Commissioning - Health Committee Contents

Examination of Witnesses (Questions 320 - 339)



  Q320  Dr Stoate: It all sounds rather wonderful, what you were saying just now. I am just rather concerned that it might sound too wonderful. We have got a report that was done for us by the National Audit Office, which was a telephone survey of PCTs, which said that in fact it is so good that 95% of commissioners thought that commissioning was going well and 82% believed it was going very well, which, of course, is absolutely splendid, and the Operating Framework of the NHS has called for "bold, capable commissioners", again, excellent stuff, and you have told us that you have developed these skills over the last few years and to really go with it. How come therefore that The King's Fund found that 80% of practice-based commissioners in particular found that they lacked some or all of the necessary skills? There does seem to be a bit of a difference here, that you all think it is going to be wonderful, and yet 80% of practice-based commissioners, so say The King's Fund, lack the skills they need to do the job.

  Mr Parkes: I absolutely believe that we are on a journey and different parts of the country may be at a different stage on the journey, but even with where I believe we have made progress we absolutely are not at the end point. There are some things that we need to be doing differently and some things that we need to be doing better, so I can certainly empathise with commissioners saying, "We believe we have made progress", but others saying—

  Q321  Dr Stoate: They did not say that. They said that 95% believe it is going well or very well. That is in some ways an alarming figure, if 95% of them believe it is that good and yet The King's Fund finds that 80% probably lack the right skills. Surely there is something going wrong.

  Mr Parkes: Practice-based commissioning is again in a slightly different position because we have got a PBC consortium that covers 98% of the population in Northamptonshire and we find that by us working with them they work with GPs, they get the views from primary care, they are able to look at changing things, so when we said, "The population are saying to us, `We would like greater choice in terms of where we die, in terms of end of life'", it was the practice-based commissioning consortium that worked with their practice nurses and they came up with a model to improve the choice for the people of Northamptonshire, and they absolutely feel that they have got to a good position and, as NHS Northamptonshire, I am grateful to them for their help. They have engaged with individual practices to win hearts and minds around delivering the necessary change.

  Q322  Dr Stoate: It all sounds wonderful. It is just that I am concerned whether it is really on the ground as wonderful as that, given that The King's Fund has picked up such disparity between the figures that they found from commissioners and the figures that the National Audit Office found by a telephone survey.

  Ms Garbutt: I am inclined to say I believe both things are true. That might sound a bit strange but the reason I think that is that there is a level of what I would call strategic commissioning which I think is what PCTs are doing now, which is quite large-scale commissioning. I suppose an example of that from my area would be the transformation of the stroke care pathway that we led as a strategic commission and changed significantly the quality of services that were available to local people. Practice-based commissioning I would call a local operational type of commissioning, and certainly in Norfolk we have struggled. It has been more of a struggle to get that moving forward as we would like and as our practice-based commissioners would like. We have made some real progress over the last year and we have been working with external consultants to really help with the organisational development, so I can see that if somebody specifically asked NHS Norfolk about that, we would cite some really exciting and positive things at NHS Norfolk level but we would also recognise that our practice-based commissioners would say, "Actually, we still have quite a long way to go". I think it is real that both those things could be true at the same time. I think what is really exciting about the last few years is the ability we have had as PCTs to start acquiring skills, capacity capability to do commissioning as we have always wanted to do it so that it has real impact on the services that people will experience, and I think that is why there has been such a degree of positivity in that feedback, because it feels tangible; it is almost within our grasp to be these World Class commissioners if we did not have massive reorganisation. I do think there has to be some stability to allow us to get on with that journey.

  Q323  Mr Bone: In a nationalised, state-run health service employing 1.4 million people is the truth of the matter not that bureaucrats grow and grow and empires are built up? Are PCTs commissioners not exactly that, just a lot of ever-increasing, overpaid pen-pushers, and is not Government recognising this by demanding a 15% cut next year in commissioners, going up to 30% over four years? If we have a different government after 6 May, will it not be even tougher because the incoming government will want even more cuts in commissioners? How is this going to affect commissioning? Can you just cut 15%, or 30%? What will that equate to—11,400 commissioners are made redundant over the next few years? What effect is that going to have on commissioning, or is the initial analysis right?

  Mr Parkes: I think that, because of the economic situation we are having, dealing with my overhead cost could never be exempt from somebody saying, "You need to reduce it". I have no philosophical problem with reducing mine by 30% over a four-year period. That is not to say that we are 30% inefficient at the moment, but there will be scope for us to be doing more things once in the East Midlands rather than nine times because there are nine PCTs. We can get efficiency through that way. I think some of our IT and IT systems will give us added benefit and insight into areas where we can again use technology to become more efficient as well. The one thing I have done and would want to carry on doing is that we use external management consultants or we employ an external company on a permanent basis, so, rather than me always having my people doing something, I have found that the opportunity to buy those services in rather than to always grow them internally—and I have tried growing them internally—will probably lead me to a position where I may well reduce more than 30% but would want to carry on using external companies to help me be even more efficient as a commissioner.

  Ms Garbutt: I would absolutely endorse what John said. I think it would be unreasonable to expect that somehow commissioning resources or management costs could be exempt from needing to be trimmed back quite considerably when you consider the economic climate that we are in. I think that does present PCTs with something of a challenge. Again, I would agree that the sorts of areas that John has outlined are the areas that we will be looking at. It is important that where we have developed skills, capacity and capability, we do not lose that, but there are lots of different ways that we can share to enable that skill and capacity to be available for more PCTs. My concern is that with a level of 30%, particularly if that is seen to be taken out quickly, and John referred to four years but certainly within my SHA area there is talk of trying to drag considerable amounts of that out in years one and two, there is a danger that you destabilise the capacity and capability to the extent that commissioners cannot do what they need to do, and commissioning is going to be the way that we go through the next three or four years and work with a vastly reduced resource and still deliver quality, productivity and good services for patients. I think there is going to be a real delicate balancing act to make sure that we do deliver efficiencies in our management resources because we must, but also to make sure that we keep that skill base and that capacity and capability. I think John is right: some of that is how you buy that in rather than investing in full-time resources in your own organisation.

  Q324  Mr Bone: Julie, you just mentioned SHAs. Would one of the easiest cuts to make not be just to scrap SHAs? I do not know what they do. They do not seem to add anything. Do you think it would be a good idea to get rid of them?

  Ms Garbutt: I believe there is always going to be a need for some sort of intermediate tier between the primary care trusts and those out in the field and the Department of Health and Government. I do not think it will be possible to have that sort of direct relationship with 150 or even a smaller number of primary care trusts. However, whether we have the right number of organisations in the intermediate tier I think is a good question. It is not one I can answer but certainly I would be making a strong case, and within our SHA area we have to say, "How much can the SHA slim back by and can they deliver more than a 30% reduction?", because we are moving into a phase where we all have our five-year strategic plans and they are fitted to the economic climate. We need to deliver those strategic plans; we need to deliver different services that are better value for money, so we need to protect the resources of the front-line.

  Q325  Mr Bone: I just want to ask Mr Parkes something on that. Mr Parkes, yes or no: do you think we should get rid of this useless SHA?

  Mr Parkes: No, but I will tell you why. I think one of the key roles will be to make sure that good practice in Northamptonshire or wherever is rolled out across the country.

  Q326  Mr Bone: I will now focus on the other side of it. Is not all this nonsense about cutting back just populist MPs looking for votes in the next general election, and is not the reality of the thing that if we want to improve productivity, which has not been improving, we have got to have first-class commissioning? How are you going to get World Class commissioning if you are having your resources cut by 30%? Your model of outsourcing was quite interesting.

  Mr Parkes: I think we have got to get to a position where you do not have 152 PCTs across the country looking at numerous different pathways. We have got to get to a position of "Here is the expert, evidence-based, good practice pathway for condition X" that we then interpret locally. If we can then use that type of methodology to avoid inappropriate admissions or inappropriate use of resource and translate those pathways with clinicians locally, I think you will see a marked improvement in the way that money is being spent and in outcomes as well.

  Q327  Sandra Gidley: We have heard evidence that there is an imbalance of power between providers and commissioners, and the Government have been banging on for years about moving resources and services out of secondary care into primary care. It does not really seem to have made huge amounts of change. I just wondered what your relationship was with the acute trusts in your regions, because presumably they want to protect what they do.

  Ms Garbutt: One of the benefits we had in Norfolk from the last reorganisation, bringing five PCTs into one—and I am no particular advocate of big or small; I think both have their place according to local circumstances—was that instead of five PCTs all trying to have a relationship with the local large provider, the NHS trust, now foundation trust, we were able to have a single point of contracting commissioning with that provider. What we have done over the last two or three years is significantly enhanced our ability to be very businesslike and professional in the way that we deal with that provider. They have seen the impact of that and they have recognised it quite publicly. What we have also done is brought them into the work we did to design our five-year strategy, so although they might not necessarily like the concept of moving work out of hospitals because that is their income base, is it not, they have been able to see what the rationale was for that in terms of meeting the specific needs of people in Norfolk, and what we have been able to say to them is, "Just because work is coming out of a hospital and being done in a community setting does not mean you could not be the provider of that service but you would be delivering it differently". I think the balance is starting to shift and I think that is about having real, good quality relationship management and contracting skills but also really working the system management to ensure that they are part of that system and feel part of it, because sometimes providers can be a little bit distant.

  Q328  Sandra Gidley: We hear a lot about GPs being involved but some of the feedback I have heard in different places is that clinicians in hospitals are not involved; it is all with the management. Are we missing a link of the chain there by not including clinicians in hospitals? You used to work on the other side, John.

  Mr Parkes: I think to be a credible commissioner you have got to be engaging with both primary care clinicians and secondary care clinicians. If I just sat in my headquarters and thought up ideas and did not involve primary care and secondary care clinicians, they would not be credible, so in that diabetes example we put in some challenge, brought in some experts from elsewhere but really did involve both primary care and secondary care clinicians in it.

  Q329  Dr Naysmith: How did you involve them?

  Mr Parkes: By showing them the evidence, showing them where their practice varied from an internationally agreed best practice pathway, not in an adversarial way but there was one particular clinician whose drug costs were, in terms of money, over £1 million more expensive than colleagues'. He did not know that.

  Q330  Dr Naysmith: You let him and everybody else know that and that changed his behaviour?

  Mr Parkes: We made that information available to that person and talked through whether there was a real benefit from the way that money was being spent rather than doing something differently, so it was done very much together. The other point I want to make is that whilst I am employed by NHS Northamptonshire I work for and will always work for the NHS, and I think that is quite an important mindset.

  Q331  Sandra Gidley: But are you unique in that because some people do get quite territorial about their little patch? You are a senior manager but you have to deal with lots of people.

  Mr Parkes: Others will occasionally fall into the trap of working for particular organisations, but I think part of my leadership role would be to get all of my managers and others to understand that we work for the NHS.

  Q332  Sandra Gidley: So it is fair to say that the best way of changing behaviour of providers is having a very good evidence base?

  Mr Parkes: Yes.

  Q333  Sandra Gidley: Is that lacking in some areas? Are there areas that you find it difficult to drive change in because the evidence base is not there because there are huge amounts of data in a hospital, less so in the community?

  Ms Garbutt: I think that is a fair comment—there are areas where the evidence will be more ambivalent and therefore there is real scope for clinicians to have different perspectives, but even then if you bring all your clinicians together, they will work their way through and generally come to a consensus about what makes the best sense for your local area.

  Q334  Sandra Gidley: But will they come to the same consensus as the PCT?

  Ms Garbutt: That would be with PCT clinicians as well. In NHS Norfolk we have very well embedded clinical leadership and clinical engagement. All of our programme commissioning boards are led by members of our clinical executive—GPs, nurses, pharmacists, whatever—but what we have also been doing is bringing PBC leads into that and increasingly forming networks with the clinicians in our hospitals. I mentioned earlier the stroke care path work we did. That was co-led by my clinical executive committee lead, who is a particular expert in long-term conditions, and one of the lead stroke clinicians in the local hospital, so they brought the project together themselves and sponsored it through the changes, and that meant that we had buy-in from clinicians both in primary care and in secondary care.

  Q335  Sandra Gidley: In the diabetes and stroke examples that is all about commissioning new services, but there is increasing evidence that there are quite a lot of clinicians out there doing things because they have always done them for years; there is no real evidence base. Have you got any examples of any services that you have decommissioned because they were not a good use of money?

  Mr Parkes: There are areas where clinical practice has moved on. For example, I really would not be expecting to be seeing large numbers of tonsillectomies being undertaken.

  Q336  Sandra Gidley: That is a bit of an old chestnut.

  Mr Parkes: No, no, or if you took C-section rates, we would be through the national—

  Q337  Sandra Gidley: They are going up and up.

  Mr Parkes: Yes, but that is why I think through the Payment for Quality indicators that there will be a CQUIN reward payment linked to those numbers being brought down. I think, rather than perhaps decommissioning things, we try and use new tools like, for example, CQUIN as a means of changing behaviours and getting to a better position.

  Q338  Sandra Gidley: Apart from your tonsillectomies, are there any other services that have changed behaviour rather than decommission?

  Ms Garbutt: I will perhaps give you an example which is a specialist commissioning example from within the East of England where the 13 PCTs collaborate. Until quite recently I chaired the specialist commissioning group in the East of England. We were, I think, probably the first group of PCTs to totally re-commission and decommission IVF services and we went through a complete tendering process which meant that some providers of IVF services that were not getting the sorts of quality results that we wanted were no longer providing that service to patients in the East of England and other providers that were offering good quality services were given the contract, so we have done some decommissioning. Because we have been in an era of growth of resources there has also been more of an inclination to look at what new things you would like to buy rather than really looking at, "Perhaps we should not be doing that". As the focus gets very tight on absolutely being certain that you are deploying all your resources to best effect, there will need to be more decommissioning and a much more rigorous appraisal of the information that allows you to say, "Actually, that is not really very good value for money", or, "The quality outcomes are not really what we expect there so we need to stop buying that and buy something different".

  Mr Parkes: We certainly have put services out to tender when we have looked at cost and quality, and there have been examples where we may have been having services provided out of county, such as wet macular degeneration, and there was a desire from the public to have the service in-county, so we have decommissioned the out-of-county service and established an in-county facility. One of the pieces of evidence that I gave to the inquiry around children's mental health was that we did not have a good in-county service; we were spending a lot of money on individual packages of care out of county, and by decommissioning those and bringing patients back into county we have been able to come up with a better experience for the patients and for their families and we can demonstrate that we have avoided some hospital admissions as well. There are things like that which we are doing quite deliberately.

  Q339  Sandra Gidley: But do you predict more decommissioning as a result of financial pressures?

  Ms Garbutt: I think there will have to be. We want to spend the money in the right places.

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