Commissioning - Health Committee Contents


Examination of Witnesses (Questions 440 - 459)

THURSDAY 28 JANUARY 2010

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

  Q440  Dr Taylor: Do your management costs include all these accounts assistants, for example, who are obviously way below the £29,000?

  Dr Zollinger-Read: They will not include that at the moment, no.

  Q441  Dr Taylor: So how are you going to cope with a cut of 30%?

  Dr Zollinger-Read: As I said, the cut may not necessarily be 30% for us because we are looking at it on a weighted capitation basis across the east of England.

  Q442  Dr Taylor: So, because you are pretty efficient already, you will not have to cut that amount?

  Dr Zollinger-Read: That is the understanding, yes.

  Q443  Jim Dowd: I apologise, first of all, to our witnesses. I had various other conflicting engagements with constituents and local schools coming in that I had to see this morning. I am going to ask some questions, but if you have already answered them I can only apologise, so refer me to the transcript which I will read later. This is just about what general impression you have of world-class commissioning. Is it a step in the right direction and when will be a reasonable time to decide whether it has been successful or not?

  Dr Zollinger-Read: I think it is a really helpful framework, because for the first time it has given us a set of competences that we should achieve to become world-class and it has enabled us to see where we are in that, what our needs are and start to put those in place. As the previous speakers, we were weak on certain areas such as prioritisation, stimulating the market and procurement, and we have done a fair amount of work in the past year looking at those areas. I think it is helpful, it gives you that framework and it helps you to put those skills and competences in place.

  Dr Brimblecombe: Can I add, as a practice based commissioner, that actually we have locally for our consortium held an away-day a year ago to look at world-class commissioning and competences to see where PBC fitted in with it and took at least five of the areas which we felt that we should be contributing to as well.

  Q444  Jim Dowd: Is there anything else to add?

  Ms Donnelly: It is work-in-progress. They are helpful guidelines to make sure we are doing the things we should be doing.

  Q445  Jim Dowd: Most things are in progress. To the question, "When would be an adequate time to decide upon its success or otherwise", would that be another year?

  Ms Donnelly: It will be longer than another year.

  Q446  Jim Dowd: Five years?

  Ms Donnelly: Hopefully it will be less than five years, but it is within those boundaries. We are hoping within two to three years.

  Dr Zollinger-Read: Demonstrating improvements in the competences is one thing, but that is not particularly helpful to the public, is it? What we have got to demonstrate is improvement in outcomes, in services—that is the final common part of world-class commissioning—and we need to demonstrate that going forward year on year.

  Q447  Jim Dowd: The difficulty with using the public as a yardstick is there is only one outcome they are interested in, and that is what happens to them. You can quote all the other numbers you like over time; if they have had a bad experience that will be their understanding of how the Health Service works. Equally, if they have had, as I have had recently, a very good experience, that is something as well. You mentioned, Dr Zollinger-Read, the weaknesses that were pointed out to you in your review last year before I could raise them, and I think you said you had looked at issues arising from that. Could you put a bit more detail on that?

  Dr Zollinger-Read: Clearly we had a world-class commissioning assessment. Out of that was clear detail of what our strengths and weaknesses were. We formulated an organisational development plan, came up with work streams, implemented those work streams and managed them over the year so that the procurement function had been strengthened. We have a very able public health team who have looked at models of how we prioritise our expenditure, which is clearly essential, and so we are following that organisational development plan. We are coming up to another assessment in March some time and would hope to demonstrate a rise in those competences.

  Q448  Jim Dowd: You would say that the weaknesses that were identified were valid, would you?

  Dr Zollinger-Read: Yes, I think so. It has set a very high bar and where we were was at a point in time, as Julie said earlier, when PCTs came together and we were re-organised. It took quite a while to settle down, to focus where we were going, and so that was a point in time. We now have stability, we are now moving forward and our plea is, please, support us to move forward rather than re-organising.

  Q449  Jim Dowd: There is a proclivity—I put no higher than that—not just in the Health Service but in the public sector generally, that if it receives bad news it tends to dispute the veracity of that rather than getting on and dealing with the shortcomings identified.

  Ms Donnelly: Are you referring to the league table, or not?

  Q450  Jim Dowd: It could be all kinds of things. People tend to like league tables when they are at the top of them.

  Ms Donnelly: I know.

  Q451  Jim Dowd: They tend to dislike them if they are at the other end.

  Ms Donnelly: I know, and I sometimes call on the Lake Wobegon for that factor, for those who like Garrison Keillor. All the children of Lake Wobegon were above average intelligence. Somebody has to be at the bottom. We accepted the competency score. In the competency score our average was 18, which is above the median point between the 23, I think it was at the highest, and the 11 in terms of the competency score. We were less happy with the way the HSJ interpreted that, but you just get on with it.

  Q452  Jim Dowd: That is showbiz, yes. Has it improved commissioning or even made it worse over the past two years in your estimation?

  Dr Zollinger-Read: No, I think it has definitely improved. First of all, we have formulated a clear strategy from that, areas that we wish to focus on and clear plans to deliver that. Pauline.

  Dr Brimblecombe: Yes, I think it has really focused, again, clinicians on to the areas that are important to us. Our priorities are community based services, are care of the elderly, better long-term conditions, rather than perhaps some of the must-dos coming down from the Department of Health or from the SHA. We have a different focus, and it has meant that we can actually get our priorities in. It has also concentrated on other things engaging with the wider community, particularly GPs. I accept we tend to only see the person in front of us and the world-class competences has made us look outside, look at social care, look at the third sector as people who have got a good contribution to make.

  Q453  Jim Dowd: I know this is a generalisation, but would you say it has improved? What has it done more effectively: improved value for money or improved services to patients?

  Dr Zollinger-Read: I think we have achieved both. I think we have got significant evidence that we have improved services for patients and, yes, value for money. Let us take an example: the management of heart attacks. Now, through the commissioning process, if you have a certain sort of heart attack you are taken into a specialist centre and you have a balloon put in and it unblocks it and people live now who would not have lived before. That is a better outcome for the patient, it is more cost-effective for the country and that has come through a rigorous commissioning process.

  Jim Dowd: I think it is undeniably a better outcome for the patient. Thank you very much indeed.

  Q454  Sandra Gidley: A question about how we can better engage GPs. Obviously, they see most of the patients first. I got a sense from Dr Brimblecombe that they perhaps were not consulted or that better use could be made of their knowledge and expertise. What plans have you got to improve that in the future?

  Dr Zollinger-Read: As I said earlier, we are having what is called the "big conversation". We are going out and talking to all the GPs across the patch, and this, essentially, is about enabling them to form clusters. The clusters are up to them to form.

  Q455  Sandra Gidley: You do not have those in Cambridgeshire yet.

  Dr Zollinger-Read: We have PBC groups, but we are now talking about all the groups getting together in local clusters. It is a much more in-depth process and the crucial bit is that they will have a real budget which will be weighted according to the need of their area and we will free-up the process so that they can assess local need, decide what they need to do and do that much more quickly than they can in the current process. I have only been to three of these meetings and there is a real buzz. You clearly have a spectrum and you have got some real leading edge GPs who are saying, "I want to put my house on the market and buy an x-ray machine and I am going to be a real risk-taker", and you have got some who say, "Over my dead body", but the weight of the curve is definitely, "This something we want to pick up with because we believe the NHS is facing difficult times. We are the local clinicians and we can make this more cost-effective", and so at the moment there is a definite move in that direction. Pauline, I do not know if you want to say anything from your point of view.

  Q456  Sandra Gidley: I do not know if you are aware of a Kings Fund survey of GPs and practice managers in 2007. They cited PCTs as a real barrier to practice based commissioning and cited high levels of bureaucracy and lack of PCT support. Has that changed or is that better now?

  Dr Brimblecombe: Yes, the information we are getting is better now. The engagement, the understanding is getting there, the trust is building up, because, again, for PCTs who carry the can, Paul loses his job if he does not get financial balance; if my PBC a budget goes over, I have got my day job still. The understanding together is that it is our problem—rather than it is the PCTs problem, it is our problem—and that is the real change, because I think GPs now are worried that all the must-dos are taking away from the things that they would like to do. We were talking about Payment by Results and, as Maureen says, that bill has to be paid. We also have all the must-dos that come down from the Department of Health, we have the must-dos that come from the SHA and then there is this little pot of money with all the things that we would love to do, which is usually improving the care for our demented patients, or our more vulnerable patients, or our learning disability patients, or people who have less of a voice, who do not actually make the headlines but who actually, from a GP's perspective, are the people we really want to put more resource into.

  Q457  Sandra Gidley: You mentioned earlier that you are having to do things in a little bit of a different way to the way you were trained.

  Dr Brimblecombe: Yes.

  Q458  Sandra Gidley: There was almost a retraining need. Are you getting that help and support from anywhere?

  Dr Brimblecombe: No, I think that is what we are doing ourselves.

  Q459  Sandra Gidley: But there will be some who are not as engaged in that.

  Dr Brimblecombe: I have to say, I think that is where central government should be. Where are the GP leaders at the top, where are they in the Department of Health, where are they in the SHAs actually saying, "This is where healthcare should go"? I have sat on a NICE committee. There was me with ten consultant gynaecologists. The last time I was in a Health Committee here was on dermatology. There was me as the lone GP amongst a sea of dermatologists. Therefore you always get pathways developed from the top rather than from the bottom, which is why sometimes, I think, some of the pathway development does not sit easily with how GPs feel we should be managing patients. We need more general practice right in at every committee. I sit on the SHA, the acute care pathway for the Darzi review for the east of England. This is one of the problems. Trying to get GPs to engage, of course, is a different matter, and a lot of it is because of our independent contractual status because there is nobody to pay for the GP to be out there. There are lots of issues why it does not work, but I think that again is changing because I think GPs are suddenly realising if their voice is not there they cannot keep bleating about, "Why is it not right?" I think things are changing. GPs do want to be engaged. Now is the time to really grab those who want to stand up and be counted because that will help with dissemination. I know the Royal College has got on board and the NHS Alliance and Michael Dixon. People like that are all saying the same things, "Please get GPs at the top, because then it will filter down."


 
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