Examination of Witnesses (Questions 160
- 162)
THURSDAY 22 OCTOBER 2009
MR GARY
BELFIELD, DR
DAVID COLIN-THOMÉ,
MR MARK
BRITNELL AND
MR DAVID
STOUT
Q160 Dr Taylor:
Thank you very much for putting us straight. We all know we have
to be careful what we say to the tabloids, but we now have to
be careful what we say to the HSJ as well.
Dr Colin-Thomé:
I think the problem is maybe my inappropriateness of language.
Chairman: We have all had our comments
taken out of context one way or another.
Q161 Dr Naysmith:
Practice-based commissioning used to mean you got a little bag
of money for a budget that you in practice could spend on what
you liked, and it is has clearly evolved quite a lot from there
on what you have been saying this morning. The other idea that
Professor Bevan was throwing about and which we have discussed
a bit was this idea of purchaser/commissioner competition, competition
between purchasers. Do you think that is the next frontier for
choice and contestability?
Mr Stout: Not unless we are going
to radically redesign the healthcare system we have. The Netherlands
example that he quotes is competing insurance-based systems. We
do not have anything remotely like that. Could you have that sort
of system? Yes, I guess you could, but it would mean yet another
fundamental reorganisation, and we have argued quite strongly
that the last thing we need is a fundamental reorganisation. Theoretically
there is choice, in that you have a choice of GP. As a patient,
you choose your GP; your GP is making commissioning decisions
every time they make clinical judgments about you. In that sense
there is a degree of choice. But to move to a competing system
of commissioners—as in, that you can choose which PCT or
equivalent you are a member of—while theoretically possible
would be an incredibly major overhaul of the healthcare system
as we know it. To be honest, from what I know of the evidence
of the Netherlands it is not particularly clear how effective
that element of their system has been. It is relatively new. The
evidence, from what I have read anyway, is not particularly strong
in terms of its effectiveness. There are other strengths of the
Netherlands system, but I am not sure that is one of them.
Mr Belfield: I agree. Hidden in
the middle of Gwyn Bevan's report is the point that they spent
a bit of time making sure that their commissioners improved their
capability first before they went to that system, and, as Mark
said earlier, we are in the foothills really of getting our commissioners
into good shape to do well for their population, so we are nowhere
near that debate at the moment. I would like to do what we are
now doing well first, please.
Dr Colin-Thomé:
I think Gwyn Bevan said there was 20 years of preparation for
some of his thinking. These things take time. I think we could
use what we have here better as a way forward. The Netherlands
are different from us anyway in some of the way they set up their
social insurance schemes. Let us use what we have and do better.
This is what our process is about.
Q162 Chairman:
We are about to publish the written evidence to this inquiry in
the next week or two. It is quite substantial. Much of the evidence
that we had submitted to us is critical of the commissioners'
specialised services, arguing that the commissioning is not joined-up
enough and that Sir David Carter's Review in 2006-07 has not been
implemented. What can be done to improve this situation, if indeed
that evidence is right?
Mr Belfield: I am mindful of that.
I have heard that a lot. There are two things we have done. First
of all, we have worked with the ten specialist commissioning groups
which fell out of the Carter Review and to work with them to understand
how we can help them become better commissioners. We have not—which
is where some of the criticism has been—embedded the specialist
commissioning groups into our assessment process, which I think
is one of the things that they would like us to do. For this year
we have put out a framework that is a voluntary framework where
specialist commissioning groups can assess themselves in a sense,
and we have said that after this year of a voluntary process we
will consider with all ten specialist commissioning groups of
next year about whether we then integrate it completely into our
assurance process for the PCTs. One thing I would like to say
though is that every PCT has the responsibility somewhere in their
portfolio for commissioning specialist services. They do not discharge
that responsibility; they involve the specialist care commissioning
groups to do it on their behalf, but hey still have to take responsibility
and accountability at a local level. Our process does look at
that, but it is a fair criticism from the group—and I am
pretty sure I know who sent this to you—and we will consider
this year hw we can do it on a voluntary basis and then we will
consider for next year whether we need to embed it into our systems
or not. It is a fair criticism.
Chairman: Okay. Thank you all very much
indeed for coming along and helping us with this inquiry.
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