Examination of Witnesses (Questions 860-879)
SIR JONATHAN
MICHAEL, MR
MIKE SOBANJA
AND MS
SUSAN HODGETTS
18 JANUARY 2007
Q860 Dr Taylor: At what stage in
their careers does that arise?
Ms Hodgetts: That comes right
at the beginning as a core competence.
Mr Sobanja: In terms of primary
care, I think there is a pressing need to see a career development
pathway associated with developmental training for clinicians
of all backgrounds, be it general practitioners, nurses, physiotherapists
and so on—all of my colleagues who work there—who
are often associated with the management task through the professional
executive committee but given very little support and development
to undertake that role. For example, one of the difficulties facing
general practitioners coming out of practice and perhaps going
part-time in order to fulfil management positions is what they
do when the structure changes or their faces do not fit any more.
There is no career pathway and it may well be that back at the
practice their jobs have been taken or altered and they are out
on a limb. There is very little incentive for some clinicians
to get involved in management if there is no clear pathway in
front of them. Having said that, there are advantages in having
clinicians in management but that is not the total story. We want
the best people whatever their professional background which means
encouraging all managers, not simply one group.
Q861 Dr Taylor: Have any general
practitioners done what Sir Jonathan has done?
Mr Sobanja: Yes.
Q862 Sandra Gidley: It was said earlier
that the reason there are more managers in primary care is that
they are taking on new jobs, mainly commissioning. Did we have
the right people with the right skills at the time? How effective
has PCT-led commissioning been over the past five years?
Mr Sobanja: I think it was in
1990 that I was appointed director of commissioning in a health
authority. I observed at the time that I did not know what the
job was, and I do not know that much better what it is now. I
can offer an opinion on the nature of commissioning and what it
should be, but I think there has been a lot of confusion about
it over the years, particularly in terms of whether or not we
have a provider-led service or commissioning-led service and how
much commissioning should be related to the needs of local communities,
which was apparent when we had 481 primary care groups. It is
less apparent now we have 152 PCTs, the largest of which has a
population of over 1.2 million. Relating the PCT to local communities
will not be easy. I think that the history of commissioning has
been remarkably variable. Without doubt there have been successes
around the country in terms of reshaping and redefining care,
which I take to be the basis of commissioning, understanding local
needs and being able to articulate those needs into service requirements
and securing those services. If we go into the area of comparative
performance we are very poor in assessing it and evaluating the
health outcomes attributable to commissioning. My bottom line
is that commissioning has been a bit of a curate's egg. It is
immensely variable round the country and commissioning is yet
to demonstrate that it makes the real difference that we thought
it might when it was first introduced in the 1990s.
Q863 Sandra Gidley: It is all up
in the air now anyway because we have changed the system. We have
practice-based commissioning, which is often referred to, quite
worryingly in my view, as GP commissioning. GPs are not trained
in commissioning. Should we be training GPs to perform this role,
or are there challenges in the new system that is being introduced?
Mr Sobanja: I think there are
new challenges. There are different aspects of practice-based
commissioning. First, it covers a very broad spectrum. On the
one hand, one can be a practice-based commissioner if one receives
information about the consequences of one's referral patterns
for other behaviours as a clinician. I echo your sentiment about
it not being GP-focused alone. On the other hand, one can be a
practice-based commissioner if one is designing or redesigning
services and making a real difference to patients. One has those
two aspects in the continuum. Second, there is a debate which
I do not believe the Department of Health or ministers have yet
resolved; that is, whether the introduction of practice-based
commissioning means the shifting of commissioning responsibility
from PCTs to practice-based organisations, be they localities,
clusters or whatever name it is, or is practice-based commissioning
to be the whole system's healthcare commissioning by PCTs through
groups of practices for designated populations? Somebody has to
commission primary care and look at the continuum. I would tend
towards the latter. I do not believe that a view of the world
which says that the time of PCTs is up is right because of practice-based
commissioning. I think that the job of commissioning primary care
as part of the whole system of care makes it potentially more
challenging. To take just a minute to explain it, I am referring
to a PCT giving a group of practices £10 million to manage
diabetes care for their registered population. They have to provide
what needs to be provided and that which they cannot or do not
want to provide they commission from a third party. That might
be another group of practices, a hospital or some other entity.
In that sense, practice-based commissioning is far more like sub-contracting
and the primary responsibility for managing all-round care for
patients rests with that practice cluster. That issue has not
been resolved. I am not sure about the Government's intent with
regard to that and until then I do not think the role of PCTs
is clear.
Dr Naysmith: I do not think we should
go too far into this subject because we were focussing on how
to get a trained workforce.
Q864 Sandra Gidley: That was the
point I intended to follow up. What training is provided to managers
to manage this? In the past there was a system which in some respects
they were ill-qualified to administer. We have changed the system
completely, and it seems that there are huge training needs that
may not be being addressed. Is that a fair comment, or are the
skills transferable?
Mr Sobanja: I believe it is a
fair comment even though there are some transferable skills. If
one has not been clear about the true nature of the task it seems
to me that one cannot then do a retraining analysis followed by
a gap analysis and put things in place. That is not to say there
is not any training on commissioning because Ms Hodgetts has mentioned
some of it in connection with the NHS Institute for Innovation
and Improvement. There have been other courses about commissioning
and so on, but I argue that it is pretty patchy and ad hoc round
the country, to coin a phrase used earlier.
Q865 Dr Naysmith: Ms Hodgetts' body
language did not quite agree with a couple of things.
Ms Hodgetts: Some generalised
statements have been made. Some training is available, but I agree
that it is ad hoc. There are some pilots in place around vocational
training schemes for practice managers which includes an element
of commissioning. We are very much at the beginning of looking
at how we can disseminate that across the country.
Q866 Sandra Gidley: To put the cat
among the pigeons, do managers in PCTs tend to be less experienced
and competent than those in acute trusts? Would anybody like to
answer that? Perhaps one cannot generalise.
Ms Hodgetts: I cannot generalise.
Q867 Jim Dowd: Referring to Dr Stoate's
point about the growth in managers in PCTs compared with acute
trusts, which is a five-fold increase in less than four years,
how much of that is due to the introduction of PCTs compared with
the relatively stable number of acute trusts? If that is the case,
do you think too many PCTs were established at the outset?
Mr Sobanja: I think that a fair
amount of it was to do with the expansion in the number of PCTs
and those groups, although undoubtedly one element is the expansion
of the functions within them. As to whether too many PCTs were
established, I think the problem is that if we go back to primary
care groups the reason for breaking up health authorities was
two-fold. There were 95 health authorities when I was a health
authority chief executive. The argument was that we needed to
get closer to local communities and local clinicians. That was
the basis for setting up 481 PCGs. Undoubtedly, those PCGs of
which local clinicians had more ownership, including general practitioners,
also got closer to local communities. If you place that emphasis
upon it there probably were not too many. If you then get into
the question of economies of scale around contracting, shared
functions and payroll and all the things people think of as being
at the forefront of managers' minds then there were probably too
many. There is a real dilemma here in understanding the nature
of the job. Personally, I regret the reduction to 152 for the
reasons I have just mentioned. The management task is about health
improvements in local communities and it should remain focused
there. It has to be done in an efficient way, but I think there
are problems in doing that and there is bound to be a cost.
Q868 Jim Dowd: Do you think that
one PCT per borough in London is an efficient use of resources?
Mr Sobanja: No.
Q869 Jim Dowd: Are there too many
or not enough?
Mr Sobanja: There are too many.
If you look at experience around the country and the population
served, the conclusion that you need 31 PCTs for the population
of London, even though the density is greater, leads me to believe
that that is too many and should be reduced.
Q870 Jim Dowd: Has the introduction
of GP contracts changed the role of PCT managers?
Mr Sobanja: I think it has because
the previous contractual arrangements based upon the red book
were about reimbursement for services provided, paid for in part
by capitation and in part through a fee per item of service. The
introduction of arrangements around GMS, PMS, CPMS—all of
the five variants to secure primary care medical services—means
that there is now a requirement to commission general practitioner
services and other services. I think that that alters the job
very considerably. In the past one needed someone in the back
office who knew the book very well. The data came in and whatever
people did they were reimbursed for. Now you need people who are
thinking about what should be provided in primary care, how it
links up with secondary care, what the transition points are and
making sense of that. It is in my view a much more skilled job.
Q871 Jim Dowd: Earlier you mentioned
the qualities and outcomes framework. Has QOF given PCT managers
more control over GPs?
Mr Sobanja: "Control"
is an interesting word. The way I put it is that it has legitimised
an area of clinical activity. What was often a no-go area for
managers is become a "go" area to challenge and to seek
justification for clinical activity. I do not recognise general
practitioners being controlled by managers as something to do
with reality.
Q872 Jim Dowd: Or as controllable
in many cases?
Mr Sobanja: Your conclusion, sir!
Q873 Jim Dowd: Should managers have
a greater role in auditing QOF returns from local GPs?
Mr Sobanja: The QOF returns are
audited, but for some behind that question may lie an assumption
that the QOF is a money-making machine that is being used by general
practitioners. I do not believe that that is the case. Undoubtedly,
the quality and outcomes framework has been responsible for increasing
the standard of primary care medical services right across the
UK, and it should be commended for that. That has come at a cost.
In my view, the audit arrangements which involve practice-based
visits and so on are perfectly adequate at the moment. One might
have a look at one or two areas such as exception reporting and
so on, but I believe that they are fringe activities and not things
that require a heavy-footed approach which would undermine the
relationships between managers and clinicians at the cost of services
to patients.
Q874 Dr Naysmith: I do not want to
let Sir Jonathan off the hook completely. I know that he is not
involved in GP practices and primary care, but some of the things
done under QOF now are things that are currently in acute hospitals—there
are moves to expand them in future—for example, monitoring
and managing diseases outside in the community which in the past
would have meant visits to acute services to see consultants or
members of their teams. Will this have an effect on you as a manager
in acute services?
Sir Jonathan Michael: Yes, it
will have an effect, but my preference would have been to move
away from the old-fashioned paradigm which separates community
from institutional care and think more about integrated care pathways,
particularly for those patients with chronic disease. If one looks
at mental health, there is an integrated delivery pathway which
includes where appropriate both institutional and community care.
I think that progressively we will move different disease groupings
into a similar model. It is then a question of who co-ordinates
that integrated care pathway as well as who delivers it, or who
contributes to its delivery. Potentially, it can have an effect,
but the optimistic view is to say that we can also have a role
in delivering an integrated care pathway in a community setting.
Q875 Dr Naysmith: Is the interaction
between community and the acute services being co-ordinated?
Sir Jonathan Michael: It is something
that is being discussed and developed locally. It is possible
given the regulatory framework within which we work, so it is
up to individual organisations and PCTs to agree what is the appropriate
way of handling it. There are already examples in this country
and quite a lot of discussions going on that are focused on specific
disease pathways.
Mr Sobanja: To give you an idea
of scale, the alliance has a network of 285 consultants working
in community and primary care settings who meet for the exchange
of ideas and so on. It is not a tiny minority.
Q876 Charlotte Atkins: Moving to
management training skills, what does the NHS actually do to get
a management workforce that is fit for purpose?
Ms Hodgetts: In terms of the whole
NHS one has the graduate training scheme which currently has about
400 students participating in it. That is where the NHS has harnessed
a great deal of intellectual capital. As I am sure you know, a
lot of those graduates will go into senior posts within the NHS.
What is quite interesting is that the graduate trainees who become
senior managers are these days less inclined to go into chief
executive posts for the reasons we have discussed, namely the
short-termism associated with those kinds of posts. That is what
the NHS does formally. Informally, there are local arrangements.
There is nothing formal for general or healthcare managers per
se.
Q877 Charlotte Atkins: You referred
to the graduate management training scheme, and there is the gateway
to leadership scheme. Are they effective? Obviously, they are
there for new entrants into the NHS. What is done for all those
managers who have been at various levels for 20 or 30 years? Do
they get any systematic training to make them more effective?
Ms Hodgetts: It is systematic
only if it is supported within the organisation, not across the
board.
Q878 Charlotte Atkins: Therefore,
it is ad hoc and depends very much on what each hospital or Strategic
Health Authority does?
Ms Hodgetts: One would hope that
within a good organisation that would happen.
Q879 Charlotte Atkins: You would
hope, but does it happen?
Ms Hodgetts: One hopes it does
happen.
| 
