Commissioning - Health Committee Contents

2 November 2010

Examination of Witnesses (Questions 96-154)

Professor Steve Field, Dr Richard Vautrey, Dr James Kingsland, and Michael Sobanja,

Q96 Chair: Gentlemen, we will begin, if we may. Thank you very much for coming to meet the Committee this morning. I think it would be helpful if I could ask you to introduce yourselves and just say a couple of sentences about the organisations that you come from and the people on whose behalf you are speaking this morning. Dr Kingsland, do you want to start?

Dr James Kingsland: Good morning. I am James Kingsland. I am a general practitioner. My practice is in Wallasey in Merseyside. I am President of the National Association of Primary Care. This is a membership organisation that has been around for about 10 years. It evolved from the National Association of Fundholding Practices and the multi-funds and total purchasing sites that formed the NAPC about 10 years ago. As a membership organisation, it looks to help interpret policy into practice to help our colleagues do their job better--and by "colleagues" it is mainly focused on the broad spectrum of healthcare professionals working within general practice.

Also, over the last 18 months I have been contracted to the Department of Health, at that time to help PBC develop but now GP commissioning be implemented.

Professor Steve Field: I am Steve Field. I'm a GP in central Birmingham and Chairman of the Royal College of General Practitioners. We are the biggest Royal College in the world and we represent 42,000 GPs in this country. We had been set up in the '50s as a charity, really, to improve the quality of care provided for patients by GPs and we see ourselves as promoting high-quality care.

  It is important for this Committee, I think, to note that we are a United Kingdom and international body. Therefore, what I will say later, hopefully, will reflect members who are not just from England but from the other countries as well.

Dr Richard Vautrey: I am Richard Vautrey. I'm the Deputy Chair of the BMA's GP committee and, that committee represents GPs in four nations, so the comments that we have brought and given to the Committee reflect the views of GPs in all four nations.

  I am a GP in Leeds. I'm also the Chair of one of the GP consortia in Leeds, one of the three big organisations that are working at the moment with a Primary Care Trust to try and make this vision a reality.

Michael Sobanja: Michael Sobanja, Chief Executive, NHS Alliance. I'm not a GP. I've been a Health Service Manager for over 30 years. The NHS Alliance is a membership organisation which deliberately draws its membership across clinical professionals, managers and lay people in the Health Service. Historically, it grew out of the National Association of Commissioning GPs, which, Chairman, you will recall as being one of the proponents of Locality Commissioning Groups in the 1990s.

  Our function is to lobby Government for sensible policy, to support colleagues in its implementation and to spread best practice.

Q97 Chair: Thank you very much. As I have already said, thank you for joining us this morning to contribute to the inquiry which the Committee has launched on the future of commissioning in the Health Service.

In parallel with this inquiry, you probably know, we are also doing an inquiry into the impact of the Government's public expenditure plans for the Health Service. When we were engaged in seeking evidence in the context of that inquiry from Sir David Nicholson, he said that he regarded the management challenge that was involved in delivering the public expenditure plan and the £15 billion to £20 billion efficiency savings that are implied by that plan as the biggest management challenge, certainly, in the public sector and probably in the economy as a whole.

  When he came back, then, to give evidence on these commissioning proposals I asked him how he thought these two processes would co-exist—the delivery of £15 billion to £20 billion efficiency savings and the delivery of these changes to the commissioning process. His answer was: "Part of the skill of the transition is going to be making the savings programme and the transition to the new system not parallel but mutually reinforcing. That's quite difficult to do but I think we can already see ways in which we can do it."

  I would just like to begin by asking our witnesses to comment on those two parallel programmes. Who would like to begin?

Dr Richard Vautrey: Shall I start? One of the things that we have welcomed as part of this White Paper proposal is the greater clinical engagements that the Government are wanting to see, and that has been lacking, quite considerably in some areas, over the last few years. GPs and other health professionals want to get more involved, in partnership with their consultant colleagues in secondary care and public health doctors, to try and re-design care pathways to make them more responsive to bring services closer to where people live. We can do that by talking with our Primary Care Trust colleagues and, by doing so, that will hopefully achieve some of those savings and enable us to re-invest resources in better care pathways.

  But that has to be done together, and I think one of the challenges over the coming years is how we actually ensure that all GPs and all healthcare professionals have a feel that they have a stake in their local organisations and in their local healthcare economies so that they are all working together rather than in an opposed fashion, as has happened in recent years.

Professor Steve Field: I would agree with Richard. We welcome the White Paper because of clinical engagement and clinical leadership. We believe it is not just about GP leadership but that GPs should be working with specialists, with nurses and with others to make this happen.

  The reality is that clinical leadership was lacking in many of the old PCT organisations and you could see that from what was happening in world-class commissioning and practice-based commissioning.

  In some areas, like Tower Hamlets, where you did get good Medical Director leadership and engagement of GPs, you could really transform the Service. But you need high- quality managers to actually support and respect the clinical input. However, unfortunately, it was very patchy across the country. Also, with some of the ideas which were good in policy terms, for example, the Darzi centres, once they were parachuted down so that every PCT had to have one, you pushed the clinicians back to the side. It was things coming down from above rather than clinical leadership locally. So we welcome the change.

  I think what we would have to offer, as clinicians, would be about evidence-based practice and about looking with patients and the public at what sort of services are needed locally. We will also need political support, I believe, because at the moment the tariff is sucking work into hospitals and sucking money into hospitals. We need to keep people out of hospital and we need to reconfigure some services, not necessarily the hospitals themselves but services within hospitals.

By clinicians leading, working across primary and secondary care, we can get more radical change than we have had over the last few years. I think that's what is needed now but I also believe it was what the policy was meant to be before.

Q98 Chair: In a sense, I think your answer is that by engaging the clinical community, and in particular GPs, more actively in the commissioning process, the Department is enhancing its chances of delivering the efficiency gain that it needs. Is that a fair summary of the answers so far, and then I'll come to Mr Sobanja?

Professor Steve Field: Correct, but I don't think it is just GPs. For example, there are savings to make with nursing leadership in the community and how we can join up health and social care around the patient. So I don't think it is just general practitioners, but your assertion I would agree with.

Dr Richard Vautrey: I think the key thing is to see greater collaboration across the primary-secondary care divide. For too long doctors have worked in silos and we have become less familiar with our consultant colleagues and with other colleagues working in the hospital. We need to bring doctors together because it is only when all doctors in an area agree about how patients can be best dealt with that you actually see change. If you have got one group competing against another, that would actually be a disaster and counter-productive. That is one of the concerns that we have with the White Paper—the greater emphasis on competition against what we believe would be a much more sensible emphasis on collaboration.

Michael Sobanja: For me, Chairman, it starts with the definition of commissioning, which is about how we commit our resources within the NHS system. If you start from that particular point and look at clinical activity, whether it be in general practice or in secondary care, the vast majority of resources are committed by clinical acts--in general practice by referral, by treatment, by prescribing and so on--and choices have to be made.

  I think one of the mistakes we have made in the past has been to try and run this rather nebulous term of "clinical engagement" alongside a managerial agenda. One of the reasons why I don't think practice-based commissioning has been any more than patchy is that it ran in parallel. A practical example would be that, when the then Government were putting a great deal of emphasis, and perhaps rightly so, on reduction of waiting times, practice-based commissioning was not seen as a means of achieving that but something you did on the side as well. So GP commissioning and the future of commissioning have got to be about how we deliver the Health Service outcomes in the future within finite resources. That is intrinsically tied up with clinical activity.

Dr James Kingsland: I remember a departmental document called An Organisation with a Memory. I went into practice in 1989, a year before the internal market was formed, and, over the last 20 years, have adopted every vehicle that has tried to manage that in the vanguard, as a first wave.

I think what we need to review is the successes of certain vehicles. The consistency about when the internal market has been managed successfully is where clinical decision making has been aligned with financial accountability. We saw that in fund-holding, albeit flawed. I appreciate this is not fund-holding plus, but the alignment of clinical and financial accountability generally led clinicians to make better decisions on behalf of their patients or with their patients and better resource usage. We didn't see clinicians making rationing decisions. That was born from the King's Fund report a couple of years after fund-holding had finished which showed that, year on year, there was a 4% efficiency in the management of fund-holding budgets, despite the budgets being set on the historic outturn, and we saw pathway design and care changing as a result of that alignment of clinical decision making. I think that was the important thing to learn from any of the processes we have used to try and manage the internal market.

Q99 Chair: You used the phrase "an organisation with a memory". The BMA Memorandum to the Committee uses the words "extremely alarmed" at what it describes as a "potential vacuum" and a "real risk of PCT implosion". That is quite strong language. It addresses, very directly, Dr Kingsland's phrase of "an organisation with a memory". I wonder if you would like to enlarge on that and then I would be interested in the extent to which your colleagues share that analysis.

Dr Richard Vautrey: We do have serious concerns, and they are already being demonstrated as a reality, that senior PCT managers are leaving the PCT and people are being offered redundancy and taking redundancy, the very people who we need in the future to make these changes work.

  What would be far more sensible is a planned reduction in PCT numbers, of the staff who work within PCTs, as is already happening and as was charged to PCTs, but done in such a way that we retain the people who we are going to need to enable these emerging GP-led consortia to be successful.

  What we don't want to do is for the best managers to leave to go to large multinational firms only then to have to hire them back at an inflated rate of pay and, also, to add on their redundancy payments as well. That would be a disaster for the NHS as a whole and would be very costly.

  We have already got examples where whole departments of people have accepted redundancy terms and so will be leaving very early on. We need to try and have a managed transition where, yes, people will lose their jobs and the redundancies will be made, but we need to try and actively retain the best people so that we can make these new organisations a success.

Q100 Chair: I know Rosie Cooper wants to come in on this, but perhaps we could have a reaction from other members of the panel as well.

Professor Steve Field: Thank you. I think transition is going to be the key. There are some fantastic PCT managers at all levels--they are just not everywhere across the country--and we just want to make sure that we don't lose them, as Richard quite rightly said.

  Transition will be the key because not only is it about setting up new consortia and supporting them, but it is managing the costs within the NHS, as you quite rightly say, during that transition period. Losing grip on transition will mean that consortia might be setting up with deficit budgets and problems with local contracting. So the PCTs need to be supported. They need good clinical leadership now so the GPs need to get in there now to support. But the SHAs, I think, have a key role in supporting the PCTs locally and making sure that they are supported during this transition period whilst the parallel world starts. We need the commissioning board to start up soon so that we have direction from there whilst Barbara Hakin and the transition team carry on keeping the grip all the way down the system.

Michael Sobanja: In its response to the consultation programme, the Alliance called for greater flexibility in the transition that would allow those who were ready in GP commissioning to move quickly and those who weren't to develop their skills and move more slowly, even within the capsule of time that the Government envisaged.

  I think one of the problems is that we see a document at the moment that could be interpreted as being a one-size-fits-all. I agree with what my colleagues have said—that this is not going to be something that will be determined in Whitehall, in Richmond House. It will be something that has got to come from the ground locally so that people can develop at their own pace within an overall time scale, keep the good and make those particular changes.

But the thought that we are going to continue with PCTs until 31 March 2013 and, suddenly, we'll wake up the following day and the world will change is not how any reorganisation I've ever worked through in the Health Service has taken place in reality. And it won't this time. PCTs will start to come together. They'll start to come together with SHAs, in my view, and the concern is that that be driven locally and not from the top.

Dr James Kingsland: We need to look for this system to leave a strong and robust legacy. We need to look at why the last system failed, and I think there were three clear reasons why PBC as a vehicle failed. Number 1 was because it was management-centric. It didn't change cultural behaviours that the commissioning programme to involve clinicians required. The system didn't allow clinicians to have the tools to do the job, which was ownership of some budgetary control, and the data we are using is still fairly poor, and that stifled leadership.

  We need in this transition period for our NHS managers to evolve what had failed within PBC and leave this legacy. My concern is that we are spending too much time on structural reorganisation, not the new function of what commissioning is trying to do, and the form should fall out of that function. We are at risk of being sanitised, at the moment, by this huge HR headache of losing or re-accommodating NHS management and not focusing on that as the main issue of the transition as opposed to what failed in the past and what we need to do to make sure that GP commissioning is successful.

Q101 Rosie Cooper: I am really interested in your comments because David Nicholson, when he appeared before us, was very clear that he thought this was manageable and that, in the interim, before the commissioning board is up and running and consortia were in place, PCTs and Strategic Health Authorities would, if you like, hole the ring.

I have put some questions down about the number of staff employed a year ago and the number of staff we've got today, and I'm sure that will elicit some interesting figures. You have made some comments so far this morning about needing more clinical engagement, high-quality managers and the fact that it is patchy across the country. These are the very people who have been abused every time you read an article "Managers are poor. We don't need them. Get rid of them. They're a waste of money. They're a drain on the NHS." As somebody who has been involved in the NHS for a long time, that is not true. There is the degree and all the rest of it.

I'm saying to you that, currently, what I'm looking at, even in my patch, is that PCT managers, PCT staff, Strategic Health Authority staff, those who are good are going off and are finding other avenues. The question is, if they have been treated in the way they have been, why would they stay in the hope that, at the end of this, somebody may employ them or not?

You talked about "managed retention". In this climate, with these sudden changes from the PCT to this new consortia world, not knowing how and when those consortia may come together, how would you manage to retain those staff today? What message would you give them and what message would you give the Department of Health that they should be doing and saying right now to make this work? Frankly, what I'm looking at is the Marie Celeste. We are all looking at each other and everybody with ability has run away.

Dr Richard Vautrey: Right from the beginning of this process the BMA has been absolutely clear that we want to retain the best NHS managers within the system because we need them to make this work.

  One of the things that has often been misunderstood about this process is the idea that GPs are going to be running everything, doing everything and managing everything--doing all the finances, the HR and all the rest of it. That is clearly not what is going to happen. There will be a very small number of GPs directly involved in management and leadership. But the bulk of the work will be done by expert lay managers, and we hope the very people who are involved in the NHS now, who we really do need, will be retained. What has been lacking is a very clear message from the centre saying, "Yes, we do need and value your services. We want to retain your expertise and your future will be best in these new, emerging organisations where you will be able to make a difference for the patients that you have been trying to serve over a number of years and, by the new arrangements, hopefully, get over this management-clinician divide that has operated for far too long and try and bring people together to work for one purpose."

Professor Steve Field: I would agree but I would go further. In some areas, it is a mixture of skills and attitude and behaviours. I think something we have got to try and do which the College has been doing, just as the BMA has, is actually to try and support managers because we need high-quality managers.

  There is an emphasis over skilling-up GPs to do commissioning and leadership which is needed. But there is also something we need to do with managers about their professional development over the next 18 months and I would like to see an increased emphasis on supporting managers so that we can get them to acquire the skills we need in the new world, and that should help with retention.

Q102 Rosie Cooper: What vehicle would they be in while they are acquiring these skills? They are either going to be in a PCT or Strategic Health Authority with the prospect of it disappearing in x months or a year. Why would they stay to do that?

Dr Richard Vautrey: It is quite possible, as is happening already in some areas, for key PCT managers to be seconded to emerging GP organisations. We are already seeing that the organisations that have been, perhaps, of longer life so they have been around already for two or three years and have been the better of the practice-based commissioning groups, are in a position to take those particular key individuals and for them to actually work on behalf of those new organisations at quite an early stage.

Q103 Rosie Cooper: So we're going to have different tiers of this policy right through the country?

Professor Steve Field: Yes, you will because the whole point, which we support, of the idea of pathfinders and people going forward at the speed that they're needed to go locally, means that you can already do a lot of what is in the White Paper now with devolved responsibility within a PCT area, including the governance arrangements.

Q104 Rosie Cooper: So why do we go through all this huge structural change?

Professor Steve Field: But what we need--

Chair: I am going to bring Mr Sobanja in.

Michael Sobanja: I was just going to say, if the Health Service sees this as another top-down managed, uniform reorganisation based upon a system change, it will fail. It will be no more successful than the ones that we have seen over the last 20 or 30 years. This is about enabling people to develop services with local people for local people in differing ways.

  I think with managers, what I would be saying to them at the moment and am saying to them because many of them are our members--we have 120 PCTs in membership--is, "Start the dialogue with your GP commissioning colleagues. Work together to develop this." What I would say to David Nicholson and the Department of Health is, "Allow some flexibility. Do not seek to impose one single programme as if this can be managed from the centre right across the country." I don't believe it can be.

Q105 Grahame M. Morris: Good morning, gentlemen. As the Chairman has already mentioned, Sir David Nicholson told this Committee in evidence on 1 October, that, "The scale of change in the NHS is enormous, beyond anything that anyone from the public or private sector has witnessed."

We have already heard, from your opening remarks, your view that GPs want to be involved in greater clinical engagement, for example, design and care pathways, but from the point of view of the Committee's investigation, how does that square with the attitude of GPs? Do your members share this view?

  The reason I ask is this. The BBC survey that was conducted quite recently found that only 23% of GPs thought GP commissioning would benefit patients with 45% saying it would not and then the King's Fund survey found that 41% didn't agree that the changes would benefit patients. Do you agree with those figures or do you have a view on the views of your organisation being in conflict with GPs?

Dr James Kingsland: I can give a view on two aspects. One is the actual surveys. Just to quickly reflect about management, I am not getting into semantics about commissioning but if you use the word "commissioning" to a manager or a GP they will understand very different things by it. I think some of these surveys have talked about commissioning where, as Richard was saying, if we are trying to create doctors into doing what PCTs used to do, there is no future in that. We have got to be clear. We need strong management on the part of commissioning that procures new services and acts as contracts managers. We need clinicians to do needs assessments and securing services against that need.

When you talk to clinicians about upskilling within their own practice, extending care, expanding the primary care team to give a multidisciplinary approach to delivering care and making better decisions with the ability to use a budget, I think most commissioners get that and say, "That is what I will do". Certainly within our membership, which is often at the vanguard of change, we have a large majority who are saying, "That's exactly what we understand by GP commissioning and what we need to get involved in." The smaller numbers, as Richard was saying, might be skilled in ways that they want to get into contracts management. So I think sometimes a survey has asked, in a process that says commissioning equals procurement, "Do you want to be involved?", and clinicians say, "No." But, if the question is "Do you want to be involved in making better decisions on behalf of your patients?", they say, "Yes." So it is not getting into semantics about the term but it is understanding what part of commissioning we need clinicians to do and where we need strong management.

Q106 Grahame M. Morris: Without labouring the point about the survey, there were two elements to the BBC survey. It was quite overwhelming. When GPs were asked, were they willing to take on commissioning, 57% said they weren't willing and 25% said they were. But, in relation to the other issue, on which there has not really been an answer, of whether GPs feel it would benefit their patients, only a minority, only 23%, thought it would.

May I just move on from there in relation to some of the other points that you raised, perhaps to ask the Royal College of GPs representative about the structure. Some of your members thought it would be more sensible, in the evidence that we have seen here, to keep Primary Care Trusts and simply to add GPs to their boards rather than go for this radical overhaul with GPs expected to go it alone. Could you elaborate on what the advantages and disadvantages would be of that approach?

Professor Steve Field: Some of our members, you quite rightly say, did think that we should carry on with PCTs with better clinical leadership. We actually only had 400 out of 42,000 members respond to the consultation, although that was a representative sample of the different types of GPs and it included people from outside England. So you have to take that part of it in that context. Many others felt that this was the way forward from a commissioning GP point of view.

  PCTs are very different to what the clusters, the consortia, are going to be for commissioning. They have different functions. It is true that, if we would have had under the previous Administration high-quality clinical leadership in the PCTs, a lot of what is being pushed now about re-design of services would have happened. But, frankly, it didn't. It failed. You can read your own review or your predecessors' review in the report. It gives, very clearly, the reasons why the Select Committee then felt it had failed.

  So change is needed. The issue that I said earlier is the most important one is the transition. The transition should be locally sensitive so that if you have got a very good PCT that is working very well with its clinicians during transition, that's fine. You hand over responsibility in a different way to an area where, actually, the managers in the PCT and the clinicians are not engaged. So it has to be locally determined.

  But in all of these transformational changes, as John Kotter says--one of Harvard's leading gurus on leadership--if you don't create a sense of urgency, if you don't actually create a clear vision and take people with you, it's not going to happen. The problem with World Class Commissioning was there was no sense of urgency for change and, actually, there wasn't a clear vision for the clinicians where we were going.

  I think what we have now with the new policy is a clear vision. What we have got to try and do is get more and more people engaged to take that vision forward.

Michael Sobanja: First, if I may say so, the numbers reflected in the BBC survey and the King's Fund survey are not those we have experienced within the organisation. For instance, over 80% of people in the surveys we have conducted have said they want to get in there and get involved. But that may be explained by the terms of the question, as described by Dr Kingsland.

  I think the issue about changing PCTs and simply changing the composition of the board goes back to this point that James made. These changes are about changes of behaviour and culture, not just about system. They require the centre to change their behaviour and the NHS commissioning board to have a different relationship than the Department of Health have had in the past. In my view, simply changing the composition of PCTs would not have been sufficient to change the culture and behaviour in the NHS.

Q107 Valerie Vaz: It is part of the same thing, but I'm trying to work out under this new commissioning body or the GPs commissioning the conflicts that will arise. Whilst you say there wasn't any urgency, and you may not have taken the managers with you, did you take the patients with you? That would be my first point.

But, also, ultimately, the GPs who do commission are going to come across a conflict between individual patient decisions and what happens with the population. So how would they cope with that?

Dr Richard Vautrey: I think even over the last few years under the current arrangements GPs have been involved in professional executive committees, in leadership roles, even directors of PCTs. So there have been issues of conflict of interest that have had to be managed and openly declared in the usual way, as I am sure you are familiar with. That will continue in the new world. There will have to be a transparency, an openness.

  One of our concerns, though, is if there is any suspicion that the individual patient feels that the GP sat in front of them is acting or behaving in a way that is conflicted and that they are more interested in the financial savings that the consortia are going to make rather than the direct patient care that they are going to be providing to that individual or treatment suggestions that they are going to be offering.

  I think what we need to try and ensure is that there isn't a significant financial conflict that starts to emerge in individual patient consultations. That can be managed and it is possible to manage that and, for the vast majority of GPs, they will not be involved in the direct, day-to-day management of the GP-led consortia in the same way that they are not involved in the direct management or running of the PCT. It will be for a small number of GPs where the issues will become more apparent, but I think it can be managed if it is done in an open and transparent way.

Professor Steve Field: You make a really important point. I think there is a tremendous opportunity, with the proposals, for more patient and public engagement and I particularly like the link through to local government with the Health and Wellbeing Board and HealthWatch. If we can start to get more engagement in the planning of services with patients, in some areas it has been reasonably good. In other areas it hasn't and I think we need to take the opportunity there. But, to answer the conflict question, Richard has answered that.

Q108 Valerie Vaz: Actually, no, he hasn't. What he said is you are going to try and ensure it doesn't happen. You haven't told me how and you haven't told the public how. Also, there are going to be individual funding decisions that are going to come up with each individual patient. How is that going to be managed by the GP and what safeguards do you have?

Michael Sobanja: Let me suggest to you that that has been the business of general practice for as long as I have been in the Health Service.

Q109 Valerie Vaz: And that's why we are concerned about postcode lotteries and health inequalities.

Michael Sobanja: A general practitioner, in deciding how much time to spend with one patient as opposed to another or to make choices on care packages which they create for individuals, has an element of opportunity cost. They have been doing it for years and this is an issue of scale at population level and, where I would absolutely agree with you, moving general practice from a preoccupation with practice list to population health will be key but the nature of the decision actually doesn't change from what has been going on for a long time.

Q110 Rosie Cooper: I agree; that is what I did when I was on a Strategic Health Authority many moons ago. But the point I really think that we need to get to is governance on consortia. A wellbeing board, accountability at a distance, is, for me, not acceptable. I believe that patients and/or the Councils, whatever the Secretary of State indicated that he believed would be the transparency--he didn't say transparency in a cupboard--he wasn't clear. I thought, when he was talking to us, that those people would be on the commissioning board and, until and unless the commissioning board itself has patients or councillors or whatever--non-exec directors--if they are not there at the heart of decision making, this is flawed because we will not have the assurance we need.

The Secretary of State also wouldn't answer whether commissioning board meetings would be held in private or in public. These are absolutely essential and go to the core of whether local people, the health of the economy, will actually be represented at the decision-making point.

Dr James Kingsland: I think we need to extend it past HealthWatch or even at the GP consortia. We have got to go into the micro systems where patients register for their care and expect that the practices who will be responsible for some budgets will have, at all levels, patient involvement in decisions.

  For example, for a long time our practice does not make any decisions, any new protocols or any new care decisions without the involvement of our Patient Panel. I think we need to see that expanding.

  Just to go back to one of the questions about where we have got evidence, and it is not a lot and some of it is within fund-holding, where clinicians had accountability for Health Service budgets, the evidence is that resources were used more effectively and efficiently, for patient care the outcomes were improved and rationing decisions were, generally, not made. So where we have got evidence the alignment produces better outcomes.

Q111 Valerie Vaz: So what happens when the GP has a private stake in a private company that is providing services? Do you know how many GPs currently have that?

Dr James Kingsland: This was something that was, I think, created from early frustration in practice-based commissioning where, as I was saying earlier, the tools weren't available to become commissioners. So GPs reverted to a provider-type model and set up for-profit companies in competition with hospitals. That was legitimate as a process but not consistent with what practice-based commissioning was trying to achieve.

  With regard to the governance around that, I think it is just that PCTs should have been a little bit sharper on the governance in that patient choice should always be paramount. If a practice is referring to an organisation in which they have a financial interest and choice can be monitored, and if choice is given and the patients don't choose to go to that, there is nothing wrong, and the pecuniary interest in that referral needs to be declared to the patient. If that is declared, then there's nothing wrong. I think that where that declaration isn't made or there are some covert referral patterns into their own service, then that is unaccountable and the GPs are in breach of their primary care contract and in breach of GMC regulations. I think that just needs monitoring. I think if practices are developing that, I don't think it is part of the commissioning programme, though.

Q112 Valerie Vaz: Do you know how many GPs have that now? I don't know. I'm just asking.

Dr Richard Vautrey: We don't know the figures and I think one of the things that we need to be careful of is that, whilst we clearly need to have robust governance arrangements and we clearly need to be open and transparent around conflicts of interest, we also need to try and encourage practices particularly to take on more services and to develop their skills. That is the only way, long term, we are actually going to be able to meet the significant financial challenges over the next few years. We have to transfer work out of the hospital and into the community and we have to get practices--not just practices, but others as well--to be able to step up to the challenge of expanding their services, ensuring that patients actually get a good deal, but locally.

Q113 Rosie Cooper: Would you be happy if patients and/or councillors were on consortia boards? Would each of you be happy?

Michael Sobanja: I would say it is an absolute pre-requirement that every general practice commissioning group has public representation on it and I would go further and say there has to be a mutual lock with local government to make sure that their public health activities and the commissioning plans of GP commissioning consortia are complementary. But, absolutely, I think that should be a key requirement.

Q114 Rosie Cooper: Can I ask each one of you that?

Dr Richard Vautrey: I think any emerging GP-led consortia would be foolish not to involve patients in a meaningful way. Over the last--

Q115 Rosie Cooper: On the board?

Dr Richard Vautrey: We don't know what the board structures are going to be yet but I think they--

Q116 Rosie Cooper: At the decision-making point?

Dr Richard Vautrey: Decision-making, yes, clearly.

Q117 Rosie Cooper: At the decision-making point, not to be considered?

Dr Richard Vautrey: Yes, because the--

Q118 Rosie Cooper: Not throwing a snowball at a moving truck?

Dr Richard Vautrey: Yes, because if they fail to do that, GP-led consortia are going to have to make very difficult decisions about prioritising one service against another. If you don't involve patients in that discussion and in that decision-making process, then you will end up with conflicts and local campaigns.

Rosie Cooper: You are going to get that.

Dr Richard Vautrey: You're going to get that anyway but it has to be seen as comprehensive as possible.

Q119 Rosie Cooper: But I'm asking a question about the people being there at the point of decision making, not and/or, not "and to be consulted", but with a vote at the point of decision making.

Professor Steve Field: If you want my answer, I would say "Yes". There are different ways of doing that, but I do believe the public should be on the boards of the consortia. But I think there needs to be much more effective work alongside that in the consortia linking across to local government where the public really truly do have much more input in designing local services, which is why I said earlier on I do like the link with local government.

What we must not do is slow down change. So you need the public to be on board. If you look at Rugby and places where they have had issues with their local hospitals and moving from Emergency Departments to Minor Injuries Units, the way you effect change is to get the public on board to really understand why you need to change things and listen to the public more effectively. I do think, actually, we have the opportunity to do that. In some areas it has been really good to date but we need to get that everywhere.

Dr James Kingsland: I would go further. I would say of the 8,230 micro commissioning systems that will be in place, practices who have budgets should inherently have a patient voice as part of their everyday practice. The commissioning board that develops from the aggregation of those practices is an aggregation of those practice-based patient groups. I would like to see every general practice have a strong voice from a patient representative organisation.

Dr Richard Vautrey: And it is that model that my own group is developing.

Q120 Rosie Cooper: A strong voice is not what I am talking about. It is a vote at the table. You can be as strong or as quiet or as noisy as you like. The only thing that matters is when you're at the table and you've got a vote.

Chair: Do you want to come in on this, Fiona, or a related subject?

Q121 Fiona Mactaggart: I've been hearing you all seeming very relaxed about what I think, if I haven't misunderstood, is going to be what is called by the media "a postcode lottery", that there are going to be very great differences between different areas in what is provided. Am I right?

Dr Richard Vautrey: No., we are very concerned about the potential for postcode practice or treatment and decision making. The decisions around NICE yesterday are a case in point where, clearly, it makes sense to have a national body making those very difficult, challenging decisions so that there is some consistency around the country.

  What we would hope that happens over the coming years is that there is a greater sharing of information and greater benchmarking so that practices and groups can measure themselves against the best more clearly and try to aspire to that and get some standardisation. But I think there is a concern that you are going to get very different decisions made in different parts of the country which patients will not necessarily understand.

Q122 Dr Wollaston: Of course one person's postcode lottery is another person's local decision making, I guess. That is always going to be the issue.

Dr Richard Vautrey: Absolutely, yes.

Q123 Dr Wollaston: Could I come in on a couple of points? We all know we want to deliver better outcomes for less money. We have heard evidence, as a Committee, about the ways that that has been delivered, and that's through integrated health and social care, better clinical decision making and clinicians working in collaboration rather than in competition, but also evidence that, in the past, it was when we reduced the number of PCTs that we actually saw real savings in the NHS.

So, looking at all the dangers in this transition, do you have fears that by going to a much greater number of smaller commissioning groups that will distract us from those savings, but also that in seeing a rigid separation between commissioners and providers and less collaboration we are going to lose a great deal?

Dr Richard Vautrey: I think there's a clear balance between having systems and consortia that are small enough to engage the clinicians and the practices within that constituent consortia but, also, having consortia or arrangements of consortia that are large enough and robust enough to be able to cope with the various risks and financial challenges and other issues that a large organisation is better able to do.

I think that is possible through two possible ways. One is to have groups of consortia linked together in some form of federation and they share a common service agency or, as the White Paper talks about, a lead consortium taking on responsibilities on behalf of the others. There clearly needs to be a working together of smaller organisations.

  Another model would be to have one large consortium which is then having a very robust locality structure underneath it that really empowers those local bodies to drill down to what the local needs of their populations are and to work together through some form of robust locality structure but the statutory organisation is the much larger organisation. It could work either way in a way that would make sense, but I think you need to have the best of both worlds, if possible.

Q124 Dr Wollaston: Do you think that should be entirely locally determined then, coming back to what you were saying?

Michael Sobanja: I think there's an issue of balance here because what I'm not saying is that there should not be accountability or performance management in the system. I do believe that performance management should be focused on equal outcomes for equal need--not necessarily the same service everywhere but equal outcomes for equal need--and that needs to be rigorously pursued by the NHS commissioning board but not in a way that attempts to micro-manage the service that we have seen in the past. So I don't see those as being incompatible but I think the trick of pulling this off is to get that balance of behaviours that energises localities while sticking to a broad template where we have very clear policy direction and priorities at the central level.

  I think also, if I may say so, linking that to the PPI, the public involvement approach that your colleague raised, in my view, the NHS commissioning board and the Secretary of State need to do a lot more to be open with the people of this country about the challenge ahead for the Health Service, what's affordable and who will be making those decisions in the future, otherwise the local groups will be stranded in that process of trying to engage local communities.

Dr James Kingsland: Creating GP commissioning consortia in itself will not manage out the system failure at the moment. The main focus is about the upskilling of primary care. That is probably the biggest challenge within this reform. It's those 8,000 plus micro systems I was talking about and giving a much better platform and voice to areas where there are challenging populations--inner cities and the vast rurals--and seeing how we can support that. If we don't get into the very units where patients register for their care and change the skill mix, the abilities and the system that makes more for patients and buys less from another sector and then aggregate that into our consortia--if we don't get that right--creating just a new body and hoping that will manage the system and somehow an NHS board will deliver and change the current system failures will not work. That is a part of the support system.

  The biggest challenge, I think, is about the improvement and upskilling of the primary care system, the general practice units.

Q125 Fiona Mactaggart: But how is the system going to do that?

Dr James Kingsland: Part of the challenge is to focus, oversimplifying to a point, on what can be made as opposed to being purchased from that unit. That can only be done by a multidisciplinary team approach across health and social care and recognising that the challenges of a patient who registers with a practice need far more than just the skills of a general practitioner and the nursing team and administration. They need a whole range of healthcare professionals delivering an integrated system of care. That means the threshold of referring to another sector into hospital is only for very highly technical, complex care--urgent admissions and operations--but the vast majority of care is delivered by the general practice.

Q126 Dr Wollaston: But that brings me back to my first point, which was that integrated pathways undoubtedly make considerable savings and provide better care. But under our current arrangements, with that rigid separation, do you see that as a problem--the whole make or buy issue —you can't make it if you're commissioning it, if you see what I mean?

Professor Steve Field: I think, again, it is a transition into a more integrated service. First of all, you focus on the patient and you look at health and social care. Look at Torbay, near your constituency, I think. You have a very good model there where you can look at long-term conditions and the chronic sick.

We know, from other models abroad, that moving to more of an integrated model, looking at the hand-offs on the pathway for the individual patient, you can actually look at outcomes and improved care, so we know that happens. But we also need to work very differently in that we need to stratify the risk of patients within a population and target those patients who are in and out of hospitals or in care homes getting poor care and actually put in more personalised care packages, if you like, for those.

  You will need a different work force in primary care. GPs will need to spend longer with patients looking at the complex, ever-aging patients with multiple morbidities. We will need to use nurses and pharmacists and others to manage patients in the community in a more rules-based way and we will have to work very closely with public health to prevent illness. The whole system radically has to change.

  But care in Totnes will be very different in how it is provided to the inner city in Birmingham, perhaps, where we have a lot of people seeking asylum and a lot of homeless. We can then target our services much more to address the concerns of those than, perhaps, the other groups that you might have where you are an MP. I think you need a much more localised personalised service and this gives us the opportunity to do that.

Chair: Andrew George has been extremely patient.

Q127 Andrew George: Thank you. I want to come back to brass tacks. This is a White Paper that we are talking about. It is not a parliamentary Act. Therefore, it is an issue for consultation. It seems to me that the Government have said to the GP community, "Would you please jump?", and it seems that your collective response to that is, "How high?" In my view, you seem to have accepted the basic premise of the Government's approach on this matter.

Dr Kingsland was saying a moment ago that clearly the bottom line and the most important thing is improvements in the delivery of primary care. I entirely agree. But the question, really, at the end of the day, is about simply allowing primary care to be managed by a narrow sectoral interest, for want of a better expression. The PCTs clearly had failed because, in my view, they were too micro-managed from the centre; they were puppets with a puppeteer in the centre within the straitjacket of central control. But simply allowing the GPs to take over that commissioning role without engaging a wider community, I don't think you are really engaging in the debate at all. You're simply accepting the Government's basic premise, are you not?

Michael Sobanja: It would be very odd indeed, with an organisation that has espoused clinically-driven commissioning centred around GPs for 17 years, to oppose that policy when it is actually brought into reality, perhaps for the first time.

  I think the question here is exactly as you put it. But it is not, "How high?" This is the right thing to do. My organisation believes that GP-driven commissioning is the right thing to do and has done for a long time. But that is not outside of accountability. That's not suddenly abandoning it and saying, "We're going to have 300 to 500 groups"--however many it is--"all doing their own thing, completely unfettered." This is not liberating GPs from all sorts of management. This is about setting free the energies to actually produce better outcomes for patients. So I refute the basic premise of what you say.

Dr Richard Vautrey: Can I add as well that, whilst the focus of this Committee is on GP commissioning, the White Paper is a lot more than GP commissioning and you will have read, I'm sure, somewhere in the BMA's response, our serious concerns around a whole range of issues contained within the White Paper. We have big concerns about "Any Willing Provider". I have already mentioned our concerns about the emphasis on competition as opposed to collaboration. We have concerns around the forcing of all hospitals into foundation trust status and the arrangements around pay and conditions, training and education. I could go on and on. But I think there are a whole load of issues that we do need to review very carefully before we can actually give any qualified support to them.

Professor Steve Field: We support the policy because it is about clinical leadership and what I said right at the start was that this has to be done with high quality managers supporting, with nurses and with specialist colleagues. The caveats would be that it is broader than just commissioning. We are very worried about what might happen in education and training because we believe that training for primary care professionals, nurses and GPs, has not been as good and as focused as is needed. GP training is woefully short. It is still disgraceful. Only 40% of GPs can have placements in paediatrics, for example, So at one time where we are pushing care into primary care, if the work force don't take this seriously and improve the quality of training for nurses, for doctors and for others, then, actually, we won't have the work force to deliver what James has quite clearly said is needed.

Dr James Kingsland: Could I just say this? Yesterday, in surgery, I was commissioning. I was conscious about it. Some colleagues aren't. It was called a referral. But I did a needs assessment. I needed a wise counsellor, a consultant colleague, at this particular time and secured a service against it--

Q128 Andrew George: For an individual patient?

Dr James Kingsland: For an individual patient. But that is the bit that general practice really wants to get involved in.

  At the moment I have a system that has designed a pathway on my behalf, has spent the money on my behalf and I have had little say in the pathway. But I am still making the commissioning decision. I am spending the public purse. I call it an FP10, a prescription. So I'm doing it anyway. Some colleagues aren't conscious that they are doing it. If we are given the tools to do it I think we would make better decisions and probably design different pathways that are being designed on our behalf.

Q129 Andrew George: So GPs know best? In terms of the shape of the service, not just the individually commissioned patient service but in terms of the shape of the service, GPs know best? It is best not for them to work in partnership with others?

Dr James Kingsland: Not at all.

Dr Richard Vautrey: Absolutely not. I think what we--

Q130 Andrew George: Let's hear more of that, then.

Dr Richard Vautrey: What I have said repeatedly today is that GPs have to work in collaboration, and not just with their other medical colleagues or their consultant colleagues. Public health colleagues will play a crucial role in making wise decisions but, also, other healthcare professionals and, indeed, patient groups as well have to be all round the table making these decisions jointly together. What GPs are good at is working in teams and working as a multidisciplinary team.

What they have been so concerned about, over the last few years, is the team that have been around them, their district nurses, their health visitors, even social care workers, have been removed and become more distant. They are very good at working in teams, embracing everybody as part of that team, and they want to replicate that on a bigger scale when it comes to commissioning.

Chair: I am conscious that we are running out of time, because we have another group of witnesses who are on after you, gentlemen. Fiona wants to come in and then Chris Skidmore wants to ask a specific set of questions.

Q131 Fiona Mactaggart: The vision of a kind of comprehensive primary care service that you all mention seems to me not to be properly reflected in the White Paper. The NHS board is going to commission primary care and is it going to commission the kind of primary care that you want? I don't understand this nationalised commissioning of a primary care service. I don't understand the nationalised commissioning of maternity services. I would like you to explain how that is going to make things better.

Michael Sobanja: On maternity services, can I just say that our view is that that is bonkers.

Q132 Fiona Mactaggart: Yes. Mine too. Good. I'm glad you agree. Keep going.

Michael Sobanja: Just to deal with that, from my point of view, get it locally.

Chair: Rather than have four people say it is bonkers, if everybody consents, we can move on.

Q133 Fiona Mactaggart: Okay. You all think it's bonkers and I'm very glad. Keep going. I want to know about the primary care service.

Michael Sobanja: I think there's a difficult trick to pull here because the alternative would be to say that the primary care services, GP services, community pharmacy, etcetera, should be commissioned by general practice commissioning consortia. That would be an interesting model.

  I think our view is that we need to allow those consortia to mature, they need to be very collegiate in the beginning and if you were suggesting that the contracts for primary care, and GPs in particular, should be held by the consortia in the early days we wouldn't support that for the reason I have just given. It may change over time.

  But you also raise another point, if I may. The White Paper is short of detail on many things. In particular, the role, functions and behaviour of the NHS commissioning board it is particularly short in and we have had difficulty in responding to that balance that I described before because we don't know what they're going to do and how they're going to do it.

Q134 Chair: There is a specific question here, isn't there, perhaps for Dr Vautrey, though others may wish to comment, that the implication of the move to commissioning primary care through the commissioning board is a move back to a single model of the delivery of primary care defined by a contract negotiated between the commissioning board and your committee? I wondered whether that is something you were seeking.

Dr Richard Vautrey: We have long advocated the benefits of having a single contract. It is how we get there and in a way that doesn't destabilise existing practices. This is the key thing.

Q135 Chair: But it is slightly odd, isn't it, to advocate a single contract for primary care and local commissioning for secondary and community care services?

Dr Richard Vautrey: But I would agree with what Michael was saying. I think you can hold the contract nationally but then you can devolve the responsibilities for performance management and overseeing that contract--appraisal, revalidation--to robust organisations that have the ability to deal with the conflicts of interest and other areas of concern. I think it is possible to do that.

Q136 Rosie Cooper: Where are they coming from?

Dr Richard Vautrey: But they would have to do that over time.

Q137 Fiona Mactaggart: Where are they?

Q138 Rosie Cooper: Yes, where are they? Where are they coming from? You are going to give accountability to local authorities who--

Chair: No. We are back on to that again. Chris.

Q139 Chris Skidmore: I would like to move on to the process of effective commissioning and, in particular, the resource allocation necessary to do this.

My question is really around the maximum management allowance outlined in the White Paper. Obviously that is set against the backdrop of a 45% reduction in management costs. The value of that MMA, let's call it, is yet to be determined--I think in December. There was a report in the Health Service Journal in August that this would be around £9 per patient. Sir David Nicholson came on 12 October and said, "Well, let's see" and was very unwilling to give a precise figure.

But I was interested in your view. What would be an effective figure for the MMA? £9, obviously, is far too low.

Dr Richard Vautrey: I think it is completely predicated on what the organisations have got to do—what they've got to deliver. One of the reasons why consortia are unsure about their structural arrangements at the moment is they are not sure what can be afforded. What is clear is they can't simply replicate what PCTs do now.

  One of the keys to the whole of this reform is that the Department needs to change the way that it acts and what it expects of their local organisations, because if what happened in the past happens in the future, where diktat comes from the Department of Health, you've got to fill in this form, you've got to produce that report, you've got to tick these boxes, and more and more of the bureaucracy wheel starts to go round and round again, that's going to be a major problem and will be undeliverable based on the sorts of sums that are being talked about that GP consortia will have to run on. So I think it is really predicated on what consortia can stop doing that PCTs currently do to actually make these reforms affordable.

Professor Steve Field: The issue, then, is where you do things at different levels in the system. Even now, we have very good cancer networks looking at commissioning tertiary cancer work. You will see, I think, networks either of the consortia or of the consortia linked through to secondary care, like now, at some levels. So you will cut down to practice level for some commissioning. As James said, you can actually go down to the individual patient. But it is where you do the different bits of commissioning and the design of the service.

  Going back to the arguments over provision and commissioning, of course, we have been promoting, very strongly, this idea of federated practices working together to provide care across a locality so that you can maximise access and you can look at having different services. That helps with your governance question in that you can commission from then a federation of practices rather than from your own practice. I think that will be one way which will aid transparency. But, again, it is where you do things in the system and how big it is.

Q140 Chris Skidmore: So, effectively, do you agree, it would be far more effective if a consortium themselves were allowed to decide, within their own set budget, what the management allowance was?

Dr James Kingsland: Yes, our difficulty is that if you set a cost per head it doesn't necessarily reflect the necessary or legitimate costs of re-designing a service. Part of a re-design--a business case to change a service--inherently will have some management costs. It is then to say, is it affordable from within your commissioning budget, which is a better way, I think, of looking at what are the necessary resources to re-design a service rather than just saying, "You've got £5, £10 or £15 a head", which doesn't reflect the detail that you will need in terms of clinical time and management time. It will be different costs depending on what service you are re-designing.

Professor Steve Field: Commissioning might well be very different. We have already seen some of the third sector organisations--charities--helping by looking at guidelines for commissioning. I think you will see much more involvement of third sector and local government in some of those decisions.

  Then it is a question of what you do. I think the future, then, is very exciting because you can start to look at different models of care, as we said earlier on, looking at more integrated care across social care and then into secondary care.

Chair: One tiny one, I am told, from Rosie and then a final set of questions from Nadine, who wants to come back to "Any Willing Provider".

Q141 Rosie Cooper: How would you react if I said to you that some GPs in my patch currently, whilst discussing a change in the way services are being delivered at a local hospital--the very thing you are talking about--have actually said, "But you must take into account that we are actually small businesses and if you want us to attend that meeting the hospital should pay for our time"? How do you react to that?

Dr Richard Vautrey: I think we need to recognise that if I get involved in commissioning then somebody has still got to see my patients. So I still need the resource to be able to pay for a locum or other doctors within the practice to do more work, to take on more time, to be able to do that. So there is a cost. What we are not asking for is more money to do it in addition to what we would get paid anyway. But this is money to ensure that patient services continue. Very few GPs will get directly involved in management functions, but if they are removed from the practice then their core function within the practice needs to continue.

Professor Steve Field: Two points on that, because it is a really important issue. In my past life as a Postgraduate Dean, I had this all the time. It was easy to get hospital consultants to go to meetings because the hospitals let them out. The reason our exam is so expensive is that we have to pay locum fees for people who are not providing care in their practice to come and do the examination, whereas the hospitals let people out. But it is a real cost to the hospitals. Actually, if people were transparent about the cost of specialists and managers' time as well as GPs it would be easier. However, I think 43% of GPs now are locums and salaried. Our younger doctors are telling us, in our response, that they want to be engaged in commissioning. Actually, many of them wanted to be engaged in PCTs as well. But if you don't pay them to go, they are not earning at all. They feel disenfranchised at the moment and the challenge, actually, is for us in the profession to get these young, enthusiastic doctors engaged. Unfortunately, it costs money. But you mustn't forget that it costs hospitals money when consultants do things as well.

Rosie Cooper: Absolutely, but we need to deal with the benefit to the patient.

Q142 Nadine Dorries: Dr Vautrey, over recent years the Government and Department of Health have had many occasions on which they have had to revert to the independent sector to provide care on a number of levels. Have you had any issues with that? Can you cite any cases where you and the BMA have been unhappy with that or do you think it has been largely successful?

Dr Richard Vautrey: I think we have produced a lot of evidence to question the value-for-money of independent sector treatments, centre programmes and a raft of other policies. The GP-led health centres that Professor Lord Darzi was initiating, whilst they may have been good in one or two areas, in the vast majority of areas have turned out to be white elephants because they weren't necessarily needed. They were imposed from above.

  I think what we need to be careful of is that, with the "Any Willing Provider" model that is being promoted at the moment, we don't replicate some of the problems, with smaller organisations cherry-picking the easier things to do, leaving the NHS to actually pick up the more complex and challenging and costly areas of work. That isn't what local patients want. They want a comprehensive local service.

Q143 Nadine Dorries: Is that the basis, then, for your concerns and the BMA's worries about more independent sector providers coming into the sector? Is that the basis of your worries?

Dr Richard Vautrey: Yes. I think we worry that there is going to be increased fragmentation so there is going to be increased complexity, leaving many patients confused about where they can get services from.

  We also need to remember that, increasingly, many of the patients who access secondary care services have co-morbidities; they have more than one condition. To refer to one particular provider who is providing one particular service that is not able to provide the comprehensive range of services, you end up with people being excluded. So we have seen some organisations that would not accept people for quite straightforward operations--

Q144 Nadine Dorries: I am sorry, when you say "organisations", can you qualify what you mean?

Dr Richard Vautrey: Private hospitals and a variety of organisations that have set particular criteria that they wouldn't accept people over a certain age or they wouldn't accept people with other co-morbidities because they didn't have an intensive care unit if things went wrong or they weren't prepared to take the risks if that particular procedure went wrong. They then left those particular patients with no choice because they had to go to the local service whilst others were being cherry-picked to go to the private organisations that were being set up.

Q145 Chair: Could we have a view from one of the other witnesses?

Michael Sobanja: I was just going to comment that I agree there have been deficiencies in that area in the past but I think you need to separate out the ideology from the practicalities of the approach.

We would come at it from the point of view of saying that the provider market may require some stimulus by the involvement of the independent sector. The failures that Richard has just pointed out, in my view, are failures in commissioning--inappropriate specification, inappropriate management of contract, inappropriate negotiation of contract with regard to the independent sector treatment centres. That is why I look forward to this arrangement producing robust commissioning, which should mean that services are patient-led and not dictated to by providers of any type.

Q146 Nadine Dorries: Could I ask, then, do you think there is a conflict of interest? The BMA doesn't mind GP members being independent contractors but it is voicing concerns about others being so. Do you think there is a slight conflict there?

Dr Richard Vautrey: No, I don't think so because many of the doctors, if not all of the doctors, who work within independent sector private hospitals are BMA members. We represent them, too.

Q147 Nadine Dorries: So it's okay for the doctors, just not anybody else?

Dr Richard Vautrey: No. We are wanting to ensure that we have a comprehensive service and that we don't have a fragmented, overly bureaucratic and costly service that doesn't deliver value for money.

Q148 Nadine Dorries: Professor Field, did you want to come in on that?

Professor Steve Field: The first thing to say, from the College's perspective, is that a number of our members, including my successor, have spoken out with concern about private industry coming into healthcare.

  My personal view is very similar to Mike's. The commissioning arrangements are the key. We already know that, for example, Turning Point, which is a not-for-profit organisation, are providing drugs and substance misuse support in a number of areas in this country already and the Priory Hospital Group are providing care particularly for anorexic young people in many areas as well.

  I would like to see a comprehensive local service but I think there are opportunities. For example, we could be leading to a better end-of-life care provision by working closer with Marie Curie and Macmillan. Rather than lots of people dying in hospital unnecessarily, we could create a new system—

Q149 Nadine Dorries: Is it, then, that you don't mind social enterprises—it is just the for-profit organisations you are objecting to?

Professor Steve Field: I am more comfortable with social enterprises. However, if it is about providing high-quality care, and you can set the commissioning or the design of the service then I, personally, have more of an open mind about what the service should be there to provide. That isn't, actually, the view that the College currently has. That's a personal view.

Q150 Nadine Dorries: So if the commissioning is structured in such a way which allows anybody to bid for that business, then, as long as the commissioning is right and the criteria are right and everybody knows what they are asking for and what they are purchasing, you have no objection to that?

Dr Richard Vautrey: I think there are problems inherent within the White Paper, as I have mentioned a number of times now, about the balance between competition and collaboration. What we would want to see is that the systems going forward don't prevent meaningful collaborations with local organisations--with my local hospital down the road. I want to be able to work with those consultants. That's where the majority of my patients want to go.

  What I don't want to find is Monitor or other organisations suddenly jumping up and saying, "That's anti-competitive," you can't work in a sensible, collaborative way that your patients would want, you have got to involve everybody or keep a distance from them and you end up with a plethora and complexity—

Q151 Nadine Dorries: Yes, but I'm getting an impression from you that what you would want to do is always to go there as the first choice, as your first choice, before you look to any other option rather than asking your patient where they would want to go. I'm kind of getting the feeling that you want that to be the default position and if that position fails then go elsewhere, which may include independent sector providers. I'm getting the feeling you are taking that from the doctor's perspective rather than the patient's perspective.

Dr Richard Vautrey: No, I'm not--

Q152 Nadine Dorries: What if the patient said, "Actually, I don't want to go there. I want to go to another provider"?

Dr Richard Vautrey: My patients consistently say they want a good-quality local service that is comprehensive and meets their needs. Clearly, if that service doesn't provide their needs, then there will be other services who I may be able to refer to.

Q153 Nadine Dorries: Yes, but they don't know if it meets their needs until they have tried and tested the system. In the first instance, it is going to be you who is referring or directing them to that service.

Dr Richard Vautrey: No. I think any referral has to be a joint decision between the patient and the doctor. The idea that "the doctor knows best" is long gone. The idea that the doctor will sit with the patient and they will decide between themselves where the best place for that referral to be made is how that joint decision making takes place within every consultation.

Dr James Kingsland: Could I add just one point on AWP? AWPs have got to be good for patients. I was part of a team who first described it. The process--you used the word "bidding"--was to get away from any bidding or tendering. An organisation that meets the standards of the NHS to increase capacity should be welcomed. I think where we got in trouble was the ISTC programme which guaranteed cost and volume in contracts, and that can't continue. But the AWP process, as a principle, has got to be good for patients in terms of increasing choice and capacity.

Q154 Grahame M. Morris: But is there an issue then of undermining existing providers, even if those providers are part of a natural monopoly? If you had a plethora of smaller providers providing a much more limited range of services, wouldn't that be bad in terms of the long-term stability of the NHS?

Dr Richard Vautrey: I would agree. I think there is also a big issue about training and education because if you cherry-picked elements of care and removed them from the main local provider where the main bulk of training takes place, then young doctors will not get exposure to those sorts of episodes of care, and that will be to the detriment of us all long-term.

Chair: I think at that point I am going to have to draw this session to a close because we have four more witnesses who are waiting, I guess increasingly impatiently, behind you. Thank you very much indeed for coming this morning and for covering a considerable amount of ground.

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