Examination of Witnesses (Questions 440
THURSDAY 28 JANUARY 2010
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
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:
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 servicesthat
is the final common part of world-class commissioningand
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,
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 proclivityI put no higher than thatnot
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
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 problemrather
than it is the PCTs problem, it is our problemand 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."