Examination of Witnesses (Questions 220
- 227)
THURSDAY 14 JANUARY 2010
PROFESSOR ANDREW
STREET AND
DR PETER
BRAMBLEBY
Q220 Mr Scott:
How important is the voice of the clinician or public health expert
in commissioning healthcare? Do you believe there are too few
public health experts on the ground at the moment?
Dr Brambleby: It is very important.
What we have in healthcare which makes it very different from
other markets and other traditional economic models is the whole
concept of need. It is not simply supply and demand or a patient
saying, for example, that he needs to check his diabetes 16 times
a day with a test kit. You need a clinician, who may be a doctor
or nurse, to be the patient's advocate and agent and say that
the evidence suggests that for his condition maybe testing twice
a day is sufficient. You need an agent to interpret the symptoms,
signs and pattern of care, so you require the clinician voice.
The appropriate involvement of clinicians in defining need and
the pattern of services is important. With that, clinicians must
also embrace the necessity to own, understand and be accountable
for opportunity cost. It is no good insisting on the very best
for the patient in front of you, never mind everybody else who
may have to go without. We have to start to address that. We also
need the patient voice. I say that not just in a tokenistic sense.
I have seen it work and make a difference and have learnt from
it. I give two very quick examples. When I was director of public
health for Norwich it was the user group for mental health services
that made me look much harder at alternatives to pills and hospital
admission for the management of a lot of mental health patients.
They asked about the arts and exercise. We took note and made
it happen. The consequence was that in two years we were able
to cut the antidepressant prescribing bill by 30% and took £2
million out of acute mental health care in the secondary care
provider. We instituted an NHS Counter Fraud and Security Management
Services review of a local private mental health provider which
we felt had possibly gone beyond gaming. That led to police and
court activity. The case subsequently collapsed in court, but
some directors lost their jobs. It took us to an interesting place.
The other example was an attempt to do a needs assessment of Bengali
women in Norwich. We rapidly learnt that we were applying too
narrow a model. They said, "What would we do? We keep house
and cook." It suddenly occurred to us that that was incredibly
useful and said, "We need people who can keep house and cook.
Would you like to show your neighbours how to do this?" It
taught us that it was about assessing and harnessing the abilities
of communities and giving them opportunities to raise their own
game, not to treat them as passive recipients of our benevolence
in a way we determined for them.
Q221 Chairman:
We hear a lot of rhetoric about commissioning and the expectations
of what PCTs can achieve. What evidence is there of strong commissioning?
Dr Brambleby: If you take the
definition that commissioning is about "co-missioning"
there is tangible evidence of co-operation to deliver a joint
vision. You could test that. I believe that would be the strongest
test of commissioning. To do that would require a combination
of not just measurement and data but narrative. There is no way
round it. You have to visit it, see it, touch it and believe it.
If your definition is whether it can be shown that more episodes
of care are being delivered by local providers for the same or
reduced cost, again there will be evidence of that, but I earnestly
steer you away from seeing that as a marker of success of commissioning
because it is so much more than just the procurement of episodes
of care in a productive mindset where more cases are going through
a hospital. Look at the outcomes. "Are more people getting
better?" Take it at different levels. First: "If a patient
has had a heart attack did he have a good experience of care and
get better?" So that would be one measure of commissioning.
Second, you could collectivise that and look at heart attacks
in general: "In general how does the local health system
deal with mortality rates in circulation disorders? Are they better
or worse than the national average?" Third, you could visit
York, Scarborough, Harrogate or other parts of my patch and ask
whether this is a heart-healthy city or community. "Is it
the sort of place where healthy options are easy options for the
population?" I suggest that all three levels of outcomes
would be tangible markers and ought to be scrutinised as evidence
to answer your question about whether commissioning is working,
and is it working better under World-Class Commissioning.
Q222 Chairman:
You heard Professor Street say earlier that he believed PCTs should
cease to commission services from the acute sector. Do you agree
with that, and do you have any additional comment to make?
Dr Brambleby: It is an interesting
suggestion. I do not agree. We are where we are and have a commissioning
function and it could and should serve a useful purpose. It is
important that someone is tasked with the job of ensuring that
the deployment of resources for a local community genuinely reflects
the needs of that community and that no vested interest group,
be it clinician, patient or particular provider or technology
manufacturer, dominates and has an unfair advantage. What we are
striving to do is achieve equity of marginal net need, to use
a technical term, which means that the next person coming into
the local health system is the next most needy person—that
there is nobody in the health system being treated who has less
need than someone outside it whose need is greater.
Q223 Dr Taylor:
Following on from that, earlier you mentioned the importance of
engaging with your community. How do you do that?
Dr Brambleby: In many and various
ways. There is a distinction between engaging with patients and
engaging with the public. Beginning with patients, we should engage
with them a lot more. You say, "How was it for you? You have
been through our system. What do you think of the GP and the hospital?"
Q224 Dr Taylor:
It is really engagement with the public?
Dr Brambleby: It is engagement
with the wider public. You can engage with them directly by leaflet
drops and the annual report of the Director of Public Health or
the PCT with a "reply to" strip incorporated. You can
have a regular slot in the local newspaper and publicity and radio
campaigns, the use of libraries and so forth, but there is also
something called "rapid participatory appraisal" for
which there is a good evidence base. You get a few "key informants"—that
is the buzzword—for example the local health visitor, the
bobby, the headmaster and a couple of businessmen, and put them
in a room and ask them what the community needs.
Q225 Dr Taylor:
So, local involvement networks do not figure in that?
Dr Brambleby: I have not finished!
I would include local involvement networks and health scrutiny
committees. But the point is to make sure you triangulate this
against several different sources because it is too easy for one
particular group with the best of intentions to over-emphasise
its experience. That in itself can skew priorities. One also needs
an advocacy role. Who is speaking for the people who do not come
to the meetings, who are not registered with a GP or are a transient
population, or do not speak the language, or have learning disabilities?
One needs an informed advocate for that. I believe that is a public
health role. One of the earlier questions, which I did not completely
answer, was whether we had enough public health practitioners.
If one takes the definition of public health as being the science
and art of promoting population health and preventing disease
and helping people live longer, then all GPs, their staff and
all other clinicians are public health practitioners. It is not
restricted to the health service—anyone with an interest
in improving the health of a population rather than an individual
in front of him or her is a public health practitioner. Anyone
who focuses on the outcome and quality of life rather than simply
a narrow measurement of whether the disease has gone away is a
public health practitioner.
Q226 Dr Stoate:
I am very interested in your definition of commissioning and how
we can separate it from purchasing. As far as I can see there
is really no role for PCTs to do much purchasing because under
payment for results, Choose and Book or NHS Patient Choice there
is very little you can do to pull the levers. Professor Street
made the point very clearly: if you cannot control the price and
the volume there is not much for you to do. Why can we not just
expand on his model in a way and do much more commissioning which,
as you rightly say, is really the procurement of good health rather
than simply the purchase of services over which we have very little
control?
Dr Brambleby: The point is about
linking it back to making it happen. It is no good simply defining
the needs of a population. I often feel that we should not do
needs assessments but needs "addressment". How are we
to address unmet need in this population with the resources available
given the people, the time, the commitment and money?" You
need a commissioner who can allow the money to follow the agreed
pattern of care.
Q227 Dr Stoate:
Most of the money is swallowed up under payments by results. For
example, in my area whenever I talk to the PCT about developing
community services there is a sharp intake of breath and they
say that unless they can strip money away from the hospital and
generate this money from the hospital there is no money to develop
community services, so it is a chicken and egg. How do you get
to the point where you can develop the very services you need
to reduce reliance on the hospital? The hospital sector effectively
has a big sign up in the car park saying coach parties are welcome.
Dr Brambleby: Easy! We come back
to the programme budget approach. You say "Here is my PCT
and I have £1.2 billion. Last year we spent approximately
£60 million on, say, cancers". The resource assumption
going forward is that there is not a lot of new money around,
so it will be about £60 million again next year. You then
convene a cancer advisory group. You put service users, primary
and secondary care clinicians and managers in a room and ask how
the budget is to be divvied up to better effect next year. It
is as simple as that. The way money will flow into the hospital
sector for that part will be by payment by results, but we say
to the GPs, the referrers, that they should sign up to the newly
agreed pattern of activity. "If we all agree that the objectives
of the cancer programme include prevention, and includes end-of-life
care, let us protect some resource for that. Does everyone agree
to abide by the rules we set?" If so, you go for that. The
money can follow the patient according to payment by results but
they will have to self-police it and be encouraged to work to
the agreed pattern of activity that has been set up, not just
let the vagaries of demand, chance and referral determine priorities
for them. It is about stepping up to the mark and using the levers
we already have but having a more collaborative discussion and,
critically, being allowed time to have that discussion and being
encouraged to scrutinise things during that discussion and not
be constantly diverted by over-elaborate emphasis on the transactional
side. World-Class Commissioning itself says that this should not
be a transactional but transformational activity. There are plenty
of people out there on the periphery who are up for that and skilled
for it; they just need the permission and the environment in which
to deliver it.
Chairman: Thank you very much for coming
along and giving evidence this morning.
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