Examination of Witnesses (Questions 399
THURSDAY 28 JANUARY 2010
Q399 Dr Naysmith:
Good morning everybody. Welcome to the Health Select Committee.
You have all, I think, been sitting in on the first session, so
you pretty well know the score. What I want is fairly sharp answers,
if you can, and not too much repetition and we will get through
quite a long agenda. Could you, first of all, introduce yourselves
for the record and say who you are representing?
Ms Donnelly: I am Maureen Donnelly;
I am the Chair of NHS Cambridgeshire. I have been the Chair for
just over three years.
Dr Zollinger-Read: Paul Zollinger-Read;
I am the Chief Executive of NHS Cambridgeshire; I have been doing
that now for nearly two weeks.
Dr Brimblecombe: I am Pauline
Brimblecombe; I am a Cambridge GP and I am Chair of our local
Practice Based Commissioning Consortium.
Mr Graves: Stephen Graves; I am
Director of Corporate Development at Cambridge University Hospital,
locally known as Addenbrooke's.
Q400 Dr Naysmith:
We have invited you all here this morning to explore how a local
health economy works. Can I start off by asking you how you see
your organisations working in the relationships with each other?
Dr Zollinger-Read: NHS Cambridgeshire
is clearly a commissioning organisation. The role of commissioning
is to work with public health colleagues to understand the need
of the local population and then, with patients and clinicians,
to implement actions that deliver for that need, ensuring that
we drive up quality. Clearly, partners within that are local authorities,
primary care and our acute colleagues and ensuring that we commission
correctly depends on collaboration between all those organisations.
Dr Brimblecombe: Just to explain
what our Practice Based Commissioning Consortium is, it was formed
very early on when PBC first came in. It is called CATCH (Cambridge
Association to Commission Health) and it presently consists of
31 practices and the city itself and actually Hertfordshire and
Bedford as well. Basically the consortium built itself around
Addenbrooke's, because Addenbrooke's is really our only acute
trust provider. Patients in Cambridge actually do not want choice,
because they have a very good acute hospital on their doorstep.
We built the consortium to improve collaboration between GPs and
we thought we would be powerful enough to perhaps influence our
acute provider, who, being a foundation trust, we regarded as
being very powerful and perhaps influencing our spend rather more
than we wished. Actually what we have achieved over the last four
years more than anything is engagement of the clinicians. I think,
if I am going to emphasise anything, the health reforms have come
in and everybody at the top understands them, but the clinicians
take a while to get on board and it has taken us four years for
the GPs to really become engaged. They now understand particularly
the health economics locally, and, as you probably know, NHS Cambridgeshire
has its problemsit still has a historical deficit to pay
off. As far as practice based commissioning savings go we have
very few, but we do have the GPs engaged nowthey at least
understand the problemand they are accepting that it is
part of their role, and the fourth principle of medicine of distributive
justice, which I think clinicians have great difficulty in understanding,
they are just about coming on board with.
Q401 Dr Naysmith:
We will explore that more later on. Stephen, how do you see your
relationships with your commissioners?
Mr Graves: I think they are absolutely
fundamental. I think from the data you will see that we have a
very large income stream from our local commissioners, but we
have an income stream in terms of acute care which is about the
same size from other commissioners and specialist services. As
a large player locally, we understand fully that we have a fundamental
role in terms of the health (in every sense of that word) of the
local system, very different, I think, to a number of years ago.
I think we fully understand that we have to live within the means
of the local system and play our role in managing that system
so the funds available to us can be used to best effect, and that,
as Pauline has said, is now something that is fully understood
by the lead clinicians as well as the management team.
Q402 Dr Naysmith:
Pauline and Paul, you both have commissioning functions. Could
you, please, describe what commissioning you each do? You do not
do exactly the same sort of commissioning, do you?
Dr Zollinger-Read: The Primary
Care Trust is responsible for the overall commissioning. That
will only work if PBC and Primary Care Trust work together. In
my view, PBC and Primary Care Trust need to agree what is the
commissioning agenda for the year coming. What is it we are jointly
going to do and how are we going to do that? Within that you will
have elements that the PBC groups are particularly interested
and want to push forward on, and then there will be other areas
that they are not particularly interested in and want the PCT
to lead on. Pauline, do you want to come in?
Dr Brimblecombe: A lot of the
things we have done, we have put our strategy in with the PCT's
strategy. Developing a community geriatrician role was something
that PBC savings actually were used for to try and help a central
frame of what we want to do, which is to improve the care of our
Q403 Dr Naysmith:
Are there any services, Pauline, that you are better at commissioning
than the commissioners in the PCT would be?
Dr Brimblecombe: Are there better
Q404 Dr Naysmith:
Are there any services that you think it is better for you to
Dr Brimblecombe: On a day-to-day
basis, because we know what our patients actually needand
I think there is a problem there with what they want what they
needlooking at the pathways is something that we think
that we can actually help develop much more effectively. Our plan
in the future is actually to look at the pathway rather than just
a service or provider. If you ask me what my role as a commissioner
is, I commission every time I sign a prescription and every time
I send a referral off. The problem is at the moment that our referrals
are actually a blank cheque, and that is something that we really
want to change.
Dr Zollinger-Read: The main plank
of our strategy is really now engaging with PBC across the patch
to enable PBC to fully commission. I have met with all the different
clusters and there is a strong appetite for taking forward real
budgets in clusters of varying size with support from the PCT.
I believe that if you devolve that, first of all, you get clinical
leadership, which is crucial for any commissioning, secondly,
you are more likely to get the joining up of primary and secondary
care working together on pathways and, thirdly, you will get local
patient involvement as well; so I think that devolution is definitely
the way that we are moving in NHS Cambridgeshire.
Q405 Dr Naysmith:
Is everyone clear about their different roles in the health of
your local communities?
Ms Donnelly: Yes.
Q406 Dr Naysmith:
Maureen, are you happy with that?
Ms Donnelly: Yes, I am.
Q407 Dr Naysmith:
Pauline, you know exactly what you are meant to be doing and you
do not feel confused?
Dr Brimblecombe: I think there
is going to be confusion because of the statutory role of the
PCT with the budget at the moment. I think that has still got
to be ironed out, whether we are going to be handed real money
or whether it is still going to be just notional budgets. I think,
probably, a lot of my colleagues are going to say, "Hang
on, do we really want the responsibility to break even at the
end of the year?" I know that a lot of my GP colleagues are
very anxious about that, because if they cannot manage the budget
at the moment, do they want to take on that whole risk? It is
very easy for GPs at the moment to be able to hand off the risk
to the PCT, and I think that is one of the challenges.
Q408 Dr Naysmith:
We will explore some of that in more detail later on. Stephen,
are you quite happy that everyone in your health community understands
what they should be doing?
Mr Graves: I think, as has been
said (and the word "journey" has been used a lot), if
you take this particular example, we are moving from something
that has been more led by the PCT to something that is being more
led by local groups of GPs. If I had some of my doctor colleagues
here, I am sure they would say, "I want greater clarity",
but we are betwixt one and the other. The reality, I think, is
that there need to be services where the core principles are the
same across the whole area but that the way it is delivered will
be more locally focused. Like many of the people coming in, Cambridge
is a small city of 120,000 people, there is a ring of villages
around the outside which are roughly another 100,000 odd people
and then you move to the north in Cambridgeshire into some much
more remote areas of the fens, and so the principle has to be
the same, but the way that it is delivered in detail will be different.
For people in Cambridge, maybe their local physical provider is
the hospital for some services, whereas in the middle of the fens
20 miles away it may be a community hospital that that clinician
in secondary and primary care needs to go to in order to provide
it, but the principle of how it works needs to be the same.
Q409 Dr Naysmith:
What you cannot say at the moment is anyone calls the shots. As
to who calls the shots, actually, in different circumstances different
organisations will call the shots.
Mr Graves: No, I think that the
joint work between PCT and primary groups, GP groups, is starting
to play out, and these are complex worlds, so I think we understand
that we have all got to work between everybody as opposed to one
person calling the shots in that way.
Ms Donnelly: May I add a comment
to that? The way we are trying to think about it is we look, with
the clinicians, at the service pathways, we then try to stop ourselves
thinking about the walls of the current organisations and think:
how do we get the most expert help and the most appropriate help
for that patient to that person in a way that suits them? Whether
it is within a hospital, outside a hospital, whether it is an
expert consultant or a local clinician, can we get them to work
in different ways that suits the clinical pathway?
Q410 Dr Stoate:
Pauline, you put it very well when you said your aim is to achieve
distributive justice, and I entirely agree with you there, but
in your evidence, which is also very well put together, you say
that the bulk of health expenditure is spent in the acute sector,
yet delivers care only to the top 10% of the health pyramid and
care in the community is mainly theoretical. What would you do
to address that obvious imbalance?
Dr Brimblecombe: Somehow we have
got to shift the care. It is the resource we need, and that is
the conundrum we all have. We know what we want to do but we have
not got the resource to be able to put the investment in community
care. All the health reforms over the last three or four years
have been directed towards acute care, so the focus has been totally
on the acute sector, which has delivered very good outcome with
the 18-week targets but, of course, it has consumed a lot of the
resource. Now we are suddenly saying, "Whoops, we had better
look at long-term conditions because if we manage those much better
and patients with long-term conditions better, we would then have
some savings." The problem is we have spent the savings first
and now we need to try and recoup it to invest in things that
we know actually down the line will benefit everybody.
Q411 Dr Stoate:
The Audit Commission recently said that PCTs have made little
or no inroads in 2008-09 for transferring care from hospitals
into the community or in dampening demand either in investment
or activity. What would you do as a GP commissioner to try and
address that? You have already said what the problem is, but what
would you do to try and put it right?
Dr Brimblecombe: I think we would
specifically start looking at employing, particularly if you look
at long-term conditions, our own specialist nurses, liaising much
more specifically with an individual consultant to come and support
us. We would try and change the way we deliver care. Choose and
Book has driven, again, a carthorse through the individual relationship
between the GP and the clinician in secondary care which has developed
over a period of years so that you learn to trust each other,
and that is really what has been lost. We want to get back the
trust so that consultants can come and support us to look after
our patients actually right there in the surgery. We need their
expertise, but we need their support rather than actually taking
over the problem.
Q412 Dr Stoate:
You mentioned that your 37 practices were very slow to come on
board. Why was that? Do you think they are being sufficiently
incentivised? Are they interested in coming on board? Would they
rather someone else did? What is the reason why it has taken four
years for you effectively to engage with your 30-odd practices?
Dr Brimblecombe: Because, as you
know, GPs are very busy people. They go to work, they see the
patients in front of them and that is their main focus. That is
what we have all been trained to do, to actually do the best for
that patient in front of you and to block out everything else.
I know in other countries they would feel that it was iniquitous
for a clinician to actually be thinking about distributive justice
and the use of resources in a different way.
Q413 Dr Naysmith:
We are empowered to do that all the time, are we not, and in practice
Dr Brimblecombe: Yes, but you
can understand that now, but with most GPs it takes a while before
you come on board and see that you have got a wider remit than
the person in front of you. The strength of general practice is
that individual relationship and individual care, but you do have
to put it into context, and GPs have been slow in coming on board
because we have not had to have budgets to look after. Before
we did not know how much we spent. We would prescribe a drug and
had no idea how much it cost. Now we doit flashes up on
our computers in front of uswe know exactly what it is
costing us, and that has, therefore, changed our behaviour. You
cannot change behaviour unless you know what you are doing.
Q414 Dr Stoate:
Is there a future then for GP commissioning or do you think David
Colin-Thome may have got it right when he said, "I think
the corpse is not for resuscitation"?
Dr Brimblecombe: I think that
was slightly misquoted. It was rhetorical, I think, is what he
says. It is like everything else, we are on a journey, and it
was just totally unrealistic to expect that clinicians were going
to understand what the big vision was when they had not actually
been involved in developing it. Once they become involved, once
they understand the problem, they come up with the solution. That
is the real skill of clinicians because that is what we do in
every day life: patients come with a problem and we help them
to solve it.
Q415 Dr Stoate:
Stephen, is the truth of the matter really that the acute hospitals
are simply too powerful in relation to GP commissioners and, therefore,
it is an unequal struggle?
Mr Graves: It is quite an interesting
position listening to the debate. I guess, over the last few years
we have seen Payment by Results as a huge opportunity for people
referring and in the past, I think, as earlier colleagues said,
people argued about what the level of marginal cost was for extra
activity, whereas if you get the whole value of an extra patient
coming in you, equally, save the whole value of a patient not
coming in. Ironically and interestingly, for some time, I think,
most secondary care providers have actually worried about the
threat of all that money stopping coming in and yet the overheads
were always going to remain. The interesting position, certainly
from our position (and I do not think we are on our own), is that
we day in, day out, say to colleagues in primary care and in the
PCT we need to find ways of reducing the extra activity. Pauline
has described from a GPs' point of view how they know what the
cost is. We started three years ago to understand what our costs
were. We can now, in effect, produce a patient bill, so we know
what per patient it costs very easily by HRG, and we start to
understand that the extra over-activity that we have been seeingputting
on Saturday morning clinics, putting on Saturday operating lists,
working later into the eveningif you look at the pure finances
of it, loses money per patient.
Q416 Dr Stoate:
I understand all that. We have looked into this in the past. I
am not so worried about your income stream. We know what those
are. I am more worried about the power relationship between you
and the GPs, which seems to me hopelessly imbalanced. As Pauline
has pointed out, 90% of the work is done in general practice in
terms of patient numbers and yet virtually all the money actually
goes to the acute trusts.
Mr Graves: We would say we want
to reduce the number of referrals coming in, and I appreciate
there will be some consultants that do not think that is a great
idea. Many of our consultants actually, quite the opposite, say,
"We want fewer patients coming in around diabetes, we want
fewer patients coming to us around COPD because we have experienced
different ways of delivering those services."
Q417 Dr Stoate:
But they are still putting you back in control; it all comes from
you. What I am trying to get at is you are saying, "I do
not want all these patients", you are saying, "I do
not want all these diabetics with complications coming in."
I am more concerned about the power structure. The relationship
seems to be, "We are the acute trust, we do not want all
these patients because we think they should be managed elsewhere."
I am much more concerned in the equality of the relationship between
you. There does not seem to be any.
Mr Graves: If you take diabetes,
one of our lead diabetologists has gone out to the fenland area
and sat down with groups of GPs and started the debate, and what
one finds about this is that people need to get to know each other
and trust each other on both sides, if there are two sides of
this clinical debate, and to start to say, "We do not believe
it is right for these patients to come here; you do not believe
it is right for them to come here. These are the skills that you
may or may not have, these are the resources, in terms of specialist
nurses, these are the clinical parameters that we think trigger
somebody needing to come into hospital or ringing us as secondary
care clinicians", and that is actually really starting to
have some debate.
Q418 Dr Stoate:
That is helpful. I want to ask Paul the same question. Do you
think that basically the hospitals are too powerful, or do you
think it is about right?
Dr Zollinger-Read: I think we
have got more levers now to manage that. I do not see it as a
power issue. I think PBC has not been as successful and now we
need to look at what we can do to make that work. Sitting on the
other side of the fence, I also work as a GP and the frustration
is that we in PCTs have not been quick at putting through business
cases. I think that is a very fair comment; so we have frustrated
PBC. If we can speed that up and liberate PBC, you then start
to get changes. The other significant issue, and you mentioned
the National Audit thing which I have not seen, but we have put
in place lots of these Tier Twos, GPs with special interests,
community clinics, and what we have not been good at is managing
the demand, and so we have got an alternative over there but what
we have not done is stopped that pathway over there. We have got
the patients going over here, but they are still pouring into
the hospital. We have got to crack that issue, and that is a primary
care issue which I would put back to the clusters: "We can
give you the tools but you have now got to start to manage that
Q419 Dr Stoate:
Are you powerful enough to do it?
Dr Zollinger-Read: Yes.