Examination of Witnesses (Questions 1
- 19)
THURSDAY 22 OCTOBER 2009
PROFESSOR GWYN
BEVAN AND
DR HAMISH
MELDRUM
Q1 Chairman:
Good morning, gentlemen. We are just a few minutes early, but
we thought, given that we are ready, that we could start the session.
Could I ask you, first of all, if you would give us your name
and the current position that you hold for the record, please?
Dr Meldrum:
I am Hamish Meldrum; I am still a practising GP and, last time
checked, still Chairman of the Council of the BMA.
Professor Bevan: I am Gwyn Bevan,
Professor of Management Science at the London School of Economics.
Q2 Chairman:
Thank you. Welcome to what is our first evidence session on our
commissioning inquiry. I have got a big ask for you here, because
I would like both of you to tell me what you understand by the
word "commissioning" in one sentence. I do not know
who would like to attempt to try it.
Dr Meldrum: I will try. To me
commissioning is assessing the health needs of the population,
discussing with all interested parties how you are going to deliver
these needs and then assessing how well you have succeeded in
that task.
Professor Bevan: I would say it
is about ensuring appropriate high quality care across the patient
pathway; ensuring providers improve quality and reduce cost; and
making hard choices for the population to achieve the best health
benefits within a limited budget.
Q3 Chairman:
What is the role of commissioners in contracting for healthcare
services in the English NHS in 2009?
Dr Meldrum: First of all, you
have got to define what commissioners are and, as I gave in my
definition, I do not believe they are just people who purchase
packages of healthcare. Going back to my definition, I think all
those who are involved in the delivery of care and in the receipt
of care, so that mean the patients as well, should be involved
in particularly the local decisions that are going to be made
about the quality and standard of the way of providing that healthcare;
so I think there is a key role for commissioners in any healthcare
system. I am sure we will get on to discuss some of the particular
situations that apply in the English healthcare system at the
moment compared with, say, Scotland or other countries.
Professor Bevan: There is a difficulty
here between the principles we would like to see achieved by commissioning
and the practice of commissioning, and actually the evidence is
that, in practice, commissioning is not done very well. We have
been trying to do it in England, I would argue, since 1974 without
a purchaser-provider split, with a purchaser-provider split and
the evidence from other countries is that it is not done very
well there either. I think behind your question is this paradox
as to why is it, when you look at what the Department of Health
has called the common instances of "world-class commissioning"
that I say are the aspirations we would like to have achieved,
many of them we would agree to, but they are so hard to realise
in practice. I think that is the paradox.
Q4 Chairman:
Would you like to tell us what you think personally the three
main effective areas in commissioning are as we stand at the moment?
What are the main characteristics of effective commissioning?
Dr Meldrum: Obviously, I think
you have to get best value for money from limited resources but
also to try to achieve the highest quality healthcare. I would
agree with Gwyn that I do not think in many places it is or has
been terribly well done. My feeling is that one of the reasons
for that is that we have not managed to get all the parties who
should be involved in these decisions around the table, and we
have tended to do it in a rather fragmented and sometimes almost
confrontational way rather than in a collaborative way, which,
I believe, is the only way that you are likely to reach the best
decisions and get the best value and end up with proper joined-up
care rather than fragmented care.
Professor Bevan: Again, it seems
to me it goes back to this paradox. If you describe it as effective
commissioning, we describe an ideal that we would like to see
and then what we see on the ground is a long way removed from
that. That is my short answer to that question.
Q5 Chairman:
When you talk about collaboration versus confrontation, do we
know what the arguments are, it is just that we cannot agree them,
or is there a dispute between these two organisations about what
we mean by effective commissioning?
Dr Meldrum: As you know, we have
never been a fan of the purchase-provider split, for a variety
of reasons. First of all, I do not think you can ever have a pure
split and coming from primary care general practice immediately
there we are both mixed purchasers and providers, to use that
term. Secondly, I think it does tend to put you almost in opposition,
the commissioner and the provider of the service, which is not
always helpful. I think actually where commissioning has been
well done they have almost ignored that split and they have worked
together despite that and reached common decision-making. I still
think that the basic environment of competition between providers
and, in that sense, having these discussions between a variety
of providers and the commissioner has not been particularly helpful
if you are going to get effective healthcare and you are not going
to get either duplication or, at times, gaps in the system.
Professor Bevan: I think there
are two related but different questions. One is the structural
organisation of healthcare which Hamish has referred to. It seems
to me you have to have a question. We have been trying to make
the purchaser-provider split work since 1991 with various different
models. None of them has looked very effective and countries that
have tried it, like Wales, Scotland and New Zealand, have abandoned
it and gone back to an integrated service. The other model that
I am attracted by interest in is in the Netherlands, where you
have purchasing competition, but that would allow integration
of primary and secondary care across the care pathway—so
the structural questions—and then there is a question as
to how would you get the collaboration that Hamish has referred
to. The work we have been doing at LSE with PCTs is a socio-technical
process where we get stakeholders, GPs, hospital doctors, patient
representatives and managers to look together at the hard choices
the PCT have to make, and in that collaborative process it is
possible to make the decisions we would like to see come out of
commissioning.
Q6 Charlotte Atkins:
From what you have both been saying, I get the impression that
you think commissioning has not been successful. Would that be
your view?
Dr Meldrum: At best it has been
very patchy. I think there are one or two areas where it has been
successful, and I think Gwyn has espoused some of the reasons
for that, but overall, generally (and this is not just over the
last few years but going back 20 years) I do not think it has
been. There have been various attempts with fund-holding, with
non fund-holding, commissioning, and such like, and in some areas
for some small parts of the system they may have worked, but as
an overall system of how to get the best value in healthcare for
populations, I do not think they have been terribly successful.
Q7 Charlotte Atkins:
Is there an evidence base which demonstrates that? As we say,
we have been trying since 1991 with the purchaser-provider to
get the right spec to get this issue right. One would assume there
would be some evidence, one way or the other, about whether commissioning
does get both best value and best service to the patient.
Dr Meldrum: I think Gwyn will
want to come in on this. There is such a huge range of evidence
that you can always find some evidence that will back up the argument
on one side or the other, but, as he mentioned, countries like
Scotland, Wales and New Zealand, having tried it, have gone back
because they find it wanting. Thirdly, I think if you are wanting
to engage with healthcare professionals and the public, then certainly
our evidence is that the majority of healthcare professionals
do not like working in this purchaser-provider split situation
and would prefer a more joined up, collaborative system of working,
and I think that is quite a key element if you are wanting to
make something work. I would add into that too that I think, particularly
as you have to make hard choices when money gets tight and you
have limited resources, if you do not involve the public fully
in those choices as well, then you are going to fail, because
you will get increasingly unrealistic demands on your healthcare
system that will be increasingly difficult to deliver.
Q8 Charlotte Atkins:
So is your position to leave it to the doctors and they will decide?
Dr Meldrum: No, it is not to leave
it to them. That is why I emphasised "the public" as
well. I think clinicians are key (and I do not just mean doctors)
as part of the process, but certainly do not just leave it to
the doctor. That is not what we are arguing.
Q9 Charlotte Atkins:
The BMA in the past has not been too keen on competition: health
centres, that sort of thing, to compete with the GP. Is your concern
about commissioning that it does actually open up competition
for the GP or for doctors?
Dr Meldrum: I do not think commissioning
of itself opens up competition. In some ways, I suppose, we are
arguing about what sort of competition. I and most of the people
I represent believe that doctors and other clinicians want to
know how good a job they are doing, and in that sense will want
to compete, as professionals, with other professionals to make
sure they are doing as well, if not better than, their colleagues
down the road. That is different, though, to having a system where
you have both a split between purchaser-provider and you have
competing providers bidding to provide services, and you have
got all the bureaucracy. You have got to add into that system
transaction costs, putting in budgetary bids and all that sort
of thing too, which seems to add to the cost but also, I think,
does not help. There is not much evidence that it has really improved
quality. The idea of the split and Simon Stevens' view of creative
discomfort was that you would drive up quality and drive down
the costs. I do not think there is a lot of evidence that that
has happened.
Professor Bevan: In terms of evidence,
you would like to have a controlled experiment, and people did
actually advocate that when Kenneth Clarke introduced the internal
market in 1991 and the Government set its face again that. Another
kind of evidence comes from the way in which successive governments
have tried to get to it work: in 1974, for the first time, organisations
were created that had responsibility for what we describe as commissioning.
Before that you just had a hospital run, essentially, NHS and
the idea of the purchaser-provider split in 1991 was that the
then district health authorities that were responsible for both
running hospitals and planning services for the population would
be freed of this dominance of providers, the concerns of purchaser-provider
interest, free to properly undertake needs assessment of the population
and shape services for that. Then the evidence is the internal
market that ran from 1991 to 1997 was not very successful. Hence,
the Labour Government decided get rid of the idea of competition
but maintain the purchaser-provider split, and the rhetoric was
all about collaboration in place of competition, and that was
called the third way. It was felt that was not working terribly
well, so they then introduced star ratings, which I was involved
with when I worked for the Commission for Health Improvement,
which did do dramatic things in terms of reducing waiting times.
Although there are critics, I think it was beneficial to the NHS.
Then they thought that was too top-down, and so we have gone back
to competition again. Then, last year, the Audit Commission and
Healthcare Commission did an evaluation of the whole package of
system reforms and found them disappointing and pointed out that
that commissioning remained weak. This is the thing that is so
frustrating. After having tried to do this for about 34 years,
the auditors go in and look at it and still find it weak on the
ground.
Q10 Charlotte Atkins:
Is that because we are expecting too much of our commissioners?
We do not put enough resources into commissioning, whether in
terms of building up skills or in terms of giving PCTs the resources
to do it. What is the problem?
Professor Bevan: I think there
is this real difficulty at the heart of the whole process. It
follows on from your earlier questions to Hamish. Basically, the
idea of commissioning is the world will be a different place,
from if they were not there and we just funded providers for what
they do; but the politics of the whole process is that challenging
providers is deeply unpopular, and so it is very hard to get strong
political support for making unpopular decisions that challenge
providers. There is another difficulty, which is that typically
we do not have the data. Doing these assessments is incredibly
difficult to do. We do not have the data we need to do that. PCTs
typically lack the skilled staff and expertise to do this properly.
You have evidence of successful examples of commissioning that
tends to be done in collaboration with outsiders. I think the
other problem is what size should they be? Recently we had 200
district health authorities. They are felt to be too small. You
create 90 health authorities and then 480 primary care groups
within health authorities. You then think primary care groups
are too small, so you create 350 large PCTs and abolish health
authorities. You then think 350 PCTs are too small, and so it
goes on. There is this continued tension as to, on the one hand,
what we would like to have, which is the sort of romantic view
I use to have of GP fund holding, of GPs in touch with their population
knowing what they need and shaping services according to that,
for which you want a small cottage industry, as in GP fund holding;
but then the skills and expertise you need for needs assessment
across the population needs a much bigger organisation.
Q11 Charlotte Atkins:
Is it because the balance of power is wrong that the commissioners,
if they are the PCT, are less powerful than perhaps the acute
hospital, particularly if they have to stick to the normal contract
anyway, and that there is this problem that the commissioner really
has not got the power to control what the hospital does?
Dr Meldrum: I think that part
of the problem (and I think it is part of the problem inherent
in the system) is that, unless you have an almost equal balance
of power between commissioners, or purchasers in this case, if
you are using the purchaser split model, on the one hand and providers
on the other, then it is not going to work terribly well, but
the likelihood of ever achieving that balance and maintaining
that balance so that actually either commissioners do not become
too powerful or providers do not become too powerful is very remote.
I think that is part of the problem. I certainly agree with Gwyn
that what also has not helped has been continual organisational
change and that actually people who at the same time have been
trying to deliver commissioning have been wondering whether they
are going to be in a job next week, or which organisation they
are going to be in, or who is actually responsible for doing this.
So I still think the basic philosophy behind the policy is wrong,
but there have been huge issues about the practical implementation
that have made it even worse.
Professor Bevan: I think you have
put your finger on a fundamental difficulty in the process, which
is that in a sense we would like effective commissioning but we
would like it in a painless way that does not upset the providers.
It does seem to me, if you think about the big London teaching
hospitals and the esteem and respect in which their chief executives
are rightly held, the idea that their local primary care trust
will somehow shape what they do I just find very hard to believe.
Charlotte Atkins: Sometimes it is better
to ensure (if you are not talking in London terms, because I think
London is a different picture), where you have a local acute hospital,
it should be delivering better services for the population more
geared to the needs of that population rather than what they fancy
doing.
Q12 Chairman:
Professor Bevan, we did look at the latest reorganisation of primary
care trusts a number of years ago now, and that was based on trying
to align health and social care in terms of the statutory body
local authorities. Do you think that was a right and proper way
of changing the size of PCTs at that time? Did you have a look
at this?
Professor Bevan: I remember when
I worked for the Commission of Health Improvement, it was about
mental healthcare, and this problem came up, exactly that—the
mental health provider saying, "We cover a number of different
local authorities"—but you also had a problem that,
because of the scale of the psychiatric services, some of them
carried a number of local authorities anyway, so it is always
hard to pitch it right. I think the sort of problem at the heart
of it is your heart sinking at yet another NHS reorganisation.
That is the overall reaction to that.
Q13 Dr Naysmith:
Both of you have just said in your replies to this little bunch
of questions that you did not think competition was essential
to this process, but surely it must be. If a commissioner does
not have the ability to take a service away, even from a big London
teaching hospital, then it has not got any levers to do anything.
I am not saying it is necessarily the cheapest, but even if you
are looking at quality, you have to have some lever, and that
means an alternative if you are going to say, "We do not
like the way you are doing this service. We are going to ask somebody
else to do it."
Professor Bevan: Absolutely. I
absolutely agree with that. I think there are these two different
models you could have of that. One is, as I say, the Dutch model,
where the commissioners become quite large insurers covering the
population, so they would have the expertise you would need to
do this job, and people can choose which insurers they use, and
there is movement of about 3% a year between different insurers.
So they are kept on their toes to make sure they are trying to
do things to improve provision in terms of quality and reducing
cost, and that is one model of doing that.
Q14 Dr Naysmith:
That involves competition.
Professor Bevan: That involves
competition. The other model that I am attracted by would be,
as within an integrated NHS, which has developed in a region in
Italy, in Tuscany, where they have linked up with an elite academic
centre at Pisa and they regularly report performance of their
integrated local health units at meetings with chief executives
and they publish this performance. I think someone referred to
peer group pressure but, basically, no-one wants to be bottom
of any ranking system when it is displayed in that way, and you
have people in the same room who are doing well and who are doing
badly and those who are doing badly can find out from those who
are doing well how to improve; but the thing is that to do that
within the NHS would involve, it seems to me, going back to creating
something like regional health authorities and real regional presence,
and the reason why Wales and Scotland find this easy to do is
because their government is, in effect, a regional presence.
Dr Meldrum: I do not think you
need necessarily competition of the type that people often think
of to achieve the right results. As I said earlier, I think clinicians
want to know how well they are doing and they use these data to
help them improve. I may have given you this example before, but
I look at what happened to diabetic services in my area 20 years
ago when an enlightened consultant came in and when 95% of diabetic
care was taking place in the hospital. He wanted move it out to
the community, so he got all the players—GPs, the hospital,
patients—together to decide what would be good services,
and over time the right training was done and there was a service
shift. I am not sure, under the present model of commissioning,
whether that would happen: because his trust would have said,
"Hang on, you cannot go out there and actually flog off,
essentially, part of our services and our income. We do not want
you to do that." In that sense, I think the market works
against actually achieving good joined-up care. If you then add
into that equation too the fact that some people's idea of competition,
looking at, say, transforming community services, is to have lots
of independent providers of, say, dietetics, district nursing,
of diabetes specialist nursing, then you have an even more fragmented
service.
Q15 Dr Naysmith:
I do not disagree with that at all, Hamish, I am just suggesting
that if you have got the present system of commissioning, I do
not see how you can make it work without having alternative providers,
which means competition. You can organise it all totally differently,
but that is not really having PCTs, is it?
Dr Meldrum: Yes, but the competition
model goes only so far. We have never really addressed what we
do with so-called failure in the NHS. It is almost impossible
for you to close down a hospital or close down a unit that is
not doing well. There are a whole lot of political and other things
that intervene when you try to do that. So I think you have to
primarily look at how you are going to work together to improve
services. Again, it has always seemed to me rather perverse that
if somewhere is not performing very well, you say, "Okay,
next year we will give you less money and that will make you perform
better." You have actually got to analyse why they are not
performing well, and it may actually be because they have not
got sufficient investment. So it is a very crude tool, it seems
to me, to try and achieve improvement.
Mr Bone: I notice the bells are not working.
They have not rung. So there will not be any audible notices of
things to say you have to watch the monitor.
Chairman: Thank you, Peter. It is a bit
worrying because I was told it was connected to the fire alarm
system as well, so just watch me!
Q16 Dr Taylor:
So far I have got a pretty bleak opinion of commissioning, and
one of the questions in our terms of reference was: has the purchaser-provider
split been a success and is it needed? I want to try and dig out:
have there been any advantage of commissioning? Can you pick out
any advantages of commissioning?
Dr Meldrum: Richard, I agree that
I have certainly been a bit bleak about the present system, but
I do not equate commissioning with the purchaser-provider split.
It has become almost a shorthand thing for purchasing. Actually
the definition I gave you right at the beginning, I believe, is
much greater than that. Any healthcare system will have to commission,
but that does not mean you have to have a purchaser-provider split
to do that. If commissioning is deciding how you are going to
provide healthcare services, whatever system you have got you
have to do that. We had commissioning, although we did not call
it that, before 1991 and the purchaser-provider split, in the
sense that we did sit down and decide where we needed services,
what sort of level of services we wanted, whether hospital A was
going to provide them or hospital B was going to provide them.
We did it through block contracting mainly, but it was still a
form of commissioning. Actually what I am saying is that I do
not believe the present system, or the system that has been running
over the last 20 years, has been particularly successful. Yes,
there have been pockets of success, but I think they have been
in spite of the system that people have been asked to work within
rather than because of it.
Q17 Dr Taylor:
I would agree that commissioning has always existed, so really
the question is different. Is it since the purchaser-provider
split that things have not worked?
Dr Meldrum: I certainly do not
feel they have worked any better, and in many areas I think they
have been worse. I think also it has been costly, both in money
and human resource terms, because there is quite a lot of work
that needs to be done to make the sort of purchaser-provider split
we have had try to work and, as we said earlier, unless you have
got some balance between purchasers and providers too, that is
another added problem. So when you add in transaction costs, when
you add in all the reorganisations and various other things, I
do not think we have made best use of the growth in NHS money
that we have seen over the last few years.
Professor Bevan: There are two
different ways in which you might put this. This is hardly giving
evidence, but before 1991 there was a problem with district health
authorities running services and planning for their population.
It certainly felt that running services took over this broader
commissioning role. I was involved with the first wave of GP fund
holders, and although the evidence is that only a few of them
had a significant impact, it did feel like a breath of fresh air
in the NHS, where GPs would talk to hospital doctors about how
they had changed services. I suppose it is just things that stick
in the mind. In one hospital you could not get to see the physiotherapist
unless you had seen the orthopaedic surgeon, and there was a three-year
waiting list to see the orthopaedic surgeon, and then the GP fund
holder, said, "This is not acceptable", and you were
allowed direct access to physiotherapy. The trouble is that this
little story hardly justifies the purchaser-provider split. If
you think about it in terms of what commissioning ought to do
is to challenge providers to do things differently, I would say
that the policy that has the biggest impact in terms of hard evidence
was the star rating process, but that had very little to do with
the purchaser-provider split, it had more to do with targets and
a process of publishing performance, and that is the sort of thing
I see them having developed in Tuscany on a regional basis for
things that matter locally there.
Q18 Dr Taylor:
In Tuscany they are really integrating?
Professor Bevan: Yes.
Q19 Dr Taylor:
Is that something we should be going back to?
Professor Bevan: I agree with
Hamish. I find it hard to believe the division between secondary,
primary and community care is a good way of organising things.
The evidence from the United States is that the high performing
providers of care, like Kaiser Permanente and Geisinger, indicates
that that is the model that they do to integrate care across a
care pathway.
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