Examination of Witnesses (Questions 70
- 79)
THURSDAY 22 OCTOBER 2009
MR GARY
BELFIELD, DR
DAVID COLIN-THOMÉ,
MR MARK
BRITNELL AND
MR DAVID
STOUT
Q70 Chairman:
Good morning, gentlemen. Welcome to our first evidence session
on our inquiry into commissioning. For the record, would you give
us your name and the current position you hold.
Mr Britnell: I am Mark Britnell.
I am a partner and head of health for Europe for KPMG, latterly
the Department of Health where I was Director General.
Dr Colin-Thomé: I am David
Colin-Thomé. I am the National Director for Primary Care,
Medical Adviser to the Commissioning Directorate, former GP and
fundholder.
Mr Belfield: Good morning I am
Gary Belfield. I am the acting Director General of Commissioning
and System Management and before that I was Director of Commissioning
in the Department.
Mr Stout: I am David Stout. I
am the Director of the Primary Care Trust Network, NHS Confederation.
We are an independent voice for PCTs representing 95% of PCTs
across the country. Prior to that, for six years I was the PCT
chief executive in Newham in East London.
Q71 Chairman:
Once again, thank you and welcome. What gains to the NHS have
there been over the last 20 years of the purchaser/provider split?
Mr Belfield: I am happy to start
on that, Chairman, having listened to the debate with the BMA.
We have needed to have a purchaser/provider split. I do not think
that we have put the support and the effort and development into
the purchaser side that perhaps we should have done and we have
put more into the provider side. When you have a system as complicated
as the NHS, with £100 billion spend this year, you need to
have a system of a tension between the purchaser and the provider.
If you look at before we had the purchaser/provider split, we
had a provider-dominated system, a hospital-dominated system from
1948 onwards, does not really focus—because it is not what
they are set up to do—on long-term conditions, health inequalities
and long-term health gain in the system. They look at the treat
and the cure side. For me, it is really important that we do have
this tension between purchasers and providers. The benefits we
have had are going to be realised only recently. Listening again
to the debate, it feels to me as if we have not really had commissioning
until the last two or three years. We have had movement of money
before that. I was in the NHS myself in the 1990s when purchaser/provider
split first came in, and all we did as a hospital was argue about
the money. We did not really talk about quality or improving care
at the time. It is wrong to think there has been an improvement
over the whole 20 years. I do not think there has, personally.
It is only in the last two or three years that we have realised
we need to help commissioners to become much stronger, to help
them develop and to help them have an equal footing with providers
so that we can have some tension in the system to improve care
for the local population. The final point I would make is that
we need to have somebody who is an advocate of the patient and
the local population and also an advocate for the taxpayer. That
is the key role of the purchaser, in terms of ensuring that we
get a high quality of care for all but also good value for money.
Q72 Chairman:
Do you have anything to add?
Dr Colin-Thomé: As you
have heard, there has been little evidence to suggest that there
has been a major change. I suppose the best evidence of change
has been that because of targets there has been the biggest movement.
But I suppose the real issue is that health services are extremely
difficult to manage. That is an international issue. The previous
model was arguably even more inefficient but it was focused too
much on the clinical providers, and especially secondary care,
which covers a tiny percentage of health care. We are searching
for a better management approach. My feel on what we have got,
even though the evidence is not currently strong, would be to
have a separation and organisations looking at the healthcare
needs rather than provider domination. I think that providers
are not naturally the most objective people to be suggesting how
health care should develop. They are a key part, but I think there
should be much more objectivity about their effectiveness.
Q73 Dr Stoate:
Surely there is still a huge disparity in power. The fact of the
matter is that the foundation trust hospitals, using payment by
results, dominated the power structure in the NHS. PCTs have almost
no freedom of movement whatsoever. In my local area when the hospitals
ran into difficulty, the PCT came banging on the GPs doors to
say that we have to save money. That is no equality of power and
control in the system. That is total domination by very, very
powerful secondary sector organisations.
Dr Colin-Thomé: The point
I am making is that basically you have a dominant position of
hospitals and maybe we have made it worse. There are two things
there. One is that we need better commissioners and internationally
they are in a weaker position. One of the MPs was saying before,
Ms Atkins I think, that it is a provider-dominated world and there
is nobody making any interjection on behalf of the population
or asking if there is any comparative data. The only thing about
payment by results that seems odd is that we always assume that
therefore it will only go to the hospital—and I think your
coach party analogy was quite nice. On the other hand, payment
by results also helps the commissioner if we can develop them
enough—which is the whole point of trying to develop them.
If you do not refer for outpatients or shorten lengths of stay,
then you do not need to give that money to the hospital and you
can use it for something else. The PBR has only been a tool, but
because of the disproportionate power—the whole point of
trying to make commissioning better and at the moment it is underdeveloped
and we have had big hospitals for 100-odd years—is to equalise
that and to have a more rational view of how we use resources.
Yes, not much success in 20 years, but the potential is necessary
because of our obsession with bio-clinical care, much of which
is now ineffective and inappropriate.
Mr Stout: I have to say I would
not be quite so gloomy about where we have succeeded. I agree
with the analysis in terms of the relative power imbalance and
so on. I have spoken to several of your local PCTs before coming
here, and if you look at the action they have been taking over
the last two or three years in terms of improving health, in terms
of redesigning services, in terms of making changes in care pathways
that both improve health and achieve better value for money, then
every one of you, in talking as you do to your local PCT, knows
that there are improvements being made. To take, as an example,
the work on obesity in Rotherham. It is fantastic work. In South-East
London, where I think you practice, there is work going on about
redesigning a pretty challenged healthcare system using an evidence
base, using proper analysis, using the tools of commissioning
to drive clinical change. There are lots and lots of examples
of really good progress being made.
Q74 Chairman:
Commissioning has been seen as a bit of a weak link in the National
Health Service for quite a while now, has it not? Why is that?
Mr Stout: If I can kick-off on
that from a PCT point of view, it is right to say that has historically
been the case. Why? First, the tools of commissioning did not
really exist until three or four or five years ago, so we did
not have a contractual system, we did not have payment by results.
PCTs/commissioners did not hold contracts with GPs or with dentists.
All those things are new. They have all happened in the last four
or five years. What has changed in the last couple of years is
a more serious policy focus on commissioning. The Prime Minister's
Delivery Unit did a review in 2007 on commissioning and basically
concluded that there was not a clear story of what commissioning
was. There was not a proper programme of support there. We are
starting to combine policy levers that are designed for commissioning
and a programme that supports the development of skills and capacity
within commissioners to use those tools. That is why it has been
weak but also why it is now strengthening.
Dr Colin-Thomé: Internationally
we are obsessed by the provider side, especially hospitals. This
is not peculiar to the United Kingdom. Whichever country you go
to, that tends to be the policy or managerial focus. This is a
chance to begin to shape different health care provision by giving
more skills and talents and other things to our commissioners.
It has been an uneven contest in the past and we need to improve
on that.
Mr Belfield: It is also right
to remember that we keep changing what we call the commissioner
or the purchaser function. We have had something like five or
six changes since the 1990s, so every time we get somebody in
post, then two or three years later they are moving on, as described
in the last session. There is something about letting us have
some continuity and some stability here to help commissioners
work. Also, picking up on David Stout's point, we have never really
set out nationally, until very recently, the compelling vision
about what commissioning was meant to achieve. We have never really
set out what we think are the real tools of development to help
support PCTs. We have never really set out what we think you need
to be competent at to be a great commissioner. We have done that
in the last two or three years. As David said, it is early days.
We are beginning to see some real improvement across PCTs. The
levelling up will take some time because the organisations are
quite young and some of the FTs have been around for a long time.
If you call me back to this Committee in two or three years, we
will be talking about a much more even balance in the system.
Q75 Dr Taylor:
My question was going to be: Is the continuous reform of commissioning
evidence of continuing failure?—which is the message I got
from the last session—but you have said very clearly that
in the last two or three years the changes have begun to lead
to improvement. Can you clarify that a bit? In what way? What
changes have come in the last two or three years that have radically
changed the whole system so that we can now look forward to commissioning
being a success?
Mr Belfield: The big differences
have been, in the last two years particularly, that PCTs have
begun to analyse deeply and understand the long-term health needs
of their population. That has not really been done before. They
are looking forward more than they have done before. We are seeing
more examples of collaboration and partnership in the last two
years, where the local providers (the voluntary sector, PCT and
local authority) are working together on single projects. Again,
we are seeing much more of that. And we are seeing professionalisation
of commissioning. An example of that—and this goes against
the BMA argument about collaboration—is that in Manchester
and Cheshire ten PCTs are working with ten hospitals and the ambulance
service to redesign stroke services across the complete care pathway
for nearly three million people. That is down to the PCT saying,
"We need to work together. We have looked at the needs, the
health needs of particularly stroke patients in Manchester, and
we want to make a difference." We have examples of that on
a large scale, and on a smaller scale, if you go to somewhere
like West Sussex, the PCT are working with the police and with
the local authority there on a very small scheme about looking
at helping women who are suffering domestic violence. We have
examples at both ends of the spectrum of PCTs beginning to understand
the needs of their population and designing services in partnership
with others.
Mr Stout: It would be characterised
by effective use of evidence; effective use of data; effective
engagement with clinicians of all sorts in both primary and secondary
care (doctors and nurses and so on on the patch); and a dialogue
with the public. Those are the four things you need. You asked
the previous witnesses what the criteria for effective commissioning
would be and I would say those pretty much define it.
Q76 Dr Taylor:
Are they getting better data? We felt from the previous witnesses
that the data was still pretty poor.
Mr Stout: It is certainly better
than it was. What are the things that hold commissioning back?
It is the fact that we still do not have data that is live; it
is still often out of date; there are still coding issues in terms
of how well activity is coded and so on. But is it better than
it was five years ago? Absolutely. Undoubtedly. Why is that? It
is because we are using it. Data will always be bad until you
use it for a purpose. If you use it for a purpose, that incentivises
everyone who provides the data to get it right.
Q77 Dr Taylor:
Has the reduction in numbers of PCTs helped?
Mr Stout: Yes, to some extent
I would say it has, but I would also caution against this obsession
which your previous witnesses touched on of constantly reorganising.
There is no optimum size for a PCT because commissioning operates
at multiple levels. You can play around with structure as much
as you like, but the downside of that is that it then destabilises.
It has the effect Gary talked about of not giving you a very continuous
leadership or a continuous focus in a particular area.
Q78 Dr Taylor:
You do not see further upheavals.
Mr Stout: That is up to politicians
ultimately. I would certainly hope not. We would certainly advocate
leave the structures where they are and focus on making them work,
rather than focus on every two or three years and then throw the
structure up in the air again.
Q79 Chairman:
Could I prod this a bit further. You say about the last few years
and you talk about what Rotherham PCT is doing on obesity, but
they are doing it on other things as well. I know very well about
the disease burdens in communities that I have lived in all my
life and represented here for many years in. We do not need people
to tell us about that, but we have only just started looking at
it in the last few years. Is that because of commissioning or
wanting to commission, or is that because of the amount of resources
that have been made available at local level? Which one is it?
Dr Colin-Thomé: I would
have said from my experience that it was because of our focus
on commissioning for broader needs and to look beyond the bio-clinical.
There is that old saying from Rohmer that a bed built is a bed
fillt, but if you just provide more bio-clinical acute care, you
tend to use it more and more without necessarily challenging its
effectiveness. We have to make a balance as to what those priorities
are. I would not take the Gwyn Bevan point about strokes: I think
you do need to both those things for strokes. But there is a whole
lot of other things that are currently being done by clinical
providers, whether in primary or secondary care, where its effectiveness
and usefulness can be heavily challenged. In fact there is a better
web page now, taking Dr Taylor's point of view, on productivity
and all such things, readily accessible to all of us, so that
we can begin to compare different services. I think it is because
of the focus on commissioning—it is beginning to shape where
we are. Of course health care is important, but also we have to
look at some of the broader issues, like obesity, which maybe
we had not focused on in the past or had looked at only on a bio-clinical
model. I think it is shaping a difference.
Mr Belfield: In answer to your
question, I think it is both things. The resources have certainly
helped and it has certainly helped as well that we have taken
away many of the access issues in secondary care. That means that
the PCTs have been able to focus on other things. That is certainly
part of the answer. The other issue as well is that as a society
we are moving away from hospital-based provision into more community-based
care. It is more about dealing with long-term conditions. Society
is moving that way anyway, but commissioning has certainly helped
push it faster.
Mr Stout: The role of commissioning
in that is both paying for and planning health service delivery,
but also paying for and planning for health promotion and wider
activities. It is that combination. The fact that there is one
body at local level responsible for both those tasks has led to
the focus in all the different areas on the right things that
matter to the populations in your area, rather than simply the
theory that you can do this once at national level with regulation
and that will give you the right answer. I simply do not believe
that, which is why we are strong advocates for maintaining the
separation of commissioning from provision of responsibilities.
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