Examination of Witnesses (Questions 260
- 279)
THURSDAY 10 NOVEMBER 2005
CHANGES TO
PRIMARY CARE
TRUSTS
Q260 Dr Naysmith: So 140 is the lower
end?
Mr O'Higgins: 140,000 I think
is about the lowest of those in the existing health authority
proposals. John?
Mr Bacon: Yes.
Mr O'Higgins: Give or take a few
thousand.
Mr Bacon: We have a small number
of proposals which are less than 150,000, largely based around
small unitary authorities, and we have a handful of very large,
1 million or 1 million-plus.
Q261 Dr Naysmith: The reason for
them is because you have this question of the boundaries with
social services and you will get that with small unitary authorities?
Mr O'Higgins: One criterion which
might justify a particularly small area is the importance of co-terminosity.
Then you have an area like the Isle of Wight which has particular
features which may make that appropriate. So in that sense one
of the reasons I said there are no absolute hurdles is that it
is a combination of factors like that which would need to be reviewed.
Q262 Mr Burstow: Back to the divestment
issue and just to be clear, will staff transferring outside the
NHS, including into private sector organisations, be able to retain
membership of the NHS pension fund?
Lord Warner: Where this has happened
in the past, my recollection is—and I will check when I
get back and correct if what I am saying is misleading—that
staff have a choice. They can actually enter new arrangements
for their future pension on terms which are meant to be equivalent
in kind to the present arrangements and in effect freeze their
current NHS pension where it is. So they have a choice. In some
cases they can transfer pensions, as I understand it.
Mr Bacon: As Lord Warner, I would
need to go back and check this. First of all, of course, under
any circumstance employees are entitled to TUPE transfer. We neither
can nor would want to do anything to disturb that. There are occasions
when pension issues are difficult. It would be wrong for me to
deny that. What we are looking at, and always look at, is how
we can make the best possible arrangement for individual members
of staff in these circumstances, so it will vary, but we are very
focused on it. It is one of the things we know staff have greatest
concerns about and we will do whatever we can possibly do.
Q263 Mr Burstow: You would not see
this being a particular impediment to divestment to non-NHS providers
of services?
Mr Bacon: As I say, we are currently
working through to ensure we give the best possible position to
staff in these processes, as we have done in the past.
Q264 Mr Campbell: Given the timescale
is tight, these organisations are being set up but they clearly
appear as though they do not know what their functions are. I
will give Derbyshire as an example, they do not know what their
functions are. Are we not running ahead of ourselves here?
Lord Warner: Can I make sure I
understand the question. Are we talking about PCTs?
Q265 Mr Campbell: Yes.
Lord Warner: The PCTs' functions
do not change. What we are talking about here is changing the
boundaries not the functions. What we are giving an emphasis to
is that they will strengthen their commissioning functions. They
already have a commissioning function, the point of the change
is about ensuring they actually give more attention to that particular
function against other functions they have.
Q266 Mr Campbell: As these new organisations
develop, they still are not quite aware of all their functions.
Will there be more functions to come?
Lord Warner: What we are trying
to do is get them to focus on particular functions in their present
domain. There are two I would really refer to. One we have talked
a lot about, which is strengthening the commissioning function.
The other area which we need to ensure that the new boards discharge
as well as they can, is this local public accountability for the
expenditure of the budgets that they have been given because the
line of money from the centre, from Parliament and the Department
of Health, is down to the PCT. The PCT is the local accountable
body. In many ways they have not been as centre-stage as they
might be in discharging that public accountability locally and
explaining the pattern of services which are being used and developed
in their particular areas. We would like to come out of these
changes with a strengthening, it is not changing the function
but it is strengthening the way they have discharged that function.
Q267 Chairman: Do you think if this
divestment had not been in the 28 July letter, that PCTs were
potentially going to divest their roles as providers in a few
years' time, then actually they would have looked at this whole
situation of PCT reconfiguration differently? Some of them may
have looked at these changes on the basis they were going to potentially
lose the provider status which they currently have. Would that
not have moulded their thinking in terms of what they should be
doing because they are going to be divesting themselves of this
particular function, which is a major part in terms of talking
to them from our perspective?
Lord Warner: It would be foolish
for me to deny, given the letters I have had from you and many
colleagues about some of these issues, that 28 July has not shaped
some people's approach to this particular set of issues. So I
totally acknowledge that. What I would also say though is that
I think there would have been some concerns expressed at some
point in some form of consultation about some of the other changes
as well—the changes of boundaries for example. I agree entirely
that probably this issue has taken a lot of the attention away
from some of the other issues which were in the 28 July document.
Q268 Chairman: When you look at the
criteria which Mr O'Higgins is looking at, his particular role
in this, has that changed anything because of the decisions later
by the Secretary of State that they may not lose their provider
status, that they would be effectively a party to them losing
their provider status in these areas? Has it changed anything
in terms of what they are looking at?
Mr O'Higgins: I do not think so
in that the criteria were not specifically about providing per
se but were about issues such as public health, co-terminosity,
business continuity and so on. It is something I guess, when we
get the substantive proposals at the end of the consultation period,
we would need to examine, but as of our review of yesterday, no.
Q269 Mr Amess: Can I ask about the
size of PCTs and local engagement. Lord Warner, I know you obviously
were not a minister at the time, perhaps you were not even a peer,
but I served on the Committee Stage of the Bill which brought
into being primary care trusts and John Denham was the minister
at the time. Looking back on it all it is certainly reading I
would recommend to the Committee because, whilst they got rather
fed up with me, many of the things which the Department of Health
now is considering introducing were all raised at the time when
we tried to scrutinise the Bill; as ever not one amendment was
accepted. I think you were listening in the room next door to
our proceedings before you came in and one of your employees told
us in 30 years this was the eighth time there had been changes.
I think you get the drift that people are not terribly keen on
these changes. The other thing, before I get to the question,
is that I am very amused by this business of consultation because
it is marvellous all this consultation you will be conducting
but my gut feeling is you will not take a blind bit of notice
of it because you have already made up your mind on all these
issues. However, I am very relaxed about it because, in view of
the votes last night, I think you will have a bit of trouble getting
your original intentions through Parliament. But, as you know,
clinicians are not terribly keen on these proposals. I think the
Committee is quite keen to know what is your rationale for returning
to more remote management structures when clinical engagement,
so we are told, is more important than ever to deliver practice-based
commissioning?
Lord Warner: I would have thought
that practice-based commissioning is getting decision-making much
closer to patients than almost anything else. Many GPs have at
the moment indicative budgets and what we are trying to do is
give them better information about their referral patterns, the
cost of those referral patterns, a wider range of services accessible
to them, we would hope, and they would help develop them in the
community. That would enable people like Dr Howard Stoate to get
closer to meeting the needs of his patients faster than what we
have at the moment. That is what practice-based commissioning
is all about. One of the big messages coming out of the public
consultation at the Birmingham event ten days ago was that people
do not see—and in some areas of your constituency travel
is quite difficult—the point of going great long distances
unnecessarily to get access to specialist care and other services.
At the heart of this is bringing both practice-based commissioning
and strengthening the commissioning function closer and getting
services more accessible and closer to the patients. This is what
this is all about.
Q270 Mr Amess: You may win the argument
but I still think you have got a bit of a way to go to convince
the clinicians. Going back to the Committee Stage of the primary
care trust legislation, I remember the then minister, John Denham,
saying how terribly important these non-executive directors were
in the organisations, how this was absolutely fundamental to democracy,
because we still just about have a democracy in this country.
How will you address the democratic deficit which will arise from
the loss of significant numbers of non-executive directors?
Lord Warner: Non-executive directors
in the new PCTs will be in exactly the same position in discharging
their non-executive functions as the non-executive directors in
the current PCTs. They will be in the majority, they will discharge
the same functions, they will hold the chief executive and other
members of the executive board to account. I thought this was
rather elegantly explained by Mr McIvor to you last week.
Q271 Charlotte Atkins: The only difference
will be that they may be serving a population of nearly 1 million.
How does a non-executive director engage with a community which
is so large? It does not make any sense.
Lord Warner: I would fully agree,
if we went down that path, the non-executive directors in particular
areas would be more distant from their localities, but I think
the question I was asked was about their functionality and their
functions do not change. They need to hold people to account and
I answered I think Mr Campbell a little while ago on this. What
we are wanting to see is these non-executives and their chairs
actually carrying out strong public accountability for the spending
of taxpayers' money that is allocated to that particular PCT for
the design and shaping of the services in their area.
Q272 Charlotte Atkins: But surely
the role of a non-executive director is not just about accountability
in terms of the management of the PCT, it is also engaging the
community, ensuring the community is actually getting the services
for the first time ever that they need, rather than having remote
health authorities which service, say, a conurbation and forget
about the needs of the rural population on the edges of that conurbation?
Lord Warner: What I would say
is that the evidence from one or two areas where there have been
very small PCTs, where they have come together, they have not
been as effective as you might suppose in being able to deliver
to their communities the range of services they need. The commissioning
function is an important element in this. There are many and varied
ways of actually understanding the needs of particular communities.
I come back to my earlier statement about health inequalities.
There are some serious problems around health inequalities, as
you will know, in some of our cities, our urban areas, but also
in some of our rural areas. What we need is a stronger commissioning
function based on evidence and information of what is going on
in there. It simply is not true that just having small PCTs close
to those communities have, if I may put it this way, delivered
the bacon in terms of services for many of those areas.
Q273 Dr Taylor: Minister, I completely
fail to see how practice-based commissioning is bringing things
closer to patients when you are reducing the numbers of non-executive
directors and the plan I believe is to reduce the number of patient
forums to just one per PCT. How the dickens are you bringing it
closer to patients when you are removing the number of patient
representatives so drastically? Or do I just not understand the
difference between PBC and the old PCT commissioning?
Lord Warner: As I recall, there
are something like 300 million patient contacts each year with
GPs, or getting on for that.
Q274 Dr Taylor: Excuse me for interrupting
but the patient does not go to the GP to say, "I want NHS
reorganised in this way", he goes to say, "I have got
a sore big toe". That is not the sort of contact we need
in a patient-led NHS; patients leading the way the NHS is going.
Lord Warner: Am I allowed to answer
the first question before going on to your second set of observations?
Q275 Dr Taylor: Of course you are.
Go on.
Lord Warner: I will get back into
my flow again. The 300 million contacts which there are between
patients and GPs are indicative, if you try to sum those and work
out what they mean, of what the patients' needs in any locality
are. What we have at the moment is a varied pattern of behaviour
by GPs up and down the country. Some have easier access to a wider
range of services than others, but the evidence we would suggest
is that if you give those GPs the budgets, the information, about
referral patterns, access to services which might not necessarily
be provided directly in a hospital, the GP can, using that budget,
using his contact with patients in a collective GP effort, bring
a different pattern of services to meet the clinical needs of
patients and provide swifter service access than at the moment.
That is not just me saying that, that is what the GPs who are
working on practice-based commissioning are saying at the moment.
You have to bear in mind, and some of this will come out in the
White Paper, for a country of our kind we have an unusually high
rate of referrals for out-patient consultations to specialists
in something called a hospital compared to many other countries.
That is not to say you do not need specialist referrals, but many
of those specialist referrals take place outside in something
called a hospital in greater numbers. What we want to do, through
practice-based commissioning, is put GPs, the primary care teams,
much more in the driving seat, armed with the budget, armed with
the data, to get a better range of services with faster access
for their patients. That we think is bringing the NHS closer to
patients.
Q276 Dr Taylor: In the King's Fund
response to our request for information, they talk about improving
commissioner skills to manage patient demand effectively. Effective
demand management—what do you understand by that?
Lord Warner: The King's Fund will
have to answer for themselves but what I would say is even with
this Government and the extra money we have put into the NHS,
you are still at a point where there is a cash limit, it is a
much higher cash limit but there is a cash limit in any country
on the amount of money you are prepared to spend on health care.
What we are saying is ensuring there is good value for money,
ensuring there is the most cost effective clinical response to
patients' needs, is likely to make the best value use of the money
that is available and get the most appropriate treatment. Sometimes
referring people to hospital for specialist services, where you
do not always hit the right spot for the right specialist so there
are further referrals, sometimes not dealing with long-term conditions
early enough and then having emergency admissions—and I
think somebody gave you evidence that it cost in his territory
£2,000 for an emergency admission—all those things
mean, I would not say wasting money, you are certainly not producing
the most clinically cost effective response to a health care demand.
What we are trying to do, working with all the professionals,
is create a model where you get a more cost effective meeting
of demand. If you can do that, you are able to provide a wider
range of services for people.
Q277 Dr Taylor: I think we would
all agree that anything you can provide out of hospital is far
better than providing it in hospital. I do not think there is
any argument there. I am still bothered though. Okay, the patient
goes to the GP with an illness, that creates a demand, but how
do they get across, without all the patients' forums, without
all the non-executive directors, major decisions about reconfigurations,
about the way the Health Service is going?
Lord Warner: How do who?
Q278 Dr Taylor: The patients, the
people for whom the NHS exists.
Lord Warner: One of the interesting
things coming out of the consultation and certainly talking to
patients on some of my own visits, is that they are themselves
often bewildered by the range of services they have to engage
with to get a response, whether it is primary, secondary, social
care, whatever. So we are not starting from a position where the
patients are absolutely clear in their minds about how to get
the best service response for themselves. They rely very heavily,
I would suggest, on the GP and the primary care team for a lot
of the navigation of that system and they rely on family and friends.
What we need to try and do is ensure we get better configuration
of local services which people can access faster and remove some
of the confusion. That is a big message coming out of the public
consultation.
Q279 Dr Stoate: Philosophically you
will be pleased to know I entirely agree with you but I do have
a problem with some of the detail and that is what I want to pick
you up on. What we set out when we came in in 1997 was to generate
a primary care-led NHS which was much more responsive to patients'
needs and there would be far more care in the community and community-based
services and that is philosophically entirely right. What I have
concerns about is the differential power structure which we have
created in the NHS. We have already let hospitals get on with
foundation status, we have already given hospitals payment by
results, but that has put a huge amount of power and control of
budgets and services into the hospital centre. What we now seem
to be doing is playing catch-up and saying that the hospitals
have run away with all sorts of new powers and new things they
can do, the PCTs cannot keep up with anything like that so we
have to reconfigure the PCTs behind that to get the commissioning
power back again. At the moment, every time a hospital admits
a patient it is £2,000, if it is the wrong thing for that
patient it is nevertheless the PCT which has to pay for it, so
PCT budgets are being severely strained by hospital activity which
they have no control over whatsoever. So we now see, belatedly,
a restructuring of PCTs to give them that control back but that
is going to take a considerable length of time when payment by
results is already up and running and will be virtually complete
by April next year.
Lord Warner: I understand the
point you are making but what I was trying to say earlier about
payment by results is it is not being introduced over night and
it is not being introduced in a totally uncapped and unmanaged
way. The rules around payment by results, and John can talk in
more detail about them, do actually limit the amount of loss of
income for any hospital or specialty in any particular year to
a certain amount, so it is not a dramatic change. However you
are right, and I do not think we should apologise for this, as
a Government we have tried to respond to what the public's concerns
were which were expressed before the 2000 NHS Plan, and what was
on their minds very seriously, which we have had to respond to,
is their concerns about A&E departments, the long wait, the
unsatisfactory features of those which we inherited, the very
long waits for out-patient referrals to be taken up, the shortage
of diagnostic equipment, the long waits for in-patient treatment
particularly for elective surgery, those were the things which
were very much on the public's mind in the consultation which
led up to the 2000 NHS Plan. We had to address those concerns
because they were very serious concerns. So it is true that we
have done a lot to strengthen and improve those hospital services.
What we are trying to do, and I do not think it is fair to call
it catch-up, is make sure the balance is better fitted in a period
of still considerable investment in the NHS, so we can rebalance
that system within what the public are asking us to do in terms
of the balance between access to a hospital and access to services
outside a hospital.
| 
