Examination of Witnesses (Questions 340
THURSDAY 28 JANUARY 2010
Q340 Dr Taylor:
One of the initial criticisms of the purchaser/provider split
was that it drove a wedge between commissioners and providers
and really what you have both said, and I think it is in the Northants
evidence, is that you have adopted a collaborative approach, working
in partnership with providers, so really you have overcome that
split in the sense that purchasers and providers do not talk.
Mr Parkes: Absolutely. If I have
a £1 billion budget, which I do, and if at the end of the
year I have not allocated that in a way that has services that
are sustainable, that are of a better quality, and if I am then
sitting on a big surplus and my hospitals are in deficit, to me
that would not be a place I would be aiming to be. Where I want
to work with them is, "How have you been spending the money
and how can we spend it in a better, more effective way?",
and manage the change in a way that allows them to alter their
size, capacity, staff numbers, et cetera, in a way that does not
suddenly result in a stop-start mentality.
Q341 Dr Taylor:
One of the criticisms we have had is that PCTs do not really have
much control over hospital admission rates and things like that.
We have been told that research in 2004 showed that primary care-led
commissioning and GP fund-holding did result in lower rates of
hospital admissions, lower prescribing costs and innovations in
primary and intermediate care. Would practice-based commissioning,
if really we gave that more support, not achieve those goals and
would that not give you control over hospital admission rates
and things like that?
Mr Parkes: If I can use a Northamptonshire
example, we have just allocated £4 million on an invest-to-save
scheme specifically for primary care, to say to them, "Whatever
the scheme iscommunity geriatricians, community diabetologists,
whatever idea you want to come up withhere is a £4
million fund that, as commissioners, we have made available for
you to use and all I want is a better return on investment than
the £4 million that I am putting up front". We are quite
deliberately making funding available to primary care, to our
PBC consortium, to develop those services out of hospital so that
they can be transforming the services and giving the public what
they want, which is a greater range of services close to their
home. Rather than just say, "You are not managing demand",
we are saying, "Here is a fund. You come up with the ideas
around if patients were being supported differently how could
they be supported to stay at home rather than being admitted to
a hospital or into a nursing home".
Q342 Dr Taylor:
How are you actually managing that, because one of the constant
criticisms we get is that it is impossible for the NHS to move
money between silos, to move the monies from acute care into prevention,
which obviously would be an economy in the long run? How do you
happen to have £4 million that you can do that with?
Mr Parkes: The way that I am doing
that is that this will be the last year that I receive, in effect,
an uplift in my allocation, so I have got a 6% uplift in my allocation
and, rather than just spreading that out in a random way, we are
using that as an innovation fund.
Q343 Dr Taylor:
To make economies in the future?
Mr Parkes: To absolutely make
economies in future, so if primary care or secondary care want
to come along and, say, do more home technology to support people
having long-term conditions monitored in the home rather than
being brought into hospital, we will use that whole 6% or the
majority of the 6% as a means of an innovation fund to support
both primary care and secondary care to be more efficient. Otherwise
I have missed that opportunity before we go into a more difficult
Q344 Dr Taylor:
Are you unique in this foresight?
Ms Garbutt: If I could add to
that, I think we are doing something very similar. My board yesterday
approved two business cases from practice-based commissions, both
valued at £1 million each, to substantially change the way
that they are managing referral patterns and service development
in the community, and I think that is exactly the right thing
to be doing. Going forward, we are looking at bringing whole budgets
devolved to practice-based commissioners into place next year.
The reason we want to do that is that we have to make a connection,
I think, between what is spent on primary care delivery and what
is spent in hospitals and in the community into one place, because
it is the GP, when they are seeing the patient in front of them,
who makes the resource allocation decisions by deciding to refer
them to the hospital, to write a prescription or to treat a patient
with one of their services locally. They are committing those
resources. In terms of our practice-based commissioning groups,
we have four large consortia. They are very keen to be able to
use that total budget to say, "If we are going to pay ourselves
more in primary care, we are going to do more in primary care
and build more services here because we know that will give us
more options to stop patients going to the hospital, which means
we will not be paying them so much", and at the same time
the hospitals are very keen to support this because we are reaching
a point where the infrastructure of the hospitals is at breaking
point. It cannot keep taking the increases in numbers of patients
and we do not want to be investing in very expensive hospital
infrastructure, so absolutely it is the right way to be going
to be putting the money with the people who are making the referral
Q345 Dr Taylor:
From your contacts with other chief executives do you think virtually
everybody is doing the same sort of thing in this one year when
there is that bit of spare money?
Mr Parkes: Yes.
Ms Garbutt: Yes.
Q346 Charlotte Atkins:
Before I go on to another question I just want to follow up on
that. You may be reducing hospital admissions but are you reducing
the length of period that patients spend in hospital? One of the
problems is, and I know there are tariffs and everything else,
that ultimately it is still the PCT that picks up the bill for
a patient who is in the hospital. For instance, if you have a
situation where a patient gets one or, dare we say it, two infections,
it is the PCT ultimately that is picking up the bill rather than
the hospital. They basically have an open cheque book which the
PCT has to pay for. How do you deal with that?
Mr Parkes: I think we have already
started doing this, but we have got to move to a position where
we do not pay for those pre-admission days and we do not pay for
those excess bed days unless there is a reason for them.
Q347 Charlotte Atkins:
An acceptable reason for them?
Mr Parkes: Absolutely, an acceptable
reason for them.
Q348 Charlotte Atkins:
If there is an infection, it is down to the hospital?
Ms Garbutt: Yes, absolutely.
Mr Parkes: Yes.
Q349 Mr Bone:
On this business of not paying for things, what is your view on
emergency re-admissions because they are climbing in percentage
terms? The hospital sends somebody home saying they are well and
you pay for that and then you are lumbered with it again. In America
they would not pay for the hospital re-admission. What is your
view on that?
Mr Parkes: Certainly for me there
is a need to change from a system that would require me to agree
not paying the invoice that the trust has submitted. I would need
to agree with them that their invoice could be adjusted. I would
prefer to have an ability to say, "That was inappropriate.
I am just not paying for it", rather than having to agree
not to pay for it. If I had that freedom but also agreed what
the right practice was, then we would be in a slightly different
position from the one we are in today. Nationally, again, one
of the CQUIN payments will be linked to patients who are re-admitted
within 28 days, so, again, trying to get the right either incentive
or disincentive into the system I think is fairly fundamental.
Q350 Charlotte Atkins:
When you are talking about those additional days you are paying
nothing or you are paying a reduction on what you would normally
Mr Parkes: Yes.
Q351 Charlotte Atkins:
Which is it? You pay nothing or you pay 30% of the normal cost?
Mr Parkes: In terms of my position,
and my position may be unique, on those excess bed days we pay
Q352 Charlotte Atkins:
And what about Julie?
Ms Garbutt: It is much the same,
but that has to be negotiated upfront, and there have to be clear
parameters because there will be occasions when it is perfectly
appropriate that patients have stayed longer or that patients
have been re-admitted.
Q353 Charlotte Atkins:
Absolutely. To move now on to the new Operating Framework 2010-11,
it calls for PCTs, in the jargon, to "commission transformed
and integrated pathways to optimise health gains and reduce health
inequalities". It says that that will require stronger joint
commissioning and collaborative working. What do you understand
by that and what evidence is there that you are doing itcollaboration,
the joint commissioning? How much of that is going on?
Mr Parkes: I will give you a couple
of examples with an integrated care pilot site, and I think the
future destination for my provider arm will be for them to be
working in a more integrated way with both primary care and social
care to try and minimise the hand-offs between those different
sectors. What we have done already is that, for example, we have
got pooled mental health budgets, we have got joint commissioning
between the social service and the health service on major areas
like mental health, and we would see the integrated care pilot
or partnership as a means of looking at how you better integrate
the care that needs to be given on a particular pathway. We touched
earlier on the organisational form debate. I am really keen that
we progress the transformational form debate rather than the organisational
Q354 Charlotte Atkins:
Some PCTs, I think, would say that floating off the provider arm
would make it more difficult to collaborate with social care providers.
Ms Garbutt: I think we are looking
to do two sets of integration as PCTs. One is the integration
of provision and, like John, our integrated care pilots, of which
there are six covering 250,000 people, are combining in integrated
teams those healthcare professionals, social care professionals
and primary care professionals, so we are testing out how we bring
the provision of service together anyway. There is a lot of support
for that, and indeed for children's services as well; it is not
just for adults. What we are doing more of now, though, is to
say how do we integrate commissioning as well so that we do not
simply say, "Social care will commission that bit and we
will commission this", but, "Could we do it together?
Could we have one single team of people or one person leading
on that?". We have a joint director of integrated provision
already in place. We are looking to have a joint director of strategy
and commissioning with our county council and across mental health,
learning disabilities, et cetera.
Q355 Charlotte Atkins:
So those will be paid for?
Ms Garbutt: They will be shared
between the two organisations, which is another way of managing
the 30% management cost reduction, to say how many ways can we
work jointly with other organisations, whether it is other PCTs,
local authorities, or indeed both, to combine the resource in
that way, get a saving but also get that real co-ordination, because,
let us face it, the patient does not differentiate between whether
they need a social care service or a healthcare service. They
just want the services to be available to them when they need
them, so we need to take those boundaries out. Certainly, my PCT
is very close to doing that and I think most are starting to look
Q356 Charlotte Atkins:
Your integrated care pilots are working well, are they, across
both your regions?
Mr Parkes: We are certainly very
pleased with the progress that has been made and we have developed
things like proactive care where we are trying to make sure that
we are giving the right individual package of care to somebody
and avoid them being admitted into hospital, and that whole better
integration between primary care, social care and hospital care
I think has got to be one of the remedies that we take forward
and take forward seriously.
Q357 Charlotte Atkins:
Does public health get its feet into this integrated model or
is public health left on the sidelines?
Ms Garbutt: No. Our public health
practitioners are part of the models to help put the needs assessment
in place and give them locally based needs assessments. The IC
pilots are still quite new but one of ours in mid-Norfolk has
been working for a little longer and they have had attached social
care staff within the practices for a while. They have recently
done an evaluation that was led by the University of East Anglia
and because they have been able to co-ordinate their efforts and
provide local services they have been able to reduce their admissions
to hospital by 18%.
Q358 Charlotte Atkins:
Ms Garbutt: 18%. I think that
is a really good indication that working together in this way
does mean you can provide better services
Q359 Charlotte Atkins:
18% over what period?
Ms Garbutt: Over a year.