Commissioning - Health Committee Contents


4  WEAKNESSES IN COMMISSIONING

57. As we have seen in a previous chapter, the NHS has been trying to develop commissioning effectively since the introduction of the purchaser/provider split in 1991. However, PCT commissioning is widely regarded as the weakest link in the English NHS.[53] In this chapter we discuss the weaknesses in local commissioning (including PBC) and the reasons for them.

How do PCTs think they are doing?

58. During the inquiry we were provided with examples of good work done by PCTs. The DH mentioned Oxfordshire PCT's work on Joint Commissioning of Primary Child and Adolescent Mental Health Services (Ev 11), Somerset PCT, Chronic Obstructive Pulmonary Disease service (Ev 11), Tower Hamlets PCT, Self Care for Diabetes (Ev 27), NHS Bristol, Commissioning of IVF Services (Ev 147) and NHS Norfolk Stroke Services (Ev 38).

59. The Care Quality Commission in its report on The state of healthcare and adult social care in 2009 assessed PCTs for the quality of their commissioning, examining their performance against core standards, existing commitments and national priorities.[54] The great majority of PCTs either "fully" or "almost" met the standards overall, with "100% of PCTs as commissioners ... complying with the 14 core standards" although there were some concerns about records management, staff training and human rights. It should be noted that this report was based on PCT's self- assessments.

60. A further indication that PCTs themselves believe they are doing a good job is evidence from a survey which we commissioned from the National Audit Office for our inquiry. The National Audit Office conducted a telephone survey of commissioners on behalf of the Committee with startlingly positive results, as Box 5 below shows.[55]

Box 5: Findings of NAO Telephone Survey of PCT Commissioners, January 2010


Weaknesses

61. However, PCTs' positive perceptions of commissioning were significantly at odds with extensive evidence which we received pointing to weaknesses in the system. The submission from the National Audit Office cautioned that the telephone survey results needed to be set in the context of recent NAO value for money reports which had highlighted weaknesses at PCT level in all three stages of the commissioning cycle: strategic planning, procuring services and monitoring and evaluation.[56]

62. Numerous submissions to the inquiry, including those from the National Pharmacy Association, the National Rheumatoid Arthritis Society, Weight Watchers, and Which?, highlighted the variability in the quality of commissioning across the country.[57]

63. The 2009 World Class Commissioning assurance process confirmed that the quality of commissioning by PCTs was largely poor to mediocre.[58] There was a sizeable gap between what was being delivered and the standards expected within the WCC programme.

64. We received evidence about three particular problems, namely that PCTs were:

  • Too passive vis à vis providers
  • Failing to improve the quality of services
  • Failing to change patterns of service provision

PASSIVITY VIS À VIS PROVIDERS

65. In the first evidence session, officials from the Department admitted to the Committee that commissioning was weak.

    It is only in the last two or three years that we have realised we need to help commissioners to become much stronger, to help them develop and to help them have an equal footing with providers so that we can have some tension in the system to improve care for the local population.[59]

66. Weaknesses highlighted by the 2009 WCC assurance process also included poor management of relationships with providers and failure to engage in constructive performance discussions to ensure continuous quality improvement.[60]

FAILURE TO IMPROVE THE QUALITY OF SERVICES

67. The quality of services is of vital importance. As we showed in our report on Patient Safety PCTs and SHAs failed to realise the appalling treatment of patients in some of the hospitals they were commissioning services from.[61] Professor Chris Ham told us:

    I do not think any of us would say hand on heart that PCTs have done a great job in being the active, intelligent commissioners leading the debate about quality and outcomes, putting lots of stuff in their service specifications and standards. That is very much work in progress.[62]

FAILURE TO CHANGE PATTERNS OF SERVICE PROVISION WHERE NECESSARY

68. Government has repeatedly stressed its policy to move care out of hospitals and into the community and primary care sectors.[63] However, PCTs have made little progress. The Audit Commission in November 2009 published a report into productivity and efficiency in the NHS. It found that in 2008-09 PCTs did increase their spending on community services, by 13.2%, which reflected the relative priority investment between primary and community services in that year. However, in the same year, provider trusts also increased their income from PCTs by 6.6%. The report concluded:

    whatever the anecdotal local evidence, the headline national figures suggest that PCTs made little or no in-road in 2008-09 to transferring care from hospitals into the community or in dampening demand, either in terms of investment or activity.[64]

69. This view was supported by the Royal College of General Practitioners:

    We are encouraged that World Class Commissioning is putting pressure on PCTs to engage with GPs, particularly PBC groups. However, not enough services have been moved to the community and there has been too little investment in generalist person-centred services (as opposed to specialist disease-focussed services). [65]

70. PCTs have the power to re-commission a service (shifting to an alternative provider) or simply decommission a service (stop funding it altogether). Some PCTs have re-commissioned services, e.g. Norfolk PCT's IVF services. Commissioners should not be paying providers to keep providing outdated and poorly evidenced treatments.[66]

    we went through a complete tendering process which meant that some providers of IVF services that were not getting the sorts of quality results that we wanted were no longer providing that service to patients in the East of England and other providers that were offering good quality services were given the contract,

John Parkes, from Northamptonshire PCT told us, "I really would not be expecting to be seeing large numbers of tonsillectomies being undertaken."[67] The Science and Technology Committee was informed during its recent inquiry into homeopathy that West Kent PCT had decommissioned homeopathy services.[68] However, PCTs appear to find decommissioning hard and there is a tendency to commission what has always been done.[69] A survey by the Health Service Journal revealed that in 2007 the majority of PCTs had failed to decommission any services.[70]

Reasons for weaknesses

71. Witnesses gave several explanations for the weakness in commissioning. These were:

  • Shortcomings in data;
  • Lack of necessary skills;
  • Lack of levers of influence over providers; and
  • Impact of Government policies.

SHORTCOMINGS IN DATA AND DATA ANALYSIS

72. The collection and use of data are of vital importance to the NHS in general and PCTs in particular. Data on what services are being provided and the health outcomes that are being obtained through those services allow the NHS to see whether it is getting value for the money it is spending, including whether or not services are adequate in both quality and safety.

73. There are two concerns about PCTs' use of data. First, whether they are making the best use of the data they already have and secondly, their failure to obtain important data that they lack. The Care Quality Commission (CQC) informed us:

    In our work we have commonly identified significant concerns about the availability and use of relevant and reliable data to inform accurate assessments of service need—for example in our most recent review of statin prescribing, stop smoking services and cardio vascular disease.[71]

74. It seems that many people in PCTs have no idea how to use the data. PCTs employ large numbers of staff, but too few of them seem able to analyse data effectively. The King's Fund told us that a recent survey of GPs and PCT managers had found that many felt deficient in the skills of data analysis.[72] We were informed that there was a reluctance among commissioners to use the data that is available to challenge providers and a reluctance among providers to be transparent about variations, as they are often unwilling to challenge clinical "norms" which may often be inefficient. This "information asymmetry" had enabled large providers to resist change.[73]

75. The CQC criticised the assessment and monitoring of providers by PCTs:[74]

    Our reviews highlight how performance data could be better utilised by commissioners to drive continuous improvement—for example in the context of maternity services and prisons.

76. David Stout of the NHS Confederation's PCT Network admitted that data had been weak and the Department admitted to the Committee that PCTs had not properly analysed the health needs of their local populations, although they were now starting to do so under the WCC programme.[75]

77. There is the issue of failure to obtain important data which they lack. The Royal College of Midwives argued that one of the key obstacles to effective commissioning of maternity services was the absence of a national or regional data set for maternity services with providers keeping information in different formats and PCTs having different information requirements.[76] The fpa (formerly the Family Planning Association) argued that commissioning for sexual health was not supported by the strong data required.[77] BUPA highlighted the need for more emphasis on data and information acquisition to give managers the tools they needed to manage demand more effectively.[78] BUPA recommend more emphasis on requiring PCTs to link existing GP, social care and national inpatient data to support practice based commissioners. The British Dental Association highlighted the importance of "properly interpreted and well managed data" as the backbone of high-quality commissioning and the failure of many PCTs to collect it.[79] The Royal College of Psychiatrists also raised concerns about the scarcity of information:

    Local populations vary considerably in their mental health needs and commissioning should respond to that. But there is a lack of good quality local information on population needs, including unmet needs, which is important because those who are in most need may be less able to seek help. Poor use of evidence by commissioners may be the reason why the fivefold variation per person in NHS budget for mental health services does not seem to follow known patterns of prevalence or need but appears to be almost random.[80]

78. John Parkes, Chief Executive of Northamptonshire PCT, also thought that PCTs still lacked the data that they needed:

    I would really like to have access to the data that, for example, is held within primary care and I would like to have access to that data to put it alongside the hospital data and social care data because we have got the ability now, if we had all of that data together, to then share it back to, for example, GPs, "Here is somebody with more than one long-term condition. Here is the particular risk for that individual. Here is how that risk can be managed", or, "Here is somebody for whom a prescription has been prescribed, never been filled, not being taken at the right frequency". We could use that information in a joined-up way.[81]

79. Dr Jennifer Dixon, Director of the Nuffield Trust, told us:

    producers have much more information than the commissioners have and in what they are doing they have huge amounts of discretion and cannot easily be challenged. There is not much information about clinical care to help commissioning.[82]

LACK OF OTHER SKILLS AND KNOWLEDGE

80. In addition to lacking the ability to analyse data, there is also evidence of a deficiency in other skills amongst commissioners. The King's Fund told us:

    More recently, renewed emphasis on how to make commissioning effective has led to a series of review studies. Each supports the view that the commissioning function has yet to reach full maturity and that those responsible for it lack many of the necessary skills required.[83]

Clinical Knowledge

81. One of the key weaknesses described in evidence is the lack of clinical knowledge in PCT commissioning. Dr Brambleby stressed the importance of ensuring that commissioning decisions were based on a sound medical evidence.[84] Unfortunately, numerous submissions highlighted PCT's lack of clinical knowledge and the negative impact that this had on patient care.

82. Although PCTs have public health physicians (albeit in declining number), they often do not have the capacity to deal with clinical specialists whose knowledge base is far superior. For instance, the fpa argued that commissioning for sexual health could be extremely complex.[85] But a review of the National Strategy for Sexual Health and HIV in 2008 found that a quarter of sexual health and HIV commissioners had been in their posts for less than a year and 11% of posts were vacant.[86] In addition commissioners responsible for sexual health were often not sufficiently senior to have influence and many had responsibility for a range of competing commissioning roles. BASHH (British Association for Sexual Health and HIV)had come across commissioners who clearly had little or no knowledge of how services were run let alone what patients' needs were.[87]

83. Several other submissions raised concerns about poor clinical knowledge, including Heart UK, the Royal College of Midwives, the National Rheumatoid Arthritis Society, the Urology Trade Association, Wakefield Local Pharmaceutical Committee, the British Dental Association and MEND.[88] The Royal College of Psychiatrists thought individual commissioners often lacked a broad enough knowledge of mental health services: "They may have responsibility only as part of a portfolio, or be in a temporary role. They may have no direct contact with provider services".[89] Neurological Commissioning Support argued that neurological conditions were complex and many PCT commissioners did not have sufficient knowledge or expertise to plan these services in a way that fully met WCC competencies.[90]

84. Professor Ham informed us of the lessons he learnt from a visit to Marks and Spencer's HQ in the early 1990s and contrasted that company's staffs' knowledge of their products with PCTs' knowledge of the services they commissioned:

    the people who were doing the buying for Marks & Spencer had a history, a career, an expertise in the things that they were responsible for buying. They had worked in food, industry, the clothing sector; they brought that deep knowledge and they were adding value to the suppliers of Marks & Spencer because they themselves were experts. Look at who we have in PCTs. Do we have expert GPs and clinicians across a range of specialties who have got the same depth of knowledge? No, we do not. That is why we have the difficulties we do.[91]

85. Some witnesses, such as BUPA, argued that the way to improve clinical knowledge was to involve more clinicians in core day to day commissioning activity which could result in more appropriate care being delivered more consistently.[92] Others emphasised the need for non-clinical PCT staff to glean more clinical knowledge.[93]

Training

86. Several submissions highlighted the need for better training for commissioners. The Royal College of General Practitioners argued that commissioners required education and training to equip them with the skills required to deliver appropriate services to patients.[94]

87. The Alzheimer's Society raised concerns that commissioners had insufficient understanding of what good dementia care was and called for them to be involved in multi-disciplinary training so that they could commission appropriately.[95]

88. MEND argued that there is an urgent need for training in the basics, such as how to commission a service and how to assess value for money.

    PCT management and staff have had much organisational, cultural and process change foisted upon them in an uncoordinated, inconsistent and unclear manner. They have received insufficient instruction, guidance and training and support in many fundamental areas.[96]

Turnover of staff

89. A compounding factor in the lack of skills was the high turnover of staff. Neurological Commissioning Support told us:

    an added challenge and frustration for patient involvement in commissioning is the regular turnover of commissioning staff and the resulting loss of organisation knowledge and history of commissioning decisions.[97]

Professor Ham observed:

    There is [...] a lot of turnover in Primary Care Trusts of the people who have those commissioning responsibilities compared with much more stability on the provider side. I remember talking to a very experienced manager in a large Acute Trust in London two or three years ago who had been in that post for about ten years, was very experienced and able, and her reflection was that the commissioners that she negotiated with chopped and changed about every 12, 18 months, were generally quite junior people making their career very bright but were not in post long enough to be able to take on commissioning effectively.[98]

QUALITY AND STATUS OF COMMISSIONERS

90. There is also clearly a weakness in the quality of management. We were informed that commissioners were not sufficiently professional.[99] It appears that most good quality managers are attracted to work in big hospitals where the pay is better. The King's Fund said:

    it has proved difficult to recruit the brightest and best into the commissioning side of the NHS with senior positions in the acute sector attracting higher pay and status.[100]

Dr Dixon told us that commissioners:

    have not been able to settle and develop talents and a lot of managerial talent resides in hospitals and not in PCTs.[101]

Professor Ham informed us:

    The reasons for the slow development of commissioning include...the lack of staff with the skills needed to commission health care to a high standard, and the greater attractions for many of the top managers and clinical leaders of working for provider organisations like Foundation Trusts (in itself linked to the higher salaries and rewards available in these organisations). For these reasons, it remains doubtful whether world class commissioning can be implemented in the timescale demanded by impending NHS financial constraints.[102]

91. The Department itself acknowledged that in the past:

    commissioning had often been seen within the NHS as a less attractive career options and of lower status than managing acute NHS Trusts, and consequently the calibre of leadership was often weaker, particularly at middle management level.[103]

DH policy development

92. Several witnesses, including Professor Ham, Mr Stout and Mr Belfield, told us that in recent years the DH had focused on policies to improve the provider side of the English healthcare system, but neglected to develop policy for the commissioning side. Professor Chris Ham said:

    in the Health Reform programme as a whole a lot of the early emphasis was placed on the development of new kinds of providers like the Foundation Trusts and the ISTCs; only latterly has the same focus been put on the commissioners, both PCTs and Practice Based Commissioners through the World-Class Commissioning programme, and I am sure we will discuss that in more detail, so there was that late start in recognising that a lot needed to be done alongside the development of providers.[104]

This view was reinforced by Mr Stout, of the NHS Confederation:

    The Prime Minister's Delivery Unit did a review in 2007 on commissioning and basically concluded that there was not a clear story of what commissioning was. There was not a proper programme of support there. We are starting to combine policy levers that are designed for commissioning and a programme that supports the development of skills and capacity within commissioners to use those tools. That is why it has been weak but also why it is now strengthening.[105]

93. Mark Britnell, formerly of the DH, told the Committee:

    My analysis, as I came into the post back in the summer of 2007, was that if people did not know what was expected of commissioners, it was almost impossible to professionalise them as a class of managers or clinicians.[106]

Effects of NHS reorganisations

94. We heard that the numerous NHS "redisorganisations" of recent years have tended to disrupt the work of commissioners and undermine their effectiveness.[107] Dr Dixon, of the Nuffield Trust, told us:

    there has been a lot of organisational turbulence amongst commissioners over time. They have not been able to settle and develop talents[108]

We likewise heard from the King's Fund that:

    lack of a skill base has been compounded by constant reorganisation. Skills and knowledge that were built up have been lost and fragmented as organisations have been forced to repeatedly reinvent themselves. Moreover it has proved difficult to recruit the brightest and best into the commissioning side of the NHS with senior positions in the acute sector attracting higher pay and status. Although relationships vary there is often an adversarial component to the commissioner/provider split and this has not helped PCTs to engage with secondary care clinicians.[109]

IMBALANCE OF POWER AND LACK OF LEVERS

95. The evidence we received indicated that, even in the absence of the factors so far identified, PCTs would still struggle to make an impact as commissioners since there is a seemingly perennial imbalance of power between providers and commissioners. When the purchaser/provider split was introduced it was intended that purchasers would have the power that customers are supposed to have in real markets, where "the customer is king." However, it is often argued that, in practice, power has mainly resided with NHS providers. Dr David Colin-Thomé, the National Clinical Director for Primary Care at the DH, agreed that providers had retained a "dominant position" and admitted that "maybe we have made it worse" by being "obsessed by the provider side" in policy development.[110]

96. The King's Fund, citing findings from joint research with the University of Birmingham, explained how various strands of DH policy had seemingly combined to inhibit effective commissioning by PCTs:

    For elective care, the payment by results tariff, patient choice and the "any willing provider" requirement mean that PCTs have little control over what they pay or where patients are treated while quality standards are set nationally. The increasing concentration of some services in specialist centres effectively creates more local monopolies and large acute hospital trusts can be even more dominant in their local provider markets […] The ability of commissioning to be an effective lever for change has, therefore, yet to be proven.[111]

97. A key problem is that it is difficult for PCTs to control the volume of hospital activity in their local health economies, which Payment by Results (PbR) has served to exacerbate, since constraints on activity have been removed and tariffs are fixed nationally.[112]

98. There is a widespread view that, in order for commissioning to be more effective, it needs more powerful financial levers with which to assert control over providers. Professor Bevan argued that:

    Effective commissioning ought to: ensure that patients are treated safely and appropriately across the care pathway; put pressure on providers to improve quality and reduce cost; make hard choices that optimise outcomes for populations within available budgets. This requires good systems to set priorities prospectively and assess performance retrospectively. Effective commissioning challenges provider dominance, may threaten the stability of poorly-performing providers and is undermined if government nullifies such challenges and threats.[113]

Professor Street told us:

    ensure that PCTs have the levers and instruments available to them to give them budgetary control.[114]

99. The DH concedes that in the past "the necessary system levers and enablers were not in place to support, resulting in unbalanced relationships and influence between providers and commissioners".[115] However, as we discuss in Chapter 6, the Department is taking various steps that it believes will give PCTs the necessary degree of leverage over providers.

Practice Based Commissioning

100. The evidence that we received from PCTs indicated confidence in the success of PBC, albeit with some admission that the policy was slow in taking off.[116] The National Primary Care Research and Development Centre (a DH-sponsored unit at the University of Manchester) also offered a largely optimistic account of the impact of PBC. According to the Centre's research, there is considerable engagement with PBC among GPs with positive impacts, including: the development of new services, engagement in the redesign of patient pathways, the development of systems to review and reduce hospital referrals and a new willingness amongst GPs to engage with peer review of performance. The Centre did, though, also outline areas of difficulty, including: calculation of budgets and savings; managerial and information support; integration of PBC into the wider commissioning agendas of PCTs; and patient and public involvement. The potential longer term impact of PBC in affecting the pattern and delivery of local services, we were told by the Centre, "depends upon the extent to which PBC becomes integrated with the wider commissioning agenda of the PCT". This requires PCT managers to be prepared to cede some control and to provide managerial resources and GPs to engage beyond their "comfort zones" addressing population health needs and taking managerial responsibility.[117]

101. The King's Fund's 2009 survey of PBC found that commitment to PBC was high and that progress had been made towards developing formal agreements and structures.[118] However enduring problems remained including:

  • Confusion over roles
  • Low engagement among clinicians
  • Lack of clarity over purpose and vision of PBC at a local level
  • Delays in decision making at PCT level.

102. One particular finding was that getting ideas commissioned by PCTs was a slow task, rarely being achieved within the eight weeks specified by the DH. Twenty-nine per cent of respondents who submitted a business case said that on average it took more than 25 weeks to get approval; 35% said it took more than 25 weeks; and in almost half of all cases it took almost a year from a business case being submitted to service change taking place. The King's Fund argues these results suggest that cumbersome bureaucracy (and "disproportionate governance processes") remains a problem in fostering PBC.

    Research has revealed that PBC has largely brought about small-scale projects involving the re-provision of elements of services outside hospital rather than large-scale strategic redesign. This is largely because the incentives embedded within PBC reward GPs for short-term gains and do not encourage longer-term investment. Thus far, PBC has not demonstrated that it can advance commissioning, especially of secondary care, and it is therefore not clear that PBC provides value for money.[119]

103. The DH admitted in evidence that PBC was "patchy".[120] Dr Colin-Thomé went much further in an interview late last year, stating that DH efforts to reinvigorate PBC did not seem to be taking off and concluding: "I think the corpse is not for resuscitation. There doesn't seem to be much traction."[121] When we questioned him about this, however, he insisted that he had only been asking a rhetorical question ("Are we trying to reinvigorate a corpse?") and had been somewhat mis  quoted.[122]

104. Professor Ham argued that PCTs had been slow to encourage GPs to get involved. He also questioned whether the incentives were strong enough to encourage them to do so.[123] Dr Dixon, of the Nuffield Trust, told us that the lack of a "hard budget" (i.e. allowing GPs to control funds directly, as occurred with Fundholding) was key to understanding seeming GP apathy about PBC.[124]

105. Dr Pauline Brimblecombe, who is herself a practice-based commissioner, argued that GPs needed to pool their resources in "clusters" in order to have the requisite managerial skills and public health information to be able to commission effectively.[125]

Conclusions

106. There are examples of good work being undertaken by PCTs. However, many PCTs believe they are working effectively although the evidence would suggest otherwise.

107. As the Government recognises, weaknesses remain 20 years after the introduction of the purchaser/provider split. Commissioners continue to be passive, when to do their work efficiently they must insist on quality and challenge the inefficiencies of providers, particularly unevidenced variations in clinical practice.

108. Weaknesses are due in large part to PCTs' lack of skills, notably poor analysis of data, lack of clinical knowledge and the poor quality of much PCT management. The situation has been made worse by the constant re-organisations and high turnover of staff.

109. Commissioners do not have adequate levers to enable them to motivate providers of hospital and other services. We recommend the Department commission a quantitative study of what levers should be introduced to enable PCTs to motivate providers of services better and a review of contracts to ensure that rigid, enforceable quality and efficiency measures are written into all contracts with providers of health care.

110. The Government has introduced new initiatives with the intention of improving commissioning. On the other hand, the situation may have been made worse by inconsistent Government policies which have tended to undermine the attempts to create powerful commissioners. These issues are discussed in the following chapters.


53   Ev 251, Ev 261 Back

54   The State of Healthcare and Adult Social Care in England: key themes and quality of services 2009. Care Quality Commission. Back

55   COM 119 Back

56   COM 119, para 1.9 Back

57   Ev 32, Ev 60, Ev 64 and Ev 124 Back

58   Health Service Journal, 5th March 2009 Back

59   Q 71 Back

60   Ev 251 Back

61   Health Committee, Sixth Report of Session 2008-09, Patient Safety, HC 151-I Back

62   Q 503 Back

63   Department of Health, Our Health, Our Care, Our Say, 2006 Back

64   Audit Commission, More for Less: Are productivity and efficiency improving the NHS?, November 2009 Back

65   Ev 283 Back

66   Q 338 Back

67   Q 335 Back

68   Science and Technology Committee, Fourth Report of Session 2009-10, Evidence Check 2: Homeopathy, HC 45, para 12 Back

69   Ev 158, 166 Back

70   Health Service Journal, 9 October 2008 Back

71   Ev 287 Back

72   Ev 252 Back

73   Ibid Back

74   Ev 287 Back

75   Q 75 and Q 76 Back

76   Ev 53 Back

77   Ev 90 Back

78   Ev 190 Back

79   Ev 227 Back

80   Ev 291 Back

81   Q 309 Back

82   Q 499 Back

83   Ev 252 Back

84   Q 220 Back

85   Ev 91 Back

86   MedFASH, Progress and Priorities: working together for high quality sexual services - Review of the National Strategy for Sexual Health and HIV (London: Independent Advisory Group on Sexual Health and HIV, 2008) Back

87   Ev 240 Back

88   Ev 45, Ev 53, Ev 63, Ev 130, Ev 137, Ev 227 and COM 120 Back

89   Ev 291  Back

90   Ev 297 Back

91   Q 514 Back

92   Ev 189 Back

93   Ev 53 and Ev 91 Back

94   Ev 282 Back

95   Ev 238 Back

96   COM 120 Back

97   Ev 297 Back

98   Q 499 Back

99   Q 75 Back

100   Ev 252 Back

101   Q 499 Back

102   Ev 331 Back

103   Ev 3 Back

104   Qq 71, 74, and 499 Back

105   Q 74 Back

106   Q 83 Back

107   Ev 15 Back

108   Q 499 Back

109   Ev 252 Back

110   Q 73 and Q 74 Back

111   Ev 252 Back

112   Q421 Back

113   Ev 335 Back

114   Q 179 Back

115   Ev 3 Back

116   Qq 343, 366, 418 Back

117   Ev 86-90 Back

118   The King's Fund, PBC two years on: Moving forward and making a difference?, July 2009 Back

119   Ev 252 Back

120   Q 153 Back

121   Health Service Journal, 14 October 2009 Back

122   Q 153 Back

123   Q 534 Back

124   Ibid Back

125   Q 460 Back


 
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