Commissioning - Health Committee Contents

Examination of Witnesses (Questions 300 - 319)



  Dr Naysmith: Good morning and welcome to the House of Commons Health Select Committee. I am obviously not Kevin Barron. Kevin is unfortunately unable to be with us this morning. He has got another engagement.

Mr Bone: On a point of order, Dr Naysmith, I would just to let you know for the record that I know Mr Parkes. He is my Chief Executive and we have crossed swords on a number of occasions.

  Q300  Dr Naysmith: Just for the record could I ask you to say who you are and who you represent this morning?

  Mr Parkes: Good morning. I am John Parkes and I am Chief Executive of NHS Northamptonshire.

  Ms Garbutt: Good morning. I am Julie Garbutt. I am Chief Executive of NHS Norfolk.

  Q301  Dr Naysmith: What do you understand by commissioning? The rub is that it has to be in one sentence, please.

  Mr Parkes: For me it is using the resource that I have been allocated to best effect and to meet the needs of the population whilst reducing inequalities.

  Ms Garbutt: I would agree with that. I think it is about assessing need and then looking at how I meet that need within the budget that is available to me.

  Q302  Dr Naysmith: What is the role of commissioners in this? What do commissioners have to do to fulfil this function?

  Mr Parkes: Within Northamptonshire what we have been trying to do is better understand not just that need at a total population level, ie, for the 700,000 people, but to then understand the needs of individuals and then what risks or lifestyle choices are those individuals making and how can we then support them into a position where they will live longer and have better lives as a consequence.

  Q303  Dr Naysmith: Do you agree with that?

  Ms Garbutt: I think for me commissioning is about ensuring that we have health improvement and good services available for local people. I think the role of the PCT is to act as a system co-ordinator to bring all of the organisations together within Norfolk in my case and ensure that we work together as providers and commissioners to deliver that health improvement and those better services.

  Q304  Dr Naysmith: Is the phrase "the role of commissioners" the same as "the role of PCTs" or is there more in a PCT than just commissioning?

  Ms Garbutt: From my perspective clearly commissioning is a large part of what a PCT does, but I think a PCT also does have that system leadership role in which it is co-ordinating and bringing together partners. I think it also has a public health role in terms of health improvement and reducing health inequalities.

  Q305  Dr Naysmith: Does it not have to commission public health services as well as acute services?

  Ms Garbutt: In some respects we directly provide public health services, and increasingly we are commissioning them from others.

  Q306  Dr Naysmith: John, do you want to add anything to that?

  Mr Parkes: All I was going to say was, because I used to be a chief exec in hospitals, that I think when you are a chief exec at a hospital you are running an organisation, but as a chief exec of a commissioning organisation you are running a system.

  Q307  Dr Naysmith: The Health Service has been trying to commission and do commissioning for almost 20 years since the purchaser/provider split began around 1991, yet even the Department of Health admits, and it has done in evidence to us, that it has been done poorly and claims it has only really been given the status it deserves in the last couple of years. Why has the commissioning role been so weak for so long?

  Mr Parkes: For my particular primary care trust, when we were created just over three years ago I do not think at that time we had the skills necessary to be a really good, effective commissioner, and we have gone down a deliberate path to try and either buy in those skills or develop those skills. I can look back over the last three years and see that we used to, in effect, spend money and now we are much more investing money and looking for that return on investment but still working in partnership with clinical colleagues.

  Q308  Dr Naysmith: It is interesting that you talk about skills in PCTs. What skills do PCTs lack?

  Mr Parkes: Certainly three years ago I would not have had the ability to do effective social marketing, so how I influence the public to make different lifestyle choices. I probably would not have had information or information systems that allowed me to look explicitly at where people live and try and then understand what individual risks they were facing as an individual. We use actuaries now to look at what has happened in order to project forward trends so that we can begin to think through in a much more measured way what is going to be not just the need today but the need tomorrow and how can we plan to meet those needs. Those skills may have been there in part previously but they certainly were not as developed as I would be able to show you today.

  Q309  Dr Naysmith: What skills do you lack now that you would like to have?

  Mr Parkes: Perhaps not a skill. I would really like to have access to the data that, for example, is held within primary care and I would like to have access to that data to put it alongside the hospital data and social care data because we have got the ability now, if we had all of that data together, to then share it back to, for example, GPs, "Here is somebody with more than one long-term condition. Here is the particular risk for that individual. Here is how that risk can be managed", or, "Here is somebody for whom a prescription has been prescribed, never been filled, not being taken at the right frequency". We could use that information in a joined-up way.

  Q310  Dr Naysmith: That is not happening at the moment; is that what you are saying?

  Mr Parkes: Certainly access to the primary care data is done very much on a voluntary basis and I think my colleagues in primary care are worried about things such as patient confidentiality. I really do not want to break patient confidentiality but I want to be able to bring that data together to support really good quality care and support clinicians at the front line.

  Q311  Dr Naysmith: Julie, do you have anything to add?

  Ms Garbutt: I would very much endorse what John has said. Reflecting on where you started with your question about we have been doing it since 1991 and why has it not worked, my reflection would be that I was working in the NHS at that point and I was working in a district health authority on what was then the purchasing and planning side, and I think there is a lot of resonance with that idea: it was purchasing. I think there was the wrong focus in the beginning and it was very much about trying to have contracts and trying to be very focused on what do you buy. What we did not have at the time, though, were any of the levers, any of the tools that we now have, and whilst I think there are many things wrong with Payment by Results, the idea of having a tariff did allow us as commissioners to start looking at moving services away from areas where they were not working to areas where we could get a better quality of care. I can remember when I was director of contracting taking an awfully long time to move some ophthalmology work from one hospital to another because I was arguing about marginal costs and the fact that I needed more than marginal costs to fund that shift. With tariff it is perfectly possible to define a service, allocate the sum of money and then test the providers who are out there to get the best possible service for local people. I think we now have a lot of different tools and techniques that allow us to be true commissioners and we spend far more time analysing need to really understand our population, not just at that whole population level but in particular pockets, and to tailor services very specifically to the needs of patients. We did not have a sophisticated approach in the nineties because we did not have the tools to enable us to be that way.

  Dr Naysmith: We will move on to investigate some more of these things in more detail now.

  Q312  Mr Scott: Could you tell me what people the PCT employ in their main roles and what they do?

  Ms Garbutt: NHS Norfolk employs 400 staff or thereabouts across a range of functions. They fall into the public health function. We have strategists and commissioners. We have finance staff, obviously, to manage the resources as they flow out to providers and within our own organisation. We have clinical leadership roles, we have a medical directorate and we have a chief nurse directorate. We commission across all of the various care groups so we have people who lead on commissioning for children's services, sexual health services, planned and unplanned care, and then we have support staff who do contracting, who do relationship management with our providers. All of the staff are commissioners or they are supporting commissioning in some way.

  Q313  Mr Scott: John, is that the same for you?

  Mr Parkes: Very similar. We have 3,000 staff but the majority of those, something like 2,700, are what we would refer to as our provider arm, providing services such as district nursing and health visiting. The policy at the moment is shifting away from a mixed commissioning provider model. If you went to being a pure commissioner, the number would drop more to 300 and my internal structure would be very similar to Julie's.

  Q314  Mr Scott: And in the same way they are doing the commissioning?

  Mr Parkes: Yes, absolutely. We are probably fixated on public health, spotting the health need, then making sure that we are securing absolute best practice in the way that that need is being met. Can I give an example?

  Q315  Mr Scott: Yes, please do.

  Mr Parkes: We looked, for example, at what we were doing with diabetes and compared our spend and population need with other PCTs and saw that our spend was high. We then looked at the evidence for where are the most effective interventions on a care pathway for a diabetic patient and put a process in place where we worked closely with our primary care and secondary care clinicians and as a result of that we have come up with absolute knowledge around, "Here are the things that will make a real difference". We have improved the quality but it has saved us £1.5 million.

  Q316  Mr Scott: With no loss of front-line services?

  Mr Parkes: With absolutely no loss of front-line services. Predominantly the saving came as a result of changes to clinical practice where some expensive analogue insulins were being routinely prescribed and once we made that information available to clinicians and said that there were other ways of doing things they were open to saying, "Let us look at this together", and we did look at it and we involved patients and patient groups as well. This was not us being an aggressive commissioner; this was us being quite a supportive change initiator and that has resulted in the PCT saving money but also in us reinvesting some of that money into diabetes so that the clinicians can see that there is an absolute benefit in participating in that process. I like that example because it allowed us to save money without in any way compromising clinical care.

  Q317  Mr Scott: Is there part of the PCT's work that you spend a lot of time doing and you would rather not, and if you had a free hand what would you do more of?

  Ms Garbutt: I think I would build on the comment that John made about the provider side of PCTs. I gave you the information about the commissioning wing in terms of number of staff. We have somewhere in the region of 3,000 staff who are employed delivering services in the community. It is such an important aspect of our push forward in terms of integrated services, more personalised services, but it is very difficult to focus on being a commissioner and a provider at the same time, and, of course, we have been on a journey, as all PCTs have, to look at divesting ourselves of that responsibility. Personally I am very keen that we make swift progress on that so that we can get on with commissioning, but particularly so that we can get on with being commissioners of a new style of community service which is part of an integrated service which is designed to help us move care out of our hospitals and into our local communities. I would like to do far less of that because I think other people are much better placed to do it. I want to be commissioning that service, not delivering it.

  Ms Garbutt: I agree with the provider comment. Certainly within my PCT and across, for example, the East Midlands we still have some administrative functions, some pay and ration type functions, for paying or remunerating GPs and that type of thing, and I think as we move forward more of us will be saying, in terms of some of these back office functions, do we need to be doing them 152 times across the country or what is the scope for bringing some of those functions together, and I would be very keen to progress that because again it is a way of making the system more efficient without in any way compromising clinical care. The other area I think we have got to move into is to be more explicit around setting standards and setting standards around the particular pathways and the interventions on a pathway that we have agreed with clinicians that we know will absolutely make a difference, managing some of that clinical variation rather than just allowing it to happen, understanding it, agreeing what the right pathway is, and then having a discipline that says that where you have got variation is that innovation or is it just variation, and having a mechanism that makes sure we are using resource to best effect to benefit patients. I do not do enough of that at the moment.

  Q318  Dr Naysmith: Just before we leave that and go on to Howard, Julie, you were talking about divesting yourself of provider functions. Is there still a bit of pressure from the top to do that because it was quite controversial at the time of the reorganisation?

  Ms Garbutt: It is still policy, I believe, to see a separation of commissioning and provision. However, in the latest guidance we have we are being asked as PCTs to firm up our plans by the end of March in terms of what we are going to do with our provider services. There is a range of options there, one of which is to keep them. However, I think the view is that there would have to be a very good, clear and strong rationale for why it made sense for a primary care trust, whose essential role is to be a commissioner and a public health agent, to want to provide services. In Norfolk we have what I would call quite an underdeveloped market in as much as we have a very large single teaching foundation trust, we have a smaller district general hospital, one mental health trust and then a plethora of independent contractors, primary care contractors and voluntary sector organisations. It can be quite difficult in a market like that, which is fairly enclosed, to have conversations that allow you to have some contestability in order to allow you to drive up quality. For us there is a big incentive to move our provider arm into a community foundation trust model. That is not necessarily one of the most favoured models nationally but, as a very large provider arm, we believe that by setting our provider services as a community foundation trust they will be able to help us create what we call a care brokerage model. We are very focused on the patient as an individual, the need to have more personalised care for individuals that is crafted to meet their needs. More and more people in Norfolk are elderly. They have multiple conditions, long-term conditions. They need very specific packages that reflect their needs. To do that we need to have an organisation or organisations in our system that we can contract with to say, "We would like you to provide 25,000 packages of care for the diabetic sufferers in Norfolk next year", and for them to have the ability to put together those individual packages of care for those patients, and that is what we would term as care brokerage. I need that organisation to have that ability to drive those services that are personalised and enable us to have ways of putting services that are currently in hospitals into a community setting, so it is a very important thing for us.

  Charlotte Atkins: Do we really want another reorganisation? It was only a few years ago we had the mergers of PCTs and we were told by doctors and hospitals, "Please: no more reorganisations", and now you are saying that you really welcome floating off the provider arm. We were told that you really do not want another reorganisation and I would have thought PCTs generally do not want yet another reorganisation, and in such a tight timeframe, by the end of March.

  Dr Naysmith: Just before you answer that Richard has a quick question and then we must move on.

  Q319  Dr Taylor: So you probably would not agree with a witness at a previous session who said that PCTs, he thought, should concentrate on providing and divest the commissioning role, exactly the opposite way round that you are saying?

  Ms Garbutt: I think if you were to concentrate on providing and divest commissioning you would no longer be a primary care trust; you would be something else. I think we are probably agreeing but from a different perspective. I think there has to be a focus on being a commissioner, and I do agree with you that I do not want to see massive reorganisation of PCTs. I think that would be so unhelpful with the challenges we are facing with the economic climate and needing to drive World Class Commissioning, but I do need a different future for my provider arm. That element of it I think is advantageous to the Norfolk system in terms of moving us forward to deliver our strategy, and we have to do something with our provider services; they cannot stay as they are.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2010
Prepared 8 April 2010