Examination of Witnesses (Questions 420
THURSDAY 28 JANUARY 2010
Q420 Sandra Gidley:
A question to the PCT, but you have only been there two weeks.
Ms Donnelly: That is why I am
Q421 Sandra Gidley:
Okay; that is helpful. Why have you been so passive in your commissioning?
It seems that the PCT has just waited for central direction such
as CQUIN before you have really thought about properly exercising
Ms Donnelly: In the case of Cambridgeshire
that is not true, and I am sure Stephen will confirm this. Just
a tiny bit of history, if you will bear with me. When I came on
board the PCT had an historic debt of 52 million, half of which
was in-year, so the first objective was to stop that money haemorrhaging
and then to pay off the debt. We agreed with the SHA that we would
have a repayment period over five years, so we have still got
a couple of more years to go repaying that debt, but each year
we have generated sufficient surplus to pay off, roughly, ten
million each year. It was also quite obvious to me and the other
members of the board that with 22% of our income going to Addenbrooke's
we needed to control that contract very rapidly, and what we did
was we gave them notice of the old contract. We did this. It was
robust but professional and friendly in the way that I expect
to work in areas outside the NHS. We asked the department to send
us down some people to help us with the contract and we renegotiated
a new contract with Addenbrooke's, which we ran for a year, which
became the paradigm for the new acute contract the following year.
I think in Cambridgeshire we have taken some initiatives. I am
not saying there is not a lot more that we can do, but not all
the levers are there; there are a number of things that could
change those levers. The key levers that work against Primary
Care Trust is the open-ended nature of Payment by Resultsthere
is no capping of itand if I look elsewhere in the developed
world where they use HRGs or a form of payment like that, there
is always some form of capping, whether it is marginal or whatever,
and the way in which the rate is calculated is almost never done
on the average across the country. There is room for a much more
professional and sophisticated way of calculating those activities.
Q422 Sandra Gidley:
A general question to everybody really. I do not know who wants
to pick it up first. I wonder if you can tell us what the impact
of Payments by Results has been and, lastly, CQUIN. Maureen, you
just mentioned that it is a bit of an open-ended cheque. I have
heard from some areas that those cheques are not necessarily being
honoured by PCTs who have no money, which obviously causes problems
for acute trusts.
Ms Donnelly: Cambridgeshire has
one of the lowest capitation rates in the countryI think
we are the tenth lowestand we still have our debt to pay
off, we have still got two more years to go in paying off that
debt, so we have always been, throughout that period, one of the
most financially challenged in the country. We have never not
paid any of our acute hospitals what is in the contract. We would
never do that. That is not a professional way to engage. What
we do is when we realise there are problems we work very hard
with our clinicians, both primary care and secondary, and, indeed,
the management at the acute trusts, to say, "It is not in
anybody's interests for this to go out of synch. How do we manage
it?", and we get through it, in general, because we all understand
that. That is partly what Pauline said.
Q423 Sandra Gidley:
How is it being managed: because when the financial pressure is
on you cannot afford these-open ended cheques?
Ms Donnelly: We manage it in a
combination of ways. With all of our main providers the staff
have set up monthly performance review meetings where they go
in at different levels: they monitor the quality of the service,
the outturn, the activity and the finances right through the day,
and they check what is going on within that provider group; so
constant checking, constant talking.
Q424 Sandra Gidley:
That is not controlling the GPs who are prescribing or referring.
You do not have much sway over them. Surely they are just pushing
people through the system.
Ms Donnelly: There is a couple
of things we do, and there is still the open-ended cheque. One
of the things we have looked at is putting GPs in at the front
end of the hospital so that, even though people physically go
into the hospital, they are hitting primary care first. By the
way, we do not want to stop people doing what comes naturally
to them. Within Cambridgeshire we have got some transient people,
both academics who come for two to three years, within the fenland
people who come from Eastern Europe, for example, to work in the
fens. They are used to a very different Health Service where they
do not necessarily have primary care; they expect, if there is
something wrong, to go to a hospital. It is hard to retrain people.
It is easier to try and provide the service in a way that matches
that and get primary care in in different ways. The other thing
we do (and Paul will add to this) is work very closely with GP
practices on monitoring GP referral, on monitoring prescription,
making sure they all have the efficacy so they can see what is
happening practice by practice. It is peer pressure in the end.
Dr Zollinger-Read: I think the
medicines management is a shining success. What I have picked
up from all the practices is that our medicines management team
are very proactive in putting the information out and managing
the variability and driving, effectively, effective commissioning.
Q425 Sandra Gidley:
What about Payment by Results? Do either of you want to pick up
on what impact that has had on what you do, if it has?
Dr Brimblecombe: We have got to
demand managethat is the problemand the problem
is being put back into the GPs' domain, because, as I said, every
time I write a referral letter, that carries a blank cheque and
often we do not know where it is going to end up, and the only
way you can do something about that blank cheque is to actually
design a pathway so that you can fix how much you are going spend.
That is for the future, and I think that is something that you
have talked about with previous witnesses, but at the moment it
is a difficult one because we have got patients who are being
told, "You can have everything you want", you have got
headline news that we have terrible cancer outcomes because GPs
refer too late and yet, on the other hand, we are being told,
"Actually you are referring too much. Stop referring",
and I think the GP in the middle at the moment is saying, "I
do not know what to do."
Q426 Sandra Gidley:
Who is telling you to stop referring: the PCT?
Dr Brimblecombe: Yes, from our
practice-based commissioning budgets, if we are overspent and
our acute budget is overspent. We have incredibly good data from
our PCT, we know exactly where our patients are going and what
is happening to them. I know when my out-patient first appointments
are overspent or my follow-ups are overspentthat is flashing
up at you, it is in the red, I can compare myself with all the
other practices in the PCTand it is, "Do something
about it", but sometimes I do not know what to do about it
because I am only doing the best for the patient in front of me.
Q427 Sandra Gidley:
Has that had any perverse effects on your patients yet?
Dr Brimblecombe: No, it has not
yet, but when we have got a deficit situation and we have got
a future NHS where we have got to make 15% cuts, why have Payment
by Results for referring the patients' care? There must be other
ways of managing that problem, and I think that is what we are
trying to look at locally and why, in handing over a bit more
responsibility to GPs, they will come up with these solutions,
but, as I said, they are only going to come up with the solutions
once they have understood that there is a problem.
Q428 Sandra Gidley:
Mr Gray, this is good news for the hospital because it seems you
are having a lot more activity and still being paid for it, but
has there been any other impact of Payment by Results?
Mr Graves: I think perhaps I would
go back; and I do mean this really seriously. We are probably
the largest single entity consumer of money, as has been described.
We know, based on the statistics you can get from the various
information sources, that referral rates per funded head of population
on a weighted capitation basis are, in general terms, above the
money that the PCT has been given for that population, and I think
it is true to say that historically, in general terms, secondary
care, we have been fairly recessive in terms of working with local
GPs to work out other ways of doing things, either to reduce the
referral rates or to reduce the follow-up rates, and because our
future is absolutely entwined with the GPs and the PCTs from both
a care point of view and a financial point of view, our doctors
now understand, I think, fully well that they have to play a different
role in working with primary care to see how we can get better
use of that money.
Q429 Sandra Gidley:
Is that really working? Doctor Brimblecombe's submission said
that hospital doctors really were not off the starting blocks
Mr Graves: No, I agree. That is
why I absolutely said that if I sat here certainly two years ago,
I think the conversation would have been, in general terms, GPs
and other colleagues send us the activity and we do the work,
it is an understood model, that is how it stood up, that is how
it was set up, that is our role. As we sit here today and we project
forward, clearly that is not going to be an acceptable way forward
or a doable way forward.
Q430 Sandra Gidley:
So, effectively, it comes back to more collaboration to try and
improve the pathways.
Mr Graves: Yes, I think it is
collaboration but actually action: because collaboration could
be slightly soft. If I look at what is happening with diabetes
and starting to happen with COPD, we are actually starting to
see patients wanting to do these things together and, in effect,
you are starting to say, "We do not need to grow the number
of doctors in the way that we historically have, we need to grow
the number of other professionals and we need to educate patients
in terms of taking on more responsibility in managing their care,
and between us we have an integrated care pilot, we also have
a health foundation funded co-creating health pilot as well.
Q431 Sandra Gidley:
That sounds a nightmare. What does that mean in practice?
Mr Graves: If I can take the latter
one, it is saying that this is not just about managing the same
bit of care in a different placein other words saying we
will follow up care in a primary care environmentit is
starting to say, "I need to train hospital doctors, I need
to train GPs and I need to train and educate patients to have
a different conversation." My terminology is that we as the
public and patients are far too often passive in our healthcare
rather than dominating or trying to lead the agenda. It is easy
to say that, but actually we have now got quite a lot of experience
of the training programmes needed for each of those groups to
actually enable a very different conversation so that when a patient
comes in to see a secondary care clinician or a primary care clinician
they more likely have an agenda that they walk in with"What
do I need to do to improve my health? What exercise do I need?
What other things do I need to do?"rather than just
listening to what the Health Service is going to do to them. I
can pick out hundreds and hundreds of examples, but I can pick
out some individual examples, and evidence shows elsewhere that
this, again, is a five to ten-year training and change programme
because colleagues and us as the public have been trained for
many years in doing it in one particular way.
Q432 Charlotte Atkins:
Maureen, do you feel that the PCT has strong enough clinical expertise
to challenge the hospital?
Ms Donnelly: Yes. Obviously, our
newly recruited chief executive is a GP, but we also have a medical
director, we have a director of public health, all clinicians,
and the chair of our PEC is a full-time director on the PCT board,
and they work with other primary care clinicians, Pauline and
her colleagues, to develop the pathways and to work with the hospital
consultants to develop the pathways. That then goes to the people
who negotiate the contracts and the targets and manage those.
Q433 Charlotte Atkins:
Some of the evidence we have had suggests that commissioners do
not have enough public legitimacy. Would you agree with that?
At least that is the public perception. Do you think you are playing
catch-up at the moment?
Ms Donnelly: If I was asked to
say what the great British public thought about Primary Care Trusts,
most of them do not know what they are, but, leaving that aside,
I do think that in Cambridgeshire (and obviously I will not go
into the democratic deficit discussions) we do have a fair degree
of public legitimacy for a variety of reasons. One of them is
that we have a very good close working relationship with all of
the councilsthe county council and the five district councilswe
work very closely in that partnership. We also manage and commission
adult social care on behalf of the county councilwe have
got section 75 agreements for thatand all those adult social
care staff have been TUPE'd across to us, so they work as part
of our provider arm, and there is a regular a meeting to monitor
that with councillors and our board, regular engagement on that
Q434 Charlotte Atkins:
I am not quite sure whether engagement with councillors necessarily
gives you much public legitimacy, because councils themselves
can be somewhat detached from their own constituents. It is only
if they are engaged. I think you are right that PCTs are not known
about by the public and very often when public health initiatives
are launched I have found in my own PCT that it is quite difficult
to get the PCT to engage in an effective way. If they put on a
meeting and try to engage people, no-one will turn up and it will
be their fault, not the PCT's fault. Likewise, if you have a health
initiative and people have not turned up, that is their fault,
it is not the PCT's fault. I think sometimes PCTs just do not
look at themselves and say, "Hold on, if we are not getting
a response here, why are we not doing more? Why are we not doing
Ms Donnelly: I agree with what
you are saying. It is very difficult to set up a meeting and get
people to come to it. We have set up several public consultations
over the past few years on reorganising community hospitals and
reorganising services on our out-of-hours contract most recently.
We have got very good liaison with the LINks teams and the patient
groups within Cambridgeshire. In fact our Director of Communications
is sitting behind me and she will kick me if I do not say this.
We have put quite a bit of effort into not just holding meetings
around the country ourselves, we have done a lot of that, but
also very deliberately going out to offer ourselves to attend
other people's meetings, and we have found that often that is
a much more effective way of doing it. For example, if there is
a local community or a local parish meeting, we will try and make
sure that they know that we are there to come and talk to them
about a particular issue.
Q435 Charlotte Atkins:
What about your involvement with LINks?
Ms Donnelly: Obviously there is
a member of LINks on our board. There are representatives of LINks
on the panel that was looking at our out-of-hours tender and the
contract negotiations on that, so they were feeding through to
that throughout the public consultation. In fact we had a board
meeting yesterday where the LINks representative who sits on our
board commended us on it and said they really appreciated the
way we had taken on board their comments throughout that process.
I am not saying it is perfect; you have to work very hard to do
Dr Zollinger-Read: I think it
is difficult to engage the public. In a previous role one of the
most difficult groups to engage were young people. We went out
of our way to work with all the secondary schools and had an adolescent
forum, and that was a really powerful mechanism for helping us
to change or improve our Chlamydia screening. I think there are
things you can do, but this is one of the most difficult challenges
we in PCTs face.
Dr Brimblecombe: The other thing
is that actually when you are well patients do not actually want
to be engaging with doctors, they are getting on with their life,
and, therefore, often people only want to get engaged when they
have got a real issue, and that sometimes makes it difficult to
put that issue in the wider context.
Charlotte Atkins: PCTs are more than
doctors. PCTs are also about promoting public health; it is not
just about doctors. In fact, it is about other clinicians and
it is also about engaging in a wider health agenda. I think patients
probably do not want to engage with doctors when they are well,
but I think there is a whole range of other things that PCTs should
be doing. I do not see PCTs as just being about doctors.
Q436 Dr Taylor:
I am just going to ask one question on that as well. In your organisation
structure chart I am sure there is a misprint. On page six you
have a heading "Communications Patient Engagement and PALS",
whereas in the jobs you are describing, quite appropriately, you
are calling the people Director of Communications Public Engagement
and PALS. Surely at the top the title should be Public Engagement
Ms Donnelly: Yes.
Q437 Dr Naysmith:
Thank you. You were with us, I think, for the first session, so
you will have heard our two chief executives reasonably confident
that they were going to manage this 30% cut. Again, in your organisation
structure chart, something the Department of Health officials
last week could not tell us at all for the country as a whole,
you have actually given us a detailed split of the number of people
you employ in finance and contracting and they add up to about
105 in the head counts. How are you going to cope with this cut?
Dr Zollinger-Read: If we look
at our management costs, overall across the east of England we
are in the lower banding of management costs compared to other
Q438 Dr Taylor:
Can you just define "management costs" for us?
Dr Zollinger-Read: That is a question
in itself. How do we define them? There are various NHS definitions.
The one we were using is above, I cannot remember, £22,000.
Ms Donnelly: Twenty-nine, I think.
Dr Zollinger-Read: There is a
Q439 Dr Taylor:
So it is on a salary split?
Dr Zollinger-Read: Yes. However,
in the east of England we agreed that what we would look at is
running costs, and so we are currently doing a piece of work to
define what exactly running costs are because it is artificial
to have that divide. My point is that NHS Cambridgeshire is pretty
efficient, and so we have agreed to do this on a weighted capitation
across the east of England. The challenge facing us, therefore,
is not as great. However, we have already done quite a lot of
work with the local authority, Cambridgeshire County Council,
and on Tuesday we had a meeting of the local strategic partnership
with all the boroughs and districts as well, and we have come
up with five or six projects which essentially look at how can
we radically transform the way the public sector works together
to take out further costs. Some of that is around pure efficiency,
back office stuff; others are around what does that actually translate
into in someone's home, be it health or social care input. We
have certainly done a lot of work there.