Examination of Witnesses (Questions 280-329)
Witnesses: Dr Peter
Weaving, Cumbria PBC consortium, Anthony Farnsworth,
Torbay Care Trust, Nigel Edwards, NHS Confederation, and
Dr Paul Zollinger-Read, Commissioning transition lead for
East of England SHA and interim Chief Executive of Peterborough
PCT, gave evidence.
Q280 Chair: Gentlemen,
thank you very much for coming this morning. I think we might
start. Could I ask you to begin by introducing yourselves so we
are all aware of who you are and where you come from?
Anthony Farnsworth:
I am Anthony Farnsworth. I am the Chief Executive of Torbay Care
Trust in Devon and Director of Social Services for the same area.
Nigel Edwards:
I am Nigel Edwards. I am the acting Chief Executive of the NHS
Confederation.
Dr Peter Weaving:
I am Peter Weaving. I am a GP and a commissioner for NHS Cumbria.
Q281 Chair: There
is one general question we would like to start with before we
go off into the detail. One issue that has been of interest to
the Committee since we started this inquiry on commissioning and
a parallel inquiry we are doing into the health and social care
spending programmes is how the two programmes of change going
on in the health service relate to each other. What I mean by
that is that we tend to refer to one as "the Nicholson challenge",
that's the £15 billion to £20 billion efficiency
gain over four years, and that is going on in parallel with the
White Paper process for changing the structures of management
in the health service.
We had an evidence session last week which the Secretary
of State and Sir David Nicholson attended. During that evidence
session, Sir David set out a process of transition which involved
the clustering of PCTs to manage a process of change during the
period between now and the full implementation of the White Paper
process, and that was the means by which he saw it as realistic
to deliver the 4% efficiency gain which is the underlying reality
required from the Nicholson challenge. Would each of you like
to comment on that process of clustering? Does that render the
clusters redundant at the end of the process and what conflicts
do you see emerging during the transition process if you have
got clusters forming on the PCT side and the emerging GP consortia
at the same time?
Anthony Farnsworth:
I would not pose the emergence of the consortia and the development
of clusters as antipathetical to each other. I think they need
to be done in a complementary fashion. The consolidation of commissioning
capabilities in clusters of PCTs is probably a very wise insurance
against some of the risks of managing the two big programmes of
change that you have highlighted. Many of the skills are rare
and many of them need implementing at a scale. It would be a great
waste of the commissioning talent that there is in the NHS if
it wasn't used. It is how that is done, though. If it is done
in a fashion that attempts to impose or command the emergence
of the developing GP commissioning structure, I suspect it will
build in a dysfunctional tension. It needs to be done with the
GPs, the GP commissioning consortia leading and driving it from
the start. That is the best prognosis for a successful component
of the transition.
Dr Peter Weaving:
The experience from Cumbria is that we have gone down this route
already in the sense that we have had evolving GP consortia. Although
Cumbria is running as one consortium, it is divided into six localities,
each with a population of about 100,000, with clinical leaders
there. What we have seen as they have developed, and the publicly
consulted plan to improve healthcare in Cumbria has been implemented,
is that our healthcare costs have come down. We started in a very
sorry place, with £50 million in debt, the public marching
on the streets and a lot of unhappiness about healthcare. We have
turned that around. We have achieved financial balance for the
last three years but, more importantly, we have seen a fall in
important areas of spend, like emergency admissions and prescribing
costs, which are the lowest in the north-west region. Indeed,
going into the future, where I would see the real £20 billion
savings coming from is the inefficiencies we still have in what
we spend, in the sense that even within our lowest prescribing
costs, I know that the variation in that sum between practices
can be 100%. Those differences are not driven purely by healthcare
need--a lot of it is clinician behaviour. So in terms of taking
us forward, I would see us continuing to evolve as we are and
feel that that is going to deliver us the benefits and the financial
savings that we need to see as a health economy.
Nigel Edwards:
Of course, part of the Nicholson challenge, as you know, is a
pre-existing commitment to reduce management costs which has been
intensified and accelerated and I think the intention is to front-load
that reduction. So, in a sense, there are three different challenges,
any one of which would be a major issue for a management organisation.
As Anthony was saying, the proposal to produce clusters has the
distinct benefit of dealing with a group of staff who have specialist
expertise that we probably want to retain but it is not clear
at the moment where they may end up. I suspect that they may end
up being employed by more than one consortium because they have
expertise in particular types of commissioning. Thinking about
their position, they will not want to be waiting around for one
or two years to see whether something might turn up. So there
is an argument in moving rather more quickly in this direction
to create these consortia so that the GP consortia have a choice
of some good talent and, more pragmatically, avoiding the necessity
for what would probably be a very nice redundancy bill—I
am guessing, but over £1 billion worth of redundancy just
for that group of staff, never mind other staff in PCTs. As a
strategy, it makes a degree of sense.
There is a bit of a problem, and we are caught
between the devil and the deep blue sea here, which is that some
places have lost significant numbers of staff already. You have
this group of staff who need some certainty so you need to act
quickly. But we do know that merging organisations is also a risky
and messy business, always with the hazard that people become
distracted in terms of getting some organisation integration and
doing that piece of work. So you end up with, possibly, not two
challenges but four. I can't really see a way out of that, given
where we are now. If we were having this conversation nine months
ago, one could have perhaps suggested some different trajectories,
but that is somewhat academic now.
Q282 Chair: You
are saying that you regard it as a practical way forward and,
in effect, the only way forward.
Nigel Edwards:
Yes, but not without some challenges.
Q283 Chair: I
guess my supplementary question is what do you think is a realistic
timescale? Once again, Sir David said last week that for everyone
who asked him to slow down there was another who emphasised the
importance of getting on with it, in particular against the background
of the requirement to deliver the efficiency gain starting from
next year.
Nigel Edwards:
And both viewpoints are right, in some ways.
Chair: That's not a very
clear guide to action.
Nigel Edwards:
I know, and this is a problem. I have a lot of sympathy—I
don't know if my colleagues agree with me—with the situation
he finds himself him. The advantage of going fast is we can give
certainty to people we need to keep and some indication to people
you don't want to keep that that is the way the future is and
they can start to have a bit of certainty, and they can focus
on doing the job rather than worrying about their future which
is a powerful point. Going faster also sends a signal to GP consortia
that people are serious about this and they can get on and formally
start to choose those people.
I'm not so convinced that there's merit in slowing
down. Once you have announced that you're doing this, history
suggests that the NHS and the NHS staff tend to implement things
faster and people already assume that the future is coming and
act accordingly. In a sense, you could not now announce that we
are going to slow down very easily, except, perhaps, if you have
particular places with problems where you need bespoke solutions
and you need to be clear to people what those were and what the
process for that is. But I think a national slowing down of this
would probably cause more problems than it creates solutions.
Dr Peter Weaving:
One of the lessons the evolving consortia learn very quickly is
that they need very strong and good support services so they are
extremely unkeen to see good people leave the organisations?
Anthony Farnsworth:
One of the things we have done in Torbay recently was to merge
the PBC consortium and the board of the care trust into a single
organisation. The chair of the PBC consortium is our director
of commissioning, so we had already begun an "in the igloo"
solution to how the transition would be managed with other GPs,
which they were enthusiastic about. A direct answer to the first
part of your question is that I firmly believe there are big benefits
to be had from engaging GPs, and consultants for that matter,
in clinical redesign and leadership of change and that includes
decision making about commissioning. The sooner we begin to capitalise
on those benefits the better. To send a delaying signal would,
as Nigel has implied, send all sorts of counter-eddies into the
system just at the point that the system is swinging itself to
get on with implementing what, presumably, is going to become
law following the White Paper.
Q284 Dr Wollaston:
I would like to direct a question both to Anthony and to Peter
because Torbay and Cumbria are held up as beacons of good practice
and it would be interesting for the Committee to hear a little
bit more about how you achieved what you have achieved, and also
whether you feel that the changes in the White Paper will be an
obstacle or actually act to facilitate what you are trying to
achieve. Could we have achieved it without the White Paper, in
other words?
Dr Peter Weaving:
Yes. When we first saw the White Paper, the reaction from Cumbria
was essentially "Business as usual" because the route
we had started down, which was towards a locality model having
clinical leadership and, basically, bringing care closer to patients
and closer to home, fitted completely with the White Paper.
The reason we started on that journey, as I
say, is because we came from quite a difficult place. Sue Page
has already had a mention in a previous session as somebody who
has provided inspirational leadership for Cumbria and set us on
this path. But what she definitely did was to engage the clinical
leads, bring us forward and engage us with the process. It is
we who want to take it forward because we believe that there will
have to be difficult decisions made in the future and I would
far rather be part of making those decisions than have them made
about me or about my services or for my patients. I would far
rather be involved in that process taking it forward.
Anthony Farnsworth:
The fundamental drift of the White Paper is something that I feel,
on behalf of our population in Torbay, is going in the right direction.
We could and we are on the way to achieving many of the benefits
that it is designed to achieve before it had been published. I
think, though, it probably is necessary to say that the change
in impetus, in terms of the clinical leadership and direction
of commissioning from general practitioners, will benefit from
the very distinct push that that has been given. Perhaps I could
mention, in parallel with the White Paper, the transforming community
services initiative which is requiring a separation out of commissioner
and provider. If it is of interest to the Committee, there are
some interesting questions about the relatively dogmatic insistence
on the separation out of commissioner and provider during the
situation when one is trying to manage—
Chair: It is something
I know Dr Wollaston is certainly interested in and other members
of the Committee as well. Please carry on.
Anthony Farnsworth:
I would like to describe to the Committee some of the things that
go along with the position that one is in as a PCT chief executive
of having a cash limit for a population. What does that actually
mean? There's a tendency to see the transactional mechanisms of
commissioning as, "That's what the job is". But that's
really only a part of it. What goes along with that is the partnerships
with other agencies. There's a defined population with a defined
cash limit, the requirement to make choices, priorities, to engage
with your local public and your local council about that, and
most importantly, from my experience, the business of being responsible
for managing the local system of care. There I am. I have the
cash limit, in my instance, for social care as well as health,
and I am responsible for it. That means I am accountable for it.
One of my concerns about the White Paper is that
it is not clear to me quite where that responsibility for managing
the system of care is going to sit in future. The cash limit itself
is being fragmented into different directions, some going to GPs
and some going to the National Commissioning Board. So how one
retains a sense of a given population with a given public resource
deployed on its behalf—Health and Wellbeing Boards may have
a part to play here, I'm not sure; that needs further clarification.
Understanding the commissioning role not just as a transactional
role but as a leadership role with public accountability for the
cash limit to a given population is an important concept to hold
on to, not least from managing in the financially constricted
period of the next decade or so, as far as I can be informed.
It is being able to retain a balanced perspective of the whole
portfolio of health and social care services for a given population.
That kind of overview, and the ability to stand
up in public and account for that to our MPs, to our councillors
and to our public, is an important component of public confidence
and credibility and the reputation of the health service in the
minds of our local taxpayers. I am working my mind around trying
to work out how I am going to recreate and achieve that in a situation
post the implementation of these reforms.
Nigel Edwards:
If I may, that matters because, of course, part of the way that
the Nicholson challenge will be met will not be by lots of small
decisions but by some quite brave and big decisions that will
need to be taken. This idea of the big assistant manager able
to take those becomes quite important. It is not clear whether
that does fit with the consortia or elsewhere but, without that,
we face some quite significant and unresolvable difficulties.
Q285 Dr Wollaston:
There is also the issue of being able to make those make or buy
decisions which are very important.
Nigel Edwards:
Yes.
Q286 Dr Wollaston:
How much do you feel the changes in the White Paper are the changes
that are already being pushed on PCTs that will impair your ability
to make savings and deliver very good clinical pathways?
Anthony Farnsworth:
It is relevant. If I step down a level from my previous statement
and go down to the level of deploying resources on individual
care packages where you have got GPs, district nurses, social
workers and physiotherapists, assessing the need for treatment,
providing treatment, writing prescriptions and making referrals,
at that level the system works well. If you have got an aligned
set of intentions amongst those professionals, the system works
well when you maximise the discretion and potential of those professionals
to make that make or buy decision themselves rather than to impose
it upon them. They will be inclined to be virtuous, in that respect,
if they are operating within a system that is inclined to make
them that way, if you see what I mean. That is one of the nuances
of the commissioner-provider separation that is not widely understood.
Lots of provider staff make, if you follow me for a minute, micro,
individual case commissioning decisions and that is tremendously
positive for patients. It leads you towards choice and personalisation
of both health and social care which I think is a part of the
policy agenda that is so welcome in the White Paper.
Dr Peter Weaving:
On the make or buy side, and this is speaking more as a GP than
as a commissioner, as my colleagues said, GPs are responsible
for probably 80% of the healthcare spend in the NHS, prescribing
the drugs, referring people to outpatients and admitting the emergencies.
There is only a relatively small proportion they are not directly
responsible for. The responsibility, which comes with the White
Paper, for them accepting the size of that responsibility, is
really quite important. In terms of improving healthcare and delivering
the savings, it is important that there is a certain amount of
"making" going on in primary care so that we can free
up some capacity in secondary care so they can do more of the
important secondary care stuff and leave the simpler stuff to
us. That is a very important cost-effective mechanism that we
need to make better use of.
Q287 Dr Wollaston:
The issue I have is that a lot of GPs I talk to tell me they are
very keen to roll up their sleeves and get on with designing patient
pathways. What they don't want to roll up their sleeves and do
is be responsible for competition law. I just wondered if you
would like to comment on that.
Dr Peter Weaving:
What has been a consequence of our journey is that we have come
more away from competition than towards it. We don't find it a
particularly useful driver of the quality of service. What we
find drives the quality of service is collaboration and sitting
down with our secondary care colleagues. The Committee may not
be aware that some GPs think it is very important to sit down
with consultant colleagues. In Cumbria we do that on a weekly
or fortnightly basis to look at some of the important issues which
are facing us because we don't believe that you can commission
your way out of trouble. If you want to improve services you need
to sit down with the people who are providing it and plan it jointly.
That will give you far better results than writing a detailed
specification and saying, "Give me that."
Q288 Dr Wollaston:
Would you like to see secondary care doctors on commissioning
consortia as well, more multi-professional?
Anthony Farnsworth:
Yes.
Dr Peter Weaving:
We are meeting with them on Thursday, exactly that model.
Dr Wollaston: That's what
you are doing.
Anthony Farnsworth:
At a very early stage in the formation of our consortium in Torbay
is the invitation from the consortium to the acute hospital trust
medical director to join the consortium for the precise reason
that the clinical engagement between primary and secondary care
is essential, as my colleague was saying, to achieve the change.
There is a place for competition and you can locate it on the
procurement and commissioning wheel, and it has that place, but
generally one gets far better results, far better alignment of
motivation and intention, by engaging clinical intelligence across
the care pathway.
Q289 Chris Skidmore:
It follows on fairly naturally to management costs and administrative
support services. Dr Weaving, you mentioned the need for strong
support services. In your evidence you talk about the consortia
in Cumbria and that they cannot and should not take on the PCT
administrative functions.
Dr Peter Weaving:
Yes.
Q290 Chris Skidmore:
First, I was interested in what you have already ongoing in Cumbria
in terms of what operations you have and who takes over the administrative
functions within the consortia and, secondly, are you concerned
at all about the 46% reduction in management function costs over
the next four years? Would that possibly impact on the commissioning
practice itself?
Dr Peter Weaving:
Yes. Obviously, we have come from the situation of being an ordinary
PCT with all those ordinary functions and my role and that of
my clinical colleagues is to provide clinical steer and clinical
leadership. It is not for us to become experts in contracts, IT
and performance. There are extremely good people in the organisations
who already do that work. I need them to support the clinical
steer that I wish to put on things. In terms of the management
costs falling 46% over the next year or so, it will be a very
interesting discussion to say, "What are the functions that
are currently done by PCTs that we wish to do away with to enable
developing consortia to do the job that they will do best but
not to take on a lot of—I think Paul Corrigan described
them as—the "worrying roles" of PCTs. PCTs are
very good at worrying about certain things but not very good at
producing good change in clinical pathways and so on.
Q291 Chris Skidmore:
You say the consortia in Cumbria are currently designing the level
of business support needed.
Dr Peter Weaving:
Yes.
Q292 Chris Skidmore:
What is that looking like in the Cumbria area?
Dr Peter Weaving:
Essentially it looks a bit like a distilled PCT. As I said, the
set-up we have in Cumbria is, following the political boundaries
within the county, there are the six localities. We are certainly
not going to replicate support functions for each of those. There
will be a central support function which will provide financial
expertise, IT, performance management and all those things. That
will supply all the localities.
I should probably explain that although the localities
are semi-autonomous and we try to operate the principle of subsidiarity
to try and get healthcare decision-making as close to the patient
as possible, we also recognise that across a geographical area
like Cumbria you still need something—we call it "the
senate"--where we meet. The senate looks after things like
the equivalent of the Post Office, roads and rail because those
functions are required across all the localities but you don't
want to replicate the management of each of those functions within
the locality. So there is, if you like, a nesting dolls model.
If you are acting as a very big organisation, you need to demonstrate
localisation and if you are very small, you need to show joined-upness.
For example, if I wish to change the way cardiac services are
provided in Cumbria and have an interventional service which we
don't have at the moment, I need to join with the other localities
to exert that commissioning clout. But if I wish to influence
an individual practice's prescribing, then that needs to be done
on a very personal, local basis. Those are the important things
for me but, underneath all that, we still need good support functions.
It is a very popular statement to say, "We're going to remove
management and administration to save money and we'll protect
frontline services", but I think we all agree frontline services
without support and management will not be very good frontline
services. I think we do need to support that.
Q293 Chris Skidmore:
Moving from the PCT model to the consortia model, how much upheaval
was there in terms of redundancy costs within Cumbria itself?
Dr Peter Weaving:
We are still going through that at the moment. But it's more the
unsettlingness of "I work for an organisation which is going
to be defunct in three years' time." Understandably, it's
an extremely upsetting place to be.
Q294 Andrew George:
May I check the population areas, the populations within the locality
area of the consortium as a whole?
Dr Peter Weaving:
It's about 100,000 population. The population of Cumbria is 500,000
and it is divided into six localities. Eden Valley is a smaller
one of about 60,000 to 70,000 but the rest are around the 100,000
mark. Even so, for something like cardiac services you need three
or four of those joined together to get the commissioning clout.
Q295 Valerie Vaz:
Is that a settled population?
Dr Peter Weaving:
Yes. Cumbria is very settled.
Q296 Valerie Vaz:
You have got registered and unregistered patients?
Dr Peter Weaving:
They are largely registered. We don't have much in the way of
migrating populations. It's a fascinating mix because we have
got wards where the life expectancy is something like 93 fairly
adjacent to wards where the life expectancy is barely 70. We have
got the deprived west coast of Cumbria--Workington, Maryport and,
down in the south, Barrow--and then you have got very affluent
areas in the middle like Greystoke and South Lakes around Kendal.
Q297 Valerie Vaz:
Do you think your model will work in areas which are not particularly
settled?
Dr Peter Weaving:
Yes. In fact, we have some of the strongest consortia in evolution.
One of the national pilots is taking place in Allerdale which
is basically deprived West Cumbria, and there they have taken
the subsidiarity model down even further, down to very small communities
such as Maryport, Cockermouth, Keswick and places like this—Keswick
being one of the less deprived ones, I would say.
Q298 Valerie Vaz:
Do you think your model works partly because you have this coterminosity
with the local authorities and you have support from the PCTs?
Dr Peter Weaving:
It makes it very simple for a lot of things. It is a very sensible
arrangement and it fits with the rough size of population you
need to be stable. But even within that, to get individual GPs
changing their clinical behaviour you need to shrink it down.
You need to drill down even further so that a GP sitting with
his surgery still feels that he is part of this system and that
the decisions he makes are part of the bigger picture. That is
particularly important when we have looked at things like chronic
disease management and trying to avoid emergency admissions. Unless
you have got people who are joined up with that—I will digress
slightly. When we lost out of hours care, GPs became increasingly
office docs and a lot of the emergency admissions are driven out
of hours. What we need to get to is the in hours doc, having plans
for patients set up so that, out of hours, an individual patient
has a clear mechanism of being looked after so that they're not
reliant on somebody who has just arrived in an ambulance or an
out of hours service, but there is a clear plan for that patient,
for example in residential care homes. In Cumbria, between 50%
and 30% of them get admitted to hospital each year as emergencies.
That is a population for which we know it is really bad to admit
them to hospital. They actually do worse being admitted to hospital
than they do if they are looked after in their place of safety.
One of the things we are setting up is for each of those individuals
to have a care plan so that it doesn't matter if it is a GP visiting
during the day or an emergency ambulance turning up at night or
an A&E department greeting that patient, they all have access
to the same care plan and know not only what the medical background
for that patient is but what that patient wants, what their family
wants, what their carer wants and what the GP wants.
Q299 Chair: Can
I interrupt the dialogue because I think Mr Farnsworth wants to
comment?
Anthony Farnsworth:
I am just going to draw the Committee's attention to the question
you raise about coterminosity with local government. We have here
an emerging situation where the consortia's population will be
defined by a group practice and practice registration and that
is not necessarily the same as a geographical patch. I think there
is some further thinking to be done, particularly along the lines
of the relationship with local government, the Health and Wellbeing
Board and how one is able to account, if you like, for a population
for a place—a given part of England. I think the concept
of "place" and the stewardship of public sector resources
in a given place and how that is developed and applied in partnership
with others, including local government, and the link between
that and accountability, remains one of the puzzles here that
is in need of further articulation as things move into legislation.
There is a risk of losing the ability to connect those things
together if it is simply left to practice registration.
Nigel Edwards:
This is an issue because if you take an area like cardiac services,
health education will be commissioned by local authorities, primary
intervention by local authorities, the primary care interventions
by the National Commissioning Board, the secondary care by the
GPs and tertiary care by the National Commissioning Board or by
group special services. So there is an issue with the loss of
a place focus of commissioning potentially becoming quite fragmented
and there needing to be the sort of machinery Dr Weaving
was referring to to stitch that all back together so there is
some geographical and population focus.
Rosie Cooper: In short,
a mess.
Q300 Grahame Morris:
Following on that same theme that has been touched upon, and I
don't know whether my question is best targeted at Mr Edwards,
but it is in relation to this issue of registered and unregistered
patients and whether that is really going to reflect local needs.
I am thinking particularly not so much about Torbay or even Cumbria
in that regard, but if GP consortia have to cater not just for
registered patients but for unregistered patients what would be
the consequences for areas suffering multiple disadvantage? I'm
thinking of Easington. I'm thinking of the old industrial areas.
I'm thinking of Tower Hamlets. If patients are choosing to register
in the cities where, perhaps, they work should there be some allowance
made for other areas who are grappling with issues of health inequalities,
ageing populations and high levels of ill-health? I know Cumbria
has issues about rural sparsity. I would be interested in your
thoughts on that and on deprivation.
Chair: All within 60 seconds.
Nigel Edwards:
There's a whole portfolio to your question. A few points. We deal,
first of all, with patients with registration problems, with areas
with lower levels of registration or with high levels of churn.
There is a practical difficulty about actually measuring outcomes.
If you are in Newham and 20% of your patients move to other areas—your
patient population is entirely being refreshed with people who
are like the last lot who have moved out—being able to make
a long term investment and show outcome improvements is a challenge.
If you are going to have a focus on being able to deal with the
homeless, the unregistered and some of these other groups who
may not use general practice in the way that the bulk of the population
do, you probably still need to have a geographical focus.
Q301 Grahame Morris:
A residual responsibility.
Nigel Edwards:
So somewhere in this system there is someone who will bring all
of that back together and look at these because many of the interventions
you need to be making are based on geography.
The question of resource allocation you raise is
a really difficult one because there is an unresolved academic
and methodological dispute about exactly what the right way to
measure the allocation mechanism should be and whether you should
count deprivation in that. To some extent, this is a technical
question. We don't, as yet, know what the new allocation formula
will look like but what is clear is that if you are going to allow
people to register with practices outside their geographical area
you probably should not be using geography, which is how it is
done at the moment, to determine what the allocation should be.
You should be using the characteristics of the patient, which
will require—and this is possible to do—a new methodology.
It will probably have the result of significantly changing things,
particularly if, as is also proposed, as I understand it, you
reduce the funding for deprivation in the funding for health services
and put that into the funding for public health. All that will
have this very significant redistributive effect so consortia
which may well find that they are thinking they are going to be
gaining from the operation of account allocation formula may very
easily find that they are losing. There will be a very interesting
debate to be had about how those formulae are calculated. Of course,
the key question is: what pace of change should you have to move
people to their new target? How public health funding will be
allocated and how that will affect different levels of deprivation
and life expectancy and the rest, we are due to find out, I understand,
in the next few days. I can't help you on that.
Dr Peter Weaving:
Although we don't know what the new formula will be, what we have
done in Cumbria, because the six localities have quite different
levels of deprivation, is we have taken the NHS formula and applied
it to each locality individually and it has produced quite significant
shifts in healthcare funding which has definitely benefited the
more deprived areas which have received quite definite increases
in funding. We have taken a rate of change of travel and I think
we are heading to bridge 50% of the gap in three years. But there
are some quite large changes in funding for health economies and
that is to the detriment of the better-off economies at the moment.
Anthony Farnsworth:
I echo the point that, in moving practice level allocations on
a pace of change towards fair shares, we have been trying for
some years to steadily—"first and most deserving"
is the expression for this—benefit more deprived practices
and, within a fixed sum, that is a redistribution. There are winners
and losers in that redistribution but I am happy to stand by the
redistribution. I think it is justified.
Q302 Grahame Morris:
Do you all subscribe to that, all three?
Anthony Farnsworth:
Yes.
Dr Peter Weaving:
Yes, definitely.
Nigel Edwards:
Of course, the more you fragment—the lesson from Dr Weaving's
example—the more consortia you have, the more variation
you have. This is just a statistical fact. There will be some
difficult conversations when these new allocations are calculated
and when the new formula is introduced which will be, particularly
in better-off areas with a relatively young population, for some
people, a quite unpleasant surprise.
Q303 Chair: This
is no longer, of course, about differential growth. This is about
actual reductions in some areas if you are to achieve any significant
resource transfer?
Nigel Edwards:
Yes.
Q304 Mr Sharma:
In answering Grahame's question, you have already partly answered
mine, but additional to that is the fact that in a constituency
like mine, Ealing, Southall, where there is quite a large unsettled
population, changes in the welfare benefit might encourage some,
if not many people to move out and a settled community becomes
unsettled for different rules in benefits, housing benefit and
other areas. A shortage of social housing forces people to move
out and then areas like Cumbria might have people from my constituency
or the south-east moving further into there. Won't that cause
a lot of problems if there is a shortage of resources, particularly
when there are cuts in administration costs that put more pressure
on the consortia as well as the local GPs?
Anthony Farnsworth:
I understand the question and I think you are quite right to be
aware of the forthcoming changes in the benefits system which
I think will impact significantly, particularly on adult social
care funding. I remind the Committee of the mechanism that was
used the last time the GP contract was renegotiated of reimbursement
for temporary residents. The health service has previously considered
a mechanism for managing turbulence in primary care registered
populations in the GMS contract. Your civil servants would be
able to advise you how that worked and I wonder if it might have
some applicability, as a mechanism, to relatively unstable or
moving populations in the light of your question.
Q305 Rosie Cooper:
I want to ask about historic debt, but before that, so as not
to lose the thread, Dr Weaving talked about the model he has got
now, in essence, being a "distilled PCT". I wondered
whether, as the Secretary of State was so fond of Cumbria, he
might have paid more attention and, therefore, applied that model
to the rest of the country to give us a good result without the
cost, the angst and the grief of both the Nicholson challenge
and the huge structural challenge currently being imposed on the
service. Perhaps Mr Farnsworth, or all of you, could tell me how,
in the models you have now got, where the patient voice is, how
the patient influences and has a say in what is being done for
them in their name?
Dr Peter Weaving:
There are a number of mechanisms. Some are informal and some formal.
As a practising clinician--as are all the GP locality leads--the
informal mechanism is that we spend quite a lot of our working
week sitting down with patients not only hearing what their side
of the story is but also hearing what their experience of other
local services, particularly the hospital service, is. That is
extremely useful intelligence. It is soft and it tends to get
forgotten. Also, within each locality we have patient representation
and that can either be patient representatives sitting with a
locality board or we also have—and I'm just trying to think
of the technical term for it—fora where we have groups of
patients we can ask questions of. That is simply, if you like,
a registered list of people who are keen to—
Rosie Cooper: A forum?
Dr Peter Weaving:
Yes.
Q306 Rosie Cooper:
But do they ever get an actual say? Are they ever involved actually
at the point of decision making?
Dr Peter Weaving:
The patient representative will sit at a locality board meeting
like this and would give a view, would take part in the debate
and would have a voting right, the same as any other member of
the locality board.
Anthony Farnsworth:
There are a couple of other avenues. First of all, we do—I
am sure all PCTs do—consult publicly on priorities. The
decisions about resource spending, new commitments and changing
services are discussed, and some of them, if they are substantial
changes, are subject to formal public consultation. We are also
subject to the health scrutiny process that local government carries
out.
Rosie Cooper: A complete
waste of time, but carry on. I do understand your role, but a
complete waste of time.
Anthony Farnsworth:
I suppose I'm trying to answer the question, what are the mechanisms
in the present system that are designed to do that?
Rosie Cooper: Yes.
Anthony Farnsworth:
It may be that it doesn't fully fulfil all those hopes but, none
the less, it is there. Then there is the advent of what were formerly
the PPI fora that have now become the links that—I see your
expression again.
Chair: We try to keep
most of our opinions until we write a report but can't always
succeed.
Anthony Farnsworth:
I think Dr Weaving's first answer was probably the most profound,
which is at the level of the individual consultation, the exercise
of choice, the provision of information to individual patients
about their treatment, about the choices they face, the options
they have, conservative treatment, intervention and so on. That
is the most meaningful level.
Nigel Edwards:
We should just say that while GPs do see 70% of their practice
population in the year, which is an extraordinary coverage, it
is sometimes not easy to spot patterns where there are weak signals.
In the opening address of the counsel to the inquiry, it is very
noticeable that the GPs in mid-Staffordshire appeared not to notice
what was happening in their patch. I think this is defensible
because hospital use is a relatively rare event and the number
of people within that is a relatively rare number of patients
who were having problems. The address said of seeing patterns
that "The sum of lots of individual GP consultations is not
a population health view." I don't know if Dr Weaving agrees
with me but there is also a need to have, on top of that, a mechanism
for systematically looking for some of these weaker signals that
may be hard to detect on an individual consultation basis. So
while individual consultation gives you a huge amount of very
rich intelligence, there isn't a sign in the GP surgery that says,
"If you want to talk about health strategy and priorities,
please book a double appointment." There is not that opportunity
to have that conversation. I think there is a need for other mechanisms,
and not just at the GP level of commissioning.
If I may, one point that is really worth making
here is that there appears to be no patient or consumer voice
in the role of the economic regulator, which is a very important
part of what will become the commissioning machinery and will
be making decisions which will affect, in some detail, the provision
of care and will be deciding on some of the integrated models
that we have heard about this morning. It will have a say on whether
or not those meet their criteria in terms of meeting patient benefits.
We should not just be looking for patient involvement at the practice,
consortia, Health and Wellbeing Board level but at other levels
in the system as well.
Q307 Chair: Can
I bring Dr Zollinger-Read into the conversation, having won through
the weather? You are very welcome.
Dr Paul Zollinger-Read:
Essex doesn't do snow.
Q308 Chair: It
may be useful to the Committee if I repeated to you the question
that the other three witnesses answered at the beginning: in your
experience, you are doing many of the things that are in the White
Paper policy. Does the introduction of the White Paper facilitate
what you are doing and how do we avoid making the development
of your ideas more difficult?
Dr Paul Zollinger-Read:
I suppose we are, in Cambridge, in the unique position that over
a year ago, long before the White Paper, we reckoned the PCT wasn't
working. So we went out and had long and detailed conversations
with all the GPs and decided that what we needed to do was form
clusters rather than PCTs. So long before the White Paper we started
setting up clusters. They range from 100,000 to 50,000 and we
have now got five of them. They are autonomous in that they now
have their own budgets. What that did was two things to us. First,
it put clinicians in the driving seat where they weren't before
and secondly, we recognised we were not good at getting the patient
voice into a PCT of 600,000. We did all the things you have heard
but we weren't good at it. We went down that road and we did one
other thing as well. We set up a whole series of peer reviews
whereby GPs reviewed the referrals and described them as their
"colleagues". We decided we weren't going to send referrals
to a black box they don't get out of, we were going to leave it
to clinicians.
The results are interesting because in our Hunts
area our activity and our stats have gone down. With Addenbrookes
the growth has reduced. I have no idea of this cause and effect
but what we know is that we've changed the system and we've got
beneficial results so far. We have certainly got much, much greater
clinical engagement.
Another thing we did that I'm not certain the
White Paper speaks as much as I would like on is the primary and
secondary care divide. That is a real issue that we haven't tackled.
We said, "What are the nine key clinical areas across this
county?" They ranged from oncology to cardiology to diabetes.
We said, "Let's set up Joint Working Groups with a consultant
lead and GP lead and patient input." Then I got it wrong
because I said, "Right, we're going to task you with being
cost effective." What I should have said is, "We're
going to task you with improving quality." Once I actually
got that right those workstreams then really motored looking at,
"Where are we?" "Where do we want to go?"
"How do we maintain or improve the quality and improve cost
effectiveness?"
We are also having very difficult discussions
about the use of chemotherapy in the last stages of life where,
because this is clinician-led, they can quote the papers and the
New England Journal of Medicine which show good quality
palliative care—surprise, surprise—will actually extend
your life. Chemotherapy will not extend your life. Good quality
palliative care will. So we have moved, in a short series of jumps,
to a clinician-led organisation and it has improved our outcomes.
Q309 Chair: Clinician-led,
meaning GPs as the catalyst for the wider clinical community?
Dr Paul Zollinger-Read:
Yes. We started off by saying, "Right. We're the Executive.
We want GP leaders. Five of you come in. You are part of our Executive.
You have the power of veto." What we are now doing is we
are setting up something which is dreadfully called "the
senate". I know it is dreadfully named, but it will be GP
leaders and they will now form the strategic group across Cambridgeshire
and Peterborough so that we will start to have a strategic focus
that they can link in and ask, "What are we doing in major
trauma centres? What is our view on oncology?"
Q310 Rosie Cooper:
If I may just continue the train of thought I was going down,
I want to try and elicit, where patients engage or influence currently,
whether, in the new consortia, you think that patients could access
or influence directly and how you feel that GPs in the consortia
would take, for example, to open board meetings and their decisions
being made in public, and, at each level of the new world, where
do you think the accountable officers should be? Who is going
to take the rap for each of these decisions? In the consortia
will the chair be the accountable officer for the decisions that
are being made in their name? Where do you think the buck stops?
Dr Peter Weaving:
I think it should stop here. I would be very happy for it to stop
here and I would very much welcome any mechanism which empowers
the public. It is quite difficult to empower the public in healthcare
decision making. There has been previous reference to the fact
that clinicians, even if they don't want to, tend to be overbearing
and put off public influence. That is very unfortunate, but I
think it does happen. So it is very difficult to get real public
engagement and I genuinely don't know how you do it. It's very
easy to get representation. How you get empowered opinion turning
into policy is much more difficult.
Anthony Farnsworth:
There is a relationship between your question and my earlier observations
about the responsibilities and accountabilities that go with having
a cash limit for a population because, right now, if something
goes wrong in Torbay I am the accountable officer and I know that
I'm the person who is responsible for it. Your question is a good
one. If a GP consortium has a cash limit for a given population,
I would have thought that it would have to carry with it an accountable
officer status just in terms of Treasury accounting terms. That
is a role that could be held by a GP and that becomes a position
of public accountability and responsibility. In that sense, I
think that is the nearest proxy I can see at the moment to providing
a good answer to your question.
The thinking about the development of Health
and Wellbeing Boards, whether they are executive or non-executive,
whether they are within the executive part of the council or part
of the partnership architecture and how they are finally constructed,
there is a potential partial answer in the design of that Health
and Wellbeing Board arrangement. But I don't think that can fully
supplant, nor is it designed to, the accountable officer role
that would need to sit within the health service for health service
responsibilities.
Dr Paul Zollinger-Read:
I am a GP and I have been a chief exec and a GP at the same time.
I think you should stand up and be the accountable officer. These
are clinically led organisations and they need to have accountable
officers who are clinicians.
Q311 Chair: Can
I just be clear: You are currently the chief exec of the Cambridgeshire
PCT and a practising GP?
Dr Paul Zollinger-Read:
I put it on hold and I go back in March. I think that was the
wrong decision. My current employer said, "This is a really
big job. You need to put that on hold." I have been a GP
and a chief exec of five or six PCTs since early 2000 and I think
it adds value.
Q312 Valerie Vaz:
So someone judicially reviews your decision and you are the named
person that they judicially review?
Dr Paul Zollinger-Read:
Yes.
Q313 Valerie Vaz:
Ultimately that is going to happen, isn't it?
Dr Paul Zollinger-Read:
Yes.
Valerie Vaz: They are
not going to be happy with your decision so they judicially review
you, as opposed to the Secretary of State?
Dr Paul Zollinger-Read:
That's an interesting conundrum. It has never happened to me.
Valerie Vaz: Because they
usually do it to the Secretary of State.
Chair: You might live
to regret it.
Nigel Edwards:
I think it is entirely unclear exactly how this will work in the
new system. It is also not clear what governance structures the
consortia will have. I think the intention at the moment is to
leave that fairly fluid. I'm not expecting to see the type of
board and machinery that we have seen in PCTs. I think it will
look quite different.
One of the interesting questions is, just by
analogy with—and this may seem odd—hospital management
in Hungary and Poland and a number of other Eastern European countries
which I'm familiar with, being hospital director is a job done
by a doctor. It is generally reckoned to be not a job worth having
and when you are sacked, which is a very regular occurrence, you
go back to your previous clinical job, which is the one you wanted
to do anyway, and you earn twice as much money as you did previously.
There is an important point which is, if this is a job worth having
it should be a job worth losing. We have serious people here who
will take this seriously but I think there is also a message to
the rest of the system about, "This is the place where all
the accountability is." I don't quite see how that works
in this new system. The point that was made earlier about judicial
review and the need for a very clear, transparent decision-making
process which currently exists in PCTs is also very important
and it would be important to make sure it isn't lost. I am torn
on this because history suggests that asking the Department of
Health to design governance structures is probably not a good
idea. On the other hand, some design rules and principles just
to help people not fall into the very obvious traps that end up
leading to judicial review would be helpful. I don't know if my
colleagues agree with that.
Anthony Farnsworth:
And locate the accountability.
Q314 Dr Wollaston:
Can I follow through on Paul's previous answer, and that is to
say with these three very successful pathfinders here today in
front of the Committee, would you have thought it was possible
to get what you have achieved without the White Paper and just
roll that out across the rest of the country or did you think
the White Paper was necessary to implement it nationwide?
Dr Paul Zollinger-Read:
I also run Peterborough NHS and you find that Cambridgeshire NHS
got there a lot quicker. Peterborough, with the White Paper, is
now incredibly motivated and the GPs are moving forward really
quickly. I don't think we would have got that without the White
Paper.
Q315 Dr Wollaston:
So you think the White Paper is going to be a good impetus to
roll out—
Dr Paul Zollinger-Read:
I do, simply because someone like me fundamentally believes that
commissioning needs to be clinically led and you need to tie the
financial accountability to the clinical decisions. The final
bit, which we probably haven't heard much about, is this. We have
heard about patient engagement but patient involvement in their
own decisions about their care is a crucial bit that we must get
right in this White Paper because we haven't done it well before.
Q316 Chair: I
guess one of the traditional challenges to clinically led commissioning
of the kind you have described is the question, does it face the
tough restructuring decisions required, service re-provision and
reorganisation? Do you have experience of that? Does it facilitate
those?
Dr Paul Zollinger-Read:
All I can say is that years ago it was fund holding and that was
a different world but we made decisions to restructure mental
health services locally because they were poor. Within a very
short space of time we had a really positive local mental health
service that everyone else benefited from as well and that happened
because it was clinically led.
Anthony Farnsworth:
A supplementary example would be with respect to cancer services,
the road cancer networks and the implementing of improving outcomes
guidance, which are clinical evidence-based standards for cancer
care. That would give you another proxy of the sort of clinically
driven evidence-based mechanisms that GPs as commissioners would
need to support them in tackling, for example, a major service
reconfiguration or a relocation of service that might be indicated
in terms of its viability or its standards.
Nigel Edwards:
If GP consortia were given the job of doing that strategic change
then they will do it. But, taking the lessons of what has happened
previously, they will probably need to club together on occasions
to do it effectively. The big lesson is whether they will be given
the licence and the support to make those difficult decisions
because while, in principle, we are very keen on people making
these decisions, when the reality of the decisions are made some
of the previous supporters cannot be seen for dust.
Q317 Andrew George:
Can I clarify? When you say clinically led decisions, of course
what you mean is GP-led or primary care-led decisions. Can I just
be clear that, in the case of Cambridgeshire and Cumbria and elsewhere,
when you say "clinically led decisions" how do you make
sure that those clinically led decisions represent, if you like,
the clinical view across the piece including secondary and tertiary?
I know that this has been mentioned already.
Chair: There is a good
bit of competition between the witnesses to answer that one.
Anthony Farnsworth:
To use the example I started with, the development of clinical
standards for cancer care is done not just by GPs, it is done
by consultants and the National Cancer Action Team and so on.
That may be a good example—
Q318 Andrew George:
No, it is not a good example, is it, because that is taken at
a more strategic level, isn't it? It is not taken at the GP consortia
level because the cancer networks cover much larger areas, don't
they?
Anthony Farnsworth:
Yes, but, in effect, their mandate or power to operate is a delegated
or devolved arrangement from a number of, at the moment, PCTs
and, in future, consortia. They hope the health service realises
that it needs to collect a critical mass of expertise in order
to make difficult strategic decisions and I am sure that has been
the case and will continue to be the case in future. It remains
to be seen as to how much of that voluntarily emerges between
consortia and how much of that is located in the infrastructure
of the National Commissioning Board or its substructure. That
remains to be seen.
Dr Paul Zollinger-Read:
Two examples on the clinically led decisions, dermatology and
diabetes: both GPs and consultants in Cambridgeshire decided that
they would move it to a community-based model. So those were clinically
led decisions. When I go round, the commonest things I hear are
"them" and "us", hospitals versus primary
care. What those groups decided was, "Right. There are consequences
of this. You, as a hospital, have fixed costs. So how are we going
to make sure we can make this transition work, not just for us
in the community but for you in the hospital?" So they have
developed a maturity of dialogue that facilitates those transfers.
Q319 Andrew George:
Is it not true, though, that maybe whilst, on the one hand, the
clinically led decisions with regard to a sub-specialty have to
be taken within the context of having a population level that
takes you to more strategic decision-making, whereas with the
kind of decision that you are talking about in Cambridgeshire,
are you not describing a situation where the GPs hold the purse-strings
and the hospital clinicians are there taking part in that decision-making
from the perspective of the providers of services? It is not,
if you like, an equal relationship. We are getting your perspective
on it and you are telling us that it is clinically led.
Dr Paul Zollinger-Read:
It is an equal relationship because you can't move a service into
the community unless you can get agreement across a clinical pathway.
So you have to agree and clinicians on primary, secondary and
community have to agree what that pathway looks like and then
agree to move it. If it is not agreeing with all those clinicians
and with the local patients then it will fall over quickly.
Q320 Andrew George:
And where does the patient come in?
Dr Paul Zollinger-Read:
The patient comes in helping to design what that pathway looks
like. So, for instance, in Fenland we have piloted moving diabetes
out to our most deprived area and we had significant improvements
in HBO1c. That is a measure of good diabetic control and that
was very much supported by patients.
Q321 Andrew George:
But they don't sit on the Board. They are not part of the planning
process?
Dr Paul Zollinger-Read:
They sit on the Board or the groups of our localities or the trusts,
as we call them.
Q322 Andrew George:
They do?
Dr Paul Zollinger-Read:
Yes.
Dr Peter Weaving:
I think the very important point you are making is, do primary
and secondary care clinicians agree and everything is fine in
the garden? If they sit down and talk constructively and look
at good clinical evidence it is usually fairly straightforward
and you can get agreement. But sometimes people have particular
ways of working and there are disagreements and there are issues
which need to be resolved. That is probably one of the very few
times when genuinely commissioning does make a difference and
you say, "Actually, we do want it this way. We do want it
provided this way." But you have to be absolutely sure you
have got it right if you are going to go down that route rather
than the far better one as described by Paul of actually reaching
a joint pathway.
Q323 Dr Wollaston:
How will that be impacted if you have to consider competition
law from outside providers?
Dr Peter Weaving:
In Cumbria we are very fortunate in the sense that although it
brings the whole choice thing up, in a way, if you really ask
patients what they want they don't particularly want a choice
of lots of providers. What they really want is to be able to take
part in healthcare decisions and they want choice about those
decisions rather than having lots of providers.
Q324 Dr Wollaston:
But do you think there will be a problem for you in designing
these pathways if you have to consider competition law and who
is providing the best value for money rather than the best quality
of service?
Dr Peter Weaving:
It will be a great distraction for many health economies where
it is very difficult to have a competitive market because, basically,
you have a town or a small city which essentially supports one
district general hospital. Can you realistically produce competition
which is going to improve the care for anybody?
Q325 Grahame Morris:
My question is related to that last issue about the design of
care pathways and the commitment to empowering patients which
everyone subscribes to. On the evidence from the NHS Confederation
in relation to market mechanisms, where it says: "There is
a risk of an over-reliance on market mechanisms to manage complex
health services", do you have a view on where the limits
should be placed upon the operation of a market mechanism in relation
to re-designing services?
Nigel Edwards:
That is another complex question. What we had in mind there particularly
was there are a number of services which are made up of other
services and the individual components of those services have
their own markets which are more powerful, individually, than
the market for the thing that they had come together to produce.
The best example of that is probably trauma. Trauma is a very
rare event but it is created by vascular surgery, thoracic surgery
and neuro surgery. There's a list of other things that it consists
of, each of which have their own market, which dominate the market
for trauma. So you cannot rely on markets, in these circumstances,
to solve these complex problems of, "How do I get all of
those six or seven specialties in one place working together?"
That is certainly one issue.
There is, then, I think a question, and there is
a bit of a danger here of regarding markets and competition as
an end in themselves rather than as a set of tools and techniques
where you have got to produce an outcome, and also to assume that
the competition is entirely for each little component that patients
experience as opposed to the whole diabetic pathway. So the solution
to Dr Wollaston's problem is to have competing providers of the
pathway who are going to compete for the whole management of the
care of those patients. That would not be the way that you would
deal with hernia repair. What you are really looking for here
is a non-dogmatic nuanced approach which uses competition and
markets in addition to the other tools that are available to you
and you make sure that you fit those tools to the job in hand
rather than just applying it within limit. The competition regulators
do seem to have that rather more pragmatic approach to have things
done.
Q326 Grahame Morris:
Perhaps you could answer this as well, because it is related to
that, and this is the issue that we have heard from a number of
organisations and witnesses who have given their evidence about
the issues around any willing provider as opposed to a preferred
provider and whether that might undermine some of the core values
of the NHS in terms of fairness and equity.
Nigel Edwards:
I'm not sure that a preferred provider model does anything for
those objectives at all. It seems to me that there are hosts of
questions about any willing provider models but there are a series
of services the NHS provides and for which an any willing provider
model seems to be an entirely appropriate way of working, with
the slight caveat that—and you need to be aware of this—they
can be inflationary because you are bringing in the supply. One
of the invariable rules of healthcare is, "If you build it,
they will come." There is supply and induced demand but if
you want innovation and if you want new entrants then any willing
provider models are fairly effective ways of providing that. Markets
are blind to questions of distributional justice and equity. So,
"Who provides this?" and how it is provided will not
make an impact on this. How you design a system about how patients
access it with the sorts of conversations they have with the people
that refer them and how they get to know about it is what is going
to have an impact on demand.
Q327 Grahame Morris:
So other than word of mouth, the only way to address that without
compounding health inequalities is to address it through the allocation
formula in terms of addressing health inequalities and special
needs?
Nigel Edwards:
I am for the decision made by clinicians because we do know, and
we're not really sure why, that deprived communities get less
access to a whole number of treatments from which they would benefit.
I suspect a lot of this is about the nature of the interaction
that happens in the consulting room. Just as an aside, it does
seem to me all of the things we have heard here do suggest, and
particularly listening to our colleagues here, that the ability
of the consortia to direct the influence and the behaviour of
their colleagues in general practice and primary care is going
to be as important as their ability to commission secondary care.
I think a trick may have been missed in the design—going
slightly off piste, if I may—in the White Paper of not giving
the people who are running GP consortia more formal power in terms
of either the management of the GP contract or at least its performance
management.
Anthony Farnsworth:
I am just going to touch on this question of any willing provider
again which your question raised. The experience I have is in
trying to run a system in Torbay of care co-ordination. There
are about 5,000 people in Torbay who are nearly all elderly, have
co-morbidities and feature on one or more than one of the GPs'
chronic disease registers. They consume more than half the adult
social care resource and at least half the hospital resource.
I find myself trying to run a system of care co-ordination and
that requires a system of care provided in general practice, in
community settings and in the hospital to work together as a system.
Whilst it is possible to envisage specifying
for that system and putting it out to tender to an any willing
provider market, I have to say that that would not be my preferred
step. If the system broke down and was not working I might be
driven to that, but my main discipline, effort and attention is
to get us managing that system and making it work for the benefit
of those 5,000 or 6,000 complicated elderly patients who are the
bulk of the non-elective and complex work that goes on in our
health community.
Q328 Valerie Vaz:
Obviously, this is quite key. You are all expected to be up and
running by 2013. How—each of you—are you going to
manage this transition?
Dr Paul Zollinger-Read:
For me, I have reached a point that I say we have to flip the
PCT because I can't keep running clusters and a PCT. So I'm having
active discussions with both Cambridge and Peterborough about,
"Right, we'll flip the PCT and now become a support service
to your consortia. We'll align ourselves with your objectives
and then we'll work out, is this the type of support structure
you need? It won't look like that in future—we will need
to bring in different skills—but we need to do that because
we can't continue to run the two."
Anthony Farnsworth:
Same answer, supported by clustering PCTs.
Dr Peter Weaving:
The same answer—
Chair: We end where we
began on that subject.
Dr Peter Weaving:
—the evolutionary process. But I think we underestimate
the management support that the consortia will need.
Nigel Edwards:
And evolution produces some unwanted and difficult consequences
from time to time.
Q329 Valerie Vaz:
What about the financial costs from flipping the PCT?
Dr Paul Zollinger-Read:
We have clearly got our management reduction targets that we are
achieving. We have clearly got our QIPP targets that we are currently
achieving. Peterborough, when I took it over, had a debt of £5
million but will hopefully end the year with much less than that.
So both organisations, due to GP involvement, are heading in the
right direction.
Nigel Edwards:
The question of debts, that is left to the end of this transition.
Given that the NHS has a sealed sum of money, there is only one
place it can come from. If it is not passed on to the consortia
there are some good managerial arguments for not saying to people,
"You will be let off any deficits." It will either top-slice
from allocations or it will come out of reserves that could have
been spent on healthcare. I think there is a little bit of a fiction
that seems to be, if you read the GP press, that someone will
come along with some additional money. No one I know who is involved
in this is expecting that.
Rosie Cooper: In fact,
I think the medical press are currently saying it will come from
surpluses held by the strategic health authorities.
Nigel Edwards:
That is usually a one-off deficit.
Rosie Cooper: Absolutely.
Nigel Edwards:
It doesn't deal with the situation where people have got rolling
deficits.
Rosie Cooper: My latest
intelligence says that.
Dr Paul Zollinger-Read:
That is my absolute point. I have taken over many organisations
in debt and paying it off would have done us no favours. It is
a structural underlying reason that you need to understand and
usually that requires declinical engagement to correct.
Nigel Edwards:
I agree.
Chair: On that note, thank
you very much for your attendance and for your contribution this
morning.
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