Examination of Witnesses (Questions 245-279)
Professor Chris Ham, Dr
Jennifer Dixon, Professor Gwyn Bevan.
16 November 2010
Q245 Chair: Thank
you very much for sitting through the last evidence session, which
I am sure will inform to some degree the discussion during
this session. Would you like to introduce yourselves briefly,
please?
Professor Chris Ham:
I am Chris Ham, Chief Executive of The King's Fund, and I have
a Chair in Health Policy and Management at the University of Birmingham.
Dr Jennifer Dixon:
I am Jennifer Dixon. I am Director of the Nuffield Trust,
a research think tank, and I am a physician by training,
a former adviser to the NHS Chief Executive Sir Alan Langlands,
and a member of the Audit Commission.
Professor Gwyn Bevan:
I am Gwyn Bevan. I am a Professor in the Department of Management
at the London School of Economics. I was an early advocate
of giving budgets to GPs. In 1988, we tried in Wales to get a pilot
experiment in which we gave GPs budgets for buying all of healthcare
and it was blocked by the local medical committee at that time.
Q246 Chair: I would
like to begin, if I may, by asking each of you to answer
the question that I opened the previous session with. The
purpose of our inquiry is to examine the Government's proposals
set out in its White Paper against the test, "Will this deliver
effective empowered commissioning?", and in particular to
ask ourselves the question whether this is consistent with the
changes required in the health service during the next four years
against the background of the comprehensive spending review. So
it is a twopart question really. Is the concept right,
and does it reinforce the management of the health service in
the short to medium term? Professor Ham?
Professor Chris Ham:
I think the concept is basically right in the sense that
we need greater clinical and GP involvement in commissioning than
we have had in the past. There is evidence, as your previous witnesses
have said, from studies that have looked at fundholding and total
purchasing, that when it is done well it can bring innovation
and help to contribute to more patientcentred care and greater
efficiency. For those reasons, moving in this sort of direction
is something the King's Fund has welcomed, but it relates to the
second part of your question, which is that there are always risks
associated with a big reorganisation and change of this kind
because for a couple of years at least the people involved
in that reorganisation are distracted from the core business.
While they are reorganising the structures, the focus on improving
care for patients and getting better efficiency will often take,
sadly, second place. We need to be cognisant of that risk, particularly
at a time when the NHS is having to find this £15 billion
to £20 billion that David Nicholson has spoken of—the
QIPP challenge. To reorganise the structure, take out 45% of management
costs, replace PCTs and SHAs with GP commissioning, and to improve
patient care and find £15 billion to £20 billion in
cash-releasing efficiency savings seems to us to be a huge
ask of the NHS at a very challenging time.
That is accentuated by the necessity of creating—quite
rightly, in terms of good management—some degree of risk
pooling to deal with provider failure on the one hand and the
possibility of commissioner failure on the other hand, because
while there will be really good GP commissioners they will not
all be terrific and there will be some that will probably need
some support if they don't manage their finances well. Inevitably,
if you are creating risk pools out of a fixed budget, you
are taking money out for that contingency that otherwise
might be put into direct patient care. That might be too detailed
a point for the Committee, but it is something of which we are
increasingly aware.
Dr Jennifer Dixon:
I think I agree with all of that. I think it is
too risky—too much, too soon. We know what we get with GP
commissioning because we have 20 years of evidence.
I would put a different gloss on the evidence
to Julian, having been involved directly in evaluating both fundholding
and total purchasing. Fundholders were small, they took off, they
had budgets for easy services, elective care, pharmacy and outpatients.
It took seven years for 50% of practices to be interested in it,
and even then, they had quite strong incentives to be interested
in it—more than practice-based commissioning groups because
they were able to set up limited companies and vire money from
hospital care into GMS. Total purchasers were also quite slow
but had some positive results. But for both those sets of groups,
they were able to do more by boosting up primary care. They had
very little impact on hospital care. In particular, the big challenge
for efficiency is emergency care and medical care, care of the
dying, older people and people with chronic conditions. There,
total purchasing and fundholding had practically no impact whatsoever.
Practice-based commissioning, as others have said, was pretty
inert. The incentives were lukewarm and it hasn't gone anywhere.
It has been a disappointment.
To do this at the same time as there is this huge
financial pressure and when the people who will hold the hands
of—mixed metaphor—or give birth to the baby of GP
commissioning are disappearing is high risk. I think, at
best, it could be pretty inert. The whole principle of putting
clinicians closer to decisions and responsibility for budget is
absolutely the right one. That is the nub of the White Paper and
it is a good one, but to enact it in this way is highly risky.
Professor Gwyn Bevan:
I absolutely agree with what has been said. The attraction
of involving GPs with budgetary responsibilities, and the reason
why I was attracted to it, is that we have a formula
that gives money to populations and we have to involve people
in managing resources for those populations. The obvious building
block for that is general practitioners and general practices
because they have defined populations and all other administrative
bodies are artefacts. But the experience, both here and in the
United States, is that it is terribly difficult to get that to
work. My very good friend Julian is from the same institution,
and he and I have disagreements from time to time. But the
experience I have, both looking at the evidence of GP fundholding,
and also because I was involved with the evaluation of total
purchasing, is that as others have said many times, a few
do it tremendously well. I am sure some GP consortia will
be absolutely fantastic and beacons and put the PCTs into the
shade, but the real trouble, of course, is managing to raise standards
across the whole of the National Health Service. For that, this
just seems terribly risky.
The truly alarming prospect here, as Jennifer and
Chris have said, is that we have five years of severe financial
restraint. We have something like three years of tumultuous reorganisation
in which I am not sure who is looking after this, and then
it will take two to three years for the new reorganisations to
bed down. Over this five years, when there is this huge financial
pressure, we just don't seem to be well equipped to respond to
it.
Q247 Chair: Sarah
is going to come in, but can I just ask one specific question,
which arose really from the last session as well as from the answers
you have just given? It addresses specifically the evidence available
of what results from GPled commissioning in its various
forms. Would it be fair to say that the evidence is primarily
around relatively simple transactionbased activities—prescribing,
elective care, referrals and so forth—rather than the more
complex issues around emergency care and around pathways involving,
in particular, longterm conditions? Is there any evidence,
good or bad, of GPfocused commissioning delivering significant
change to those more complex issues?
Professor Chris Ham:
The way I would respond to that is twofold. One is that most
of the evidence, as you say, is about the benefits you get from
GPled commissioning around elective planned care bringing
more services into the practice than would otherwise be the case,
because those are the bread and butter issues that are of most
concern to most GPs in their day to day work in their practices.
The more complex things around how you organise stroke services
across a city so that you concentrate them to get better
outcomes, or how you reorganise children's services, as has happened
in Manchester after many years of debate and discussion, are not
issues that most GP commissioners will have much expertise, appetite
or confidence in engaging with. You need an organisation, which
is the local, we would call it, system leader taking that strategic
view, and able to work across a very complex set of hospitals
and other organisations, to bring about those kinds of benefits.
But the other way of answering the question is this.
Both Jennifer and I in our respective institutions have looked
at the US experience, because there are a lot of examples
in the States where, if you capitate medical groups—these
aren't just GPs; they are GPs and specialists—what results
do you see? And you do see, from the managed care era, that the
incentives in that arrangement do encourage physicians controlling
budgets to look at how they can avoid avoidable emergency admissions
to hospital and deal with more complex patients by putting in
place case management and services in the community to deliver
those sorts of results.
The caveat is that they often do so with very generous
management allowances, much more so than seems to be the case
for the emerging GP commissioning consortia, and they invest hugely
in developing their GPs to take on the key leadership roles to
make that happen. It takes them many, many years from a standing
start to be able to do so. One of the issues that is of concern
is the speed at which these ideas are being put in place. They
are moving in the right direction, but it is hugely ambitious
to do so this quickly.
Dr Jennifer Dixon:
I think your assessment is correct. I would just add
a couple of things. The first thing is that some total purchasing
pilots did actually track patients and arrive at the house when
the ambulance came in order to go to hospital, or to decide that
the patient didn't need to go to hospital, or tracked an older
person around a hospital by putting a nurse in, paid for by the
practice, to try to get them out as quickly as possible because
that was better for the patient and efficient. So there were some
sporadic examples of that. There is some evidence, but it is weak,
that they then made some dent in the upward rise of emergency
admissions. It was not strong evidence, but there was some suggestion
in the early days that that is what happened.
The other thing that total purchasers and fundholders
did was that they spent a lot of time building up primary-caretype
activities over which they had more control than the hospital,
to boost some of those activities. But as Chris said, the big
thing that is going to sweep us is the need to close down hospital
beds, effectively, or whole institutions, and there is no evidence
that practicebased commissioning or anything from fundholding
had any influence at all on that big issue.
The other thing was that they didn't really engage
with hospital clinicians, which they need to do to get patients
out of hospital. There is very little email contact; there is
very little phone contact. It's the 1948 Berlin Wall—still
there, outside of a few specialties. If we are going to really
make these efficiency savings, we have simply got to get over
the contractual, budgetary, cultural, training and governance
divide that separates general practice from primary care. So this
is a provider issue, not necessarily a commissioning
issue.
Professor Gwyn Bevan:
I strongly support what Jennifer has said and there is the
great division in British medicine between general practice and
specialist care. One of the early studies in the 1960s showed
how they communicated by mail only. It was an observation that
Alain Enthoven made in 1985 and it is what strikes American visitors
today.
On the point about more structural change, when we
were doing this evaluation of total purchasing, I remember vividly
a discussion with one hospital that relates to the point
Julian Le Grand made that GP fundholders were able to move money
around between hospitals. They said, "We are very happy to
give them the average price for moving money around because that
is a limited part of our budget, but once they move into
the whole of hospital care it is destabilising to let that happen."
They found it much harder to do the sort of structural changes
that we are talking about.
Q248 Dr Wollaston:
We have heard from several witnesses about integrating health
and social care, providing the best model for savings and also
delivering better care; there are some very successful pilots
around the country, in Torbay, for example. Do you think the White
Paper puts models like that at risk or do you think it is likely
to make it more likely to be deliverable, and do you see the loss
of coterminosity as being a really serious threat, and, again,
the issue of a rigid commissioner/provider split?
Q249 Professor Chris Ham:
I think there are risks, inevitably, when you go through this
kind of structural change with the established partnership arrangements.
I know Torbay very well, and they have been working at integration
of health and social care, particularly around frail older people,
with really excellent results for many, many years. But it is
based on the care trust now being in place and the formal arrangement
between the NHS and the local authority.
If I can generalise from that particular example,
there are many of those formal partnership arrangements in England
under the Health Act flexibilities. They take different forms
and they are all based on the primary care trust and the local
authorities having signed up to formal statutory arrangements.
I am not aware of what the plans are for the future of those
formal partnership arrangements. If GP commissioners, for example,
say, "Actually, we think there is a better way"—I know
some GPs in Torbay would say, "We want the nurse attached
back to our practice rather than working in this integrated health
and social care team for a locality"—they may
want to move away from what they have achieved. For them, it might
be a different model.
The answer is we don't really know what is going
to happen to health and social care integration. We do know that
there are likely to be some risks because of the structural change.
I think a lot will hinge on the new health and well-being
boards that are going to be set up under the White Paper, the
stronger role that local authorities will have there, how they
engage with these nascent GP commissioning consortia, and whether
they are able to take forward those partnership arrangements in
a positive way and not lose some of the really good examples
out there.
Q250 Dr Wollaston:
Would it have been your preference to have built on existing models
of good practice?
Professor Chris Ham:
Absolutely. I think many of the laudable objectives set out in
the White Paper, around patientcentred care, better quality
and better outcomes, could be achieved through evolution, not
revolution. In the example that Jennie Popay gave earlier—again,
I know this from personal experience—in Cumbria, which
the Secretary of State is fond of referencing in support of his
policies, they are already doing, through the existing PCT practicebased
commissioning arrangements, what the White Paper would like to
see done across the whole of England under the current system.
If you go to Cumbria, if you go to Torbay and you can see the
White Paper ambitions being delivered, surely we could get there
more generally without the risks associated with such a "big
bang" radical reform.
Dr Jennifer Dixon:
I agree with all of that. Coterminosity is a loss if it undermines
integration of health and social care. The White Paper is pretty
opaque, as Chris says. Some of the issues about GP consortia forming
seem to be based on their affinity for one another, and for me
that is almost a coda that practices who don't necessarily
get on don't have to join the same club. But there is the actual
rub, because to have a step change in the quality and commissioning
of general practice you really need to manage GPs. GPs need to
be managed. It is very difficult, as we know, within a practice
to manage other partners, let alone to manage across a consortium.
I think that is the thing that needs to be tackled more than
anything else.
Professor Gwyn Bevan:
I agree with what is behind your question, which is that
I think now there must be doubt about the efficacy of the
purchaser/provider split. Other countries have gone away from
this and abandoned it, although they started this in the 1990s,
and integration—the sort of thing that Alain Enthoven talked
about when he talked about GPs and specialists working alongside
each other, sharing notes and all that sort of thing—you
just think that must be better.
On the point about coterminosity, I remember vividly
when I was at the Commission for Health Improvement that
we were trying to look at how we could assess mental health care.
With the move to community care, these have become large organisations
so one was covering two counties, which meant it dealt with a
number of local authorities and a different number of primary
care trusts, and it just found it horrendously difficult to co-ordinate
health and social care plus mental health.
Q251 Rosie Cooper:
Have any of you been consulted by the coalition or made any submissions
to them in the development of this White Paper?
Dr Jennifer Dixon:
Not directly.
Professor Chris Ham:
We have made submissions. We responded to the White Paper.
Q252 Rosie Cooper:
Yes, but not before the White Paper, i.e. to the coalition Government
in their thinking in outlining what is going on.
Dr Dixon, I have four quick points and
the fourth one you have already answered, which is that it is
really difficult to manage any group of people, particularly doctors,
all independent contractors, and not necessarily agreeing with
them, and then from the consortia upwards having a long distance
to the Commissioning Board.
To come to the two real questions I would like
to ask, the first is the danger of PCT implosion, which is right
on our doorstep now. The Secretary of State, and indeed Sir David
Nicholson, talked to us about the time between now and 2013, which
would enable consortia to get up and running, and the PCTs and
strategic health authorities will be there to support them. I would
suggest there is an almost imminent implosion there. What do you
think the consequences will be? And could you perhaps address
conflicts of interest in discharging the commissioning role within
consortia and how that should be addressed?
Professor Chris Ham:
I think there is a risk around the impact on PCTs because
as we are already seeing, especially in London—this will
be the best example—the NHS has said that it wants to move
more quickly to winding down PCTs, the rationale being to free
up some resource to invest in GP commissioning consortia to enable
them to develop more quickly and to take over the responsibilities
of PCTs. But effectively it means that the existing PCTs will
cease to exist in all but name from March, and we are talking
about March/April 2011, not 2013, and the arrangements in London
will then be based on sectors, so five or six PCTs will be having
to take on that responsibility.
Inevitably, middle and senior managers in those organisations
will be thinking about their own personal futures. We have a lot
of people in the NHS who thought they were coming in for a career,
a job for life, who are now thinking about their mortgages,
their financial commitments and their families, and how all that
is going to work when management costs are being taken out. It
wouldn't be surprising, therefore, if PCTs, whatever form they
take in the interim, were losing a lot of the talent and
the experience and expertise they need to manage the transition
effectively. That is what I think David Nicholson has been
arguing for the last six months in his two major letters to the
NHS on managing the transition well to avoid the "implosion",
to use your word, and to ensure that that transition occurs as
smoothly as possible. So I think you are absolutely right.
On the conflicts of interest, that is a very
negative way—I know it's the phrase that's being
used—of talking about some of the issues around GP commissioners.
I put it more positively. I think the interesting issue
here is that the Government are saying, "We are going to
put the main primary medical care providers in charge of commissioning",
at the same time as the Government are saying, "Actually,
we want to make sure there is a real separation between commissioning
and provision." There's a kind of gap in their logic
there, isn't there? And what you would say, potentially, is you
can use that to your benefit, because if GPs have the ability
to provide as well as to commission, it gives them the opportunity
to make, not just buy. A lot of the GPs we have talked to
at The King's Fund say the big prize around commissioning is not
writing more detailed contracts with big acute hospitals and getting
them to be more efficient; it is the opportunity to use control
over commissioning to develop more services in the practice, in
the community, to avoid those avoidable admissions. Sometimes
that will involve practices working together with the community
and nursing staff, with social care, to develop better models
of provision in the community.
Q253 Rosie Cooper:
I don't demur from that. I think we have to deal with
the perception that there is a really big conflict of interest
and that any "profit benefits" are actually for the
health service and not for the consortia and the practice.
Professor Chris Ham:
If you follow through the logic of that, one response would be,
therefore, we need a very open, proper competitive tendering
process. Any contract that a GP commissioning consortium wants
to let has to go through standard procurement rules. I hope
none of us wants to see that, because you would end up with telephone
directory documentation around making sure there is fair play
and you avoid those conflicts of interest. There needs to be a
better, simpler and more transparent way of avoiding the legitimate
concerns that people have while ensuring proper accountability.
Q254 Rosie Cooper:
On the boards of consortia?
Professor Chris Ham:
Through the mechanisms that consortia have to use in deciding
how to use their funds, which would include the governance arrangements,
as yet to be defined.
Q255 Chair: It
does also leave open the question, doesn't it, of how you deal
with the areas that we were hearing about earlier where primary
care isn't currently innovative, cutting edge, likely to rise
to the kind of challenge that you describe. You describe what
an effective primary care commissioner does, but the next question
is who commissions the primary care commissioner?
Professor Chris Ham:
Indeed. If you say that the problems with the NHS and performance
require more choice and more competition to avoid provider capture,
shouldn't the logic be, well, maybe choice of competition should
apply on the commissioner side as well as the provider side rather
than ending up with geographical monopolies of GP commissioners?
There are big debates there, but you can see the logic.
Professor Gwyn Bevan:
I have been working with a scholar in the Netherlands on the development
of their model of insurer competition there. I am enthusiastic
for more integration between primary and secondary care because
the evidence is that that is beneficial. But we also know in the
United States that there are models of these fantastic high-performing
organisations like Kaiser Permanente, but when they tried to spread
that in the 1990s it failed and there was this backlash against
managed care, with some of them being dysfunctional. The troubling
thing is that if we were to move away from the purchaser/provider
split towards integration, which I favour, but you didn't
allow people choice, then they could be stuck with a truly
dysfunctional organisation. Although when Alain Enthoven proposed
an internal market he wanted the Kaiser Permanente model in England
and thought choice would be politically unacceptable between them,
I now think, given the evidence we have in the 1990s, that is
undesirable.
In the Netherlands they have moved towards insurer
competition, but it is a quite complex process to get right, with
a sophisticated regulatory regime, and it took them 20 years
to do it. It may take even longer than Martin Roland's two Parliaments
if we want to do it.
Dr Jennifer Dixon:
On the integration business, if you integrate across health, primary
and secondary, then, as you say, there still has to be some commissioner
at some level. The reason why all this is blurred is because if
you have integrated networks taking on a capitated risk fund,
effectively, those physicians or clinicians inside that organisation
are indeed commissioning; they are making or buying—okay?
So they are doing what you want them to do—the principle.
Somebody then has to not just allocate resources directly to those
people but needs to commission from them and hold them to account,
and there are a variety of ways of doing that. Inside these
integrated care organisations we know some of the features that
make them work in the United States, which goes back to your question
about incentives and conflicts. The best ones are pretty clear
that they don't have very much personal remuneration as an incentive.
For example, Denis Cortese of the Mayo Clinic came
over here recently. He was absolutely adamant that they pay everyone's
salaries, and the added incentives come from professional incentives;
they are nonfinancial. It is about doing a better job,
the working day being easier, better quality care for patients,
reputation enhanced, and those seem to be incredibly powerful.
Kaiser used to have huge extra pay—something
like 20% to 25% extra pay for clinicians if they did a good
job and didn't spend up to the budget, and then they thought that
that perverted professional behaviour so they then scrolled back
to something like less than 5%. Sure, professionals do need to
be incentivised to do this type of stuff and manage budgets well,
but there may be other ways that actually are pretty strong that
are crafted inside the organisation—not an external pressure
coming from contracting, from regulation, or indeed from some
command or control or community group—that relates to information,
shared governance, clinical leadership and aligned incentives.
Those sorts of things can be as powerful, if not more so, as we
have seen in the United States in a highly competitive arena.
Q256 Yvonne Fovargue:
I want to go back to choice. At the heart of this is supposed
to be patient choice, and we have heard that, in fact, obviously
the more articulate have more choice. Do you believe that this
system will actually reduce or increase inequalities in the service?
The other thing I want to ask about is the market
being involved. Of necessity, we have heard that some providers
may well be squeezed out of the market. How will that affect perhaps
the more disadvantaged areas and the people who depend on those
services?
Professor Chris Ham:
On the choice issue we, at the King's Fund, published a big
review of the experience of patient choice under the previous
Government. It came out about six months ago, and I think it showed
that we are in the foothills. Although there has been a policy
for a number of years now to give patients more choices at
the point of GP referral and at other stages in the system, patients'
awareness of that and GPs' willingness to support patients in
exercising those choices is very variable and actually in some
places quite limited. I don't think it is because of fundamental
opposition to the idea. It is just that it takes time for these
ideas to get traction.
One of the things that came out from that work was
to say, "If this is going to be part of the health policy
reform programme in future, we need to do a lot more to raise
awareness of the existence of choices, to provide really good
information to support people to make choices and maybe to provide
more advice and support for patients when they are in that position."
There are some groups in the population who will find that relatively
easy to do and others—I think this is where your question
is pointing—who will need more advice, more support and
more confidence to be able to realise the potential of patient
choice.
Professor Gwyn Bevan:
This is one of the points on which Julian Le Grand and I have
a continuing disagreement about the efficacy of choice as
an instrument of change. No one is arguing about whether you should
have choice, and it is right that we have gone away from a system
in the NHS where you had no choice at all. But there is choice
in principle and there is choice as a lever of getting better
services.
There are systematic reviews in the United States
for putting information out on a hospital's performance.
They consistently find that people do not switch from poor to
high-performing hospitals. One of the paradoxes about the New
York study where they issued data on risk-adjusted mortality rates
for cardiac surgery is that patients continued to go to hospitals
with high mortality rates. But by publishing the information,
the hospitals got better. The most famous case is Bill Clinton,
who had his quadruple bypass in a hospital that the information
said at the time was one of the two worst outliers in the whole
of New York State he could have gone to.
The other evidence relates to the point Jennifer
was making earlier. It is reputation—putting stuff out in
the public domain, and putting pressure on providers who are performing
poorly—that is the one that causes them to respond to that.
When I was at the Commission for Health Improvement, I was
actually involved with the star-rating exercise and there's a
vast amount of evidence showing that to be very, very powerful
in driving improvements. So I am sceptical about choice as
a driver of change.
Then you get into the further problem that if choice
were to be effective and money moved, then the people who will
suffer—it is your concern—is the local population.
If you have a poorly managed hospital and it is in serious
financial difficulties, it is even worse and the people who can't
go elsewhere will have to keep going there. There are these issues.
I remember this being raised by Ken Jarrold at the
start—this was in 1991 when Working for Patients
came out. We know what the high-performing hospitals look like
but what about those who suffer in the marketplace? It is a serious
problem.
Dr Jennifer Dixon:
People need support, and some people need more support than others;
that's for sure and that should be in the system. Patient choice
at the moment is too anaemic to prod providers into better performance,
which is where we need to be for the Nicholson challenge. It is
not going to work any time soon. It is important to have, but
it is not going to be a major instrument for efficiency or
effectiveness, I don't think, and in the meantime, as you
say, there is a lot of turbulence going to go on. There needs
to be some regulatory or some national oversight as to what is
happening on access to care, some process measures during the
next transition period, because there could be quite a lot
of chaos going on in terms of some services disappearing, cuts
here, there and everywhere, which could systematically add up
to a poorer service in some parts of the country. So somebody
somewhere needs to be monitoring that. Who that will be, whether
it is the CQC or whether it is the Board, is not clear yet, and
also what teeth they will have to do something about it.
Q257 Valerie Vaz: Politicians
sometimes are a bit disingenuous. We're always saying we want
to do things in the people's name, but I was just wondering
whether you think Joe and Josephine Public on the Clapham omnibus
are part of all this, whether we have taken their views on board,
and whether you have any evidence that they are engaged in this
process. Secondly, do you have the latest figures on how
many GPs want to be part of consortia, because there have been
a number of polls out to say that many of them don't want
this? And, thirdly, £80 billion of public money is going
to be in their hands. How do you see the accountability of that
money when GPs obviously haven't been elected?
Lastly, Professor Ham, could you outline what is
so good about Cumbria? I don't know about it and I've never
been there, so it would be helpful if you could outline the best
practice there.
Professor Chris Ham:
Okay. Let me pick up the last point. I will leave the other
easier questions to my colleagues.
Cumbria is really good because for a number
of years Sue Page, who is the chief exec of the PCT in Cumbria,
has been an advocate of more integrated models of care in the
way we have been discussing. She has sought to devolve as much
budgetary and other responsibility to a locality level. Cumbria
is a county of—what?—500,000 people. They have
six localities. Those localities are the units for practicebased
commissioning, which will be renamed GP commissioning at some
point in the next two or three years, and Sue and the PCT have
been strongly committed to pushing as much responsibility out
there as the GPs are willing to take on. They have some great
GPs in Cumbria and they have been wanting to take on more responsibility
year on year, not just for a commissioning budget but, as
I said earlier on, so that they can use their commissioning
budget then to develop these new models of care, making use of
their local community hospitals, providing more services in the
practice. They have an example of integrated diabetes care in
Cumbria, where they have a specialist to come out of the
hospital to work in the community to support the practices to
be better at routine diabetes management so that only the most
severe patients then end up being referred to the local acute
hospitals.
As I say, I think that is very similar
to what the Secretary of State for Health would like to see happen
in the whole of the NHS in England in three or four years' time,
and it has happened because you have a visionary PCT with
a chief exec who has thought about the model of care, has
some great GPs and has supported them and given them training
and development opportunities to go away and do wonderful things—and
they are.
Q258 Valerie Vaz:
So you don't really need the reorganisation to get good practice
like that?
Professor Chris Ham:
The problem is—if the Secretary of State were here and I
wouldn't want to put words into his mouth—that not every
PCT is like Cumbria, not every chief executive has that same vision,
and that is just a generic problem across the health service.
We have wonderful examples of innovation in many aspects of care—Torbay
being a good example around health and social care integration—but
they are exceptional, isolated examples.
Q259 Rosie Cooper:
So sharing the chief executive's vision could help us achieve
this without the "big bang"?
Professor Chris Ham:
Well, yes, people matter much, much more than structures.
Q260 Rosie Cooper:
Absolutely, which is why I am just left frozen in this process
because I can only see paralysis. I used to work in
Littlewoods and we had this up-down structure, it was fantastic,
and then a chief exec came along and talked about matrix management.
So then, suddenly, we were all responsible to each other, going
across as well as up and down. Nobody knew who the hell we were
responsible to, what we were doing, and it was not a good
system. I can see us going into that here—so much going
on, money being required, efficiencies being required, the "big
bang" structural system. Very quickly I would like to ask
you, are we all—
Valerie Vaz: After me,
Rosie, after my question.
Q261 Rosie Cooper:
But this will answer it. What will the NHS look like in 2014?
Professor Chris Ham:
In 2014?
Q262 Rosie Cooper:
Yes.
Professor Chris Ham:
When you say "look like", what do you mean—the
structure or the service to patients or something else?
Q263 Rosie Cooper:
How will the patients see what is going on around them?
Professor Chris Ham:
I think you can construct an optimistic scenario or a pessimistic
scenario or something in between.
Q264 Rosie Cooper: What
is your scenario?
Professor Chris Ham:
At the King's Fund, and I think Jennifer has echoed this
from the Nuffield Trust's perspective, we think that there are
significant risks in going so far so quickly, even if the objectives
that the Government are pursuing are absolutely the right objectives.
The risks are around the transition and losing experienced managers
to maintain the financial control, the control of performance,
keeping waiting times short, and so on, over the next two or three
years, while creating the as yet nonexistent GP commissioning
consortia to take on responsibility for £80 billion of public
money, as you were saying.
The reason that is actually revolutionary and not
evolutionary is that although it is very similar to previous primary
careled commissioning initiatives, we have never before
been in the position where so much of the financial responsibility
rests with the GPs. I hope I am wrong. I hope we
can navigate successfully during the transition and there will
be patient benefits at the other end, but none of us can be sure.
Professor Gwyn Bevan:
I think where we will be in 2014, as I said before,
is there will be a small number of GP consortia that have
done fantastic things, then there will be the rest who are still
in a state of shock and some where it is dreadful. The thing
is that with the pressures you are under, obviously, on the one
hand you would like to get it done fast, because otherwise the
clock is ticking in the financial crisis and every year you delay
the pressures get more and more intense. Leaving it for three
years means it is going to be horrendous when they actually get
in a position to do something. But if you take too long over
that, then it is going to get even worse when they get there—with
limbo and blight from reorganisation. Words fail me at this point,
so I'll shut up.
Q265 Grahame Morris:
I have a fairly short question for Professor Bevan, hopefully,
in relation to some of the issues around identifying what the
evidence base is from overseas. You mention in your evidence the
dangers of the NHS going down the Dutch road, and I am particularly
thinking within the context of some of the earlier contributions
from Professor Popay about material aspects of choice where there
isn't free choice of GPs or services, particularly for areas where
there are issues around health inequalities. What do you mean
precisely by the risks of going down the Dutch route?
Professor Gwyn Bevan:
There was this famous health insurance experiment by RAND that
randomly allocated people to different kinds of insurance coverage
and showed that the integrated care organisations, the Group Health
Cooperative of Puget Sound, was more cost-effective and had better
outcomes for all except the poor and seriously ill. People thought,
"What we need to do is to replicate. That is the secret.
We'll just get that to happen throughout the United States."
Alain Enthoven saw this as the way they would get universal coverage
at a price they could afford, and then they discovered they
couldn't.
It is very, very hard. The things that Jennifer has
described—what they have looked at, and the way these organisations
work—have taken them decades to work out how to do it. They
have a particular culture and they carefully select people
who work there. The idea that you can just roll that out and create
an organisation in which GPs and specialists work together with
a capitated sum and, there you are, you'll get Kaiser Permanente
in two years' time, we know just doesn't happen. The problem is
that if you go for integrated care without choice you could be
trapped in a dysfunctional organisation.
I wasn't talking about the dangers so much of
the Dutch system. The Dutch system works quite well and they do
have choice of insurer, and the Dutch system could evolve where
you do have choice between integrated care organisations. But
I am saying that again both these models—both the highperforming
integrated care organisation and managed competition between purchaser
or commissioner—are quite complex things to evolve and they
take a lot of time and development to get there.
Dr Jennifer Dixon:
On the story about the integration in the US, there are probably
about 10 highly performing integrated organisations in the US,
and there has been a study about why they haven't been able
to transplant to different states. The biggest one was why Kaiser
California, which was incredibly successful where it started,
did not transplant to North Carolina. The story there was that
it wasn't the model that was the problem: it was the environment
in the state that was hostile. The regulatory environment, the
professional environment, the financial environment, was not conducive.
It is almost as if you have got these seeds that were flung on
to stony soil.
There's an issue for us here, if we do go down the
integrated route, that we have to make sure the soil is fertile
enough to let it have a chance to grow. That is a complex
issue—interplay between what the regulatory environment
is, what the payment mechanism is, what the medical and training
culture is, and do they get in the way of integration and so on
and so forth.
Q266 Chair: Presumably,
to pick up Professor Ham's point, it is also about people as well
as structures?
Dr Jennifer Dixon:
It's about people. The other big thing about these organisations
is that they can select in people who have the same mission, and
that really makes them fly. If you can't select in or, conversely,
deselect out people with the wrong mission, they don't fly.
Q267 Valerie Vaz:
Can you continue with my questions?
Dr Jennifer Dixon:
Yes. Yours was about engagement of the public in the reforms?
Q268 Valerie Vaz:
The public and the GPs, whether they want it, the latest figures
on that, and the accountability of £80 billion of public
money.
Dr Jennifer Dixon:
With the engagement, I don't know. I haven't seen any
evidence that the public have been involved in the crafting of
these reforms and with the topdown national system
that we have, it is very difficult to involve them. If we want
to involve them, we should have a different way of going
about things.
I have seen various surveys that run along that
20% of GPs are quite interested, but those are BBC surveys. So
it will be the minority, but you don't need every GP to be enthusiastic.
You just need a few to lead and bring the others along, but
it does help if more are enthusiastic. The incentives for GP consortia
to take part do not seem to be as strong as those in fundholding,
so again they are asking the question, "Why should we?"
Yes, the accountability of the money is a severe
issue, isn't it? With PCTs, there is no evidence to suggest, the
way these consortia are set up, that they will be any more successful
than PCTs were before them at controlling costs and expenditure
and extracting value, and PCTs had a long way to go, even
though they have been formed for several years.
Professor Gwyn Bevan:
Can I follow that up? We looked at this in the total purchasing
pilot, which is where the GP fundholders could opt to take on
a larger share of the hospital and community health services
budget. As it happened, in the pilot some of these were singlepractice
fundholders that had taken on a wider purchasing role and
others were networks of quite large populations, something like
50,000 to 100,000. It is one of these things that is obvious after
you have found it, but we found that if you have the GPs in the
single-practice total purchasing pilots they were involved in
managing budgets, but once you go from one practice to a network
it was much more difficult to get them involved. That led to the
paradoxical finding that in terms of managing risk of real costs
of their referrals, the larger networks, although they had a bigger
population, were no better than the single practices because it
is about getting the GPs involved in the process. Of course, these
were GPs who had actually opted for fundholding, taken on budgetary
responsibility and opted to extend it to total purchasing, and
now this proposal is to uniformly require all GPs to get involved
in this, so it is going to be a major challenge.
Professor Chris Ham:
One thing we haven't touched on, which we think is really positive,
is the Government's commitment now to develop the pathfinders
among GP commissioners, which wasn't in the White Paper but has
come out in the recent past. It is to be able, if you like, to
develop proof of concept in some parts of the country by enabling
the enthusiastic GPs, working with supportive PCTs, to use next
year and the year after as shadow years to learn some lessons.
That seems to us to be a very common-sense way of going about
it.
Chair: Chris Skidmore
would like to ask some questions about the Commissioning Board.
Q269 Chris Skidmore:
Dr Dixon, I was intrigued that in your evidence you said, "We
anticipate that the NHS Commissioning Board will quickly become
the 'headquarters of the NHS'." To what extent is this whole
process smoke and mirrors? We have seen devolution of power down
towards doctors' surgeries, GPs and consortia, and at the same
time the Commissioning Board will have an enormous sway about
how these consortia are run, delivering outcomes and for their
financial performance in particular. You also say in your evidence
that you are uncertain as to what extent the Commissioning Board
will be able to truly remain independent of the Secretary of State.
I would like to get the panel's view on the
Commissioning Board, whether this is actually going to centralisation,
in effect, with the Commissioning Board running the NHS rather
than actually the consortia having true freedom to commission?
Dr Jennifer Dixon:
Of course, in the White Paper it says explicitly that the Commissioning
Board will not become the headquarters of the NHS, but I guess
the reason why we put that in is because we think that if GP consortia
are too green, effectively, to be able to manage expenditure,
then effectively what happens is that someone will have to step
in. The less traction there is with consortia, the more that the
Commissioning Board will have to exert itself. I think, if
things go pear-shaped, it could really have to take on quite a large
role, and it has the mechanism to do that because the consortia
will be statutory NHS bodies with a performance management line
straight to the centre.
The intention is the right one for devolution, but
given the financial squeeze we are now in—we are not in
five years ago; we are in a different land now—that
is the worry. Yes, like many people, I have longstanding
issues about whether there can ever be an independent board separate
from the Secretary of State. And not only that, but there could
also be unresolved conflicts, unless this is carefully crafted
between the Commissioning Board and also the economic regulator,
whose objectives may not be the same. That has to be thrashed
out pretty carefully.
Q270 Chris Skidmore:
Professor Ham, would you like to comment at all?
Professor Chris Ham:
The issue of having an arm's length board separate from the Department
of Health has been around for as long as I have been around, and
that is saying something. Every time it has been looked at before,
the decision has been that it is probably not a runner because
if you need to ensure proper accountability to this place for
spending £100 billion of public money, can you offshore that
to a National Commissioning Board even if you put in place
proper arrangements for that to relate to the Department of Health
and the Secretary of State? This time round, the argument seems
to have been won and we are going to go in that direction, but
as always, the devil is in the detail, particularly the relationship
between the National Commissioning Board on the one hand and the
Department of Health and Secretary of State on the other. Exactly
how is that going to work? How can we avoid the kind of Michael
Howard/Derek Lewis challenges of the Prison Service from a number
of years ago?
Then, secondly, what about the relationship between
the National Commissioning Board and however many GP commissioning
consortia we have? I won't speculate on the number, but my
expectation is that there will be more GP commissioning consortia
than there are PCTs at the moment, and therefore there will be
quite a big span of control between the National Commissioning
Board and those commissioning consortia. There will be regional
office structures, also known as strategic health authorities,
in some shape or form, to mediate that relationship because there
always has been an intermediate tier at the regional level since
1948 onwards. Why would this be any different from that? So that
kind of looks like we are recreating, but putting different names
on the door, some of the elements of the system we have at the
moment.
Q271 Chris Skidmore:
What does the panel think about the fact that the new GP contract
with the BMA is going to be negotiated by the NHS Commissioning
Board rather than the Department itself?
Professor Chris Ham:
It is a continuation, isn't it? When I had my four and
a half years—it sounds like a prison sentence and it
felt like it at times—as a secondee in the Department of
Health, at that time the Government, in its wisdom, said it wanted
the NHS Confederation, through what we now call NHS Employers,
to take on responsibility for negotiating contracts, not with
doctors—well, actually with doctors to some extent, because
that is part of the mechanism we now have. It was one of the elements
around distancing Government, and DH in particular, from some
of the detailed issues that the NHS in theory was better placed
to deal with. This arrangement around the GP contract you could
see as being a continuation of that. I don't think it
removes from the table any of the complex issues that will undoubtedly
be involved in renegotiating the contract as that goes forward
from here.
Dr Jennifer Dixon:
I just wanted to add something, and it is slightly different
from the question you asked. It is about the ability of the Commissioning
Board to manage some of the local contracts, the PMSs and the
locally enhanced services, which are additions to the GMS contract.
So 60% of the country at the moment is GMS and 40% is PMS. There
is quite a lot going on locally that is a very long
way away from even a region actually, so how a board
can do this sensitively in a way that reflects local needs
for primary care provision is again opaque.
Q272 Nadine Dorries:
Going back to your earlier points about how groups of people are
difficult to manage, do you see that it will be viable and useful
for the negotiations taking place at the moment for there to be
contracts which are not dedicated to GPs but to the consortia,
so that there is a consortia contract directly with the Commissioning
Board rather than a GP contract?
Dr Jennifer Dixon:
Yes, I agree with the other witnesses that there should be
a consortia contract, not with practices. It is just unmanageable
at practice level, I would think, and the consortia really
should be more actively managing primary care provision, which
may be a reason why some GPs don't want to get involved in
it, because it's hard. But, effectively, that is the single biggest
thing that the consortia ought to be doing.
Q273 Nadine Dorries:
There is a resistance.
Professor Gwyn Bevan:
There is an issue around this because it is my understanding that
within the consortia the practices can choose to move between
consortia, so when we discuss how we allocate resources to the
consortia, it starts with the practice as the building block.
If you were to negotiate a contract with a consortium
and then a practice decided it was going to move, that would then
become enormously clumsy and you would have to renegotiate.
Q274 Nadine Dorries:
Except that it looks as though, just on the information that we
are going through at the moment, the consortia are more or less
going to fall on a county or county-wide basis. It would
be tricky for one to move from one consortium to another if they
were on a county basis; it would be a highly unusual situation.
Professor Chris Ham:
Do you mean the contract for primary medical care provision to
be with the consortia?
Q275 Nadine Dorries:
Yes. The negotiations are taking place between the Department
of Health and the BMA, and the NHS Commissioning Board will be
the actual holder of the contract between the Department of Health
and the GPs. It will go to the Commissioning Board, directly to
the GPs. My question is, does it not seem more sensible, rather
than individual GP contracts, if the consortia had one contract
because that would possibly provide scope for savings also but
would be just much simpler in management? Dr Dixon raised
the point a little while ago about personalities and how
individuals would be difficult to manage, but consortia would
be easier to manage than individual GPs.
I want to put a point that was raised with me last
week. At the moment the timing may not be right and there is a generation
of GPs who would be absolutely resistant to this—who will
probably, as a result of this, be falling off the edge in terms
of this is not going to be for them—but a new generation
of GPs are coming through enthusiastically who now find GP practice
a more interesting sphere of medicine to go into and they
would be more amenable to that kind of thing. I suppose the
timing is probably the issue.
Dr Jennifer Dixon:
Yes, and actually the younger GPs may be less interested in a
GMS contract. They don't want to become a partner; they actually
want to be salaried and have flexibility. They don't want to buy
into a mortgage for life in a practice. It could be that
GMS withers away anyway as more people leave, and it could be
also that some of the GMS practices could be bought out or traded.
At the moment that's not allowed, but it could be that consortia
could take on this role to remove some poor performers, or at
least to bring them under performance management through a different
route.
Q276 Chair: Marketability
of GP goodwill might be a dangerous subject to raise at 6
minutes to 1.
Professor Chris Ham:
In concept, of course, you could do it. The practicalities are
twofold, aren't they? One is that it would pull the rug very firmly
from under the BMA because a large part of its raison d'être
is to negotiate a contract on behalf of GPs across the country.
Nadine Dorries: Absolutely.
Professor Chris Ham:
You may see that as being a good thing or a bad thing; I wouldn't
want to prejudge that.
Nadine Dorries: On the
basis of what happened a few years ago, I'd say it was probably
a bad thing.
Professor Chris Ham:
Okay. The second thing is in terms of the psychology. If I am
a GP with a GMS contract at the moment, thinking about
whether it would be beneficial to me to have that contract held
by the commissioning consortia in future as opposed to the current
arrangements, I think it would depend a great deal on
who I saw leading the commissioning consortia where I was
practising in future. If there were really respected, credible
GP leaders and good managers there, it probably wouldn't make
a huge amount of difference to me, but if the opposite were
true then I think there would be a lot of antibodies
in the GP community because what this does is to change the whole
dynamic within general practice. You are getting one group of
GPs to manage and lead all the other GPs and, as I say, there
could be an upside to that but there could be a real downside
too.
Chair: Grahame wants to
ask a quick question and then I think we are probably coming to
a close. Rosie wants to ask a quick question as well.
Q277 Grahame Morris:
It is just in relation to the health and social care provisions
and the £1 billion of resource that is being transferred
from the NHS capital budget. If this transfer to social care is
an integrated model of care, particularly thinking about care
of the elderly, older people, where the purchaser/provider split
perhaps is not advantageous, should we really consider that is
part of the NHS, or is this part of a partnership that Dr Nixon
referred to between the NHS and local government?
Professor Chris Ham:
My view on this is that I think it is, on the whole, a good
thing that this has been done around identifying some of the NHS
funding to support social care, because I think the NHS is
going to be under huge pressure anyway, but without that flexibility,
the ability to discharge patients at the right time, to free up
beds and to enable admission from A&E would be much more challenging.
It raises the bigger question as to whether we should sustain
this budgetary and organisational division between health and
social care. If you go back to examples like Torbay, which has
the care trust and they have broken down those divisions certainly
around adult social care, although not around children's services,
their experience is that they have invested health money to increase
spending on social care because that is a better way of keeping
people independent and living in the community and avoiding avoidable
admissions than more investment in health and medical care services.
The caution here is let's look at Northern Ireland,
which has had a fully integrated health and social care system
for many, many years, but it's a structural integration,
not a real service, and clinical integration in many areas,
and that really isn't the solution to these problems. You have
to get the teams working together on the ground. It is back to
the people who will make it happen rather than the structures.
Q278 Rosie Cooper:
Finally, could Dr Dixon give us her view of 2014?
Dr Jennifer Dixon:
Yes. I think this partly rests on how successfully the NHS
will be able to control expenditure while maintaining a decent
level of quality and access. I just fear that the rapidity
of all these changes will mean that the NHS could be in danger
of slightly being overtaken by events, that cuts and discontent
will be high and that there will be a retraction to central
control of the type we have seen in the past. So 2014 may look
surprisingly familiar to us.
Q279 Chair: There
is precedent for that analysis. Thank you very much. Are there
any issues that you think we have glossed over that you would
like to draw out?
Professor Gwyn Bevan:
There's one thing I should have mentioned which is in my
evidence. We have been doing work funded by the Health Foundation
to help—it was and still is—primary care trusts, but
I still think of them as on the way out really, to set priorities.
We worked with Sheffield last year to help them move money around.
In one service—eating disorders—the lead was sure
things weren't right, and working with stakeholders, patients,
the local authority, providers from the charitable sector, etc.,
we found ways of moving resources so they got better outcomes
at reduced cost. We were hoping to continue that next year, but
it is in abeyance now because PCTs are being reorganised. That
is at the back of my deep concerns about this. Through this reorganisation
we are losing time to get to grips with what the NHS really has
to tackle.
Dr Jennifer Dixon:
I have a very practical issue. There was a question
earlier about what the right size of the consortia is and the
size is different according to what is the issue to be discussed,
but one of them is risk-sharing. I just wanted to say that
it is an empirical question rather than a valuebased
question what size they need to be to take on what level of financial
risk. In fact we are doing some modelling at the moment to decide
that. Some practices of GP consortia will be too small to take
on a lot of purchasing of services, and that will have to go back
to the Commissioning Board. So it's an empirical—you don't
have to have a finger in the wind.
Chair: Thank you very
much for your time.
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