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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