Examination of Witnesses (Questions 20-39)
DEPARTMENT OF
HEALTH, PARTNERSHIPS
FOR HEALTH,
PARTNERSHIPS UK AND
DR KOHLI
17 OCTOBER 2005
Q20 Kitty Ussher: That is extremely
useful; thank you. Might I turn to issues which have arisen locally?
I have to say, so that people can understand, that we have a building
powering up in the centre of my constituency which is a health
and leisure centre and people are amazed by how good it looks
as though it is going to be. However, some specific issues have
arisen. I have four specific ones. The first one is on design
and architectural design where about two weeks before the contractor
was due to start digging the hole huge concerns were raised by
CABE, the Commission for Architecture and the Built Environment,
which is the national body to look at architectural standards.
I felt that there were some last minute modifications made to
the design as a result of that, but I suspect that had those come
sooner there would have been more substantial revisions, to be
honest. How can we make sure this situation is avoided in future?
Mr Johns: Partnerships for Health
have collaborated with CABE since the very start of LIFT and indeed
we invited them to comment and they did comment on the original
technical specification for LIFT. They also provided design enablers
on a number of the schemes which were the original schemes to
be developed. They are working with us on the fourth wave of LIFT,
again providing design enablers, but they have limited resources,
so they are not able to provide an enabler for every scheme. The
most important answer to your question is that we are now working
with CABE and DoH Estates to undertake a design review of all
the LIFT buildings which have been developed to date. The intention
of that design review is actually to provide lessons for designs
for architects for future schemes. That is how we are systemically
addressing the design issue.
Q21 Kitty Ussher: Thank you very
much; that is encouraging. We obviously have a huge shortage of
dentists in my part of the world—I am sure I am not alone—and
my constituents are desperate to see as many dental seats in there
as possible available to the public on the NHS. Are there any
guidelines as far as you are concerned to ensure that happens?
Mr Coates: I am not aware of any
formal guidelines on the number of dental facilities to provide
within LIFT. If you wanted a note, I would have to come back to
you with that. I am sorry.[2]
Q22 Kitty Ussher: It would be useful
to know whether there are.
Mr Johns: There are actually dentists
taking up occupation in buildings already. We have about a dozen
dentists and in fact in Birmingham we have a dentistry training
facility which has been developed as part of the initial LIFT
scheme there.
Q23 Kitty Ussher: It is obviously
a great opportunity. There has been concern amongst local independent
pharmacies that the way that the contracts are being given for
pharmaceutical services inside the new LIFT building effectively
crowds out local provision. My understanding of current government
policy is that they do wish to support independent pharmacies.
That certainly will not happen as a result of the way the contract
has been let in my constituency, which is a pity. They have not
felt able to bid commercially. Is that something you are seeking
to avoid?
Mr Coates: No. There is no guidance
of which I am aware where we say that sectors cannot bid for franchises
in LIFTCos and there is certainly no central guidance which tries
either to target or limit independent involvement in LIFT premises.
Mr Johns: Indeed on the visit
last Thursday there were two representatives from local pharmacies
who were there, who are operating from the facility we visited
in Church Road in East London. What they told us was that the
local independent pharmacists had formed a consortium so that
they could provide services from the LIFT building. I think that
is a model which has been considered in other localities as well.
Q24 Kitty Ussher: Perhaps I could
pose the question the other way. We only have one or two local
independent pharmacies which are interested and I think that the
national players are not interested in forming a consortium with
them, so they are completely unable to compete in the absence
of guidelines to say that local pharmacies should be looked at
sympathetically. Should we not have that?
Mr Coates: Is your question around
the money side of it, affordability?
Q25 Kitty Ussher: I presume it is
money. I presume that the large pharmacies like Boots and Moss—I
do not know the specifics—are able to undercut by virtue
of economy of scale.
Mr Coates: My understanding on
the pharmacy side in LIFTs is that PCTs can support the rental
cost within the development. For example, if they feel that it
is essential that there is a pharmacy within the building then
they can subsidise the rental paid by the independent contractors.
Q26 Kitty Ussher: So this is something
we can take up with the PCTs.
Mr Coates: Yes.
Q27 Kitty Ussher: There is also concern
that some GPs who are currently based in deprived areas, which
is seen as a good thing, will be sucked into this momentum to
relocate into the centre of town. Is that something you are seeking
to avoid?
Mr Coates: To avoid?
Q28 Kitty Ussher: Yes.
Mr Coates: The location of health
services within any economy is clearly down to the local PCTs
and their Strategic Service Development Plan (SSDP). All LIFT
tries to do is to provide a framework within which we can provide
assets and services flexibly to the local economy. There is no
central guidance of which I am aware which tries to do what you
are suggesting in terms of bringing people in from the suburbs.
Q29 Kitty Ussher: Do you accept that
if the facilities offered in a LIFT centre are of excellent quality
then GPs may be more likely to want to move there and thereby
provide a less good service to people out in deprived communities?
Mr Coates: That is a risk, but
with the additional funding going into the NHS over the next two
or three years it is a case of rolling out improvement as and
when we can. All we can do is target the initial developments
on the areas of greatest need and then cascade those out to other
areas over time. I am not aware of any policy which you are suggesting
in terms of trying to squeeze anybody out.
Q30 Ms Johnson: I should like to
start by talking about the role of the local authority and the
important role that I think they should have within this structure.
I was interested to see in the Report that there is only one local
authority which is actually a shareholder and I think that is
Barnsley. Do you have any comments about the role that local authorities
could or should be playing and are not at the moment?
Mr Coates: May I ask Brian to
answer the question about local authorities' involvement in LIFT
now as opposed to when the Report was written?
Mr Johns: Things have moved on
since the Report was undertaken by the NAO. I am aware of four
localities which have local authority shareholding already. They
are Newcastle, Barnsley, Doncaster and Nottingham. There may be
one or two others of which I am not aware but at least those four
do have shareholdings. I fully agree with your question. We think
it is absolutely vital to get the joined up working between primary
care trusts and local authorities. Referring back to the Burnley
scheme, that is actually an integrated scheme which is both health
provision and also a sports centre for the local population. The
strategic partnering board encourages that joint strategic planning
between PCTs and local authorities.
Mr Coates: You do not have to
be a shareholder to invest in local authority accommodation. It
does not necessarily follow that you have to be an investor to
get in.
Q31 Ms Johnson: I wanted to ask about
that because, as you were saying, you can become a tenant of the
premises as a local authority without being a shareholder. Are
most local authorities taking up the option?
Mr Johns: I could not quote exact
numbers but the majority of local authorities have signed up to
the partnering agreement, that is the long-term agreement, which
means that they can actually commission the schemes from the LIFTCo.
As Mr Coates said, they do not actually have to be shareholders
in the company to have that facility. The majority have taken
that option and, having done that, they can be tenants in LIFT
buildings going forward.
Q32 Ms Johnson: I want to refer you
to paragraph 2.5 in the Report which talks about the constraints
preventing the full involvement in LIFT which local authorities
have found. What were these constraints and have they started
to be addressed?
Mr Coates: I think the constraints
relate to their own corporate governance arrangements within the
local authority. There are no barriers of which we are aware to
prevent local authorities becoming shareholders within LIFTs.
My recollection of the Barnsley transaction is that the local
authority there did seek legal opinion on whether they were entitled
to invest or not and eventually came to the conclusion that they
could do so. There are obviously the usual things about change
and doing things differently. All we can say is that over time
local authorities have become more accustomed to the idea of LIFT
and you often see articles now in papers and periodicals written
by the 4Ps, local authority advisory group encouraging local authorities
to participate in LIFT and become more fully involved in it.
Q33 Ms Johnson: So there are no structural
barriers, it is just a perception that this is not how they have
operated in the past.
Mr Coates: Not that I am aware
of.
Mr Stewart: There is one practical
point which is that when the LIFTCos are set up for the first
time there are the sample schemes which are bid on. In practice
the local authorities have not had a very significant involvement
in these sample schemes, but they will have a much greater involvement
downstream. They are looking at a LIFTCo and they are wondering
whether they are involved, whether it is worth putting their equity
in and becoming a shareholder in the LIFTCo from day one, probably
thinking it is not really and that they can sit on the strategic
partnering boards. That is the very practical consequence of the
makeup of the first schemes.
Q34 Ms Johnson: What interests me
about this is the idea that you can bring together the primary
care sector and the care sector that the local authority provides.
Is there any kind of condition or coercion about making these
two work together in a more coherent way? At the moment it just
seems to be left that if people feel this might be helpful they
will do it. Is there a way of making people work together?
Mr Coates: We have to provide
a framework within which the local communities can work together
and deliver services on a collective basis. I confess I cannot
answer questions about any specific examples where we can give
incentives to the voluntary sector. We obviously have good examples
locally where people have come together, but all these things
depend on the gradual learning from others who do successfully
involve the voluntary sector, for example. There is no framework
here.
Q35 Ms Johnson: May I turn to GPs?
I want to ask about the extent to which you think that LIFT will
contribute towards an increase in recruitment and retention of
GPs?
Mr Coates: There is evidence from
the LIFTs we have, indeed we heard it from our visit on Thursday,
that people generally, not just GPs, want to come and work in
LIFTs because of the buildings, because of the better quality
facilities, but we are collecting no data to try to demonstrate
whether that is the case or not.
Q36 Ms Johnson: So it is just a feeling
that it might help.
Mr Coates: We do have evidence
from individual LIFTs saying that it is helping recruitment and
retention, but we do not try to collect data in that area.
Q37 Ms Johnson: Why do you think
that there is a problem with dentists and opticians being interested
in getting involved in LIFT?
Mr Coates: I think in the Report
it was their associations which said that rather than the individuals.
All we can say is that when we try to have those facilities within
our buildings by and large we are able to attract the tenants
and the one you saw last week did have both optometrists' and
dentists' facilities.
Q38 Ms Johnson: I was also interested
that in the Report there is mention about PCTs having to subsidise
rents to meet the wider health agenda. I think it is paragraph
2.14 of the Report. How often is that happening and is this an
indication that rents are too high?
Mr Coates: It is partly a reflection
of the ability of the location to attract enough of these businesses
and certainly for chemists there is the ability for the PCT to
subsidise the rents. It is one of those areas and situations where
it is up to the local PCTs to talk to the health economy more
widely and demonstrate the benefits of bringing together these
services on one site.
Q39 Ms Johnson: What is concerning
me is that again this might be taking money away from the local
health economy to subsidise rents; that concerns me somewhat.
Mr Johns: The way the PCTs look
at it is that they see pharmacists as part of primary care. Pharmacists
can provide a substantial amount of assistance to GPs in the work
they do and it is in those circumstances that PCTs have elected
to provide some sort of subsidy for the pharmacists to come in
there. If that were not the case, because the pharmacy has the
opportunity of over-the-counter sales and that opportunity does
not exist for GPs, the LIFTCo could be charging a more commercial
rate for the pharmacy. If the pharmacist is assisting the GP to
provide primary care services, then in those circumstances the
PCT may subsidise part of that rent.
Mr Coates: However, we do accept
your point that there is this perception that as you develop one
area it seems to suck resources in out of other areas. All we
can say is that there is record funding going into the NHS and
over time these things will equalise.
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