Commissioning - Health Committee Contents

Examination of Witnesses (Questions 380 - 398)



  Q380  Dr Stoate: Does either of you expect it to make much of a difference?

  Mr Parkes: Personally I think that for it to make a significant difference we would probably need to have a greater figure than the 1.5% and it would probably need to be there as a reward rather than part of a base payment.

  Ms Garbutt: I agree with that.

  Q381  Charlotte Atkins: John, you mentioned that the Operating Framework sets CQUIN at 1.5% but they are talking about the possibility of it rising to 10% in 2011-12. Are you comfortable with that and also have you ever fined one of your providers for poor performance, such as infection?

  Mr Parkes: Yes, we absolutely have fined and we do it quite deliberately in order to try and get that balance between rewards and penalties as a means of influencing behaviour. I would be interested in the move towards 10% but I am worried that if that is part of the base funding it could have a destabilising effect, so I think perhaps the clever thing—

  Q382  Charlotte Atkins: Can you explain that a bit more? Why would it be destabilising?

  Mr Parkes: If I went back into running a hospital, if I potentially lost 10% of my income because I had failed CQUINS without there being a proper period of notice for recovery, it would have the ability to destabilise me financially, so I think the 10% would have to have periods of notice and periods of improvement before the 10% was either earned or removed.

  Q383  Charlotte Atkins: In terms of fining for performance, can you give an example of that, and did it improve performance in future?

  Mr Parkes: We have certainly fined providers in the past for failing to achieve things like A&E targets, and, depending upon their financial position, it has either had an impact or not. It is probably more the threat of it that is the real value.

  Q384  Charlotte Atkins: Julie?

  Ms Garbutt: We have not fined, although the threat of that fine is there. I think for the reason that John said, unless you are talking about really sizeable chunks of money it is not going to have the desired effect. We need to incentivise more but I think there has to be the ultimate sanction if, after periods of recovery and notice, you are not getting improvements.

  Q385  Charlotte Atkins: From April 2009 the Patient Related Outcome Measures were introduced into the NHS in four areas: hips, knees, hernias and varicose veins. Where that shows poor performance will you alter your commissioning? You have already mentioned this, John, that you have altered your commissioning in some ways.

  Mr Parkes: Yes, and one of the things that we want to do is use that information to help patients make choices around where they want to go for their elective surgery.

  Q386  Charlotte Atkins: But the evidence shows that patients are more likely to decide where they go on the basis of what the car parking is like rather than the quality.

  Mr Parkes: I absolutely agree.

  Q387  Charlotte Atkins: They look to their GP, do they not, to advise them which hospital to go to because they do not usually feel competent or aware enough to be able to choose?

  Mr Parkes: If I need my hip doing, there is a model that says, "An expert orthopaedic nurse will call you tomorrow. We will talk through the treatment options, agree with you success, be it reduced pain or increased mobility, and we will share with you who the local providers are, the local surgeons, and what the feedback is in terms of outcome and patient satisfaction", and experience from other economies shows that the public like that because it is a half-hour conversation rather than a five- or ten-minute one, and it also in some instances results in people saying, "No, I do not want that operation because of the potential risk or lack of benefit to me", and we are wanting to get to a position where we pilot that in Northamptonshire.

  Ms Garbutt: I think it is very early days still with PROMs, but I think making that sort of information available to patients does empower them to make different choices, and particularly the one about choosing not to proceed with having treatment is very important. Although, obviously, clinicians do go to great lengths to explain the pros and cons of any particular treatment that they are suggesting, I think knowing how other people have got on and what their experience has been and whether it is a total success or not is very useful in terms of empowering the patient to make their own choices.

  Q388  Charlotte Atkins: Including deciding not to be treated?

  Ms Garbutt: Yes.

  Q389  Charlotte Atkins: Do you think that fines have a problem in terms of maybe destabilising your local health economy, or is it just about shifting financial pressures from yourselves to providers? How do you see fines?

  Mr Parkes: I think I have a role in terms of managing risk, and risk to the patient is at the forefront of my mind so I would want fines to be used to mitigate that risk, but at a secondary level I do not want to completely destabilise my providers, I want to have a professional relationship with them. My health economy would know that if we are having high cost, poor services, they will be put out to the market and market tested to see whether there are other people out there able to provide better quality at reduced cost.

  Q390  Dr Taylor: World Class Commissioning in one minute. What difference has it made to the work you do? You have given us a list of things: the SWAN Partnership, Child and Adolescent Mental Health from Northants and Telehealth stroke services and things like that, so why could you not do those in any case? What has World Class Commissioning done to allow you to do that?

  Mr Parkes: I think it has allowed me to move from a spending regime to an investment regime because it has set out almost a set of exam questions that represent good practice that I know I should be aiming to achieve, so that whole testing of what are now 11 competencies and being clear around what excellent is in those 11 competencies has allowed me to develop the form and functioning within my commissioning organisation.

  Q391  Dr Taylor: It has really just been a way of focusing your efforts on the right way to go?

  Mr Parkes: It has given me a whole set of questions that I have had to answer in terms of making myself a World Class commissioner, absolutely not there but I can see the journey and I can see where I need to get to.

  Q392  Dr Taylor: You did, I think, rather better than Norfolk on the scores. Julie, why did you not do quite so well on the scores? How were the scores worked out?

  Ms Garbutt: I would probably start off by saying I think it depends on where you start from. A number of the PCTs that did particularly well and boast very good scores were ones that had not been reorganised, so they were able to hit the ground running, they did not have the instability of having to reorganise, reappoint people, et cetera. We had a very complex and difficult reorganisation. The five previous PCTs did not particularly want to merge. They had not done much in the way of transition planning and, as they did come together, the ledgers proved that there was a 50 million deficit. I could say, therefore, no wonder, but I am also very conscious that John is sitting next to me and he had much the same start and he performed much better, so I do not think that can be a legitimate response. When I reflected on it I was saying two things. The first is that we did not have the capacity and capability in place that we needed, and the second is that is we did not have a strong strategic plan, and both those things feature very heavily in terms of whether you can demonstrate you are delivering competencies, and the strategic plan determines whether you are agreeing on your governance, your finance and your strategy. What I can say is, since we have had that experience, we have now got a first-class five-year strategic plan which has been benchmarked and agreed by our strategic health authorities as one of the best it has seen. We have a very comprehensive organisational development plan. We were supported both by external consultancy to make sure we were challenged and we have made great inroads to implementing those. I do intend and expect that we will do much better in the round that we are now in, but we were where we were and we needed to move fast. The good thing about world-class commissioning is it gives us very clear standards and very clear benchmarks and there is nowhere to hide.

  Q393  Dr Taylor: Did it make you focus more on competency, engaging the public and partners?

  Ms Garbutt: No, we were stronger in engaging public and partners and in system leadership. Our weaknesses were in the technical competencies, the market making, the utilisation of information, contract management, all areas in which we have significantly boosted our competences in terms of capability and capacity.

  Q394  Dr Taylor: How much did either of you use the external organisations? We are told in the Framework for procuring External Support for Commissioners there are 14 private sector companies that you can call on for support.

  Ms Garbutt: Yes.

  Q395  Dr Taylor: Did you use those? How much did you spend on those?

  Ms Garbutt: We used external support from the FESC agencies to develop our commissioning processes through our commissioning boards, we used them to support us in developing the strategic plan, we used them to support us in developing our organisational delivery plan. We also used a number of interim agency appointees to boost senior leadership in the PCT whilst we embedded those practices in the PCT and we made substantive appointments. The investment was quite substantial and would run into millions.

  Q396  Dr Taylor: Do you think that investment is going to pay off?

  Ms Garbutt: Yes, I do.

  Mr Parkes: We have the largest FESC contract in the country and regularly use external management consultants. I have no issue with that as long as whatever I am spending I can actually demonstrate that by so doing they have added real value. So far we have had no problem with a number of our external consultancies but, as with any external company, they do need to be managed and I am sure at some point we will part company with some but will play in others.

  Q397  Dr Taylor: This would be one of the large proportions of money spent across the NHS on management consultants?

  Mr Parkes: Yes.

  Dr Taylor: Thank you.

  Q398  Dr Naysmith: A final question. What would you like to see the Government do to help you to improve? That question could be framed another way. Do you want to be left alone or do you want further reform?

  Mr Parkes: I certainly do not feel the need for further reform, and I think there is good evidence that says we tend to reform things on a three-year cycle when most things take six years before they reach their optimal level. I do not want to be reformed, but I do think that there are things that you could do, for example giving me access to the primary care data that would allow me to become a more effective commissioner but would allow clinicians to be more effective practitioners.

  Ms Garbutt: Give us time to bed in. Please, no more re-organisations. Continue to support the shift in terms of the balance of power, so more of the changes around the tariff to enable us to move money around the system, and a slimmed down intermediate tier, please. We need to maximise the devolution of the money and the responsibilities to the frontline.

  Dr Naysmith: Thank you both very much indeed. You have given us a lot of useful information that will help us to write our report. Thank you.

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