Examination of Witnesses (Questions 80-99)
NATIONAL HEALTH
SERVICE
26 MARCH 2008
Q80 Angela Browning: Have you done
any analysis into the fact that there is this identified problem
of speed of access, that people would short-circuit the system
and go straight to casualty and other hospital services.
Professor Colin-Thomé:
There is no evidence that the increase in A&E attendances
came after the GP contract; that was going up for some reason
before and actually has tailed off. That did not seem to be cause
and effect is all I can say.
Q81 Angela Browning: There is obviously
a cost factor there in terms of the hospitals and their A&E
departments.
Professor Colin-Thomé:
Yes. What I can say is that in the areas which often surround
hospitals, some of the more socially deprived areas, there are
insufficient doctors and nurses in primary care and that is why
we got this big push. Just having primary care there, even without
QOF does seem to produce better health outcomes for our population
and that is why we are so keen to do that. It is often areas around
hospitals which attract people who have not been able to access
their traditional general practice and that is why we have more
practices coming in and extending their hours.
Q82 Angela Browning: I want to move
on to PCTs but first very briefly, in the NAO Report there is
reference to a concern they have picked up about younger GPs not
being amenable or looking to become partners for various reasons.
That does not auger very well for the future.
Professor Colin-Thomé:
Yes, it does. The difference in being a partner is that he or
she has to run the practice as an organisation and many GPs say
they do not want to do that, they just want to be a GP. So it
does not auger badly for having GPs, but it does say that the
management of the practice is less popular and that might mean
you have to have different people managing it rather than GP partners.
Certainly in our practice there are many partners coming in now,
even if they are partners, who do not want, for instance, to take
their share of owning the property. So there is a shift in attitude.
Q83 Angela Browning: Is this purely
a financial business commercial thing? The reason I am asking
this is because I am just wondering about the fact that there
are lots more part-time GPs and therefore if you are a part-time
GP you may be less inclined to seek a partnership?
Professor Colin-Thomé:
Yes. I do not have any detailed figures on that but certainly
I have practised where several of us became part-time or were
part-time and they all were partners. It is a choice, but if you
are a partner you have to run the business as well as be a good
doctor and that is an added responsibility and some do not want
to do that.
Q84 Angela Browning: But we do need
to ensure that there are people capable and qualified as managers.
Are you addressing that in your future planning?
Professor Colin-Thomé:
Yes and part of our strategy for the future which we are doing
with the Lord Darzi work is addressing some of those issues.
Q85 Angela Browning: I want to move
on, if I may, to pages 12 and 13 of the NAO Report which are specifically
to do with PCTs. On those two pages there is a long list, a very
long list, a to h, with recommendations of what PCTs should be
doing in terms of their role in all of this. It does seem an exceptionally
long list and it covers a multitude of disciplines and I wonder,
before you answer, whether the restructuring of PCTs around the
country has had anything to do with this.
Mr Nicholson: One of the reasons
we went for restructuring was that it was pretty obvious to us
that it was unlikely that we could deliver the level and quality
of people in 303 organisations across the country. We had to improve
the quality of our commissioning in primary care and primary care
trusts.
Q86 Angela Browning: May I just stop
you there? I am sorry to interrupt but you say that it was impossible
for you to do this. Surely when you had smaller PCTs they would
have had a much better handle on local needs, local practices
and local demographics of populations. I speak from the County
of Devon where we now have one PCT. I have to say that if you
look at the geography of the County of Devon with two moors in
it plus big cities like Exeter, Plymouth, et cetera, I would have
thought you would have benefited from the experience of people
running smaller areas within a PCT region.
Mr Nicholson: There is no doubt
that small PCTs geographically focused could get lots more information
and knowledge about local circumstances; it is absolutely true.
The issue for us is what they would do with it when they had that
information. What was pretty clear to us was that PCTs were not
strong enough, did not have the depth of expertise, the depth
of analysis, the depth of understanding and the commissioning
ability, commissioning capacity to drive the change that we needed
to do. That is one of the arguments around going from 303 to 152.
We think that having bigger PCTs with more concentrated managerial
and analytical ability, coupled with practice-based commissioning,
which does give you that local experience, is the best balance.
We have put quite a lot of effort now into making sure that our
PCTs can commission and deal with these issues and Mark has been
leading that.
Q87 Mr Davidson: I and my colleagues
would agree with the objectives and see them as laudable but what
I am not entirely clear about is the competence with which all
of this was handled. On page 42 we have a timeline of much of
what was done. Just at the bottom, on 19 January, the Secretary
of State made a statement "I think if we anticipated this
business of GPs taking a higher share of income in profits we
would have wanted to do something to try to ensure that the ratio
of profits to the total income stayed the same". Then on
1 February we have one of the BMA negotiators saying that the
BMA were astonished to be offered such a generous package. That
does look rather as though the union basically took the management
to the cleaners, does it not? Is that basically correct?
Mr Nicholson: What I would say
about the contract is that—
Q88 Mr Davidson: A simple yes or
no would be sufficient.
Mr Nicholson: No.
Q89 Mr Davidson: Do you know whether
the BMA negotiators got a bonus from their colleagues?
Mr Nicholson: I do not know the
answer to that.
Professor Colin-Thomé:
It is unlikely.
Q90 Mr Davidson: They possibly should
have, should they not really?
Professor Colin-Thomé:
I think Simon Fradd's view was a minority view in the BMA.
Q91 Mr Davidson: It is a minority
now I suspect; a minority on the basis that he should not have
said it.
Professor Colin-Thomé:
That may be one interpretation but I think it is a different interpretation.
Q92 Mr Davidson: Am I right in thinking
that this has been a private company, as it were, with a limited
income and not having access to the bottomless pit of government
funding this deal would have bankrupted the NHS?
Mr Nicholson: No.
Q93 Mr Davidson: How much was the
overspend?
Mr Nicholson: It was £400
million and we have got it back over the last years or we think
we have got it back.
Q94 Mr Davidson: But not at the time.
Mr Nicholson: No.
Q95 Mr Davidson: Companies who get
bankrupted do not generally get away with it by saying they will
be all right in a while. They are bankrupt at the time. Somebody
had to bail you out basically.
Mr Nicholson: No, we sorted the
issue out ourselves. Over the last three years the NHS has moved
from deficit to surplus. Not only have we paid back our deficit,
we have also produced a surplus.
Q96 Mr Davidson: Let me be clear
then. You already actually had that £1.78 billion or £400
million, the figure being in dispute. You had it in your back
pocket ready, so you could have paid more to the doctors. You
actually had that money for this deal, did you, or was it money
you had to take from somewhere else?
Mr Nicholson: We had to take it
out of somewhere else. It did not bankrupt us.
Q97 Mr Davidson: It would have bankrupted
you if you had not had that money floating about.
Mr Nicholson: We did not take
the view, nor is there any evidence that we thought there was
a bottomless pit of taxpayers' money when we went into this.
Q98 Mr Davidson: Where did the money
come from then? Which other services suffered?
Mr Nicholson: The NHS had a deficit
of £250 million in one year and £500 million in the
other.
Q99 Mr Davidson: Fine, so you were
bailed out.
Mr Nicholson: No, we were not
bailed out.
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