Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 760 - 779)



  760. Have you been involved in all of the six pilot schemes?
  (Mr Goldstone) Yes, to a greater or lesser extent. What our organisation has been set up to do is to make LIFT work in practice on the ground. There are two or three strands to that. We have been working with the first six schemes on the ground in terms of developing the plans they have which they would want LIFT to deliver. One of the things we have been trying to do there is to encourage greater integration of thought about what services we require locally and therefore what sort of facilities we want and trying to use the development of PCTs as something which helpfully brings together a wider view and have one organisation which can take that view about what services are required, encouraging that, working with local authorities and the voluntary sector to come up with a strategic plan of what is required. We have been working in detail on those and then it takes you into what actual health centres are wanted on the ground and what that might cost and what they would look for and developing specifications. We are working with all six in that sort of way. One of the difficulties of the existing regime is that each project, each scheme, tends to be done bespoke. It is done as a one-off; an individual practice or in some cases a local primary care organisation takes forward a scheme and tries to do a deal with a developer. There is an enormous transaction cost in doing that. People will tell you it is very, very painful and drawn out and often there is an enormous risk of the scheme not working. We are developing, in the sense of ones for local teams to use, a whole suite of documentation which will be a standard package you can use to implement your local project and to get individual premises delivered, including the specifications, including the lease terms and that will help make it much more efficient and much more predictable about how these things will be delivered on the ground. That is a further part of what we are doing in trying to make this work locally.

  761. Do the BMA or NHS Alliance have any views on how it has been operating?
  (Dr Stanton) The honest answer to that is that it is too early to say because as yet none of these six first wave schemes are up and running. They are still very much in the preparatory stages. Going back to your previous point, whether, in a sense there is a problem, the answer is yes, there is a problem with the provision of surgery practices. That is really in two broad categories. First in areas of deprivation it has not proved possible always to deliver solutions through existing mechanisms. That is sometimes due to lack of resources, sometimes due to lack of will. Just south of the river Lambeth, Southwark and Lewisham has done quite well on the development of surgery premises through the years because they have had people who have been concentrating on that within the authority. If you go over to the London Borough of Newham perhaps, that has not been the case. There is that patchy thing and in Devon and many other parts of the country there probably is no basic problem. The second strand, reflecting back on the earlier discussion about shifting the way in which patient services are delivered, there is a question as you wish to do more and more at primary care level of whether it is any longer the right mechanism for individual GPs to be responsible for the provision of those buildings. There is one argument when it is delivering your service as a business, when you are being expected to provide the bricks and mortar for a whole range of community based services and it could slightly get out of control.

  762. That is the nub of this whole question, this whole area, whether things should be provided by the National Health Service, either privately or publicly and then used by GPs and other Health Service professionals. What does the BMA prefer?
  (Dr Stanton) We have a pragmatic approach to this really that what works is going to be the best solution here. If you take the experience of health centres, it has not been an entirely happy one. I think I am correct in saying they were originally built by local authorities. They then passed into the ownership of health authorities and then to community trusts and now they pass technically into primary care trusts. There has been a long and sorry history of neglect of the fabric as a generalisation. Most of them were built with flat roofs and they leaked and that sort of thing.

  763. My point would be that now we are concentrating primary care trusts on primary care, maybe it will be different or could be different.
  (Dr Stanton) It could be. We look at it with interest and we see it as a contribution to delivering the solution to the problem, but it is only part of the solution.


  764. One of the issues over the years—and some of us do remember local authority health departments—is that with GPs being private contractors their provision of premises was a factor financially of benefit to them in some respects. Does the fact that we are perhaps moving away from that in the direction we were discussing this morning indicate a wider philosophical change that I pick up with younger GPs who are more prepared to be seen as employed by the NHS than being contractors?
  (Dr Stanton) Yes, it does.

  765. Is that something you welcome?
  (Dr Stanton) It is something we recognise as inevitable. Yes, we are moving into a mixed economy really of GP provision and we have to recognise that. It is a fact of life.

Julia Drown

  766. You said that you are pragmatic about what works in terms of primary care. Am I right in thinking that the BMA have opposed the PFI in secondary care?
  (Dr Stanton) It is not being exactly enthusiastic about it.

  767. Why are you pragmatic in primary care but not in secondary care?
  (Dr Stanton) It is really that traditionally that has been the way that the vast majority of GP surgery premises have been provided.

  768. So long as it is tradition it is okay. I am sure that will go down marvellously in the House of Commons. I am interested in some of the points Mr Goldstone was making earlier about how you get the private sector partner to look at a wider level than just individual practices. Could you say a bit more about how you could ensure that you get integrated service delivery and you do not actually get private sector partners within that overall remit of a particular area just wanting to pick of particular projects?
  (Mr Goldstone) One of the things we are working with the grain of that is helpful in the way we want to move in that direction is in encouraging the local teams as PCTs come in and about working with the other elements of the primary and social care environment locally. One of the things we have been trying to develop over the last few months in developing the first of these projects is that they come up with a strategic service plan for that locality which is an integrated plan about how they want to take forward primary care in terms of the services and therefore the facilities and premises necessary to do that and that has the vision about where they want to go but also then some concrete proposals about improvements they want to deliver. We are not taking forward any of the projects into any process that will lead to delivery until we have that coherent plan in place and that the PCTs and the other stakeholders in the local community actually have signed up to that and agreed that is the way forward for that area. We are starting from that base of an integrated plan which in many cases has not been there before. You could do that if you were not a LIFT area, but what we have been saying is that we cannot take forward a LIFT project unless we have that sort of integrated view and coherent plan that the local health community and the local health economy have signed up to. There is a starting point there of that sort of strategic plan.

  769. Is there space for the private sector partner to come in and say they like the plan but they do not want to build a health centre at location A, they want to build it at location B? What happens then?
  (Mr Goldstone) The question is about cherry-picking, is it not? Out of that plan we are going to have a group of requirements which will say we need a new health centre here or we need to replace these two with a new whatever it is, the different types of scenarios which will come forward. There will be some defined requirements and the private sector will be asked to propose solutions and that will be done in a competitive process where different solutions will be put forward and the PCTs and the other stakeholders will get responses they can evaluate. It will be quite open for a potential private sector partner to ask whether we had thought of building it over here instead of over there. A view would then be taken and that would be something which involved the PCTs and stakeholders including the individual practitioners involved in a particular facility who could take a view on whether they wanted to go forward or not. A private sector contractor could not determine it without it being accepted and approved by the health practitioners locally.

  770. Might it be that if the private sector contractor said he was prepared to put in X million, LIFT would then come up with the other bit if really the PCT decided that they wanted to have it in a less popular area, possibly an area which would have negative equity some time in the future? Is that an area where some of the LIFT money would come in?
  (Mr Goldstone) Potentially, yes.

  771. Has it happened in any of the six pilot areas?
  (Mr Goldstone) In terms of funding centrally for taking forward schemes, in terms of what has been committed and spent, funding has mainly been on physical asset issues about demolishing health centres which were really unsuitable and putting them in a temporary facility as a reasonably new modern but temporary structure where better facilities were available prior to a permanent solution being put in place once the LIFT is there or for requiring sites where there is a need for a site for a future development and the locality wanted to secure ownership of a site to do that. Money has not yet been used for GP ownership issues on individual premises but it can be used in that way once we have clarity of individual localities saying they need to deal with these two situations, can they use the enabling fund. It certainly can be used for that.

  772. Within the six pilot sites, we have temporary buildings from what you are saying, but do we have any work started on permanent buildings?
  (Mr Goldstone) Not yet. The projects are in development at the moment, we have been working over the last few months on the plans of what we want to get achieved and it will be some time yet before we have physical permanent solutions coming forward.

  773. What would you say to those people who say that Partnerships UK is simply creating another organisation and another body which would mean delay and also private sector partners are taking another profit out of the NHS at that level.
  (Mr Goldstone) I would say two things. There is enormous delay now in getting implementation of proposals to improve the primary care infrastructure in the estate. It is very, very difficult, it takes a very long time and it is not a system which works efficiently now. To the extent they have set up a new organisation, it is a new organisation which is totally focused on delivering the improvements and delivering the investment. That is what it is there to do. That has not existed in the past. There is an new organisation, but it is one which is focused on delivering improved investment locally in a more efficient way than has been achievable in the past. There will be an element of private sector profit, there is no getting away from that; I am not denying that. It is important to say that where GP surgeries have been developed in the past that has always been a part of the equation; that has been how it has been and that is how it will be in this scenario. The public sector is much more involved in the Health Service and the public agencies will be much more involved in a LIFT structure than we have had in the past and will actually be accessing the profits through being a minority shareholder in the company which is actually providing the services. There is a greater level of involvement.

  774. The other side of that is that it is not streamlined, is it? Most private sector companies would look at some of these charts you have given us in evidence and see partnership boards, credit boards, public bodies, Partnerships UK, national joint ventures and think they will never get their decision so why should they get involved in this extra complicated scheme.
  (Mr Goldstone) They are not getting them done now. It does not work in many cases or many parts of the country to deliver these things in any efficient way at the moment. There is an infrastructure around this but at an individual local level what we are setting up is a way of delivering efficiently locally once the LIFT is established. You would not need to come into contact with all that once you have got there. So it is trying to set up a local relationship between a company which has that ownership structure, but that is only to do with its ownership structure, and the local health community. Part of that infrastructure you have just described is to bring together the PCTs and the local authorities and the various commissioners of health care in a locality in a way we have not done before. Because we started this about integrating services, we see that as an important part of achieving that.


  775. One of the interesting messages we got from looking at some of the hospital PFI schemes which are actually in operation was that a major lessons had been learned in respect of involving wider partners. A key mistake in two of the schemes we looked at was that the social services department had not in any way been engaged in the discussions about the schemes. Clearly those of us who look back wistfully on local authority health departments and the concept of primary care centres recognise that at that stage there was engagement with social services and in many respects the idea that it would be a one-stop shop, you would go through the door and see whatever you needed in terms of primary community care. How are you taking these lessons on board? Is that part of your remit to look ahead at what hopefully we may achieve in terms of integrated services locally?
  (Mr Goldstone) Yes, it is certainly part of the objectives of LIFT and part of what we are trying to work with the local teams in these localities to encourage them to do and the local authorities in all of the six areas are part of the plans which are being worked up, certainly in the social services sense, and about integrating those services. Many of the facilities which will be delivered as the first investment provided by LIFT will include community services and social services that the local authority is part of commissioning or supplying. That is absolutely part of what we are trying to achieve and are achieving on the ground. Yes. We are trying not to prescribe what is in individual facilities, as it seems to us that is something right and proper for the local teams to develop based on the need on the ground locally. The infrastructure we are putting in place is about the commercial relationships and how we get to deliver these things but the local requirement and the local working together between PCT services or GP services and local authorities is very much part of it and something we are achieving.

John Austin

  776. As someone like the Chairman who was in local authorities pre-1974 I would not attribute the perceived failings of health centres to the structure or the control. Wherever you look at buildings and in particular public buildings from the 1970s, whether in education, housing, health, we are living with the consequences of the construction habits of the day. All I would say is that when public health featured very highly on the agenda of local authorities in the 1930s democratically elected bodies did deliver very substantial public health centres, many of which are still being used to good effect today. That is the political bit.
  (Dr Stanton) Although I understand the famous one in Peckham is now a block of luxury flats.

  777. Yes, but the one in Woolwich is still being used for clinical purposes. Following on about this package, essentially the centre is supposed to be meeting the needs of the health improvement programme. I am pleased that the local authorities were mentioned and Mr Goldstone did say "and the services they commission". I hope we are not going to lose sight of the very important role that the voluntary and not-for-profit sector plays in delivering primary care services and seeking assurance that is being taken on board, not only by the PCTs, but by the national partnership.
  (Mr Goldstone) It is. It is one of the aspects which varies around the country and you cannot sit centrally and define a national template for it. Across the piece a wide range of service is being provided by voluntary sector participants and we are making sure the structure enables that to be part of the solutions encouraged and facilitated and not obstructed.
  (Dr Dixon) I quite agree voluntary sector and also part of the community. The important thing is that the vision the PCT and the local professionals and people have is translated into action. One fear might be that we might just end up rehousing people as the services stand without having that vision of what we want to achieve in 10 or 15 years, which is a centre which crosses all the borders we have discussed, between social care, voluntary sector and elsewhere. One of the problems I suspect is going to be to make sure that the private investors are going to have to look at something which is revenue affordable; people with a vision are going to have something which may not add up when it comes to what the private sector is prepared to invest in. We are going to have to look very closely at any mismatch which might occur there.
  (Dr Fradd) One of the major problems, certainly in my experience of working in a health centre, was the inability to develop as the service developed, It is not very easy to crystal ball gaze 10 or 15 years ahead about what the needs of the service will be. Therefore we need to have buildings which are flexible, which can be adapted, but also a commitment that the investment will be there to take that forward. Certainly that was where I did what Michael did and moved out of a health centre because I could not get the most trivial things in the way of helping me to develop my practice.

  778. Without debating the merits and demerits of PFI, when the first tranche of the big PFI scheme came in, I accept there was little or no experience to draw on and we have seen a lot of mistakes which were made in those early days. Will the involvement of Partnerships for Health ensure that this will not be repeated in the LIFT schemes?
  (Mr Goldstone) That is a big part of the reason for setting up Partnerships for Health. There are several ways in which PFIs were procured which our role is trying to address. In the early days of PFI projects were taken forward with local teams in isolation trying to work out how to deal with problems, trying to work out the contractual terms and each engaging their own advisers to do that and work out solutions to problems which may be common across schemes, working them out and paying for advice to do that individually. Then, as you say, it being difficult to learn and recycle those lessons which came from that. One of the things we are doing is developing this documentation now. We are trying to standardise commercial terms and all the legal drafting issues once up front so that can be taken forward in local schemes, learnt once and recycled. The fact that we have a team which is working with each of the first six and will then work with the next wave of LIFT areas enables us to recycle the knowledge and learning and be a facilitator which will help make sure those lessons are learned and that we apply the documentation consistently and effectively and recycle that knowledge. Part of the whole purpose of setting up a focused organisation to deliver this is helping to ensure consistency of approach and recycling of lessons; that is absolutely part of it.

  779. One of the criticisms many of us had of independent fund holding was the way in which independent fund holders could underspend on their budget and with authorisation perhaps use some of that money to increase their capital assets in terms of their premises at the end of the day. There are clearly some benefits from the new system in a coherent way. Dr Stanton may have partly answered the question I am going to put when he replied to Dr Naysmith. How do the challenges of providing refurbished doctors' premises differ from the provision of the one-stop primary care centres? What are the tensions between those two competing issues?
  (Dr Stanton) There will be tensions. One of the difficulties with the concept of the one-stop centre is that once you start consulting the community in the democratic way we were talking about earlier, about what the community would like to see provided in places, you almost end up with a description of something not a million miles away from the district general hospital. I was at a meeting in Newham on Monday evening which is one of the first wave areas and people wanted, understandably, virtually everything other than surgery and possibly even that. Obvious things like medical care, social care, pharmacy services; then people want physiotherapy, they want dentistry, etcetera. You just see the whole thing escalating. There will be a balance to be struck between the needs or wishes of patients, young mothers with prams. Are we talking about having centres within traditional pram-pushing distance or are we talking about having to get to a centre which requires two changes of buses and things of that nature? There are difficulties there. Unless I have misunderstood the NHS LIFT concept, it is not just about providing one-stop centres, it is about helping with the provision of a whole range of premises from which health care and social care might be provided. One of the difficulties is going to be, and quite honestly we have to face up to this, that if a PCT is part of a LIFT project in its area then understandably all the available financial resources to it will be targeted at supporting the NHS LIFT project. It may well be that there will no longer be any money available for improvement grants for existing premises or for new cost/rent projects which individual practices might wish to pursue. That will be a tension.

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