Examination of Witnesses (Questions 360
THURSDAY 28 JANUARY 2010
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
Q362 Mr Scott:
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
Mr Parkes: Yes. It is in effect
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:
Mr Parkes: Nene.
Q366 Sandra Gidley:
Nene Commissioningwhat 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
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
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
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
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
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.