Examination of Witnesses (Questions 40
- 59)
THURSDAY 22 OCTOBER 2009
PROFESSOR GWYN
BEVAN AND
DR HAMISH
MELDRUM
Q40 Sandra Gidley:
How many of your members would miss practice-based commissioning
if it was abolished?
Dr Meldrum: As I said, you would
not abolish it and leave nothing, because I think you still have
to have GP involvement in commissioning. I think a lot would depend
on exactly what the nature of that involvement was; what you were
replacing it with. If you said, We are going to get rid of it
and have nothing", then that would not be very welcome.
Q41 Chairman:
Commissioning is about improving the patient's lot. You have just
given a description there that some of your members do engage
in commissioning work within groups and things like that, and
some of them remain GPs in small practices that do not want to
get involved other than seeing their patients. Is that because
of the contractual situation that GPs have with the National Health
Service, or not?
Dr Meldrum: If you want to go
back to 1948, and here I can have a chance to lay to rest the
idea that the BMA opposed the NHS, we did not. We did oppose doctors
being employed within the NHS, which is why you ended up with
GPs as so-called independent contractors, so they would not have
this conflict, in one sense, being advocates for their patients
and, in the other sense, being state employees, which they felt
was a conflict. I think that there is always a tension, and there
are some doctors who believe that if they are really behaving
in the best interests of the patient in front of them, that is
the only person. I personally think that is a minority and I think
these days that is not an acceptable position. We work in a healthcare
system, which is a system of social solidarity, and if you do
not consider the wider interests of the population and take that
very narrow view where it may make you feel easy in your bed at
night, on the one hand, that you have done the best for that individual
patient, if you are looking to do the best for the wide population,
it is not sustainable, but I do not think it is the contract particularly
that does that, Kevin, I think it is more the mindset of doctors,
and when they see these very difficult problems that involve very
difficult decisions as to how you are going to, in effect, ration
or make best use of limited resources, they almost find it too
difficult and they resort to the safer place of saying, "I
am not having anything to do with it, I am just going to think
purely of the best interests of the individual patient in front
of me at the time."
Q42 Chairman:
You are pretty clear in that respect, that maybe a single-handed
practice is something that should not be around.
Dr Meldrum: No, I do not think
that is anything to do with single-handed practice. I think it
can occur in a big practice as well. I am talking about the relationship
between the doctor and the individual patient; nothing to do with
the size of practice. What you are talking about is the tension
between that individual relationship and the wider population
decision. Do not get me to say that single-handed practice is
bad and should be abolished.
Q43 Chairman:
No, no. I have experience of single-handed practices with another
hat on. I have a lot of sympathy for them in terms of how they
are treated in the system. I have to say that. I am more interested
in this suggestion of yours that wider collaboration between groups
of GPs and their immediate partners in terms of healthcare is
better for the patient. Is it better for the population as well?
Dr Meldrum: It is better for the
overall population, but it will create tensions for what you are
doing for the individual patient. To take an example, if it is
decided that actually you are only going to refer people for hip
replacement when they have got to a certain degree of disability,
or whatever, because you have to ration resources, it might well
be that a doctor with individual patients might want to refer
them much sooner than that, at an earlier stage, because they
feel that for that individual patient it would be better, but
in terms of the good of the wider population, then they might
have to fit in with what are the normal referral criteria.
Q44 Chairman:
Do you think that professional regulation is going to get practices,
multiple partnerships, or whatever, looking at the wider needs
of the population and their involvement with the immediate health
service in terms of revalidation, and things like that? If not
now, do you think in the future that is how you may get the small
co-operative work taking place in communities?
Dr Meldrum: I do not think revalidation
of itself will improve co-operation. What I do hope it will do,
though, is provide people with better information about how they
are doing relative to others and to ask questions, if they do
not appear to be doing as well as others, as to why not and how
you generally raise the standards and get rid of unacceptable
variations, but I do not necessarily think that of itself it will
necessarily make the commissioning process or make collaboration
work better.
Q45 Dr Naysmith:
Given that neither of you seems to be very enthusiastic about
the current system of commissioning in England, there would seem
to be three options. We could either spend more money on it to
do it more thoroughly, or we could do it more cheaply and simply,
or we could abolish it, as has been done elsewhere, as has been
pointed out by you already this morning in Wales, Northern Ireland,
Scotland and New Zealand. What do you think about these three
options?
Professor Bevan: I do not think
either of us was saying you should abolish commissioning.
Q46 Dr Naysmith:
No. Let us say the current system of commissioning, even if we
call it world-class commissioning or not.
Professor Bevan: Academics like
to enumerate. (You used to be an academic yourself actually.)
Q47 Dr Naysmith:
I did once upon a time, yes. I get very confused in these sessions
as well!
Dr Meldrum: Surely once an academic
always an academic!
Professor Bevan: There is commissioning
and there is the purchaser-provider split, and there is commissioning
in practice and there is commissioning in what we would like to
see in principle. I suppose the feeling I have (and Hamish is
saying the same) is that, having tried the purchaser-provider
split for 18 years in various forms, with not much evidence of
it working, it does make you wonder whether this is a good way
and whether it is an unsatisfactory halfway house between an integrated
organisation within an NHS in a regulatory regional system.
Q48 Dr Naysmith:
It is always difficult for academics, as you pointed out, to come
to a conclusion firmly.
Professor Bevan: It is so nice
of you to compliment me in this way, if I may say so.
Q49 Dr Naysmith:
Are we going to abolish it, are we going continue with it and
improve it or are we going to try and find a compromising manoeuvre
that is much simpler and easier to understand, or none of these
three, which is the other option, of course?
Professor Bevan: The evidence
from elsewhere is that there are enormous advantages from integration
between primary and community care, and things that get in the
way of that are a hindrance to that; but that will enable us better
to improve care across the care pathway. The other issues we have
are that we have to challenge the providers of care to improve
quality and reduce cost; and these hard choices that Hamish was
talking about, about the population good and the appropriate clinician's
view of the patient in front of them. I think if you were to move
towards an integrated organisation, which I think would be the
better way of improving care across the care pathway, how could
you then make sure that we have commissioning effectively representing
the patient's view? As I was saying, there are these two different
models. One would be as in the Italian scenario, which was actually
modelled on our National Health Service, a proper regional structure
with power and authority to regulate and examine performance of
these integrated organisations, or the other much more radical
model would been as in the Netherlands, where you have purchasers
in competition and people can move between different insurers,
but that may not be the question.
Q50 Dr Naysmith:
That is fine. One of the things that strikes me about the places
that we have kept talking about where they have abolished it—Wales,
Northern Ireland, Scotland and New Zealand—is that they
are actually all relatively small countries. We quite often in
this committee visit Scotland and we get lots of interesting initiatives
from up there, but it is quite clear when we do go there that,
whatever bit of the National Health Service you are talking about,
if you get all the experts from Aberdeen, Glasgow, Edinburgh and
Dundee in one room, you can have a discussion that involves almost
everybody in Scotland who is involved in any particular area of
the National Health Service and thrash out something that everybody
agrees upon. That is much more difficult than in big countries.
How would you apply that?
Professor Bevan: Italy is a big
country.
Q51 Dr Naysmith:
You keep talking about Tuscany, and we are just discussing whether
we should have a trip to Tuscany to find out what is going on
there!
Professor Bevan: Yes, I suppose
in the winter it would not be a bad thing to do. The Italian Health
Service is modelled on the English National Health Service with
a regional structure the way we used to have but because of the
structure of Italy (it has regional governments), the regions
continue to exist. So, unlike ours (they get abolished every four
years), they have been in existence now for 20 years and they
exist and there are regional elections. My wife is a clinician,
and I remember her talking about the regional meetings that they
used to have when there would be a community of clinicians who
would meet together and you would know each other and then you
keep on re-organising and changing the boundaries. I think the
sort of thing you are hinting at is that that model, if we were
not to have competition in it, an integrated system, would entail
a strong regional structure. So within England you would create
regions of the same sort of size as Scotland.
Q52 Dr Naysmith:
We would be going back to regional health authorities.
Professor Bevan: We would, yes.
Q53 Dr Naysmith:
And that is not getting us very far. Do you have any views on
this?
Dr Meldrum: I do take the point
that the countries you have mentioned tend to be smaller. One
of the problems we have seen with the NHS is that it was too big,
too monolithic. I personally still think it could have been made
to work better and that fragmentation is not necessary. There
will always have to be a degree of regional delivery or organisation
in terms of how you are going to deliver, but within that you
have to maintain the ethos of a national health service. You have
to get around some of the problems. People have said to me, "It's
only with choice and payment by results and budgets that as a
GP you can start to refer people to particular areas outside your
area," but when I started out as a GP I could refer anybody
to any part of the country without anybody saying anything.
Q54 Dr Naysmith:
It did not happen very often, though, did it?
Dr Meldrum: It did a bit. But
then huge restrictions were put upon you and you could only refer
where you had a contract. We are starting gradually to get back
to a system which prevailed 20/25 years ago. I still want to see
the concept of an NHS, but I agree that, in organisational terms,
in order to get the collaborative approach we have been talking
about you will need to have areas of a manageable size where that
sort of activity takes place.
Q55 Dr Naysmith:
You are clearly in favour of abolishing the present system.
Dr Meldrum: Yes.
Q56 Dr Naysmith:
You have both mentioned the voice of the clinician being important
in organising commissioning and in doing the job properly no matter
what system you have, but one of the things that particularly
Dr Meldrum has emphasised is the population importance, that really
we are talking about public health. Are public health experts
involved enough in the process? If not, why not, and what can
we do about it?
Dr Meldrum: Public health experts,
yes, need to be involved. We have been mainly talking about commissioning
for an illness service, which is 99% of what the NHS does. If
you are looking at wider public health or at health of the public
issues, then you are looking much wider than just the healthcare
system.
Q57 Dr Naysmith:
It is commissioned still in the same sort of way, is it not? Other
initiatives come in from the top every now and again, but there
is a public health component to whatever is seen to be necessary.
Dr Meldrum: Yes. Obviously if
you are looking at areas like smoking and alcohol, yes, you want
to make sure that all these services are aligned. Public health
needs to be involved in that.
Q58 Dr Naysmith:
Is it involved enough, is really the question at the moment.
Dr Meldrum: No. Partly because
there are not enough public health people. There has been a huge
reduction in the number of public health doctors and they are
stretched pretty far and wide. I do not think there is enough
input there, but unless, as I say, we involve all the other areas,
like social care, education and such like, we are not really going
to address the wider health issues. You can divert resources from
the illness service but there is a long lag time before you get
buy-in or improvement by putting them into public health. Of course
there are some arguments which say that putting more money into
public health is great: people live longer and healthier lives,
but the overall health costs will probably go up because people
living longer develop the chronic diseases, the cancers, which
are expensive. That is not to say you do not do it. Of course
we want the public to live healthier and longer, but on a purely
economic argument I am not sure that it will necessarily make
the system cheaper.
Q59 Dr Naysmith:
If you are suggesting there are not enough of them, what would
they do if there were more of them?
Dr Meldrum: They would be more
involved in these wider public health issues for their populations.
As I have said earlier, one of the problems, particularly, with
involving GPs and other clinicians is that they still think of
individual patients, and you do need that wider population base
perspective which public health would help to offer.
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