Commissioning - Health Committee Contents


Examination of Witnesses (Questions 340 - 359)

THURSDAY 28 JANUARY 2010

MR JOHN PARKES AND MS JULIE GARBUTT

  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 is—community geriatricians, community diabetologists, whatever idea you want to come up with—here 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 economic situation.

  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 decisions.

  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 pay?

  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 nothing.

  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 it—collaboration, 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 form debate.

  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 at that.

  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: 18%?

  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.


 
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