Commissioning - Health Committee Contents


Examination of Witnesses (Questions 100 - 119)

THURSDAY 22 OCTOBER 2009

MR GARY BELFIELD, DR DAVID COLIN-THOMÉ, MR MARK BRITNELL AND MR DAVID STOUT

  Q100  Dr Naysmith: Does anyone have anything to add?

   Dr Colin-Thomé: One of the international issues is what Al Mulley at Harvard calls "unwarranted variation" and that is true in providers as well as commissioners. A bit like the GP QOF system, World Class Commissioning is about a continuous quality improvement programme, so it is trying to systemise that and iron out as much of the unwarranted variation as you can. In which case, there will be a good process to begin to shape that but the issue that David mentions is hugely important, that we need to make certain that the variation in capability is tackled, but if you want to have a certain amount of devolution, individual PCTs have to have the incentives to make decisions which are appropriate to their population. Those are two separate issues, but in terms of capability, we are trying to make certain that we can get a more standard set of PCT people.

  Mr Belfield: We would absolutely agree with the point that PCTs are starting from different places and so capability, like in any large organisation, is variable. We have recognised that as part of having a development programme to support individuals as well as the PCT, but the places that did not do so well in the first year of World Class Commissioning are already having intervention with their SHAs, helping support that PCT to improve. We know that time is of the essence and we need to move on, so we are doing something now rather than waiting for the future. On the point you make about CQUIN, that is definitely where this trend is going. We are going to give more tools and more support for PCTs to be able to commission for quality. That is absolutely the direction of travel.

   Dr Colin-Thomé: Also, it will help to get more clinicians excited about this, because otherwise it seems a hugely bureaucratic thing. It is very hard to be a good commissioner without having responsive, good quality providers, and this is one way of getting clinicians involved in setting some of the standards. If you do set your own standards, again there is an international evidence base that peer group review is a powerful way of learning and improvement.

  Q101  Dr Naysmith: The other thing that happens quite a lot now to do with competency is that PCTs collaborate. A PCT will take the lead in a particular area where they have the competence. Presumably you would think that was a good thing.

  Mr Belfield: Absolutely. That is happening organically. Particularly where people have low expertise in something or it is technical, they are working together. We are finding that all over the place. There are 14 PCTs in the West Midlands working together on data, for example, to take Dr Stoate's point earlier. We are seeing that happening across the country and it is a good thing.

   Dr Colin-Thomé: Sometimes you are commissioning for individuals, and that is what clinicians are often doing, and yet you can be commissioning for quite rare things, like forensic psychiatry. One of the fits for practice-based commissioning is that you can do some of that local clinical stuff and be an adjunct to PCTs and then for other functions PCTs need to merge their functions.

  Q102  Dr Naysmith: We are going to deal with specialised commissioning a little bit later.

   Dr Colin-Thomé: I am saying that we should not be frozen by the structure; it is about the attributes of these organisations. We have to tackle local stuff as well as having the big stuff, which is part of what our process is certainly going to improve.

  Q103  Mr Bone: World Class Commissioning. Have the spin doctors taken leave of their senses? We have heard from the previous evidence and from what you have been saying that it is trying to make a little bit of an improvement. Should it not be, "Err, we are trying to get it a little bit better"? The idea that we are moving from now to world Class Commissioning seems to be ludicrous. Discuss.

  Mr Belfield: Everyone is looking at me. We are one of the largest organisations in the world, we have 60 million people in England looking for our care, and we need to have high ambition. I do not apologise for calling it World Class Commissioning. We are not at anywhere near world class. I completely accept that we are nowhere near world class at the moment, but we need to aim high. If we aim low, then we will hit low. We need to aim really high and have great ambition for our local population, for the health of the local population, and say we can do things differently. I do not apologise for calling it World Class Commissioning.

  Q104  Mr Bone: That is fine. It is an aspiration.

  Mr Belfield: It is aspirational.

  Q105  Mr Bone: Given where we are at the moment and given the limited resources, what can we realistically expect from commissioners at the moment?

  Mr Belfield: With the impending financial change that is coming, I think we need commissioning more than ever. Otherwise, we will end up reverting back to type. We will revert back to a big provider system. In times of financial tightness—and remember it is still £100 billion, so it is a lot of money—we need to make sure that we are looking on prevention agenda, we need to make sure that we are delaying illness for people. That is why commissioning for long-term health is even more important than ever. That is why we are pushing harder this year for year two of World Class Commissioning, to help PCTs to get ready for what will be a tighter fiscal regime 2011 onwards. It is even more important than ever, I think.

   Dr Colin-Thomé: We could also lead the way in this country on beginning to challenge ineffectiveness. There is a huge international evidence base that there is much duplication and inappropriate ways of organising health care. Hopefully we can drive that out, so that it does not damage services or quality. Sometimes it is called rationing—which is nonsense. You ration by not giving people the stuff that has a good evidence base. But if you look at the way we structure a lot of our health care, and if you look at the NHS Institute webpage and all the others and the amount of money we are spending on things which we should be shedding. We need commissioners to be able to lead the way on that, to try to get providers to shape up on those issues.

  Q106  Mr Bone: We have heard some media reports this week about PCTs banning together to lobby NICE, to restrict cancer drugs. Is that an appropriate way of commissioners spending their money?

   Dr Colin-Thomé: If there is a strong evidence base for clinical intervention, it is very hard to say no. The issue is that what happens is we focus on cancer drugs and can we afford more expensive drugs, or on this stroke issue, say, on whether you need both high-tech care for people who have had a stroke and also prevention. My argument is that there are lots of other things we do—and I will come to some of the bees in my bonnet. The construction of out-patient care in this country, which amounts to 45 million patients a year, probably has the flimsiest evidence base of anything that we do, and yet we spend millions of pounds on that when, in fact, a lot of the time they are not necessary contacts or are duplicating what is happening in general practice. If you began to drive out some of the unnecessary high volume/low cost care and began to challenge that, you would release significant amounts of money. The NHS Institute talks about comparisons in performance between hospitals, that if the bottom hospitals, as it were, were to achieve the levels of lengths of stay and all the things that the top hospitals do, we could save over £2 billion within our resource. There is a lot of money available from high volume/low cost things. That is what commissioners might need to do, because providers have obviously not been up to beginning to challenge that.

  Mr Stout: The media report you refer to is, I have to say, slightly misleading. PCTs are there working together—as I think we have all argued they should—to use evidence effectively to make sure that decision making is as consistent as we can make it, and to work with NICE to make sure that when NICE is appraising new technologies that is done with specialist input from commissioners as well as specialist input from the pharmaceutical industry, patient groups, clinicians and so on. It is not a lobbying intervention; it is a using skills intervention.

  Q107  Mr Bone: This Commissioning Support Appraisals Service is a PCT initiative, not set up in the Department of Health.

  Mr Stout: Yes, it is PCTs working together collaboratively to get the most effective collective input to the NICE process that they can. As I say, I think that is something we should welcome rather than criticise.

  Q108  Mr Bone: Some of the personnel that are advising you from a company called Bazian also work for NICE. Is there not a conflict of interest in that? Most people I speak to would expect your money to be spent on commissioning services, not really in the lobbying field, I would have thought.

  Mr Stout: As I say, I do not know the detail about the company but this is not work on lobbying; this is work on expert input to the process of appraisal.

  Q109  Mr Bone: Is that not lobbying?

  Mr Stout: No, I do not think so—not what lobbying suggests to me, anyway.

   Dr Colin-Thomé: NICE does produce commissioning guidelines on many issues. I have been involved with some of that, and I suppose I could say that was a conflict of interest with the Department of Health, but they need information from people who have been involved in the service. NICE use other people from the service to begin to help not just on the clinical appraisal of drugs and technology but also on the clinician guidance. On the NHS evidence they are going to be producing, they have used many of us. Conflicts of interests are sometimes raised that stop all advance. If there is a conflict of interest, sometimes you have to make certain it is transparent rather than stopping some of those tensions inherent. Otherwise, you get a bureaucratic nightmare and you do not get the best innovation.

  Q110  Charlotte Atkins: We are going to be hitting a tightened period of public expenditure. How is that going to impact on commissioning? Some witnesses have suggested that we should get rid of commissioning to be done in other places. Others have said that we should spend more money on it. Others are saying we should make it cheaper and simpler. What is your approach? Clearly all of you have said that commissioning has a role. In a situation where there is going to be tightened expenditure, in those straitened times what will the role of commissioning be? Will it still have an important role within the NHS?

  Mr Stout: Gary has already said, and I agree, that in straitened times the role of commissioners becomes even more important than it ever was. In terms of who is responsible for driving up quality and driving up value for money in the healthcare system, it is the commissioning function. The arguments you have heard from previous speakers were about how you do it rather than whether you do it. I did not hear anyone saying, "You shouldn't be doing that function." In terms of the question about investment and how we use the commissioning capacity that we have, everything we have already discussed suggests that we need to continue to strengthen the way we do commissioning. I do not think, necessarily, that means extra investment. It means using the skills and capacity we have to maximum effect and making sure we develop those skills as far as we can. The pressure is that it is probably only a year or 18 months away before the real financial burden on the NHS starts to be felt in a very significant way. We have this period of time to do the kinds of development that Gary was talking about earlier and we have to get that right to make sure when times get really tough we have those skills in place to deliver commissioning efficiently and effectively.

  Q111  Charlotte Atkins: Will that ensure that the primary care focus of present policy will continue rather than going back to the old system, where acute hospitals completely dominated and ruled the roost?

  Mr Stout: Absolutely.

  Mr Belfield: I would completely agree with that. I am not advocating that we spend more on commissioners necessarily. There are some things that commissioners can do together to reduce their back-office costs—personnel and payroll and such like that—so there are savings that can be made.

  Q112  Charlotte Atkins: Do you want to go into that a bit more?

  Mr Belfield: Instead of having, say, 152 PCTs all having their own back-office function, like payroll, HR departments, et cetera, we are finding already that people are beginning to collaborate. One might do it on behalf of ten others, which makes a lot of sense in terms of the public purse. I think we will see more of that coming through. I know we will see a debate in the next weeks and months about how you can have improved quality and also improved productivity, and some of the things we have already talked about to date, particularly David's point about reducing some of this unwarranted variation between practice, is where we need to help PCTs/commissioners to really step up, in a sense, and challenge the providers to change their practice. We will see commissioning being strengthened from that point of view—not necessarily with more money, but strengthened. It is also really important that we remember that we have, all things being equal, another 5.5% growth next year, so there is an opportunity, if we think through now what we need to change in the future, that we can invest money now, which means we will save money down the line. We will see elements of that this year, particularly in 2010-11 coming through.

  Q113  Charlotte Atkins: Can I ask you to give me an assurance that you are not talking about more mergers of PCTs, you are just talking about sharing some back-office costs.

  Mr Belfield: Absolutely. I am sorry if I have given you the wrong impression.

  Q114  Charlotte Atkins: No, I just wanted to get that on the record.

  Mr Belfield: One of the messages I wanted to leave the Committee with today is: Please, please no more national reorganisation. It does not really help the situation at all. But we can have collaboration. The 14 PCTs in the West Midlands are collaborating together to share their data, only doing it once rather than 14 times. Those sorts of things make sense, but it still does not take away the statutory responsibilities of the individual PCTs. There is certainly no policy at all from this current Department of Health to have any mergers. That has been made clear by the last two or three secretaries of state.

  Q115  Charlotte Atkins: Do you think that the bigger the PCT, the more unlikely they are to be able to reflect the real needs of their local communities? I fought very hard to keep a local PCT and I am not intending to see it merged.

  Mr Belfield: Absolutely. I agree with you completely.

   Dr Colin-Thomé: I was involved when I was at London Region in looking at PCGs and how they were going to develop. I think we get stuck on size and structure rather than the attributes. I used to say that if you are big you have to demonstrate localness and if you are small you have to demonstrate collectiveness. It is the attributes we need to be judging on. That is what some of the competencies are about. They are principles rather than a set model. That is what I find so attractive. If you have a huge PCT, they have to demonstrate some locality and leadership for connecting with primary care and local communities. We have already described that if you look at some of the rarer things, they need to begin to say that there is a lead commissioner with all the skills. It is in those ways we will improve, without having to have a lot of cash going to them but more effective ways of working, depending on what level of commissioning you are looking at and what population you are looking at.

  Mr Britnell: Since the introduction of the competencies, I genuinely believe that for the first time in the history of the NHS it has given PCTs nowhere to hide. It is a very explicit way of judging their competence against the 11 criteria. We are finding—and Gary has just spoken to you fairly eloquently—that it is producing larger scale where that scale does not detract from patient care. In some of the analytics in knowledge and information management, you can still have localism but have a big powerful engine that sits behind a number of PCTs. As you well know in the West Midlands, in your particular patch, that knowledge centre could be based literally anywhere in the West Midlands or somewhere else, as long as the information is then applied to the populations concerned. The assessment is making people move on much more quickly. In a sense, that is more profound and organic and better than having a top-down solution. When the previous speaker said the evidence base was limited, it really is the first time in 60 years that we have tried to assess commissioning and we are only second year into it. It is a bit early to say, but I think all the movement is in the right direction.

  Q116  Charlotte Atkins: We have acute hospitals which would very much like to have commissioning from one big commissioner. It makes their lives easier just to have one commissioner, a big area, with their commissioner being the person or the organisation that they just deal with, rather than having to deal with different PCTs that may have different needs: a more rural community, an older community, a more deprived community. They would much rather deal with just one organisation. That means that what they deliver suits them rather than suits the local community.

  Mr Britnell: The issue that Mr Bone raised as well, about the next five years or so in the fiscal efficiencies that need to be made. There is a big debate that needs to be had—and perhaps you are at the foothills of it today in the first meeting about commissioning—about whether the systems are simple funding systems for hospitals to provide care or they are active commissioning systems. One is completely different from the other about how you make investment over a long period of time. With World Class Commissioning the department has tried to give PCTs the ability and permission to have five-year plans. Of course it is sometimes difficult to predict exactly how much funds will be going on after the next comprehensive spending review, but you can model it and make different scenarios. It seems to me that whichever system you have, you need an intelligent commissioner to wrestle with these issues. None of these issues is pain free. The idea of having fully integrated systems does not obviate the need for a very stringent and crisp and challenging discussion and debate over how resources are used. That is why you need local commissioning, because it needs to be closest to the population served.

  Mr Stout: On that flexibility that we are talking about, again in your local patch, looking at the redesign of services, North Staffordshire and Stoke PCT are working together on that because it makes sense to. In other services which will be much closer to home, it makes more sense for the local PCT to be drilling much closer to the community through practice-based commissioners and so on. It is both and. It does not have to be either or, it really does not.

  Q117  Sandra Gidley: Mr Britnell, you provided us with a PowerPoint presentation from your time when you worked at the department, and it looks as though the PCTs have only been scored against ten competencies. Why were they not scored against the missing one, which seems to be "make sound financial investments"? Because that seems to be quite an important one to me.

  Mr Belfield: Do you mind if I answer that? It was deliberate

  Q118  Sandra Gidley: I assumed so.

  Mr Belfield: We measured finance very stringently through the governance system. We had ten competencies which we measured separately and then we measured governance looking at strategy, finance and how the borders are operated. We had a very stringent look at the finances through that route, alongside the Audit Commission who supported us on that. For this year, even though we thought it worked pretty well, we have considered the changing financial regime and we have changed competency 11 slightly to be about how effective care is commissioned, and therefore we have made it a separate competency that will be measured separately this year.

  Q119  Sandra Gidley: So finance has gone now.

  Mr Belfield: No, it is part of competency 11.


 
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