Examination of Witnesses (Questions 565
- 579)
THURSDAY 4 FEBRUARY 2010
RT HON
MIKE O'BRIEN
MP, MR GARY
BELFIELD AND
DR DAVID
COLIN-THOMÉ
Q565 Chairman:
Good morning, gentlemen. Thank you for coming along to help us
with what is our fourth evidence session on our inquiry into commissioning.
For the record, would you give your name and the current position
you hold, please.
Mr O'Brien: Mike O'Brien, Minister
of State at the Department of Health, responsible for health services.
Mr Belfield: Gary Belfield, Acting
Director-General of Commissioning and System Management in the
Department.
Dr Colin-Thomé: Dr Colin
Thomé, National Clinical Director for Primary Care.
Q566 Chairman:
Minister, in the first evidence session for this inquiry, one
of your officials stated that "we are in the foothills really
of getting our commissioners in good shape to do well for their
population" and yet a survey that was done on our behalf
by the NAO found that 95% of commissioners thought that commissioning
was going well. Is this because commissioners are hopelessly complacent
and unaware of their failings or were your officials being overcritical?
Mr O'Brien: Or maybe it is because
they are just doing very well in the foothills. The situation
is that we have started this programme of World Class Commissioning,
it is going to be very demanding, and I think most of them feel
that they are doing well in so far as we have gone so far, but
we would be the first to say that World Class Commissioning is
there in order to deal with a weakness in the system; that is,
that commissioning was not done as well and as competently as
the public needed it to be done. It has been improving steadily
over the last decade, but since the NHS plan ten years ago we
have had a big job to do. In a sense, it was not until about 2005
that we really recognised that there was this purchaser/provider
split, and it does not work by itself. Local problems with the
NHS are not self-correcting, you have to have intervention, you
have to have a programme to create the change. We have carried
out, as you know, a lot of reforms in the NHS. We have not only
the increased demand there on managers for skill and competence
because of commissioning but also because we have a new agenda
around personalisation of health care so that people can identify
much more what they want, a greater agenda around choice, a requirement
to link up much more with local authorities. All of these are
competencies which even the best of the commissioners needed to
improve. World Class Commissioning is not just about increasing
the competence in commissioning of the ones that were mediocre
and were not so good, it is also about increasing the competence
of those who are very good and appear to be among the best. They
too have to increase their ability. We all need to raise our game.
Weaknesses are there and we need to ensure that we have a programme
to improve the skills of the managers who have to carry out commissioning.
Q567 Chairman:
We have just heard in our earlier session about the lack of people
who understand what providers do. Have you thought of seconding
people from the acute sector into PCTs so that they are able to
advise and give advice about what works at the other side of the
fence?
Mr O'Brien: We will see, increasingly,
some element of movement between PCTs and providers, but that
has not happened much in the past. If you were a high-skill manager
in the past, you would want to go and run a hospital and run a
mental health centre or something like that. Some of the people
who were involved in running PCTs and health authorities tended
to be more management orientated than having an in-depth knowledge
of clinical requirements and of what was needed clinically, and,
therefore, there is a need to get a greater degree of cross-fertilisation.
We are seeing some movement between the two, but we still need
to go further with that.
Q568 Chairman:
Do you know the ratio between the salary of a chief executive
of a foundation trust and a PCT?
Mr O'Brien: Given that the salaries
of foundation trusts, Chairman, vary quite substantially, I do
not know the exact figure but I would imagine it is probably about
double—but I am guessing.
Mr Belfield: The average is somewhere
between 20% and 30% different.
Q569 Chairman:
That is quite a large chunk. Do you expect that people are going
to drift to taking their skills into a PCT if there is that type
of difference?
Mr O'Brien: It is not necessarily
the chief executives you want moving across; it is the people
who will do the detailed commissioning, and so you are talking
about that middle rank of management in hospitals and other health
provider units, rather than necessarily the chief executives.
I would have thought that once you get to that height in running
a hospital you are probably going to want to move to larger and
larger hospitals.
Q570 Chairman:
I know it is argued that things are getting better now as far
as the commissioning of PCTs is concerned, but how worried are
you as a taxpayer and a politician that 80% of what is now a £100
billion a year budget for the National Health Service is spent
by PCTs which for quite a long, long, long time have been quite
weak, which some people would argue are still quite weak now,
although we have tried to address that in the last year or two?
Mr O'Brien: You always need to
ensure that the quality of the management is improving, particularly
when you are making new demands on them. The only reason that
you would want to worry is if the quality of that management skill
was not improving. You are not going to find it easily elsewhere.
Given that we need to improve commissioning, and we have to improve
it across the board and across the country at a local level, that
is a big job. Providing we get the priorities right, that is patient
safety and the quality of care for patients, the second priority,
in a sense, is value for money for that. That is what commissioning
needs to do, to ensure that we get both quality and value for
money. By and large we are getting the first. In terms of the
second, we need to work a lot harder at that. As I say, providing
we are improving the skills I would not get too worried about
it, because, frankly, there is not an alternative. We need to
get this right and we need to ensure that we have managers who
are competent to do it. If they are not there, we have to train
them, because those skills do not come easily.
Chairman: Okay. We will move on.
Q571 Mr Bone:
I apologise, gentlemen, that I have to leave shortly after my
questioning. Following that last issue through logically, that
you have to have the right people and the right skill sets, is
it then strange that at the top of this tree, when £80 billion
is spent on PCTs, we have an excellent solicitor in the Minister
before us? He is not an accountant or anything. Is that strange,
if we are talking about looking after £80 billion, that he
should be a solicitor rather than an accountant or something like
that?
Mr O'Brien: I am definitely not
sitting here as a lawyer; I am sitting here as a minister who
has held eight or nine ministerial positions over a decade or
more and, therefore, I am probably as well skilled in managing
a department and dealing with policy issues. The key role of a
minister, of course, is not to be responsible every time, to use
Nye Bevan's phrase, "bedpan is dropped in Tredegar."
I am not there for my skill at running a hospital; I am there
in order to identify as a politician what the policy of the NHS
ought to be in order to respond to the needs of my constituents
and yours—and I think I am fairly well briefed on that.
Q572 Mr Bone:
You did touch in your opening remarks on commissioning, but what
do you understand as commissioning, very briefly?
Mr O'Brien: Without commissioning
who would really control the Health Service? Would it be the provider
interest? That is always the risk: that the provider interest
would dominate. Commissioning represents the patients and the
taxpayer. Commissioning is about assessing the needs of a local
area; it is about ensuring you get a greater degree of openness
into the process; it is about ensuring that there is a requirement
for clinical input into what is happening and how the NHS is run.
It also does the important thing of switching the focus of the
running of the NHS, particularly for managers and those with the
money, the PCTs, from administration to policy. It is very tempting,
if you are running an organisation, merely to manage it and to
keep it in some sort of steady state and to deal with the problems.
If you are commissioning and you are in that commissioner role,
then you have to look at the policy, what have we got to be delivering
here? How do we best deliver it? Therefore the focus is on long-term
health gains.
Q573 Mr Bone:
Never ask a minister to be short in his answers.
Mr O'Brien: Such as prevention
of healthcare issues and health protection and long-term issues.
Q574 Mr Bone:
Thank you, Minister. The reality—and we have had evidence
of this—is that commissioning is failing. It is not making
any significant difference to secondary care whatsoever. Would
you not agree that your reform over the last 13 years of commissioning
has been rather like moving the deckchairs around on the Titanic,
and that it is making no overall difference? The ship, in the
case of the Titanic, is slowly sinking, but in our model the PCT
is slowly sinking. Is that not the reality of the situation?
Mr O'Brien: First of all, the
NHS has not been slowly sinking since 1997.
Q575 Mr Bone:
Commissioning. Sorry, commissioning.
Mr O'Brien: We are now in a position
where the NHS, as a result of commissioning, is making a number
of changes that will improve the quality of health care. At the
risk of giving you a longer answer—the objective of select
committees is elucidation rather than sound bites—let me
just say that if you were in Somerset, where commissioning has
had a particular success in terms of getting people with COPD
treated in the community rather than this business of yo-yoing
in and out of hospital, that is a result of successful commissioning.
If you were in Manchester, ten PCTs have got together to develop
through their various hospitals a new stroke service, which is
a major change in the way in which stroke is dealt with in Manchester.
It is a health improvement. It is the result of commissioning.
It is a result of the way in which changes are taking place in
the Health Service that have arisen out of the purchaser/provider
split and the development of proper commissioning. I would not
necessarily ascribe it all to the success of World Class Commissioning,
because that has only had four years, but I would say that those
sorts of initiatives have shown that commissioning works and that
it makes real change. We also need to ensure that we get other
PCTs up to the standard where the quality of their commissioning
is as innovative as that.
Q576 Mr Bone:
We are not on the way down; we are on the way down, you think.
Mr O'Brien: I think the NHS has
gone from being poor to good and we now need to get it to great—so
we are on the way up, yes.
Q577 Dr Stoate:
Minister, you have given us some good examples of where commissioning
has worked, and I accept that there have been some examples. However,
witness after witness and evidence after evidence really has left
us with one feeling in this inquiry, and that is that the providers
are dominant and the purchasers are weak. Is that a criticism
you would share?
Mr O'Brien: The whole objective
here of commissioning is to try to deal with this issue where
the providers' interest has become very dominant. 1.4 million
people work in the NHS. The doctors, as you will know, Howard,
are a very powerful lobby. The nurses are now well organised.
Even the pharmacists—seeing Sandra Gidley there—are
well organised. It is important that we have some counterbalance
to that, and therefore the purchaser interest, the PCT, is there
to represent the taxpayer and the patient and to try also to represent
the long-term interests of health care, to try to ensure that
we get the policy going in the right direction. You are right
to say there is this real problem with the way in which the providers
could be increasingly dominant. But that is not just a problem
here; it is a problem in other countries across the world where
providers can set the agenda. That is why improving the quality
of the purchasers through World Class Commissioning is the objective
of the exercise.
Q578 Dr Stoate:
We have been hearing from witnesses before that PCTs do not have
the skills; they do not have the top quality managers. The best
managers are all in the secondary sector. They are in the acute
sector, they are working for foundation trusts—possibly
for financial reasons, possibly for other reasons—but, nevertheless,
the situation is that PCTs are very weak on commissioning and
providers remain dominant. That has constantly come back to us
throughout this inquiry. Are perverse incentives being built in?
Foundation trusts. Payment by results. The choice agenda, which
seems to us to run counter to the philosophy of moving care back
into the community.
Mr O'Brien: We are trying, in
a sense, to address the very problem you are identifying, both
by having this purchaser/provider split and by trying to improve
the quality of the purchasers. The whole objective of the World
Class Commissioning exercise is to address the issue you are identifying.
Are there perverse incentives? There are various incentives in
the system. You cannot put all the burden of improving the quality
of the NHS on to the commissioning process. It is one very important
part of that policy—certainly an important part. One of
the things we want to do, as you know, is to see if we can get
more care taking place in the community and out of hospitals.
There are issues around PbR, where this is the third kerchink,
kerchink, as somebody goes into hospital, and there is a temptation
to yo-yo patients with long-term care conditions in and out of
hospital. Those sorts of issues are matters that we do have to
look at. PbR, for example, has had beneficial effects in relation
to getting down waiting lists—enormously beneficial effects.
Just because you have some perversity in some of the outcomes
does not mean that you, in a sense, throw the baby out with the
bathwater. You try to identify how you can use the system to better
deliver what you want overall.
Q579 Dr Stoate:
I entirely agree with that; it is just that we have heard, again
from primary care trusts, that PbR can so distort their budgets,
because they have no control whatsoever over it. It makes it very
difficult for them to develop other programmes because a huge
chunk of their budget is effectively totally out of their control.
That severely hampers their ability to be more imaginative in
the commissioning of providing alternatives.
Mr O'Brien: There are several
points there. Not all providers are well managed, so there is
a lot of improvement that needs to be made there, and some PCTs
are pretty good at commissioning. It is not uniform across-the-board.
In terms of PbR, yes, it means that some of the PCTs do not have
full control over their budget, because, in a sense, the demand
will dictate and money will go to hospitals if they are carrying
out operations. That results in the PCTs having to predict the
level of demand that will come from PbR, but over time they will
become better able to gauge that and be better able to ensure
that we get finances effectively managed even with PbR. The benefits
of PbR, for example, although I appreciate there are issues with
it, are that it improves choice, so that patients can choose where
they want to go, and it supports greater efficiency because hospitals
get a certain amount of money for a procedure and if they can
do it more efficiently then the result of that could be that they
make a saving which they are able to spend elsewhere in the hospital
system. With PbR—and perhaps we will come back to this later—we
need to look at how we better use it to improve the quality of
the way in which care is provided, and PCTs will need to be involved
in that as part of the Darzi agenda.
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