Examination of Witnesses (Questions 20
- 39)
THURSDAY 3 NOVEMBER 2005
CHANGES TO
PRIMARY CARE
TRUSTS
Q20 Dr Stoate: How are we going to
rein in the current big hospitals then that effectively are going
to have hello nurses in the outpatients department rather than
goodbye nurses there? It will simply pay them hugely to admit
the patient.
Mr McIvor: There are two things.
First, I think practice-based commissioning is critical to this.
That is to say that those people who have responsibility for referring
the people into the hospital also have the responsibility for
the money and can use it differently.
Q21 Dr Stoate: I am not talking about
referrals. From next year, A&E and emergency treatment will
come under payment by results. How are you going to control the
hospital's power in that situation?
Mr McIvor: South Yorkshire it
has been under payment by result for the last two years for A&E
and emergencies. In A&E, I think you are right, there could
be a perverse incentive for hospitals to say, "Hello, come
in", and to lie you on a bed. We are doing two things in
South Yorkshire: firstly, there are sets of criteria that say
that unless patients have these things wrong with them, there
are other alternatives to admission; secondly, why do I not have
a GP in A&E; why do I not have my community response team
in A&E? They operate in there at various points in the year.
From this Christmas, they will be in there permanently.
Q22 Dr Stoate: Perhaps I ought to
ask some of the others? The evidence I am getting from PCTs I
speak to is that they are extremely concerned that payment by
results, particularly when it becomes universal for A&E and
emergencies, will mean that it is almost impossible for primary
care trusts and organisations to have any control over the hospital
whatsoever. Maybe the others have a different view or maybe I
have got the wrong ideas.
Ms Jeffrey: You are absolutely
right but I think it is unhelpful to regard this as a power struggle
between the secondary and the primarily care sector. It is not
a power struggle. It is about recognising the importance of patient
care pathways. You are right to say that when the Government set
this up, it was supposed to be a primary care-led NHS. Is it?
The difficulty then was that the primary and community efforts
did not speak very well together. They were trying to cope with
sucking of patients, if you like, in the acute sector in separate
ways. What has happened since the development of the primary care-led
NHS has been a coming together of community and primary care and,
most of all, clinical engagement in both the commissioning and
the management of the NHS by GPs. What we have seen, in terms
of trying to prevent, if you like, over-activity in the acute
sector has been a range of initiatives, really innovative initiatives,
in both primary and community care to prevent people needing non-elective
or emergency or urgent admission in the first place. Could I just
give you two excellent examples from my part of the country, which
is North West Derbyshire? One is that, in collaboration with our
local authorities, local strategic partnerships and local area
agreements, we have put citizens advice bureaux into GP practices.
This is the answer to your question about shire counties and how
you make the smaller PCTs able to operate on a much wider shire
county basis with all the local authorities. Once a week in every
GP practice there is a CAB session in all our surgeries, in all
our practices, so that people can consult on things like benefits.
We have managed to established that there is about half a million
pounds of unpaid benefits throughout our population of 100,000
each year which can be accessed by people being able to speak
to the CAB in this way. This is an initiative which we would now
like to roll out over the whole of Derbyshire. The second thing
is that we are a rural farming community and in those isolated
areas 33% of the population is involved in farming or secondary
farming activities where farming does not pay any more. The farming
community has very high health needs. One of the major reasons
for that is because they do not seek help. Traditionally, they
do not seek help. We have put a walk-in clinic staffed by physiotherapists,
a nurse and a health visitor actually in the agricultural centre
where people come to sell their beasts on a Monday morning, and
it is full. That has made a great deal of difference. That is
a primary care led initiative, which has prevented those people
from having to seek maybe orthopaedic or major surgery in the
secondary care sector.
Q23 Dr Stoate: I am very pleased
about that. The final question is this. Those PCTs that genuinely
feel that they are being bankrupted by payment by results are
either wrong or they are just badly organised, are they?
Ms Jeffrey: No. We have been operating
in a full payment by results regime for the nearly last 18 months.
We contract with four major providers, all of whom are foundation
trusts on PBR. It is extremely difficult. Our financial situation
is very challenged, not totally because of that but also because
of the rural factors and because we are above equity. However,
that is a very good signal to us that we need to highlight what
is going wrong; we need to make sure that behaviours around payment
by results are properly controlled, codified and monitored; that
there is a code of behaviour here; and that when it is rolled
out to the rest of the country, we have already understood and
established what the pitfalls might be. That is so that when payment
by results is rolled out to the rest of the country, we can make
sure it happens in a controlled and managed fashion.
Dame Gill Morgan: There are two
further matters. We should not be talking about one bit of the
NHS leading another bit of the NHS. The NHS is there for patients
and we have much more to put patients at the centre and be much
more listening to what they want. I think that change has happened
and so we do not talk about being a patient-led NHS now; we talk
about trying to put the patient at the centre. It is an aspiration;
we are not there. We really do have to remember what the service
is there for. It is not for doctors, nurses and the hospital;
it is for patients. That is the first point. The second point
on payments by results is that there is a lot of international
experience which says exactly what you suggest. When you start
to introduce a payments by results system, it puts a real set
of pressures on the commissioners. The commissioners have to find
new ways of doing things to prevent admissions. What the international
evidence also says is that after it has run for a couple of years,
you find that the alternatives to admission start to bite on the
hospital. After a few years, it is the hospitals that find there
is a real challenge to them. What we have here is a transition
pathway to introducing a new system. It is quite right and natural
that PCTs have real, genuine concern about how to management payment
by results, but that incentive needs to be there to get people
to change the way they deliver and to have this whole set of new
alternatives, which would keep people out of hospitals and in
their own homes, which is where they want to be, and which will
deliver better outcomes for them. This is really important.
Q24 Mike Penning: This is very important.
What you are saying here is to do with the pressure on the hospitals.
That is only possible really if there is the capacity within the
hospitals to offer the services you are talking about. I am fascinated
to hear how well you are doing in your part of the world. I declare
an interest here. John de Braux is the Chief Executive of my strategic
health authority. We do not have the capacity, and John knows
this; we have a major problem with capacity. That is partly to
do with deficit. It is all about structure. How is this going
to work in our part of the world, in the south-east, where there
is a particular problem with capacity and where the pressure is
going to come on to the commissioner and there will be more pressure
on the hospitals? The hospitals cannot survive now under the pressures.
How is it going to work?
Mr de Braux: We probably have
more capacity in and around an area like Hertfordshire, which
not only has hospitals within the county but also in all of the
counties around it, and more choice for people than many other
parts of the country. I think we are not talking here about trying
to stop people going into secondary care or staying in primary
care; it is for patients to be treated where that is most appropriate.
In some parts of Hertfordshire what we are seeing, and this demonstrates
how it should work and will work in the future, is that where
we have good GPs, those that have done best on their quality and
outcome framework points this year, we have very strong evidence
in one or two PCTs that for patients with chronic conditions like
diabetes and COPD, chest problems, we are seeing an increase in
admissions to hospital, or referrals to hospital. This might seem
perverse but these are planned referrals for a specialist opinion
that is appropriate for these patients. We are also seeing a corresponding
reduction in emergency admissions. This is not about stopping
patients going to hospital but about making sure patients get
the right and appropriate treatment, led and helped by their primary
care practitioner.
Q25 Mike Penning: I beg to differ
with you on the first point.
Dame Gill Morgan: It is important
for people to recognise that already 90% of interventions happen
in primary care. That is where most people make their contact.
We are talking here about how you strengthen those opportunities
that keep people as near to their homes as possible.
Q26 Mr Campbell: When we talk about
patients and what they want, in my view, they want to get in to
see their general practitioner very quickly but sometimes they
have to wait a week; they want to be seen by a specialist at a
hospital very quickly. Will a system, such as you are referring
to, help the situation where you cannot get to see your GP and
you cannot get to see a specialist, let alone have an operation?
You have to wait a long time. Is this going to help that situation?
That is what I hear in my surgery.
Dame Gill Morgan: Yes, it should.
That is what patients say, if you ask the question that way. If
you ask a patient with back pain, "What do you really want?
Do you want to go to the hospital and sit in a clinic to be seen
by an orthopaedic surgeon who will refer you back to your GP for
some physiotherapy, or would you rather have extra physiotherapy
provided in your practice that treats you without ever having
to go to the hospital?" I think people would come up with
different solutions. This is about how we answer the question.
If all you have ever known is that a referral to hospital is the
right pathway, that is all you will ever know. We are trying to
stimulate more developments outside hospital of alternatives.
For example, general practice has been very innovative in setting
this up. There is a whole set of GPs with special interests. There
are now services run by physiotherapists for back pain and the
PCTs have actually trained people to do different things and manage
this differently. This is a revolution in how we deliver care.
Part of that has to be about how we explain to the patient and
to the staff that things will be different, but that that is good.
The knock-on effect or the benefit of that, if we start giving
physiotherapy outside, is that when you do go to the hospital
because you need the time, there is more time, less pressed clinics,
and you can get a better and more tailored expert opinion than
you currently do at the moment. This all takes time because there
is a big revolution in how we deliver service.
Ms Jeffrey: Mr Campbell, may I
add that in the part of the country where I come from, most people
cannot get to hospital for an outpatient appointment and back
in the same day by public transport. Think about that. Some of
us forget about that. Therefore, it is vitally important that
primary and community care services are there for those people
and are able to provide other ways for their back pain, for example,
or any other kind of musculoskeletal problem, to be dealt with.
By the way, Mr Barron, I do not believe the service will fall
over for 18 months. I do not believe it will fall over at all.
Managers are used to this. They will cope as they always have
done in the past.
Q27 Dr Taylor: How will larger PCTs
keep their local focus?
Mr McIvor: There is a balance,
as I said previously, between size and clinical engagement and
clinical engagement goes with a local focus. They will find structures
and work in ways which perhaps go down to localities and neighbourhoods.
Practice-based commissioning, after all, is that way of getting
down to that neighbourhood level. I think there is a balance between
their desire for co-terminosity in clinical engagement so that
we actually make practice-based commissioning and real neighbourhood
involvement work properly. That is the one we have to try to find.
Q28 Dr Taylor: If there is a merger,
will local groups like professional executive committees still
exist for local groups? Will patient forums still exist for localities?
Mr McIvor: My understanding, and
I am from a PCT where there are no proposals for mergers, is that
professional executive committees will continue. I have not seen
anything from the Department of Health that says anything contrary
to that.
Q29 Mike Penning: It will happen
in your part of the world. What is going to happen then, John?
Mr de Braux: We will be moving
probably from eight to one PCT in Hertfordshire. We are consulting
on whether it will be two or one. Most people are saying that
one would be better. Our preference for one rather than two is
that both probably manage to be significantly large enough to
take on the commissioning agenda, but, if you go to one rather
than two, you can release more funds to develop your local services.
You have a smaller core to do the large-scale planning of commissioning,
monitoring, et cetera. You can release more money to be at your
local district council practice-based commissioning type level
to keep that local focus.
Q30 Dr Taylor: I think Gill Morgan
said that many PCTs will not change. Could we possibly have a
list of the numbers that will not change at some time?
Dame Gill Morgan: We can give
you a list of the submissions that have gone in to the Department.
Those are subject to consultation, so it does not necessarily
mean that that is how it will end up. I have a document here from
the Health Service Journal which has a complete summary.
I will leave that with you. It gives you the scale and range of
what people are looking at.
Dr Taylor: We already have that.
Q31 Charlotte Atkins: I believe that
the emergency panel is meeting next Tuesday to look at those issues.
Earlier on, of you said that where you have a number of PCTs,
the SHAs would lead the development. Do you not really mean that
the SHAs are dictating to PCTs what the future will be, particularly
in places like the shire counties, to go back to an earlier point,
where the messages come from on high about "you will merge
into a giant shire county PCT", which is even more remote
than the health authorities we got rid of several years ago?
Mr de Braux: I do not think we
are dictating to PCTs. We have arrived at our conclusion in consultation
with PCTs and many other groups, particularly local authorities
and social service authorities. I do not think we are dictating.
In this instance, in helping them through this change, it was
something one of the PCTs suggested to us that we should do. It
seemed a sensible way forward and we have taken it on with them.
This is working together and not working in a dictatorship.
Q32 Charlotte Atkins: That is very
interesting because in my patch SHAs, having received hostile
responses from virtually everyone within the pre-consultation
period, then progressed to put exactly the same recommendations
to the Secretary of State. I am talking, of course, about Staffordshire.
Understandably, a social services authority would want to promote
co-terminosity because, of course, they have everything to gain
from that. The issue is one Richard Taylor raised. You have a
shire county PCT of 800,000 in terms of Staffordshire or one million
in other areas. Given that PCTs were set up to have a local focus,
an intimate relationship with GPs, and to work with other local
authorities within the LSP area, to have that intimate knowledge
and non-executive directors working with the community they know
so well, how do you do that when you put six PCTs into one huge
PCT, especially where, as in Staffordshire, there is a natural
north Staffordshire health economy and you lump these together
just because of the accident of the fact that social services
happens to operate on a county-wide basis?
Ms Jeffrey: I come from a neighbouring
county, Derbyshire, where exactly the same thing is proposed.
We have 8.5 PCTs and the proposal is to move to one, or possibly
two. The same thing goes for Nottinghamshire and Lincolnshire.
Across the centre of the country we have the same thing with the
shire counties. To answer your question, Ms Atkins, I do not think
that this has been dictated by the SHA in terms of configuration.
What has been unhelpfully dictated has been timescale and process.
We are experienced people and we are able to do something like
this ourselves. Personally, I have experience of organisational
change and huge massive reconfiguration in a variety of other
sectors, and I know what the rules of engagement are. One of the
drivers for this, which nobody has mentioned, is to release £250
million. It is in the manifesto. That money has got to be released.
If you do not reduce the number of organisations, it is hard to
see how you are going to release that money. It is true to say
that in some places large organisations would not be appropriate
and in other places they would. In Derbyshire, we have always
worked as north of the county and south of the county in the past.
Those very disparate communities have worked together. We had
a community trust covering the north and a community trust covering
the south.
Q33 Charlotte Atkins: You have two
separate organisations?
Ms Jeffrey: Yes, but that would
have been an option: we could have had two PCTs for Derbyshire.
Absolutely nobody in Derbyshire thought that would be a good idea.
We thought that inasmuch as the north of the county could work
together and the south could work together, so could the whole
county.
Q34 Charlotte Atkins: How did you
consult them?
Ms Jeffrey: As I have said to
you, it has been very unhelpful that we did not have a very great
deal of time to consult.
Q35 Charlotte Atkins: You have just
told me that in Derbyshire nobody wanted a north-south divide.
How did you consult them? How did you come to that decision?
Ms Jeffrey: The PCT boards, the
local authorities, MPs, and the local strategic partnerships,
were part of the pre-submission engagement, but it was not long
enough. It was not nearly long enough. Some MPs were not asked
at all. They said it was not on their radar. Given that this announcement
came out on 28 July after Parliament had risen, when people were
going on holiday, when I got my two local MPs together, it was
September before they had come back from their holiday. Our submission
had to be in by 12 September. What time was there for them? What
time was there for the local authority chief executive? Whilst
he is being consulted, he could not get his members—
Q36 Charlotte Atkins: It is interesting
that you said you document had to be in by 12 September. In Staffordshire,
the pre-consultation finished on 16 September. It is interesting
that you had a different time-span than others.
Ms Jeffrey: I think it was to
do with strategic health authority board meetings, for example.
To answer the second part of your question, how can we make a
PCT for the whole of Derbyshire locally relevant? How can we make
sure we have clinical engagement in all those local areas? I think
we can because this is a commissioning organisation which needs
to have, as I said at the very beginning, bargaining power; it
needs to have muscle; it needs to have the best tools; it needs
to have the best organisational development to be able to deal
with the multiplicity of providers around the patch. That does
not mean to say that a large central organisation cannot receive
intelligence from its periphery and those locality directorate
arrangements or locality public involvement arrangements or locality
clinician arrangements. This is not just about GPs; we are talking
about multi-professional clinical engagement in commissioning.
It is perfectly possible to do. This is a large corporation with
subsidiary organisations feeding in.
Q37 Charlotte Atkins: Then why did
we bother to create PCTs in the first place? We may as well just
have stayed with health authorities?
Dame Gill Morgan: There is already
a model because in many of the shire counties, if you look at
performance for social services, they run their social services
already broken into localities. That is the way they deliver service.
They manage both to have a corporate whole across a large geographical
area and local sensitivity. If you were going to design a system,
the localities within the large PCTs are going to want to work
very closely with the same geographical boundaries that social
services work on. I do not know any shire county that does not
work with social services through a series of sub-components.
Q38 Charlotte Atkins: That is absolutely
right, but then to put the PCT on a county-wide basis means that
you have the same problems with remoteness and with lack of focus
from GPs. You were talking about commissioning. It is important,
if you are going to get commissioning right, that they know what
the local situation is. You spoke very movingly about the situation
in a rural area like the High Peak. Exactly the same issue arises
in places like Staffordshire. You have a very different set of
problems in South Staffordshire from North Staffordshire, just
as in Derbyshire. How do you overcome that?
Dame Gill Morgan: This is no different
from positions we have been in before. What you need to understand
if you are commissioning are not the needs in large geographical
areas but those in small neighbourhoods. PCTs and strategic health
authorities map their population needs at very small areas. If
you go to an area I know well, Devon, most of our mapping is around
individual towns. You have to be as sensitive at that level. There
is no reason why you cannot have a big organisation with governance
in terms of covering geographically and be incredibly sensitive
at a local level and have partnerships that actually bind all
the different bits together. They are not in conflict. It is just
about how you structure yourself.
Q39 Charlotte Atkins: But that is
why we created the PCTs in the first place because those structures
did not work in the past. Is that not right?
Mr de Braux: I think we created
them in the first place because what we really wanted to do was
engage primary care practitioners in commissioning and planning
services for patients. They had no previous experience of doing
that, other than fundholding. I know PCTs were set up in order
to get that engagement from clinicians into this because, without
that engagement, we would never really meet the needs of patients
and for patients to have the confidence in what their clinician
was saying to them. I think we have moved on now. We have a body
of clinicians in most primary care areas that want to take on
this agenda. It is absolutely appropriate to move some of the
bureaucracy away from this and have a governance structure that
fits with the larger commissioning planning requirements but leaves
the local focus for groups of general practitioners and other
primary care practitioners to develop. I think they are ready
to do that.
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