Examination of Witnesses (Questions 120
- 139)
THURSDAY 22 OCTOBER 2009
MR GARY
BELFIELD, DR
DAVID COLIN-THOMÉ,
MR MARK
BRITNELL AND
MR DAVID
STOUT
Q120 Sandra Gidley:
Are we talking about clinically effective or financially effective?
Because there is a difference.
Mr Belfield: There is. In our
competencies we look at both, but competency 11 is about how financially
effective the commissioning plans are. I can give you more details
on that after.
Q121 Sandra Gidley:
You can still balance your books but not make sound financial
investments.
Mr Belfield: Yes.
Dr Colin-Thomé:
That has been a problem in the past,
Q122 Dr Naysmith:
Mr Britnell, do you think that any country does commissioning
well? The World Class Commissioning we are talking about now,
does that exist anywhere in the world?
Mr Britnell: The answer is no.
However, in reference to the earlier questions asked and answered,
we have tried to take the best out of different systems and so
we did spend a lot of time looking at North America, and that
includes Canada as well, and looking at the developed nations
in Europe and also Australasia. I would say there is no perfect
system. There are some interesting systems that people want to
know more about, such as Singapore or Hong Kong, but they have
no relevant context to the English NHS. There are things that
you can pick out of different systems, and that is what we have
tried to do with the competencies. It is worth saying, by the
way, in relation to one of the issues that Mr Bone raised about
the spin of World Class Commissioning, that the Commonwealth Fund
in 2006-07 did rank health nations and on a mixture of indicators
considered that the English/UK system was probably the most developed.
Of course that has been open to some comment and debate, but it
is worth bearing in mind that we have some excellent preconditions
for commissioning because of the nature of social insurance that
is the NHS. In a sense, many of us formulating the policy—and
Gary might want to say something—felt that the odds were
stacked with this lot against us because of the way the funding
has developed in this country.
Q123 Dr Naysmith:
Why did you involve Kaiser Permanente when you were doing your
panels for WCC? Did it turn out that they were value for money,
bringing them from, for example, California?
Mr Belfield: When we were forming
panels, we wanted to have a really rigorous test, as I said earlier,
so the panels that we created would spend a whole day assessing
the PCT, they would be chaired by the SHA, would have a clinician
on board from the local area—a doctor or a nurse, so broader
than just doctors. We would have a local authority person (often
a director of adult social services on the Panel—not always
but often) and then we would have a PCT chief executive of the
patch. We thought that was quite a partner with the SHA. We thought
that would be a pretty rigorous test. Given that we were looking
to aspire to being the best across the world, we thought it might
be helpful for the first two years to have another organisation
in to really push and test. Because we were quite taken with some
of the work that Kaiser Permanente are doing in California about
integrated systems and they know our systems quite well, we thought
we would bring them into the assessment for the first two years.
The reflection back from the panels was quite mixed. Where the
panels in terms of Kaiser Permanent were really good, the directors,
then it was a very good experience, very developmental, very challenging.
Some other PCTs did not find it as helpful, but that is partly
because we got the wrong people. This year we have learned from
that and we are bringing a smaller number of people from Kaiser
Permanente, the better ones, who will test the system. The better
PCT panels certainly found it was helpful to have Kaiser in the
room.
Q124 Dr Naysmith:
Previously this Committee has had discussions with Kaiser Permanente
and visited them in the States. One of the things they do is to
limit your choice of doctor—you see the company doctor,
to put it rather crudely. That is not part of our system, is it,
because GPs now can refer to any specialist in the country they
want? Do you think about involving this principle or not?
Mr Belfield: When we were bringing
Kaiser Permanent directors and senior clinicians along, it was
for their personal expertise rather than for the organisation
they stand for. We were not making any statement that this is
where we think the NHS is going at all. It is only for the first
two years. We will not be using them after this year.
Q125 Dr Naysmith:
We have Mr Britnell's view that commissioning is not done very
well anywhere in the world and there is no world class commissioning
anywhere in the world that you can go and look at.
Dr Colin-Thomé:
Professor Bevan was suggesting maybe the Netherlands.
Q126 Dr Naysmith:
Yes, so that is worth looking at, is it?
Dr Colin-Thomé:
Maybe not—because, like I say, it is too radical a shift,
is it not? Mr Britnell and Mr Belfield have said that it is almost
like looking at the design principles of what makes a good commissioner
that we would go for, rather than to try to bring a model from
abroad and dump it here. The structural difference would be so
radical as to be a nightmare to try to absorb, but some of the
principles of how they do it are what we would like to learn from
rather than imposing a model. I was brought up to believe that
the right model is that there is not a model. It is about what
are the basic principles and how can that help a management in
the context of whatever health system you are in.
Q127 Dr Naysmith:
The other thing which flows from this line of questioning is that
we heard earlier that in New Zealand and Wales and Scotland and
Northern Ireland they have decided to go the other way. Having
been exposed to commissioning type systems, separation of provider,
they have gone back and decided to do something else. Have they
made a mistake?
Dr Colin-Thomé:
They may have done. I suppose the proof of the pudding is how
good are their health systems going to be in terms of their quality
and use of resources? There is quite an issue that they might
go back to a much more provider-dominated approach. They may or
may not. The real issue for all of us internationally is that
health services are hellishly difficult things to manage. The
jury is out. I do not think going back means it is going to be
better. That was the assumption certainly of Hamish Meldrum, but
it is a reflection of the fact that these are very difficult issues.
I would argue that the design principles we have tried to bring
in to keep that slight separation from the providers has a lot
to offer, but rather than saying it is right or wrong we will
have to wait and see about evaluation. I know we have caught up
virtually with European averages, but we do do a lot of work.
Productivity could be better, but compared with other healthcare
systems we do use our resources much better than many. That is
what the Commonwealth Fund Assessment was about.
Mr Stout: It is fair to say that
Scotland and Wales are still doing commissioning.
Q128 Dr Naysmith:
You cannot get away from commissioning. You have to commission
services somehow.
Mr Stout: Yes, you must be commissioning
because someone is planning, someone is remunerating service providers
and so on. The point you made earlier about the scale of the country
does make a difference. The question is how separate have they
made their commissioning function from their provider function.
It must be separate to some extent. I cannot see how it cannot
be. Whilst I am no expert on their healthcare systems, (1) I do
not think it is quite as different as your question implies, and
(2) David is right that this is, if you like, a great natural
experiment. We will be able to see in five years time how the
two different types of systems evolve.
Q129 Charlotte Atkins:
What are the benefits of bringing in external support for World
Class Commissioning? Is it cost effective? Given the comments
about commissioning in other countries not being particularly
brilliant either, what are the benefits and what are the costs?
Is it value for money?
Mr Belfield: If PCTs are intelligent
commissioners, then they can use outside bodies really helpfully.
That is my starting point. If we are trying to move commissioning
forward in the way that we have all talked about today, then it
is important, where there are weaknesses, if they can bring people
in for short-term or even medium-term to help them improve their
skills and experience, then that is okay. We have encouraged that,
but only where they have their gaps. For example, in management
of data, where PCTs in some areas have been quite weak they have
found it beneficial to bring in organisations to help them improve
their data. That then flows on very quickly to improving their
commissioning decisions, which improves the health of the population.
I can see the benefit of that. Answering your question about whether
it is value for money and how much is being spent, I do not know
that. I do not collect that at a national level. Anecdotally,
it feels to me that PCTs are getting better at using organisations
to bring them in. It is moving on quite quickly. PCTs are now
looking to help each other as well, so there has been quite a
shift in the last 18 months. I cannot answer your question properly,
I am afraid.
Q130 Charlotte Atkins:
Is it the decision just of a PCT, or are they pushed into it by
the Department of Health or by the strategic health authorities—as
they were, for instance, with the ISTC contracts, where they were
told basically they had to buy into them? How voluntary is this?
Is the decision making made by the PCT or are they told by the
SHAs or by the Department of Health that they have to appoint
people?
Mr Stout: It is the PCT's job
to decide how it spends its resource, and that includes decisions
about how to spend its resource on commissioning and whether to
bring in external support or not, so it is absolutely the PCT's
decision.
Q131 Charlotte Atkins:
In the past we have seen, with the ISTC contracts, for instance,
that basically they had to.
Mr Stout: That was not a PCT decision.
That was explicitly a national procurement process. That is very
different.
Q132 Charlotte Atkins:
But the level of their involvement was a PCT decision.
Mr Stout: Where there might be
pressure would be if in your World Class Commissioning assurance
assessment and your SHA's view of your competency more widely
your PCT appears not to be doing very well, and you say, "Well,
I am not going to do anything about that. I am happy." Then
I think there would be pressure to say, "That's not good
enough." I think that is entirely legitimate. That is not
pressure necessarily to bring in external support; that is pressure
to improve. External support is only valuable where it is adding
skills and capacity that you do not have internally. In those
circumstances, a PCT board absolutely rationally will say, "The
quickest and most effective way of getting better at our job is
to bring in skills from outside that we do not have." That
is the PCT's board decision and they should be held to account
on that like any of their other decision-making processes.
Q133 Charlotte Atkins:
Is there any analysis of the use of these consultants to make
sure that they are getting value for money? Clearly, if they are
spending a lot of money on consultants there has to be some sort
of scrutiny of how effective the choice of the PCT is in bringing
these people in. To take United Health, a US insurance company,
they probably do not have a huge amount of experience of providing
free universal health services because they do not have those
in the States, so what relevance do those particular companies
have in PCTs? Are they given a short list of companies that they
could look to buy expertise from? Is there a list of approved
contractors, as it were, from the NHS, or do they make their own
arrangements either at regional or local level?
Mr Belfield: The Department of
Health is not mandating any PCT to use private contractors at
all. That is not part of what we are doing. To help PCTs who want
to bring in expertise from parts other than the NHS, we have created
a framework of companies that we have approved and assessed, to
say to PCTs that these have been kite marked, in a sense, to say
that they could help you with some of your commissioning decisions.
United are in there as part of their data management, because
they are very good at data management, for example. We do not
tell PCTs they have to use them; we say, "You could use this
framework." Equally, if PCTs want to go out to the market
to tender locally, they can do that. In terms of your question
about how much is being spent and value for money, et cetera,
we do not collect any of that data nationally apart from this
framework I have mentioned. I am very happy to write separately
to the Committee to explain how that framework has been used in
terms of where it has been used and the costs incurred.
Q134 Charlotte Atkins:
Those that have the sort of Department of Health kite mark, do
their charges also have a kite mark? Given that we have already
been talking about the balance of power between PCTs and secondary
care, if you are talking about a big company that they are buying
in to with great expertise, what sort of kite mark do they have
in terms of their tariff of charges?
Mr Belfield: It works very similar
to the other national commercial frameworks we have. The tariff
is set, so it is part of the process of approving a company on
to the framework. We do not only approve them whether they are
fit for purpose, but we also approve their prices, and therefore,
transparently, PCTs can see the price in terms of per day or per
week or whatever as standard practice.
Q135 Charlotte Atkins:
They also go to other providers who do not have the kite mark.
Is that the case?
Mr Belfield: That is right. If
they think that there is something very specific to them that
is not served by this framework—because this framework is
not comprehensive—then they can go to other people. It is
completely a local decision.
Q136 Charlotte Atkins:
In terms of transparency, does the PCT separately identify the
amount of money that they spend on consultants of this nature
in their annual accounts?
Mr Belfield: I am sorry, I do
not know the answer to that.
Mr Stout: I do not think there
is any statutory obligation, but I would expect a board to be
transparent in its working. I would expect that kind of information
to be transparent about how they are spending healthcare resources
in every sense.
Q137 Charlotte Atkins:
If someone were to put in a freedom of information request, for
instance, they would have to reveal that, would they?
Mr Stout: As far as I know. I
am not an expert on FOI, but as far as I know, yes, unless it
is commercially confident you are obliged to publish.
Q138 Charlotte Atkins:
Again going back to the ISTC issue, we have had problems in the
past where we could not get information about the nature of contract
with independent secondary treatment centres because that was
commercially sensitive. I am trying to find out whether PCTs buying
services from outside consultants, whether they are kite marked
or not. Would the services they buy be itemised in some way or
another so the public could see them? If you do not have the answer,
maybe someone could come back to us and give us the answer, and
also the answer, if it is not identified in their annual accounts
and a freedom of information request was put in, whether that
would indeed also be revealed to whoever might ask for it by the
FOI.
Mr Belfield: We will come back
to you on that one.
Charlotte Atkins: Thank you.
Q139 Mr Bone:
My PCT, Northamptonshire, is very keen on external consultants
and they are spending millions of pounds on them. They think it
is the way forward. But theirs is performance-related. They are
not paying the consultant by the hour; but related to the success.
They think other PCTs should be doing the same. One extraordinary
answer is that the Department of Health does not know how much
money PCTs are paying to external consultants. There are only
152 of them. Would you not like to write to them and ask them?
I think that should be in the public domain. We are talking about
millions of pounds of public money paid to private contractors.
Why on earth does the Department of Health not know about this?
Mr Belfield: First of all, I agree
with you about the way they are working in Northampton. Increasingly
PCTs are looking to have a risk-share arrangement. That is what
I think you are describing for Northampton, and certainly we would
encourage that. That is certainly happening. In terms of the collection
of data, I think it is quite difficult really, in the sense that
whenever we do try to collect data then PCTs and the NHS complain
that the Department of Health is quite bureaucratic in collecting
data. We are trying to get a system where PCTs are the local leaders
of the NHS in running their system and they need to be transparent
and accountable to the local population. I am not sure necessarily
it is always the answer for the Department of Health to collect
data. There is something about transparency locally, with PCTs
taking some responsibility of this, rather than the department.
Mr Bone: No, I am not thinking of that.
I know what happens. I can find out from my PCT what my figure
is, but I want to know what is happening nationally. I want to
know where it is happening in different regions. Every time I
send a freedom of information request to my local hospital, they
send me back reams of pages telling me why they will not answer
it. Come on, it does not work. Transparency. If the Tories get
in power, you are going to have publish anything you spend over
£25 grand, so you had better get used to providing this information.
Chairman: I think this is something we
can pick up in our PEQ annual exercise. We will have a look at
it.
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