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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 646-i House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE HEALTH SELECT COMMITTEE
CHANGES TO PRIMARY CARE TRUSTS
Thursday 3 November 2005 DAME GILL MORGAN, MR JOHN McIVOR, MS DIANE JEFFREY, MS CARO MILLINGTON and MR JOHN DE BRAUX Evidence heard in Public Questions 1 - 137
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Health Committee on Thursday 3 November 2005 Members present Mr Kevin Barron, in the Chair Mr David Amess Charlotte Atkins Mr Paul Burstow Mr Ronnie Campbell Anne Milton Dr Doug Naysmith Mike Penning Dr Howard Stoate Dr Richard Taylor ________________ Memorandum submitted by NHS Alliance
Examination of Witnesses
Witnesses: Dame Gill Morgan, Chief Executive, NHS Confederation, Mr John McIvor, Chief Executive, Rotherham PCT, Ms Diane Jeffrey, Chair, High Peak & Dales PCT, Ms Caro Millington, Chair, North West London SHA, Mr John de Braux, Chief Executive, Beds & Herts SHA, examined.
Q1 Chairman: Good morning. May welcome you to this first session on our inquiry into the changes to primary care trusts and SHAs. I realise you do not all represent one organisation. After an answer you may offer your view, if it is different, to the committee. We start by looking at organisational change. Everybody who works in the NHS falls back two or three paces when that is mentioned. PCTs and strategic health authorities were introduced in 2002 when health authorities and regional offices were disbanded. Do you think under the current proposals we are now moving back essentially to similar structures to the ones that were abolished just three years ago? Dame Gill Morgan: I think superficially you could say that we are but there are some fundamental differences. The nature of practice-based commissioning is quite different from the nature of fundholding; it much more akin to what we used to call locality commissioning where you get groups of practices, not just GPs because you have to have a broader clinical engagement, coming together really to influence what is best for their patients. Because of the nature of how that is set up, that is quite different from fundholding. The other thing that is very important about this is that some of the changes are built on things that the service itself wanted. If you look today, there are 43 PCTs that felt for some reason they were too small and already had shared management arrangements. Some of this is about implementing the learning that has come from PCTs. There were a number of PCT which had already begun to develop shared ways of doing things - for example, the Manchester commissioning group of GPs - because they felt that if you were very small as a PCT, you could not get the leverage with the acute sector. They have tried to put together the learning of the last three years. In many cases, this is about implementing that learning at a local level. Q2 Chairman: Does anyone have another view or an alternative to that? Mr de Braux: With some of the other changes that are likely to happen to providers, particularly the introduction of organisations like foundation trusts and other alternative providers, and with the responsibility for the performance managers when they are moving to monitoring rather than strategic health authorities, there is a very good argument for the future that strategic health authorities perhaps need to get bigger and have a bigger span of control. I think we are also seeing, in terms of developing services, the need to look over a much wider area than just the areas that some of the strategic health authorities cover. The need to have a strategic view about what health services should look like so that the local commissioning can work within that is another reason why strategic health authorities probably need to be larger and fewer. Q3 Dr Taylor: If PCTs are already doing this and coming together in larger groups, why ever do we need this huge big bang approach to make this tremendous change? Dame Gill Morgan: Where the 43 organisations have shared arrangements, they need to be allowed formally to merge to produce the changes and the benefits. What you have at the moment are organisations maintaining two boards but one set of management teams. There is the necessity for some structural change where we are at the moment. For the others, where they are developing shared commissioning arrangements, they tend to be small unitary authorities which are co-terminus with metropolitan boroughs and therefore have some very good reasons for staying small because of that co-terminosity. They are trying to develop models that allow them to have more leverage when they talk to the bigger trust. Without doubt, when you are very small and you are one of very many PCTs buying services from an acute trust, you could be at a disadvantage. PCTs have been trying to get those shared commissioning arrangements. Many of those will persist after the current changes. Q4 Charlotte Atkins: Could we have that list, please, of the 43 and of the shared arrangements? In your experience, if you take the 43 and those that have already the shared experience, what numbers does that come to out of the 300? Dame Gill Morgan: I could not give you a number now but we could find that out. Q5 Charlotte Atkins: Is it your impression that it is half or what is the number? Dame Gill Morgan: We think it is 43, plus 40, plus 8; that makes 91. Q6 Charlotte Atkins: That is less than one-third that you are talking about. If we are led to believe that it may come down to about 100, we are still talking about very significant change, as Dr Taylor mentioned, in those areas not covered by the shared arrangements and the other arrangements you spoke about? Dame Gill Morgan: But some of that is about the learning from the areas where they have put in shared arrangements and some of that is about this issue of scale and size to work with acute trusts. One of the difficulties with this is that there is not a single right answer. We are very supportive of the direction of travel which takes primary care trusts and makes them co‑terminus as far as possible with local government. We think that is a really important opportunity. When you go back four years, many of the primary care trusts that were set up were not co-terminus with social services; they crossed boundaries. We believe that one of the great strengths and successes of PCTs over the last few years has been the development of a whole set of new community services, intermediate care services, with social services. We think the opportunity to get the boundaries more closely aligned is an important opportunity we should be taking. Mr McIvor: I do not think there would be any PCT in the country that is not part of some shared arrangements. Often those shared arrangements are around the health improvement agenda because of a need for a greater co-terminosity with the local authority; to take the example of Sheffield, next door to me with four PCTs, it is very much working very closely together with that one local strategic partnership on the whole of the health improvement agenda but equally on the commissioning agenda. Q7 Charlotte Atkins: When you are talking about co-terminosity there, are you talking about co-terminosity with the authority that provides social services or are you talking about co-terminosity with an equally important local authority, maybe in the district or the LSP boundaries? Mr McIvor: I am talking in that case about a co-terminosity with the local authority that provides social services, but equally importantly provides for education and leisure and those other services, housing and so on, which are very important determinants of health. Therefore it is important that those boundaries are, wherever possible, and obviously this is a holy grail you would never get, co-terminus as well. Q8 Anne Milton: You are going to miss some of them and gain others. Where there are not unitary authorities, you are going to lose some co-terminosity and you are going to have a problem with size. Are we not going to see huge problems with size? Dame Gill Morgan: I think the conundrum that faces this is that you have two scenarios happening in parallel. If you believe that the holy grail that you really need to get is social services co-terminosity and that is the number one priority, that could leave you with some very small metropolitan unitaries. Simultaneously, it could leave you with some very large shire counties. One of the things we believe in trying to assess this is that you cannot set a national template; you have to make an assessment at local level. Where people are going for small unitaries, the question we have to ask is: how do you share services to get the best, to get the leverage? If it is a very big shire county, the question has to be exactly what was asked, which is: how do you then get the leverage you need with local government at the second tier level? It is that level that a lot of the health promotion activity and health improvement agenda, particularly with housing and things like that, is focused. If it is big, we are going to have to think local. If it is small, we are going to have to think shared. That is the sort of conundrum that is facing people at the moment. Q9 Chairman: Moving on further, we have received evidence from one PCT official that, following PCT reorganisation, it will take as long as 18 months to restore systems to their current levels of effectiveness. Given that the NHS is at a crucial stage in implementing payment by results and developing practice-based commissioning, are you concerned that these reorganisations will impact on your ability to develop commissioning skills and fulfil your current statutory functions as well? Mr McIvor: I think we need to be concerned and take on the fact that reorganisation always takes time. However, I think we are building on a lot of good practice and experience to date. I would be very concerned if it did take 18 months. That is just far too long. This reorganisation has to happen when it happens. It is not a question of when it happens; it has to happen quickly. We need to put in place the right people to continue to ensure that we continue to deliver. I do not think that should be a problem. There are some very good and experienced people out there who can continue to do that. We are, after all, going down from a large number of organisations to a smaller number, whatever that may be. Ms Jeffrey: It is interesting that you mention payment by results because small PCTs that are operating in a full payment by results economy, which some of them are, do not really have enough bargaining power and muscle to cope with that. It is a completely new regime. We are all learning. Inasmuch as we think that perhaps 303 PCTs were not really affordable in the first place with all the management on-costs and board costs that those entail, in the same way 303 PCTs probably did not have enough bargaining muscle, commissioning power, strength of commissioning tools and equipment to cope with the new payment by results regime. I think there will be a great deal of attention paid to keeping the show on the road. Obviously business continuity plans are very important, but a smaller number of PCT will, I think, be in better shape to do that. Q10 Chairman: Quite clearly, there is some support for this. I suppose the obvious question is: would you have initiated this yourselves if it were not for Sir Nigel Crisp's letter of 28 July? Mr de Braux: Within the strategic health authority that I manage, we had already moved towards that model because of the difficulty PCTs were finding. If you take Hertfordshire, for instance, there are eight PCTs in Hertfordshire averaging about 100,000/120,000 people each that they cover, which are trying to commission from two very powerful providers. They spent most of their time, in terms of commissioning, bargaining with each other rather than with the two providers that did rather well out of their inability to get their act together quickly. We had already started to move to a model where we were already at four teams instead of eight; I think we had recognised that we had to take that even further than we were taking it. We were doing it on a step-by-step basis rather than in one large attempt. My own view of that is that it was better than staying at eight, but in fact the time taken on each step was not terribly valuable time when you could have done it all in one go. Whilst it does lead to some disruption - all reorganisation is disruptive - I think, as we have already said, if we make the decision to do it, we need to get on with it and do it quickly and make sure we retain the good skills we have in the many organisations in the fewer organisations in the future. Ms Millington: It is patchy in the health economies around the country. As to direction of travel, I have not met anybody who is against it, but I think it has been a flawed process. The pace, for some of us certainly, has been very challenging indeed. I do not think there has been a proper communication plan, either within the NHS or between the NHS and everybody else involved. I think there has been a danger, as always in any restructure, that form has come before function. You are trying to design organisations before you have fully worked out what their new function is going to be. There is a huge passion and commitment to making it work, as you would expect, and to making sure that improved patient services come out of this. That is what it is about, but it has been a flawed process. I think there would be very few people who would not acknowledge that. It is easy for a non-executive to say, however. Q11 Mr Burstow: That is a useful insight perhaps into evidence sessions like this. On this 18‑month period of disruption which we have had put to us in some of the evidence, and I hear what Mr McIvor has said to us, I wonder if you could give us some sense of what you think the best case will be in terms of loss of focus on day-to-day running of organisations and what you think the worst case could be? What are the parameters in terms of how long there will be a disruption to normal service and in terms of trying to make sure the commissioning now is being done well? Mr de Braux: May I say what we are doing in my strategic health authority? Recognising that business continuing is very important during this process, in working with our primary care trust, we have agreed with them that the strategic health authority will be the level at which we manage commissioning for the next year. We are bringing people from the PCTs together in a commissioning team to work on the commissioning for our four main providers. Whilst the PCTs will retain responsibility for that commissioning, the actual management of it will be done by a larger team working out of the strategic health authority. The role of the strategic health authority is to make sure during this process of change that business continuity is maintained.
Q12 Mr Burstow: That is helpful. It gives us an insight into process. It does not answer the question which is about the worst case and the best case. It would be very helpful to gain some sense of what those might be? Dame Gill Morgan: You have to remember that many PCTs will not change at all. The best case is that there will be no disruption because people will continue to work in their own patch. There are significant numbers of PCTs in that category. Q13 Mike Penning: How many are there? Dame Gill Morgan: I cannot answer that because the things are being looked at. For example, if you take London where there are currently 32 PCTs, the current proposals are that that will continue. There will be large areas. If you take Manchetester, the scale of the change is probably from 14 down to 10. Q14 Mike Penning: Both of those PCTs are metropolitan. Lots of the small PCTs are not metropolitan. Dame Gill Morgan: Absolutely. The places that are going to have the most difficulty will be the big shire counties, which is where the sort of solution that John is talking about, which is trying not to have any delay in terms of commissioning by having the strategic health authority take a key lead, should reduce. It may take 18 months for the PCT to be up and fully running, but that does not mean we drop the ball in the meantime. Q15 Mike Penning: That is the risk. Dame Gill Morgan: Of course that is the risk and that is why each submission is being assessed for its business continuity and how it will deliver the current agenda, as well as what the organisation boundaries are. Q16 Dr Stoate: When this Government came to office in 1997, the plan was for a primary care led NHS. Is it primary care led? I should ask the PCT to start with. Mr McIvor: In the majority of cases there is a huge amount of primary care involvement in leading and setting the direction for the NHS. The challenge of this change, it seems to me at the moment, is to balance this desire for co-terminosity while keeping that clinical engagement and ownership of what happens in the NHS. Q17 Dr Stoate: What about the power structure between the primary care and secondary care sectors? How do you think that currently pans out? Mr McIvor: I think a lot of the context in the NHS has changed over the last year or so, particularly this thing called payment by results, which has meant that, from my PCT's point of view, we feel we have a much greater ability to commission services in the right place and see the money move, if that is appropriate, from the acute sector into the primary care sector. I know the GPs, nurses and allied health professionals who are part of my PCT have seen real investment in out-of-hospital services. Q18 Dr Stoate: But the Government does not see it that way because the Department of Health's view is that there is currently an unequal power structure between primary care and secondary care, which is one of the reasons for your reorganisation. I am slightly concerned that you think things are going pretty well. Mr McIvor: Perhaps I am talking about my area and perhaps they are going well there, and it may not be the same across the country, but I know that the majority of PCTs feel that there is much better clinical engagement than there ever has been and that the context means that we are actually seeing much greater investment in out-of-hospital services. Q19 Dr Stoate: Most of the PCTs I speak to, and it is a fair number, are very concerned indeed in the hospital sector about gaining power at the expense of PCTs, which is one of the driving factors, I am told, behind the reorganisation and the mergers. Is that the case? Mr McIvor: My own view on that, and it is a personal view, is around the context in which we are operating and the fact that the biggest driver for this is about the way we pay for hospital services. I can give you an example. I know that every time an emergency admission goes into my local hospital, it is going to cost me round about £2000. If that emergency admission does not go in, I do not pay £2000. That is a great incentive for my primary care professionals to look at better alternatives and to invest in them. 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 bureaus 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 per cent 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 y ears, 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 per cent 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. Practised-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 here 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 LSB 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. Q40 Charlotte Atkins: I think we are turning back the clock. Mr McIvor: What is new in what we are doing now is practice-based commissioning. That is probably the bit that allows us to go to that much larger level if we get that right and allow a much more local ownership, local accountability and local responsibility around groups of perhaps 30,000 to 40,000 population, which, after all, is half the size of some of the current PCTs. Q41 Dr Naysmith: If this is a change that is going to take place partly because we have this situation where some people at least believe that PCTs have not been doing a particularly good job in some areas or in some places, helping practice-based commissioners to do the job is something that PCTs are going to have to do. What makes you think that you will be able to do that any better than you have done as PCTs commissioning directly? Mr McIvor: You have quite rightly referred to "some PCTs". I think a large number of PCTs have done a very good job. What has changed is the context we are now operating within, which means there is need for a change now. I could show you that we have done a good job in our part of the world in both GP engagement, nursing engagement, clinician engagement and giving them greater responsibility now through practice-based commissioning. It is something about which they are saying, "Yes, we want to explore and try that as well because it will allow us to do better for our patients and that is what we are here for". I think there is the experience. The question, though, is about where it has not worked well and what would give you the confidence. Then we come to what is the future role of the strategic health authority and how are they going to performance manage the PCTs that are not doing well? Ms Jeffrey: Dr Naysmith, you are absolutely right that one of the first problems is persuading practices that practice-based commissioning is something that they ought to be involved in and that will give benefit to their patients. That is step one. That is the role of the PCT as well. It is by no means universally the case that all practices want to do this. Particularly for single-handed practices, it presents significant challenges where they are going to have to operate in groups. Therefore, you need a PCT to bring that together and make it happen to enable them to do it. Q42 Dr Naysmith: Looking at the history of all this a bit, when primary care groups were first set up, they were pilots for all this. They were going along at their own pace. Some groups were doing this and some doing that. Then, all of a sudden, the Department decided that everyone had to move into primary care trusts. That strikes me as one of the big mistakes that happened because we were going to develop many kinds of things we are starting to develop now and that is what this is all about. Since I have the floor I want to ask a quite different question. We are going to reduce the number of managers in the National Health Service by quite a large amount. As Gill Morgan says, even if the majority of places do not change, there is still going to be quite a big reduction. At the same time, we are reducing management skills in the National Health Service by 40 per cent, in Richmond House or at national level. I am not somebody who believes that managers are a waste of money and time. I think they are absolutely essential so that we get good management in the National Health Service. How are we going to be able to deliver this when we are losing lots of good managers? Have we got jobs for them elsewhere? Dame Gill Morgan: I think there will be some real loss of management. If you had to look and define the management cohort in the NHS, we did expand very rapidly with the number of organisations. To expand, you not only need chief executives but you need directors of finance and various other things. We spread the management skills and capacity we had very thinly, without a doubt. That is not a criticism of any one individual. Q43 Dr Naysmith: You are suggesting some PCTs were badly managed then? Dame Gill Morgan: No, I am suggesting that some PCTs had very little management capacity, which is fundamentally different. You might have had someone quite inexperienced. This gives us an opportunity to retrench and to make sure that the best managers are there and can begin to answer some of your earlier questions about how you develop these different structures. We did spread the management capacity very thinly, and large numbers of PCTs did not and were not able to appoint to their posts until fairly late on in the process. It has been a very difficult and challenging time for PCTs to retain and appoint managers of the calibre they would like. That would be an overall conclusion. We did spread ourselves too thinly. That is no criticism of any one manager or any one organisation; it is collective. Q44 Dr Naysmith: So you are quite confident that we will have the management capacity at this reorganisation? Ms Millington: I think you are right and that it is a risk. What you are capturing here is a snapshot of major change in the NHS. It is a huge change and it is a huge organisation, as you know. To cut the number of managers in particular - and managers do need administration as well - at a time of major change is a risky thing to do. I think, as far as keeping good people is concerned, there is a lot of churn; people change jobs a lot and come in and out of the service. With a bit of luck and a bit of management, we will manage to retain the good people, not necessarily where they are at the moment but they will pop up elsewhere in the system. It is something to be aware of. It always distresses me, coming from outside the NHS, that the NHS is under-managed rather than over-managed. Proportionately in percentage terms I think the Audit Commission has twice put in reports saying the NHS is seriously under-managed at under 4 per cent of the total staff. It is a risk that needs to be recognised. I think it can be managed but it is part of the business continuity, which is really important. Q45 Anne Milton: May I challenge this business about how long it will be before the new organisations get up and running? I cannot accept that we will just move on because what nobody has talked about is the staff. If you are going to cut eight PCTs down to one, at this moment and for the last six months, the staff have been more concerned, rightly so, about how they are going to pay the bills after the reconfiguration takes place. They are concerned about their jobs. The one thing that creates a huge loss of function and focus is people worrying where they are going to be working because they do not know. For as long as that uncertainty is there, and so certainly for the whole of this year and certainly for the next six to nine months or maybe even a year, there will be loss of function and loss of focus by the staff because they have something else to think about and that is what job they will be working in and where that will be. Dame Gill Morgan: What you have to remember is that if you look at the people who work in primary care trusts, the vast majority of staff are working on the provision side, not the commissioning side. Commissioning is already the smallest component of most PCTs. We are now clear that provision will stay with PCTs. There is some reassurance, therefore, for the vast majority of staff working in PCTs that the provision will remain in the PCT. You are talking about the people involved in the commissioning function who need to have these new relationships. That is why having a proper system of continuity plan can help. I am not saying that in no part of the country will it all be dropped, because that would be overly brave, but I think that in the majority of strategic health authority areas there are very strong plans being developed about how to manage the interim around the commissioning function. Sometimes, because of the sheer numbers of staff, people believe that most people in PCTs are doing commissioning. Actually, most people are doing provisioning and there is no change for them. Anne Milton: At this stage, unless you can say to staff, "I guarantee you will have a job in this town", they are going to be worried. Until that uncertainty goes, services will suffer. Q46 Chairman: I think that is pretty obvious, by and large, in this whole process and the submissions we have had from various organisations and representatives of staff. May I ask about this issue? Diane Jeffrey, you spoke about the consultation process you had in Derbyshire. You did not mention patients or patients' organisations in that consultation. Was there any? Ms Jeffrey: This is not the major consultation. Once the submissions have been received by the Department, the strategic health authorities will arrange a full 90-day consultation for everybody who is involved with health care delivery and in receipt of health care. Q47 Chairman: Including MPs? Ms Jeffrey: Yes. Q48 Chairman: You included MPs in the first one but not patients. Ms Jeffrey: Exactly. What I was talking about was the pre-submission engagement. It is not really a consultation. We had very little time but we did the very best we could to engage with those people locally who could give us the best of their opinions about what was being proposed. In our case, we did manage to consult with patients. We have an older people's congress in Derbyshire. Q49 Charlotte Atkins: Did you change your views as a result of that pre-consultation? Ms Jeffrey: We did actually because one of the proposals was for three organisations. You will understand that there are North Derbyshire, South Derbyshire and Derby City. We felt that because we had worked so well together in North Derbyshire across a really disparate area of the country with urban and rural areas, then why could we not work equally well together across the whole of Derbyshire, which had the same sort of patchwork and tapestry of differences? The more we took out of the overhead, the more there would be to channel into front-line services for patients, in particular palliative care and cancer care. Q50 Chairman: Does anyone else have anything to say on the issue of patients' consultation? Mr de Braux: I could leave you a list of all the people we spoke to in this pre-consultation phase, including patients' forums and the process we went through. I am happy to leave that. You did ask about whether we changed our views. We had a public board meeting, a three‑hour discussion, and, by the end of that, the board came to the conclusion that one of its recommendations would change because of the representations. Ms Millington: Perhaps I can speak for London because I chaired the steering group of the five London SHAs? We collectively engaged, rather than consulted, with the list that has been gone through already and with patient forums and patients' organisations. We originally came up with two options for the London PCTs. We have recently revised that and said we should have one option, which is the status quo. In fact, it is 32 rather than the current 31 PCTs, just to go against the grain there. Yes, there has been a big listening exercise. I think it is easier, frankly, in the cities than it is in the country. It is much easier to get people together. People worked very hard in the time allowed to get as many voices heard and listened to as possible. Q51 Anne Milton: Can I ask whether you feel that non-executives and PCT chairs add value to the PCTs currently? Dame Gill Morgan: Absolutely. One of the things the Confederation believes very strongly is that you do not get good governance unless you have strong corporate boards. Strong corporate boards means having good chairs, good non-executives and engaged executives. That is one of our passions. We argue all the time that you will not get good governance unless you build up and strengthen the chairs and the non-executives. We are on record as having said that if you look over the last few years, one of the things that has been weakened because of there being lots of small PCTs is the strength of the corporate board. One of the things that we will push for very hard is proper corporate board development of the new PCTs so that boards can be properly held to account and begin to deal with this issue of locality and what is shared and do the things that a good board does. Q52 Anne Milton: Do you feel that the current non-execs of PCTs have not been effective? Dame Gill Morgan: I think we have had a very managed system which has actually made it more difficult with a whole series of central imperatives that have had to be delivered, it has left less space for local organisations than in the past. Q53 Anne Milton: Are you emasculated? Dame Gill Morgan: Yes, but I think we are in a time of transition though, which has been going on for the last year, although there is a recognition that you cannot drive a system like the NHS from the top and you have to begin to put the power back where it needs to be, closer to patients, and that is beginning to happen. We have seen a reduction in the amount of central reporting and the amount of bureaucracy, it is beginning to dribble through and I think this set of changes will see the corporate board become important and powerful again. Anne Milton: But if we are going to have mergers, maybe eight down to one, we are going to have less non-execs in the system. Q54 Mike Penning: There will be less accountability. Ms Jeffrey: Maybe there will be fewer but maybe they will be of better quality. Q55 Anne Milton: Just correct me if I am wrong - and I would be interested to hear others' views - you feel that they did not have enough power, the system was too centrally controlled which did not allow them any room to breathe and you do not think that they were that good. Ms Jeffrey: I did not say that they were not that good. Q56 Anne Milton: You said maybe they will be better. Ms Jeffrey: I think it has been difficult to find enough people to put on the number of boards that we have had, with the experience, the skills and the expertise that we need. After all, we are bringing people in from outside in an advisory capacity and in a non-executive capacity to these boards which have control of significant amounts of expenditure, and that expenditure control is very, very difficult for PCTs because most of the money is spent by other people. Having influence and control over that is extremely difficult. Mr McIvor: I have a board which oversees the expenditure of £310 million each year; my non-execs hold me to account, they scrutinise what I do and I feel that they also bring me a view of what the local population says, but the most important role they have is that role of governance of expenditure of that public money. I think they do it exceedingly well, and I have a very good chair and board. Q57 Anne Milton: But there are going to be less of them in some ways. Mr McIvor: In the bigger PCTs the board will have the same role. Q58 Anne Milton: But there will be less of them if we are going to merge PCTs and their non-execs down to one. Mr McIvor: But they are still going to oversee the expenditure, the governance and the way it operates and they will still have that overseeing role. There will be less of them for the local opinion which they bring in, which is one of their roles, but their overseeing of expenditure and of the use of that money will be exactly the same. Q59 Anne Milton: There will be less of a local voice, you would concede that. Mr McIvor: Yes. Mr de Braux: There might be fewer non-executives, but they will still be in the majority of every board, so they will still have the authority over boards that they have today. Q60 Anne Milton: But there will be one instead of eight. Mr de Braux: The other point I was going to make about the quality, Gill made the point that when we expanded PCTs we did struggle to find people to fill all of the executive posts, and we recognise that there has been a lot of development. Exactly the same applies to the huge expansion in a short time to find people who can come with all the necessary skills, which is why we run the programmes we do to develop the skills of non-executives. The NHS is much better for having very good and very well-developed and trained non-executive directors. Q61 Anne Milton: My concern is that in doing that some of them go native and actually lose their local links. That local voice is quite important. Ms Millington: One of the things that have changed since PCTs were first set up is that there have been other developments elsewhere - scrutiny committees have been set up, for example. The accountability is not just through the broad structure of the NHS itself, it is through local government, it is through national government as well. When my non-exec colleagues and I are good we are very, very good, and when we are bad we are horrid, so there is not a simple answer that they are all good or they are all bad, of course not, they are silly people like the rest of us. Equally, I do not think numbers necessarily make for better governance: if you doubled the number of MPs in the House of Commons I am not convinced that the country would be a better place, but what is changing is the understanding that to get the local input you do not necessarily do it by those representatives on the board, there are other ways and arguably better ways of doing it. You work very closely with your local government colleagues, you work very closely with the voluntary sector, you work very closely with the patient and public organisations and voluntary organisations, and I think that is a better way of doing it. The proper use of non-executives is that you get that slight detachment which allows them to query the executive about how policy is being carried out. They can bring their particular skills to articulate and then define that policy, and they share the full accountability and responsibility. It is a remarkable thing that you get so many people who are prepared to do this badly paid and remarkably thankless job, but thank heavens we do because they are very passionate about the NHS. Chairman: Can we move on now because we are running out of time, unfortunately. We have just two questions that we would like to finish off on; Paul is going to take the first one. Q62 Mr Burstow: I will try and encapsulate ten questions in one breath, if possible. It really boils down to an issue of clarity, and I was very interested in what Dame Gill was saying earlier on about PCTs now retaining their provider functions, because that is a much clearer and more explicit version of the statements that have been made and have changed over the last few months. We had Nigel Crisp's letter which was very clear about the direction of travel, which was that PCTs would be minimum providers of service, we then had the qualifications that it did not have to be until December 2008 and then we had the Secretary of State coming on and saying some soothing words in September, but still say basically that PCTs would not be in the business of providing. We then had the written statement on 18 October and then we had oral questions last week, and at each stage the clarity seems to have gone down rather than becoming clearer. I want to ask two things: one, do you feel that the officials in the Department, in terms of what they are saying from the very top of the organisation, and the political leadership of the Department are on the same hymn sheet and are saying the same things; two, do you really think that the direction of travel is still as it was in Nigel Crisp's letter, or is it now something else? Where are we in fact in terms of service provision? Are we really just going to have commissioning organisations by December 2008 or are we going to have something that is a bit more of a hybrid, varying from one part of the country as well as varying in terms of whether or not you have commissioning functions or provider functions? Dame Gill Morgan: That does span 16 questions in one. Do you want to start? Mr de Braux: It is unclear where the future will be. This proposal is fundamentally about strengthening commissioning and that is what everybody has focused on. One of the realities, I think, is that if you spend 80 per cent of your time and concerns worrying about the provision of services, then you do not have the energies to put into commissioning, and what we know in primary care trusts is that most of the staff are involved in providing services, so there is a real desire to make sure that these new organisations focus on commissioning. There are other examples in the public sector where organisations have a focus on commissioning but still carry out some provision - local authorities are a very good example of this - and I thought the statement about "unless and until PCTs decide otherwise their provision will stay" is pretty clear actually. There will always be cases where provision rightly remains --- Q63 Mr Burstow: That is very important, that is the new phrase, "unless and/or until" - depending on who actually utters the sentence, but it is along that line. The "until" is the bit that is interesting because there is always a caveat by reference to the White Paper and what the White Paper says, therefore, is absolutely critical as to whether that "until" becomes when. I just want to understand what you think the relationship between that statement about "unless and until" and the White Paper actually is going to be. Mr de Braux: I do think that the White Paper, which we have not seen yet, will come out with things that we have not seen. I was in Birmingham on Saturday, with the Listening event there, and it is quite clear that when you address a much wider body of people as they did, different ideas come up than perhaps people have been thinking about for many years, and that is going to be very interesting. But I stick to the point that there will always be some services for which I believe PCTs will say there is no alternative provider, much as we have tried to find an alternative provider it will not be safe to do so, or nobody is interested in providing that bit of the market or whatever, and I think it will stay with PCTs. Q64 Mr Burstow: How long should these new organisations, once they are set up, be given to demonstrate whether they have succeeded or failed? Mr de Braux: I think what we have to do is demonstrate that they are commissioning effectively, and where the challenge will come from strategic health authorities to them is if they are not commissioning as well as they might be and a lot of their energies are going into providing services, then we will be asking them to --- Q65 Mr Burstow: One year, two years, three years? Dame Gill Morgan: If you were looking at a change of this scale in industry you would be saying you have to give a minimum of three years run to begin to see the benefits. The NHS is very good at dealing with change. That three years run to see the benefits, that does not mean you drop the ball in the meantime, those are two different philosophies, because this is meant to be about improving things for patients, not just doing as we are, so to be seeing the benefits systematically, you would give it three years in industry. Q66 Mike Penning: We should be seeing the benefits of PCT restructuring about now. Dame Gill Morgan: From the last restructuring, yes, and we have seen some of the benefits and some of the difficulties. Mike Penning: We have not had a chance to even see the benefits yet. Chairman: The last one then is Richard. Q67 Dr Taylor: It really bothers me when you say it takes three years for changes to take place, because how many changes have we had in the last three years? Dame Gill Morgan: If you were sitting in industry and you were making a change of this scale - this is such as ICI and British Airways - they look to see the real benefits coming in and clicking in after about three years. Q68 Dr Taylor: You think you can do it quicker. Dame Gill Morgan: If you are in industry and you produce a change, you have a graph which says performance dips and then it picks up again, and then you get the gains. What the NHS has become very good at doing is actually not having the dip. We tend to make the change, keep the thing flat rather than dipping - we cannot afford dipping in performance because that is affecting patients - and then the improvement comes in after three years again. The NHS is actually quite unique in terms of how good it is at managing the change without a dip in performance. Q69 Dr Taylor: Contestability is the buzz-word; how does that apply to community services? John said that there sometimes would not be alternative providers. Dame Gill Morgan: Yes. Q70 Dr Taylor: How are you going to make sure there is contestability in community services without splitting up what already exists? Dame Gill Morgan: It is going to be different on service for service, but let me give you an example of what I would be thinking about and doing in a PCT. I would be looking at which of services that I provide are not delivering the level and the quality of care that is being delivered in other places, so I would be benchmarking my services, I would be identifying who was best in class. For example, one set of issues at the moment, which you as a committee have actually looked at, is sexual health services. We know that in many parts of the country sexual health services are not up to scratch; in those areas I would be talking to people like the Terence Higgins Trust which we know has a fantastic sexual health integrated service, which is already running in a number of PCT areas, and I would be finding out whether, one, I could steal their best ideas; two, whether they actually would want to come and provide the service at the local level; and, three, how do I get the services in my patch up to the best in the country? That is contestability; at the end of the day it does not necessarily mean that you take the service away from a local provider, but it does mean you really know how you are doing and you aspire to be the best you possibly can, because at the end of the day you have got to be the best because you are serving the patients. Q71 Dr Taylor: I accept that with the Terence Higgins Trust, but really coming down to the more bread-and-butter things, the general practice staff and the community nursing staff who work together --- Dame Gill Morgan: My personal view - and this is a personal view - is that a number of the issues around employment law and TUPE makes it highly unlikely in my working lifetime that you will see large numbers of these staff working for private or other independent organisations, I just do not believe that is a possibility. I think that what you are much more likely to see is the type of approach that I am talking about, which is that you will find organisations identifying where they are strong and where they are weak and looking for ways of improving the services where they are weak. Q72 Dr Taylor: As a generalisation, where general practice staff and community nursing staff are working well together, it is unlikely we will see a change. Dame Gill Morgan: If something is working well, why would we want to go and bust it? Q73 Dr Taylor: This is the terrible impression that we get, that very often when things are working well this is exactly what the Government does want to do. Dame Gill Morgan: Dr Taylor, you are talking about us now. Ms Jeffrey: This goes back to what Mr Burstow was saying: you are absolutely right, it would have been much more helpful had we had the correct story from the beginning, and it has been very difficult to work through the changes, the reversals, the tweaks and the amendments. Take, for example, Derbyshire: would we have gone for one Derbyshire organisation had we known that that would have been a providing as well as a commissioning organisation? I cannot answer that, but you are quite right, it has made it very difficult. Q74 Mr Burstow: This inquiry is about establishing whether the system currently is broken. I do not actually think, from the evidence we have heard today, chairman, that there really is an argument that the system is broken, there are bits of it that are defective is what you have been telling us. Dame Gill Morgan: I think, if I may say so, it is not whether it is broken, it is whether it could be better. I do not think any of us would argue that it is broken because we all believe there have been huge benefits from the last restructure, but could we do things better, could we provide better patient services, could we provide services that actually meet public needs in an improved way? Yes, I think we could. Q75 Dr Naysmith: Looking at the Derbyshire thing that has just been said, you said there is only one, but that is a proposal which is now going out to consultation which can be changed. Ms Jeffrey: Absolutely. Q76 Dr Naysmith: If, in the light of changes, you think there is something better then maybe you will have to do that. Ms Jeffrey: Absolutely, but maybe there will be further changes to policy in the future which we have not even thought of yet. Going back to what Dr Taylor said and John de Braux's answer, I think it would be very sad if PCTs ended up as providers of last resort; in other words, we only provided that rump of services that nobody else, that the housing associations, that the private sector, that the voluntary sector, that the community sector did not want to provide. That would not be the best outcome for patients and I for one will try hard to see that that does not happen. Mike Penning: But that is where we are going. Mr Campbell: That is what people fear the most. Q77 Chairman: At the very opening of this session we had a number of examples from yourselves collectively about how this current structure has been responding to commissioning and to providing services inside the community as it were, and how you have gone across PCTs on occasions when there is need to commission at a wider level as well. Are we to assume that you thought that was happening anyway and really what we have here in terms of this reconfiguration is something that in a sense could potentially disturb that or not? Dame Gill Morgan: Like anything which develops in an organic way, it is patchy. One of the issues is about how do you spread the learning, so although I talked about sharing there are other communities that have not shared very effectively, so this is an opportunity to make the learning from the places that have been sharing both management structures and also commissioning functions more widespread and more available. It is a different type of question really. Chairman: Could I thank you all for coming along and I am sorry about the overrun. Memorandum submitted by Oxfordshire PFI Alert Group Examination of Witness
Witness: Dr Helen Groom, GP, member of PEC Oxford PCT, examined. Q78 Chairman: Good morning, Dr Groom, I am sorry for the overrun this morning. You have probably been more involved in this debate than we have for the last hour and a half, and really we would like the benefit of your overview on many of the things you have heard here, certainly how it has impacted in Thames Valley and what your views are on the current Thames Valley proposals. Dr Groom: I think it is quite important that we deal with why Oxfordshire is actually different from what is happening in the rest of the country. It was interesting, listening to my colleagues before talking about the changes; I think we are turning the clock back slightly and in terms of the PCT reconfiguration we are looking back towards the size that the old health authorities used to be at, and I think there are some reasons why you might want to go to that level. Certainly in Oxfordshire we have struggled as PCTs to actually have the discussions with our secondary care and tertiary care providers in terms of the Oxford Radcliffe and the Nuffield Orthopaedic Hospital, and there is that power struggle that Dr Stoate was referring to. There are real tensions there and there are reasons why it might be better to work as one group, which increasingly, as was said, we have been doing. So although there have been a lot of discussions about losing the local focus, I think there is broad agreement in Oxfordshire that one PCT may work. We are turning the clock back because there was a lot of discussion about practice-based commissioning and over the last few years we have lost a lot of the clinical engagement - in some areas, not in all - of practitioners on the ground - the GPs, the community nurses, the pharmacists, the therapists - directly in commissioning, and I do think we need to go back to where doctors talked to doctors, the therapist talked to the therapists in primary, secondary and tertiary care, the people doing the work actually talked to each other about the services they are providing. In that way we are turning the clock back. What is very different in Oxfordshire is that we suddenly had the announcement, whilst we were having all of those debates and discussions about how we might make it work, and in the paper that went to Thames Valley Strategic Health Authority there were two lines that said that our strategic health authority wished to tender out the management and leadership services for the future single Oxfordshire PCT and that they would wish to invite bids from NHS bodies, the voluntary sector and private sector companies. It has been made very clear that whilst in Oxfordshire and certainly in Oxford City we are a three star primary care trust in terms of QAF points across Oxfordshire, we are top of the league and you would think that that would indicate we are providing good quality service across primary care, we have been told that we are very poor performers in terms of commissioning, in particular because of our £35 million deficit, and that is why it is extremely important that these changes happen and that, in particular, we have the best possible management for the future PCT. I do not disagree with that, I think it is really important that we have the best management and leadership for the PCT, but what it is very important that we question is whether we should be tendering out to a private sector company to take on the commissioning of services for Oxfordshire. We are saying that a private sector company would actually come and hold the purse strings for the £600 million of money that is spent on healthcare services in Oxfordshire, and whilst I think we can debate whether private sector involvement in the way we run our buildings might be appropriate, and private sector involvement in the provision of hip operations, cataracts, of MRI scans may be appropriate, this is a much, much bigger step that has actually been taken with no discussion and no consultation. The senior managers knew about this on the Friday before the paper went to the strategic health authority on the Wednesday, staff knew about it on the Tuesday before the paper went to the strategic health authority on the Wednesday. Our strategic health authority are very clear that they do not need to consult on this - they need to consult on the PCT mergers but in terms of the tendering-out process, this is not a service change and therefore they do not intend to consult on this. We feel that we need to be questioning whether this is an appropriate way within a national health service, is this an appropriate direction of travel? If the agreement is that it might be, we at least should be consulting on this proposal and have much, much wider discussion with patients, the public, MPs and staff about whether this is actually something that is going to really move us forward. My mouth was open when Gill was saying that she could not see it in her lifetime, in Oxfordshire the PCT senior management are going to be in the private sector. The private companies that are interested are not just interested in the commissioning - that is where they want to move into - they are providers. Until the PCT decides that we are actually going to move provision into the private sector I think there is quite a large conflict of interest there. I could go on. Dr Naysmith: Could I ask a question here? Chairman: Yes, go on. Q79 Dr Naysmith: Where do you think the idea comes from? Dr Groom: I think it is part of a direction of travel that the NHS has been set on. It is interesting, again when my previous colleagues were saying that things will not fall down: they will not because the NHS is so used to constant change that actually clinicians on the ground and the vast majority of managers who work in it are determined and committed as public servants to making sure that things continue to happen for patient benefit. Q80 Dr Naysmith: What I am really asking is why Oxfordshire? Dr Groom: Why Oxfordshire? I upset my colleagues sometimes when I say this, but I think it is because we have a complex secondary and tertiary care provider. We have a world-renowned teaching hospital that does lots of research, and in commissioning terms they have been the most difficult people to engage in a discussion about what we need to provide based on health needs. In Oxfordshire, though, we are quite a simple geographical area. The other major teaching hospitals are within the major metropolitan areas such as London, Manchester, whatever. In Oxfordshire we are one shire so we can have one PCT, we have a major provider and I also think we are an area where we do not have any major Labour councils, we do not have a huge number of Labour MPs and in terms of an ethos it might be an area where, in terms of public perception and certainly in terms of their ability to accept more private sector involvement and to actually use the private sector, it was felt that it might be more acceptable than in other areas. Q81 Dr Naysmith: I am trying to get at who is feeling this, "it was felt that" - who is doing the feeling? Dr Groom: Again, I am a member of the professional executive committee, I am here in a personal capacity but involved with a group that has been concerned about the changes and the privatisation that has been happening through the service over the last eight to nine years, and the cumulative effect of all of the changes that we have been through since this Government came to power. Q82 Dr Naysmith: You are not really answering my question, which is where is the idea being pushed? Who is pushing the idea? Dr Groom: Who is pushing it? Do you want my answer to that? Q83 Dr Naysmith: Yes, that is why I am asking. Dr Groom: I think Number 10. United Healthcare have been very clear that they are extremely interested and feel that they would wish to bid for this tender, and the chief executive of United Healthcare is Simon Stevens. Q84 Mr Campbell: Do you think they want to make money? Dr Groom: They are a private company, of course they want to make money. Q85 Mr Campbell: Lots of money. Dr Groom: The average return for most private sector companies is 10 per cent. They might say to begin with that they do not want that - £600 million, that is £60 million and we are already being asked to take £35 million out of the health economy. £100 million gone, what is that going to do to services in Oxfordshire? Q86 Anne Milton: Can I congratulate you for actually coming in a personal capacity and putting your head above the parapet. Good for you. My mouth also fell open because I have met a private healthcare provider who would say exactly the same, that the messages from the Government are very strong and this is why it will go ahead, so I may be not as surprised as many people would be that Oxfordshire are thinking of doing this. Dr Groom: It is the strategic health authority that is thinking of doing it. Q87 Dr Taylor: May I pick up two points from your submission. First, the purchaser/ provider split was shown after its introduction in the early 1990s to have doubled administrative costs. Do you see any way that the mergers that are being considered at the moment are going to save money? Dr Groom: When the PCTs were first set up, each one of them tried to work on commissioning and, as was made very clear earlier on, PCTs are already working together as teams to work with the major providers, and I think from that point of view there will be economies of scale. The major problem is around payment by results and the increase in plurality of providers means that there will inevitably be a big increase in the amount of transaction costs. Q88 Dr Taylor: Secondly, a reduction in the number of PCTs from five to one in Oxfordshire will lead to a diminution in local knowledge and it also, you say, will reduce the frequency and ease of direct contact between primary care staff and the hospital staff. Can you elaborate on that, because the purchaser/provider split drove a huge wedge between primary and secondary care, and you are saying this is going to make that even worse? Dr Groom: You need to take the sentence after that which then comes back to commissioning, because I think commissioning is actually different from purchasing. Within each of the PCTs in Oxfordshire there have been some very good examples where clinicians from primary and secondary care have managed to get together, but they have been infrequent and sporadic. The worry in terms of five into one is all the worries that were expressed earlier on in terms of there will be less non-execs and there will be less clinicians who are actually involved in the PCT. Practice-based commissioning is what we will have to make work if we are going to have larger PCTs. We need to ensure that practice-based commissioning takes off so that you can ensure that you do not have the diminution in contact between GPs, consultants and therapists across the primary and secondary care divide. I think that is very important; that is what will achieve the change. Q89 Dr Taylor: If it was possible would you agree that professional executive committees ought to remain, even though there are more of those than the PCTs? Dr Groom: I think that professional involvement in the PCT should remain, although obviously if we are run by a private sector company we have no idea what the actual structure of the PCT will be. Q90 Mr Burstow: I am very interested in this issue of accountability. We asked Sir Nigel Crisp about this last week and he said, of course, that they are not outsourcing the governance arrangements, they are just creating an outsourced commissioning function. That though begs some questions about the issue of commercial confidentiality which, certainly in my experience through asking questions here, is often an obstacle to obtaining information about performance of those organisations that are now providing services under contract to the NHS. Many of the performance indicators and measures that are collected by those contracts are not available under the grounds of commercial confidentiality; has that been discussed in any way in Oxfordshire in terms of how an outsourced commissioner could be scrutinised both by the public, elected members and by those involved in the governance arrangements for commissioning? Dr Groom: I know that that has been of great concern to the chairs of current PCTs and to the non-exec members on the boards, and they have been pursuing discussions with our strategic health authority over what those governance arrangements will mean. I think one of the things that has really worried them is that there will still be consultation on five to one, so in terms of the board actually being set up, that cannot happen until at least March/April next year. The advertisement for the tender goes into the European Journal this month. We do not understand how there can be public board involvement in the setting up of the contracts that people will be tendering for, we are not clear about who is involved in those discussions and, in particular, who will be the non-execs who will be involved in that. We are not clear who it is who will be writing those contracts that they will be tendering for and we are also not entirely sure who will be on the selection panel for who actually wins those tenders because it will not be the board of the future PCT because they will not be there. Q91 Mr Burstow: We would have liked to have asked Nicholas Relf, the chief executive of the SHA those questions, but unfortunately he declined our invitation, and it is a great pity that we are not having the chance today to ask him those questions. Dr Groom: It is interesting you say about putting my head above the parapet, I went to the strategic health authority meeting at which this was discussed and it was true they discussed the paper for 45 minutes, there was one question from their non-execs on this proposal and that was to say, as a point of clarification, was this process going to be as well as the standard NHS recruitment procedure and it was made very clear that obviously it was not. That was the only discussion that was held at the strategic health authority, there was no public involvement. I have to say that that is why people like me, and there are many others, are prepared to put their heads above the parapet. Q92 Chairman: Could I just add to what you have been told, Dr Groom? I have the letter that declines his attendance here today, although we did request him to come along. It is our intention to hand this to the Minister and ask questions of this letter and its contents to the Minister when he comes to give evidence to the Committee next week. We will be pursuing many of the issues you have brought up in your short time here this morning, so if there is nothing urgently pressing from my colleagues I would like to thank you very much indeed for coming along this morning. Dr Groom: Thank you. Memoranda submitted by NHS Alliance Examination of Witnesses
Witnesses: Dr Michael Dixon, Chair, NHS Alliance, Mr Robert Sloane, NHS Alliance, Dr Peter Reader, NHS Alliance, Ms Yvonne Sawbridge, NHS Alliance, Dr Tony Stanton, Joint Chief Executive, London Local Medical Committees, Ms Lucy Marks, Tower Hamlets PCT, PEC Chair, examined. 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 the 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 say. 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 London Local Medical Committees which represents GPs in London from the west in Mr Burstow's constituency, to the east in Dr Sloane'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 of first of all why the change and the outcomes and the process for those outcomes. 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 per cent of our PEC chairs said they were not consulted by the strategic health authorities at all, and as far as frontline commissioners 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 just looks like a map of England with the counties and the unitary authorities. I am not sure how much work has gone into producing this, but anyone could have produced it on August 29 or whenever without much effort, which means that there has not been a great deal of sensitivity towards local culture, local history and the like, and it means also 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, which is something that is going to be looked at in 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 the top up, making sure that localities bring those practice-based commissioners together and that we also make sure that the PCTs as they are 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 per cent of PCTs have got less than 50 per cent 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. 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 per cent 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 per cent 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 per cent 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 over as the first bit. 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 in 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 which 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, 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 hesitate to call them a PCG and I think what we would say is that it needs 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 per cent 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 focussed and smaller PCTs which are very focussed, 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 a 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. Q120 Charlotte Atkins: Do you accept that there has been a huge amount of uncertainty and a loss of morale among staff because of this debate about the fact that the PCTs may no longer employ them? I am not just talking about nursing, I am talking about health visitors and I am not just talking about GP employees but right across the piece. Dr Stanton: An outrageous effect on them and on managers employed in PCTs. Ms Sawbridge: The nursing network of the NHS Alliance does include health visitors, district nurses, school nurses, practice nurses and we ought to have links with the AHPs, the primary care practitioners. They make up the largest community workforce employed by PCTs at the moment so they are the ones that are the most affected by the divestment of provider. There has been large scale anger, dismay and concern about these changes and it is not just about pay and pensions, although I know that is what is hitting people, it is much deeper than that. It seems to be around three areas. One is the fragmentation of care that plurality of provision is likely to come to. The second is core values. In the community we deal with people not disease. We are trained in acute, we moved into community and we want the chaos and the richness that come from helping people live their lives. It does not fit neatly into "You've got diabetes" or "You're having your hip replaced". People have all sorts of things happen to them at the same time and that is a core value that makes people get out of bed and want to come to work and they are very anxious about losing that and going into organisations that do not understand that difference, which is intangible, you have to work in it to see it. The third is around training, development and the workforce. Who is going to train our future workforce? Who is going to plan across the health and social care when you have got plurality of provision? I just do not understand how that will happen. It is hard enough now. At the moment we talk to community nurses about having student nurses and "post-reg" nurses and doctors and everybody else and sometimes they moan and say, "I'm trying to get my day job done. It gets in the way," but you can say, "This is your day job. You are part of the NHS. This is what you need to do." How are we going to say that to other providers who will not see it like that? When we start trying to get clinical placement in general practice, who have got much more business acumen, they will say, "Yes, it's really important but it costs." Q121 Charlotte Atkins: What do you think the impact on the quality of care will be as a result of this loss in morale and concern about where they are going to be placed in the future? It may be very easy for certain people to say, "We might place them in a different town," but life does not work quite like that. Ms Sawbridge: There will be loads of unintended consequences and it is really hard to try and second-guess what will happen. It depends how the provision of services happens. Obviously you will get people looking at bits of the patient pathway. People are unlikely to bid for the old lady with Alzheimer's disease needing foreleg compression bandaging. There were comments made earlier about how we should not leave PCTs with the services that nobody really wants to do; that is not a very exciting place for anybody. You need to make sure we have got a variety of things that people can do that matter. Q122 Charlotte Atkins: This is supposed to be patient focussed. Do you think it will fragment the so-called patient platform? Ms Sawbridge: Yes. Seamless care is difficult enough to do at the moment and the more fragmentation the more people you are going to have knocking on the same door to deliver different aspects of care. Dr Dixon: I would say yes-ish to Yvonne. I think she has illustrated very well the feeling of insecurity and lack of control and we really do need to make sure that the front-line practitioners are involved in whatever happens and they clearly did not feel that they were. I take Tony's point, I think the direction is still quite unclear, which is towards a bit more contestability in primary care. After all, we had it in secondary care and I think we must accept that it is going to happen in primary care because you do not want complacent services that offer what they offer. Hopefully we will have these PCT bottom-up commissioners who are fairly sharp, fairly tight, who can look at proposals which sometimes may not be PCT provided services, they may sometimes be front-line provided services, perhaps not-for-profit, perhaps mutual, but they do offer things better. At the moment in my own practice I have got a healthcare assistant that comes from an operation seven miles across the hill. I have got mental health services that are coming up from outer space! Bringing them together would be a great thing and maybe we could make some front-line ethical provider organisations that could do things better. Q123 Charlotte Atkins: Might we see our community hospitals being run by private for-profit organisations? Ms Sawbridge: Yes. Dr Reader: Yes. If you are opening the market up to contestability then yes, absolutely, anyone can come in and bid for that. I think it was highlighted by the speaker from Oxford that these people are not going to be doing it for love. Dr Dixon: That will depend upon the commissioner. I would think front-line practitioners could always put in a better bid because they will be there 20 years hence, they know the people and they have got the confidence and the track record. Anne Milton: It has been very interesting having these two panels. I think it says it all. We have had the strategic approach and then this huge gap between what is happening on the ground which we are hearing from you. Just picking up on what Yvonne Sawbridge said, if practice-based commissioning will lead to less acute trusts' time being used and will actually reduce demand, which I think the general public would find a very difficult concept in itself because, from where they sit, they go to a doctor or seek care when they need it so they do not understand reducing demand, it will be the community staff that pick up the tab. There has been no mention of social services here. Essentially this will lead to a cost-shifting exercise. We have got councils already pleading about council tax, not having enough money and making council and social service provision. The bottom line is it will be the community staff, the district nurses and social services that are picking this up. I would be interested in your views about what is going to happen. I can see a huge number of people falling through this big hole. Yes, the demand on acute trusts will go down, people will be demanding less care, but I think there will be more misery and suffering in people's homes as a result. Q124 Dr Naysmith: Is Ms Sawbridge sufficiently reassured by what the Secretary of State has been saying, as Charlotte outlined, about our PCTs being able to carry on as providers if they want to? Ms Sawbridge: The network members welcome the Secretary of State's statement. It has been a really helpful statement. It has allayed some of the anxiety. However, I think the "until" still hangs in the air a bit. I do not think anybody is saying that it is not a good idea to look at alternatives and contestability, I think people accept that. It is that it should not be an absolute "thou shalt not provide," that is the issue. You should be able to work out locally where you think your best staff are coming from that are going to able to meet the needs of your local population and that will include linking with the local authority and looking at the integrating of roles, all that sort of stuff, which is difficult enough at the moment but possible with good partnership and good leadership clinically and professional engagement. It will get more difficult if the services are fragmented and you are not even sure who you need to talk to to link the pathway. Dr Reader: The original point of this paper was about strengthening commissioning. The devolvement of those provider organisations actually cuts that whole section of community staff out of that loop and out of practice-based commissioning possibilities. As practice-based commissioning came in other professional staff have been champing at the bit to get involved, but it has been more complex to see where that fits in and people have been trying to work on that. As soon as the divestment to providers came along lots of PCTs' doors - including my own - suddenly closed on thinking about them because somebody else was going to be running them. There is a whole raft of skills and knowledge and involvement that can be used there in practice-based commissioning in different ways to evolve and change services that would be lost. Mr Sloane: There has to be a balance struck because to suggest any wholesale resistance to involvement in the private sector of the private sector in health would be a misrepresentation. Already the evidence is that the private sector can delivery efficiency gains in acute services, they can actually improve quality. As Yvonne was saying, primary and community care is a much more complex fabric of services. It needs careful thought about the design and commissioning of those services prior to planned involvement with the private sector. It is not off-limits. It can actually deliver some of that cost saving that has been held up as the reason why the organisational change is being taken forward. I think we need to keep an open mind on it in that respect. Q125 Mr Burstow: I want to make sure we do not lose Anne's other question, which was this issue of cost-shifting and the extent to which some of this agenda will end up shifting responsibilities onto already very hard pressed and - compared to the National Health Service - substantially less invested in services over the last three years and over the next three years as well. What is your view about that in terms of whether this will really prove to be an aid to better integration of health and social services? You have already queried the whole value of co-terminosity compared to other criteria in all of this. I think this is an issue we did not grapple with earlier. I want to make sure we have some sort of comment on this issue as to what extent there will be a shift of responsibilities on to social services to meet needs in the community that hitherto would have been treated as health needs either in the acute sector or even within the community healthcare sector. Ms Sawbridge: I am not sure if I can answer that totally. If we look at the care trust models that we are beginning to develop, I think there were around nine that were beginning to be piloted before commissioning a patient in the NHS, I think they were looking to address exactly that because that is about going further than pooling section 31 budgets, it is about organisationally managing, employing and delivering services across health and social care. There are duplications of workers going in, healthcare assistants, social care workers doing slightly different things, ie can they give eye drops, all that sort of debate that happens locally. I guess those sort of models would be looking at that. I am really not sure how that will play out if care trusts do not take off and people are integrated and co-terminosity and plurality of provision happens around that; I think it is a risk. Q126 Mr Burstow: I think one of the issues from the point of view of the patient is when they cease to be a patient and become treated as a client because as a client you get charged for the service and as the patient you get it free. Is that a concern that we should be looking at when we have our social services colleagues before us in the future? Dr Reader: I think inherently once you have got services that are contracted to provide a little bit then you start to have delineations and barriers. Drawing on some of the London experience where we are worried about losing the co-terminosity with boroughs, there is an awful lot of joint working already going on with those small populations, with the boroughs, around these health and social care issues, even getting into some of the issues of housing which previously was suggested could only happen if you are working at a much bigger level. In Islington there are examples where new housing has been designed with walk-in showers so that when somebody turns 70 and a bit more infirm you do not have to go and put one in instead of the bath. It is back to this thing about how long does an organisation need to take to get onto its feet and for these things to start to happen? All of these things are happening, it is organic, therefore it is sustainable and the partnerships and the trusts that really make the change work rather than just shifting the big boxes are there. Dr Stanton: There are hopeful signs of that closer integration. The Chief Executive of the care trust is also the Director of Social Services for Bexley and there is a similar arrangement in Southwark. That is a positive sign. You are quite right that if less work is done in hospitals more work will be done in primary and social care but, equally, one of the biggest difficulties - and I am sure Michael would agree - over the years has been getting money out of the very expensive hospital sector into primary care. The overwhelming majority of our activity takes place in primary care for a tiny proportion of the budget. It is only really by finding alternative ways of providing some of the care that currently takes place in a hospital that you can get the extra investment which is needed for primary care. I think it would be very difficult to achieve but it is the only realistic way forward. Dr Reader: I was very pleased to hear some of our colleagues from the NHS Confederation quote you examples of where local clinical leadership has done that despite the difficulties. We have now had the tools of practice-based commissioning which, if the balance is right around the commissioners and the providers, actually can really move that agenda forward. The restructuring change that will happen out of this will just throw all of the commissioning side into turmoil and weaken those essential clinical leadership link developments and there is a real danger of the provider side being far too powerful and taking off. Q127 Mr Burstow: Dr Stanton, you were talking about the direction of travel being one in which the NHS becomes a brand that puts on services or a badge that is used. Dr Stanton: Let us be clear, I was not advocating that, that was my analysis of it. Q128 Mr Burstow: You were saying it was the direction of travel. Would it be fair to describe the direction of travel as you see it as one that will result in a mixed economy in the health service rather similar to the mixed economy we already have in social services? Dr Stanton: Yes. Q129 Dr Taylor: We talked to the Secretary of State last week a bit about contestability and level playing fields and she actually admitted that in secondary care there was not a level playing field with the independent sector treatment centres. Dr Dixon said quite clearly that the NHS can compete perfectly well if it is a level playing field. Are there any clues that there may be unlevelling of the playing field in your sort of aspects when it comes to competition or contestability? Dr Dixon: In primary care? Q130 Dr Taylor: Yes. Dr Dixon: No. One thing that the Alliance will be pushing very hard is that it is a level playing field. It is not a level playing field, if you think of it, because front-line professionals have an inbuilt advantage in that we are used to being private businessmen in general practice, we also know our population well, we know their needs and we know what they want, a level playing field in a conventional sense and that must be so. I know the argument for not creating a level playing field in secondary care was because that was the only way to create the capacity and to encourage people to get into it and the like and that may or may not be true. I do not think those arguments apply in primary care. Q131 Dr Taylor: So you would agree with the previous set of witnesses that, as far as contestability with community services is concerned, there really is not going to be a problem because there are not alternative providers? Dr Dixon: I think alternative providers will come along and they will go to PCTs and say, "We can manage your community hospital better," or they might say, "We can run a better diabetic service in your locality than those four or five practices are doing," and the like. That is where commissioning is going to be very careful to avoid the sort of things that can happen, which is fragmentation and over-provision because that is going to be very expensive. I think commissioners are going to need to be extremely competent umpires in that game. Coming back to Robert's point, there are gaps in primary care, the quality is not uniformly good, the access is sometimes not as good as it might be and all of us need a bit of a creative edge to keep our standards up. I see the sum effect of this as being something about upping the game of public providers rather than a massive invasion by private providers. Certainly if the private provision comes in, I would hope to see them as enablers rather than us all becoming services under their yoke. Q132 Dr Taylor: Could you see them moving in to try and take over some of the threatened community hospitals? Dr Dixon: I think there will be experiments going on all over the country and it is probably good that there should be because if we find that a private provider goes into a community hospital and suddenly it is twice as good as it was and other people have not found the solutions, then I think we must let that sort of thing happen. I would hope that we would pilot them and watch them. Ultimately the decision will be for the PCT commissioners and I hope the PCT commissioners will act wisely in that. Ms Sawbridge: I would not disagree with anything that Dr Dixon has said. What has happened with some of the nursing homes in the past is they may well go bankrupt the night before, they do not give you three months' notice and then you have got the residents there to move and to sort out. Who is going to be left sorting out the community hospital if they cannot make it work? I think we should look at it and where it looks in the interests of the local population we should do that, but we should be mindful of some of the real risks. Ms Marks: I would like to add something about the voluntary sector. I think the voluntary sector, certainly where I work, in Tower Hamlets, which is very mixed in terms of the cultures and ethnic groups, does have quite a key role to play. They are involved in advocacy and interpreting services, they are involved in expert patient programmes to develop self-care for different groups of people and that is positive. I think we should remember that we need to ask questions about where it is sensible to think about whether contestability is going to help us move things forward, not just have it as something that is a blanket. Q133 Dr Naysmith: It is fairly significant that we have got to the end of a very long evidence session and we have barely touched on the public health function which lots of my friend who work in public health will tell me is always what happens, but it is a really important function. How do you think these primary care trust changes are likely to affect public health and public health programmes and the administration of public health activities? Dr Reader: I would have concerns that it would be quite a negative effect because it is back down to that local knowledge. Within very close proximities to each other you can have huge differences in health needs of the population. The bigger those get the more difficult it is to focus on those. What PCTs have increasingly been getting into over the last year or so is ways of focusing down on their communities and because of the close links that they have with the practice and the other services around that they are able to set up schemes which will address those health needs in a small localised way. I would be quite concerned that the enlarging would actually lose that focus and you would go back to the more sweeping, larger public health-type approach that we had in the health authorities. Q134 Dr Naysmith: Is that the general view? Dr Dixon: I think Peter is sounding an important warning, but I think there are ways of preventing that. Going back to practice-based commissioning, we produced a document recently on practice-based commissioning in health because it is the bit that could easily get left out because GPs are not awfully good on health, nurses and other professionals are far, far better. Q135 Dr Naysmith: Do you mean they are good on illness but not so good on health? Dr Dixon: We sometimes stick to our surgeries and we do not see our role as outside in the main street and the housing estate and elsewhere and I think that is something very exciting that we need to emancipate and see ourselves as needing to take on. In a way these changes, if managed right, could turn out better than Peter suggests. One of the problems with public health and PCTs is that sometimes it has been a bit of a dog's dinner because you have been trying to roll up your sleeves, get into the housing estate and sorts things out there a bit while having to worry about some strategy for a disease, the commissioning of the PCT and the rest of it. It seems to me that we could make something out of this if we see these much larger PCTs having public health at a higher level, that is very strategic to do, with improved commissioning and then we devolve health down to communities, going even deeper than we have with PCTs thus far and emancipating all local professionals and the local population as well to meet all of its business and be far more practical and grounded in health initiatives. Some PCTs have done that but quite a lot have not. It would be nice to see the sort of things that have been going on in PCTs through our own "Fast-Forward" and "Can Do" happening everywhere. Ms Sawbridge: We have got a chance, if we get the commissioning organisations right, to start doing some of that work around commissioning for health, not just ill health. I would agree, I think general practice has not been a natural ally of public health in the past because it does not tend to think big enough, although it can use local developments and get involved in debt, for example, by having debt collectors in their surgery and recognising the link between poverty and ill health, etcetera, it is a chance, but in order to do that you have got to have somebody who is strategically scanning that horizon at the commissioning level and who understands it and who is able to influence other people take that on board. So we need to watch that when the commissioning organisations are set up they have got the right level of clinical involvement, public health, GP, nurse, AHP, et cetera, at strategic enough levels to make sure the corridor discussions that happen are happening with clinicians and not managers alone. Q136 Chairman: Could you ever see a situation where a PCT was not a provider and another organisation could take over issues like dental health and issues like prescribing? PCTs at the moment look at the prescribing lists of all the GP practices and in some areas can and do save money for the local health service. Even going along and chatting to people that are around now that maybe were not around when you first started prescribing this drug may save your practice quite a lot of money. Who does that wider role that is out there guiding the primary health care services? Do we see this being done without PCTs? Dr Dixon: I think quite a lot of it can be done without PCTs. Practice-based commissioners will have an inbuilt advantage to make sure they are improving the local health because that will move costs upstream and they have an inbuilt advantage to rationalising their prescribing in terms of their budgets. I hope an awful lot of this will go downstream. As Yvonne says, you will need the strategy and you also need the experts who can give you the tips as to how you might be able to do it in your practice-based commissioning scheme. Chairman: Practice-based commissioning, as I think everyone would agree, in terms of a GP practice in particular is different in all cases. I know some very strong GPs who work together collaboratively with the PCT at the moment on public health and other issues. I know others who are small business people that do not go much beyond their surgeries and everything else. I have no doubt they are committed to their patients. Are they committed to the wider issues that involve the public health of the people of Rotherham and communities like it that have some very, very difficult issues in terms of public health, through industry and through culture and lifestyle? That is the real issue, is it not? Maybe it is one for Tony Stanton to answer in terms of the local medical committees. Are they able to do this? They do not do it at the moment in any great detail. Q137 Dr Naysmith: You have got to build some incentives in and some of the incentives have not been very good ones in the past. Dr Stanton: We have many tasks in local medical committees but organising the public health has not been one we have tackled so far. I would have thought, in answer to Dr Naysmith's question about the role of public health in PCTs, whatever their size and configuration, as I understand it from Sir Nigel Crisp's document, that this is their number one responsibility. The PCT should be setting the public health agenda for the area and should be identifying health need for the whole community so that commissioning groups, however they are formed, know the framework within which they are working, so they have that responsibility. Mr Sloane: I think what you are describing could well lead us on to another set of discussions around what is the future of those organisations that we currently call primary care trusts. Even using the term tends to reinforce the idea that the primary care trust is a model that is well established. What you are actually describing is a managing agency of the sort that is existing already in Brighton, where the commissioning of services is the predominant role and what that turns on is local accountability, local governance and a local demonstration that the proper stewardship of public funds is in safe hands and the performance of contractors who are executing those services is to the very highest standard that the public would expect. I think it is a hint of something that is already turning and possibly the way forward. Chairman: Thank you very much indeed. I think that has been a very good session. We are trying to cram this in to two sessions and I hope we make it. It might be a little bit ambitious in view of what we have picked up in this first one. Thank you very much for your attendance. |