Commissioning - Health Committee Contents

Examination of Witnesses (Questions 480 - 497)



  Q480  Charlotte Atkins: You have an adolescent group, do you not, and, of course, very often mental health is not picked up very early. Do you get much information from your adolescent committee about issues around mental health, because I think youngsters in particular are quite concerned about that issue?

  Dr Zollinger-Read: I think that is the most challenging area. Pauline can speak to what it is like on the ground, but in all the areas I have been the child adolescent mental health services are the most challenging area and have required the most significant investment. Do we get as much information as we would like? Probably not, but that is part of the evolving commissioning development, as I would see it.

  Dr Brimblecombe: We have a very good relationship between the Mental Health Trust and GPs. One of the clinicians, the GPs, on the executive board works very closely with the Mental Health Trust. It is one of the areas which we think we have actually got good relationships with. They listen very carefully to what GPs say because so much care has already moved out into the community that we have a symbiotic relationship. Certainly, as far as the adolescence, again, our GP is waving the flag for that and certainly she has developed psychological services for that age group.

  Q481  Dr Taylor: As a committee we asked the National Audit Office to do a telephone survey with directors of commissioning within PCTs just for their views, and they tell us that they did 114 telephone interviews from a sample of the 152 PCTs and had a response rate of 75%. The results really, I think, probably amazed most of us because they have not been fully analysed yet, but the general perceptions of commissioning are very positive with 95% of commissioners stating that commissioning is going well. Of these 82% believe it is going very well. That rather contrasted with what we have been told by the Department of Health, who felt that it was not as good as all that.

  Dr Brimblecombe: I think it has changed too. I think before they just phoned up random GPs who had never heard of commissioning in their life. I think they changed and started to target people who were involved with commissioning.

  Q482  Dr Taylor: So these were directors of commissioning?

  Dr Zollinger-Read: Yes, they will be people in PCTs who are clearly under the belief that things are going swimmingly well. I think that the reality, as I said earlier, is that world-class commissioning has been extremely useful. It has provided a framework, it is enabling us to develop and there are always challenges; there are huge and significant challenges. We have had emergency pressure challenges. In Cambridgeshire the main challenge for us is managing the elective over performance, so routine referrals, but are we in a better place than we were a year ago? Definitely, and the journey has helped us to get there. I think if you were to ask PBC groups do they think it is going well, you would not come out with 95%, but if you asked them are they optimistic that PCTs and PBCs are now getting together and cutting through some of the bureaucracy we put in place, I think the answer is, yes.

  Q483  Dr Taylor: Again, the survey showed that up to a quarter of PCT commissioners do not know what they spend on practice based commissioning. How can you not know what proportion of your commissioning is being done by PBC? You probably do know the proportion, do you?

  Dr Brimblecombe: We do not actually commissioning anything directly, i.e. we do not hold the contracts with anybody. We are actually at the moment much more of an advisory service, so, no, we do not commission anything.

  Dr Zollinger-Read: I think that is a difficult question that we might have got variable answers for. In another place we had a clear plan and they were taking care of this so you could quantify it. In other areas there is more input and advice, which is difficult to quantify. I suspect that is why there are some strange answers in that.

  Q484  Charlotte Atkins: What would you like to see in terms of helping improve your commissioning? What would help you improve commissioning for your local population?

  Ms Donnelly: Stability.

  Q485  Charlotte Atkins: You mean no change.

  Ms Donnelly: Stability is probably a better way of describing it; there is always room for some change. Every time there is a big reorganisation it destabilises everything and knocks things back. No organisational structure is ever perfect, but it is better to try and do the best with what you have got.

  Q486  Charlotte Atkins: Floating off your provider arm: how would you see that? Is that going to be destabilising?

  Ms Donnelly: That has been running as a separate organisation for the best part of two years. We very deliberately set it up with its own nominal P&L account. We really wanted to try to get to grips with the blancmange in the provider arm so that they began to look at business units and the value for money of each different business unit line, and they have gone a long way towards that, but they have been working on that for two years. Whether it crosses the boundary or not into either a trust status or, eventually, an FT status will not make that much difference to the way we interact with them at the moment. We treat them at the moment as a wholly owned subsidiary.

  Q487  Charlotte Atkins: Anybody else?

  Dr Zollinger-Read: Yes, being a GP and being a manager, I know very clearly which the most challenging is. We need to invest in NHS management because it is a really tricky thing to do. It is managing really complicated relationships. A lot of what we do is through influencing others, so, first of all, we need to nurture our management and, secondly, we need to get more clinicians into management. When I was at medical school they did not tell you anything about management, and I am not sure they tell you very much now. Other countries are starting to integrate management into medical school, and I think that is a really good place to go. We have really got to crack this GP consultant business. If I look at the vision for my clusters, I would like to see a model where GPs and consultants are the same unit and they are not actually having a contract with my friend next door but they are working as one unit, that they will go to a hospital as a place of work and have a contract with them. Then you are commissioning a whole care pathway rather than a bit in primary care and a bit in secondary care. Finally, incentives. PBR has been useful and it is evolving and we need to involve it further. We need to think through carefully what are the other incentives that we need for primary care to manage how we commission primary care, because those are much woollier at the moment.

  Q488  Charlotte Atkins: Would either of you like to comment, Pauline or Stephen?

  Dr Brimblecombe: Personally, one of the problems we have is actually we would like more money.

  Dr Naysmith: Everybody says that.

  Q489  Charlotte Atkins: Why does that not surprise me?

  Dr Brimblecombe: I know. The reason I say that is our patients are allocated a certain amount of money with which we have to deliver the total part of their care, and I do not think patients actually realise that a patient in south Cambridgeshire is worth a different amount than a patient in east Cambridge, fenland or in the city, Birmingham or somewhere like that. Of course, that was done for very good reasons, possibly not so good reasons actually, in that it was felt that by differential funding of medicine you could equalise health inequality. Some of it will help, but most health inequality, as we learnt earlier in the week, is to do with things completely outside of our control, and because healthcare has historically been done on demand rather than on need, actually at the moment, particularly at our south Cambridgeshire practices, we are having to be able to say to patients, "I am sorry, you have really good healthcare, you have very good outcomes but it is costing us too much money." Therefore, somehow we have got to be able to either take it away from them, be more efficient, which, obviously, I am sure you would like us to be, or is the formula right? I put that up as one because it is going to be a real challenge for us locally to engage the GPs, because when they are already 4-5% over budget, and I have already shared this with our local MP, who is the shadow Minister of Health, how are we going to engage GPs when they are already facing a two and a half million deficit in their GP budgets?

  Q490  Charlotte Atkins: So you are suggesting we should give more money to GPs so that you can meet the demands of your demanding patients rather than the needs of those where health inequality is the greatest?

  Dr Brimblecombe: I would like that, unless you can help me engage with my public to understand that actually they have got to take a role in the total health, the distributive justice that I have talked about earlier.

  Q491  Charlotte Atkins: Is that not what GPs are supposed to be so good at doing: engaging with their patients and public?

  Dr Brimblecombe: They are on an individual basis. As we have said before, for an individual patient what they want is what they want and putting it into context is difficult.

  Q492  Charlotte Atkins: That is what we have got to do; we have got to do difficult things, have we not?

  Dr Brimblecombe: Yes.

  Dr Zollinger-Read: I think one of the benefits of this cluster model is that what works with GPs is peer to peer pressure and what does not work so well is a PCT with a big stick. We have the information, and what we would expect within the cluster then is for GPs to sit down, look at their relative information and start to question each other. This is the sort of Holy Grail when you start to question each other about clinical decisions because you are an outlier, but that is where I believe we need to tread.

  Dr Brimblecombe: Also with the politicians, I do think you have a role to stop fuelling demand the whole time and saying you can have whatever you want, because you can within a resource allocation, and to engage the public, as I have said before.

  Q493  Jim Dowd: Let me clarify this, because just to say you want more money is pretty naive.

  Dr Brimblecombe: I was being slightly facetious in that.

  Q494  Jim Dowd: That is what I wanted to clarify—not whether you are being facetious or not, that is a matter for you, but whether you were actually saying you wanted a higher proportion within the current allocations or you just wanted more beyond that?

  Dr Brimblecombe: I suppose I am challenging: is the allocation right? That is one thing, but for a GP to want to take on that budget they have got to be sure that it is a fair budget. What we are trying to say is we are going to go to fair shares, and what that means within Cambridgeshire is we have got from certain areas in Cambridge to hand over to GPs in a different part, so we have got to take from the rich and give to the poor, if you like.

  Dr Zollinger-Read: I think there is more to it than that, because there is so much more we need to do. One of our issues is orthopaedic growth, and that cannot bear any resemblance to a change in population because it has happened too quickly. If we also look at prescribing, we are relatively good but we are still giving shed loads of drugs out that if we stuck to rigorous guidance we would not do; so there are still more efficiencies we could get. Finally, there is the quality agenda. We have looked at MRSA and C.diff and clearly the improvement in those has substantial cost savings. There are many other quality areas we can start to look at which will drive out cost.

  Q495  Dr Naysmith: Before I wind this session up, I cannot forbear from mentioning, Pauline, that some us on this committee have known for quite a long time—about 30 years—that medical intervention was not the most important things in terms of getting rid of inequalities, particularly those of us who have read the Black Report.

  Dr Brimblecombe: That is why GPs would like to take on more commissioning, because, I have to say, that is not what comes from the Department of Health, it goes into acute care. We know that one of the greatest things that has happened is banning smoking in public places, which actually did come out from clinician pressure but eventually was taken on board by the politicians. Again, I know some people want to keep politicians out of medicine. Actually I think I would like to bring politicians into my cluster as well.

  Q496  Dr Naysmith: Be careful what you wish for!

  Ms Donnelly: Pauline always very passionately defends her patients and her population and we admire and respect her for that. It is very clearly one of the reasons why we engage so closely with our districts, and having a good health outcome is something that goes way beyond the Health Service. At the meeting that Paul referred to that we had yesterday with the local strategic partnership, we had the Chief Constable talking about domestic violence and how that interlinked with care of children, we had the Head of Fire Service saying when his people go in to talk about fire safety why do not they talk about not smoking. That is the sort of thing we really want to develop and work on.

  Q497  Dr Naysmith: But that is not the base for it, surely.

  Ms Donnelly: No

  Dr Naysmith: Can I thank all four of you very much for contributing to our evidence this morning. We are not quite sure when our report is going to appear, but we will try and get it out before the election, which none of us knows when is going to happen. Thank you very much indeed.

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