Examination of Witnesses (Questions 240
- 259)
THURSDAY 10 NOVEMBER 2005
CHANGES TO
PRIMARY CARE
TRUSTS
Q240 Mr Burstow: It is either yes
or no.
Lord Warner: I am not going to
put in that yes or no. I am making it clear.
Q241 Mr Burstow: John Hutton did
and he was very happy to give the answer yes.
Lord Warner: He is a Cabinet Minister,
I am rather slower of thought and movement. What I would say is
that the direction of travel is in the direction that John is
saying. We are saying it is down to people at the local level
to get the timing of that right. It follows arithmetically that
if you want to strengthen commissioning and you have got expanding
community services, you are not going to go on enlarging the direct
provider side of PCTs. The pace at which that is done is down
for local decision.
Q242 Dr Naysmith: I would like to
be clear as well because this, as you know, has caused lots of
problems in lots of places. Are you saying it is the Government's
policy not just to facilitate divestment but to encourage it?
Lord Warner: If we expand services
we must allow new providers to come in, and some of the worst
parts of this country with the greatest health inequalities are
some of the poorest areas in this country in terms of primary
and community services. In some of those places we have to ask
why the traditional methods have not given those people a fair
level of services, and we must enable new providers to come in
to provide those services, and we must enable new configurations
of services to be provided in many of those hard-to-reach communities
in terms of health and social care.
Q243 Mr Burstow: That is not the
same as PCTs giving up their existing services and divesting themselves.
Lord Warner: It could mean the
inadequacies of the present pattern of service provision have
to be changed. That is why I cannot give you a straight yes or
no because it turns on the needs of particular areas. I would
say as a general statement it is some of the worst-served areas
with the greatest health inequalities which most need new entrants
to provide new services in their particular communities.
Q244 Chairman: I think we accept
that but is not the real question here, if it is about PCTs not
being providers any more, and that is the general direction of
travel—and at least you and John Hutton agree on that—could
we foresee a situation where because a PCT would not be encouraged
to keep providing services, that those services provided by another
organisation may not be as good? I do take the point about what
you believe to be the poorer services out there in primary care
should be improved, and maybe this is a method of doing it, but
could you envisage a situation where a PCT could be effectively
stopped from providing the service and that could go to somebody
else but it could be a lesser service that they provide?
Lord Warner: That is certainly
not our intention and it would be a contradiction of what I have
been saying about strengthening the commissioning function. The
purpose of strengthening the PCT commissioning function is to
improve the quality of services. If they were substituting an
inferior service for a current directly-provided service by the
PCT, they would actually be failing in their commissioning duties.
Q245 Chairman: It is an extreme example
I give but I think it is important for people outside who work
in and people who receive services from the primary care sector.
You could have suggested on 28 July that this was going to happen
within a very tight timetable, it was going to be removed from
them as providers, and that is what has caused quite a lot of
concern within the primary care sector, but we are not saying
that has been withdrawn altogether, are we?
Lord Warner: What I am saying
is the direction of travel with PCTs providing fewer direct services
is in our view an inevitable consequence of strengthening the
commissioning function. What I am also saying is that both Patricia
and I regard the wording which was used in the 28 July document
on this territory as far too prescriptive and that is unfortunate.
I am acknowledging it is unfortunate that the confusion and concern
that has been caused has actually happened. I cannot be plainer
about what I am saying about that.
Q246 Charlotte Atkins: Can I ask
you to be plain about the future running of community hospitals?
Will it be the case that if PCTs continue to want to run community
hospitals they will be allowed to do so?
Lord Warner: In the future what
we are trying to do is ensure you have strong commissioners. That
is the starting point for PCTs, that they actually look at what
the needs of their community are, and that could include a community
hospital with a certain range of services. The thing about community
hospitals is that they are not uniform, they have a variety of
services in them and they are likely, if I may speculate a little,
to have an even wider variety of services in the future and I
will come back to that remark in a moment. What it is down to
the PCTs to do is look at what is the best way of providing those
services.
Q247 Charlotte Atkins: But it will
be a decision of the PCT? Yes?
Lord Warner: Can I put this in
context. If the community hospitals expand following the public
consultation we are going through and the White Paper which comes
out, it is not really consistent with strengthening the commissioning
function of PCTs that they should take on a bigger role in managing
an expanded version of community hospitals. That is not consistent
with policy direction or our wish to get commissioning at the
centre of their functionality. What I am saying is, it seems to
me the logic of what is coming out of the current public consultation
is to try to get more services closer to patients and more accessible
than in a big acute hospital. The logic of that is, and we have
committed ourselves to providing more community hospitals in our
manifesto, that we will be making some policy statements about
the future direction of community hospitals in the White Paper,
that is an area in all likelihood of expansion rather than contraction,
but there needs to be a local dialogue about precisely what services
you put into those community hospitals, which are likely to be
different in a suburban area from a very rural area, and there
is going to be a mix of arrangements so they will be very varied
I would suggest in their future pattern.
Q248 Charlotte Atkins: You rightly
say, and I accept this, in certain circumstances PCTs have to
merge to strengthen commissioning, but you do not seem to have
any problem with strengthening GP commissioning while they are
still providers of services.
Lord Warner: We are not going
to stop GPs being providers of services, they are at the centre
stage. 90% of people's contacts with the NHS are through primary
care and community services, that is where we are at. So the GPs
are clearly providers but they are already, if I may say so, providers
and commissioners. The group of people who come in on the average
morning surgery, some of them they will provide the service for,
others they will refer to somebody else, so they are commissioning
and providing at the moment. What we are saying is that the evidence
suggests to us that actually giving GPs a stronger role in that
commissioning, what they can commission, what they can access
more directly for their patients instead of sending them off to
an acute hospital in a more traditional way, both takes advantage
of the skills of GPs and actually is more beneficial for many
of their patients. We do not want to artificially disrupt the
relationship between GPs and their patients.
Q249 Charlotte Atkins: But what you
are saying is that GPs are able to ride both horses in terms of
providing and commissioning, but PCTs somehow find the two tasks
impossible to parallel.
Lord Warner: I am not saying it
is impossible, what we are saying is we think the evidence so
far is that many of them have struggled, and some of the evidence
which was given to you suggests they have struggled. What we are
saying is what is critical for the future of the NHS is very strong
commissioning, if you want to get the right balance between services
which are provided in an acute and general hospital and the services
which are provided in primary and community care services.
Q250 Charlotte Atkins: We certainly
found that some PCTs have struggled but from the evidence we have
had, and I am glad you have read it very carefully, we also heard
that joint arrangements were being developed by PCTs and those
arrangements were beginning, given that PCTs have only been around
for three years, to work effectively.
Lord Warner: I think the answer,
as Lord Morris said, is that is variable, but there are certainly
cases where the act of trying to do this jointly is of itself
consuming management effort to the distraction of the actual process
of commissioning. We have heard from a number of PCTs that they
would prefer to be in a single statutory organisation so they
do not have the issues of having to negotiate between themselves
before they can negotiate with their providers. So I think there
is quite a strong driver to get the best fit we can for the act
of commissioning, but you cannot impose a single solution to that
because it is very dependent on geography and population density,
so what you would find in London I am sure would be very different
from what you would find in some of the shire counties. We want
to ensure that the management effort goes into commissioning and
not trying to make an imperfect set of statutory bodies work better
together.
Q251 Charlotte Atkins: So it is okay
for shire counties to come up with a PCT which is even larger
than the old health authority we got rid of some years ago?
Lord Warner: If they are able
to demonstrate against the criteria we have set that they will
come out with a good commissioning model, and if the external
panel believe those criteria have been properly addressed and
then if the public consultation process is considered to be supportive,
then there is no reason why they should not. But the acid test
is whether it will be fit for the purpose we want in commissioning.
Q252 Charlotte Atkins: Presumably
local opinion will be taken on board even though it has not been
in the pre-consultation period?
Lord Warner: I have said that
before any decisions are taken, round about early December, I
would expect us to put in the public arena a set of proposals
which take account of the views expressed by the external panel
for public consultation where there is a change of configuration
across England for a three month period. Some of those proposals
will be more than one option because that is what has come up
from the different areas. There is not a single option, they have
actually proposed several options with pros and cons, we are not
going to distort that and we are not going to arbitrarily remove
those options, they will go forward for public consultation on
a three month period and those views will come in before ministers
take any decisions.
Q253 Charlotte Atkins: Mr O'Higgins
was nodding his head at that point and, as he is sitting there
for a reason, perhaps I could bring him in. How many times has
the external panel met? I know you met on Tuesday but will you
be meeting again? When is the external panel likely to come up
with its recommendations as to the consultation period?
Mr O'Higgins: The external panel
met yesterday for the first time, an all-day meeting, and we are
quite clear our brief at this stage is to determine whether the
proposals which have come from authorities meet the criteria sufficiently
to go for public consultation. It was not our goal yesterday to
make substantive comments on proposals in one direction or another,
because that would pre-empt the consultation period. What we did
yesterday was to go through each of the submissions, examining
the extent to which we believed they met the criteria. We have
not yet had the chance to report to the Minister on those deliberations.
However we will be setting out some general observations including,
if I may, the fact that in certain areas the pre-consultation
process was not fully adequate, because we have had representations
which make that clear, but we will be setting out area by area
our view on whether the proposals as they stand at present are
appropriate to go for public consultation, and in some instances
recommending modifications or raising questions about the extent
to which perhaps other options should also go for public consultation.
Q254 Charlotte Atkins: So you consider
submissions not only from the SHA but also from other organisations
within the process?
Mr O'Higgins: We did not do a
comprehensive consideration of everything anybody submitted in
the timescale possible, what we did have was a sense from other
intelligence that the Department provided us with, and which individual
members of the panel had, of where there was satisfaction or less
satisfaction about particular proposals and about the extent of
consultation on those proposals.
Lord Warner: We did actually make
sure all the comments from MPs and other local authorities, et
cetera, which have been made to us and that we were aware of were
fed into the panel. So they had them alongside the SHA proposals.
Mr O'Higgins: As you can imagine,
panel members have been receiving individual comments from different
authorities as well.
Q255 Chairman: Can you tell us when
we are going to see signs of that, not just as a Committee but
people who have written in as well? Is there likely to be some
publication?
Lord Warner: We will do our best
to put this in the public arena. Some of these are phone calls
so there is a slight problem; they are not all quite as formal
and well-documented as the SHA proposals. We will try to put in
the public arena, providing they are not actionable, the comments
which have come in on this, so that MPs and the public can see
what has gone to the panel.
Q256 Chairman: That would become
part of the consultation process?
Lord Warner: That would be available
for people to access as we move into the three month consultation
period. We have no interest in not being as transparent as possible
about this and we want to be as transparent as possible. The next
step is for ministers to receive and consider these proposals
and we will then have to take a decision whether they are in a
fit state to go out for the three month formal consultation or
whether the remarks and observations by the panel suggest we should
not start that process, we should refer matters back to the SHA
for some further discussions locally with people including with
MPs.
Q257 Mr Burstow: Can I ask Mr O'Higgins
a question about the criteria, whether or not any of the criteria
you are evaluating, and which have been set out in Nigel Crisp's
letter, are considered to be hurdle-criteria which have to be
got over before any of the other criteria are taken into account?
Mr O'Higgins: In the way we conducted
our deliberations yesterday, no, but I emphasise the deliberations
yesterday were about the extent to which the proposals were adequate
to go out to public consultation. At the end of the public consultation
process when we are considering what has emerged from that, we
may then examine certain issues more substantively.
Q258 Mr Burstow: So, for example,
finance would not be an overriding criterion, the 15% savings?
Mr O'Higgins: No, finance is not
an overriding criterion. Public health is an issue which is quite
important and we need to be examining substantive documents. Nor
indeed is size an overriding criterion. The proposals we have
reviewed reflect quite a wide range of sizes of proposed PCTs
in the new structures and the panel has not assumed there should
be specific limits, upper or lower, for the population size of
new PCTs and in many cases of existing PCTs which will not change.
However, what we do assume is that particularly small PCTs can
expect to be challenged on the extent to which they can achieve
economy of scale savings and about their ability to ensure contestability.
Rather large PCTs will be challenged and be expected to have quite
clear proposals to ensure local patient and stakeholder needs
are met.
Q259 Dr Naysmith: What is a rather
small PCT? I know you are not setting limits but what are we talking
about when you say a rather small PCT?
Mr O'Higgins: The proposals as
they have come in at present have PCTs varying from 140,000 in
size through to an upper limit of 1.2 million.
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