Examination of Witnesses (Questions 760
THURSDAY 29 NOVEMBER 2001
STANTON, OBE, AND
760. Have you been involved in all of the six
(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
(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 yearsand
some of us do remember local authority health departmentsis
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.
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
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
(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
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
(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
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.
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
(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
(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.