, although new pay rates would then be backdated to a October 1 "effective date". Health minister John Hutton said: "The government is still fully committed to Agenda for Change. This is a sensible arrangement that the unions and the Department of Health have agreed which will not affect anyone's entitlement to better terms and conditions from October 1" [9].
Patient choice
A feature in Hospital Doctor began by summarising doctors fears over the patient choice initiative: ‘being left with the more complex cases’; ‘adverse affecs on performance ratings’; ‘pushing up average lengths of stay’; ‘juniors’ training suffering suffer because they will not be able to experience such a wide range of procedures’. Another fear is that this new system, which operates on payment by results, will end up with some hospitals benefiting at the expense of others. Some hospitals that attract fewer referrals could lose money and become run down in a vicious spiral’.
It is likely choice will not operate in a uniform way as it is implemented in different ways in different parts of the country. In Greater Manchester, the StHA ‘has been running a scheme in which all their GPs send their outpatient referrals to a call centre, which discusses options and choices with patients. ‘Patients are told how long they will have to wait and are offered the most convenient slot, which will then be booked electronically. The scheme has helped to cut waiting times and lists’.
The authorities ‘choice and electronic communications manager admits the scheme can offer only a limited choice of treatment. “We are only able to offer locally commissioned slots, which are paid for in advance by PCTs. ‘Patients can’t pick everything they really want, such as treatment on a Saturday or 24-hour services, if it is not cost-effective to provide those services’ [10].
The article quotes the president of the Royal College of Opthalmologists who says it is important patients are given a free and informed choice and are not just influenced by a service agreement. “I am not sure that all the effort being put into this initiative is not just adding to the NHS bureaucracy, as opposed to putting money into local services and making them more efficient”.
This view is reflected in the activities of Trusts in parts of the country where providers are working to cut waiting times so they attract referrals (as most think choice will be on the basis of waiting times). Bradford Teaching Hospitals has recruited more general and orthopaedic surgeons, plus additional theatre and support staff. Consultants have been encouraged to do more outreach work, establishing partnerships with GPs with a special interest – and 15,000 operations that were performed in hospital are now carried out in primary care.
Nigel Edwards, NHS Confederation policy director, says that choice offers incentives for Trusts to work differently, a view the example above supports. “In future, money will come with the patients and this could give doctors more flexibility if they want to develop services outside hospitals”.
The article speculates that ‘in due course, PCTs may decide, for example, to pay orthopaedic surgeons directly to run outpatients appointments, as this could prove cheaper than providing the service in a hospital. ‘Consultants could rent space in hospitals or one of the new purpose-built primary care centres’
‘Doctors should watch this space and should be finding out about how they could use this initiative to develop their services and provide better care’.
When politics and choice collide
According to the Health Service Journal, ‘the temperature is about to rise across north central London’ when ‘the patch’ will ‘be subject to two major consultations on changes to services’.
The services could not be more politically sensitive: paediatrics and maternity services. The proposals (originally for release in July but now put back to September) ‘will mean reducing the number of hospitals offering [the services] from six to four’. ‘The geography of the patch raises the odds on a straight choice between the Royal Free and Whittington hospitals’.
‘And with north London packed to the gills with Labour MPs – including a couple of marginal seats – consultations in the run-up to a general election over which local hospitals will lose acute children’s and maternity services is bound to get interesting’, especially since; the loss of the traditionally Conservative seats of Hendon and Finchley to Labour in 1997 was widely attributed to the closure of Edgeware General Hospital’ [11].
Plurality
Another example of politics and choice not mixing well, came out in the case of South Oxfordshire Primary Care Trust.
The story of the imposition of a TC on Oxfordshire Primary Care Trust
In previous summaries, HPERU have reported the tensions generated in Oxford over the establishment of a treatment centre (TC) to provide cataract operations. Several months and three resignations later the full story has emerged.
In an interview with Society Guardian, former chairman of the area's PCT, Martin Avis (who stepped down as chair of the PCT in January after being unexpectedly asked to go through a contested reappointment procedure) explained how his board was bullied by Thames Valley strategic health authority (SHA) to sign a contract with a South African company for a treatment centre that it did not need. The (also) recently retired chairwoman of the SHA, Jane Betts, admits bullying tactics, but claims her authority was merely "the jam in the sandwich". It behaved as it did because it was under heavy pressure from the Department of Health. (Betts resigned at the end of March after concluding that the SHA was becoming "a local office of the NHS".)
The PCT first expressed an interest in a treatment centre in 2003, but at that stage expected ophthalmic work to form only part of a wider package of general surgery. And when the full details of the proposal (i.e. the provision of ophthalmic services only) were discussed in July that year, the non-executive members did not like what they heard. The non-executives thought this made no sense in their area, where great strides were being made towards reducing the cataract waiting list. Why pay for Netcare to carry out operations that could be done more cheaply at the highly-regarded Oxford Eye hospital? In private session, the board made a formal decision to withdraw its expression of interest. ‘Then the pressure started’.
‘In October, Avis and Jane Hanna - a non-executive member of his PCT (who resigned in May, complaining of interference from above) attended a meeting with the StHA and Department of Health officials working on the treatment centre programme. Avis and Hanna both recall being threatened by an SHA executive, who said PCT members could be personally surcharged if they failed to vote through the scheme. Nonetheless, the PCT rejected the deal at a "frantic" November board meeting. "We eventually got the full business case only an hour before the start." Most of the executive members backed the scheme, but all the non-executives present opposed it. Avis then used his casting vote to have the deal thrown out’.
Avis says: "I contacted Jane Betts, the SHA chair, to communicate the decision. She used an interesting phrase, telling me 'the tumbrils are ready'. I took that to mean my job was on the line and she was aware that hers was too." Betts told him to use his powers as chairman to override the decision, but he refused. "She said our jobs were at risk if there was not a note on the secretary of state's desk by the beginning of the following week saying the decision would be reversed."
After a month of mounting pressure, the PCT board relented. Avis said: "The result was achieved by a form of bullying. Part of me understands it and part is deeply annoyed by it. The annoying bit is that the trust has to run its relationships with full-time staff in a correct manner, very carefully and properly. It's completely different when things are done by politicians and top civil servants and imposed down the system."
Sir Nigel Crisp, the NHS chief executive, apologised for the "distress" that had been caused by the case, but added that the health service was still learning how to balance devolved powers with national priorities. He says: "Clearly, a PCT can say no, but they are not the only people involved. Nothing we have said implies that we passed total decision making to PCTs" [12].
When pushed on the details of the case, Crisp walked out of an interview with Radio 4 because (his office later explained) the discussion moved from the principles behind the national treatment centre programme to the specifics of South West Oxfordshire [13].
A Health Service Journal leader captured the central point for many when it said, ‘agreeing the terms of a national deal first and asking questions locally later seems guaranteed to make a mockery of the process’ [14].
The implications for the UK private sector from overseas competition
The Times health editor, Nigel Hawkes notes that: ‘Years of enmity by Labour health secretaries have failed to dent the private sector. But the new policy of NHS co-operation with private health providers has done what ideological opposition never did. Falling NHS waiting lists, the chance of bidding for NHS work, and the arrival of foreign competition have stirred up the market for private medicine, and threatened the future of the big operators.’
Private sector group’s profits have been ‘fuelled by long waits in the NHS and growth in medical insurance and self-pay patients. But fast-rising insurance premiums have hit consumer resistance. The analysts Laing & Buisson reported that in 2002 the market was static. During 2003, says Philip Blackburn, the company’s senior economist, “self-pay slowed sharply and may have reached a peak”. At the same time, he says, NHS use of private hospitals grew strongly, accounting for 8.5 per cent of the patients they treated. Mostly, these were operations bought at prices 40 per cent or more above the NHS rate to help to reduce waiting times. The effects have been dramatic.’
‘In heart operations, for example, waiting times have dropped dramatically, largely as a result of the use of private hospitals. An executive of one of the major groups claimed yesterday that 80 per cent of the reduction in NHS cardiac waiting lists was due to the use of private capacity. But this very success poses the private sector a dilemma. Does it try to cut costs to chase more NHS business? Or does it rely on widespread scepticism among the public about the future of the NHS to keep the private patients coming?
‘Private hospitals face a massive shake-up as competition from abroad and a resurgent NHS threaten their future. ‘Cost-cutting, lower fees to surgeons, a better deal for patients and a decline in health insurance premiums could all follow as private medicine feels a chilly draught of change. Two big groups have already cut their charges to win NHS business [15]’
Bupa offers different tiers of private service and plans to cut surgeons fees
BUPA announced plans to sell ten of its smaller hospitals in order to reposition itself in the market. BUPA is selling hospitals in Farnham, Reading, Hythe, Hastings, Halifax, Leeds, Hull, Macclesfield and Wrexham. All are profitable, but, with about 30 beds, half the size of BUPA’s 22 other hospitals. To improve the others, the company will invest £100 million over three years to produce greater consistency in the way they operate, and to drive costs down. Investing this kind of money in the smaller hospitals would not have produced an economic return, so they are to be sold.
‘The group has also decided to ‘make itself an off-the-peg rather than a made-to-measure supplier of healthcare. In future, its customers will be offered a choice: if they want Rolls-Royce treatment, they can have it, for a limousine price. But if they are prepared to wait a few weeks, take the surgeon they are offered, and settle for a standard hip implant, they will find the bill agreeably reduced. ‘
The plan was described by the chief executive of Standard Life Healthcare as “scrapping was has traditionally been a low-volume, high margin business [into] a high-volume low margin one”.
Bupa plans to cut consultants fees, which pleased medical insurers. A spokesman for Axa PPP describing Bupa’s initiatives as “excellent news”. Standard Life Healthcare said the shift made sense. “If you look at the airline industry, there was a lot of resentment from British Airways when Virgin and then EasyJet came in with lower prices, but they had to respond. That is what is happening here” [16].
Some facts about The UK private sector
- 216 private hospitals in Britain have 10,500 beds in acute hospitals.
- Traditionally the customers for private hospitals are consultants not patients because surgeons bring in patients - the hospitals serving as places where they practice.
- Private hospitals perform a million surgical procedures a year, and 20 per cent of “elective” surgery in Britain. They also provide four million outpatient appointments.
- 30% of hip replacements take place in private hospitals, 14 per cent of all heart operations, and 44 per cent of all vein removals.
- The typical cost of a hip operation, say, £6,500, breaks down as £1,100 for the surgeon, £525 for the anaesthetist, £1,500 for the hip implant itself, £1,660 for accommodation and nursing, £480 for use of the theatre, £400 for pathology, histology, X-rays and blood grouping, £595 for drugs and dressings, and £240 for physiotherapy.
- The NHS “tariff” for the same operation is £5,568 (around £1000 les) with the difference in cost accounted for by the fact that surgeons and anaesthetists in the NHS are on salaries and not piecework.
Consultants to resist big fee cuts for private operations
The Financial Times reported that consultants would resist reductions in fees. Derek Machin, chair of the BMA’s private practice committee was cited as saying that while some reduction in fees was reasonable ‘deep cuts’ would be resisted. “If they are talking about something that is half or less, then I doubt that people would be prepared to do it”. In particular, for private and self-pay patients, the fees were “nothing to do with them”.
Because the new consultant contract pays doctors for the sessions they do, this coupled with the driving down of private fees will mean there are weaker incentives for NHS consultants to undertake private practice [16].
Incentives
Community based matrons to coordinate care for patients with long-term conditions and incentives to be offered for practices to deliver care via multidisciplinary teams
The government is concerned about the numbers of patients with complex chronic health needs who are being admitted to hospital, at great expense. To counter this, ‘a new breed of nurse called 'community matrons' is being created to take responsibility for patients in primary care. ‘The £500 million proposal is being lined up as one of the eye-catching initiatives for Labour’s next election manifesto’ and will give patients ‘a single point of contract with someone who can dispense clinical advice, co-ordinate hospital appointments, improve treatment and support
carers’ [17].
‘About 3,000 of these new nurses will be employed to manage the 250,000 patients who have multiple and complex chronic health needs. ‘They will be senior nurses likely to offer some care themselves, but who also have a major responsibility to co-ordinate packages of care across different agencies. How these matrons would fit into the GP practice hierarchy and whether they would be able to prescribe has yet to be decided, said a source close to the health secretary’.
The health secretary has made it clear that services for patients with long-term chronic disease will be the next health priority for the government – a group that Reid says accounts for “80% of GP consultations”. (The Times said NHS data shows 5% of people use 42% of capacity). By 2008 everybody with a chronic disease who wants an "expert patient" will have one.
He also revealed that there are plans to offer incentives to GP practices that deliver primary care-based diabetes care to patients via a multi-disciplinary team.
Dr Andrew Dearden, the chairman of the British Medical Association's community care committee, welcomed the creation of the community matron because it would improve care in the community and take some administrative work away from GPs.
He said: "Specialist nurses with some specialist training in chronic disease management have proven to be extremely effective and efficient - patients love them. We certainly won't feel threatened by the community matrons - GPs have more than enough work to share, much of which does not need to be done by a professionally qualified doctor."
The Royal College of Nursing also welcomed the introduction of community matrons, but problems with nurse recruitment made it difficult to identify where these 3,000 experienced nurses would come from [18].
Fundholding: back to the future?
The Guardian’s social affairs editor, Malcolm Dean argues that a form of GP fundholding is on its way back: a trend to devolve budgets to GPs.
‘From their beginning, PCTs have been accused of being either too big (in London, they became twice the size of the PCGs, expanding to be coterminous with borough boundaries but more remote from GPs) or too small (for drawing up strategic reviews or negotiating with powerful teaching hospitals)’. But ‘most serious structural flaw currently is that the PCTs which hold the budgets do not refer patients to hospital, while the GPs, who do, do not hold the budget. This has led three PCTs - two in London and one in Bradford - to begin talks to devolve budgets down to their GPs. Unlike the Conservative model [of fundholding], it would include chronic care that now accounts for 70% of NHS spending. This would give them incentives to carry out more work in the community.
‘But will Labour's ministers agree? They can hardly object to PCTs following a devolved principle already set by ministers. What the PCTs must do is remain a critical friend. Without being pushed, GPs will not want to change their pattern of behaviour, as the 1990s schemes demonstrated’ [19].
A new King’s Fund report calls for practice-based commissioning
In a report published on June 10th, the King’s Fund took this idea further and set out the benefits of ‘practice-led commissioning’ [20].
It claims there is government support for the initiative. The Fund says, ‘ministers have sanctioned this approach as part of a wider strategy to increase the influence of front-line clinical staff and to make the NHS more responsive to patient needs’. While the lack of detailed guidance from the Department of Health may lead to different forms of practice-led commissioning, this diversity may well prove beneficial so long as primary care trusts and GP practices act quickly to agree how this should be enacted locally.
At a press conference, the report’s author, Richard Lewis, said: “This could also help reduce the burden on already over-stretched hospitals. It should help reorganise health care delivery around local services and act as a powerful incentive to pull patients back into the community. It’s a great idea, the problem is so far it has failed to receive the attention of other government health reforms” [21].
King’s Fund chief executive Niall Dickson believes: “This is an exciting development not least because two of the key organisations representing primary care are broadly agreed on the way forward - both the National Association of Primary Care and the NHS Alliance have helped us develop this report and endorsed this approach. This is a topic that has been controversial in the past but our report shows there could be real benefits from giving local practices more scope to shape services and with fewer drawbacks than the experiments in the 1990s.”
The report highlights the similarities and differences between practice-led commissioning and GP Fundholding, a prominent feature of the Conservative Government’s internal market in the NHS in the 1990s – under that scheme practices were allocated a cash-limited budget to purchase services directly from health care providers on behalf of their local communities.
Niall Dickson said: “There are similarities to earlier health service reforms, but the context is different. Patients in all practices should increasingly be offered choices about where they are treated which should avoid the earlier concerns about creating a two tier system. And the new market will operate in a different way with fixed prices for all operations, which should remove the potential for individual practices to lever favourable prices from hospitals desperate for extra income. All that should go some way to reducing anxiety over potential inequities that in theory could re-emerge if some GP practices are given greater freedoms to commission over others.”
In a Health Service Journal article promoting the report, it was argued that the initiative ‘could act as a much-needed counterbalance to the apparent dominance of providers in the commissioning equation’. The article also anticipates an obvious criticism of the proposal: ‘that practice-led commissioning will lead to fragmentation and inequity’. This potential ‘can be mitigated by sensible cooperation between PCTs and practices (in a context where PCTs have the final say)’.
‘It is important to recognise that PCTs have, and will retain, the vital role of setting health and healthcare strategy locally. PCTs, informed by discussions with clinical and public stakeholders, must set clear direction of travel. Practice level commissioners will work within these boundaries, but will expect room for manoeuvere as long as they do so. For highly specialist services, in particular, it is likely that PCTs will retain commissioning responsibility’ [22].
There will no doubt be a lot of tension in negotiating the balance between PCT and practice commissioning and the level of autonomy practices will have in selecting treatment paths. In the context of the Oxfordshire story, recounted above, will practices be able to avoid referring to a Treatment Centre, or will PCTs pressure practices in the way Strategic Health Authorities have pressured them?
Service and organisational development
Can an integrated IT plan delivered by several companies work?
The Economist turned its attention to ‘the biggest information [technology project in British history’ – The National Programme for Information Technology, in the NHS.
‘At its heart is a national database of patient records covering all of England. BT won this contract, running to 2013. Also national is a seven year contract, won by BT as well, to organise (from local competitive bids) a broadband network, which not least, will let x-rays and the like move as data, not bits of film; a small five year contract for hospital appointment bookings; and, eventually, a contract for email and an NHS directory.’
‘But input and access to the national database, and much other local IT, will come via regional suppliers: in two of give regions from Accenture, in one apiece from Fujitsu, Computer Science Corporation (CSC) and BT. Given that the NHS wants a seamless whole, why have rival solutions?’
‘One reason is the projects sheer scale and complexity. It does not start from zero: for a time, many varying bits of older IT will survive, and it has to work with them. No one contractor, it was felt, could handle that. A cruder answer is burnt fingers: lone suppliers have messed up, at the Inland Revenue and elsewhere. Now, if one fails, there will be others ready to do the job.’
‘Yet can the four solutions really be integrated to work as one? The suppliers “are crying out for central co-ordination”, says one outside specialist. Another cause for concern is a ‘non-technical issue’. New IT works best with refashioned business practices. Will the managers, clinicians and GPs who must use the new IT actually adapt to it, and how fast? ‘Much has been made of an alleged lack of consultation…three-quarters [in a recent poll] said they have never been consulted. ‘Yet support by the users is indeed vital if the huge project, however technically successful, is not to become a glossy package with little inside’ [23].
Managers should better use data to challenge doctors
While the national programme for IT is concerned with future use of data, Professor Alan Maynard has urged managers to make better use of data already at their disposal. He accused managers of failing to make the best use of hospital episodes statistics which have been available for two decades’.
Following an NHS Confederation report showing widespread variation in the productivity of doctors, managers have been urged to ‘squeeze more activity’ out of their clinicians. Maynard told the Health Service Journal, “We need to challenge doctors and we should be much more collaborative with doctors to use data to improve activity”.
The report ‘says trust boards and clinical leaders need to start asking tougher questions about variations in results, and the differences between organisations’. ‘Some amount of variation is understandable and at times even desirable, the report says. It might be unwise to ask a slow surgeon to simply operate faster’.
“This is not rocket science, it’s bloody obvious…Hospital managers haven’t looked at the data and they haven’t managed the data. Neither have clinicians. There’s the data, go out and use it”.
Maynard says managers and clinicians still lacked incentives to improve efficiency and that actions to address clinical variations could be examined in annual appraisals for trust chief executives and chairs, and that consultants might be better motivated by a fee-for-service arrangement [24].
References
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