Commissioning - Health Committee Contents

Examination of Witnesses (Questions 460 - 479)



  Q460  Dr Naysmith: Carrying on in this area a bit, would it be fair to say, Pauline, that quite often practice based commissioners do not have the levers and skills to manage providers and clinicians properly?

  Dr Brimblecombe: I think that is perfectly true. We are clinicians, we have ideas, we are great at coming up with the ideas, but we do need the management skills to help us to actually implement them. We need in our clusters to have public health. You have to have public health there to ensure that you are focusing on the needs rather than on the wants or the demands.

  Q461  Dr Naysmith: What would you say the three primary skills were that are needed to ensure that practice based commissioning works efficiently?

  Dr Brimblecombe: We need good information—if we do not have information, we cannot do it—and I think we need a good manager to direct us. As I said, clinicians are great at ideas, they are really good at developing ideas, but they do need those ideas containing, help with prioritisation and help with actually implementing things.

  Q462  Dr Naysmith: Have you tried to invest in these skills? Have you got them on board or are you trying to get them?

  Dr Brimblecombe: In our cluster at the moment within CATCH we have a dedicated PBC manager, we have a team with informatics and finance that we have direct access to, and I particularly have direct access to because I can go into the PCT and I can see these people immediately. The problem is that still needs to be filtered out a bit more to the actual individual practices, because, of course, they still get their data and are not sure what to do with it. More support needs to be done on an individual practice basis, which, again, is part of my role as a PBC lead in trying to help and support the practices to come up to the level of understanding that I am at.

  Q463  Dr Naysmith: What do you think the optimum size is for a practice based group?

  Dr Brimblecombe: I think it depends. As we all know, it depends on what you are commissioning for a start, but I think it also depends on your circumstances. As I say, CATCH has about a quarter of a million patients and I think that is too big because we have disparate and different needs. The city practices have a different set of problems and needs than the rural practices, so we are looking at somewhere between 50-100,000. Again, if you are in a market town, there may be three or four practices who perhaps only will have 40-50,000, but that makes sense. The reason for being in a cluster is because you have got a shared agenda, you have got a shared vision, you have got a shared population that you can look at specifically; so it will vary.

  Q464  Dr Naysmith: Is there any evidence for the optimum size? Have people written about this?

  Dr Brimblecombe: I have written to all the different health economists I know in the country, including Martin Roland, who now is in Cambridge, and at the moment there is not very much evidence. It does depend on what you are commissioning. On an individual basis, from my practice I could commission for a lot of things like out-patient care, manage my own drug budgets, and you could risk-share because you could take off patients who are very expensive, which is what we do at the moment, but it is more for the system change that you need to be able to share resources within practices, because otherwise the transactional costs like the fund holding is so enormous. That was the problem with fund holding. To have a manager earning 60-70,000 for each practice was crazy; it was too expensive.

  Q465  Dr Taylor: Integrated care. Your pilot looks to me to be one of the most difficult of all—end of life care. You have got to cut across GPs, nurses, pharmacists, social care, ambulances, schools, hospitals and hospices. How are you getting on? How are you doing it? Who is in charge of that?

  Dr Brimblecombe: It is being led by the three providers we have. This was something that GPs were very keen on because we have the acute trust, we have our community trust and we now have Assura Cambridge LLP, which is the GP provider side of things, the patient voice, and they are taking the lead and collaborating very closely with Stephen and his management and with the community services and with the hospice and with the PCT. We are not going to solve end of life. A lot of it is actually taking quite a small project which is basically making sure that everybody is sharing information on that patient so there is no duplication and the patient voice is at the forefront and that everybody knows what that patient's requests have been. It is all about communication.

  Q466  Dr Taylor: How are you involving social services? Is that going well?

  Mr Graves: Yes. Social services are formally brought in through the provider side of the PCT who have contact with social services directly which are run from the social care budgets locally, so they are directly integrated into it through that particular route.

  Q467  Dr Taylor: So even though you are crossing different budgets and different management structures you are managing to do that somehow.

  Mr Graves: I will be very clear; it is not easy. As the colleagues said earlier, some of the challenges in this is where is the information held? Can you access that information? People are in an end of life pathway from different areas, but, if you took one group from a nursing home, one of the issues that has come up is who has the information about that group of patients? Which GPs are actually formally "having a relationship" with that group of patients? I think all of us will have relatives or former relatives who have been in that environment, and the nursing home may or may not be in the geography of where the patient has historically been cared for. If I take my dad, he popped in and out of respite care into different places, one may be in the core catchment area of our GP practice and one may just be outside depending availability of space. Unlike the past where it has probably been managers like me talking to other managers, it is actually GPs sitting there going, "How do I adapt my information system for Mr Blah Blah and Mrs Blah Blah, and how can I share that with the nursing home and what direct conversation can I have?", because it is likely to be the GP who is the person, if we can get it to work, who will be called to actually do something. Once a patient is put into an ambulance and arrives in an A&E department of a hospital, actually the best place for them to die at that point in time, sadly, maybe inside the hospital, having had all of that. The issue is: "Why did they get in the ambulance in the first place?", and that does require people in nursing homes to have the skills to deal with it and GPs to be available or other local clinicians to actually keep people in that environment.

  Q468  Dr Taylor: You are able to look wider than just at cancer deaths: you can include motor neurone disease and things like that?

  Mr Graves: Yes, we are looking at every group of deaths. In Addenbrooke's there are some 1,500 deaths per year and our goal is to focus on the notable groups and where we can have an effect.

  Q469  Dr Taylor: Is there yet any evidence that integrated care is saving money or improving care?

  Dr Brimblecombe: No, it is too early to say.

  Q470  Dr Taylor: When does this pilot finish?

  Dr Brimblecombe: It is three years, is it not?

  Mr Graves: It is.

  Q471  Dr Taylor: It is three years, and it has only just recently started.

  Mr Graves: It started about a year ago, but I guess it is fair to say it has taken a year for us to all get our brains round the issue.

  Q472  Dr Taylor: From your point of view, can you see that it is likely to be improving care?

  Dr Brimblecombe: I am sure it will in the future, but it is also the spin-offs, it is the actual getting three different organisations working together and talking together, because from that, hopefully, it will be a model that we can then roll out to other areas of care, because that is the problem. It is working together and trusting each other, and you can only learn trust through actually doing things together.

  Q473  Dr Naysmith: There is quite a lot of improved data nowadays about performance in hospital care, but there is still quite a paucity of data about primary and community care. I am sure you would all agree with that, would you not?

  Dr Brimblecombe: Yes.

  Q474  Dr Naysmith: Which aspects of performance data would you prioritise to improve commissioning, understanding and to facilitate better care for the patients? Where are the data gaps? Maureen, do you want to have a go, or Paul?

  Dr Zollinger-Read: I think one of the major areas that we need to improve on is community services. We have contracts with community services, but what is it exactly we are purchasing? How are we going to measure that? If we look at the history of commissioning, I think we have come a long way with acute commissioning and the information on acute commissioning is quite sophisticated, but certainly on community care it is fairly embryonic. In terms of primary care, we have a reasonable amount of data, in terms of prescribing, that is well advanced and referrals, so we do have information to manage primary care, and so my focus through this year will be to develop community services data.

  Ms Donnelly: I would add to that, because I think it is not just about managing community services data, it is how that fits into the whole picture of our spend and the quality of services we provide and relates to some of the questions that were asked earlier. I am very conscious that somewhere between 36-40% of our total budget is spent on the over-65s and we commission on behalf of the county council for the adult social care a significant proportion which is in the care of the elderly, and it relates to the discussion recently on the end of life care. We really want to get that working as efficiently as possible and as effectively as possible, first, so that the elderly are looked after properly, do have a very good experience, people who are coming to the end of their life are properly looked after, that you do not just have a fall, the ambulance comes and takes you to hospital, you are there for two weeks, you come out again and you have gone downhill several steps. If you can get the information correctly together and commission that together correctly, it is my very strong belief that not only will we be delivering a much better service to the people of Cambridgeshire, but it will also be cheaper in the end. Just reducing inefficiencies in that in itself would ensure that.

  Q475  Dr Naysmith: What couple of sources of data would help you, Pauline, to improve the way your organisation does its job?

  Dr Brimblecombe: As I said, we actually get quite a lot of good information which allows us to compare. I think from the community side of things though (and this again, I think, is where some of our secondary care colleagues could help) it is actually setting the bar even higher, because most of the practices, particularly within the city and south Cambridgeshire, get very good QOF outcomes, they all get over a thousand points, but that does not indicate we could not do a lot better. We were talking about diabetes earlier and having outcomes actually set in collaboration with our consultants to enable us to actually push the bar a little bit higher would help and, I think, if we were given a more commissioning role in long-term conditions, we would then actually work with our community staff, because, again, our specialist diabetic nurses take great pride in the care they give their patients and, particularly being in Cambridge, we actually like a bit of competition; we like to be marked. We all think we are at the top and we do not like it when we are at the bottom, but we actually do like to improve. At the moment the data is still a little bit about the number of referrals. The score card, or whatever, that the PCTs are marking GP practices on, I think it is five or six areas, is just being developed and I suspect that will be a little bit gross at first, but unless you get something you cannot improve on it. If we get something, then we can say, "Actually, that is not quite right." We get a lot of feedback on patient information, on what they think about us, because of the patient questionnaires that go out, so I think we do actually have a lot of information in general practice that we just need to share.

  Q476  Dr Naysmith: It has just struck me that all morning we have not mentioned the commissioning of mental health services at all. Do you have a separate Mental Health Trust in Cambridgeshire?

  Ms Donnelly: Yes, we do.

  Q477  Dr Naysmith: For whom the PCT will be involved in commissioning services?

  Ms Donnelly: Yes, we commission the services from there.

  Q478  Dr Naysmith: Is there anything special about commissioning for mental health?

  Ms Donnelly: They were one of the pioneers of IAPT, the early intervention. We have got a very good Mental Health Trust.

  Q479  Dr Naysmith: You have got enough information to enable you to improve?

  Ms Donnelly: I would never say we have got enough and it is good enough, we can always improve, but we know that the outcomes are very good and we know that the value for money is very good from our Mental Health Trust, so on those two basic measures we have got sufficient.

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