Commissioning - Health Committee Contents


Examination of Witnesses (Questions 20 - 39)

THURSDAY 22 OCTOBER 2009

PROFESSOR GWYN BEVAN AND DR HAMISH MELDRUM

  Q20  Dr Taylor: As it is likely that we are rather stuck with the present system, what are the main weaknesses that we should be tackling?

  Dr Meldrum: I hope we are not stuck with the present system because, as we have been saying, we have had it for 20 years and, despite all the changes we have tried to do, it has not really worked. I would not want to say that we should tinker yet again with the present system and try and do something else with the present system to make it work because I think there is a fundamental flaw in the present system.

  Q21  Dr Taylor: So you are saying we should get rid of it altogether.

  Dr Meldrum: Yes.

  Q22  Dr Taylor: As they have done in Scotland?

  Dr Meldrum: Yes.

  Professor Bevan: I think there are these two models. There is a difficulty. If we move towards a wholly integrated system in which you have got the health authority, in a sense, contracting with GPs and hospitals as an integrated body, and if that was not done terribly well—and you had an inquiry into Mid Staffordshire just before the recess with really troubling things coming out of that about how things can go wrong with an organisation. In the United States, it is actually hard to believe, but they did a randomised controlled trial, allocating people with different insurance packages, with free care, paying user charges and integrated care, and they showed integrated care was the most cost-effective system; but then that led to the growth of health maintenance organisations and concerns over them under serving their local population. So I think that if you were to get rid of the purchaser-provider split, you are still going to have to have some challenge to those organisations and, as I say, you can either do it, it seems to me, as in the Dutch system, where people can move between different integrated organisations or you have an effective system of regulatory challenge to what is going on.

  Dr Meldrum: Can I add to that. I was not suggesting, when I said the very short "get rid of it", that we would go back to some so-called idyllic period in the sixties and seventies. I think you absolutely do need challenge within the system and, as I keep saying, I think that requires really good data about outcomes, including patient reported outcomes, which will challenge providers of care, not using it in the purchaser-provider sense, to ensure that they are doing as well if not better than their colleagues. To some extent we have seen in GP practice and in the quality and outcomes frameworks that actually colleagues want to know that they are doing as well if not better than their colleagues down the road, and I am sure if we can move towards better quality data and outcomes that is what will raise standards, that is what will provide the sort of grit in the oyster, the competition in the system, and if there are poor standards, that is what will make people look at the reasons for that and try to remedy that.

  Q23  Dr Taylor: So with better data and better skills in commissioning, could it work?

  Dr Meldrum: I still do not believe it will work with the present purchaser-provider split system.

  Q24  Mr Bone: It is all doom and gloom here at the moment, but in the past a lot of things that are now being done in GP surgeries were done in hospital.

  Dr Meldrum: Yes.

  Q25  Mr Bone: Surely that is as a result of PCT pressure to change things. Would that necessarily have happened if we had a different system? Has there not been some success?

  Dr Meldrum: I have been a GP, I am afraid to say now, for over 30 years, before purchaser-provider split really got going in that sense. There are shifts of care. I did work for three years as a hospital doctor, and certainly there were shifts of care taking place and taking place long before you did that, because actually clinicians and the public decided that was a better way to provide care. The idea that if you get rid of the purchaser-provider split you will get stagnation I do not think is true, because I think people will always be looking at new and innovative ways and cost-effective ways of providing care. I actually think these discussions will be easier to have in that non-confrontational, "You only want to talk about this because you want to take our money away", sort of environment, and actually you will get better decisions because of it. So I do not hold with the idea that, in order to create change, you need the purchaser-provider split.

  Professor Bevan: There was a very interesting study in the British Medical Journal a few years ago that compared Kaiser Permanente health maintenance organisation with the NHS, and they looked at the nature of service supplied, and what was striking was in the US health maintenance organisation there were far fewer hospital admissions than there were in the NHS, and that is an integrated organisation without a purchaser-provider split.

  Q26  Dr Stoate: I start with my usual declaration that I am a practising GP, a Member of the British Medical Association and a Fellow of the Royal College of GPs. Hamish, you have made some very interesting observations that you believe that the purchaser-provider split actually has not helped at all, and yet we do obviously have to have some form of commissioning to ensure that somebody decides what the needs of the population are, how they are best provided and which institution or unit is the best place to provide them. So there is no argument that we need commissioning, although the purchaser-provider split does seem not to have helped very much. What I want to do is to move on to the latest initiative to try and improve commissioning, which is this "world class commissioning". Do you think that has made any discernable difference at all to the situation?

  Dr Meldrum: I am conscious of who is sitting behind me, so I had better be careful what I say.

  Sandra Gidley: We would like the honest answer.

  Q27  Dr Stoate: On the record, the honest answer.

  Dr Meldrum: I do not think it has made a huge amount of difference, to be perfectly honest. I think it is an attempt to try to make a system that is obviously not working well work a bit better, and it may have helped if you can have better expertise, if you can decide on various other things that will help to maybe improve it, but I come back to my fundamental view, that I think the system is flawed. So whatever you do, or whatever you call it, I do not think you are really going to succeed, and there is certainly not much evidence—to be fair, we have only had "world class commissioning" for about a year or so—that there has suddenly been a great upsurge in uptake in commissioning either amongst GPs or by PCTs, or whatever. So, with all due respect to Mark, nice try, but I do not think it has really helped, and that is because I do not believe the underlying system is the right one.

  Q28  Dr Stoate: I accept that—that is a perfectly clear argument—but if we have to have commissioning, how would you like commissioning to look?

  Dr Meldrum: I go back to my collaborative model. Depending on which services you are discussing, you get the important key players in the provision of that service and the management of that service and the receivers of that service, and that includes the patients too, and you look at how it is being provided now, in what way might it be provided better, what are the challenges there, look at how other people are doing it, look at your results compared with other people and sit down in that collaborative atmosphere to work out whether or not you need to change and, if so, how you need to change.

  Q29  Dr Stoate: Gwyn, have you got the same view or a different view on that?

  Professor Bevan: I am conscious of Mark Britnell sitting just behind us.

  Q30  Dr Stoate: Do not worry about him; it is for us to worry about him.

  Professor Bevan: I hope he will talk to me afterwards. I think it is very helpful in laying out the aspirations of what we would like to see commissioners do, and it has articulated those extremely clearly. The difficulty, of course, is for PCTs to achieve those aspirations. We have talked about the many challenges that there are in doing that. It is about skills and expertise, and the research that we have been doing, funded by the Health Foundation, we think, is one approach that helps people do that. There is hope in this, but there is a long way to go to realise those aspirations.

  Q31  Dr Stoate: You do not think yet that "world-class commissioning" has made any difference either to patient care or to taxpayer value for money?

  Professor Bevan: It is not because Mark is sitting behind me, but I do not think I am in a good position to answer that question, because we have worked with just a few PCTs.

  Q32  Dr Stoate: I want to come on to CQUIN (Commissioning for Quality and Innovation Payment Framework). We all know that Payment by Results, effectively (and we have looked at this before) is hospitals putting up a sign in the car park saying, "Coach parties welcome". The more activity they do, the more money they get. Clearly, that is a flawed system, and CQUIN is designed to try and counteract that by at least measuring quality of outcomes rather than just activity. Hamish, do you think that has made a difference?

  Dr Meldrum: I think it is potentially a move in the right direction, because, as I said earlier, although we would probably advocate a system that would be nearer to block contracting, you would have to build in variation for that for both quantity and quality; but I do not think you can just purely use a crude financial lever to achieve that. As I said, I think when you find variable quality, that should make you ask more questions rather than just say, "Okay, it is not so good. We are going to pay you less", or, if it is better, "We will pay you more." Certainly, in terms of the idea that you want to try and monitor quality and get better data about quality, I am very much in favour of that, but I think, again, it is tagged on to this rather flawed system of Payment by Results, which, as you say, can have perverse incentives in it, and even though you built in quality to that, you may not necessarily be paying for the right quality in a particular service.

  Q33  Dr Stoate: Do you think that Payment by Results has undermined the commissioning process?

  Dr Meldrum: The short answer is, yes. The problem I have with Payment by Results is that you either have a very crude system where you have a relatively small number of resource groupings, in which case it is easy for certain providers to cherry-pick the easy cases, leaving the more complex ones to the NHS who have got intensive care facilities and such like, and get paid the same. So you either do that, or else you go down a much more complicated route where you have many, many more disease groups and payment groups, but, of course, the more you go down, the more sophisticated you make that, the more bureaucratic it becomes and the more you get more onto the American system where almost for every aspirin you have to put a tick in the balance sheet. So I think there is a real Catch 22 situation that actually, if you want to make it fairer, you have got to make it more bureaucratic. The more bureaucratic it is, the more costly it is to administer and to run and you will end up with administration costs of getting on to 30%, as they have in the American healthcare system.

  Q34  Dr Stoate: Do you have anything else to add to that, Gwyn?

  Professor Bevan: I think there are a number of things. There is the problem about just paying providers because they do activity. CQUIN is an attempt to remedy that in some way. Over the years I have been very impressed with the work that Jack Wennberg and colleagues have been doing at Dartmouth looking at variations in medical practice, and they have found extraordinary variations. They have done interesting work recently looking at care in the last two years of life in academic medical centres in the Unites States studying two-fold variations, and the spend in the last two years of life comes to about 30% of healthcare costs, and this is very significant. The cheapest provider is the Mayo Clinic, which has a reputation for very high quality care with lower use of intensive care and more patients dying at home. The general message from nearly all the Dartmouth work is that less is more. So you do not want to have a system that simply rewards activity. The whole point about these integrated care organisations is that is exactly what they are trying to avoid. CQUIN (and I am thinking aloud now really) feels like having got a system that actually is not working that well, can we modify it to make it work better and, you might think, is that really the system we want to have in the first place? There obviously is a conflict here between paying primary care trusts as a fair share of the NHS budget for their population and paying providers for the volume of services that they supply. There is no guarantee, of course, that these two will equate, and as we are entering very hard times in the NHS, it is difficult to see how these tensions will be resolved. If you look at the evidence on pay for performance, which is very fashionable in the United States, there is very weak evidence of it having been an effective innovation.

  Dr Stoate: That is very interesting. Thank you.

  Q35  Sandra Gidley: I want to hone down onto practice-based commissioning. We have heard generally about the advantages and disadvantages of commissioning, so it would be helpful if you can both say what you think are the three main advantages and disadvantages of practice-based based commissioning. Hamish, do you want to go first?

  Dr Meldrum: I have to preface it by saying that it is still something within the system that I think is fundamentally flawed. I personally, although I am a GP, do not really like the term "practice-based commissioning", not because I do not think GPs should be very integrated and involved, but actually I think to place it in either a practice or in secondary care is wrong because of the fact that I believe more in collaborative commissioning and, therefore, I do not think putting all the power in the hands of GPs is the right way.

  Q36  Sandra Gidley: So you do not support Conservative Party policy then.

  Dr Meldrum: I do not say whose party's policies I support. I promote the BMA's policies and it is for other people to judge which party's policies they are more closely aligned with. You are trying to catch me out on that one, Sandra. We have talked about fund holding and, although it had some limited success in certain areas about trying to change services, a lot of the things that Gwyn was talking about, we sat down and talked with consultants locally long before we had fund holding. I think it was maybe a lever in those cases where there were poor relationships to try to bring people to the table, but it seems to me a rather crude way of doing it, that actually you cannot get colleagues round a table to talk about the service unless you threaten to take their money away. We should be a bit more grown up and better than that. I think also, if you are talking about single practices, the unit is too small. So you are then talking about groups of practices, and if you are talking about groups of practices, as I said earlier, where groups of practices have got together and worked collaboratively with their providers and with their PCTs, I think that is where you have seen the greatest successes, but that is why I still think the term "practice-based commissioning" is a wee bit of a misnomer.

  Q37  Sandra Gidley: The groups have been imposed; they have not been natural collaborations.

  Dr Meldrum: Well some have, and, again, I think where it is imposed, it is less likely to work. If you get natural collaboration between groups in an area who share a provider or common providers, then it is more likely to work. It often works more in the smaller, more rural areas where you may only have one or two providers. I think it is much more difficult in the big cities like London where you may have a dozen providers on your door step, but even then there is much more reason or argument to me to have real joined-up thinking about how you are going to provide care. I know we do not want to get into how we are going to rationalise London's healthcare again, but I do not think practice-based commissioning will achieve it.

  Q38  Sandra Gidley: Were there any advantages? I did not pick any out in what you were saying.

  Dr Meldrum: The advantages are that you must involve GPs in the decision—they do know a lot about their patient populations—but there is always a dilemma for GPs. Are they advocates for the individual patient that is in front of them or are they really deciding healthcare for populations? That always puts them in difficulty, because on the one hand they want to do what they believe is their absolute best for the individual patient, but that could conflict with the greater need of wider population, and I think it does produce tensions. They are not insurmountable, but, again, that is why I would not purely base it in general practice and I would have this wider model.

  Professor Bevan: I have to say, I am not aware of the evaluations of practice-based commissioning; I have not been involved in it. Years ago when there was enthusiasm for GP fund holding, I was part of a massive research team that did an evaluation of its extension, which was called Total Purchasing, which did create networks of GPs, and the idea was that since GP fund holding was felt to be so successful, they could extend out of the narrow range which were restricted for the whole range of hospital and community health services. That proved to be a very disappointing development, and part of the problem, in a way, what we found, going back to the nub of the point that Hamish just made, is that in terms of getting GPs to manage referrals against budgets, that worked well when they were in single practices, but when you extended it to a broad network it became much more difficult to do. So you are still back into this difficulty, which is the tension between the attraction of the GP in touch with his or her patients and in touch with a consultant, having that input, together with the scale you need for the support and resource allocation for it to work. It is very hard (and I am a member of advisory groups on resource allocation) if you want a fair allocation of a budget, to give that to a practice of 10,000 population. You just cannot do it very well, so you have real difficulties.

  Q39  Sandra Gidley: Some of my local GPs were heavily involved with the Total Purchasing pilots and actually won awards, so they were very enthusiastic about practice-based commissioning, but felt very let down by the reality and the limited input they actually had into the process. Were they unusual in wanting to be involved? I am aware of other practices who have no interest at all in becoming more closely involved with commissioning. What is the more normal picture?

  Dr Meldrum: There is a very wide spectrum. I think there are, at one end, the enthusiasts and, at the other, there are the ones who really want nothing to do with it and who say, "Just let me get on and see my patient." I think there is a big group in the middle who, depending on the system and what they are being asked to do, would be quite keen to get involved. I think all of us feel that, whilst we want to look after individual patients, there are these wider healthcare issues that we have to discuss and we have to get some rationality into. Therefore, I think if the system they were asked to work in was perceived to be fair and effective and adequately resourced, then more would get involved.


 
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