Examination of Witnesses (Questions 600
- 619)
THURSDAY 4 FEBRUARY 2010
RT HON
MIKE O'BRIEN
MP, MR GARY
BELFIELD AND
DR DAVID
COLIN-THOMÉ
Q600 Dr Naysmith:
Than it is when there is plenty of money about.
Mr O'Brien: Which it is.
Q601 Dr Naysmith:
You have to get it right and make sure that the right cuts are
made.
Mr O'Brien: Yes, you do. You have
to get it right. You are absolutely spot on to say that at a time
when there are tougher financial circumstances, the quality of
commissioning is crucial. That is why the old fashioned, Thatcherite,
1980s, across-the-board, slash-and-burn cuts are unacceptable.
We have been reading in some of the medical magazines that this
hospital or that PCT are talking about x% cuts in budgets. That
sort of thing is old management speak. It is the sort of thing
that if we find they are doing it, we will name and shame them.
We need quality managers who make serious decisions and not just
across-the-board cuts, who say that they will be able to find
this by collaborating with other PCTs in terms of provision of
various services, management facilities, who say they will cut
some of their consultants' budgets or they will cut some of the
administrative procedures that they have carried out as far as
the back-office is concerned, that they will use clinicians to
help guide them in terms of the decisions that they make. There
are a number of areas where we expect managers to find those savings
so that they can redirect the funding into the frontline.
Q602 Sandra Gidley:
What improvements do you expect to see in the second year of World
Class Commissioning? How will that league table to which Dr Taylor
referred earlier improve?
Mr O'Brien: In a sense, I have
already referred to the key area where we need to see improvement,
and that is in the quality of management. We want to see the quality
of boards' decision-making improved, the quality of the skills
that they are able to display and will be measured on. It is not
just the operating framework, which is going to measure the quality
of what is being done, but also the PCTs will be subject to the
commissioning Performance Framework which is due in April, which
will measure the quality too of decision-making and direction
of the local health service by the PCTs. We also want to see the
SHAs provide more development and support to PCTs that need it,
so in the second year of World Class Commissioning we are going
to be taking it a step further. The first phase, year one, was
getting a baseline of how good commissioning was being done. It
was box-ticking, in a sense, and that is where we needed to be
because we needed to establish that baseline. In year two we then
had to move on to the skills and competencies that we need to
ensure that each group of managers have to improve and that they
are getting the opportunity to improve them. In year three we
have to ensure that those improvements are put in place and we
are measuring the improvement in the quality of commissioning.
We are now into the situation where we have given them the chance
to improve, we are measuring the quality of what they are delivering,
and we now want to be able to say to them, "Look, you have
improved this much." Some of them will not have improved
enough. "This is the support you are going to get" or
"You're just incapable of improving, we now have to take
some serious action in terms of you." We are now into that
much more decisive phase. It is a process of baseline identification,
putting in place the services to improve it, ensuring the improvement
is taking place, measuring the improvement, and then, where it
is not improving, dealing with it and reinforcing the improvement
that is taking place. It is a year-upon-year process.
Q603 Sandra Gidley:
I can accept that the first year was benchmarking, but I am not
quite clear whether there are any targets for improvement, how
the average patient will realise things are better.
Mr O'Brien: Once you have benchmarked,
you can then see whether there is an improvement in the quality
of what you have done.
Q604 Sandra Gidley:
You are talking about seeing whether there has been an improvement.
I am trying to get out of you how much of an improvement you hope
to see. Can you quantify that in any way?
Mr O'Brien: It will vary depending
on the PCT. Each of the SHAs, for the very reason that I described
earlier, will have to intervene if there is a failure to hit the
three+ rating (four being the highest) in seven of the 11 competencies.
There is a measurement: "This is the minimum you need to
be at, otherwise we are going to intervene—not to necessarily
sack you, but we are going to intervene." In terms of the
answer, I suppose it is that that is the measure, that three+
in seven of the 11 competencies.
Q605 Sandra Gidley:
You said if they do not achieve that, the SHA will intervene.
SHAs have always struck me as particularly powerless and useless
organisations. What do SHAs then do, slap them over the wrist?
You cannot sack anybody, it seems. I am not quite sure how we
are going to drive things forward.
Mr O'Brien: Certainly in my region,
the SHA has intervened and people have gone. Whether those were
the right decisions or not, I am not convinced they always were.
In fact, I am pretty sure that in some cases they were not. The
idea of seeing the SHA as some sort of toothless tiger is wrong.
They do get rid of people. They do not always do it to allow publicity
but people are moved on and I have seen it happen.
Q606 Sandra Gidley:
So we sack the chief executive and then there is an interim period
where there is not anybody in charge and we get somebody new in
and we still have the same rubbish commissioners.
Mr O'Brien: The idea of bringing
new managers in—you would not do it otherwise, would you?—is
to improve the quality of performance. New managers come in to
do that, and if they do not do it, then you have to get someone
who will. You seem to be saying, "Let's all despair about
it." Of course we cannot do that: we have a Health Service
to run and if somebody is not up to it, then they will be moved
on.
Q607 Sandra Gidley:
You mentioned box-ticking and explained why the first year had
to be a tick-box exercise, and there has been some criticism levelled
at that, but there seems to be a lack of evidence that health
outcomes are genuinely being improved. When will we know if World
Class Commissioning has delivered improved health outcomes?
Mr O'Brien: Because they will
be delivering on their outcomes, because they will be able to
show that they have set out a strategy, that this is what they
want to do in the local area and that they have delivered it.
They have to measure themselves and they have to be objectively
measurable. The SHA will be able to say, "At the start of
this year, you as a PCT said that's what you wanted to achieve,
let's have a look at whether you have done it. You have in this
area; you have not in that area"—why have you failed
and how have you achieved.
Q608 Sandra Gidley:
But some health outcomes are longer term than a year to measure.
Mr O'Brien: It will be. If you
have a longer-term project over a five-year or ten-year period
(say, for example, to shift patients more into the community in
terms of their care) then you can say, "Each year we will
seek to achieve this." You will break that down and say what
each year is supposed to deliver. You will not say, "You
have to deliver a ten-year project in a year." You will say,
"You have to deliver one-tenth of a ten-year project in a
year and you have to identify what it is that you are going to
have as your objective for that year as a PCT," and the SHA
will be able to measure that and ensure that it is delivered.
It is about ensuring they deliver their outcomes.
Q609 Sandra Gidley:
We have had practice-based commissioning for a while. The aim
with a lot of the reforms has been to move services from secondary
to primary care, but PCTs seem to have been unable to stimulate
the market to achieve this. Why is that?
Mr O'Brien: In terms of practice-based
commissioning?
Q610 Sandra Gidley:
PCTs seem to have limited ability to stimulate the market to change
things, to get best value for money.
Mr O'Brien: I am not convinced
that that is the case. I can give you a couple of examples, which
are fairly obvious, in a sense. PCTs have created 120 GP-led health
centres. They have commissioned them.
Q611 Sandra Gidley:
Only because they were told to by government.
Mr O'Brien: But they have done
it.
Q612 Sandra Gidley:
They were told to do it. That is not exactly stimulating the market.
An individual PCT does not seem to have much muscle to flex.
Mr O'Brien: They have been told
by government to create 120 GP-led health centres. They have to
find the providers for that. In my local area, they have done
it. I am sure in yours they have done it. That is one example.
Q613 Sandra Gidley:
That is not local decision making. What do we have that is not
a top-down initiative, evidence that PCTs can stimulate their
local markets? It is not happening.
Mr O'Brien: I have already provided
you with a couple of examples, and I can give you some more. I
described the changes they had created in Somerset by commissioning.
PCTs have led the process in Somerset to deliver COPD care in
the community much more effectively. They have seen a 15% drop
in hospital admissions in Somerset. That is an entirely new delivery
of community care, stimulating the market. In Manchester the ten
PCTs have provided new stroke care services. Another example would
be at Bexley, where the cardiology service has been developed
through PBC. PBC was the innovator of that at the request of the
primary care trust. The primary care trust funded the innovation
that has taken place, by delivering care for people with cardiology
issues much more in their homes, rather than having them coming
into hospital—a saving of £4 million, by the way, in
the local budget—which is a combination of the PCT being
prepared to innovate and, also, the way in which PBC has operated.
Likewise, we have seen the co-ordination of GP visits in Halton
and St Helen's PCT. There they have decided to get the GPs to
work together much more effectively to carry out visits to homes
during the day. As a result, because GPs are being commissioned
to co-operate, they have managed to get 27 more patient visits
per day out of the GPs and also seen a 30% drop in hospital admissions.
That saved £1 million in the first six months in the budget
and had a 90% patient satisfaction rate. All of that has been
as a result of the ability of PCTs to innovate. There are a number
of examples out there. It is happening.
Q614 Dr Naysmith:
People currently complain that there are structural complexities
inherent in the current commissioning arrangements. Do you think
World Class Commissioning is going to solve this and make it more
straightforward and easier?
Mr O'Brien: It is part of the
process but it is not going to do it all. We were talking earlier
about what is top-down and what is not, and there need to be some
policy changes. If we want more people to be cared for in their
homes rather than in hospitals, to stop the yo-yoing of the long-term
care patients—which is something I feel very strongly about,
as you can probably tell: I have mentioned it twice so far—then
we do need to look at the way in which finances operate within
the NHS. We do need to make sure that we have got the funding
right on that. World Class Commissioning can carry some of the
weight of change but it cannot carry all of it. There are structural
complexities in the operation of the NHS and commissioning, managing
data and so on, and we need to ensure that we get a greater degree
of joint commissioning by PCTs and that we get the development
of joint budgets too. Particularly important—something I
announced the other day—was getting PCTs to work much more
closely with local authorities on integrated care projects.
Q615 Dr Naysmith:
We have also heard quite a lot of evidence that is critical of
the amount of information and the quality of the data that commissioners
have available to them. Do you have plans to improve the data
to enable them to make better decisions?
Mr O'Brien: Part of the World
Class Commissioning exercise is precisely that, to see if we can
improve the quality of data handling. It is not just getting the
data. There was an idea that if you get the data, somehow it would
be used properly. There is a two-fold problem: you have to (a)
get the data and (b) ensure the managers know how to use that
data.
Q616 Dr Naysmith:
I was about to say: you have to have people who know how to use
data.
Mr O'Brien: Exactly.
Q617 Dr Naysmith:
And have experience of the areas they are getting the data about.
Mr O'Brien: That is about improvements
in skill and competence. Also, through the World Class Commissioning
exercise, we are identifying the key areas of data that managers
will need to have in order to commission effectively. We are also
getting them to identify for themselves what locally they really
need to be able to measure the outcomes of care for patients where
they have commissioned, so they need to go to the providers and
say, "In order to measure what you are providing for me,
I need to have this data and you have to provide it." That
would be a local decision. There is a national view about what
needs to be provided and then there is a much more local one.
Q618 Dr Naysmith:
Will patient recorded outcomes be part of this process? That is
something that we do not know about.
Mr O'Brien: Gary is saying yes
to me.
Mr Belfield: From a national level,
through the information centre, we provided every single PCT with
baseline data to help them do commissioning, so we have helped
from a national perspective. Locally now we are finding more and
more PCTs working together to pool their information: to do the
information once, which obviously saves money. Last night I was
with six PCTs in the West Midlands who are working together on
risk stratification, for example, to look at where the patients
who may end up in hospital are, so they are getting to people
earlier through their GPs. We are seeing something from the top
and action from the bottom as well. It is not perfect, though,
I agree with you completely.
Q619 Dr Naysmith:
There is some way to go.
Mr Belfield: Yes, but we are taking
action.
Dr Colin-Thomé: I would
say two things. We already had Public Health Observatories and
since the Darzi Review we have set up Quality Observatories, which
are a source of information and data analysis that PCTs can tap
into. I think we have set up quite a bit. Of course we can always
do better.
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