Examination of Witnesses (Questions 80
- 99)
THURSDAY 22 OCTOBER 2009
MR GARY
BELFIELD, DR
DAVID COLIN-THOMÉ,
MR MARK
BRITNELL AND
MR DAVID
STOUT
Q80 Chairman:
Does this mean that if things get tight in terms of NHS resources
commissioning of lifestyle issues will remain?
Dr Colin-Thomé: I am hoping
so. I think that is the balance you have to make.
Q81 Chairman:
You are hoping so?
Dr Colin-Thomé: Yes.
Q82 Chairman:
I am looking for this change.
Dr Colin-Thomé: That is
the potential. That is what the World Class Commissioning assurance
bit is about, to look at health as well as health care. My premise
would be that a lot of what we currently spend on health care
is not always the most effective way of spending our money. That
is significant, if you look at the NHS Institute figures about
the different use of resources and if you look at some of the
clinical interventions which now are not as effective as maybe
we thought they were, if you add that up there is a significant
amount of money in our current resource which we could begin to
release for both better health care on things we are not doing
but also on some of the broader health issues as well, such as
obesity.
Q83 Sandra Gidley:
Mark Britnell, originally this was your project, as it were. We
have heard from Gary Belfield about how he has perceived the system
has changed, but, more specifically, what would you say were the
three main changes that you introduced into the system? What was
your evidence base for those?
Mr Britnell: It is quite important
to go back to the 2005-06 reorganisation, which is when we first
met each other back in South Central. All the commissioning of
patient-led NHS was produced from the Department of Health, which
reduced the number of PCTs, and then quickly after that, in 2007,
as I was invited to joint the Department by David Nicholson, the
Prime Minister's Delivery Unit produced a report which basically—to
try to summarise a 20- or 30-page document—said that the
reorganisation itself had been for its own sake and that it lacked
some vision, ambition, definition of competence and definition
of health gain as well. If one were being playful, one might say
that the last eight or nine reorganisations that we have had since
I joined the NHS in 1989 have concentrated on giving providers
more freedom. I used to be a foundation trust chief executive
but did not really concentrate on purchasing. The great reforms
of the 90—I think project 26, as it was called—referred
to purchasing. My analysis, as I came into the post back in the
summer of 2007, was that if people did not know what was expected
of commissioners, it was almost impossible to professionalise
them as a class of managers or clinicians. In a sense, therefore,
I wanted to create something which had the discipline and rigour
of the foundation assessment exercise and the stretch that gave
people the ambition to raise their sights. We looked at different
systems from around the world and, recognising that the English
NHS is the English NHS, we tried to pick bits and bobs, as it
were, from different systems: insurance-based systems, integrated
systems, trying basically to reach a consensus with a number practitioners—which
we did in the summer of 2007—with managers and clinicians,
local government and private sector/public sector. Basically,
we defined these 11 competencies—which I do not think anybody
really disagreed with. It might strike you as slightly odd—it
did me coming into the department—that no-one had defined
what good commissioning was in 20 or 30 years. As one of the speakers,
the academic, said before, the star rating systems—which
I know very well from my experience in a foundation trust—define
some optimal levels of a narrow range of performance in a hospital
but not for a PCT. We looked for evidence across insurance-based
or integrated systems, we reached a consensus with firms and clinicians
and managers about the competencies, and then we tried to let
the commissioners have five-year plans. In my 20 years' experience
of the NHS we have never asked commissioners—probably because
they got reorganised more quickly than five years—to put
their money where their own ambition is. The "Adding life
to years and the years to life" slogan was trying to maximise
investment in a local population and do it much more professionally.
That was and I think still is the theory and, increasingly, it
is the practice behind what we try to do.
Q84 Sandra Gidley:
Coming back to "we picked some bits and bobs," which
sounds a bit random, what evidence was available for the bits
and bobs that you picked? We have been picking up so far that
there is not much evidence around for what the UK is doing. What
evidence is available from other countries to back up what you
were doing, to make sure you were doing the right thing?
Mr Britnell: I will start the
answer and then hand over to Gary, who did a lot of the work.
We commissioned research looking at different commissioning and
insurance models from around the world and then distilled what
we thought the key competencies were. Without rehearsing the 11
competencies, one is the effective use of knowledge and information.
Of course different systems around the world, be it in the States
or Europe, do use, in my opinion, information in a smarter way—something
which we have not historically done in the NHS. We looked for
competencies and criteria from the desk-based research and we
spoke to people to try to get these 11 competencies, and they
basically form the definition of what good commissioning could
be like. I do not know whether Gary wants to add to that or not.
Mr Belfield: We looked at more
than just the health sectors across the world, I think it is important
to say. For example, when we looked at some of the research coming
out of Birmingham and other places that looked across Europe,
one of the weaknesses of health systems across Europe was that
they did not really do detailed health needs assessments, which
meant they could not plan their services longer term. We looked
at that and we thought that would be a key competency. Then we
looked at the industry where internationally they are the best
at looking ahead, the pharmaceutical industry. It takes, as I
understand it, 16 years for a drug from concept to licence in
the UK, and as a business they are now looking forward 25 years
all the time to stay in business. We looked at how they did that,
to think about building that into our competencies. We looked
at places like Google and how they use information, to think about
how that would be built into our competencies. We also looked
at the retail industry.
Q85 Sandra Gidley:
I am sorry, I am not quite sure of the relevance of Google. Did
you just Google "commissioning".
Mr Belfield: I apologise. As part
of a series of workshops in the middle of 2007 we interacted with
a number of different people—beyond health, is what I am
saying. We sat down with the NHS but also with representatives
from Google and from Marks and Spencer to ask them about how they
ran their businesses and which aspects or principles were transferable
into the UK or the English NHS. We tried to look beyond health
systems. We started there, but we wanted to look beyond health
systems. When we got our 11 competencies, we wanted to say, "This
looks like the best in the world," which is where the World
Class Commissioning point came from.
Q86 Sandra Gidley:
I am sorry, I think you were going on and I disrupted your flow.
Mr Belfield: Health needs assessments
were something we looked at from the point of view research. We
looked at research, in terms of the insurance-based markets in
Germany, France and the States, to look at what we could learn
from them. The key for me was always not to bring a system from
somewhere else into England but more about bringing principles.
For example, in the US we looked at the Kaiser Permanente system
and why that had worked in California in terms of integration
but why it had not worked in Carolina. We then tried to bring
the principles back. For a four- or five-month period, from when
Mark joined in July through to about November, we probably had
interactions with dozens of organisations and from that we distilled
what we now call World Class Commissioning. I cannot, hand on
heart, point now to one single piece of evidence that then affected
that piece because we were bringing things into the melting pot
over a period of months.
Mr Stout: It is worth emphasising
the amount of work with primary care trusts and primary practice-based
commissioners in developing this. It was not just an academic
exercise, a theoretical exercise.
Q87 Sandra Gidley:
But they were not very good at it, so why were they involved if
you were starting from first principles?
Mr Stout: I do not think that
is right: they were very good at elements of it and always have
been. The point was that we were not doing it systematically across
the piece in an effective way, and so testing the theory with
the practitioners is the same as we do in any other type of research.
Mr Britnell: We have just been
through, as you can recollect, a fairly bloody battle reorganising
303 PCTs into 152. It struck me as being rather strange that you
would not then involve the 152 people who had been appointed as
chief executives, because we were trying to help them create their
future as much as improve the health of the population. They were
not all involved in the design but a good 50 or so must have been.
Mr Belfield: I was absolutely
determined that we would do this Department of Health policy differently,
so we went out to the NHS with a series of ideas about how we
could improve commissioning, and then we wanted to work with them
so that we were producing together. Because we did it together,
we probably managed out many of the mistakes, many of the unintended
consequences. We also have better buy-in from the NHS as a whole
because we involved them from the very, very start. David Nicholson
now uses World Class Commissioning as an example of how the department
needs to develop policy in future of the NHS.
Q88 Sandra Gidley:
That is good. We talked about the evidence base earlier and you
mentioned some general themes that seem to have improved, but
is there any hard evidence that World Class Commissioning has
improved efficiency?
Mr Belfield: Is that any hard
research-based evidence?
Q89 Sandra Gidley:
Yes.
Mr Belfield: No, not university-based
evidence, but we are only in year one for World Class Commissioning
and we intend to do some desk-based research at the end of year
two. We do now have anecdotal evidence and evidence from a variety
of surveys that were done within the NHS that it is beginning
to make a difference. I go into a PCT maybe once a week, and the
first thing I ask is "What have you done differently?"
I am hearing examples—quite small ones, quite large ones—where
people are making a difference. We surveyed the whole of the NHS
between Christmas and February last year, an online survey asking
people, "How is commissioning beginning to make a difference
now that we have this format?" and an overwhelming majority
of people came back from PCTs, SHAs and local authorities that
are involved to say that they could see this was beginning to
make a difference. But I do not have hard evidence yet. It is
too soon.
Mr Stout: In terms of some objective
evidence, hard evidence if you like, the Care Quality Commission,
and the Healthcare Commission before them for the last five years,
have published ratings of core standards—so performance
against the core standards for health. When that started, PCTs
were the worst performing sector in the NHS. PCTs in the year
just published, 2008-09, were the best performing sector in the
NHS. That is an evidence base of an improvement in performance.
Q90 Sandra Gidley:
Or it could mean the others had got worse!
Mr Stout: No. In compliance with
core standards, PCTs are better than any previous performing part
of the NHS. It is not that the others have got worse; it is that
PCTs are now, historically, the best performing ever part of the
NHS.
Q91 Dr Stoate:
I would like to ask Mr Belfield a question. Considering that we
are talking about £100 billion of public money every years,
it sounds alarmingly patchy and, frankly, alarmingly amateurish.
The assurance process published earlier this year showed weaknesses,
some quite significant weaknesses in some areas, particularly
the ability to stimulate the market and procurement skills. What
is being done to address this? How can you distinguish between
weak and less weak PCTs?
Mr Belfield: We have put in place
the most rigorous process of assessment for PCTs that we have
seen across the NHS. It is comparable with the monitoring of FTs,
but it goes beyond that because it looks at development as well.
We have put a system in place and the result from year one, a
developmental year, are exactly where I expected them to be. Because
we have never really asked PCTs in the past to manage markets
and such like, why would they, from a standing start, all be able
to do that? We knew which scores would be relatively weak in those
areas. Equally we knew that people would score well on partnership,
because traditionally the NHS has done well on that. That was
my starting point. The more important point for the future is
what we are doing to develop that. We have had a development programme
that we have run with the SHAs and with the NHS Institute for
Improvement, looking at helping every single PCT in the country
to improve their performance, so I would expect to see, for example,
competency scores to rise this year. We are doing things on the
technical side, about how to do procurement well. We are doing
things on how to manage markets, which is as much about collaboration
as it is about competition. We are helping people to showcase
where they are doing really well on public engagement, for example,
and public engagement is beginning to move forward very quickly.
Where PCTs are doing that well—and I am sure David has examples
of that—we are using those PCTs to help showcase, to show
others how quickly you can move forward. Absolutely this is a
longer-term project. It is £100 billion, as you say. We need
to put a lot of effort into development and we are certainly doing
that nationally but also very locally as well. Quite encouragingly,
35 PCTs, recognising that they need to do things to develop, are
working together for their own development, so there are a lot
of things happening at a very local level as well.
Q92 Dr Stoate:
I find it even more alarming that you talk about a standing start
as if we have only just invented this. The purchaser/provider
spilt has been around since 1991 or whatever, 28 years ago, and
you talk as if we have just decided we ought to look at quality
of commissioning 27-odd years later. That is the most alarming
thing. Why have we not been doing this for the last 20-odd years?
Mr Belfield: I am talking about
this in relation to the way that we have defined commissioning,
which I think is the first time we have ever really defined commissioning.
Q93 Dr Stoate:
After 20-odd years we have just decided to define commissioning,
and then we will have a standing start and see if we might be
able to improve it—and we are still spending £100 billion
a year in, to be honest with you, a fairly random fashion.
Mr Belfield: I am just thinking
whether I can answer for 27 years of policy.
Mr Stout: I am not from the Department
of Health, I am sure I can say something. As a national health
system we did not invest appropriately in commissioning. We did
not give it sufficient clarity, we did not give it sufficient
support, we did not give it sufficient status, and we suffered
as a result. We are now catching up a little late in the process—but
we are catching up.
Q94 Dr Stoate:
I would like to quote from a paper from the Office of Health Economics
1998: "The best American Commissioning groups have concluded
that health care is far more complicated to purchase than anything
else." That was ten years ago and yet we are still grappling
with the basics.
Dr Colin-Thomé: I do not
know if it is basics. It is because it is down to complexity.
This is not unique to Great Britain. Most of the countries that
we know of have focused very much on the provider side. If you
look at some of the American insurers, the aim seems to have been
to shovel money to the acute providers rather than making more
discerning judgments. I am not defending this—of course
we should have done stuff earlier, but the fact is that most healthcare
systems have focused predominantly on that. In one sense we should
get some credit in this country for making an attempt to professionalise
commissioning. Other countries have palpably failed to do that
and have spent a lot more GDP on often just more inefficient health
care rather than making a huge difference to health gain.
Dr Stoate: Thank you. I am a bit more
reassured.
Q95 Dr Naysmith:
How can we be sure that PCTs are up to the job and that they have
the expertise and the resources necessary to do what they need
to do? Before Dr Colin-Thomé starts telling me all about
the good things that South Gloucestershire and Bristol PCTs are
doing, I am very well aware of that. Quite a bit of evidence has
been submitted in previous hearings that a lot of people think
the PCTs do not have the resources and they do not have the expertise
to commission lots of things.
Mr Stout: The assurance points
in the World Class Commissioning system were designed just for
that purpose; in other words, it is a public, systematic, rigorous
assessment of how effective commissioning is. We have never had
that before. We have never had a means of giving the assurance
you are asking for. We now have a system that does that and it
shows, as we have already said, that there is some way to go before
we can claim, hand on heart, that we are world class or anywhere
near it. It definitely shows there are development needs of PCTs.
Beyond the "I want to do a good job because I want to do
a good job" incentive, it also creates some incentive, by
being held to account in a public way, for organisations to take
their responsibilities seriously and to do something about it
where they have deficiencies in capacity or capabilities. You
can see PCTs individually and collectively starting to work on
those areas where they do not have those skills. That is either
through bringing in external partners to work with them or working
together. For example, on Howard's question about market-making
and procurement, most PCTs are now starting to say, "Let's
not do that 152 times over; let's set up specialist units working
to us who will ensure that our procurement skills are up to scratch
and that we do not dissipate resource by doing it 152 times over."
You can be assured by the system of assurance and the public nature
of that and by seeing what PCTs are doing in terms of action to
address the deficiencies that system has thrown up.
Q96 Dr Naysmith:
When this Committee was doing the inquiry into the commissioning
of dental services quite recently, we discovered that there was
huge variation between PCTs in their ability to commission dental
services. In some places—and Bristol was one—they
were really good onto the job of commissioning dental services.
We found that in other PCTs they asked the office boy or girl
to do it and they did not have the skills to do the job properly.
How can we ensure that does not happen?
Mr Stout: You will have variation
and we do have variation. You are quite right: there is variation
in performance of commissioners that is exposed in this process
I have described. There is also variation about where commissioners
put their efforts and some of that variation is entirely legitimate
and reasonable. If in analysing your local patch you find that
your fundamental health problem is the inadequacy of your stroke
services, then, given limited management capacity, you should
focus your efforts in that rather than dentistry if that is less
of a problem. The areas that do have particular problems of NHS
dentistry characteristically are the ones who have put particular
management effort into doing something about it. The areas that
have had historically poor access to NHS dentistry, by and large—and
I cannot say for certain that they all have—are the ones
which will have invested time and effort into procuring new services,
developing, be they new GDP practices or mobile services, whatever
is the right answer in their local patch. You will see variation,
just inevitably, because we start from different starting points,
and almost systematically, because people will be focusing on
the specifics priorities where you are going to get most impact
for your investment of time and management of the commissioning
effort.
Q97 Dr Naysmith:
What roles do Commissioning for Quality and Innovation (CQUIN)
and Never Events have? Also, is there any role for punishing providers
for not doing or—even worse—making people ill when
they are supposed to be making people better?
Mr Stout: They are two examples
of commissioning interventions around quality. The CQUIN one being
incentivising through cash—either more for doing better
or less for doing worse—incentivising providers to respond;
the Never Events being having a systematic approach to publishing
data on things that should never happen.
Q98 Dr Naysmith:
Is it used? Is this a way of having consequences now?
Mr Stout: As a policy it came
out in the Next Stage Review, so it is relatively recent, but,
yes, it is starting to be used as one measure of quality in the
commissioning process. Those are two examples rather than the
whole way that a commissioner can intervene in relation to quality.
Every PCT lead commissioner for a hospital, for example, will
be having monthly clinical quality review meetings now with much
better data on what good looks like, so much better metrics for
performance, and starting to use those to drive the dialogue about
their performance at the hospital rather than simply counting
widgets. Earlier the PBR critique was that it was simply about
numbers of people; now we are looking in much more fine detail
at the quality of commissioning.
Q99 Dr Naysmith:
Traditionally that is what happened.
Mr Stout: It is caricaturing it
a little, but, yes, there was an element of the concept of commissioning
being a remuneration system rather than a commissioning system.
That is what we are moving away from. This not simply about how
you get money from the Treasury to providers of service; this
is about treating that money as a health investment rather than
just a spend mechanism. That is the sort of change we are talking
about.
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