Examination of Witnesses (Questions 100
- 119)
THURSDAY 3 NOVEMBER 2005
CHANGES TO
PRIMARY CARE
TRUSTS
Q100 Dr Stoate: I want to talk about
practice-based commissioning and obviously many of the plans that
are currently being put forward are going to hinge very much on
whether practice-based commissioning actually works. We have heard
from people on PECs that there is a huge enthusiasm within the
PECs to try and drive local practices and trying to make this
work, but actually it seems to be a bit difficult to get across.
I would like to ask Dr Stanton a couple of questions, because
I know from long experience and knowing Tony very well that he
meets ordinary workaday GPs on a frequent basis, possibly more
than most. Do you honestly think, Dr Stanton, that GPs are enthusiastic
and engaged with the whole process of practice-based commissioning?
Do they actually understand what it is and what it means to them?
Dr Stanton: We are trying to make
them enthusiastic and informed, but I have worked in and with
the NHS for 41 years and the truth of the matter is that first
of all none of us should be surprised at yet another round of
organisational change because it happens every time, usually soon
after an election. That is the first thing. Secondly, anything
from the Department which comes out called Commissioning a
Patient-Led NHS you can guarantee is nothing to do with patients
leading the process, but I do think we have to see this as part
of an overall process. Dr Naysmith was asking previously where
this direction of travel had come from, to which Dr Groom was
referring, and we are, it seems to me, with this Government—and
probably with both the other major political parties—going
down a road where the NHS is a brand and the provision of the
services can be sub-contracted out to whoever against certain
criteria. If I am correct in that analysis and if there is to
be a move to practice-based commissioning, then the question has
to be asked what are primary care trusts for and what are PECs
for, because much of the enthusiasm with clinicians who went on
PECs, it seems to me—and Peter and Lucy would speak from
first hand experience—was precisely to try to inform the
commissioning of care agenda for the patients of their practices
or their client groups with which they worked. I think it has
been extremely difficult for PECs to influence that process because
the whole thing is money-driven. I relate to 12 PCTs and they
vary, in my opinion, in terms of the efficiency with which they
are run, but even the best-run of them have major financial problems.
They are all predicting overspends in the current financial year,
which is concentrating their minds. I was at Dr Stoate's local
hospital yesterday talking to the next generation of GPs and that
hospital has an admitted deficit of £6 million—it may
well be more. You see this all across London and it is quite impossible,
I think, for individual PCTs to control that hospital expenditure,
it is impossible for hospitals to cope with the limited budgets
they have. Moving to a scenario of payment by results where every
time a patient activity is undertaken in a hospital there is a
bill, you have to find some way of controlling that demand. The
only way, it seems to me, that you can attempt to control the
demand is by making practice-based commissioning successful. It
has been difficult, Dr Stoate, in all honesty to get practices
heavily involved in this for a number of reasons: first of all,
a woeful lack of information from the Department of Health, with
technical guidance promised earlier this year, which when it eventually
came was not worth the paper it was written on, was supposed to
come again in another edition in October—we are now in November
and there is no sign of it. I am sure it will not be worth having
when it comes and I would hope that you, as a GP in London in
part of your time, would agree that probably the only information
you have had is from the local medical committee on how the process
would work. This is, I think, extremely sad. Ms Millington referred
to people worrying about the future of their jobs: we have had
this ludicrous exercise in London where, for the last three months,
every PCT person has been consumed by what is their future and
then suddenly, yesterday apparently, a decision has been taken
that it is the status quo. People have been terribly worried about
their jobs, what is the future direction of travel, and I gather
that the only possible change in London is demerging the one two-borough
PCT that there is. It is madness and I think the Department really
needs to be held to account on this.
Q101 Dr Stoate: I think I should
distil from your words that enthusiasm is not unalloyed.
Dr Stanton: No, and why is not
unallowed? If we take Bexley, where your practice is, the PCT
is in deficit, the hospital is in deficit. If groups of practices
take overall responsibility for the commissioning budget, who
is going to be responasible for that budget? Where is the pump-priming
money to help practices get involved, but where are the promises
of adequate management costs, where are the promises about size
of and purposes to which savings made can be put? They are totally
absent.
Q102 Dr Stoate: You have actually
anticipated my next question, because I was going to come on precisely
to that. How do you think that we could try to engage GPs, because
you have already said yourself that the future of the NHS, because
of the power balance between primary and secondary care which
I have already hinted at, will largely depend on whether practice-based
commissioning can be made to work. How do you see it working?
Dr Stanton: The engagement is
patchy across London. In some parts of London there is very widespread
engagement, and Islington where Dr Reader works is a good example
and Sutton and Merton Primary Care Trust is another example with
heavy involvement.
Q103 Dr Stoate: I accept there are
good bits, but as Dr Reader has already said, even by the end
of next year some PCTs say that only 50% or less of their practices
will be engaged. How on earth are you going to sort that out?
I am not worried about the good because the people who are good
and enthusiastic are already getting on with it, but what about
the 50% or more who currently are either not engaged or, frankly,
are uninterested?
Dr Stanton: I can only speak for
myself and my own organisation. We are taking the initiative and
as well as producing briefings, copies of which I have sent to
the Committee, we are organising a series of major events across
London later this month and in the early part of December, precisely
to sell the message. I think this is the only way it can be done.
Q104 Dr Stoate: I am very pleased
about what LMCs are doing, but our purpose is to advise Government
on what we think Government should be doing. What do you think
Government should be doing, and I know that other people want
to answer as well?
Dr Stanton: I think Government
should be giving clear guidance as to what they mean by practice-based
commissioning, they should make it compulsory for there to be
adequate preparation funds, they should be very clearly defining
a range of management costs and they should be very clear about
the use to which savings can be put and also deal with the problem
of inherited deficits.
Ms Sawbridge: I wanted to answer
your question through a different route, if I may, which is where
you started, which is what should PCTs be doing to engage practices
in practice-based commissioning, because it is not just about
GPs, as you said, it is about the whole workforce having solutions
to problems. I think that is about going out and describing visions,
and it takes really skilled managers and leaders who understand
the art of the possible, because there is a great deal that can
be gained from practice-based commissioning. They need to understand
what that is, bridge the gap between the policy and the context
within which people are working, and that takes time going out
and talking to people, working out what their money could look
like, what savings they could have, what they could spend that
on, are there local problems? The difficulty with the current
system is that this organisational paralysis which is affecting
us all—and I very much hope you come back and talk to the
provider bit of the changes that are proposed—is getting
in the way of finding time to go out and talk to people about
exactly that. What the Government should do is make sure that
we are supported, that there is policy support, understand the
fact that change management takes time, effort, engagement and
needs to be allowed to let happen in local areas.
Dr Reader: I would certainly reflect
Tony's point about greater clarity on issues such as management
costs and what it all means, and I would completely agree with
Yvonne, but one of my concerns is that the impact of this re-configuration
by actually removing a number of PECs, by making these bigger
organisations that are actually far more remote, means that these
processes are just not going to happen. Even in areas where you
still have the borough boundaries, such as in London, you have
still got a 15% management reduction which is going to cause organisational
stagnation, there are going to be restructurings to actually make
that saving around commissioning and a whole load of other functions
which are going to cause organisational stagnation and the eye
is going to be completely off the ball of driving forward practice-based
commissioning. The other thing to think about is if you look at
practice-based commissioning without strategic local leadership,
you have really got fund-holding; whilst fund-holding delivered
some improvements, there was none of the kind of systematic innovation
that we really need if we are going to make the changes that the
NHS needs to move the healthcare over in the next 10 or 20 years.
We need those local clinical leaders who have actually developed
some of that leadership skill, some of that strategic nous to
be actually there supporting those practices and helping them
deliver and develop within those localities, to actually really
get what you can get out of practice-based commissioning.
Q105 Dr Stoate: Are you saying that
the reorganisation of PCTs is going to make things worse or better?
Dr Reader: Worse.
Dr Stoate: Worse. Okay, thank you very
much.
Q106 Chairman: Did you want to add
to that?
Mr Sloane: Simply to add really
that the last two points illustrate quite clearly how the level
at which corporate accountability is exercised is material, because
if practices feel that the organisation to which they relate statutorily
is remote and distanced, they have a disconnect in terms of confidence,
they have a disconnect in the people that they have got to know
and trust. It is quite interesting to look at the way the responses
in the Your Health, Your Care, Your Say exercise are panning
out, and one of the predominant themes is about things that patients
feel most passionately about, and that is the connectivity (or
lack of it) between health and local authority services. Those
are functions of course of statutory organisations, but they are
also functions of the myriad of other organisations that support
them.
Dr Dixon: If I may quickly come
in, I think the reason stopping many GPs at the moment is because
they want to make a difference and they are afraid that this time
they will jump in with both feet and nothing will change. When
you have this reconfiguration going on above their heads, without
them being involved at all, that slightly adds to the message
that they are not really part of the scene at all, and that is
the bit that we need to get first. If you ask where it is working
there are two elements: they have either got clinicians who are
taking leadership roles and running with them, either on the PEC
or sometimes individual practices gathering a few at the same
time, or you have got local managers who are polarising local
practices together. In terms of what the Government should do,
it needs to provide people with the confidence that practice-based
commissioning really will be able to run its course and there
will be real emancipation at the front line. We have to overcome
that suspicion at the moment, but I think the other thing we need
to do as PCTs go through this transferring stage is really invest
in these local managers, making sure that the local scene is set,
so that by the time the PCTs come back into office as it were,
you have got your localities, you have got your practice-based
commissioners and you have got your enthusiasm.
Q107 Mr Burstow: Something that puzzles
me about a lot of this is really what the role of PCTs as commissioners
will be, in an NHS where the tariffs are set nationally, the patients
choose the hospitals and you as the GPs hold the indicative budgets.
What do you understand to be the role of a commissioning PCT in
that sort of environment?
Dr Dixon: I think it will chair
the process to some extent, act as local chair for the process
in many ways. I hope that it will be thoroughly connected up to
the localities and the practices, because if it is not in a sense
their enabling voice piece then we have the problem I have just
illustrated. That is practice-based commissioners will go home
because they will say that they are not able to make that difference.
So it will be partly making sure that practice-based commissioning
can work, that local clinicians and people really do see what
they want happening, and it will be partly also making sure that
the thing hangs together and that you do not get things that you
did not predict, like hospitals closing that people did not want
to close, or you are losing out on national objectives which really
are quite important but may not seem so at the frontline.
Q108 Mr Burstow: A chairing or facilitating
role sounds rather different to the sort of role that we were
hearing from the previous set of evidence-givers earlier on, and
indeed from the Department itself where the talk is of powerful
commissioners in the role of PCTs. How do you square that, do
you see an inconsistency between what you have just said and what
appears to be . . .
Dr Dixon: They are holding the
ring and they need to be powerful commissioners because as previous
speakers have said you can only commission powerfully, say with
an acute trust, when you have the primary care clinicians and
the secondary care clinicians talking to each other. So you go
up from the bottom and you make sure that when you are having
these powerful commissioning conversations they reflect what is
happening down at the practice-based commissioning level and at
locality level. If it is disengaged—which unfortunately
sometimes it has been and commissioning has become a managerial
process, not a clinical process—then you do not get any
change, you just get bits of paper going back and forth. You do
not see patients actually being cared for differently. They will
only be powerful, therefore, in as much as they are empowering
the front line that they are meant to be representing.
Ms Sawbridge: I would agree with
that. The role of the PCT as commissioner will be about improving
the health of local residents, which is its job now, and in simple
terms I think it is probably what are the top ten PSA targets
or public health initiatives we have to do in order to improve
health at the centre. We are keeping an eye on what all the major
policy objectives and local objectives are, and then what do the
practices see where they sit that needs to be done, having your
top ten matches and making sure that one does not skew the other.
It is that sort of approach.
Q109 Mr Burstow: How is that sort
of ring holding to be achieved in an environment where there is
a greater emphasis on contestability and arguably competition
and where some of the services that you historically might have
provided might arguably be provided by someone else? How does
that fit into this collaborative environment that you are talking
about?
Ms Sawbridge: I guess there is
something about holding the ring and managing the market too.
You have got your ten things that need to be done and there are
people who either are not doing that well or there is a gap, and
it is a bit like the previous speaker was saying about the Terence
Higgins Trust: that you have got services that you are talking
to that could turn round and develop services differently, but
you need to be talking to practice-based commissioners about that
too. It is challenging, and as I keep saying I hope we will come
back to the provider divestment bit, but I can see that that is
why that sort of discussion started because it does start making
it look like how do you do both because lots of people have lots
of interest. Actually, that is not usually different to what we
have got now, when we have got PECs with GPs talking about enhanced
services and actually that is money into their business, and we
manage that now.
Mr Burstow: Can I fulfil your request
and deal with this divestment issue, which I asked about earlier
on and which we had an interesting set of answers on—sorry,
is that someone else's question? I am going to pause because I
would not wish to steal someone else's question, it was my question
earlier on.
Chairman: Just a couple more supplementaries?
Dr Taylor.
Q110 Dr Taylor: I was really quite
bothered by Dr Reader's assumption that there would be the removal
of PECs with mergers of PCTs. That to me would be an absolute
disaster; surely we have got to keep, as we said in the previous
session, some sort of local professional executive input into
the PCTs, however big they are. What should we recommend as the
form that that should take? How do you see the equivalent of PECs
feeding into the bigger organisations?
Dr Reader: When I said removal
of PECs I am hoping and anticipating that even bigger PCTs will
still retain a PEC.
Q111 Dr Taylor: They would still
have a PEC, but they might only have one PEC.
Dr Reader: My concern is that
they would have difficulty relating to the locality, and you are
absolutely right: what you will need if these big PCTs come into
existence is a number of locality-based, PEC-like structures.
I think you have had a paper that we have written that has suggested
that there should be clinical executive groups of smaller numbers,
with people linking into the PEC and linking down into the practice-based
commissioning.
Q112 Dr Taylor: This has got to be
one of our recommendations then.
Dr Reader: Yes, is is very important,
absolutely.
Dr Dixon: We would hesitate to
call them a PCG. We would say, however, that they need to be quite
lean and fast-moving.
Dr Reader: One of the points about
the tension between the big and powerful commissioner versus the
small localist is that the small localist is not going to be able
to instantly be effectively a good commissioner at any level,
and for some of the higher stuff they will never be in a position
to make that commissioning decision. There is a whole developmental
process that needs to go on and it is going to take two to three
years to get practice-based commissioning and locality up to an
effective level and develop those people with those skills. Again,
it is absolutely vital that the people who have been doing this
and have evolved from PCGs into PCTs have an opportunity to continue
that good work.
Dr Taylor: Thank you.
Q113 Charlotte Atkins: I just wanted
to ask one question about practice-based commissioning before
I move on to another issue. Dr Stanton said that the reason that
practice-based commissioning has to work is to control demand.
Would you accept that there are other ways of controlling demand,
particularly with accident and emergency departments, perhaps
by ensuring you have proactive arrangements locally, for instance
with an ambulance service that achieves a 40% rate of not taking
people to hospital? If you have an emergency service that arrives
at the patient's door or in the street or wherever it is and they
have a paramedic-based community service, they can decide to save
£100 a go by not taking that patient to hospital. That is
another way of doing it.
Dr Stanton: Absolutely.
Q114 Charlotte Atkins: Do you think
that that area of managing demand is sufficiently developed?
Dr Stanton: No.
Q115 Charlotte Atkins: You have been
talking about a trade-off between a large PCT which is not locally
focused and smaller PCTs which are very focused, with clinicians
working very closely on a community basis, using people like community
matrons, but looking very much at the group of people who are
likely to be subject to emergency admissions and working with
them on a proactive basis in the community rather than incurring
large hospital charges for taking them in on unplanned admissions.
Dr Stanton: I think that is absolutely
essential. That would seem to me one of the key areas that any
worthwhile practiced-based commissioning group could do. We are
not talking about this process being undertaken at individual
practice level, we are talking about consortia of practices.
Q116 Charlotte Atkins: Is it possible
to do that in a very large PCT possibly covering one million people?
Dr Stanton: With respect, this
is the misunderstanding. It is not the PCT, as I see it, in this
brave new world—if brave it is—which will be determining
that process, it will be the enthusiasm of the clinicians of all
types engaged in commissioning groups. That is where I would see
the energies and talent.
Q117 Charlotte Atkins: So you see
no conflict between having a very large PCT which is not locally
focused and clinicians talking to other clinicians, it is perfectly
capable of organising that on a very large PCT basis?
Dr Stanton: I think it would be
capable because I think the enthusiasm and initiative of everyone
who works in the NHS is perfectly capable of coping with any system
that comes along.
Dr Dixon: Let me give you a concrete
example. In my own practice, which is a practice-based commission
with a budget of £4 million plus, the first thing we did
was to employ a modern matron. As Tony says, it does not matter
too much what the structure is provided you have got your budget
and you have got your freedom to do that.
Q118 Charlotte Atkins: Can I just
move on to another issue which I think Dr Stanton raised, which
is basically that we were back to square one in terms of the provider
function of PCTs. As I understand it, the Secretary of State has
made clear in Health Questions, when speaking to us and in other
statements that PCTs can now decide themselves whether they want
to employ staff and continue to do so. Do you think that PCTs
would also be able to continue to run community hospitals?
Dr Stanton: I do not think I did
make any observation about the provider functions of PCTs, unless
my memory fails me, not least because many of my best friends
are in the RCN and I do not want to upset them! As far as I can
understand it, whatever the Secretary of State has slightly pulled
back on, there is clearly a direction of travel towards PCTs no
longer being the direct employers of what we might loosely call
community staff. We are not blessed with large numbers of community
hospitals in London, they have been largely closed down over the
years, although with the Better Healthcare Closer to Home
proposals that Mr Burstow will be familiar with we may be.
Q119 Charlotte Atkins: In more rural
areas would you accept that community hospitals are pretty important?
Dr Stanton: Terribly important.
The BMA's General Practitioners Committee has been very closely
involved in the fight to strengthen their position.
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