Commissioning - Health Committee Contents

Examination of Witnesses (Questions 192-244)

Professor Julian Le Grand, Professor Martin Roland, Professor Jennie Popay, Professor Steve Harrison.

16 November 2010

Q192 Chair: Ladies and gentlemen, thank you very much for joining us this morning. Can I begin by asking you very briefly to introduce yourselves to the Committee, starting with Professor Le Grand?

Professor Julian Le Grand: I am Julian Le Grand. I am a Professor of Social Policy at the London School of Economics, an economist by training. I was an adviser to the previous Government.

Professor Martin Roland: I am Martin Roland. I am Professor of Health Services Research at the University of Cambridge. I am also a GP and, by chance, the practice I am in is one of the leading pilot commissioning practices, not because I am a great believer in it but because my senior partner is.

Professor Jennie Popay: I am Jennie Popay. I am Professor of Sociology and Public Health at the University of Lancaster. I have the reputation of being probably the most failed non­exec in England in that every organisation I join is immediately abolished. I've been on CHIME—the Commission for Patient and Public Involvement in Health—and the Mancunian Community Trust, all of which were abolished quite quickly after I joined them.

Chair: It might be regarded as a considerable success story.

Professor Jennie Popay: Yes, absolutely.

Chair: Wear it as a badge of honour.

Professor Steve Harrison: I am Steve Harrison, Professor of Social Policy at the University of Manchester where I lead a team of researchers, essentially researching NHS organisation, particularly primary care.

Q193 Chair: Thank you for joining us. As I am sure you are aware, the Committee is doing two parallel inquiries: one into the impact of the comprehensive spending review in what one might regard as the more short­term context, and then this inquiry into the impact of the Government's NHS White Paper on the future of commissioning. The question in our mind is how these policies are going to deliver more effective commissioning than we have seen historically in the NHS.

My first question, which is to all of you, is whether you think the core proposals in the White Paper around commissioning, the abolition of SHAs, the abolition of PCTs and the replacement with GP­led commissioning groups, will deliver better quality commissioning than we have seen historically in the health service, and in particular whether it is going to do so in a time scale that will allow us to address the immediate efficiency challenges that the health service faces over the next four years. Who would like to start with that question?

Professor Julian Le Grand: Let me answer the first part of the question first. Do I think it will deliver better commissioning? The answer is, yes, I do. We have some experience of GP commissioning due to GP fundholding and so­called total purchasing pilots under the Major Government and practice­based commissioning under the Labour Government. In both cases the evidence suggests that they do a pretty good job. We might get to talk about some of that evidence, but, basically, the GP fundholding experiment demonstrated that, on the whole, the GP fundholders had shorter waiting times, reduced hospital referrals, reduced prescription costs, and apparently did so—although the evidence is flimsy here—without reducing the quality of the care concerned. There was plenty of anecdotal evidence concerning the innovations that the GP fundholders introduced.

Similarly, with practice-based commissioning, it was a fairly anaemic version of fundholding, I think I would say, but none the less, it is quite extensive; 92% of GPs are involved in some form of practice-based commissioning, and there are about 600-odd practice-based commissioning consortia already in existence. Again, there are some interesting examples of how they have significantly improved commissioning in their areas. Although it would not be true to say that every GP commissioning consortium will be better than every PCT—there are some excellent PCTs and there will be, undoubtedly, some terrible GP consortia—on average, and your question was about "On average, will they do a better job?", the answer is, I think they will.

Q194 Chair: What about the handling of the immediate challenge, which is the second part of my question?

Professor Julian Le Grand: I am not so worried about that as many people are. The NHS has actually got level funding. In fact, if anything, I think it has slightly increased funding. There is the Nicholson challenge. However, I am a little more sceptical than many of my colleagues about whether the NHS is going to come under enormous financial pressure over the next few years. I cannot see that the ageing of the population or the cost drivers have significantly accelerated to such a degree that it is going to be significantly different. I think that, yes, the commissioning was, and indeed was widely regarded to be by most analysts, the least satisfactory part of the reforms that have been introduced. It was time to address that. It is being addressed, I think, in the right way and, yes, I think we will be able to hold the fort on the finances over the period.

Professor Martin Roland: I am a bit less optimistic than Julian on all counts. If I could answer your second question first because it is the easier one, things will undoubtedly look a lot worse in three to four years' time, which members of the Committee will, of course, realise is about the time for an election. There is always a risk that either this Government or another Government would choose to change things, because major health service reforms always cause a lot of perturbation. This is as big a one as we have seen probably since 1948. Therefore, there will be considerable disruption to the system, with GPs trying to form themselves into groups. I know from my own experience of Cambridge, where Cambridge is ahead of the game, that this is quite a difficult business and everybody, never mind the willing people, has got to be in the commissioning groups in two or three years' time.

I think there will be considerable disruption at a time when there is obviously reduced management support. Even if the whole thing looks brilliant in 10 years' time, my prediction will be that it is going to look fairly terrible in three or four years' time. So there is a key issue as to whether this or any other Government is going to have the patience to see things through.

My interpretation of the past GP commissioning is a bit positive, and against Julian's rather optimistic view is the quote I have put in my evidence to you from the Government's own primary care tsar that primary care commissioning is "a corpse not fit for resuscitation", which is probably a little bit extreme on the other side. I think the balanced position is that in fundholding there were some real successes but they were patchy, and I think we will see exactly that with GP commissioning. In the first few years we will see 5% or 10% of commissioning groups doing really well, the bulk doing kind of all right and maybe not noticeably better or worse than the rest, and a few going seriously wrong, including seriously overspending.

Long term, I am a bit more optimistic than I am short term, for which I am not optimistic.

Professor Jennie Popay: I think one of the recurring themes for you is probably the half full or half empty interpretation of evidence. I am not an expert on GP commissioning, but I was involved in the evaluation of total purchasing pilots on the community care/social care side. My memory of that is that the diversity that began to appear in the system was really important, but that the kind of disparities that Martin is talking about—the successes and the failures—are socially patterned so that the failures tend to be in those communities, those distressed places, which have the least capacity to manage the failure and dysfunctionality of GPs. It will be interesting to see where the experts end up on the interpretation of whether they were or were not a success, but those that are not successful will have a disproportionate impact on those people, those communities, less able to cope with that.

Professor Steve Harrison: On your first question, I wouldn't disagree with what Professor Le Grand was saying in characterising the evidence, but may I put in two caveats about that? One is that in terms of quantity there is a lot more research evidence about GP commissioning in its various forms over the years than there actually is about PCT commissioning. We don't have maybe as much information about the latter as we would have liked to have and, of course, we are not going to get that now.

The second caveat is that a received wisdom has grown up that part of the problem with PCT commissioning is that the managers aren't very good. I have seen that said in a lot of places. There is not, to my knowledge, any systematic research evidence for that. Again, it is one of those things we seem to all believe but it is not clear that it really is the case.

On the second part of your question, I would only say that there is a lot in experience with GP commissioning to make one optimistic, but there is a huge problem of attribution in terms of looking at the kind of GP commissioning we have had in the past, which was on a much smaller scale than we are anticipating in the future—with GPs choosing what to be interested in, what to focus on and choosing who to work with a lot of the time. Interpreting that in a future situation where it is compulsory and it is a big chunk of the budget, I think it is very difficult to guess that one.

Q195 Chair: Are you simply saying there is no evidence of that?

Professor Steve Harrison: I am not saying there is no evidence. I think the evidence is very difficult to transfer from the past situations that have been researched, which, as I say, are relatively small scale compared with what is envisaged for the future—in the past very much built round groups of GPs who have wanted to work together, who have wanted to set their own agenda—and projecting that into a future where GP commissioning is compulsory and covers a much wider scope of services.

Q196 Dr Wollaston: Which aspects of previous models have been the most successful, and do you feel it would have been better to exploit the existing potential in successful models rather than create a whole new system?

Professor Julian Le Grand: I think there are a number of aspects that appear to have been successful, and some of them were specific to the time, to take up Steve's point. But one of them was waiting times: they did significantly reduce waiting times. I had a PhD student working on that, who was also the practice manager of a GP fundholding practice, and it was a very interesting study. It was quite clear they significantly reduced waiting times for their patients. They appeared to be better at managing their budgets than their equivalent health authorities at the time, and incidentally, there was a sort of comparative framework in the sense that there were other forms of commissioners at that time—health authorities, which are somewhat closer to PCTs than GP fundholders.

They did, as I say, reduce hospital referrals, by the order of 5%, which is not enormous, and prescription costs also by the order—I can't remember the exact figure. Again, I wouldn't want to exaggerate this; I wouldn't want to say that there was in some sense a massive difference in terms of the hard evidence that we have. There was quite a lot of anecdotal evidence about the innovations that they introduced and so again there is quite a lot of anecdotal evidence about practice-based commissioning, about various things. I was talking to somebody in Cambridgeshire, actually, one of the GP consortia. I am not sure whether it was Martin's or not.

Professor Martin Roland: It wasn't me.

Professor Julian Le Grand: No, it wasn't you. It was holding five nursing home beds in reserve over the weekend in case of emergency care, so that instead of putting elderly people into hospital, they had a cheaper and more effective option. It is that kind of evidence, which, interestingly, in terms of an academic view of social policy, is rather more than we have evidence for other forms of social reform or social revolution that we engage in.

Professor Martin Roland: I have two quick points to add. I am always a little bit worried about the evidence of improvement from fundholding because, again, it is very anecdotal. But fundholding practices are believed to have inflated their prescribing and referrals in the year up to fundholding because the budgets were set historically and therefore they would have bigger budgets; and that is what they did.

To answer the question in a slightly different way from Julian, the things that are successful are the things that appeal to GPs' entrepreneurialism. They are very good small businessmen and they are fleet of foot. In a sense, what is attractive to the Government about the successes of commissioning in the past is that when they want to do things, they actually are quite good at going off and doing innovative things. The difficulty, as Steve points out, is scaling that up.

In the commissioning group I am involved with in Cambridge at the moment, the lead guy is spending a long time reorganising dermatology services, because he thinks he can provide a much better service to patients by pulling consultants out of the hospital and providing services in the community. That may well be absolutely right, but it is taking him a lot of time to do one little service, and the question is, how do you scale this up? I keep saying to him, "How do you run a £60 million enterprise, which will be the Cambridge budget for this group, with a one­day-a-week chief exec and at the moment a one-day-a-week commissioning manager?" That clearly won't work. So how can it be scaled up so that the individual successes, which undoubtedly happen, can be seen on a broader scale?

Q197 Chair: The Secretary of State's proposal isn't actually to scale up to allow individual GPs to do that. It is to have GP­led consortia employing managers to do it, isn't it?

Professor Martin Roland: Sure, absolutely. They have got to find the management capability to do that. Clearly they will have to employ people to do that. The Secretary of State's view—he may well be right—is that if you have clinicians leading that, that is actually going to be a better model than clinicians being disempowered and subservient to managers, which they have felt in the past. So he may well be right.

Q198 Dr Wollaston: My question is predominantly around whether or not you could achieve that using the existing PCT structure and build on the successes of previous models rather than reorganising.

Professor Steve Harrison: I will, if I may, hazard a guess that you could. It is a different matter as to how long it would take, and of course you couldn't do it once PCTs were abolished. That may be a critical part of the policy reasoning.

Q199 Chair: Do you want to add anything on this point?

Professor Jennie Popay: The other part of what they do well—I am not an expert—was on the elective side, which is really important, which is where the fundholding successes were. There is a vast area of activity that isn't elective care where fundholding didn't really get involved. I think that is quite important in terms of this massive shift that is going on.

The other thing I am worried and a bit surprised about is the focus on anecdotal evidence here, because if we are going into that place, then there is a lot of anecdotal evidence about dramatic innovation, "fleet of footness", in all aspects and all places in the NHS in existing providers, in PCTs. I'm not sure who has the most anecdotal evidence of innovation, but I certainly don't think it should be the basis for a policy of this magnitude.

Chair: I think that is Rosie's cue.

Q200 Rosie Cooper: In my whole time in the health service we always talked about "evidence­based" everything. Do you have any evidence base, or can you see an evidence base for the Secretary of State's White Paper—what I call the "big bang" that is due any time before 2013 but heading towards us pretty fast like a train, with PCTs going in 2012? Can you see any evidence base for that decision? Have you put any evidence in?

Professor Julian Le Grand: I think I have referred to the studies that have been done already. There have been quite a few studies. We have quite a lot of evidence on GP fundholding and the total purchasing pilots. They give the kind of results that we have been putting forward, and I think there is a question, which my colleagues have raised, about the applicability of that to the new situation. Total purchasing pilots did, incidentally, cover emergency care as well as the electives, although Jennie is right about GP fundholding being mostly concerned with the electives. As I was saying, we do have a certain amount of evidence and, rather unusually for these kind of massive reforms that have been injected into the NHS over the past 20 or 30 years, this one is quite evidence-based.

Q201 Rosie Cooper: I must admit to feeling a great deal of disagreement with that statement.

Professor Martin Roland: It is a slightly tough exam question, to be honest. I would say it is probably as evidence-based as many other major policy decisions, because, on the whole, policy has to be made—

Q202 Chair: That good?

Professor Martin Roland: Yes, that good. I guess that Mr Lansley has probably listened to several people in the room over the last few years, but there is a gap between what the evidence says and what we should do now. Nobody has done a controlled trial of what we are now going to do.

Professor Jennie Popay: This is a profound area of disagreement: whether there is evidence that general practice involvement in commissioning has worked or whether there is evidence that it has not worked. My reading of the evidence—I have not read it as carefully as these gentlemen around me—is that there are some examples of extremely good general practitioner commissioning, but the evidence for it working at a system level is not there. The evidence that is there suggests it is going to be very, very hard to deliver that, even in 10 years. I said that Martin was being very optimistic suggesting only two.

Professor Martin Roland: Two Parliaments.

Professor Jennie Popay: Two Parliaments, yes.

Q203 Grahame Morris: Chair, may I follow on from that? In his written evidence, Professor Roland identifies that there are potentially problems with GP commissioning from recent history; he mentions the example of the untested resource allocation—the Carr Hill formula. I know colleagues alluded to it earlier, but in terms of submitting evidence to the coalition in order to work up this quite radical proposal—I know Professor Le Grand sees it more as a kind of evolution than a revolution—I want to try to identify which of the panel have actively been involved in working up this proposal with the coalition. None?

Professor Julian Le Grand: Not me. Inevitably one has talked to some of the people involved, but I personally was not directly involved in any of the discussions leading up to the production of the White Paper.

Q204 Chris Skidmore: Professor Le Grand, may I put something to you on that point? I am interested in the blog article you wrote and also a letter you have written in the Financial Times on 29 October where you talk about this evolutionary rather than revolutionary process. You say the coalition's reforms are "a logical extension of the reforms put in place by Tony Blair's government", which you were advising. If Tony Blair was still the Prime Minister, do you think these reforms would be on the table for a new Labour Government?

Professor Julian Le Grand: He would have tried.

Q205 Chris Skidmore: You would have been encouraging these reforms?

Professor Julian Le Grand: I certainly would. I always felt there was a sort of fundamental logic to what we, if I can say that, or what that Government were trying to do, which was the introduction of patient choice to try and introduce incentives within the system to increase efficiency, to raise up quality, and indeed to improve equity—that is a question we can come back to; payment by results, which has meant the money followed the choice; and the introduction of new types of provider—the independent­sector treatment centres, foundation trusts and so on—to encourage competition.

The only weakness, or the major weakness, was on the commissioning side because we were putting in place a system—this was the one worry I had about it—that the Americans would call fee for service, where hospitals had a strong incentive to undertake as much activity as they possibly could, which is sometimes a good thing but on the other hand could lead to a cost explosion and some of the problems that the Chairman was alluding to earlier on. So you needed a good demand management system in place—a strong demand management system. I was impressed by the evidence on GP fundholding. I started off as a sceptic on GP fundholding, I have to say, but I was a convert as the evidence came in. I was always very sorry that the Labour Government made a mistake in abolishing GP fundholding in the first place. We would be in a much better place now if they had not.

I was quite heavily involved in the reintroduction of GP fundholding via practice-based commissioning. It was not as strong as I would have liked and it was not as strong as I think the then Prime Minister would have liked; indeed most of these reforms are very much where he, and indeed I, would like to have gone if we had not encountered some of the road blocks that one did.

Q206 Rosie Cooper: Can I just test that a little more? You are saying it is a general direction of travel. Would you as an academic, or you as somebody who was actually in charge of this, pilot this going forward, or would you do the "Big bang, throw it all up in the air, see where it lands, make it up as we go along" route that we are now on?

Professor Julian Le Grand: I think I would have gone for the "big bang" because, as I say, in a sense we have already piloted this. It has been piloted; it has been tried. The total purchasing pilot is perhaps the closest to it but it has been piloted. I think there was a problem with commissioning, and there is a problem with commissioning. We have a solution that is on the table and I think it is a sensible solution to start with.

Rosie Cooper: So in four years' time, when we are facing the almighty implosion that the health service will probably have, we will know which door to knock on. That's okay then.

Chair: I don't want this to be a dialogue just with Professor Le Grand.

Professor Jennie Popay: For me, there are potentially revolutionary aspects of it. It is obviously the case that GP involvement in commissioning is not a revolution. It depends what you mean by "revolution" as well, doesn't it? But a dramatic, profound change—a radical change—is the move away from commissioning of healthcare on the basis of the resident population, a geographical population.

As far as I can understand from the deluge of documents that is coming down at the moment, what is actually being put in place is a tension between healthcare commissioning for a registered population, which has very fuzzy boundaries—you move away 20 miles and you can stay with the same GP—and some of the most difficult commissioning for some of the most vulnerable groups in local authorities with a public health service with the joint strategic needs assessment on a resident geographical population basis.

How that is going to work is a mystery to me really. But it is a profound change in the way our NHS is operated for the base of commissioning to be with this registered population. I think that is a revolution and the risk is around equity. That is what Margaret Whitehead, Barbara Hanratty and I were writing about in The Lancet. It is unknown. We have no experience of doing commissioning in that way, I think.

Q207 Grahame Morris: Could I follow up from that in relation to the risks? We have heard from earlier evidence that the international trends are towards larger commissioning units rather than smaller commissioning units—I mean internationally. What are the risks here if we do see a variety of size in commissioning groups, GP consortia? It seems to me that in my area we are going to have a fairly small population and Professor Roland said there would be a whole Cambridge consortium. What are the risks there in terms of equity and service delivery?

Professor Martin Roland: One of the consistent misunderstandings of some people is that one size fits all and that there is somehow a structural solution: if only you get the deck chairs in the right order, then the Titanic will sail happily on. It is the case for commissioning that there is no one size for all their functions. If you are talking about commissioning renal transplant services, that clearly needs to be in a very large area. If you are talking about holding GPs to account for the referrals that they make to hospitals, that needs to be very small—one or maybe a very small number of practices. Whatever size you are, you have either got to be able to devolve within that larger element to perform those functions that need a smaller group or you have to be able to amalgamate and merge and work with others. In a sense, the one size won't work and therefore the natural differences in sizes that will happen in different places will have to be reflected in their structures.

Professor Steve Harrison: The one thing I want to add to that—I am not a specialist here and I'm sure Professor Le Grand can do better than I can—is to think about different sorts of risk, because there is the risk of natural randomly occurring variations in populations, their health status and hence their health needs, which, in a sense, one has to design a system to cope with. Then there is the risk of different groups of clinicians systematically behaving in different ways, with higher rates of prescribing or higher rates of referral or whatever. It seems to me very fine to make that distinction analytically, as I just have done, but to tell the difference in the real world may be harder, I guess.

Professor Julian Le Grand: There clearly is a tension over size. There are arguments, as indeed Martin was saying, that go both ways, whether it is for small or large. I think Professor Bevan, from whom you will be hearing later on, did some research at an earlier stage and he would be better placed to comment on this. I think he is suggesting that as far as the risk pool is concerned, as I recall, it was of the order of about 100,000. This is appropriate in some ways.

It is quite interesting in looking at the experience of GP fundholders, again concerning size, that there was a problem with the health commissions—the parallel commissioners—which were in a sense almost too large. They were so large that they were locked into their health providers—their big acute hospital trusts. It was the old business of, "If you owe £100 to the bank and you can't pay it back you are in trouble. If you owe £100 million to the bank and you can't pay it back, the bank is in trouble." There were elements of that relationship in health commissions and the big acute hospital trusts. The GP fundholders were much more nimble and better able to play the market in many ways than were the health commissions.

On the other hand, there are some disadvantages, which my colleagues have already pointed out, about having them too small. So I think there is an issue there. I would tend to go myself for about 100,000 as being the least worst of the sizes.

Q208 Valerie Vaz: May I start by apologising; I was actually in the Chamber on an exercise. I am sorry I am late and have missed the first part, and you may well have answered some of these questions.

Professor Le Grand, many people don't share your optimism about the evidence, partly because everyone has been screaming out for a pilot study and no one can say where that has been done. This is a general question to all of you because I am really confused about the White Paper and what is happening. There are lots of unknowns, and I would like to find out from each one of you what the benefits are of this exercise, given that the NHS has gone through a lot of reorganisation. We have had maternity services centralised with the NHS Commissioning Board, but now it appears that is coming back locally. Then we have coterminosity in terms of local authorities, but that is not necessarily going to chime with the consortia. How does that all fit in and how is that good for the patient? Where does public health fit in, in all of this?

What, really, are the benefits for the patient, who apparently can decide to register with one doctor, but if they don't like that doctor or are not getting the services, they will then go and register with another consortia? How does all that fit in and where are the benefits in terms of saving this £20 billion and actually providing a decent health service? If it was evolutionary, why could we not just have worked with the current model and made that better?

Q209 Chair: That is several questions. Shall we go the other way? Professor Harrison, would you like to start and pick at least one of those questions?

Professor Steve Harrison: I won't make any claim to know where any savings might come from. The assumption—it is a reasonable one—is that if thoughts about what services ought to be like, commissioning, if you like, in the shorthand, have doctors closer to them, then they are likely to be better decisions than if doctors were not close to those decisions. So that's the unstated underpinning rationale, I guess, for all the forms of GP commissioning, plus another rationale that says clinicians may be able to make decisions about better use of resources—call it rationing if you want to be controversial.

If you think that they are things which need to be done, then there are obvious potential benefits of the new system. I presume that we have to have in the future a purchaser/provider or a commissioning/provider split because, if we don't, then the preference which Governments of more than one political party have had for private providers to be involved in providing NHS healthcare cannot happen. So even if one were to mount an argument that says the whole idea might have some problems, you have to maintain the idea in order to maintain the potential involvement of private sector providers. That's probably enough for my bit.

Professor Jennie Popay: I will just focus on one issue. My preference would have been, if I had had any say, to go with what is there now and to identify a bit more systematically what is working well in primary care commissioning, because I agree with Steve that the evidence base on that is thinner. It is absence of evidence, not evidence of absence, much more clearly for primary care trust commissioning than it is for GP commissioning. We needed to look more systematically at what is working well. In the South Lakes, for example, there is really good GP involvement in commissioning, quite a lot of control of commissioning but in partnership with the primary care trust. It is a good model but it might not work everywhere. But why that should be unpicked for this system change, with what I believe is quite weak evidence, is, I think, really problematic.

At the heart of my concerns, though, is the issue that what will benefit the patient is more empowerment—a greater say in decision-making. The focus in the White Paper there is on choice and that is choice about where you will go—which consultant­led team. It is not actually about the really tricky stuff, at the individual level, about shared decision-making about care, wherever that goes on—whether it is in primary care or secondary care—and at the collective level a voice in what kind of service is being provided and where. There is not a lot in the White Paper that makes me feel we are going to do patient empowerment any better in this new system than we have up to now. One of the key barriers to patient empowerment—all social science points to this—is what we call in the social sciences the positional power of health professionals, and particularly the medical profession. What these reforms are doing is giving more power to the medical profession. In a way, there are the conditions there to make it more difficult to empower individual patients and collective patients.

If we are looking at patient benefit, I think there is a lot of evidence, much stronger than the GP commissioning evidence, that if we can get patient empowerment and patient voice really embedded in the system, then that will deliver a better patient experience. But that is not the central concern of this White Paper, I don't think. The proposals that are there don't look remarkably innovative.

Professor Martin Roland: Can I pick up on the point of, "Will they save money? Will they essentially make more cost-effective use of resources?", and come to the incentives that will be attached to that because I think they are absolutely crucial?

In my practice we sit down regularly and look at our referrals to hospital. When we see that a 98­year­old lady has been admitted to hospital by the out-of-hours service over the weekend that we think could have been managed at home, we are actually quite cross about it. There are lots of instances where we look at people who have been treated one way or another and say, "If I was buying care, I wouldn't buy that because I think I could do better for my patient." So if the incentive is to improve care for patients, I would be somewhat encouraged, sort of halfway between Jennie and Julian.

The key question, I think—we don't know the answer to this—is, what are the incentives of GPs going to be? There is no doubt that if GP commissioning groups are going to work, they will have a budget and they can't be given free rein just to spend willy­nilly, so there must be some constraints. The real key is how much will those constraints come down to the financial position of each individual practice? In other words, to what extent will the practices' financial fortunes, and therefore the fortunes of the GPs who take home the profits at the end of the day from their practice, be dependent on the performance of their commissioning group? I think it is extremely important that that financial equation only makes a small difference, because you really don't want to go and see your GP, think you have something that needs to be seen in hospital and are not sure whether he is thinking, "Shall I refer you?" or "Will I go on my skiing holiday if I do that?" You do not want him to have that conflict.

Somehow the rules—the detail may be absolutely critical—have to give some incentive to GPs to behave responsibly with the public purse without that overpowering what they want to do clinically for their patients.

Professor Julian Le Grand: I think internal discretion is very important. I think that is right—getting it right. If a consortium makes a surplus on its budget, what can it do with it? Under GP fundholding on total purchasing, if they made a surplus, they could spend it on improving facilities for patients but could not spend it directly on themselves. That seems to me to be the kind of model that would be quite satisfactory.

Three questions were raised: choice, coterminosity and public health. With regard to choice of GP, this is where I think there is something of a weakness in the proposals: first of all the strength. Unlike PCTs, patients will, in a sense, be able to choose their consortia, so there will be a measure of accountability there because they can switch GPs to another consortium. I think it is a fairly weak instrument for accountability on that route because patients, on the whole, are reluctant to change their GP for one reason or another. Secondly, of course other consortia may be very big. For example, in Northamptonshire I don't think there would be any possibility of changing your consortium unless you moved out of the area. As I say, I would prefer the consortium to be rather smaller, which raises the second point about coterminosity.

I think that is a pity. I think it is a shame we are losing that. We will lose it, I think almost inevitably, but it has to be put, it seems to me, on the negative side. It is a shame that we are losing coterminosity. It does relate to the general question of public health that you raised. I'm not privy to the inner workings of this Government, but there is going to be a public health White Paper fairly soon. I suspect what is going to happen is that most public health is going to be at the local government level, which is quite a good place for it, if I may say—a rather good place for it—but it does mean that there will be an issue in working with the consortia on that.

Chair: I would like to move on, if I may, because Nadine would like to look at the relationship between the commissioning groups and the Commissioning Board.

Q210 Nadine Dorries: I think if you were to describe this organisation as a meal of meat and two veg, the NHS Commissioning Board appears to be the meat in terms of its responsibility and diversity because it is going to be responsible for organising the GPs, and we are going to have to negotiate a GP contract to provide the care for a little boy in my constituency with cystic fibrosis. I would like to ask a number of questions which will probably be quite diverse.

The first is this. The NHS Commissioning Board are to be the facilitator in terms of negotiating between the Department of Health and the BMA in terms of the new GP contracts. Do you think it is necessary for each GP now to have a contract, or should it be each consortium which holds a contract? Who would like to answer that question?

Professor Martin Roland: That is an interesting question. I don't know the answer to that. If the contract was at consortium level, what would the meaning of a practice then be? I'm not sure.

Q211 Nadine Dorries: Exactly; that's really the answer. So why would you think the Department of Health, the BMA and the NHS Commissioning Board would be going through this whole protracted negotiation in terms of GPs' contracts? Would it not just be simpler to have a contract per consortium?

Professor Julian Le Grand: Yes is the simple answer to your question and I am very much in favour of the consortia holding the contract.

Professor Martin Roland: And then the consortium would manage the provider functions of its constituent practices, which it will have to do to some extent anyway.

Q212 Chair: I think this is an important question: whether it should be a single national contract negotiated by the Commissioning Board or more local flexibility with the consortium.

Professor Martin Roland: It is a different question because it is a single national contract now. The question is, is it held with practices or commissioning groups?

Q213 Chair: Yes. The present system allows for greater flexibility through PMS contracts as alternatives to the national contract.

Professor Jennie Popay: It would be very interesting to watch them trying to implement that in terms of trades union power.

Q214 Nadine Dorries: You mean in terms of the BMA power?

Professor Jennie Popay: And the independent contractor status—this precious status of general practitioners. Moving away from the individual and the practice base to these consortia, it would be very interesting to watch that happen. I think they would struggle to get it through.

Q215 Nadine Dorries: Do you think the resistance would come from the BMA or the GPs?

Professor Jennie Popay: From the GPs, and the BMA supports the GPs, so, yes.

Q216 Nadine Dorries: Professor Harrison, did you want to say something?

Professor Steve Harrison: No, I think that is absolutely right. Presumably someone has calculated that this isn't politically feasible.

Professor Julian Le Grand: Are you interested in the nursing contract as well, more generally?

Q217 Nadine Dorries: In terms of practice-based nurses?

Professor Julian Le Grand: No, I was just thinking in a more general sense in terms of the centre holding contracts as opposed to allowing local pay negotiations or local contract negotiations.

Q218 Chair: Yes is the answer to that. If you are asking whether we are interested, the answer is, yes, if you have a view to contribute.

Professor Julian Le Grand: There is some very interesting research undertaken by a woman named Carol Propper at the University of Bristol. One of the starkest things about the health service, which is somewhat odd in some respects, is that on almost any quality assessment of the various kinds that are done, on the whole, the hospitals in the north come out rather better than the hospitals in the south—on average—and a possible explanation for that is to do with the quality of nursing differing between north and south. A possible explanation for that is because of having a uniform wage scale across the country. The average private sector wage is higher in the south than in the north and that has knock­on effects on the quality of nurses employed in both. As I say, there is some research to support that, but again it argues rather in favour of, "Let's have some more local pay or a local contract."

Q219 Nadine Dorries: That's interesting. Of course, there are also the cost implications on whether a centrally negotiated contract per consortia would deliver savings over and above the individual contracts.

Professor Julian Le Grand: Indeed.

Q220 Nadine Dorries: That is, I suppose, the nub of the issue.

Professor Jennie Popay: There is another point that relates to what Julian was just saying, which is about this notion in the White Paper of liberating the staff, which seems to me to be liberating GPs because other staff could potentially end up with deteriorating conditions of employment—potentially.

Q221 Nadine Dorries: Or improved?

Professor Jennie Popay: Potentially. It is a debatable point, but there is no evidence for what happens except in the private sector. In the local authority sector, when the direct services were moved out, in general the evidence suggests conditions deteriorated; they didn't improve, which could be the same thing. So it would be risky to leave it to the market to happen. If the idea is that they might improve, then presumably that would need some careful monitoring, it might need some regulation and there are all sorts of cost implications of that. But the evidence we have suggests it is more likely that they won't improve. They might stay the same, but they might deteriorate.

Q222 Nadine Dorries: At a local level, I think one of the issues people are finding most difficult to get their head around is possibly the more needy patients, in terms of particularly CF children and those with very special medical needs. Whereas at a local level the PCT now deal with the provision for both their medical care and social care, how do you see the National Commissioning Board going forward in terms of working at a local level, particularly for those more vulnerable and needy patients? One of the criticisms that is levied is that they will be so distant from the need at a regional or local level that there will be issues as a result of that. How do you see it working at a local level and how do you envisage specialist care, particularly for the most needy, being implemented from the consortia via the NHS Commissioning Board?

Professor Martin Roland: You've left the easy questions until last, haven't you? I'm not sure that I agree with your formulation of the problem, because surely the NHS Commissioning Board will say, "It is the GP commissioning groups' job to look after those people".

Q223 Nadine Dorries: But they are not, though, because the funding isn't being allocated to the consortia for those specialist groups. That is going to go via the Commissioning Board.

Professor Martin Roland: It depends how much of—CF? I don't know how much of—

Nadine Dorries: I just picked that as a condition.

Professor Martin Roland: I think that the Commissioning Board will have an extremely tough job in doing that. Again, the commissioning groups, at 100,000, are going to have quite a lot of most rare things. That may not apply to, say, transplant services, and I do not think it is the case that commissioning groups will necessarily ignore such things. I remember when fundholding came up, my wife, who is a paediatrician who looks after severely disabled children, said, "Our service is going to be gone because GP fundholders are never going to want to commission that sort of rare stuff." And it wasn't the case. So I think it is the case that GP commissioning groups will have to commission for all their populations. I don't know quite how—

Q224 Nadine Dorries: Particularly with disabled children, is it not the case that if there is a get­out for the consortium to remove itself, absolve itself, from responsibility for those high­cost groups, they will do that, and I think within the White Paper at the moment there is the provision for them to be able to do that?

Professor Martin Roland: Yes.

Professor Jennie Popay: This reflects, in part, that unthought­out part of these major reforms. I think Martin's response makes that very obvious. If you take them out and the commissioning is at a national level, then you are going to have to put something in place regionally if these patients are to have a voice in the kind of care that is delivered for them, which means replicating. Instead of removing layers and simplifying, you are getting more and more layers back in again.

Q225 Nadine Dorries: That is exactly my point. Are we going to see another layer—the national consortia and Commissioning Board cascading down into a local level of layers?

Professor Jennie Popay: You certainly could, but you are also then removing groups of patients from not a very good system at the moment—the HealthWatch system locally—but that system is about giving patients a voice, individually and collectively. You are removing them from the main commissioning bodies, so it does seem to me to be an example of quite a serious unthought­out part of this.

Q226 Grahame Morris: I want to be more specific about the organisation below the national NHS Commissioning Board. Is it the view of the expert witnesses that we need to have an intermediate level? Professor Le Grand suggested the GP consortia would be of 100,000; others have suggested that it should be much larger. What is your view in terms of how the GP consortia, of whatever size, are going to relate to this very centralised controlling mechanism in Whitehall of the NCB, or however we are going to describe it?

Professor Steve Harrison: I will speculate, if I may, that one of two things will happen. Either the National Commissioning Board will have some regional offices of one sort or another—I'm obviously not the first person to have said that—or else some kind of liaison arrangement will be developed between groups of consortia and the National Board. Some intermediate something will grow up; whether it is formal enough to call itself an organisation is a different matter. I would strongly guess that something will happen.

Q227 Valerie Vaz: Is that PCT under a different name?

Professor Jennie Popay: The obvious thing is that it should be linked into the local authority joint strategic needs assessment and the commissioning responsibilities that are being built in there. That is the obvious place, rather than another layer, putting back the SHAs and so forth.

Q228 Rosie Cooper: But then as that well-being board is set aside—you know my view of that—the patient, the public, the local authority will be on a well-being board, not directly at the table and not making decisions, so everything could be second hand. I am on the record as saying that is absolute nonsense and no representation whatsoever, in essence. I shall press it again next week with the Secretary of State, but we haven't heard what non­exec arrangements, what accountability, there will be inside the consortia. I think it is outrageous to give people the view that the local authorities—that sort of area—will be the patient's accountability line, when it stops at a well-being board, which is not at the table and doesn't have a vote. It is simply not effective.

Professor Jennie Popay: No, I agree. I wasn't suggesting that the current proposals for the health and well-being board were actually a way of giving localism, local accountability, to those commissioning. They are not but they could be. If this is going to happen, that seems to me to be the place to begin to think about the way in which the commissioning consortia have local accountability and are tied into population­based commissioning rather than registered population, both for healthcare and for other issues. It seems to me that introducing yet another layer is completely counter to one of the principles of these changes in terms of de-layering and simplifying. It is putting in another layer.

Chair: I am conscious that we have three more witnesses sat behind you. Nadine wants to ask a further question on her series and Grahame has one set of questions about fragmentation that he wants to ask.

Q229 Nadine Dorries: Professor Le Grand, there has been some confusion over the NHS Commissioning Board and the commissioning of maternity services. Do you have a view on that? Do you understand how the commissioning of maternity services is going to be going forward?

Professor Julian Le Grand: No, I don't, and I am puzzled. It seems to me that maternity services were only going to be done at the consortia commissioning level. I have no idea why it was moved or why the proposal to do it nationally ever came forward.

Q230 Nadine Dorries: But your opinion is that it should be done at the consortia level?

Professor Julian Le Grand: Absolutely.

Q231 Chair: I should say that the Committee has received correspondence from the Royal College of Midwives expressing support for the Government's proposal, and I would be interested to know whether any of the witnesses wish to comment.

Professor Jennie Popay: I am surprised. It doesn't seem to make sense to put it nationally. It is very local.

Q232 Grahame Morris: I would like to return to a point that Professor Popay made earlier about equity—referencing the article in The Lancet about your argument about the involvement of for-profit providers in the NHS leading to fragmentation and having an adverse impact on services and issues around health inequalities. I wonder if you could just place your views on record for the Committee.

Professor Jennie Popay: Yes. Obviously, in terms of for-profit providers, "Any Willing Provider" is, in a sense, evolutionary, but it does seem that these proposals are a step change in that, both in terms of the providers and taking off the cap in terms of private patients within foundation trusts or any trusts. In that context and the context of a continued interest in choice, and the context of financial constraints on the service, what we are arguing is that the equity implications could be quite profound. We know from both fundholding and total purchasing that there was diversity and that the least innovative, the least successful, were in areas with greatest need. We know primary health care is either at its best or at its worst in our most disadvantaged areas. There is, therefore, a real risk that the GP commissioning model will compound the inequalities in access to care. What you will get is the innovation going on in places with the least demands from the population.

Q233 Grahame Morris: How could we mitigate against that trend if that is going to happen with for­profit providers?

Professor Jennie: I don't think it is only the for­profit providers that are the problem. Some for­profit providers could quite easily be providing very good care in disadvantaged areas. I think it is the whole model that is potentially a problem in disadvantaged areas with disadvantaged communities rather than just the for­profit providers.

Q234 Chair: This is part of a rather broader question, isn't it, Grahame? One of the points that is often made about a GP­led commissioning model is that it is inconsistent with pathways of care, that it leads to fragmentation of pathways. I wondered if the witnesses agreed with that proposition or whether there is a way of addressing the need for consistent pathways and making it consistent with localised GP­led commissioning.

Professor Martin Roland: Could I comment on that? I think all leading healthcare analysts—I can say that without fear of contradiction; they are all actually in the room—say that the one thing we need is integration in our healthcare system, particularly for the increasingly aged and the comorbid population. There is a very real risk that "Any Willing Provider" particularly will lead to fragmentation. What we need is GP commissioning groups talking to their local hospitals, their local consultants, getting them together, working out the pathways of care that their patients need and commissioning those. It seems quite possible that depending on how the rules are set, Monitor may actually prohibit them from doing that, and that will be regarded as anti-competitive and not fair to the other willing provider who might wish to bid to provide that service. I think it would be a disaster if that happens.

Professor Julian Le Grand: I have two quick points—one on the integration point. Of course it is worth noting that one of the great advantages in GP commissioning is that the people making the resource-allocation decisions and holding the budget are the same. Actually, the potential for integration is there, in that if you have a system of different agents doing resource allocation and different agents holding the budget you do get fragmentation.

On the specific question that you raised, Grahame, "Is there any way of mitigating this?", an idea that I have been considering—you will recognise the genesis of this—is the idea of a patient premium. The original idea of a pupil premium was that pupils from poorer backgrounds should have a larger amount of money associated with them under the funding formula. We could do something similar on the patient front with patients from poorer backgrounds. There might well be clinical reasons for doing that, but also there might well be incentive reasons that actually provide an incentive for hospitals, whether for profit or not, to take on those patients.

Q235 Grahame Morris: With the weighting in the funding formula, in the funding allocations?

Professor Julian Le Grand: Raising it would have to be arranged under the payment by results system.

Q236 Chris Skidmore: Professor Le Grand, very quickly, that premium would surely necessitate compulsory registration in the same way as with the pupil premium at school you have to go to school? It is compulsory; that is the way the pupil premium works. In a way, the whole element of this White Paper is about compulsion. It is compulsory for GPs to join consortia. In terms of Professor Popay's article in The Lancet, surely the natural progression or evolution would be to have compulsory patient registration in order to allow these commissioning procedures to take place.

Professor Julian Le Grand: I'll think about that, but I don't think so. I don't think the patient premium idea itself necessarily requires that. It would simply be that a patient, when they turned up at a hospital, so to speak, would write down their postcode and the postcode would have an extra amount of money associated with it.

Q237 Chris Skidmore: But in order to deal with the equity issue in the White Paper you would have to have compulsory registration to avoid the issue.

Professor Jennie Popay: Or it is this tension between a geographically resident population and a registered population. That brings it right into the fore. We would have people in prison for not registering at their GPs, but there we are.

Q238 Valerie Vaz: But do you take that with you when you move?

Professor Jennie Popay: And you take it with you when you move.

Can I just put one other aspect of the equity issue and that is the choice issue? Again, you have in the room just about everybody who has written about choice here to speak with you. But I do think there is a serious problem with framing choice in terms of information and framing choice in terms of knowledge. That is an issue, absolutely. It is a necessary but not a sufficient condition for choice to operate as an equity­promoting thing for people to have the right information, appropriate information and to be helped to understand it. But choice is also a material thing. You have to have the resources to do it. You have to have flexibility at work, you have to have childcare, you have to be able to travel; it is all the kinds of things that actually people living in the most distressed places don't have.

Q239 Nadine Dorries: So you are basically saying that to make a choice, for patient choice to work, the patient needs to be of a certain level of intellect so that they can understand the choices that are being offered to them and have the ability to be able to discern between those choices? You are saying that patient choice doesn't work with certain groups of people because they don't have the ability to do that?

Professor Jennie Popay: No. What I am saying is that from my own qualitative research people do understand the choices. The problem is that they may not have the material resources in their lives, flexibility at work, childcare, travel, etc., to be able to make the decision they would like to make about choice. So if we are going to make choice an equity­promoting aspect of a healthcare system it will cost, and Citizens Advice Bureaux and HealthWatch are not going to have the resources to enable the material aspects of choice to be addressed.

Q240 Nadine Dorries: Because they can't provide travel costs and childcare costs?

Professor Jennie Popay: They can't provide them; that's right. They are information-focused and complaint-focused organisations, and that has been the problem with choice in terms of equity all along.

Q241 Nadine Dorries: But that is never going to change, is it?

Professor Jennie Popay: Then we shouldn't assume choice.

Q242 Chair: Never is a long time. We have three more witnesses who are sitting behind you. Are there any concluding comments any of the witnesses would like to make, something they have been burning to say and have missed the opportunity, or would they like to draw a conclusion?

Professor Steve Harrison: May I rescue one point that has been made in the last couple of minutes but I thought was in danger of getting lost, which is that there is nothing inherent in GP commissioning that prevents integration? It is the competition rules and the rest of it that may militate against that.

Professor Martin Roland: Yes.

Professor Steve Harrison: And GPs, we know from research, are willing to think about integrated pathways and so on but they need an incentive to use them, and I do not mean a financial incentive; they need to know that they can use them and that they will be able to do that.

Q243 Chair: That is helpful; thank you. Are there any other points?

Professor Julian Le Grand: Simply the final point about choice. Of course, much of the evidence is that choice is actively preferred by the less well-off. There are greater majorities in favour of choice of hospital, and indeed of school, among the less well-off than there are among the better-off. That is understandable because the better-off are rather good at manipulating non­choice systems—they can get what they want without having the choice— and of course the poor are not well served with existing services. Here, Jennie and I are probably in agreement. I do think that supporting choice is a very important part of the choice policies in order to achieve better equity.

Professor Jennie Popay: The only point I would make is that the financial incentive, presumably, is partly building on QOF and is somewhat problematic; it's a half full, half empty experience of QOF. But it did require quite careful monitoring. It doesn't come at no cost to use financial incentives as a way of pushing up. There doesn't seem to have been, "How much will it cost to get these financial incentives to work in the way that we want them to work?" I have not seen any estimate of that.

Q244 Rosie Cooper: And who would monitor it?

Professor Jennie Popay: Absolutely, and that costs.

Chair: The discussion will run and run, but thank you very much for coming this morning. We appreciate your time.

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