Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 740 - 759)




  740. I am slightly concerned. We have skewed in a direction I find very attractive and I could spend the rest of the morning on this area. One other question on the commissioning issue in respect of commissioning health care by one PCT. What about the impact of the commissioning on neighbouring PCTs? How do you deal with that?
  (Dr Stanton) That is very important. It goes back to what I think Mr Dowd was getting at earlier. You have to have co-operation across a greater area than that served by a PCT. In London very sensibly PCTs are configured on borough boundaries with one or two small exceptions. Clearly the wish of a PCT in the way it would wish to commission a hospital and other secondary services cannot be allowed to destabilise the provision of heath care across the sector as a whole. It is absolutely essential that you have some overall commissioning structure greater than the individual PCT.

  741. One of the issues I raised with Alan Milburn was an experience from the Yorkshire area which has interested. Within Sheffield we have a private hospital which under the concordat is now treating a series of streams of NHS patients. The question I put to him, which to be fair he said he could not answer and I understood the difficulties, was how we ensure, bearing in mind the basic principles of our NHS which we hopefully we all still subscribe to, that those patients coming from different streams are treated in accordance with their clinical needs. In addition to the NHS streams coming through the concordat from separate purchasers, there are the NHS patients of those consultants in the local Sheffield hospital to take into account. How do you see that in respect of the arrangements between a purchaser and the private sector? How do you see the basic principles of the NHS being sustained?
  (Dr Stanton) I am not sure I fully understand your question.

  742. I have a concern. One of the worries for me about the involvement of the private sector is that we may well be, by virtue of having a series of separate purchasers in a similar area like Yorkshire, sending streams of patients—I believe cardio-thoracic is the specialism—to one particular private provider. I am not clear how we cross-prioritise the different streams to ensure that those people on the several waiting lists and the several purchasers' streams of patients are treated in accordance with their genuine clinical needs; in other words, the patient who needs urgent intervention receives it before somebody who is less urgent.
  (Dr Stanton) I am sure that the GP community would wholeheartedly wish to sign up to that.

  743. How do we sign up? That is the question I am asking you. How would you ensure, if you were sending people in those circumstances, that your people were not losing out compared with your people from Nottingham or wherever?
  (Dr Fradd) I do not think that is any different from the NHS generally to be honest. If you have 20 GPs referring patients to a single consultant within a NHS hospital, the consultant has to make priorities according to the information you have given him or her. It is no different whether they are working within a private facility or within an NHS one. The only complicating factor you have is of course that you still have the potential for fast-tracking private patients through that system. I see no new dilemma in terms of equating between the NHS and the private facility you are working with. We have to have some faith in professional colleagues that they have no vested interest and that they have the skills to make the appropriate decisions.

  Chairman: I am not sure I have fully explained the concern I have. It struck me that there were serious questions about how we ensured, with a range of streams, and obviously basing decisions on information provided by the different purchasers, that we were able to establish what is current practice I accept on NHS waiting lists now in specialisms.

Dr Taylor

  744. May I go back to Dr Stanton's point about communication between PCTs? It is going to be absolutely crucial. In my own county there will be three and they will have to share out what happens. What arrangements have been made for that? The only cross-PCT group that I know about will be the LMC and there you have doctor participation but no patient participation. Going back to the crucial bit about patient participation, how do they get in on the communications between PCTs?
  (Dr Stanton) Clearly they have to.

  745. How?
  (Dr Stanton) I suppose the answer is: with very great difficulty. Certainly the responses that the local committees which I service in London have made to the consultation documents for Lewisham and Wandsworth precisely make this point that there will need to be co-operation between neighbouring PCTs. Dr Dixon said that he chaired a commissioning group of three PCTs.
  (Dr Dixon) Yes. It is a potential problem, but I am not sure it is going to be an actual one. The way it is actually turning out is that we have formed a commissioning college of three PCTs and I chair the commissioning group for those three PCTs so it is joined up and clearly has to be and almost has to be because of the system. Though each PCT theoretically has its budget and therefore theoretically could go off into the mist and create all the problems which we have implied, that is not actually going to happen because each PCT and the local health economy has also to keep to various national standards and the modernisation reviews cover numerous areas which have to be kept within the NHS plan. That really is working between PCTs, so many PCTs are working together in the modernisation reviews, looking at how they are achieving things like the MS sufferer, coronary artery disease and therefore having to work together anyway. When it comes to commissioning they have already formed a group. I do not see that happening. One of the problems with PCTs is that they have become quite large. Although this was a potential problem with PCTs at 50,000 to 100,000, the average size of PCTs is now going above 150,000 so they are often large enough not to create the fragmentation which we would not want to see.

  746. Do you have citizen input into your commissioning college?
  (Dr Dixon) We do not yet; we do not yet, I have to say.
  (Dr Fradd) Michael is absolutely right about moving to amalgamation of PCGs both into PCTs and using the same commissioning group, but I take your point very much that there is a great tendency to see the lay people left behind in this process. That is why 18 months ago we set up the National Association of Lay Members for PCGs which is very much a going concern. You may well want to contact them to see how they see organising lay people at a more local level. That is a national organisation which we floated off and let fly on its own.
  (Dr Dixon) I do mean "yet". I know it is going back a bit in the discussion but it is really important as an example, coming back to this patient/public and professional involvement. In my own practice last year we did an inventory which most GPs will be doing in two or three years, where patients scored us on our consultation performance, whether we gave people time, listened to them, etcetera. We then formed a focus group, not entirely democratic, selected to some extent, to look at those and to give us some ideas on how we should develop the practice, the commissioning decisions at micro level. What happened, and this has been the most extraordinary finding for us, in spite of the paranoia both of the clinicians and the managers within the practice, was that this focus group turned out not only to be very good on advising us what to develop and commission as a practice, it has also been very much the arbiter in terms of this division we have already discussed between an individual patient and the population in terms of asking patients what sorts of things we should be able to do ourselves and what sorts of things should they not be coming to, the resource usage of the practice. I know I have gone down to micro level there but that seems to be the model for the patients and professionals operating as a partnership and moving things and being perhaps friendly critics in that relationship. That comes down to the commissioning level and this might sound patronising but some of the things we are discussing within the commissioning meetings at the moment are so complex that it will take some time to get lay people up to speed. However, we have to do that, without any doubt.

Julia Drown

  747. Picking up these points about how you deal with one PCT's activities influencing another. The NHS Alliance's memorandum talks about the strategic health authorities being the arbiter of those disagreements, so it might be two PCTs both wanting to set up a health centre next to each other at the boundary not making sense, or one PCT wanting to put a lot of work into the private sector which would then mean the other PCT was covering all the fixed costs of the local hospital.
  (Dr Dixon) Quite.

  748. How would it work practically with that health authority being the arbiter?
  (Dr Dixon) There would have to be an appeal mechanism, say in the situation you describe where a trust is suddenly finding it is having to close beds by default because of the actions of one PCT where the other PCT is actually trying to plan some . . . There would have to be an appeal by the trust and the PCT which felt their services were being compromised to the strategic health authority and the strategic health authority would then have to develop an arbitration procedure. In practice I am not sure that is going to happen because PCTs are working together and to some extent they see up there as the enemy and see themselves as having to sort things out.

  749. But ultimately the strategic health authority should be able to say "Sorry. This is what has to happen".
  (Dr Dixon) In the final event, yes, if there really cannot be an agreement, but I am not seeing that happen in the field.

  750. The other question is about clinical standards and particularly in the light of Dr Fradd's comments about GPs not having a majority on the PCT. How would you envisage ensuring that appropriate services were commissioned, that were of a sufficient clinical standard? What auditing processes do you think should be there after the event? Or should there be some appeal mechanism, if, for example, lay members of a PCT said the GPs said things should be done in one way and they have this marvellous scoop cheap offer from somebody else so they want to run with the other one instead? What mechanism should be in place to ensure there are clinical standards?
  (Dr Dixon) We want a uniform mechanism. One of the problems between the public and the private sector has been that government systems are so entirely different. There should be a principle that wherever a private service is commissioned, that should fulfill the same government criteria as the public ones which otherwise would apply. CHI, for instance should be involved in assessing any private utility which is purchased by the NHS.

  751. Would that be an after-event check?
  (Dr Dixon) It would be a bit post hoc as far as CHI was concerned, yes. The commissioning college or whatever, the commissioning agency the PCT had would also to have to make sure that it had standards which fitted both sectors.

  752. Do you feel comfortable that the lay members could as a majority overrule what the GPs on the PCT thought was good clinical practice in terms of commissioning a particular service?
  (Dr Fradd) I am comfortable with that. My experience is that where lay and professional people get together, you actually very rarely come into a situation where there is a division along those lines. The divisions are normally elsewhere. In fact the problems you face are the same. The doctor does not have a different interest to the patient. I have no interest in doing anything but getting the very best care for my patient; not only my patient, but spreading that into the generality. The tension is not between the professional and the lay person, it may be between the individual needing care at a point in time and the needs of the community. The split then is just as much between lay people as across that other boundary. In terms of the quality issues, we should not take our eyes off global developments. There is appraisal which we believe, once we have sorted out the resourcing of it, is going to be an extremely useful tool. That is going to lead into re-validation. Those things must apply just as much to the private sector as they do to the public sector. We are now getting some sort of handle on outcomes data. You have probably all seen the Dr Foster guides which have come out in the Sunday Times. They are still fairly crude, but they are an enormous advance on what we had historically and we have to work with these things. In the event everything is historic. You cannot say what an outcome is going to be; you can predict it but you cannot say what it is going to be. You base that on what previous performance has been. I think we have some very good mechanisms coming in. They will need resourcing. It comes back to what I was saying about the contract. Unless we get the necessary resources in there, how can we pull doctors out of their practice for, say, ten days a year for continuing professional development unless we make sure the resources are there to provide the service?
  (Dr Dixon) I agree. The people have to have the casting vote at the end of the day. I may disagree slightly with Simon because I think it is going to change the centre of gravity. Medical evidence will not be as sacrosanct as it has been in the past. Maybe the myopia we sometimes had in making global decisions about local health and also about patient welfare as opposed strictly speaking to clinical outcomes will be much more balanced. We are going to balance the clinical with the human and the personal with the medical so there will be a shift of gravity and we may find a different use of evidence; NICE-type evidence on complementary medicine may be reviewed differently in the future by a joint lay/professional panel and not as it is today by a purely professional one.

Jim Dowd

  753. Do you think the possible conflict between PCTs having different commissioning patterns needs to be regulated in some formal way above the PCT level, that there needs to be an oversight to prevent threats to local acute units? Secondly, could you say something about the amount of management time which is being used by clinicians in managing PCTs which is taking them away from clinical activities?
  (Dr Fradd) I am wary of introducing any regulation until we find it is necessary. One of the problems has been the lack of freedom. I am not saying it will not prove necessary, but I would rather see whether it becomes necessary. There is enormous potential for solving such problems and you are much better to solve them at the ground level. If it proves we are constantly having to appeal back to strategic health authorities, then we should re-visit that. In terms of the consumption of time, it is considerable because it is not just the management function of PCTs, but all sorts of other functions such as prescribing, clinical governance. I am probably not the best person to give the list but an enormous amount of time. What we have found is that much more time has been needed than was predicted and not just for getting these things up and running, even though you start to get the structures and the decision-making process into train, it is very consumptive of resources, of medical time, which is a very rare commodity at the moment unfortunately.
  (Dr Dixon) I agree with Simon, we do not want more regulation. PCTs are meant to be risk-takers, they are meant to be developing new things and if we handcuff them any more we find they cannot deliver what they are meant to be doing. Professional involvement? Yes, it is taking up rather a lot of professional involvement but this has been the problem in the NHS in the past because you have had professional devolvement from the services and what is delivered. The exciting thing now is that people take responsibility for the NHS and the use of public money as well as the purely clinical decisions. It was the complete isolation of those areas in the past which led to a lot of the problems we have at the moment.

Dr Naysmith

  754. In your submission to the Committee, Dr Dixon, it is really interesting when you are talking about health centres being one of the benefits people hope to achieve from primary care trusts. You say, "Health Centres, funded by public money, failed to meet the expectation of those who advocated them during the 1970s/80s and are now virtually extinct. If funding by public money failed to produce the level of investment and sensitivity to local population/professional needs (in comparison to premises owned by GPs themselves) then the onus must be on the private sector to prove that they can do better". There are two things I want to take up on that. One is that in my experience there was a health centre movement long before the 1970s and 1980s and certainly in Bristol there are two which are still flourishing, both of which started long before that. I know of a centre in Liverpool and also in South London and probably more. Most of them are still flourishing. Over the time you are talking about, the 1970s and the 1980s, we have had regional health authorities abolished and re-phased, area health authorities, district health authorities, we have had trusts and budget holding and probably numerous other things which I have forgotten, all of which might have contributed funds which would have helped the health centre movement to grow. Now we are going on to using private finance. What do you think can now be contributed by private finance which could not have been contributed before?
  (Dr Dixon) In many ways my statements were personal, as I shall explain shortly.

  755. I am not criticising.
  (Dr Dixon) Ideologically the health centre movement was very much Alliance ideology and it has worked in many areas just as you suggest. My own experience of a health centre was having to work in a room eight by eight for seven years where when the roof leaked no-one came to mend it and it was cold during the winter months because nobody came to mend the radiators and the complete relief eight years later of going into privately owned by us building which met the specifications we wanted for ourselves and our patients and a situation where, because I am the one who puts the lights off as I leave the building, because it is in my interest to do so, we end up with a much more sensitive building to the incumbents and the people. I know that has not been the general experience, but in actuality that is how it turned out and I suppose some of the fears I have referred to which could happen with LIFT or any third party agency, whether it is public or private, is a problem of sensitivity to those working in the building and the people coming in and out. We have to make sure that we do not repeat those mistakes which were fairly widespread, although it did depend upon your health authority or SPC as it was in those days. It was very variable, you are dead right. It is an ideal which after a while people just did not have their hearts and souls behind which is why we ended up with leaky buildings.

  756. You also say you want to concentrate on areas of deprivation, which one suspects will not be the most attractive to the private sector.
  (Dr Dixon) Quite, but that is the added benefit. In places like Devon where I practice, we do not really have a problem with premises. It would be daft to start trying to improve things which are more or less okay already. It is the inner deprived centres where there is a desperate need for proper capital, not only for buildings there, but also for proper infrastructure, something along the lines of the primary care centres in the NHS plan with locality resource and treatment centres which we described in implementing the vision last year. There is a desperate need for that sort of service in the inner cities because it is all very un-joined-up and fractured. I suppose in our submission we were saying that the big added benefit would be there, so let us focus there and let us see if we can deliver there.

  757. Mr Goldstone, what do you think your organisation can contribute to these two problems we have just been talking about? One is the trickle effect and the cutting off of funds and the other one is the question of moving into deprived areas.
  (Mr Goldstone) In terms of the description of health centres leaking and being unheated, we are trying to develop an approach which will require the private sector parties coming in to deliver these facilities, to maintain a standard of accommodation, a standard of facility which is what the practitioners and the users of that building have specified at the start and actually putting that responsibility for a life-cycle of condition, of maintenance and repair on that provider. So even though we get a suitable building built in the first place, it is not, as so often has happened in the past, left to deteriorate over time and not properly maintained because of shortage of resource for that.

  758. Why should this continue? Why would it not peter out?
  (Mr Goldstone) Because what we are trying to do with LIFT schemes, what the approach involves, is first of all a specification which lists the standards required for new premises to meet and putting the responsibility for the maintenance and sustaining of that standard over the whole life of the accommodation on the provider of that facility. So you are actually saying you will only pay to the extent it meets that accommodation; you have the facility not to pay. For example, if it is leaking and it is not suitable for treating patients in then you would not pay for that time. That is a very strong incentive on a commercial organisation to make sure that standard is maintained.

  759. What kind of practical assistance does Partnerships for Health offer to LIFT?
  (Mr Goldstone) I am sorry I did not answer your second question about deprived areas. In terms of the localities where we are taking LIFT schemes forward, we have six areas which are working up the first such schemes and they were chosen by the Department of Health through an appraisal and evaluation process. Areas of relative deprivation as a big part of wider areas were chosen. Part of the reason for that is that around the country there are several new GP surgeries and in some cases more widely used primary care facilities which have been developed by third party developers on individual third party developer schemes. Those tended to be in areas of higher affluence and where there was a land value which a private sector organisation found attractive. It has been much more difficult to do those sorts of things in deprived inner city areas for reasons you are referring to. LIFT areas are focusing on areas where effectively there has been no effective alternative way of delivering these things and saying to the private sector that we need them to come into this area and be a long-term partner for the PCTs and the local health economy which is in there and deliver these sorts of improved facilities and certain accommodation which is at the required standard to meet the practitioners' needs over its life. Then it is not just about a land value, it is about a structure which is giving an organisation a long-term right to be a partner in a long-term business opportunity, in terms of providing, for example, leased premises to GPs or other practitioners for health centres.

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