Commissioning - Health Committee Contents

Examination of Witnesses (Questions 155-191)

Dr Paul Charlson, Dr Peter Davies, Dr Kambiz Boomla, Dr Jonathon Tomlinson.

2 November 2010

Q155 Chair: Gentlemen, thank you very much for coming this morning and for waiting patiently as the four previous witnesses gave their evidence. Could I ask you, briefly, to introduce yourselves and say a couple of sentences about where you are coming from and the basis on which you are here. Dr Charlson, would you like to start?

Dr Paul Charlson: I am Paul Charlson. I am a sessional GP now in Hull and I am also a local Medical Director of a Darzi centre in Grimsby. I was previously a full-time partner in a big dispensing practice in rural East Yorkshire, and I also work as a GP with special interest in dermatology, both for a private provider and an NHS provider. So I have an overview of a lot of different things that you have been talking about.

Dr Peter Davies: Hello there. My name is Dr Peter Davies. I'm a GP partner in a big practice in Halifax. I also think a lot about the NHS and write a lot. I have done some writing with Civitas and, in the references, my book Putting Patients Last was my "son" for the last year. So, yes, I have a lot of interest in all this.

Dr Kambiz Boomla: My name is Kambiz Boomla. I am a GP in Tower Hamlets, which I think is credited as being one of the PCTs that has done quite well during the last regime. I chair City and East London's Local Medical Committee, which is the GPs' representative body.

  Until very recently, I was on the practice-based commissioning executive in Tower Hamlets but I stood down from that very recently.

  I also chair the PCT's ICT Committee which has been responsible for rolling out an integrated general practice and community health service's record, which we think is in the process of helping to transform care. I also work as a senior lecturer in the Department of General Practice at Queen Mary.

Dr Jonathon Tomlinson: I am Jonathon Tomlinson. I am a GP in Hackney, in East London. I have worked in hospitals and primary care in East London over the last 15 years. I have experience working in vulnerable communities in Afghanistan and Nepal and a degree in Global Ethics, which is another interest I have. I am a GP tutor as well and I have been working with the campaign group Keep Our NHS Public for the last three years.

Q156 Chair: Thank you very much. I would like, if I may, to open the questioning by asking each of you the same question that I asked the previous group of witnesses, which was to link what I describe as the Nicholson challenge—the efficiency gain associated with the search for £15 billion to £20 billion of efficiency savings in order to allow the NHS to deliver the budget that was set out in the Comprehensive Spending Review—with the challenge of implementing the White Paper proposals and to ask you how you react to that challenge.

The previous witnesses, as you will have heard, stressed the importance, if the efficiency gain is to be delivered, of engaging the clinical community in the management and the delivery of that efficiency gain. Is that a perspective that you share? Do you think that that is the right answer to the question that is implicit in the position that the Government and the NHS management now find themselves in?

Dr Paul Charlson: I think it is all about releasing innovation. That's the real way to make savings. People who have got a stake in managing budgets are much more likely to want to innovate and make savings. I think that is the absolute key thing about the White Paper and commissioning. It is about getting stakeholders involved and making sure that they can really innovate and re-design services.

  A typical example of the kind of thing that is happening is this. Say you go to the hospital for haemorrhoid banding, which is a common thing that happens. It costs £600. You can do it for about £20 in general practice. Obviously, there are on-costs on that but you can save a huge amount of money. So there is a great incentive, if you are commissioning and providing services, to innovate. I think it is all about the release of innovation and people having a stake in that because you are much more, in a way, spending your money rather than feeling it is an amorphous thing. That is what I feel is the key issue--one of many, obviously.

Dr Peter Davies: I am going to echo Paul on that. How do I see it? Just looking at the total NHS budget of roughly £100 billion a year and saying, "We're going to take that down to £80 billion", even if we can do that over four years, it is still £5 billion a year, which seems a huge amount to take out of the system. If we are going to get anything to work, I think--at the moment, as a doctor, I sit there in my consulting room and do lots of referrals, hopefully in consultation with the patient and this is probably the best place for the patient to go. But, at the end of the day, I send a bill for that to the PCT which they then have to pay.

  In fact, once these new commissioning consortia come together the doctors and the PCT managers, or the new commissioning managers, are going to have to work hugely together. I think bringing the economic and the clinical perspectives together actually gives us some chance.

Dr Kambiz Boomla: I suppose I take a different view. I think that if you were going to do this you wouldn't start off with the economic position that we have got now. We are setting up new bodies which I think are being set up to fail, in a way.

  Let's imagine that we had a 5% improvement in our efficiency. My fear is that the public spending cuts that will impact, particularly, on social services and will, therefore, impact on healthcare provision will mean that we will be running to keep up with where we are now.

  I look at the experience that we have had in our GP practice-based commissioning group. We were able to make quite large improvements on the quality of our outpatient referrals, but where we always struggled was to deal with unscheduled care, people turning up in A&E, getting admitted to hospital as emergencies, things that GPs felt they had very little control over. In order to get control over those sorts of things, you need much larger whole system reform, which really required a body that would stand above the sectional interests of general practitioners--and I am a general practitioner--and would be able to engineer a total system reform of the local health economy. My worry is that GP commissioning groups aren't really going to be quite in the right position to do that.

  I appreciate lots of things that the previous panel said. Lots of steps could be taken to ameliorate that position, bringing in lots of patient involvement, working closely with public health and bringing in lots of different stakeholders on to our GP commissioning board. But then, I think, one is ending up by re-creating an organisation which I was actually a great fan of, which was the old Primary Care Group, where we actually did have much larger GP involvement in commissioning but it wasn't seen as primarily or exclusively a GP-focused activity.

Dr Jonathon Tomlinson: In my memorandum of evidence I think I started off by saying that I felt the challenge for any system of universal healthcare is to provide that care according to need so that the people who need the most healthcare receive the most healthcare and that the healthcare they receive is appropriate. I believe if that is your aim then you will create efficiencies that way, although of course you can provide healthcare that people need that is not necessarily efficient. For example, the time that I spend explaining to somebody about the consequences of their diagnosis of cancer or talking somebody through a bereavement can never really be measured in classical economic efficiency. Certainly, if you are treating somebody you don't want to over-investigate them or over-treat them. You can save a lot of money if there were better distribution to clinicians and they made better use of NICE's recommendations.

We know that doctors, sadly, are very poor at following best evidence. An analysis of common conditions shows—and as a doctor I have to stand here and I am guilty as well —that perhaps doctors follow recommended guidelines only 20% to 60% of the time for very common conditions. If we could use the information that we already have about how best to treat our patients not only would they be a lot healthier but we would save a lot of money.

  Of course I think it is important not to muddle efficiency with giving patients what they need. You can screen a population who are at low risk very efficiently and make a lot of money. It doesn't mean that that is what they need. You could distribute Viagra very cheaply by having a website. That's not necessarily what patients need. What we do know is that patients with conditions that are complex and enduring need a relationship with a doctor. I don't think that is something that can be measured by simple efficiency savings. I think that is something that is really threatened by a focus on efficiency rather than a focus on distributing healthcare according to clinical need.

Q157 Chair: I understand what you are arguing, but the challenge is that, against the background of resource constraints, unless there is a willingness to address what Dr Boomla described as "system change", there is a danger that people are simply squeezed out because they are at the back of the queue rather than because there is a conscious clinical choice based on priorities.

Dr Peter Davies: If I may say, whatever the economic climate of the country, NHS resources are always confined. There is a finite amount of money that the country can afford to spend on healthcare needs. As doctors, we can think of enough tests and enough things to keep patients busy and entertained for many, many years. To some extent the Government actually need to restrain our enthusiasm and in fact it is probably better to do that.

Q158 Fiona Mactaggart: Isn't it better if you do it rather than the Government do it?

Dr Peter Davies: It depends. If I have time on my hands I can invent new diseases for people to catch. There is almost an element that, in fact, you get supply-induced demand and you get demand-induced supply across the NHS. Actually, there comes an element that, in fact, if you are dealing with, say, casualty and you are trying to get through the patients quickly, you will do what's needed at the time to deal with them when the Casualty Department is full. If you have got a nice big empty clinic you will find something to do with it.

Dr Paul Charlson: On the other hand, if you get a little bit more time with the patient often it does actually save you money. I can think of lots of times when, in a rush, you will do something. Often, you will actually do a test or something because it just buys time. So that costs money. Similarly, with things like dermatology, which I am very much involved in, if you actually explain to the patients how to use the right medication they don't bin it and go and see someone else; they actually use it properly and they get better. So I think a lot of it is about releasing time and working efficiently. That is about using other people in the healthcare team, so that is a little re-design.

  The other thing, which I didn't hear much about in the last evidence, is really about patients taking a lot more responsibility and getting real, too. Getting patients involved is really important so they actually get some concept of what costs are and what the issues are around costs because, as you say, there is not an unlimited pot. There are always going to be restraints. It is just how to use those resources best. I think that is how I would see it.

Q159 Fiona Mactaggart: I am really interested in this thing about patients. My constituents think, "Here's my poor health doctor." They really do think that and, actually, when I try and get them to do things like--we have a very high level of heart disease in Slough--keeping active after their first MI and so on they think, "Oh no, I'm going to die if I walk anywhere. I'm going to stay on the sofa for the rest of my life." I think it is really hard with certain populations to help them to take power over their own health.

I think that our whole society, and I am not actually blaming doctors for this, is really bad at helping people take responsibility for their own health. I don't see anything in this White Paper which is going to help with that and I would not be uninterested if any of you have got a good idea about how it can be achieved because, certainly, in terms of improving the quality of the Health Service, however it was structured, it would be a good thing to do.

Dr Kambiz Boomla: Can I come up with an example that we have done in Tower Hamlets, which is our primary care investment programme? The PCT took the decision, because we were a resource-gaining area because of our deprivation—under the last Government we did have money to invest—that as far as possible that money would be invested in primary care rather than adding to the hospital bill.

We chose diabetes and childhood immunisations as being the two areas that that investment would be in. That demanded a very close collaborative approach between the GPs, the hospital consultants and the other staff--the sort of thing that Dr Richard Vautrey was talking about earlier on where work is done collaboratively. As a result of that and as a result of investing in the networks of practices that Steve Field was talking about, we produced quite a massive change in the way that patients also thought about their diabetes. It is a different example to your heart disease. For example--I think you will be able to see this--the proportion of patients who now have a care plan for their diabetes in Tower Hamlets has risen from 10% or 15% at the bottom to about 64% now, which I think is quite a shift.

  On childhood immunisations, here the graph is slightly deceptive. We have risen from 84%--

Q160 Chair: We are trying to take a verbatim note. Could you simply tell us the numbers?

Dr Kambiz Boomla: The thing has gone up enormously. Collaborative working across the primary-secondary care sector has resulted in the sort of system change that I was talking about. But if we had Monitor coming in and telling us that we were not allowed to talk to our local provider unless we talked to "Any Willing Provider", we wouldn't be able to make those shifts and we wouldn't be able to make the whole system reform that I was talking about.

Q161 Chair: Can I just probe that for a second? I understand why stable pathways of care are necessary to secure good-value, high-quality care. But before you commit to a stable pathway system what is the objection to considering what alternatives might be available? "Any Willing Provider" isn't the same thing as "Any Willing Provider on a spot market basis". You can make a considered choice for a period of time, it seems to me, having considered the alternatives. What's wrong with that?

Dr Kambiz Boomla: I am not saying that all state monopoly providers have a God-given right to hold their contracts. What I am saying is that, in our area, we have a lot of very experienced clinicians who have given up a very large amount of their time to developing and improving the care that they offer their patients. Once you move to a system of five-year renewable contracts, which the "Any Willing Provider" model tends to move towards, you end up--let me give you one example in primary care. A very large multinational company won the contract to run a particular practice in Tower Hamlets and the turnover of the salaried GPs within that practice has been enormous with no continuity of care happening in that practice. Contrary to what the PCT was expecting, that practice has dropped to the very bottom of the balance scorecard in Tower Hamlets.

  The danger is that the organisations themselves will, in my view, retreat into a financial bunker where they do not want to share their knowledge and the way that they have reformed their care pathways with other providers, because they see that that is taking away their competitive advantage when it comes to contract renewal. So, rather than having a collaborative approach to healthcare, you end up with the balance shifting to competition rather than collaboration. Where that may work well when you go to buy your holiday, I don't think it works well in healthcare.

Q162 Chair: Dr Charlson was shaking his head.

Dr Paul Charlson: I don't agree with you, really, because I've seen the opposite happening. I have seen my local hospital trust really being incredibly anti-competitive and charging and gaming quite a lot. I think you do need competition in healthcare to raise standards and prevent partner gaming which I think is going on. So I don't agree. I agree you need stable and collaborative working but I don't think, necessarily, you need one provider to do that. I think patients do deserve some choice. They may not necessarily want to go to their local hospital. I know that quite a lot of times they do but they may want to choose to go somewhere else which gives them a shorter waiting list, better opening times, better quality care. That happens and I think competition is important for that. I don't think you want a Wild West. I think that would be worrying. But I think you want high-quality care. Patients don't care who provides it as long as it is good quality and they are not paying for it. I think that is the thing and it is what they want.

Q163 Valerie Vaz: I am not sure that's right. I think patients do want to go to a very good local hospital. Maybe it is slightly different for you in your specialty, but there are certain illness, diseases and conditions that don't need just some cream and off you go.

Dr Paul Charlson: No, I'm not just talking about dermatology. I am talking about a lot of conditions that can be managed much more conveniently locally. Certainly there are a lot of outpatient functions that happen in hospitals that certainly don't need to happen as they do because they are very expensive, difficult to park for patients, not easy, poor appointment systems and all that stuff. But it doesn't necessarily mean a local hospital either. It may be a fairly local hospital which is better for that particular sort of care. Of course, some bits of care do have to happen in a specialist centre—we know that—but not as much as it does at the moment.

Q164 Fiona Mactaggart: One of the things that I was hearing from the previous panel was the suggestion that a clinician-led commissioning system could mean that secondary care is brought more under control. I am just putting it rather crudely. I think that is what you are saying and I think Dr Boomla was also saying that in a way and wasn't saying that you just need one place. There does not necessarily need to be a monopoly but there does need to be relationships. I think that I think, listening to everyone, that, if there is something to be said for GP-led commissioning, it is to do with clinical relationships between primary care physicians and secondary care physicians being able, hopefully, to migrate more care into primary care. Actually, patients prefer it although they think that the hospital doctor is probably better than you lot, for no particularly good reason, but they do sort of think that. But if it can be done quickly in the local GP practice and you can get home and look after your kids, "Whoo, great." So I am wondering, if it is about relationships, then if it is all going round purchasing, how do you sustain the relationships?

Dr Peter Davies: There is already a purchasing relationship going on.

Q165 Fiona Mactaggart: Yes, I know. It is very managed at the moment.

Dr Peter Davies: Yes, but there is, actually, a set of default decisions built into the current system. This is actually a balance which has altered. If I go back to, say, when my dad was a doctor 40 or 50 years ago a GP couldn't get a full blood count done. That was highly specialised. He sent you to the hospital. So you end up with a hospital that has all the investigations and x-rays and a GP has, basically, just his clinical wits.

  I am sitting as a GP now and I can now order all my blood tests, pretty well every x-ray I want and every scan I want. There are about 10 very specialised ones which you would only do if you were a second-line specialist anyway. But, other than that, I can order pretty well any investigation I want. I am also now getting the results back to me quickly. So, in fact, the potential to do more in primary care is there. This default that there are lots of patients on reviews in the hospital clinic and people going through that, actually, maybe doesn't need to be there any more.

  One of the things in fact--you can speak to PCT chief execs about it--is that they will say, "I'm in bed with an elephant. This hospital is hoovering money up by payment by results", and, "How do I shift some of this lot back to primary care?"

In fact, for a lot of the outpatient follow-up, which is routine, and where the disease is controlled and diagnosed and we know what we are doing with it, most of the routine management could actually be done in primary care. Then, in fact, when we use the hospital we can use it much more for, "There's a new illness here. We need a new diagnosis. This illness has got worse. We need some specialised treatment on it." That would actually take it. But a lot of the routine stuff for the hospital just doing follow-up could be moved out to primary care.

  I suspect our information systems these days in primary care are streets ahead of the hospital, apart from digital imaging which a hospital is good at. We could, actually, do quite a lot with that. There is potential to move quite a lot to us.

Q166 Chair: Just before you come in, does Dr Tomlinson agree with that view from Dr Davies?

Dr Jonathon Tomlinson: I do, but I think that is a completely different issue. I don't think it has anything to do with competition and markets and multiple providers.

  We have to look at what evidence we have. Certainly patients are more satisfied having their blood tests in primary care. There is evidence of cost in a competitive environment. On the recent review of healthcare in the States, they said there that the single reason for the high cost, which is two and a half times per head of population--that is what the Government spend on it in the United States--was that it is the only healthcare system in the world that is so much owned by investors that medical care has become a commodity rather than a right. That is really important. It is terribly expensive to run a market in healthcare. It is very cheap to do things in primary care. I have no problems with that. We do everything we possibly can in my own surgery.

  I don't believe that it is in patients' interests to have lots of people competing to do your blood test. Why do not all of my patients have it in my surgery? Why have somebody open up, next door, for instance, saying, "Blood tests. Come here and get them done even quicker than Dr Tomlinson"? What's the point of that?

Dr Paul Charlson: It is innovation. That's the point. It is encouraging innovation. That's what you need because that's why we have been stuck--no, we do--

Q167 Valerie Vaz: We just want a blood test.

Dr Paul Charlson: Okay, but the fact is we have been stuck, for years and years and years, not being able to innovate. I am a real innovator and I have been incredibly frustrated by the restraint of what we have at the moment. We just cannot innovate and provide better services for patients. That's what it is about.

Q168 Fiona Mactaggart: Dr Boomla has described to us how he has innovated in the present system.

Dr Paul Charlson: Okay, but that is one example. On the whole, if you talk to most people, that isn't the case. We haven't been able to innovate anywhere near to the extent that we need to. And that is what it is about. It is releasing innovation.

Grahame M. Morris: Can I have a question opposing this, Chair? Thanks very much.

Chair: What that is illustrating, Grahame, is that disagreements aren't confined to the political world.

Q169 Grahame M. Morris: Absolutely. But on this big picture I am interested in your views on maintaining the stability, in the long term, of the NHS, and also if perhaps you could elaborate on your views on the introduction of this internal market approach in the NHS. I can think of some practical examples. Obviously I have common cause with our colleagues from Tower Hamlets and Hackney, representing Easington, an area of high deprivation. We have had some excellent examples of innovation in terms of our COPD pilot which was nationally recognised. So I think there is scope on the existing arrangements to recognise innovation.

But I want, particularly, to come back to your issues about commissioning and how it would be advantageous to patients and in terms of efficiency and value for money. I can't quite understand how the 8,230 micro commissioning units that Dr Kingsland referred to in his earlier evidence can be any more efficient in terms of sustaining the service and in providing value for money than 150 Primary Care Trusts that we have at the moment. I would be interested in your views on that.

  I am also concerned, having talked to people in the hospital sector, about the instability that may be introduced. Dr Charlson referred to an example of a particular procedure that could be done more economically at lower cost in a primary care environment. The example that was given to me was if, for just cause, it seems a good idea for primary care to transfer something like x-ray screening into a primary setting. A relatively small transfer may undermine the financial stability of a large general hospital because they are operating on the margins. It may undermine the whole basis of the health economy.

Why don't we, without a firm evidence base, look at a larger-scale pilot and evaluate that and see what the impact would be on local health economies before we roll out a whole national programme? I would be interested in your views on those points.

Dr Peter Davies: It is strange. In medicine and, particularly, in surgery we have moved ever more to more precise, more specialised and more micro surgery and laparoscopic surgery and cutting less. The old days of abdominal surgery and opening up down the middle, opening up the abdomen and going, "I wonder what's going on in here?" are largely gone.

  At the political level it appears--dare I say it--that successive Secretaries of State for Health have done the equivalent of an old-fashioned laparotomy. They have said, "Let's open it. Let's do a change and see what happens." Yes, the NHS does seem to have had wave upon wave of major surgery performed on it over, dare I say, probably the last 20 years.

Q170 Grahame M. Morris: But is the lesson that you should learn from that that we should take a more considered approach to change, that we should effectively pilot and see where the potential problems are and perhaps review the pace of change? I am interested in your views as GPs having been subject to such major change over the last perhaps two decades.

Dr Peter Davies: I suppose I am being a realist. I am not expecting anyone to do a pilot, but in fact I think doctors have been saying, "Pilot these changes" many times previously. I have a suspicion that in fact it is going to happen in a big bang. I don't know if that helps you.

Dr Kambiz Boomla: I agree with some of the previous speakers on this panel that greater clinical engagement into the commissioning process from a range of clinicians, hospital consultants, GPs and community health services staff is urgently required and that there was, under the old system, a disarticulation between practice-based commissioning on the one hand and real control over the resources on the other. That meant that practice-based commissioning was, to a degree, dysfunctional. The question really is, how do you bring this back without all of the risks that have been talked about earlier on of the destabilisation and losing good managers, etcetera, which we are already beginning to see?

  My view is that the way to achieve this would be to graft the clinicians into the PCT boards and, in that way, you wouldn't require the wholesale managerial change and the destabilisation that that would cause. But you would get clinicians into the heart of commissioning decisions and I would include your patients that you were talking about in that. Then, I think, one would have a board that was publicly accountable, that was clinically led and that could achieve the sorts of wholesale system change that we are talking about, without all the destruction and risks that we are talking about.

  I want to give two terribly small concrete examples of how I think this could easily go wrong. One is where we have done it right around diabetes, which I have already talked about, and one, I think, where we have done it completely wrong, which is around anticoagulation. We shifted, without those collaborative conversations, quite large chunks of warfarin blood-testing, anticoagulation into the community and we thought we would save lots of money because it was cheaper to do it in our surgeries than in the hospital. The result of that is that the few patients that were left in hospital were called back far more frequently by the hospital managers, thus generating entirely the same amount of revenue to the hospital under the payment by results scheme. So we ended up paying for everything twice.

  That is really the activity that an internal market, particularly with a plethora of "Any Willing Providers" who are there simply to maximise their profits to their shareholders, will do. As a consequence of that, the GPs then get sent spreadsheets, and this is what we will increasingly be asked to do under the new arrangements, where we are asked to clinically check all of these activities to see whether they were clinically justified or not. And we now have to turn these round in three days. So at seven o'clock, seven-thirty, at the end of evening surgery, I want to go home. Can I? No. I've got this spreadsheet to go through with 120 patients on saying, "Was that follow-up justified or not?", or "Should that patient have been discharged?" This isn't good use of clinical time.

Chair: There is somebody else who does this. I will come to you in a second, but Sarah.

Q171 Dr Wollaston: Can I just ask the whole panel, is it your view that we should have had a more evolutionary approach and that we could have achieved the changes that are desired from the White Paper by having more clinical leadership rather than something completely revolutionary?

Dr Jonathon Tomlinson: Yes, I agree. I'm concerned that the White Paper is giving all the money to GPs. I don't see any particular reason why hospital doctors should have been excluded from that. Why does it have to be given only to GPs? I think there are a lot of things that we do that are very different and the way that we think about our patients is quite different from hospital specialists. I am worried that it is going to further divide and make it more difficult for GPs and hospital specialists to work with each other. So I think there must be a better way of doing it.

  Certainly my experience of practice-based commissioning is that GPs are highly suspicious of hospital specialists keeping patients in to do tests that are unnecessary and calling them back for appointments that are not necessary because they can generate more income, and keeping patients--admitting them for a few hours from the Accident & Emergency Department--because they can charge £600 rather than £300. It is a real worry and my hospital colleagues fear that GPs are not referring patients who really need to be seen in hospital because they are having to pay for every referral. So there is a horrible level of suspicion and distrust. Twenty years ago, as a medical student, there was a real disdain of GPs and they were really looked down upon. With this practice-based commissioning it is really making things worse and I can see the White Paper is only going to drive a bigger wedge between GPs and their hospital colleagues.

Dr Paul Charlson: I agree with you, Sarah. I think evolution would have been preferable but I don't know what the situation is around the money. All I know is that things are pretty bad. No change was not an option. It is just about the pace of change, really.

  I take your point about pilots which you asked, which we haven't answered. I think it would be a good idea if you can make a pilot really happen. But these tend to take such a long time and I don't know how tight things are.

  I think, in a way, creating a "big bang" does create a lot of activity and, hopefully, will produce the results we want. But, I agree, there are huge and inherent risks and I think every one of us will have the same anxieties--every one.   So I think evolution would have been ideal but I don't know whether evolution is that possible given the financial position that we are in.

Q172 Rosie Cooper: Sadly, hope is not strategy.

Dr Paul Charlson: It isn't, no.

Q173 Andrew George: I am very encouraged by some of what I have heard in that, in comparison with the previous panel, there is a greater level—and pardon the pun—of healthy scepticism towards the White Paper amongst this panel than the previous one. If you are looking at the White Paper as not a done deal and something which is up for debate and that you wish to try and influence as much as possible for the good of primary care, and one of the possibilities, as Dr Boomla has said, is to graft into the existing management structures, then what would you say are the core, say, top two or three, if you like, building blocks of a system of effective locally-commissioned healthcare?

Dr Kambiz Boomla: The top--can you just elaborate on that?

Q174 Andrew George: If you were to create a new system, in other words, rather than simply adopting the proposals of the White Paper, what are the core building blocks? You mentioned greater clinical engagement, for example. You mentioned that as critical to this. I just wanted to expand on that. If you are looking for this new structure, and a structure that actually works, let's start from a different direction, if you like, and say, "What are the core building blocks?" What are we trying to achieve in order to get the essential improvements that I think we all desire because the old system has become dysfunctional?

Dr Peter Davies: The one I would really love—the building block of the whole of the NHS is the GP-patient consultation. At the moment it is beleaguered, it is crammed, it has got too many requirements in it and it is rushed. For any disease you care to name you can find any number of patients who we have not spotted and not diagnosed. Of course we haven't. We are too busy to spot them. If we spot them we don't have a service to refer them on to to get them going. So there are problems at the level of the GP-patient consultation.

  If we are going to run a primary care-focused NHS, then "primary" has to mean that the GPs have to become a lot more accurate in their diagnosis. We need to be much more accurate in our problem definition of the patient because--

Q175 Andrew George: So you need more time with the patient?

Dr Peter Davies: We need more time with patients.

Q176 Andrew George: And, therefore, you need more GPs?

Dr Peter Davies: Probably—yes, we need more GPs.

  The quid pro quo I would offer the Government or the taxpayer on this would be, if I get more time per patient and I define the problem right, my choice of referrals, investigations--my understanding of the patient will be better so the rapport is better. Better rapport with patients means fewer complaints. It also means I get the diagnosis better because I'm actually talking to them properly. So we've got a win all ways round, plus it's nicer medicine to do. Then my use of additional services onwards will either stay the same or drop because I will be more targeted and go, "Actually the real problem here is—but, yes, there is an issue we need to investigate. The tests that will give us the answer to this is" and just get on and do it. I hope we would use secondary care less if we can get to the problems. GP consultation is so packed at the moment that there is a temptation to do a test, come back, do a referral, come back. There's an element of passing on, I am sure.

Dr Kambiz Boomla: One of the things that I think nobody will regret their passing very much are the Strategic Health Authorities. A lot of us feel that they were an unnecessary tier. However, in terms of these building blocks that you were talking about, I'm worried that the NHS commissioning board is too remote from primary care to be able to commission us, as GPs, properly.

  I go on holiday to Wales and there are Welsh sheep farmers there. You have to know your hill in order to properly manage it. My feeling is that the GP commissioning board will not know their hill when it comes to commissioning general practice, when it comes to commissioning us as partnerships of practices in these GP provider units.

  When we, in Tower Hamlets, took the decision to invest substantially in primary care we increased the total NHS spend from 9% of the NHS budget in primary care up to about 12% or 13%. I can't see how a GP commissioning group would do this without everybody crying, "Conflict of interest." I just don't see it.

  Therefore, I do see that there has to be some kind of a local body that will command sufficient independence from the general practitioner body as a whole--it may include some GPs on it wearing a commissioning hat--but that would be able to make bold decisions about care re-design without people turning round and saying, "It's just GPs putting money into their own pockets."

Q177 Andrew George: Would you say that we might call them Primary Care Trusts and would you say a scale of about 152 in the country might be about right?

Dr Kambiz Boomla: I'm not going to quite come into that--

Q178 Andrew George: You mean about 152 hills?

Dr Kambiz Boomla: I have already said that I feel that those Primary Care Trusts need to be radically restructured. But I don't feel that they should be focused into being GP commissioning groups.

Dr Jonathon Tomlinson: I think that there needs to be, as far as commissioning is concerned, real collaboration between primary healthcare, hospital healthcare, public health and something nobody has really mentioned before, patients, and I think it needs to be democratic. I think public health is important because I have actually locumed in parts of the country that are much less deprived than Hackney, and it is a very relaxing type of general practice compared to where I normally work, which suggests to me that healthcare is not distributed according to need. Some of these GPs from nicer places could come and work in Hackney and see just how much burden there is of need.

  There has got to be some sort of planning that distributes GPs according to where they are most needed. That will probably mean paying them a bit extra for the stress and the discomfort, but you can't have commissioning only done by GPs who are seeing what is happening in a consulting room. You have got to have a range of perspectives, including hospital specialists, public health and patients as well.

Q179 Chair: That obviously does go on, as I am sure you appreciate. One of the perspectives that is regularly reported is the problems in developing high-quality primary care, in particular in inner-city areas such as the ones where you work. Securing the quality of decision making in primary care that is implicit in this structure in some of the inner-city areas, as you have said on a number of occasions, is one of the issues, it seems to me, isn't it, in this White Paper?

Dr Paul Charlson: Yes.

Q180 Valerie Vaz: Can I just ask, if you were commissioners, would you be able to balance that conflict between individual patients' needs and the public perspective? I have asked the question of the previous panel and I would like to hear what you think.

Dr Paul Charlson: I think we do that--

Q181 Valerie Vaz: Are you able to do that as GPs?

Dr Paul Charlson: I think we do that now, to a certain extent.

Q182 Valerie Vaz: The PCT does that, doesn't it?

Dr Paul Charlson: I can decide where I send a patient and I might have an interest in an organisation that has run such a service. So I can already do that. I think we do do that.

  The conflict of interest thing actually worries me a bit because if you are an innovator, and many of the people who are going to get involved in commissioning are going to be innovative practices and innovative people because they are going to be the people who want to be commissioners just naturally, and if they are going to be excluded from providing or being involved in provider services, then it is going to put them all off either commissioning or providing. I think that is just daft. We are going to commission and provide. That is the reality. We have just got to work out a system of making that transparent and safe. I think that is a really difficult thing to do but it can be done.

  I do think that the reality is about putting individual patients and cost, which is what we are talking about because there is always a cost-quality tension, isn't there? We have got to be real. The reality is if we do something for an individual patient that costs money then someone else may well be denied. It is about getting the most bang for your buck, if you like. It's about making sure you use the money most wisely. That does mean bringing patients' groups in and I think that is a really key thing, bringing in patients' involvement, getting them actually involved in the cost bit of it as well--

Q183 Valerie Vaz: And the articulate Mrs Smythe will be able to do that rather than the inarticulate Master Smith?

Dr Paul Charlson: That is a real problem and I have worked in both communities, your wealthy East Yorkshire and your poor Hull. It is different and I think it is up to us to kind of fight the corner a bit for patients.

Dr Peter Davies: Interesting. I think Paul has spoken sensibly there.

  I think the reality we all have to acknowledge is that however we distribute the money in the NHS it is a finite pot of money. You can only spend £1 here. You can't then spend the same £1 again there. So, at some point, there are going to be hard cases where someone is going to say, "I haven't got what I should."

  The NHS, at the end of the day, is an insurance policy. We pay in about £1,600 per person per year through our tax. But all insurance policies, at some point, have a limit to them. I think Aneurin Bevan, when he gave us the great phrase, "all care necessary from the cradle to the grave", gave us an absolute. It is great rhetoric but I think it is too much. I think he probably got carried away on the rhetoric on it because, in fact, to actually deliver to that is a practical impossibility. We are never ever going to fulfil or deliver on that promise. So, at some point, we are going to achieve to do this bit of care but we are not going to achieve to do that bit. We need some fair process for choosing between who gets what.

  In any fixed system like this the articulate middle classes will always do slightly better than the poor.

Q184 Rosie Cooper: Is there any future for single-handed practices?

Dr Peter Davies: I am going to be controversial here but my suspicion is probably not.

Q185 Rosie Cooper: And what can you contribute to that agenda?

Dr Peter Davies: The only way that single-handed practices are going to do well is if they federate so, in fact, you've got five or six single-handeds forming a sort of loose group. But there are too many activities which I do now—I am in a six-partner practice and we can talk to each other. If we've got problems we can go, "I'm getting wound up by this one." Then we can sort it out between ourselves and calm each other down or whatever. If you are a single-hander you take all that yourself. Also, with things like clinical governance, audit and reviewing the notes, you have got to have a group of people together and do it. As a single-hander, you can't really just review it yourself.

Q186 Rosie Cooper: Absolutely. I have just one very quick question. Doctors will need to be paid to do the commissioning. How do you think that will work? What do you think is going to happen?

Dr Peter Davies: To be honest, I hope that it is seen as additional work. At the moment I have to be paid to come out of my surgery. If I take a surgery off then my partners at the surgery will go, "Actually, no, you need to cover that work." That usually means a payment into the practice.

Q187 Valerie Vaz: Could you each give us your view. Dr Tomlinson?

Dr Jonathon Tomlinson: Where I am at, the proposal is that the commissioning organisation will encompass City and Hackney, Tower Hamlets and Newham. That is three PCTs in size. So it is an enormous number of patients with a hugely diverse range of needs. Clearly, you are not going to have 600 GPs doing that. There will be a handful of people who are either elected by their peers or self-selected. We don't yet know who will be doing that. There is a problem that all GPs have to be part of commissioning organisations. Actually, just as my colleagues here have said, single-handed GPs will probably have to be federated. There is a real problem with getting GPs to work together. We are independent contractors. We are quite independently minded. I think there needs, probably, to be some better financial incentive for GPs to work collaboratively. So not only do single-handed GPs need to share resources but group practices need to share resources for things like minor surgery, gynaecological procedures, dermatology and so on. There has to be, not only between primary and secondary care but between primary care, some kind of collaboration.

  For commissioning to be successful, all the GPs in the group need to be taken on board, but I worry that, even at the level of our present PCT in City and Hackney, which geographically is quite small, it is very, very difficult to have all the GPs involved.

Dr Kambiz Boomla: Can I make one point around the conflict of interest? I think what we are likely to see—and I would be very careful when you pass whatever legislation gets to be passed that you look at the sale of goodwill issue. At the moment there is an abolition on the sale of goodwill in general practice and my worry is that, if the legislation gets rid of that, then you could get Virgin and other large corporate healthcare providers coming in and buying up general practices not because they can make a better job of running those general practices as practices, because the evidence is that these private providers often don't, but that that will give them control of the commissioning budget. Then, any conflicts of interest that we are talking about, about individual small businessmen GPs, will pale into insignificance compared to the conflict of interest of Virgin Healthcare commissioning healthcare from a Virgin hospital. I only use them as an example. I have got nothing against Virgin. I use them all the time.

  But I do feel that GPs generally, because the scale of the enterprise is small, because we are in close day-to-day personal contact with our patients and feel an allegiance to those people, our conflict of interest, whereas it is there theoretically, we manage to manage it most of the time. I think, if healthcare becomes corporate, both on the commissioning side and on the provider side, then conflicts of interest will be enormous.

Q188 Chris Skidmore: You mentioned the commissioning budget. I think we are getting down to what the reality of these reforms involve, which is one of cost. Obviously there is not much money in the system.

Dr Kambiz Boomla: Exactly.

Q189 Chris Skidmore: The hope, obviously, is that commissioning services by GPs will free up extra resources within the NHS. I just wanted to get your view of whether you thought it was possible to create surplus in the commissioning budget, whether that was possible and whether you think GPs would be incentivised to do so.

Dr Kambiz Boomla: But I already said at the very beginning that my real fear is in the current economic climate that there are going to be more losers than winners in that regard. One of the strands that runs through this White Paper is that there will be no toleration of commissioners or providers—I can't remember the exact phrase—"who fail to reach financial balance". Then there will also be a failure regime to remove the management of those organisations and replace them. A lot of people said that one of the faults of the present NHS is that there is no failure regime. But if that failure regime then says, "Right. We will remove the management of this hospital trust and bring in a private provider", or, "We will remove the management of this GP commissioning group and give it to all the different organisations that are vying to provide commissioning support. Health Dialogue, all these companies, are bombarding us with material about how, as GP commissioners, we should take their services rather than going to our retiring PCT commissioners", they will get their nose in the trough, as it were. When the GP commissioning groups fail, as I think some of them will do, then I think they will be very well placed to become commissioners in their own right.

That may be what some people want but it is certainly not what I want, and I think it would produce enormous conflicts of interest and vast amounts of corruption in the NHS like we see in America with different commissioners and providers actually ending up in court for defrauding each other. I think this White Paper is pointing in a direction which I think it would be very foolish to go down and follow.

Dr Jonathon Tomlinson: Commissioning generates its own costs. There have to be administration and transaction costs involved with running commissioning and running a market. The evidence from those costs in the NHS is that from the late '70s when it was about 10% it has gone up to about 24% in this country.

In the States, if you look at public hospitals, the administration and transaction costs are about 20%. In private non-for-profit hospitals it is about 24% and in for-profit hospitals it goes up to over 30%. So the more that you introduce competitive commissioning, the more you have to pay for all the complex negotiations, price-setting and so on--

Q190 Chris Skidmore: This is where, I guess, the maximum management allowance comes into play and, obviously, contrary to the flow of the White Paper, a maximum management allowance caps these administration costs. So what do you all think about that being introduced?

Dr Paul Charlson: Can I just break in a little bit? All the talk is about America. There are other systems in Europe which work really well and there is competition there. So I think let's not always talk about America. I think we are going to move more towards the European system than the American system.

  The other assumption that seems to be made is that, when we are talking about change, that that is going to be open to all this terrible risk. But there is terrible risk with sitting still. At the moment it hasn't worked so we have got to think about how it is going to work. That is my fear.

  The other option about, "Oh well, it's really dangerous. All this is going to happen" is that we won't do anything and we will just sit where we are. We have spent loads of money on the NHS and our productivity--I haven't got the figures--hasn't gone up very much. So there has been a lot of money peddling to stand still.

  My fear is, and it is very easy to be a sceptic but what are the alternatives to what we have got? We have got to change it so how are we going to change it? This seems like a good way forward. There are going to be a lot of flaws in it and those need to be ironed out. That's my thing. I don't think we should keep talking about Americans because I don't think that's the way the White Paper necessarily points.

Rosie Cooper: You wouldn't necessarily go for the big bang, would you?

Q191 Valerie Vaz: You said "evolve it" and I think that is the view you are coming from.

Dr Jonathon Tomlinson: The one thing it does seem to suggest is that we are going to move to a health management organisation-style of health insurance where patients will register with an insurer rather than with a single practice, particularly now the Government have said that we are going to abandon GP lists and patients will be able to choose to register wherever they like, which, where I work, will be disastrous. The people who will choose not to wait behind my schizophrenic patients who take a long time to see and don't want to be kept waiting will go and register at the Virgin Walk-In Centre where they can be seen immediately and get what they want and get out straightaway.

  I will be left to look after the elderly, the confused, the mentally ill and so on because the most mobile patients, who do not want to sit around in a waiting room full of the ill and so on, will choose to go somewhere else—not all of them, but you won't need many to go before some practices are looking after all the sick people and some have got all the young, healthy ones.

Dr Paul Charlson: Can I just make one little point about that? Where I work in Grimsby we set up an open access centre which opens 8 till 8. The reason we have got quite a lot of registered patients now is simply because local practices don't open. They are not affluent, articulate people. These are the poorest people. They are walking into another place because they can get an appointment and then get seen by a doctor who spends time with them. That is not a criticism of local GPs but that is the reality.

Dr Jonathon Tomlinson: We also run one of those. We have a traditional practice and we have a Walk-in Centre. After 20 years in a traditional practice, you work with your patients and you negotiate. They understand when they need to come and see you and when they don't. The way we get paid for running our Walk-In Centre is getting people across the door. So those patients you have spent 20 years saying, "No, really, you've got a cold or a sore toe. You don't need to come and see your GP", now we can send them all to our Walk-In Centre because we get paid every time they come in. That is the kind of crazy system that the Government have put in place and those are the kind of incentives that GPs are working for now. It is just all wrong.

Chair: I think, probably, what we have done is to illustrate this morning the breadth. We had four witnesses in the first panel who gave us differences of emphasis and four witnesses on our second panel who developed those differences of emphasis. Thank you very much for your time this morning. We shall reflect on what you have said. Thank you.

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