Examination of Witnesses (Questions 140
- 159)
THURSDAY 22 OCTOBER 2009
MR GARY
BELFIELD, DR
DAVID COLIN-THOMÉ,
MR MARK
BRITNELL AND
MR DAVID
STOUT
Q140 Sandra Gidley:
I must admit I have become slightly confused with all this talk
of different types of commissioning. I listened to where we have
got with the practice-based commissioning, but we have heard a
lot talked about PCT commissioning. What is the difference between
the two?
Mr Belfield: The PCT is the statutory
body that holds the money. When I talk about commissioners, I
talk about the PCT, because they are the body which is given the
money to then spend it on behalf of the taxpayer locally. PBC
fits within that though.
Q141 Sandra Gidley:
Can you explain how it fits within it, because it is not at all
clear to me.
Mr Belfield: For commissioning
to work, it has to have much more clinical engagement, so practice-based
commissioning fits within PCT commissioning the following way.
The PCT looks at its needs assessment for the local population.
It does that with its partners, including local GPs and clinicians.
They then choose their top ten health outcomes that they want
to achieve: reductions in cancer rates, improving heart disease,
et cetera. The idea is that the practice-based commissioners and
GPs have had a say into that.
Q142 Sandra Gidley:
They have only had a say into the top ten.
Mr Belfield: We did not want people
to have 500 objectives; we wanted them to focus on ten so that
they could really start to make a difference to the people's lives
for those ten things. Practice-based commissioners or GPs if they
are not practice-based commissioners all can have a say with the
PCT. Then the PCT says "This is where we want to get to,
say in five years time, for the reduction in cancer rates, the
reduction in obesity, the reduction in smoking rates" or
whatever they have chosen, and the practice-based commissioners
can have a contribution by providing some services to try and
move the services forward or, equally, by being part of the challenge
to the local secondary care organisations to say about how they
want care pathways to change. Practice-based commissioning—or
clinical commissioning is probably a better phrase for it—fits
very much within what we are describing as PCT commissioning.
Q143 Sandra Gidley:
Are the ten priorities decided at PCT level?
Mr Belfield: They are decided
at PCT level, yes, within the local population.
Q144 Sandra Gidley:
My PCT is Hampshire—very diverse. If you have this group
of surgeries in an area that is not interested in that ten but
wants to do something completely different, they cannot, are you
saying?
Mr Belfield: Not at all. You are
talking about practice-based commissioner, are you, in that example
you have just given?
Q145 Sandra Gidley:
Yes.
Mr Belfield: We would like everyone
locally to all work towards the ten, so reducing obesity, smoking,
et cetera, but if you have local ideas that can make a difference
to your patients and you want to move, say, a phlebotomy service
from being in hospital to your practice, then you are completely
free to do that within practice-based commissioning. It does not
run counter.
Q146 Sandra Gidley:
They do not have to run it past the PCT.
Mr Belfield: It depends on what
the processes are at the local level. Some places, depending on
the value, might need a business case to approve that, but other
places would let things go. I do not know Hampshire that well.
Q147 Sandra Gidley:
How often does a PCT say no?
Mr Belfield: I could not tell
you that information.
Mr Stout: It would vary depending
on what you are talking about and what they say. The process by
which PCTs are making their strategic decisions should be fundamentally
clinically driven. That is basic to being a commissioner. You
cannot commission without clinical leadership being part of that.
Many PCTs are building their clinical leadership teams out of
the leads for each individual practice-based commissioning group.
Hampshire is doing something along those lines, if I remember
rightly, from what I know of Hampshire. For the overall strategy
for Hampshire, that would have been led by the clinical leads
of the practice-based commissioning groups. That is for the overall
strategy for Hampshire. Within Hampshire and within individual
local areas, clearly there are other more localised initiatives
going on. In some cases that will need a business case to be signed
off by the PCT. How often will they be signed off? That would
entirely depend on how good the business case is, obviously. The
smart PCTs which have this well developed, work really effectively
upstream of the business case being received, so they work together
on what a good business case would look like, debate whether it
is a runner at all in the first instance. The more you have done
that upstream work, the more likely you are to say yes to a completed
business case once it comes through. But you only need a business
case in instances where, in effect, practices are increasing their
income base because they are providing new services, and there
needs to be some due diligence over that decision. In other words,
PBC groups cannot just sign cheques for themselves.
Q148 Sandra Gidley:
There is an awful lot of stuff that falls outside those ten.
Mr Stout: Ten is just the high
level objectives of the organisation. That is not the only ten
things going on in the PCT. We should not over-emphasise them.
Q149 Sandra Gidley:
It is a bit of a mish-mash really, is it not, trying to get a
handle on it?
Mr Stout: It is like any big organisation.
There will be big strategic objectives and there will be local
initiatives happening.
Q150 Sandra Gidley:
I meant that it is very hard for us to get a view on what is happening
around the country because it is completely different anywhere.
Mr Stout: Yes.
Q151 Sandra Gidley:
Those who are into localism might support that but it is very
difficult to find out where it is working well and where it is
not.
Dr Colin-Thomé:
We are doing a major bit of work in the Department of Health about
getting evidence-based measurement, metrics, both on clinical
care and on the processes, and that is quite a big push from both
the medical directorate and others. As Gwyn Bevan said, when the
Conservatives introduced fundholding, in one sense it was meant
to be slightly competitive, even though the size was different
between the DHA and the fundholders. We thought there was a lot
of money spent on some good stuff in fundholding, but it also
costs a lot from a bureaucratic point of view. Practice-based
commissioning is an adjunct and also covers some of the idea that
commissioning is not all at one level. The only thing about British
general practice is that we have a population, and not many general
practices in the world have that. Some do, some do not. What we
are trying to encourage is that you can give a budget to a practice—they
will not have to have skills to run everything and the PCT and
them will have to have a relationship—but there are some
things which, like in the old fundholding model, you can make
a big impact on in changing because you have a clinical knowledge
of the processes. We need clinicians to help the PCTs with their
commissioning, and we need secondary care colleagues as well as
primary care, but because you have a registered population and
you could release money yourselves—because you could say,
"I do not like how we are wasting money this way" and
that is sometimes us in primary care—you could then have
also local objectives. If these practices, single or multiple,
are good enough, they will get more and more freedoms, including
an element of hard budget to make some of those decisions. It
might make it more complex, but this is a complex way of running
a health service, and to have it just stuck at the PCT does not
capture some of the localism in clinical energy. There is a double
dimension: clinicians need to help in commissioning but there
is also an element that around a local population clinicians and
not just GPs could begin to have a local focus as well to tap
into energy. Otherwise it becomes too distant. Of course this
is difficult, but we do not want linear management in the Health
Service. We want people who are helping to transform the Health
Service and we have to play into different skills. That is some
of the test of what commissioners are going to be.
Mr Stout: If it helps, it is analogous
to a hospital having clinical directorates and then teams within
the clinical directorate with decision making happening at different
levels of the organisation. It is a very similar model but in
a more complex environment.
Q152 Dr Taylor:
I am really quite puzzled because you have all said that commissioning
is working better in the last two or three years. Practice-based
commissioning seems to be a part of what has been happening in
the last two or three years and yet we have the King's Fund saying,
"In its current form, PBC is clearly not operating effectively"
and, unless David has been completely misquoted—
Dr Colin-Thomé:
It has taken a long time to come to this!
Q153 Dr Taylor:
—he is saying, "I think it is a corpse, not for resuscitation."
Dr Colin-Thomé:
You are all far more expert communicators than me, and using rhetorical
questions maybe is not the best thing if the press are there.
I said, "Are we trying to reinvigorate a corpse?" and
that it was a challenge. I then went on, which the press did report,
to say that there are many examples of good practice. Maybe I
should have had better judgment. I have now been told that the
best way never to make a mistake in a speech is to be really boring.
Maybe that is a lesson learned. The issue is that it is hugely
patchy. That is what I was addressing.
Q154 Dr Taylor:
Is that what the King's Fund is getting at too?
Dr Colin-Thomé:
Yes. In fact the King's Fund used practice-based commissioners
as part of their assessment, yet in some places it is hardly functioning—and
that could be the PCTs' fault, it could be the practices'—but
in other places they are doing some fantastic things. It was a
challenge by me, which it was probably inappropriate to say, but
it is like all the rest of life, in that there is a huge variation
in its uptake and yet it is a great vehicle to get clinicians
involved, to be challenging some of the clinical stuff I was talking
about—the use of money and so on. Some PCTs are doing it
brilliantly with their practices and others are not. That is what
we are trying to make certain, that there is push to try to get
less variation and more ambition in this.
Q155 Dr Taylor:
To be fair, the King's Fund do go on to say, "However, to
abandon the idea of PBC entirely would most likely be regarded
as a significant breach of trust among GPs." It would certainly
not encourage GPs.
Dr Colin-Thomé:
You asked, "Should not all GPs be doing it?" and I suppose
in an ideal world yes, but most of us were trained to be good
doctors. I led on the Primary and Community Care Strategy, the
Darzi Review, the Next Stage Review, and we had a deliberate event
and the patients were saying, "Don't get involved in all
this stuff. I just want you to be a good doctor for me."
That is something we cannot lose. If GPs are great doctors but
are not keen on looking at this whole organisational stuff, why
stop them? But there are a few of us who also think we need to
do more than that. If we can do that and bring our colleagues
along and help them, that is great, but to say all GPs have to
get involved in this organisation when their real job is to be
seeing patients seems to get in the way of good patient care.
How do we use the skills of some of us to move on the concept
that practices should have both an individual patient look as
well as a population accountability? This is a new world and there
is huge variation in PCT/GP relationships, and that is what we
are working on.
Q156 Dr Taylor:
Is practice-based commissioning one of the ways of getting integration?
Dr Colin-Thomé:
Yes.
Q157 Dr Taylor:
That the other people were talking about.
Dr Colin-Thomé:
Yes.
Q158 Dr Taylor:
We are told here that practice-based commissioners work closely
with PCTs and secondary care clinicians.
Dr Colin-Thomé:
Yes. I would like to be more ambitious.
Q159 Dr Taylor:
How widespread is that?
Dr Colin-Thomé:
We went further in our Primary and Community Care Strategy and
asked for pilots of integrated care to push the pace on. The reason
we asked for pilots was not because of our obsession with pilots.
Even though Gwyn Bevan says that integrated care is the way forward,
remember the more you get integration, the potential downside
is that there could be a collusion of providers and the patients
get less choice and responsiveness. In the pilots we were looking
to test out the mindset of more ambitious models of integration,
but practice-based commissioning with a budget, and even if GPs
think it is their play thing, if they have responsibility for
budgets it will make them certainly realise that we need the help
of our pharmacists, our social care workers—because the
best outcome for patients with long-term conditions is that you
need social care input to lessen the need for hospital. It is
almost like a training process, with incentives to create some
more ambition locally amongst clinicians to be broader. The population
is important in that respect.
Mr Stout: I talk to PCTs a lot
and one of the things I ask about is how practice-based commissioning
is working locally. Almost every PCT will say, "We have really
embedded clinical leadership into our commissioning process very
effectively." When you then go on to say, "And how about
the indicative budget incentive to individual practice, as in
individual practitioners?" that is often a lot less embedded
and a lot less powerful, and that is a lot more patchy. It kind
of depends what we mean by practice-based commissioning, to be
honest. If you mean effective, meaningful clinical leadership
in the commissioning process, I would say that we are doing pretty
well. If you mean to what extent is every single practice directly
and effectively thinking about their own population in expenditure
terms, quite a lot less well or quite a lot more patchily. We
have to come back to what we are trying to achieve.
Dr Colin-Thomé: We were
trying to achieve both, I suppose. To get the first stage is great
progress, but we need to be more ambitious.
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