Examination of Witnesses (Questions 60
- 69)
THURSDAY 22 OCTOBER 2009
PROFESSOR GWYN
BEVAN AND
DR HAMISH
MELDRUM
Q60 Dr Naysmith:
Do you have any views on this, Professor?
Professor Bevan: The work we have
been doing is essentially trying to introduce a population perspective
into the choices PCTs have to make. Working with PCTs, we have
found that we have this social process where the stakeholders
are involved, which includes GPs, hospital doctors, patients,
the public and managers and so on. You are able to show to them
the impact the different options are having on the health of the
population and what it costs, and they make choices. For example,
we are doing work in the Isle of Wight on prevention and treatment
of stroke. Stroke causes a massive burden of disease in England:
there are about half a million Quality Adjusted Life Years every
year from premature mortality and disability. The Department of
Health's two main priorities are to ensure that patients are treated
in specialist stroke units—and the last Royal College of
Physicians stroke audit showed that only 50% spent most of that
on stroke units—and thrombolysis—which you have to
have within the first three hours of a stroke to break the clot.
Of these acute interventions, putting people in a stroke unit
would reduce the burden of the disease by about 6%, and thrombolysis
by about 1.4%, so the huge burden of disease that we are all troubled
by will not be tackled by these acute interventions. To treat
thrombolysis on the Isle of Wight would mean 24/7 helicopter cover
to get patients to the mainland, and we worked out that eight
patients a year would benefit from this. The question is: If there
are only limited changes you can make in a given year to a system
like the Health Service, is this the change you really want to
make for population health? If you have a stroke, of course you
would quite like to have thrombolysis, but in terms of population
health is that a helpful thing to do? We found that by displaying
information in a way that people can visualise and understand,
you do get stakeholders to agree on what the hard choices ought
to be, but it is a radically different way from the methods that
are conventionally used to help people set priorities.
Q61 Dr Naysmith:
We are moving into a time when there is probably going to be restriction
on public spending. What effect do you think that will have on
the current commissioning set up?
Professor Bevan: I agree with
the point Dr Meldrum made earlier, that it is going to be even
more important that we find ways of getting the public involved
to make these hard sorts of choices. The process we have been
working on enables the public to do that. If you can have a proper
debate that involves the public, then you are in a much better
position, it seems to me, for the primary care trusts to present
these difficult choices to the public and to the media.
Q62 Dr Taylor:
Is one of the problems with the current system of commissioning
that too many cooks are involved? We have PCTs, GP commissioners,
NICE, Tsars, clinical networks, patient choice.
Professor Bevan: There are two
different things. One is the drivers of change. As you say, there
are PCTs, PBC and patient choice, so in effect we have three different
sets of purchasers. The whole idea about paying providers on cases
through patient choice is not consistent with PCTs having a budget
that they have to manage a population for. That is a tension.
As regards the other issues, about people being involved and NICE
and so on, we talked earlier about the need to get people involved
across the care pathway to improve quality of care, and NICE provides
useful evidence for that. It is not in that sense that there are
too many cooks, because they are cooking different recipes, there
are different meals—I am sorry, I must not get carried away
with the analogy. We would say that you need to have a good process
to which you can harness these different viewpoints and take the
view for what is best for the population. That is the most important
development.
Q63 Dr Taylor:
Is it not a huge argument for integration? Should not all these
people be integrated together?
Professor Bevan: Neither of us
has expressed enthusiasm for the purchaser/provider split, but
we have been working with PCTs at the moment and you can get the
different stakeholders here, including local authorities, to look
at the choices and provide their views. In the end, of course,
it is the PCT which has to make the decision.
Dr Meldrum: We do not need physical
or organisational integration to get practical integration. I
do not think it means that primary care needs to take over secondary
care or vice versa and they have to be all in one, but they have
to be working together. I am not sure if it is a case of too many
cooks, but certainly the fact that there are so many types, in
various places, of people getting involved shows that there is
not one model that seems to work very well. It is not so much
about the numbers of people involved; it is how effectively they
are working together and whether the system helps them achieve
that.
Q64 Dr Taylor:
Going back to integration, you have rather implied that if that
happened we would have to have regional health authorities back.
If you look at the whole programme of reforms of the NHS over
the last 20 to 30 years, it has been a continual cycle of going
back to what had been discarded before, so it would not be anything
new to go back to RHAs and an integrated service.
Professor Bevan: It is the old
hymn about history repeating itself. I certainly would not say
and I do not think Dr Meldrum would be saying that we should go
back to as it was in 1974, because then we had this division between
primary care, and hospital and community health services, and
you would want to create a different form of organisation. The
first time I got involved in the Health Service was doing research
for the Royal Commission in 1978, when it was a heavily bureaucratic,
hierarchical structure, and people found planning a rather strange
concept which they seemed to liken to Stalinist five year plans
really. We are talking much more about integrated organisations.
I am thinking about this as a regional body, which would be challenging
that organisation in terms of its comparisons of provider performance,
what the needs of its population are and all sorts of sets of
additional information, and saying, "Look, these are things
we think you should develop." I have this idea that, as part
of that, you would have annual meetings at which the local organisation
would report to the public what they have achieved as had been
set over last year: where they have done well, where they have
not done well, how they are going to do. I have a different vision
than going back to the past.
Q65 Dr Naysmith:
You would go back to the late 1980s.
Dr Meldrum: In general practice
I have seen FPCs, FHSAs, and then we went to DHAs, PCGs, PCTs.
It is just a list of acronyms. I do not particularly want to see
another massive organisational change. If we change the underlying
system, I would like to see it evolving. You can change the way
people behave and operate and the processes without necessarily
having to have major organisational change. That may evolve, but
I would want to see it ideally being done and evolving, and not
going back but going to something better. If you want to ask me
where in all that process I thought things worked pretty well,
when we had DHAs—we had about 100 of them—maybe some
of them were too small but at least you did have quite good integration
of primary and secondary care at that time. But they were not
allowed to last very long before they were changed again.
Q66 Mr Bone:
I would like to go back to something Dr Meldrum said on commissioning
for the population. Your argument is that with public health improving
it costs more because people then get chronic diseases. The biggest
move forward has been the banning of smoking in public places.
Should we not reverse that and encourage people to smoke because
they are voluntarily laying down their lives for the rest of the
population, reducing a huge amount of duty for the Government
for the rest of the population? Would that not be the logic of
your argument?
Dr Meldrum: I did say that on
purely economic terms we should not expect it in the long run
to be cheaper, but of course the fundamental idea is that we are
trying to get people to live longer, healthier lives. I am a passionate
supporter of the smoking measures, but I was trying to make the
point—which even goes back to the days of Beveridge and
Bevan and the idea that with the National Health Service costs
would go down—that there is no evidence in history or in
any healthcare system, I am afraid, that the longer people live
and such like the costs will go down. They tend to increase. But
of course we must be trying to ensure that people live as long
and as healthy lives as possible.
Q67 Mr Bone:
Professor Bevan, I was attracted to your radical approach using
the Dutch model. I do not think we have ever seen in the NHS competition
with purchasers.
Professor Bevan: That is right.
Q68 Mr Bone:
But I am not sure how you can translate the Dutch model into a
state-run health service. Would there be advantages to have competition
between purchasers and how could we do that?
Professor Bevan: In the 1980s
we were thinking about GP fundholding and the idea which I and
Kenneth Clarke had then—he was on a beach in Spain when
he had the idea, so he says—was that patients would choose
their GP and the GP would then choose hospital care. Right at
the start there was the idea that you would have choice, being
the purchaser. Alain Endhoven's ideas were very influential. He
saw it as an integrated organisation, in which district health
authorities would employ general practitioners and they could
contract out if they were unhappy with local services. He thought
that the better thing would be purchaser competition. How you
do it, I agree, is going to be quite tricky. The Nuffield Trust
will be publishing a report which explains how we might do that.
In the Netherlands they started off from a system of having multiple
insurers, so it was very easy to introduce competition there.
You could envisage people being able to choose between neighbouring
PCTs, but that is going to be a marginal thing. The other idea
would be to allow private insurers to come in and organise services.
Two things were very important in the Netherlands to get it to
work. One is that they essentially have universal coverage through
multiple insurers and people are free to choose different insurers
and they are subsidising that choice. The same individual will
pay the same premium to different insurers and then there is a
complex risk adjustment formula, because the costs of health care
are very skewed, so the most expensive 5% of the population account
for 60% of healthcare costs. It is very important, given the choices
people have made by these different insurers, that you adjust
the risk profile of those insurers for the mix of risk that they
have. They have also introduced things to ensure and protect competition
to regulate quality. There is a complex set of regulatory arrangements
you would have to have in place if you were to move down a radical
reform of purchaser competition. When I talked to Professor van
de Van from Erasmus who is working with me on this report, he
described that in the Netherlands the government feels they can
get out of having to deal with day-to-day problems of healthcare.
There was a recent issue in the Netherlands where a hospital was
threatened with closure. Under the system, they should have been
able to leave that to these different organisations to resolve,
but the government intervened because they felt, as Dr Meldrum
says, that ministers cannot stand by and let hospitals close.
Afterwards, however, there was a lot of criticism of the government
acting in that way and it was pointed out that various providers
had decided they were already going to try to move in to fulfil
the gap in the market left by that hospital. There is a feeling
now that if that issue were to recur, the government would probably
stand back and let the get on with it.
Q69 Mr Bone:
Absolutely that can happen in Holland. I do not have a hospital
in my constituency, we have two outside, but there is no way a
private company could build a hospital in my constituency and
then there be competition between purchasers as to whether they
use that one or others. I do not see how you can do that in our
system. I know we are talking about the purchasers, but you also
have to be able to move between different providers, do you not?
Professor Bevan: They do have
selective contracting. At the back of this is the idea that in
well-designed markets organisations will choose forms that minimise
both costs of transaction and costs of production. It looks as
if the most effective way of doing that is through an integrated
organisation. We both have this thinking—although it has
to be said, in all honesty, it has not happened yet—that
if you were to create a proper regulated market, organisational
forms would then evolve to provide the best form of health care.
The way we describe this is as a thought experiment for the NHS.
As you say, we are a very long way and it would be a very radical
step from where we are now.
Chairman: I would like to thank you both
very much indeed for coming along and helping us with our inquiry.
|
