Examination of Witnesses (Questions 800
- 819)
THURSDAY 29 NOVEMBER 2001
DR MICHAEL
DIXON, DR
SIMON FRADD,
DR TONY
STANTON, OBE, AND
MR DAVID
GOLDSTONE
Sandra Gidley
800. You have all of these different partners.
Who actually guarantees that if it goes pear shaped? Could that
be clarified? What mechanisms are in place. You have commented
on how things will evolve and I accept that argument with a certain
amount of reservation. Obviously financial situations evolve over
a period of time so what protection is there? Will you be jumping
in to help that?
(Mr Goldstone) Yes. Part of the reason that Partnerships
for Health is shown on there as one of the shareholders is to
help the local teams sort out problems as they arise when the
thing is going on. The first order of pear shape which may happen
is the facilities not being delivered on the ground and that is
the key interest if you are a practitioner. It is getting a new
surgery, getting new premises and those meeting the requirements.
The first redress there is non payment. That gives a lot of protection
and a lot of incentive for delivery. That is the first port of
call. There is redress in terms of being able to replace that
partner, being able to take away the rights they have as having
been the partner appointed in the first place.
801. Are clear mechanisms in place common to
all PFIs or are they all a hotchpotch?
(Mr Goldstone) It is different from PFIs.
802. I am sorry, I meant all the LIFT schemes.
(Mr Goldstone) There absolutely are and I shall say
now that this is stuff we have been developing relatively recently
and have been working out how this is actually going to work.
It is part of the standard suite of documentation we are preparing
but it is not something we have yet had a chance to disseminate
fully. We have been working on it recently. Absolutely, it contains
provisions to deal with the situations you describe.
803. So the first six schemes are all different
because they have not had the—
(Mr Goldstone) No, the first six schemes are all going
to be working with the approach we are developing, so they have
not gone far yet to prevent that. We are going to work with them
in terms of the documentation we are preparing.
804. How will that be? How is this going to
be protected? At the end of the day who carries the responsibility?
(Mr Goldstone) For what?
805. For making sure that it goes ahead if the
private partner goes bust.
(Mr Goldstone) If a private partner goes bust then
the local health economy, like the PCTs, could sell those shares
and bring in a new partner.
806. So it is market forces.
(Mr Goldstone) Yes, it is a market solution. If there
is not, they can take it over themselves.
Chairman
807. If they have the money to do so.
(Mr Goldstone) Obviously I am not getting away from
the fact that it would be a difficult situation if that happened.
The documents do allow a resolution.
(Dr Dixon) You need more of a contingency plan than
that, do you not really?
(Mr Goldstone) It is at the very end of a whole series
of things going wrong; that is the very end game of a process
which is started off almost certainly with non performance on
the ground about buildings being built and to the required standards.
Sandra Gidley
808. Does your suite of documentation include
a contingency plan?
(Mr Goldstone) It includes the provision of non-payment
and then all the interim steps before you reach the end point
I have described; yes, it does.
(Dr Dixon) If things to go pear shaped and the thing
goes bankrupt, the NHS must not lose out here and therefore maybe
the NHS should have some demand, as will the creditors, on the
bankrupt scheme and they must make sure that the ratios agreed
and the formulas with the estates management mean that the local
NHS does not go bankrupt as well. That is going to be quite complicated
to work out. Unless we have that, it is a bit insecure, yes.
Dr Taylor
809. May I just explore individual GPs' preferences?
Do they want to be renters? Do they want to be leaseholders? Do
they want to be investors in LIFT? What are your reactions? What
are your messages?
(Dr Stanton) This will not be an enormously attractive
investment vehicle for GPs. Some may.
810. As opposed to a hospital PFI.
(Dr Stanton) It will not be an enormously popular
investment vehicle and I do not think equally that GPs will necessarily
wish to be leaseholders in these arrangements. We already have
difficulties. There is no magic solution to this question of younger
doctors coming into general practice. They express reservations
about buying in to the fabric of a building, but they also say
they do not want to sign up to a 25-year lease that their third
party developer would like to see because they are not sure they
will be there in 25 years' time and if they cannot pass their
share of the lease to someone else, they could be taken to the
cleaners. All of which I understand from our legal friends is
correct. NHS LIFT may—may—give the opportunity either
to have shorter leases because there will be a greater overall
security for the developer or perhaps my own thinking at this
stage is why on earth does not the PCT hold the head lease and
there will then either be a sub lease or some sort of licence
arrangement for the individual tenants. I suspect that might be
a more attractive proposition.
Jim Dowd
811. Or the health authority could hold the
lease.
(Dr Stanton) In this brave new world I do not think
the strategic health authorities are going to be the people for
that.
812. In the interim.
(Dr Stanton) In the interim; absolutely.
(Dr Dixon) They will be gone by the time the first
one comes off the run.
813. I have had exactly that sort of problem
in my constituency.
(Dr Stanton) Yes, I think I know the case you are
thinking of.
(Dr Fradd) The reasons why GPs want to be involved
in investing in premises is firstly some say over what happens
and secondly some return for money put in. I agree with Tony,
that I do not think it would be attractive on either score, because
they will not have a great deal of power and as far as the profit
is concerned, it could go either way. The advantage of this for
general practice is really being able to hand the whole thing
over to the primary care trust.
Sandra Gidley: Conspiracy theories abound, particularly
in this place and particularly in the NHS. It occurred to me,
if we are having an increasing number of these LIFT projects,
to ask the BMA whether this is a backdoor route to persuade more
GPs to become salaried rather than the system which is currently
in existence.
Chairman
814. That is something I touched on earlier.
It is a very important point because it is the whole issue of
the way the system has worked in the past and the move away from
GPs resourcing, the premises themselves. It is a very relevant
point. Do you want to expand on that?
(Dr Stanton) You referred to the 1940s previously
and Dr Fradd confessed that he is too young to remember them,
but I was struggling around as a five or six-year old during the
formative years of the NHS and my understanding is that there
has always been a master plan there in the appropriate civil servant's
drawer for salaried GPs working in publicly provided health centres
under the direction of Directors of Public Health. I do not think
the plan has ever gone away. There is a movement in that direction.
(Dr Fradd) A few colleagues do wish to have a salaried
position. We are very open to providing that for them. Surprisingly,
because salaried employment has been available for some time now,
even under the old GMS contract salaried appointments were available
and are available, but they have not been popular. We are only
talking about handfuls throughout the country. That is very different
from wanting to put several hundred thousand pounds of personal
investment into the NHS; those are two different things. What
we have now, particularly with the demographic change in the population
of GPs is that people want to maintain flexibility. They are not
sure what they are going to be doing in five years' time and therefore
do not want to get themselves involved in complexities which are
going to restrict their freedom of movement. That is very different
from saying they want salaried employment.
815. What advantages can LIFT bring to primary
care in terms of IT strategies? What is your thinking in respect
of advances in tele-medicine. Dr Fradd was talking about diabetic
treatment being primarily now in your sector. I am sure we all
recognise that certainly-tele-medicine will move things on in
a number of specialties. Is this an area you would argue can be
assisted by this process of funding?
(Mr Goldstone) In terms of making the facilities available
to achieve that sort of vision, and I know from talking to PCTs
and PCGs a lot want to move in that sort of way but feel hamstrung
by the difficulty of actually getting the physical facilities,
in that case it is more about IT and technological links than
bricks and mortar. Some of it may be about the appropriate bricks
and mortar in which you can house that local service. In a sense
that LIFT can certainly help deliver the investment in that infrastructure,
where that is the required service and it wants to be delivered
in that way that is absolutely what we are trying to achieve.
We are not going to go around telling people this is what they
have to do in terms of how they deliver that service, but where
that is the way they want to move we think this is a way which
will help them deliver that vision.
816. Obviously tele-medicine schemes require
development in conjunction with the acute sector.
(Mr Goldstone) Yes.
817. I throw this open to our other witnesses
as well. Are you satisfied that in relation to planning for capital
budgets, both in primary care and in the acute sector, really
taking seriously where we shall be 20 years down the line—I
know it is guesswork, but you can all see very clearly that there
is going to be some remarkable advances in that respect—you
are connected in this sense with the acute sector, from your own
perspective?
(Mr Goldstone) It is certainly a difficult issue to
crack and certainly an objective, but I would not claim it was
achieved. The service objectives do involve bringing services
which are currently in hospitals into a more local, a more primary
setting and what we are trying to do is work with that grain and
try to help that happen. It involves working together with the
acute hospitals about how that is delivered now. Part of the reason
we have taken the view all along with LIFT that we cannot say
now what we want to deliver over a long period is because we do
not know what those evolutions are going to look like. For pragmatic
reasons of that sort if no other we need to set up a partnership
which can agree and develop and deliver things as it goes. We
cannot define it all up front on day one and say we want a great
big thing which looks like this now for the next long period.
We are trying to work with that grain. Somebody mentioned the
revenue consequences and things being affordable. A lot of these
things will actually only be affordable if we can effectively
be diverting resources from the way things are delivered now to
more local settings. It is a task and something which is part
of the process, but I should not like to say it was achieved at
this point, no.
(Dr Fradd) You put it in context when you talked about
20 years. Some of it will be sooner than that but we must not
over-emphasise how far down that line we are at the moment. It
is still something very much in its infancy, a great need for
flexibility because we do not want to be going round knocking
down buildings because they are totally unfit for adaptation to
the brave new world. The reality is that there will have to be
a business case. If the balance of providing a service really
locally, using tele-medicine, means that you have to knock all
your premises down and start again, that changes the dynamics
of the business case.
818. Do you see any form of strategy here, both
in terms of IT and tele-medicine? The slight worry I have about
what we have heard this morning—no disrespect to Mr Goldstone—is
that we are looking at some potentially huge, important, quite
remarkable developments very shortly and I am not clear we have
any real steer.
(Dr Fradd) We have real problems at the junction between
the primary care sector and the secondary sector. The primary
sector is actually getting very well sorted, primary care trusts
are looking at purchasing across a whole combination of trusts,
not just a single trust level into information technology to get
economies of scale. The software systems for general practice
are the best in the world in clinical terms, but unfortunately
every hospital has a different system.
819. You have illustrated exactly my point.
(Dr Fradd) Sending the simplest messages between one
and the other, just telling you what your blood glucose is, seems
to be almost an impossibility. Interestingly enough, you can do
stuff down the web that you cannot do between a hospital and a
general practice. We should like any support we can get for saying
we need a proper IT policy which allows the two sides to communicate,
because we are a single Health Service.
Chairman: You are pushing at an open door. It
is certainly something we shall take on board for this inquiry.
Any further questions? May I thank our witnesses for a very interesting
morning; we are most grateful to you. Dr Fradd, you said you would
send us some further information on Newcastle and we should be
very grateful if you would. Thank you very much, gentlemen.
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