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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