Examination of Witnesses (Questions 140-159)
NATIONAL HEALTH
SERVICE
26 MARCH 2008
Q140 Mr Bacon: I use the word "lose"
loosely. What I meant was that it was quite a lot of money to
spend without realising that you were spending it.
Mr Nicholson: It was being spent
on primary care services and, retrospectively, because of the
nature of the old contract, it was impossible for us to get to
the bottom of it in time for these particular discussions. We
did subsequently and the new contract puts us in a position whereby
we can identify what we are spending and where we are spending
it.
Q141 Mr Bacon: From that point of
view the new contract is better.
Mr Nicholson: Yes.
Q142 Mr Bacon: So you are saying
that you had managed to devise a set of contractual arrangements
which made it impossible to keep track of where money was being
spent.
Mr Nicholson: No.
Q143 Mr Bacon: What do you mean by
"no"?
Mr Nicholson: The 1948 contract
for general practice was incredibly complicated and it was only
recently that it became cash limited. Up to then it was essentially—
Q144 Mr Bacon: Mr Davidson's bottomless
pit.
Mr Nicholson: We have changed
that now. Now we are cash limited and we know what the resources
are and we know what they are being spent on. That seems to me
one of the great benefits of the implementation of the contract.
Q145 Mr Bacon: Yes, I just accepted
a minute ago that the new contract is better now; I said that
a minute ago. However, the previous system was one in which it
was impossible to keep track of how much money was being spent.
Mr Nicholson: It was not impossible
to keep track.
Q146 Mr Bacon: You said it was impossible
to get to the bottom of.
Mr Nicholson: What happened was
that in the timescale we had it was several months after the year
end that we were able to get a position on what the money was
being spent in a particular year. That is true.
Q147 Mr Bacon: May I ask about the
QOF? Why did you ignore the BMA's warning that your estimate of
the number of points that GPs might achieve under the QOF was
too low?
Professor Colin-Thomé:
Hindsight is interesting. At the time I think the BMA's position
was that many practices would do much better than the average
but the estimate from academics and people in the service was
that on average we thought the practices would only get 75%. One
issue in general practice which QOF has addressed is the variation
in performance across practices. So when the BMA said that they
warned us, if in fact you look at their words they said they thought
many practices would do better than that.
Q148 Mr Bacon: In paragraph 2.12
it says "... the BMA told us that it warned the Department
that achievement would be much higher. In addition, Departmental
documents suggest that the Department was aware that the estimates
were low".
Professor Colin-Thomé:
At the time our best guestimates, which included what some BMA
people were telling us and others, including academics, was that
we thought 75% was a shot. However, this was a completely new
system that nobody had tried in the world before and GPs did better
because they put more services in. At the time the best guess
of all of us was that 75% was a reasonable estimate of what we
would do.
Mr Nicholson: It is true that
we did overspend the amount of money available to us, but, as
I have said on two or three occasions, in the last two years we
will have clawed that money back.
Mr Bacon: In conclusion just to say that
last week I was off with flu and, lying in bed on Good Friday
at about six or seven o'clock, despite my protestations my wife
insisted on calling the doctor. At about 6.30 or seven o'clock
Friday evening, within two hours of a phone call I had a GP at
my bedside in my house. I think most of us think GPs do quite
a good job.
Q149 Mr Dunne: Am I right in saying
that the increase in GP pay rates since the period of this contract
has been 0% for the last two rounds, the year we are about to
start and the current year?
Mr Nicholson: Is this from the
Doctors' and Dentists' Review Body awards? Yes, 0%.[2]
Q150 Mr Dunne: The introduction of Lord
Darzi's polyclinics is taking place now not just in London but
across the country. Is that right?
Mr Nicholson: Yes.
Q151 Mr Dunne: Am I right in saying
that each PCT has been encouraged to open one polyclinic in their
area?
Mr Nicholson: The London review
came up with a model around what was described in that review
as a polyclinic, which is a combination of general practice and
secondary care clinicians all working together in one organisation.
That is not what we are saying should happen across the country
as a whole. What we are saying across the country as a whole is
that it is up to local circumstances to determine what model of
care you have. So the idea that we have this model of a polyclinic
which has been developed in London, which can be rolled out across
the country is simply not the case. We have been really clear
with the NHS about that. What we have said is that we expect a
whole series of new health centres to be set up across the country.
We have been pretty clear about some of the core bits of those
health centres, open from eight until eight and GP-led, but over
and above that we have said it is for local circumstances to decide
what best fits into your pattern of care and pattern of service
locally.
Q152 Mr Dunne: So you are requiring
each PCT to invest in one new health centre per PCT, to be GP-led.
Mr Nicholson: Yes.
Q153 Mr Dunne: That is very similar
to a polyclinic; it is just called a health centre.
Mr Nicholson: No, because a polyclinic
in the London perspective talks about a whole range of different
services which are supposed to be in it and talks about size.
We have not talked about size in relation to these health centres
at all.
Q154 Mr Dunne: I accept that the
polyclinics in an urban environment may well have advantages to
concentrate service provision in a particular area. If you look
at a rural environment, where many of the 152 PCTs which are not
in urban areas are covering rural areas, this focus on a health
centre per PCT is almost inevitably, and certainly in my area,
going to lead to the development of a health centre in the largest
urban area within the PCT area to the detriment of the existing
GP practices elsewhere in the area because the funding is being
creamed off to support the new health centre. Is that not the
case?
Mr Britnell: No, that is not the
case. There are two things it is very important for the Committee
to realise. First of all, we are asking PCTs to commission services
not centres. We are not asking them to build new bricks and mortar;
it is up to them whether they need new bricks and mortar. We are
asking PCTs to commission new services. The second issue is £1
billion over five years—I think I said £1.2 billion
before—is new money going into the NHS to provide more accessible
and responsive services. Thirdly, as a result of the primary and
community care strategy, which unfortunately we have not had a
chance to talk about today, we shall be looking at some issues
which the NAO has raised with us, including MPIG and other matters,
to make sure we get more accessible and responsive services for
the patients we serve in the future.
Q155 Mr Dunne: They may be more accessible
for the few who have the benefit of living nearby, but they will
be much less accessible, if this is where the investment is going,
for the majority of people where investment in the other GP services
provided will be declining. I am interested to hear you talk about
services rather than centres. I have a letter here from the Minister,
Mr Bradshaw, which I received on 18 March, which talks about 152
GP-led health centres and he keeps referring to centres not services.
Centres sound to me like premises and that is certainly how it
is being interpreted by the PCT.
Mr Britnell: In the guidance that
we have sent round to PCTs in terms of their local procurements,
their local commissioning, we make it clear that PCTs have to
commission new services. It is the case that some PCTs also want
to develop new health centres; there is nothing wrong with that.
Just to go back to your previous question, we are very clear that
it is not a question of either/or. We are progressing the agenda
on extended hours for all practices. Of course it is a matter
for them whether they choose to extend their hours but we now
have recycled money, thanks to the contract, to make sure that
those practices which do want to provide more hours will be paid
for doing just that whilst also putting in extra money to procure
and commission new services, not only for GP-led health services,
but wider services, whether in Morecambe Bay or somewhere else,
basically looking at services that local people need.
Q156 Mr Dunne: On the subject of
hours, which I am glad you raised, I can understand that the health
centres may be fully staffed from eight to eight, as you are intending,
but it is a small proportion. The impression given by the Government
and your Department is that ordinary GP services will be readily
accessible to everyone: in fact they are bookable appointments
only. In most cases, in the small practices which are not in a
position to employ their staff for the extra hours because they
do not have the funding to do that, it will be doctors' appointments
only. So people will not be able to turn up, knock on the door
and expect to be received because there will be no-one to let
them in.
Mr Britnell: That is not the case
at all. First of all, we have to make sure we are providing enhanced
services for patients. We expect, as we said before in answer
to a previous question, that GPs can combine their services to
tender for new commissioned services. How they do that is a matter
for them. I hope that nobody would think that actually providing
new services for extended hours is a bad thing for patients. If
it encourages professionals to think how they work together, then
so be it.
Q157 Mr Dunne: It is not a bad thing
for those patients who are able to book appointments and meet
those appointments. However, for the general public to get the
impression that extended hours are going to mean access when they
are advertised as having appointments, but actually it is by appointment
not by open access, is misleading.
Professor Colin-Thomé:
On the health centre which is open eight to eight seven days a
week, that is for booked and non-booked.
Q158 Mr Dunne: I accept that, but
that is only 152 and there are 8,000 practices or more around
the country where that will not apply.
Professor Colin-Thomé:
It is a minimum. If practices want to open for extended hours
and if it is a single-handed practice then many, as my father
used to, will work with other doctors who can provide that range
of services without doing it themselves. On some things you might
want to compete and on other things you should collaborate. You
cannot have it both ways. If you want to be small, that is great
in one sense, but you cannot then provide an extended range of
services. There are ways round that and many practices share that
responsibility.
Mr Britnell: That is a matter
for local PCT discretion, listening to what its population wants
and then deciding what it wishes to commission.
Q159 Mr Davidson: It is a question
again of dealing with areas of deprivation. It was stated that
one of the objectives was to deal with the shortfall in areas
of deprivation. Really, from the report we have here, it is clear
that has not been achieved. Can you give us a note indicating
what steps you intend to take to address that? Maybe you could
just give us an indication now of when you expect that element
of the contract will have been dealt with adequately.[3]
Mr Nicholson: There are two aspects
to it: one is the 100 more GP practices in the deprived areas.
We are working through a procurement process at the moment and
we expect that to end in December, so we would expect those practices
to come on stream in 2009. The second part is the reform of the
minimum practice income guarantee which enables us to move money
around and much more effectively fund areas of deprivation.
2 Information provided by witness: NHS Employers
negotiated 0% in 2006-07, DDRB 0% in 2007-08 Back
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