Commissioning - Health Committee Contents

Examination of Witnesses (Questions 360 - 379)



  Q360  Mr Scott: Briefly, could you explain to us what clinical networks run in your region, what is their function and, as they cost a great deal of money, is it money well spent?

  Ms Garbutt: There is quite a large range of clinical networks in our region. They cover things like cardiac network, cancer network, neonatal intensive care network, and they go on. There is an emergency care network. I think networks are a good idea in as much as they bring clinical leaders together, experts, to look at how services should develop and change, but they are not commissioning entities. Commissioning is done by PCTs. My perception is that probably over the last few years clinical networks have lost their way a little bit. I think as PCTs have grown their clinical engagement locally and as SHAs have built clinical engagement into their work, clinical networks to some extent have got a bit lost in that. It still seems to me that intuitively they must have value if they are bringing clinicians together, but I think it probably is time for that to be reviewed because they do carry a management overhead cost because they have to be serviced.

  Q361  Mr Scott: Is that currently money well spent or not?

  Ms Garbutt: It varies by network, would be my sense of it. Some of the networks are more effective than others.

  Q362  Mr Scott: John?

  Mr Parkes: I led a review of the networks in the East Midlands probably two years ago and we did not reduce the number of networks but we had a slightly different model where we were absolutely clear, "This network is there for providers. It is to support the movement of intensive care patients", or whatever. "This network is here to support commissioners and to inform the commissioning decision". What we have tried to do as a result of that is get the right product at a reduced cost. We absolutely think they still add value but they are subject in effect to an annual review.

  Q363  Dr Naysmith: Where does the money come from if it does not come from PCTs?

  Ms Garbutt: It does come from PCTs.

  Mr Parkes: Yes. It is in effect top-sliced.

  Q364  Sandra Gidley: I want to move on to a bit more about practice-based commissioning and how you work with GPs. Could you give a very brief overview of how you involve those clinicians?

  Mr Parkes: We have got Nene Commissioning, the largest PBC consortium in the country.

  Q365  Sandra Gidley: What, sorry?

  Mr Parkes: Nene.

  Q366  Sandra Gidley: Nene Commissioning—what is that?

  Mr Parkes: It is the name of our practice-based commissioning consortium. It covers 98% of the population, so just under 700,000 people, and has within it six localities. It is very similar to the previous PCG areas.

  Q367  Sandra Gidley: Are these GPs you are talking about?

  Mr Parkes: Absolutely. It is GP-led, chaired by a GP. It has a chief executive and we use Nene Commissioning as the main route for us to be working effectively with GPs and to be influencing what is happening. What they will now be doing is using those localities to, in effect, have a federated model between GP practices so that if you cannot have a specialist nurse in one GP practice then by federating that specialist nurse becomes available to a locality and it supports more work being done out of hospital.

  Q368  Sandra Gidley: It sounds like the sort of thing the Royal College of GPs was advocating. Did you follow up on that or were you doing that before?

  Mr Parkes: In the original model we had two main consortia and they merged a year ago. It is a model that continues to evolve but one that we are very supportive of.

  Q369  Sandra Gidley: Will they come up with an idea or a proposal? How long does it take to work it through, process it and adopt it?

  Mr Parkes: When, for example, we asked them to look at the end-of-life provision it would have probably taken my team four times as long as it took their team.

  Q370  Sandra Gidley: What are we actually talking about? Years, months?

  Mr Parkes: No, it was done in three months, because they had won the hearts and minds and engaged with the clinicians at the front end, so therefore it was a proposal that was not meeting any opposition. I think the reality is as well that PBC is there and it is seen to be supportive of GP, primary care, changing practice, whereas I am seen more as the agent of government, so there is probably more openness to some of the ideas coming through the PBC board than would be always from me as a commissioner.

  Q371  Sandra Gidley: Julie, is it the same in Norfolk?

  Ms Garbutt: I think we are just a little bit further behind than John is. We have four practice-based commissioning consortia in Norfolk. Over the last year we have worked much more closely with them. We have a director and a number of business cases that work with each of the PBC groups to help them with their development. They are coming round to the realisation that they need to build their infrastructure and their capability in much the same way as John has described in terms of having resources, chief executives, people who can turn the good ideas that the clinicians have into the reality of business cases and service changes. Having said that, in terms of business cases, we have worked with them to improve the quality of the business cases they can produce. That means they go through the system that much faster. The two business cases I referred to earlier that were around referral and demand management were sizeable, challenging business cases because they were looking at seeking £1 million worth each of funding. Because they worked so closely with us on developing them we were able to process them and get them agreed within a month and they will implement within the next three months. For something as big as that I think that is a fairly quick turnaround.

  Q372  Sandra Gidley: So that is starting to work a lot more quickly?

  Ms Garbutt: Yes.

  Q373  Sandra Gidley: How do you go about improving the management of primary care networks and GPs? Would GP fund-holding be a way forward again? We always go round in circles in the Health Service anyway, so it is probably about time for it.

  Ms Garbutt: I think the good thing about fund-holding was that it did allow the decision-making about who went where and got what in terms of services to be tied into the sums of money that were used, and I think fund-holders were very good at looking at how they could spend that money better, so I am a supporter of giving real budgets to practice-based commissioning groups providing that they have got the infrastructure and the ability to manage the money well.

  Q374  Sandra Gidley: At what level would you do that? That would be at the group level, it would not be at the individual GP surgery level?

  Ms Garbutt: No, I think they would carry too much risk in terms of the volatility of their budgets if they tried to do it at individual practice level.

  Mr Parkes: My concern with going back to a GP fund-holding model is that, whilst I think there were elements that were effective, I do not think it was ever able to deal with, "Here is an area that is well resourced versus here is an area of real inequality and deprivation and how do you move the money between the two?". Peter Bone wants to talk to me about one of his constituents who has a particular need that will cost £250,000. As a £1 billion organisation, I can consider whether that treatment is warranted. I think that would be very difficult for an individual GP to say yes or no to.

  Q375  Dr Stoate: How did you develop your local CQUINs?

  Mr Parkes: We have six that are in effect coming down through the SHA and we have two that have been specified nationally, and then we are agreeing probably another four locally.

  Q376  Dr Stoate: You have not developed the majority of them yourselves? You have taken national or strategic models, essentially? Is that the same for you, Julie?

  Ms Garbutt: We have the two national but we are developing the rest locally with oversight from the SHA to spread good practice across.

  Q377  Dr Stoate: How will you ensure that they are evidence based if you are developing them locally?

  Ms Garbutt: Because we are working with our providers and looking at evidence-based and looking at where there are particular areas where we think that by giving the stimulus of CQUIN we can drive through quality change.

  Q378  Dr Stoate: You believe that you have the capacity to exploit CQUIN properly to make it work?

  Ms Garbutt: I think it is still very early days. I suspect we may need to deploy capacity more to that area in order to get the best benefit out of it.

  Q379  Dr Stoate: Is it the same for you, John, or do you feel as though you have got the capacity to deal with CQUIN?

  Mr Parkes: I have. I just think that there is 1.5% in CQUIN and an expectation of 3.5% efficiency. We just need to be careful that we are not destabilising our providers but getting the right focus on improving quality.

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