Examination of Witnesses (Questions 160-165)
PROFESSOR SUE
HILL, SIR
LIAM DONALDSON,
DR DAVID
COLIN-THOME,
PROFESSOR BOB
FRYER AND
MR ANDREW
FOSTER
11 MAY 2006
Q160 Sandra Gidley: You say there
is a baseline, but it is quite difficult to assess what more is
being delivered because I have seen reports which say that what
has actually happened is that the good GPs are just getting paid
more for what they delivered anyway and with the GPs who perhaps
needed the biggest kick the improvement has not been quite so
great. Hospital episode statistics have been collected since 1987,
but there are no parallel statistics for GP activity. Is anything
being done to address this imbalance?
Dr Colin-Thome: The quality and
outcomes framework now does that. All we had were patient contacts,
but now two things have come from the contract. One is that it
is much easier to put this information on the computer, because
it is really hard to track patients if you have paper-based records.
One of the side benefits is that we have a fantastically better
database of what patients have got wrong with them. That is number
one to build up for the future. Two, we do have quite key markers
now about the effectiveness of care. What the QOF people did,
quality outcomes framework people did, including our expert panel,
was look at process measures which were easy to measure because
they would fit a contract, but which you know will lead to outcomes.
That is why a lot of the clinical points were for things like
diabetes and heart disease and stroke because we have better evidence
that those measurements lead to better health outcomes. That is
what they did. It was not that good doctors were not doing good
things; it was that we managed to raise the level of all our patients
rather than the variation because there was a more systematic—
Q161 Sandra Gidley: Would it not
have been better to have had a year of base-lining to find out
what was actually happening in practice so that you could actually
see whether you were getting better value for money in the end?
Dr Colin-Thome: In a scientific
sense yes, but the real issue for us was that we were desperate
to get more investment into primary care because the number of
GPs' had remained flat for years and the number of consultants
was growing. One of the negotiation points was how to get more
money into primary care to make it a much more attractive career
and that seems to be working in the early days and that certainly
ought to work if you look at the same sort of event which happened
in 1966 with the contract. The second thing is what we were determined
not just to give lots of money but at least to try to link it
with a quality based contract. In an ideal sense it would have
been better, but on the other hand there is some urgency to invest
more in primary care and that seems to be benefiting. It would
not have been ideal, but often a negotiation contains a lot of
different issues which you are trying to address and that was
what we came up with. At least now we have this baseline. What
we are going to do is introduce new facets and we do not have
a baseline for that, but at least it is a start. Often people
collect better data when they have some incentives to do so and
that means that the database will be much tougher and more accurate.
After all, we do get reviewed at practice level by our PCTs to
check that we are not doing things correctly. In an ideal sense
I would agree, but there was a whole package of reasons why we
were investing more into general practice, not least the fact
that since we have better outcomes and better effects for the
health service from primary care we needed more people in primary
care.
Q162 Dr Naysmith: May I comment on
something you said? You said that some PCTs in some parts of the
country came in on budget and therefore they maybe estimated better
what the cost of the contracts was going to be for PCTs, but actually
what happened in the PCTs where that happened was that they postponed
development and investment plans that they had planned for that
year and they have now had to postpone them or give them up so
they could come in on budget. That is what they tell me.
Dr Colin-Thome: That is the job
of a manager really: to manage that resource and set priorities.
Q163 Dr Naysmith: Of course. All
I am saying is that it was not because they estimated better what
the contract was going to cost.
Dr Colin-Thome: Some might have
done, because they may have had a better shot at assessment. If
you look at some of the personal medical services, PMS, 40% of
GPs, the PCTs had a clear view, as a sort of exemplar, of what
practices could achieve, because they had local contracts. You
are right in some senses: you manage a budget by setting out the
priorities and one of the biggest priorities for the best hit
for your pound is actually investing in primary care. There is
an international evidence base to back that.
Q164 Dr Naysmith: I am not disagreeing
with anything else you have said, that is the only bit you said
that I disagree with.
Dr Colin-Thome: That is what a
manager does. If there are some issues you have to prioritise,
you may have to delay others.
Q165 Dr Naysmith: They had carefully
budgeted for developments they intended to put in place this year
and they could not do them because the contracts came in at slightly
more than they expected.
Dr Colin-Thome: Right; yes.
Chairman: May I thank you all very much
indeed. May I also thank you and some other organisations for
contributing to our written evidence which has now been published
and will be available for people to look at. We have had quite
a long session this morning and thank you Andrew Foster particularly
for being involved. Thank you all. This is the first public session
of a very long inquiry which I hope will come out in a few months'
time with some guidance in terms of where workforce planning should
be going in healthcare in general; not just in terms of the National
Health Service but where we all often need to have different forms
of healthcare. Thanks again very much. Sorry about the lateness
of the hour; these are becoming far too predictable now.
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