Examination of Witnesses (Questions 480
- 497)
THURSDAY 28 JANUARY 2010
DR PAULINE
BRIMBLECOMBE, MS
MAUREEN DONNELLY,
DR PAUL
ZOLLINGER-READ
AND MR
STEPHEN GRAVES
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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