Examination of Witnesses (Questions 380
- 390)
TUESDAY 18 JANUARY 2005
MR PETER
HAY, MR
GRAHAM URWIN,
MS CHRIS
FEARNS AND
MS DOREEN
HARRISON
Q380 Mr Prentice: In this era, where
choice is the new mantra and patients are becoming empowered,
how are the GPs responding to this, if patients say "I would
like to take you through alternative courses of treatment"
and demanding of the GP that they give time to discuss this with
the patient? Is this happening on the ground?
Ms Fearns: To be honest with you,
it is early days. There are some concerns amongst general practice
that their own ability to flex their opening lists around workload,
loss of staff, particular crises in the practice, has now gone,
and they are now beholden to us to approve decisions with them,
which they think is overly bureaucratic. In the main, so far,
we have not seen that.
Q381 Mr Prentice: They are not making
unreasonable demands of GPs because the PCT has these health voice
networks we have heard about earlier, and patients may be waking
up to the fact that they expect more from the GP than a prescription.
Ms Fearns: There is an increasingly
empowered patient in South Birmingham, without a doubt, but it
is very early days. It is difficult for us to measure that at
the moment, if I am honest. We see that in the feedback we get
within these small health voice networks where we have a set of
people who come from the local community and who we hope will
be able to work with us on a long-term basis to reflect back some
of their concerns. In discussions we had today, the fact that
GPs are now required to provide a ten-minute consultation—
Q382 Mr Prentice: That is what I
give my constituents!
Ms Fearns: It might not seem very
much but a two-minute consultation is fairly challenging in terms
of patients being able to get a lot out of the system, and the
promotion of a ten-minute consultation, and that being a contractual
obligation, is an empowering thing. As Graham said, we have to
make sure that patients understand and are able to articulate
that in practices. We have teams now working with each locality
of about 16 practices on some of these particularly challenging
elements of the contract.
Q383 Mr Prentice: I asked the question
because we have the BMA submission, and the BMA seems timid about
a lot of the choice agenda. I wanted to ask about the involvement
of the private sector. The BMA told us that choice and capacity
must be considered hand-in-hand, and at present increasing capacity
seems to be synonymous with commissioning private sector involvement.
The BMA wishes to see investment to create additional capacity
being concentrated on the NHS. To what extent are you being forced
to involve the private sector as part of this choice agenda that
the Government is asking you to embrace?
Mr Urwin: It is Department of
Health policy, and the Prime Minister I believe has made recent
statements on this. By 2008-09 we are expected to commission about
8% of our planned work from the private sector. That does a number
of things. It introduces some innovation, and some of the levers
that are associated with choice, and then perhaps go on to the
levers for quality and efficiency and value for money in the future.
To deliver that level of entry to the markets, there has to be
some protection to allow the private sector providers to enter
that market place in the first instance. We cannot realistically
ask them to set up a new facility, and patients might or might
not come; and that is a particular challenge for us. When you
look at the impact of this on different parts of the NHS it is
quite interesting. In South Birmingham we are already achieving
far better than the NHS current standards for access to services,
so nationally people are expected to have their planned operations
within nine months but if you live in South Birmingham you get
them within six months. Nationally, people would expect to see
a specialist for an out-patient consultation within 17 weeks but
in Birmingham you get that within 13 weeks. We have not introduced
in the past private sector capacity to enable us to deliver Government
targets, so we now feel, because this is Department of Health
policy, that we have a challenge in catching up. There is not
sufficient growth money in the system for us to purchase this
private sector capacity from new monies that come into the system,
so we will have no choice but to look at opportunities for substitution,
to look at work that is currently carried out within the NHS being
placed within the private sector.
Q384 Mr Prentice: This is perverse,
is it not?
Mr Urwin: The observations I made
to you about market entry and protection for market entry in the
first instance—ultimately patient choice will determine
this because ultimately for all common conditions we need to give
patients, from next year, starting with cataracts and orthopaedics,
which will eventually build up for all common conditions, choice
of up to four or five different providers where they can receive
their treatment. One of those will be a private sector provider.
Q385 Mr Prentice: This contract will
be for a given period, say five years.
Mr Urwin: What we know is that
the contracts for the first wave of independent sector treatment
centres, of which we do not have any in Birmingham, were let for
five years, and they were let on the basis of a guaranteed income
flow. The procurement exercise is not concluded for this next
round yet.
Q386 Mr Prentice: But you could be
guaranteeing the income of these private sector providers, even
although you are not sending patients to them for treatment.
Mr Urwin: That could happen in
the short term.
Q387 Chairman: I would like to pick
up on a couple of things with you. We have been trying during
the inquiry to get a sense of concrete examples where choice mechanisms
work, and one of them that is always cited is direct payments.
We have taken no direct evidence in fact from anybody on direct
payments along the way. Can you quickly tell us exactly how the
direct payment system is working? I know the principle of it which
is that you give them the money and they buy the service, rather
than you simply providing the service, and that is choice. Is
it like that? Has it changed the terms of trade? Are there problems
associated with it? Just give us a snapshot.
Mr Hay: A good case example is
people, particularly with physical disability, instead of receiving
a service where we send in our own carers to get them out of bed
and get them on their way to work, roughly at a point in the morning
between seven and nine, by direct payments they take on the employment
of their own home carer. They appoint, select and then recruit
who they want to do it. I remember very clearly the person I have
in mind saying to us, "if you are going to wipe my bottom,
I am going to choose who you are". Previously they took who
came in through the door at the time. They can say, "I will
not be there at such and such a time because I want to be away
at half eight." They can guarantee the time, as part of the
contractual terms, as opposed to being at the mercy of the local
authority and the priorities facing the service that morning.
Equally, they can say, "I want something far more imaginative,
and I want to go and use the swimming pool, and I want someone
to take me to the swimming pool, rather than having another hour
here", so adding in to the package. There are problems with
it. The bulk of what we have done is with third-party assistance,
so we use an independent voluntary sector agency to do all the
pay and rations work, because most people do not want to take
on payroll and VAT, and it can be done through a third party.
There are still some bumps in the carpet that we are ironing out,
and if you buy back home care from the local authority, then you
buy it back at more than I paid for it. We have some ironing out
of things like that still on hand. There is still a debate about
improving that. That said, the concept of being more in charge—I
am not sure it is necessarily choice, but certainly control is
the important bit. Most users talk about being more in control
of the arrangements in their lives than making a choice, because
most of them would choose not to be in that situation.
Q388 Chairman: That is very helpful.
Related to that, in your paper and also in what you said to us
in your presentation this morning, you added in this notion of
supporting people to make choices. That is quite important it
seems to me for the direct payment system, and you have explained
how it works. The evidence coming out of choice systems is that
they work better if people have people to help them make the choices.
How are you thinking about the whole business of supporting people
to make choices—the advocacy role—and how integral
that is to your choice agenda generally.
Mr Urwin: It is all very well
having this wonderful concept that says whilst you are sitting
with your GP you have described what is wrong with you, and the
GP says "you need to go and see a specialist" and he
turns his computer screen round and you look at it together and
book your appointment with the specialist there and then; but
it is pretty unrealistic. If I am told I have to go and see the
specialist, I might want to go home and discuss it with my family
before I choose where and when I want to go. It is also unrealistic
to say that it would be the best use of a GP's time to carry out
that function. We envisage a range of what we could call clinical
assessment centres, where effectively a GP has made a decision
and he will then say to the individual, "phone this number
tomorrow and they can take you through it in more detail and help
you make their choice and book your appointment for you; or go
to this clinical assessment centre and we can do a further diagnosis;
and when we have that we can move on and make that choice together."
Then we will talk about using a range of advocacy and nursing
and other healthcare skills to assess the patient; so we do not
focus all of this around the scarce resource of the GP.
Mr Hay: You are absolutely right
to bring it back to the basic advocacy. All people in our inner
city homes have an individual advocate, and it is part of the
debate in talking about their future. That is an important issue
in being able to make a choice and in being well guided in doing
that. Equally, in direct payments, one of the reasons for the
growth is that we have put a lot of work into what we call a direct
payment forum where you can talk to us directly in question and
answer style about direct payments, you hear from other people
using them—the good, the bad and the ugly. That means that
people make a well-informed and rounded choice, and they also
feel they have a place to come back to if they choose to put their
toe in the water. I tried to make the point in the paper that
we must not forget the importance of good, basic information,
from the very point at which you contact services like ours all
the way through, and part of making the choice is knowing the
full range of what is available and what that means. Historically
we do not put good resources into information because we see it
as froth and bubble, whereas diversion of resources—and
that is a really important issue about getting the basics right
on which you build informed choice.
Q389 Chairman: People still trust
professionals, do they not? They trust them more than they trust
people like us—I do not mean you!
Mr Hay: We could not possibly
comment!
Q390 Chairman: This raises all kinds
of issues, does it not? If I get on to a bus, I do not say to
the bus driver, "where should I go?" because I just
want to go somewhere on the bus. I am quite likely to say to a
doctor, "tell me what to do; what do you think?" He
has his list of clinicians and places I might go. I am more than
likely to say, "what would you do?"
Mr Urwin: The important point
I made is that I described it as a clinical assessment centre;
I am talking about a facility that will be staffed by professional
clinicians. It will not always be with your family GP that perhaps
you make a difference because there is the practicality of delivering
that, but there will be GPs, nurses and advanced nurse practitioners
and other specialists.
Mr Hay: At points in your life,
you do not want to be confronted with an overwhelming choice.
Sometimes we are dealing with people in extreme crisis. We went
to a house of a young man in his early thirties who had became
disabled as the result of a very serious car accident. He did
not want to make any choices. He said, "when it came to designing
my new house, I did not want to play". He grudgingly went
with it and was discharged from the regional centre to that house.
The house has actually been a major part of him rebuilding his
life, and he is now at university, because it was designed in
a way that did not stigmatise him. There was the classic story
of the postman knocking on the door having been delivering there
for about three months, and he answered the door in his wheelchair,
and the postman said, "I did not know somebody with a disability
lived here." That is what we set out to achieve, but at the
time of making the choice he was in a crisis and did not want
to make some of those choices. Some of it is trust, and sometimes
you have to carry people through those, but building up to the
point where they assume that full control.
Ms Fearns: Some of it is also
about the sort of issues that people are being asked to make choices
about. If you were diagnosed with cancer, or you need a very minor
procedure done in a local hospital, the issues around how you
might want to make deliberations about choices available to you
are different. A lot of the early work on choice is done around
heart surgery. We learnt a lot from people willing to travel internationally
or anywhere across this country to get care done quickly because
they thought they were going to die. The issue with cancer is
that people want to feel they are with the best surgeon who provides
the best possible chance of survival. Choices are also about the
particular impact on your life at that point.
Chairman: Sure, and it brings out the
relationships that are needed between service users, professional
managers and professional clinicians in this case. It requires
them to have skills and relational skills that many of them have
not had to have. All parties have to learn new ways of doing this,
have they not, once we stop providing services in a traditional
top-down, provider-knows-best, way? It is a challenge for all
of us. We will have to stop now. I cannot thank you enough for
your time this afternoon. I thank the PCT people because you have
had two lots today, which is more than you should be expected
to put up with. We are very, very grateful for seeing us this
morning and coming back and talking to us more formally this afternoon.
We have learnt a lot from it. Certainly today in Birmingham has
been hugely valuable to us in matching some of the things we have
been thinking about, through talking directly to providers on
the ground. Thank you very much indeed, and we thank Birmingham
generally for its hospitality.
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