Examination of Witnesses (Questions 460
THURSDAY 28 JANUARY 2010
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
informationif we do not have information, we cannot do
itand 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
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 allend 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
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
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.