Examination of Witnesses (Questions 260
- 279)
THURSDAY 14 JANUARY 2010
PROFESSOR ROD
GRIFFITHS, MR
JOHN MURRAY,
MS DEBORAH
EVANS AND
MS TERESA
MOSS
Q260 Dr Taylor:
Is it right that one of our recommendations should be that the
presence of PCT executives in these groups is absolutely vital?
Ms Evans: I think so.
Q261 Dr Taylor:
Mr Murray, in your evidence you have picked out some SCGs where
there are very few PCT chief executives.
Mr Murray: At the extreme it is
one out of 24. Most of them are somewhere in the middle ground.
For some the previous structures are reflected in current chief
executive attendance, so there may be some subsidiary collaborative
arrangements. Let us say there are 15 PCTs represented in the
SCG but there will be five chief executives who go along to represent
in each case two of their colleagues. It is that kind of approach.
Q262 Dr Taylor:
I believe the Carter Review called for commissioners to seek the
views of patients, carers and the public.
Ms Evans: Yes.
Q263 Dr Taylor:
How do you do it?
Ms Evans: We do it in lots of
ways. We have built into our process for service review and development
some approaches which include having stakeholder days that include
clinicians, service users and the local authority overview and
scrutiny representatives. We often get them to work together so
the clinicians directly hear the views of patients as do the local
authorities. We have service user representatives and interest
group representatives on some of our steering groups to implement
services, of which neuromuscular is another example. As to the
burns review, when we designate services we have visits to the
centres which include representatives of LINks; they include service
user representatives and they can also include representatives
from the relevant interest groups. We have a lot of standard mechanisms
by which in all our routine work we incorporate the service user
view and the great expertise of the sorts of organisations that
are represented by the Specialised Healthcare Alliance.
Q264 Dr Taylor:
Do you find that overview and scrutiny committee members and LINks
members are helpful and interested in these very specific and
rare conditions?
Ms Evans: I think they are interested.
Local authority representatives quite understandably are always
interested in the impact of a service proposal on their local
area. They start with the local area as one would expect, but
they have made a good effort to understand what happens when you
have to serve a very wide geographical area where you have small
numbers of patient and the different challenges involved in that.
Q265 Dr Stoate:
Listening to this session one matter that comes through without
question is the horrendous complexity of it all. I am genuinely
more confused by the level of complexity than I was when we started
the session. There are so many different tiers and so much bureaucracy.
We have heard from people like the Specialised Healthcare Alliance.
Some of the SCGs commission only six out of a possible 36 services.
The possibilities for postcode lotteries and confusion are endless.
When patients move from one part of the country to another I despair
at how they can access what services they might need. Rare Disease
UK argues that with payment by results, practice-based commissioning,
foundation trust commissioning and regional and national commissioning
the system is altogether more complex than it was before. The
top prize goes to the witnesses who can come up with a way of
simplifying the system in a few words. Who wants to pick up the
challenge?
Mr Murray: I am surprised to hear
you say that. The system is not as complicated as it was prior
to Carter. If you go back to the arrangements prior to Carter
not only were they very complicated but there was even more of
a laissez faire approach and enormous scope for services to fall
between the paving stones at many different levels. The levels
of commissioning that we have are probably right. The problems
relate to the way in which services are picked up by those levels
and there is simply not sufficient consistency across the country
in the way those services are funded. Ultimately, I think experience
shows that unless you have responsibility for services along with
the funds to procure them you will not be in a position to do
a good job.
Q266 Dr Stoate:
If PCTs can withhold or keep back the funding it makes it is practically
impossible for an individual SCG, let alone across the country.
It is a dog's breakfast.
Mr Murray: That is why in our
submission we propose that the funding issue should be revisited.
I do not pretend that this is an easy issue because obviously
one does not want to enter into a fixed funding arrangement when
one does not understand the costs properly. For example, the Spinal
Injuries Association has drawn our attention to the fact that
no one knows how many patients there are with such injuries across
the country, let alone in different regions of it. Carter proposed
that as a priority costs should be properly mapped in relation
to the different parts of the national definitions set. It has
scarcely got under way.
Q267 Dr Stoate:
We have had the purchaser/provider split now for 20 years and
you are telling me that it has scarcely got under way. In inquiry
after inquiry we hear about the purchaser/provider split; we have
had the internal market. It has been going for 20 years. Guess
what? Most of it has not started yet. What will it take to get
anything moving?
Mr Murray: I tell you one thing
that might get it moving, although it will appal Ms Evans. Let
us suppose that the money went to the specialised commissioning
groups and that it was, as it is presently, top-sliced from the
primary care trusts but only on the basis of proper costing analysis
by the SCGs. That would concentrate minds very rapidly in terms
of introducing a far more robust approach. I also think that in
a situation of greater economic stringency there is a huge amount
to recommend the greater use of commissioning at regional level.
Notably, a couple of the specialised commissioning groups observe
that their management costs are in one case .4% and in another
case .5%. That seems to me to be a strikingly low figure. I might
say that it is not necessarily adequate to do the job properly
which may be one of the reasons things are not progressing as
fast as they should, but it suggests there is tremendous potential
to do a good job and do it efficiently in relation to these services
at that level.
Q268 Dr Stoate:
We always hear there is a lot of potential. Professor Griffiths,
there is a lot of potential to do better but no one has actually
achieved it. What can we do to simplify this?
Professor Griffiths: The crucial
point is that the system should be patient rather than system-facing.
I accept that the country is a complicated case and what you do
in Birmingham is likely to be different from what you do in Cornwall
or whatever just because of life. Why does not the system deal
with it rather than make the patient have to grapple with it?
If we gave SCGs the responsibility for facing the patient with
all the regional services and somebody had a problem because he
or she moved to another region and wanted to know what to do the
patient could phone them and they would sort it out. You might
well have an arrangement whereby some PCT commissioned this or
that in your particular patch, but that is not to bother the patient.
At the moment it is a system-facing arrangement and it is left
to the patient somehow to grapple with it. That can be tricky
and you need determination above and beyond the call of duty sometimes
to be able to do it, but it is being paid for by the patient.
Q269 Dr Stoate:
All I ask for is a system I can understand. I have been a GP for
a long time. Frankly, I am really now more confused than I was
a while ago. I thought I knew this stuff but now I find I do not.
I just want a system I can understand and I hope I can help my
patients understand and I do not see it happening.
Professor Griffiths: In that case
we ought not to reorganise every five years. Yes, we started in
1990 but we have messed it about. Any time anybody got any good
at it we kicked the horse from under them, but somehow or other
you must change the way performance management thinks to make
the system face towards the patient.
Mr Murray: Having policy is one
thing; implementing it is another. The Carter policy is absolutely
right in establishing SCGs as a one-stop shop for people who need
information about services which they or their families require,
whether those services are commissioned, as they probably would
be for the most part, in a fully implemented system by the SCG
or for whatever reasons commissioned by the PCT, but that is not
happening because it has not been properly implemented. It requires
consistency of purpose which sadly is sometimes lacking in the
NHS.
Q270 Dr Stoate:
We heard from Ms Evans earlier. We even have to decide whether
to go to public consultation which will take two or three years.
By that time I will probably have forgotten the question. It is
completely insane. There must be a simpler way of doing it. There
is silence.
Ms Moss: If we could simplify
the public consultation systems that would be enormously helpful.
They are truly very complex and we need to do something about
that. This is a complex arena and I am not sure we will ever make
it very simple. Dr Brambleby talked about programme budgeting.
For that you have to get all the people in the room, focus on
the patient pathway and plan their care along that pathway: the
key interventions and the right places to prioritise. You need
to get these different systems into the room to do that planning,
decide your priorities and then leave them to commission appropriately
to high standards the part of the care pathway for which they
are responsible.
Dr Stoate: I know the theory; it is just
that I do not see it happening.
Q271 Dr Naysmith:
Mr Murray, what do you think about public consultation? Is it
too onerous or could it be done in a much simpler way?
Mr Murray: You are not talking
about patient engagement but public engagement?
Q272 Dr Naysmith:
We heard about how long it was taking.
Mr Murray: It is hugely complex
and sometimes it militates against very necessary change.
Q273 Sandra Gidley:
Our earlier session was mainly about payment by results. How does
that work in the area of specialised commissioning?
Ms Evans: In specialised services
as in PCT commissioning we have a mix. Some of it is under payment
by results and some of is not. Most of it is not under payment
by results. In particular, there are whole sectors like mental
health where payment by results is said to be coming but we do
not have it yet. Probably for the south west 20% to 30% of our
whole portfolio is payments by results. Next year our portfolio
will be £520 million, so we will have moved to one of the
SCGs who is commissioning a huge amount of the potential portfolio,
but only 20% to 30% is payments by results. Examples of the parts
that fall under that are cardiac and bariatric surgery and paediatric
intensive care, but renal and neonatal intensive care does not.
Therefore, the large and some of the more commonly used parts
of specialised services are not subject to payment by results.
That means one has local pricing. The price for something might
be different in Plymouth from what it is in Bristol. That means
PCTs and specialised commissioners have to work together because
if when wearing my Bristol PCT hat I am commissioning ordinary
general hospital services for Bristol from the main teaching hospital
and specialised services are being commissioned from the same
hospital and there are parts which are not payment by results,
if we are not careful we shall pay for things twice. That is another
complexity in specialised commissioning. Increasingly, we need
to be able to make cost comparisons and know what we are getting
for what we are paying and its quality, so it is difficult.
Q274 Sandra Gidley:
Perhaps I am being a bit slow here. Why are some areas of specialised
commissioning part payment by results and others not? How was
that decision arrived at?
Ms Evans: Because the payment
by results national financial regime has been rolled out over
a number of years. It started with things that were relatively
easy which would be common hospital procedures that are approximately
the same up and down the country where one can set a normative
tariff. Obviously, specialised commissioning is much more complex
and quirky than that. By and large, specialised commissioning
has not been able to be boxed up and put into payment by results.
We are working on some areas. For instance, I have a responsibility
for spinal injuries commissioning in the south of England. Currently,
we are leading some national work on standard commissioning. We
are working very hard to get to the point where we have standard
pricing for spinal services across the whole country. We are one
of the areas of specialised commissioning that has been working
hard on that. We have had good support from the Department of
Health, but each service must be worked through individually.
Professor Griffiths: For a lot
of the national services there is not the level of detail in the
standard data systems to be able to recognise them. You might
be commissioning a particular procedure or just the delivery of
a particular drugs and that is not coded in a way that you can
pick it up nationally to work out a cost for it, so in a sense
you are stuck; you have to do a local deal with the person who
does that process. Maybe we will get it one day but we have not
got it so far.
Ms Moss: I fear that we are coming
again to the term "granularity". What it means is that
sometimes we need bespoke databases to be able to capture this
information from the services we commission regionally and at
national level. We need stronger support to be able to put those
in place and have co-ordination if we are to progress in the way
we need to do.
Mr Murray: It is crucially important
if payment by results is extended to specialised services that
it captures the costs involved in delivering high-quality care
effectively. That is always a concern for us. If it cannot do
so we prefer payment by results not to be applied to specialised
services. Equally, we have always been acutely aware of the fact
that because it is difficult to control expenditure under payment
by results everything outside potentially could come under a squeeze
and that includes those specialised services. We see the process
of designation as potentially a very important tool in identifying
the providers who deliver requisite quality services in these
areas and consequently giving an opportunity to capture the costs
involved. That is another reason why we are very concerned, notwithstanding
the more recent evidence of progress, about the very slow rate
of progress in terms of designation. Service specification and
standards of care were according to Carter meant to feature within
the revision of the national definitions set. That was taken out
of the national definitions set and put into designation. It is
therefore very concerning that designation has progressed so slowly.
That slow rate of progress, which is due partly to lack of resource,
has potential knock-on effects in relation to things like payment
by results.
Q275 Chairman:
We received a submission from the Cystic Fibrosis Trust. Getting
a tariff for somebody who suffers from cystic fibrosis is no mean
task, is it? It affects so many different parts of the body. These
are not simple things that can be dealt with rather quickly; they
are complex areas.
Mr Murray: The Cystic Fibrosis
Trust is strongly committed to the development of the tariff on
a banded basis.
Q276 Chairman:
It is still no easy task, committed or not.
Mr Murray: It is not.
Q277 Dr Naysmith:
That is a relatively common condition.
Professor Griffiths: As relatively
rare conditions go it is one of the more frequent ones.
Q278 Dr Naysmith:
Ms Evans, how effective is the present system in sharing risks
and costs? Some patients require expensive treatment but in relatively
small numbers. Does it achieve equity in terms of sharing costs,
or not?
Ms Evans: I was interested to
listen to the concerns of the Specialised Healthcare Alliance
which clearly see the fact that SCGs tend not to do risk sharing
as a negative factor or perhaps prevents patients from getting
treatment. I do not see it in that way. We might be at a turning
point and as more financial pressure comes upon the system PCTs
as they sit round the specialised commissioning group table may
find risk sharing more appealing than they have in the past. There
are two or three reasons they have not felt the need to do it
so much since the Carter Review in 2006, some of them simple.
One is that in the 2006 reorganisation many PCTs were put together
to create bigger ones. The bigger ones felt that they had more
critical mass to withstand financial risk and did not necessarily
feel the need to risk share. In addition, at that point the health
service took the view that there was a need for health authorities
to hold contingency funds on behalf of PCTs and for PCTs themselves
also to hold bigger reserves than they had previously. The question
then is: how many reserves and contingencies do you need? Those
were the probable reasons why the risk sharing and pooling arrangements
were not immediately taken up; they were not felt to be quite
so pressing, but we may see signs of that beginning to come back
as the NHS financial settlement is less generous than the very
generous amounts it has had in the past two or three years. The
other point I pick up is about PCTs taking a decision to withdraw
certain treatments from the SCG portfolio and take decisions in
their exceptional funding panels. In my experience that tends
to happen where the evidence base is not absolutely clear and
that is why the PCTs say they will look at it on a one-by-one
basis and consider the evidence and be held accountable for it.
I cannot give a view for the whole country; it may be there are
different positions in different parts of the country.
Q279 Dr Naysmith:
But you suggest that risk sharing is not taking place all that
much?
Ms Evans: It probably is not.
Ms Moss may have a bigger national picture than I do; mine is
not substantial.
Ms Moss: Different PCTs and SCGs
come up with different views. There is an element about: how do
you retain the engagement of a PCT in treating their patients
with diabetes well? That may move on renal failure and the need
for a specialist service. You need to keep all PCTs engaged in
that good proactive treatment of diabetes. That is one area where
it is said we need PCTs to take responsibility for their specialist
treatments. There is a different area where people may have groupings
of inherited disorders in their PCT. Frankly, the allocation formulas
do not take account of that. I believe that cost and risk-sharing
arrangements are appropriate for PCTs that happen to face those
problems. There are different tensions in play and again there
is complexity.
Mr Murray: It is not the policy
of the Specialised Healthcare Alliance; it is the policy of the
Department of Health which is set out clearly in its submissions
that risk sharing of this kind is a primary function of specialised
commissioning. On the basis of the numbers that I quoted earlier
with SCGs pooling as little as 1% of their funds by weighted capitation
it is self-evidently not happening. Why is it not happening? It
arises possibly because they look at an individual service and
with that specialised service, which may be a high-cost one, they
do not have many or any patients within their patch and so have
no incentive to risk share. Maybe their neighbours do but that
is a neighbouring PCT, not them. It is only when you look at a
broad spectrum of services where what you gain on swings you lose
on roundabouts and vice versa that the incentive for sharing grows.
I think this is part of the problem with the pick-and-mix approach
to the national definitions set that we have at present. I find
it deeply worrying that in Dr Howell's submission he calls into
question the very purpose of the national definitions set and
says he really does not believe it will have much relevance to
the West Midlands in future. That is a pretty worrying attitude
when so much time and effort has been invested in the revision
of the national definitions set.
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