Examination of Witnesses (Questions 720
- 739)
THURSDAY 29 NOVEMBER 2001
DR MICHAEL
DIXON, DR
SIMON FRADD,
DR TONY
STANTON, OBE, AND
MR DAVID
GOLDSTONE
720. I got the impression that what you were
implying was that the cost to our system in respect of prescriptions
is in the fact that a patient who is eligible for free prescriptions
is required to see a GP to get that prescription, which means
that they trouble the GP when they may not need to, rather than
going straight to a pharmacist where they have to pay money for
that.
(Dr Fradd) Correct.
721. So we need to look at that as an issue.
(Dr Fradd) Newcastle has a model of it.
Chairman: We should like to look at that, it
would be very interesting.
Dr Taylor
722. I am going to change the subject, although
I think you have picked up an extraordinarily important point
which we will obviously follow up. I have already declared that
I am a member of the BMA, so my interest has been declared. I
was delighted to hear you say that use of the private sector,
although for some years to come, is a temporary expedient to use
spare capacity up to help NHS patients. My understanding of this
is that consultants will take people off their normal NHS waiting
lists in order to put them onto the private sector. I should like
to see the Government being a little prescriptive about how the
recent large windfall of money which was announced on Tuesday
is used. There are certain places where this could be targeted
which would make a difference very quickly and one of them is
exactly into this because one could make a difference on waiting
lists by using spare capacity which exists at the moment. I hope
in a way the BMA will be pushing for that because I certainly
shall be as one of the users. That is perhaps not the most important.
The most important is for extra pay for nurses to bring them back
from agencies and the private sector. I must just stand up for
the consultants, but coming to my question. Would the BMA and
the NHS Alliance agree that one of the priorities for this vast
amount of money which would produce an improvement almost immediately
is to ask for some of it to go into funding for private sector
operations as a temporary catchup expedient?
(Dr Fradd) What I would say to that is that it ties
in with what Mr Dowd was getting at. One of the problems we have
with new resources is that they just go straight down through
the system and then get swallowed up in secondary care. We have
fought very long and hard for earmarked money and this year we
had some money for primary care development and in many cases
that got swallowed up in trying to deal with overspends in the
secondary sector. I am not necessarily saying that I would at
this time prioritise funds to go in that direction. It is a very
worthwhile cause but there is a very good case for at least earmarking
funds, if not ring-fencing them, so that we can move the NHS on
and part of that is to make sure that we deal with the backlog
and part of that is to move the agenda on and give us some seeding
money with some headroom for freedom of development.
John Austin
723. I can obviously see the attraction of commissioning
services in the private sector or elsewhere in the patients' interests
if it is going to reduce waiting time. In the area Dr Stanton
represents, the pressures there are on the secondary trusts financially—and
I think I am right in saying that several of the trusts you are
responsible for have substantial deficits—
(Dr Stanton) That is a very polite way of putting
it.
724. Is the commissioning of services elsewhere
by the primary care trust likely to assist or contribute to the
difficulties the hospital trusts are in?
(Dr Stanton) Given that the trusts have a finite pot
of money in their unified budget, in the circumstances you outline
it will not make matters better. It will obviously reduce the
number of people on the waiting list, which is a ministerial priority,
but it will not fundamentally address the problem.
725. In the short term you will have assisted
some patients.
(Dr Stanton) Yes.
726. What are the long-term consequences for
those trusts?
(Dr Stanton) That is it and there is always an inherent
tension for a GP in their day to day life between the needs of
the individual patient, which clearly come first, and the needs
of the system as a whole. This is a very, very difficult balancing
act and it is one which causes a huge amount of stress in the
day-to-day working lives of GPs who are well aware that if they
do take routes to speed individual patients through the system,
they are almost necessarily slowing down the system as a whole.
That is the difficulty I think.
Julia Drown
727. You were saying, Chairman, that in terms
of devolving work to pharmacists it was about those people who
have free prescriptions. But presumably, if someone were prescribing,
whether the patient was entitled to free prescriptions or not
you would be in favour of pharmacists being able to prescribe
for everyone.
(Dr Fradd) Absolutely.
728. You said in terms of the change in the
GP contract that you were concerned Ministers would interfere
in the negotiations between yourselves and the Confederation and
stop you delivering what you want to deliver for patients. What
particular things do you think Ministers will not like?
(Dr Fradd) We currently have a contract which came
in in 1948; it is said to be the longest contract in the world.
It is approaching the length of War and Peace. Those of us who
live and breathe it find it remarkably difficult to find our way
round it, so it is certainly time to have a change. That contract
is based on high volume: pile `em high and sell `em cheap. One
cannot help feeling that is something of the philosophy of the
NHS in the twenty-first century. We want a very radical move away
from that to a high quality service. There are difficulties with
that because the capacity is not yet there. In order to increase
capacity, there are necessarily going to be cost implications.
We are going to have to make the nursing contract and the GP contract
attractive enough both to keep people and attract new ones. It
is the cost implications. I also think that there may be funnily
enough an even stronger desire amongst Ministers to make primary
care a managed service, even more than we feel that our Confederation
colleagues who are in effect our managers seem much more confident
at a local level to have a hands-off approach to it and to manage
quality and monitor quality rather than necessarily to interfere
in how the service delivery happens at a local level.
Mr Amess
729. In my area there was a big falling out
when primary groups and then primary care trusts developed as
far as GPs were concerned; very, very different views on this.
Would you first of all expand—we have heard a little from
you—how you see your involvement in terms of commissioning
health care? You did not go into much detail about this.
(Dr Fradd) I would have to declare where I started
from. I was very anti-fund holding and actually was one of the
founding members of the Nottingham Non Fund Holders which was
a commissioning group and very much the model on which the whole
of the PCG/PCT was based. There were various problems. Firstly,
when there were PCGs there was the difficulty that they were sub-committees
of the health authority and did not have real powers so everything
could be vetoed. Secondly, there was a very radical move to include
the public in primary care groups, which certainly we welcomed
at the BMA but some GPs felt very threatened by. This is why we
made a stand to have a majority of GPs on primary care groups.
I am very pleased to say that as they have evolved, my colleagues
have become great fans of the lay input because they realised
that actually they were very much on the same side and talked
the same language. Now we are moving to PCTs there is the tension
about being given the responsibility without the funding, which
is what I was talking about earlier. There is another tension
which is how we truly get public input into the development of
the Health Service both at a national and a local level. The present
structure does seem to me slightly bizarre where lay people are
appointed; they put their names forward and they are appointed.
There is no accountability back to their local community. That
seems to me very disempowering and I have always maintained and
the BMA has supported me, that we should actually have elections
for lay input. I am quite happy to have greater lay input but
there should be a line of accountability back to the local community
which is empowering.
Chairman
730. This is music to my ears. The BMA are pleading
for a democratic Health Service. The reason we do not have a democratic
Health Service is that the BMA argued against it in the 1940s.
Has there been a sea change? Have I missed something?
(Dr Fradd) May I point out that I was born in 1950,
so I am not prepared to take responsibility for my predecessors
in 1948. I do think we have moved on. I do not know the details
of what went on back in those days but I would say that the BMA
is absolutely committed to an NHS which is free at the point of
demand and which is funded out of central taxation. We produced
a paper from our Council earlier this year which pre-empted the
report we heard on Tuesday. We are absolutely delighted to know
that it is going that way. It is the public's Health Service at
the end of the day and the public should be able to decide what
size it should be, what it embraces and how it is delivered and
we are right behind that.
731. So I can stand up in the next debate we
have in the House of Commons and say that the BMA favours a democratic
Health Service.
(Dr Fradd) We do.
(Dr Dixon) Important but possibly not relevant to
the subject we are mainly debating today is this public involvement
thing. It is absolutely crucial that primary care trusts are local
people and professionals empowered and working together. We do
not have the model quite right at the moment. We need to make
sure we have the public properly represented inside the primary
care trust, not an old-fashioned non-executive system which is
the prescribed one at the moment. We need also to make sure that
we have proper involvement of the public outside and some form
of democratic input. I am not sure whether votes and things are
necessary; something like the Newcastle system is good where they
just choose a number from the 250 who meet four times a year from
the local communities. There is an awful lot of work to be done
on that, which Alliance is leading at the moment with the Department
of Health to make sure that happens. You asked about commissioning
and I come back to Richard's point which is the crucial bit. I
too was a commissioning group but we did actually commission knee
surgery from a private hospital at one point during our evolution
five or six years ago and it comes back to this question of what
we do with the extra money. At the moment commissioning is at
a fairly immature phase for some of the reasons I have already
outlined. At the moment acute trusts still have their own vested
interests almost solely within the local health economy. This
is a problem because some trusts are performing differently from
others; some specialities locally are really committed to getting
their waiting lists down, quality audit, all the things we all
approve of, others simply are not. There is not quite that leverage
in the system at the moment to make it happen universally and
therefore quality is variable and so is access. We have not yet
created the incentives to make sure that those who can deliver
and can deliver quick services in the way we want are actually
doing that. There is a danger that if we simply lob the money
into trust deficits, if you simply put the money back into trust
deficits, the money will be going where it has always gone, nothing
happening and nothing changing. I would to some extent follow
Richard's hypothesis that some of this has to go into just cutting
off this tail end of the waiting list to begin with. Having spoken
to the Secretary of the Cardio-thoracic Association last night,
it was interesting to find that our views rather merged on this.
We really need to cut these people off and either send them abroad
or into private capacity in this country rather than suddenly
do a quick ramshackle change within the NHS of importing resources,
personnel, which may not be appropriate in the long term, and
then finding another day we have not actually developed the Health
Service in the way we want. The answer to this dilemma is yes,
we probably do need to sub-contract in the short-term to get the
patients the waiting times they want, because there is probably
no other way of doing it within the NHS at the moment. In the
long term what we must do is get our commissioning straight and
make sure that local services really respond to local people and
professionals in a way they are not yet.
732. That is very helpful. We shall not follow
this any more because you have given us your view, but very quickly,
when you talked 15 minutes ago about moving the agenda on what
did you mean?
(Dr Fradd) It is a matter of moving it to a patient-centred
service and one which is focused—
733. How?
(Dr Fradd) You can do that at three levels. You obviously
have to have input at the one-to-one level and my colleagues have
moved on enormously over the last two decades where the paternalistic
aspect of care is no longer a model which is followed, where it
is the patients' health care and they must as far as possible
be informed in order to make an informed choice. The difficulty
is that often choice is slightly restricted as to what you can
offer.
734. You can say that again.
(Dr Fradd) At the second level, there is the input
into primary care organisations of the public so they can have
some effect. I believe in addition to what the basic guaranteed
service of the NHS should be, rather than a complete free-for-all
of what the structure of the service should be locally, there
should be much more input at a national level, a truly lay input,
as opposed to civil servants or ex Health Service managers and
some public input into what the service should be. When you come
down to the local level, there is this real potential for shifting
the skill mix, to use a populist word, and allowing us to do far
more in primary care to give services nearer the patient, which
has enormous ramifications. If you look at something really simple
like the management of anti-coagulation, we introduced this into
general practice in Nottingham some years ago and in the first
year alone we save £60,000 in transport costs. If you interpret
that into what it meant for the patient, in terms of days sitting
in cabs, going up to the hospital, waiting for the bus to take
them home again, it absolutely transformed the service to one
where you have an elderly person and the community nurse goes
out and takes blood in their own home. You can transform it in
such simple ways at a local level, but you do have to have the
infrastructure support, you need more nurses, you need the powers
of the pharmacist to take on some of the work, you may need additional
space within your surgery to deliver the services.
Dr Naysmith
735. Chairman, I was as astonished as you were
to hear Dr Fradd, this suggestion about democracy. My recollection
is that at the time of PCGs when PCTs were in prospect the medical
profession just united and said they were going to have a majority
on these committees or were not going to take part. A lot of what
you are saying is very progressive and I am very much in favour
of it. Are you actually now saying that doctors are prepared to
give up some of the power they still have in order to encourage
more patient participation? I should be very much in favour of
that and I am sure the Chairman would as well.
(Dr Fradd) Yes. I was sitting with the team which
negotiated that potential majority of doctors on primary care
group boards. The reason for doing that was to give the ownership
of change in there. If you had gone in and said we should have
seven lay people and four doctors, my colleagues would have been
terrified by it and stood way back on it. The whole point of this
was not in order to give us the power over the service but actually
to say to people, which is what Alan Milburn who was then the
Minister was saying, that this is to empower general practitioners
to drive the NHS. I and my colleagues wanted GPs in general to
feel that, to know it. It was a stepping stone, it was always
a stepping stone and if you look at primary care trusts that majority
is not there in the same way.
736. So the BMA has recommendations to make
on that in terms of involving more lay people.
(Dr Fradd) We are very committed to the involvement
of the public. I am the Chairman of the doctor/patient partnership
which was founded by the BMA as an outcome to the out-of-hours
problems we were getting.
737. You were talking about the democratic—
(Dr Fradd) It is more than that, it is the involvement
of the public throughout the service. It is an ethos change.
738. It is very easy to talk about involvement.
To get people involved in the best and the most basic way is to
give them a vote.
(Dr Fradd) I accept what you say; there are limitations.
I am doing some work with the King's Fund at the moment on patient
centred care and it is very interesting. There is a point at which
you cannot centre the care on the patient. We were talking about
the limitations of choice. It is no good saying to the patient
that they can have beta-interferon for multiple sclerosis if there
is a national policy that beta-interferon is not going to be available
within the NHS. There are constraints on what you can offer and
it comes back very much to what Tony was saying earlier about
the balance between the individual patient and the system. I believe
if you get the structure right with public involvement at all
levels, so the development of the service at the local organisational
level, and being heard and informed as much as possible at the
one-to-one level, then you get a much more patient-centred focus
and I think you can make it democratic. There are limitations
in the same way as I cannot—
739. What does democratic mean in terms of what
you have just said?
(Dr Fradd) In exactly the same way as I have an input
into saying what services I think should be available. It is the
public's service and they should have a stronger voice. They cannot
demand it, that is where the democracy ends; it is up to Parliament
to decide what is going to be available in the global terms. They
should have input, they can certainly have a majority, as they
do on the PCTs in lay input if you include management and people
as lay, but we have no problem with being in a minority on PCTs.
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