Examination of Witnesses (Questions 93
- 99)
THURSDAY 3 NOVEMBER 2005
CHANGES TO
PRIMARY CARE
TRUSTS
Q93 Chairman: Good morning—it
is nearly good afternoon, I am afraid, and I do apologise for
that. Most of you have been in the room for all of this morning
and you will have seen the areas that were covered. I wonder if
first of all I could just ask you to introduce yourselves to the
Committee for the record.
Dr Dixon: I am Michael Dixon,
I am a working GP but I am also a practice-based commissioner,
a local lead commissioner and chair of NHS Alliance, and I can
speak for NHS Alliance. I felt it was appropriate to bring three
experts, if you like, who this morning will be speaking for three
of our networks: Dr Peter Reader, who is a GP as well, who leads
our PEC chair network, so he can speak for PEC chairs in PCTs;
Yvonne Sawbridge who leads our nurses network, who is going to
speak for nurses and also for allied and other professionals,
having discussed it with other leads in that group; and Robert
Sloan who is a previous chief executive, has been acting chief
executive for several PCTs and leads our national leadership network,
so he is speaking for chairs, chief execs and leaders in the primary
care trusts. I felt it was important that they should come along—although
they will not be representing official Alliance policy—so
that you can find out what their various constituencies are saying.
Dr Stanton: Chairman, I am Tony
Stanton, an ex-GP—I used to be a proper doctor, as my mother
would say—and I awarded myself the wonderful title of joint
chief executive of Londonwide Local Medical Committees which represents
GPs in London from the west in Mr Burstow's constituency, to the
east in Dr Stoate's constituency.
Ms Marks: I am Lucy Marks, I am
a clinical psychologist, PEC chair in Tower Hamlets and I am a
member of the Confederation.
Q94 Chairman: Thank you very much.
I do not think we want to try and attempt to go through the last
session in as much as we got pulled in all sorts of ways with
every question, but given that you all sat through it, could I
ask for your views around the last session. Maybe we could start
with organisational change as a strap line and ask your views
about that and any interaction you may have with what was said
in the last session, either by witnesses or actually by members
of the Committee.
Dr Dixon: Shall I start off because
there are issues around why the changes are necessary, the outcome
in terms of current plans for reconfiguration and the process
by which those plans were made. Why the change? Alliance would
agree that there is a need for change because not all primary
care trusts are uniformly good, and there are three particular
problems: there are some which are weak commissioners, some which
did not engage fully with their local professionals and some which
did not have the clout to be strong commissioners of their local
acute trusts. Reconfiguration would seem to be the solution for
that, and in terms of the general direction Alliance is happy
with the direction but we are unhappy with some of the implementation.
In terms of the actual process, certainly we feel that there has
not been great consultation, we have heard there was very little
time, but certainly 40% of our PEC chairs said they were not consulted
by the strategic health authorities at all. As far as frontline
clinicians are concerned I think they felt very disempowered and
not engaged at all, it has just gone on above their heads, which
I think is not a good start in trying to get practice-based commissioning,
patient involvement and the like occurring. In terms of outcomes,
I do think this map looks a little bit depressing because it is
just a map of England with the counties and the unitary authorities
marked on it. I am not sure how much work has gone into producing
this, but anyone could have produced it on 29 August or whenever
without great effort, which means that there has not been a great
deal of sensitivity towards local culture and local history. It
also means that the focus has been on co-terminosity with the
local authorities and not on what I consider to be the far greater
and more pressing problem in the NHS at the moment, which is a
proper commissioner/provider relationship between primary and
secondary care. That is something that I hope will be taken seriously
in considering the submissions. The other issue is about how we
relate local people and clinicians; we have raised it already
and it is an issue, I quite agree. The other issue, when we have
these merging PCTs, some with large budgetary deficits and some
which have not, is how we continue to engage our local clinicians
who are trying to go into practice-based commissioning but who
may find themselves suddenly with budgets that are rapidly changing.
Those are the issues and I think there is a solution. As always
the frontline can find a solution to any change. The solution
is going to be about creating very strong localities, making sure
that practice-based commissioning works from bottom up, making
sure that localities bring those practice-based commissioners
together and that we also make sure that the PCTs are listening
to the frontline and not vice versa, which has sometimes been
the case previously.
Q95 Chairman: Has anybody got anything
to add to that?
Mr Sloane: There was an earlier
reference to the evolution of primary care organisations in this
country, and reference was made to the establishment of primary
care groups in 1999. That was a process that was quite unique
in the history of the NHS because it required the organisation
to identify what were then termed natural communities, and natural
communities were known to the people who lived there, whether
that was in Bristol, Birmingham or anywhere else beginning with
B. It was actually a process of identifying where people lived,
where people worked, where people related and where people felt
they belonged. We managed to carry some of that sense of localness
through into the evolution that constituted primary care trusts
and, really to follow on Dr Dixon's line, that process of organisational
change was tracked in some work that we did with Birmingham HSMC
(Health Services Management Centre) in April of this year, and
what was becoming very clear at that stage was that PCTs were
looking at their three-fold functions of improving health, commissioning
services and providing primary and community care. The range of
models that was emerging was hugely diverse, it ranged from the
single unitary, compliant structure like Southampton City through
to the association model of Greater Manchester, but I suppose
the two characteristics that distinguished that work were essentially
about principles of subsidiarity, how can services best be organised
locally, and only when economies of scale or other functions that
could not be accommodated locally were evident did the scaling-up
then take place. The other aspect that characterised that change
was essentially around having a core rationale that was clear
to clinicians, managers and local organisations, whether they
were voluntary groups, carers groups or church groups, and I think
our contention would be rather along the lines of the previous
speakers: that process had already taken root, it was already
well-established, there was a median size of primary care trust
which hovered around 175,000 people. The escalation of that process
runs the risk of losing those core ingredients or core organisation
changes, so it is not so much about whether it is the right thing
to do, it is about the place and the now in which this change
is being taken forward.
Q96 Dr Naysmith: I was the one in
the previous session who raised the question of primary care groups,
I was a great fan of them at the time and thought, you know, it
was a pity we moved them up too quickly. The root question that
arises from what you have just said and what I was arguing is
what sort of level of engagement is there now with primary care
trusts before we start talking of what it will be in the future,
and maybe Ms Marks would be the one to answer, if you know all
about PECs. To what extent does primary care contribute to the
kinds of decisions that primary care trusts make at the moment,
in the current situation?
Ms Marks: One of the differences
between primary care groups and primary care trusts obviously
is that it was the coming together of community services and GP
practices, and I think that in principle the idea of having a
PEC (a professional executive committee) which is multi-professional
and which is also needing to work very closely with the management
team of the primary care trust, has meant that new partnerships
have developed and this puts us in quite a good position for redesigning
services that we need to do in terms of commissioning in a different
way, because I think what good commissioning is about is getting
clinicians and managers involved, but essentially new services
need to be clinically led. But they need to be clinically led
in a partnership, so a partnership between multi-professional
groups of clinicians as well as managers. We have to make sure
that the changes that are coming on board now enable us to continue
doing that and enable the PECs to work very closely with the local
medical committees and all our GP colleagues as well as all the
therapists and nurses to do that properly. Partnerships are the
key here really, we do not want people to go off and do things
in isolation. We also need to work with the local authority, so
on our PEC we have a local authority member and we also have somebody
from patients and public involvement. Those partnerships are essential.
Q97 Dr Naysmith: I know quite a few
GPs in Bristol and many of them were interested when primary care
groups started off, but I get the impression now that some of
them are not nearly as interested in taking part as they were
then. Is that unreasonable?
Dr Reader: I would like to come
in on this because the view of the PECs is that we would actually
welcome anything that strengthens commissioning—PEC chairs
are very much there because they are driven, they want to commission
an improved patient care—and I use the term "commissioning"
carefully, rather than procurement, because there is a very big
difference in here and the PEC chairs feel that this process is
actually being driven by two things, co-terminosity—which
does bring some benefits but is not a panacea—and also making
management savings. There is a very strong feeling from the PEC
community that that is driving an awful lot of the shape and form
that is coming out, not the function. If one turns to what really
makes commissioning work, I think we have accepted that there
is an element around size of that and, as we have also discussed
already, a lot of PCTs have been evolving organically to deliver
that, and there is a lot within there which is about local relationships,
local clinical leadership, trust and partnerships, which is actually
what delivers real commissioning. You need those clinicians having
that clinician to clinician conversation that can actually evolve
and innovate and change a service as opposed to just shifting
big blocks around.
Q98 Dr Naysmith: Do you think the
proposals will be an improvement on the current situation, or
is there the possibility that they will be an improvement?
Dr Reader: I think they will put
a huge stall on the benefits that we are now just beginning to
see. The thing has been quoted variably as 18 months to three
years to organisations actually beginning to be effective: I have
been hearing down the network and from talking to other PEC chairs
that they are finally beginning to move forward in those agendas
and the advent of practice-based commissioning is actually going
to be a huge help with that. But even if we look at practice-based
commissioning, 50% of PCTs have got less than 50% of practices
likely to be involved by December 2006 and most of that involvement
has been driven by PECs taking local leadership forward, engaging
with the local practices, showing them what the benefits are and
translating to them what it really means. That is absolutely key
and vital, and there is at least one example I know of where there
has been a very large buy-in to practice-based commissioning prior
to the Commissioning a Patient-Led NHS document came out
and, subsequent to it, an awful lot of cold feet and back-pedalling
from the local GPs because it is going to destroy their local
clinical leadership that they know and trust and have actually
been building up over three years; they just do not know who they
are going to be working with.
Q99 Dr Naysmith: It is not just GPs
because there are other professionals, that is why Yvonne Sawbridge
is trying to come in.
Ms Sawbridge: Thank you very much.
I just wanted to add to that really to say that any change is
really hard work and it takes transformational leadership. One
of my worries is that while we are getting rid of some of the
organisations, transformational leaders are rare beasts, in my
experience, and we do not want to lose them, we need them to be
engaging all clinicians, managers and local communities in order
to make sure that we are getting the changes that we are all committed
to.
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