Commissioning - Health Committee Contents


Examination of Witnesses (Questions 420 - 439)

THURSDAY 28 JANUARY 2010

DR PAULINE BRIMBLECOMBE, MS MAUREEN DONNELLY, DR PAUL ZOLLINGER-READ AND MR STEPHEN GRAVES

  Q420  Sandra Gidley: A question to the PCT, but you have only been there two weeks.

  Ms Donnelly: That is why I am here.

  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 purchasing power.

  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 Results—there is no capping of it—and 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 country—I think we are the tenth lowest—and 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 manage—that is the problem—and 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 overspent—that is flashing up at you, it is in the red, I can compare myself with all the other practices in the PCT—and 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 yet?

  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 place—in other words saying we will follow up care in a primary care environment—it 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 councils—the county council and the five district councils—we work very closely in that partnership. We also manage and commission adult social care on behalf of the county council—we have got section 75 agreements for that—and 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 level.

  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 things differently?"

  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 this.

  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 and PALS.

  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 PCTs.

  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 figure.

  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.


 
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