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. 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.
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
Box 5: Findings of NAO Telephone Survey
of PCT Commissioners, January 2010
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.
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.
63. The 2009 World Class Commissioning assurance
process confirmed that the quality of commissioning by PCTs was
largely poor to mediocre.
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
- Failing to improve the quality of services
- Failing to change patterns of service provision
PASSIVITY VIS &AGRAVE; VIS PROVIDERS
65. In the first evidence session, officials from
the Department admitted to the Committee that commissioning was
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.
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.
FAILURE TO IMPROVE THE QUALITY OF
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.
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.
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. 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.
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).
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
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
The Science and Technology Committee was informed during its recent
inquiry into homeopathy that West Kent PCT had decommissioned
However, PCTs appear to find decommissioning hard and there is
a tendency to commission what has always been done.
A survey by the Health Service Journal revealed that in
2007 the majority of PCTs had failed to decommission any services.
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 needfor
example in our most recent review of statin prescribing, stop
smoking services and cardio vascular disease.
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.
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.
75. The CQC criticised the assessment and monitoring
of providers by PCTs:
Our reviews highlight how performance data could
be better utilised by commissioners to drive continuous improvementfor
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.
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.
The fpa (formerly the Family Planning Association) argued that
commissioning for sexual health was not supported by the strong
data required. BUPA
highlighted the need for more emphasis on data and information
acquisition to give managers the tools they needed to manage demand
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.
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.
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.
79. Dr Jennifer Dixon, Director of the Nuffield Trust,
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.
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.
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.
Unfortunately, numerous submissions highlighted PCT's lack of
clinical knowledge and the negative impact that this had on patient
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.
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. 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.
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.
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
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.
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.
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.
Others emphasised the need for non-clinical PCT staff to glean
more clinical knowledge.
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.
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.
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
Turnover of staff
89. A compounding factor in the lack of skills was
the high turnover of staff. Neurological Commissioning Support
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.
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.
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
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.
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
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
91. The Department itself acknowledged that in the
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.
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.
This view was reinforced by Mr Stout, of the NHS
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.
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.
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.
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
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.
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.
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
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.
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
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
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.
Professor Street told us:
ensure that PCTs have the levers and instruments
available to them to give them budgetary control.
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
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.
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.
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.
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.
103. The DH admitted in evidence that PBC was "patchy".
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."
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.
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.
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.
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
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
53 Ev 251, Ev 261 Back
The State of Healthcare and Adult Social Care in England: key
themes and quality of services 2009. Care Quality Commission. Back
COM 119 Back
COM 119, para 1.9 Back
Ev 32, Ev 60, Ev 64 and Ev 124 Back
Health Service Journal, 5th March 2009 Back
Q 71 Back
Ev 251 Back
Health Committee, Sixth Report of Session 2008-09, Patient Safety,
HC 151-I Back
Q 503 Back
Department of Health, Our Health, Our Care, Our Say, 2006 Back
Audit Commission, More for Less: Are productivity and efficiency
improving the NHS?, November 2009 Back
Ev 283 Back
Q 338 Back
Q 335 Back
Science and Technology Committee, Fourth Report of Session 2009-10,
Evidence Check 2: Homeopathy, HC 45, para 12 Back
Ev 158, 166 Back
Health Service Journal, 9 October 2008 Back
Ev 287 Back
Ev 252 Back
Ev 287 Back
Q 75 and Q 76 Back
Ev 53 Back
Ev 90 Back
Ev 190 Back
Ev 227 Back
Ev 291 Back
Q 309 Back
Q 499 Back
Ev 252 Back
Q 220 Back
Ev 91 Back
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
Ev 240 Back
Ev 45, Ev 53, Ev 63, Ev 130, Ev 137, Ev 227 and COM 120 Back
Ev 291 Back
Ev 297 Back
Q 514 Back
Ev 189 Back
Ev 53 and Ev 91 Back
Ev 282 Back
Ev 238 Back
COM 120 Back
Ev 297 Back
Q 499 Back
Q 75 Back
Ev 252 Back
Q 499 Back
Ev 331 Back
Ev 3 Back
Qq 71, 74, and 499 Back
Q 74 Back
Q 83 Back
Ev 15 Back
Q 499 Back
Ev 252 Back
Q 73 and Q 74 Back
Ev 252 Back
Ev 335 Back
Q 179 Back
Ev 3 Back
Qq 343, 366, 418 Back
Ev 86-90 Back
The King's Fund, PBC two years on: Moving forward and making a
difference?, July 2009 Back
Ev 252 Back
Q 153 Back
Health Service Journal, 14 October 2009 Back
Q 153 Back
Q 534 Back
Q 460 Back