Examination of Witnesses (Questions 300
THURSDAY 28 JANUARY 2010
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
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
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
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
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
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
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.