Examination of Witnesses (Questions 493-595)
Rt Hon Andrew Lansley CBE MP, Dr David Colin-Thomé
OBE, Dame Barbara Hakin DBE
15 December 2010
Q493 Chair: Secretary of State,
Dame Barbara and Dr Colin-Thomé, you areall threevery
welcome.
I would like to begin, if I may, by expressing
formally, on behalf of the Committee, our disappointment that
we have not had the opportunity to consider the documents that
you have published this morning. That creates a problem, given
that this session was intended to be our last evidence session
to look at the evolution of policy on commissioning in the context
of the White Paper. I understand that there was contact between
the Department and Committee staff that was designed to try to
facilitate the Committee having access to these documents overnight
so that we could have had the opportunity to read them and question
you on them this morning. It is regrettable that that was not
possible. However, against that background, I think that a message
was sent to you, Secretary of State, asking for a brief statement
of the key points so that they don't come out slowly during the
session. Will you make a brief statement to introduce the session?
I then propose to allow a general question session based on your
introduction before moving on to more detailed questioning. That
seems to me, given where we are, to be the sensible way of handling
it. I hope that is acceptable.
Mr Lansley: Of course. I am in
your hands.
Q494 Chair: I invite you to make
a brief opening statement of the key points announced today.
Mr Lansley: Thank you, Chair.
May I introduce my colleagues? Dame Barbara
Hakin is the Director of Commissioning Development for the Department
of Health, and Dr Colin-Thomé is the National Clinical
Director for Primary Care. I think that you have had the opportunity
to talk to both Barbara and David in previous evidence sessions.
Both of them are, by profession, general practitioners of seniority
and long standing.
I entirely understand the Committee's point
of view, but it will understand that there are limitations to
how far in advance of publication before Parliament these documents
are ready to be circulated. That is the matter, I am afraid. It
would have been, in my view, far more regrettable for us to have
met today and then to have published them at some later point.
At least they are available, and they are available to the Committee
to consider before you publish your report. I note that the Committee
had to publish a report on spending yesterday that expressed views
on the quality, innovation, productivity and prevention plans
and their credibility before they had been published by the Department.
I hope that all the evidence will be available to the Committee
before you have to publish your report on this occasion.
I am very glad to be able to say a few words
about what we are publishing todayalmost literally in three
minutes' timeto Parliament, and which you received earlier
this morning. First, there is the response to the consultation
on the White Paper and those documents published in late July,
on which we asked for responses by October. That document, Liberating
the NHS: Legislative framework and next steps, sets out how
we propose not only to respond to the points made in consultation,
but to take forward the policy for the Bill. To that extent, although
the Bill is planned for introduction in January, the policy for
the Bill is in the response published today.
We are also publishing today The Operating
Framework for the NHS in England 2011/12 and the allocations
to primary care trusts across England. In my view, the three documents
collectively give a platform for improvement in the NHS, a platform
for development during the course of 2011-12, and a platform for
the reforms generally for the service to pursue.
Liberating the NHS: Legislative frameworks
and next steps sets out in particular our conclusion that,
on the basis of the response to the consultation, we reaffirm
our commitment to deliver reforms on the basis of the principles
that we established. There was very wide support for the principle
of greater patient control of their own care. The principle of
"no decision about me without me" was set out very clearly
in the White Paper and has been widely supported. Indeed, I would
say that it has been embraced across the NHS, literally, over
the past few months. There is a great deal of work to do and further
consultation is still under way on the information that needs
to be supplied to patients to hold the NHS fully to account. Another
consultation is still under way on how patients can exercise greater
choice. None the less, the principle in the White Paper was very
widely supported.
On the second principle, our ambition to achieve
outcomes at least as good as anywhere in the world was also very
strongly supported, particularly the structure of the new framework
of outcomes for the NHS. If we want to deliver the best possible
outcomes, we need to focus on them and have a process to measure
them. Of the 6,000 responses to the White Paper consultation,
some 800 were specifically related to the draft outcomes framework.
I think that when anybody sees the draft outcomes framework, which
we hope to publish before Christmas, they will see that it has
enabled us to break new ground in capturing a representative set
of real outcomes for the NHS on the basis of which the service
will properly hold itself to account. The service will be held
to account not just by the public, but by those inside the service.
People will see these as clinically relevant outcomes that are
a proper basis for clinical peer review and clinical governance.
I think, in its breadth and detail, that this is something that
has never previously been attempted by other health care systems.
So this is ambitious, and we make no bones about that.
Thirdly, the principle is that the service should
be professionally led, that it should be decentralised, and that
decisions should be made as close to patients as possible by front-line
clinicians. As a consequence of that, we wish to increase the
autonomy of health care providers, creating a more independent
structure. That is reaffirmed in the Command Paper, as is the
determination to move towards GP-led commissioning consortia at
a local level and towards a much enhanced and stronger role for
local authorities.
There are clearly issues with the implementation
and the process, on which good points were made in the consultation.
If I may, I will run through some of the main enhancements and
adaptations to the proposals. First, we have decided to strengthen
further the role of health and well-being boards in local authorities,
not least through a new responsibility to develop a joint health
and well-being strategy spanning the NHS, social care, public
health and, potentially, other local authority services. Local
authorities and NHS commissioners will both be statutorily required
to have regard to that.
Secondly, HealthWatch England is to have a distinct
identity as a statutory committee within the Care Quality Commission.
There were people who felt that HealthWatch England should be
entirely separate from the Care Quality Commission, but the conclusion
we reachedthere was strong support for this in the responsewas
that the powers and responsibilities of the Care Quality Commission
are in themselves very important and, overall, that HealthWatch
England could play a stronger role, particularly at a national
level, by being able directly to influence the way in which the
Care Quality Commission goes about its quality inspection and
enforcement tasks.
Thirdly, we will increase the transparency of
commissioning by requiring all GP consortia to have a published
constitution. I should emphasise that we will not prescribe the
nature of those internal constitutions.
We have taken on board all the views expressed
and, on balance, have concluded that, contrary to our original
proposal, maternity services should be commissioned not by the
NHS Commissioning Board, but through the GP-led commissioning
consortia.
We intend to extend councils' formal scrutiny
powers to cover all NHS-funded services. Again, contrary to what
we initially stated in the White Paper, local authorities will
be given freedom to determine how those scrutiny powers should
be exercised. Many local authorities have taken the view that
they wish to have independent scrutiny in other areas, and in
health and social care, too. There will also be a phased timetable
for local authorities to take on responsibility for commissioning
NHS complaints advocacy services and for giving them more flexibility
over from whom they commission complaints advocacy services.
We will give GP consortia a stronger role in
supporting the NHS Commissioning Board to drive up quality in
primary care. Many respondents, especially GP consortia themselves,
wanted a strengthened role for consortia in relation to their
practices in quality focus. We will create an explicit duty for
all arm's length bodies to co-operate in carrying out their functions,
with a new mechanism for resolving disputes between those bodies.
The context of all that, as the Committee will
remember, is that recently the first wave of GP-led commissioning
consortia responded to the invitation to become pathfinders. I
issued the invitation in the second week of October, I think,[1]
and by the end of November, a significant number had put themselves
forward. Of those, 52 have become the first wave. They represent,
collectively, 1,860 practices and 12.8 million patients, which
is a quarter of the country. To be fair to them, there are many
consortia that, in every reasonable sense, are as well-developed;
it's just that the timetable for them wasn't quite the same as
the initial first wave.
To a large extent, I would say that, today,
not only are we publishing the Command Paper in a way that is
clear about the policy for the Bill, but we are seeing much more
of a transfer to the service of the responsibility for shaping
the reforms, and we are doing so from the bottom up rather than
top down. Some two dozen local authorities have expressed an interest
in being trailblazers for the establishment of new health and
well-being boards in anticipation of the new statutory arrangements.
Through The Operating Framework, we are
giving an opportunity for the service to be clear about how the
management of transition and the introduction of reforms are going
to work together. I think we discussed previously, when I was
last here, that, through The Operating Framework, we are
going to be clear in 2011-12 that PCTs will be clustered together.
That will do two things, essentially: it will create a source
of financial and managerial control within the service to assure
ourselves about quality and financial accountability during the
transition; and, at the same time, it will give space for the
GP commissioning consortia. The PCT clusters will not fulfil all
the day-to-day responsibilities of their constituent PCTs. They
will meet their statutory responsibilities and the control responsibility,
but they will also facilitate the devolution of commissioning
activity alongside GP commissioning consortia in 2011-12.
We now stand at the prospect of having, through
The Operating Framework, the commissioning consortia really
actively engaged in 2011-12 in shaping the system of learning
from each other, in the learning network that Barbara and her
colleagues are putting together, and also in what is being done
through, for example, the Royal College of General Practitioners
and its centre for commissioning, and the National Association
of Primary Care and others, which is going to enable that to make
a lot of progress.
There are details in The Operating Framework
that are probably not specifically what you want to discuss today,
which relate to how we are going to make further progress on key
priorities such as reduction of infectionshospital and
health care-acquired infectionsthe elimination of mixed-sex
accommodation, the emphasis that we place on veterans' health
and support for service personnel, the implementation of the dementia
plan, the implementation of carers' breaks, the introduction of
the health visiting implementation plan and the doubling of family
nurse partnerships. Those are all set out in The Operating
Framework.
We have also now published the allocations to
primary care trusts. In total, there is a £2.6 billion cash
increase in 2011-12 over 2010-11. That represents a 3% average
increase across England in the cash available to the NHS next
year. The individual primary care trust increases vary from a
minimum of 2.5% to a maximum of 4.9%. Of course, this is achieved
not least by our being very clear about holding down management
costs, the costs of arm's length bodies to the Department itself
and the central budgets that we control. This gives a pretty strong
platform for 2011-12 for the reforms.
Of course, in addition to that, as you observed
in your report published yesterday, there is a great deal of scope
and, indeed, necessity for the generation of savings through improved
productivity, efficiency and quality gain inside every part of
the service, which will, I hope, enable us next year not only
to meet demands, but to improve the service that we offer.
Chair: Thank you very much.
If I may, I encourage the Committee to focus
this morning's discussion on the commissioning inquiry, which
is our current concern. As I said at the beginning, I think that
members of the Committee would like to question you in general
about what you've said in relation to commissioning, and then
we will move on to specific questions arising from the material
that we had available to us before this morning.
Which member of the Committee would like to
go first? Valerie.
Q495 Valerie Vaz: Thank you. Secretary
of State, I am pleased that you have mentioned the report, and
I hope you take it on board in any of your considerations. I think
it's fair to say that the NHS is facing a number of challenges.
One has been dubbed the Nicholson challenge, then, as far as I'm
concerned, the White Paper is clearly the Lansley challenge, and
we may yet face a third challenge, which is the Letwin challenge.
Focusing on the Nicholson challengethis £20 billion-worthI
wonder if you could tell the Committee how you are getting on
with that. Is it being delivered?
Mr Lansley: The first thing is
that there is a slight misconception around the idea of the proposalor
the intentionthat there should be between £15 billion
and £20 billion of savings achieved within the NHS. That
was not initiated by me; it was initiated before the general election,
with a view to its implementation beginning in April 2011. To
that extent, asking "How is it getting on?" is misplaced,
because technically it hasn't started. Everybody in the NHS is
preparing to achieve this degree of efficiency savings.
There have, of course, been substantial changes
compared with when that was first promulgated. It was promulgated
on the basis that £15 billion to £20 billion was a range,
depending on whether the NHS was going to receive a flat cash
settlement or a flat real settlement in future years. Essentially,
the £15 billion was over three years under circumstances
where there was flat real, and the £20 billion was under
circumstances where there was flat cash.
David Nicholson, who was with me last time we
were here, explained that a number of things have changedand
changed positivelysince then. First, through the spending
review, the NHS has had a settlement that is in excess of real
terms. To that extent, we are on the more favourable scenarios
for financial support for the NHS. What we have done, however,
is not to confine ourselvesthe spending review was not
over three years; it was over four. The intention of the efficiency
gain is now stretched over a four-year period, and therefore we
did not revert to the original £15 billion figure but have
sustained the £20 billion figure over four years. In addition,
across the public services, a pay freeze in the first two of those
four years has been agreed. That, in itself, will deliver something
approaching 10% of the overall savings that are required. I have
made it clear, and we set it out in the spending review, that
we would reduce in real terms the total administration costs of
the NHS by £1.9 billion by 2014. That will deliver 10%.
You are aware, and you said in your report,
that there are continuing requirements for efficiency savings
through the operation of the tariff. I won't go on at length now
about how we can further develop and improve payment by results,
but one of its purposesonly oneis to deliver continuing
efficiency gain and productivity gain in the hospital sector.
That is probably equivalent overall to between one third and 40%I
think it is between £7 billion and £8 billion of the
total £20 billion savings. How that is achieved will vary
from place to place. The point of the QIPP process is to equipif
you'll forgive the punpeople working in health care services
with a substantial range of opportunities as to how they can do
that. I am sure that you will have looked at the QIPP website,
for example, for the breadth of ideas on how the service can improve
productivity, reduce cost and improve quality. The Better Care,
Better Value programme is already achieving that. It's true to
say that, at the moment, in this year the hospital sector in the
NHS is achieving, on average, 3.5% efficiency savings. We are
looking for that to rise to 4%. The sector is doing that while
sustaining quality and, in many respects, improving the quality
of what is being provided.
I think your report did say this, but the critical
area beyond thatthat needs to be done, but beyond thatis
the achievement of improved services in primary care through improved
commissioning and community services. Of course, the reform process
is central to that. I don't think that, in the past, we've achieved
what was possible in terms of improving the management of long-term
conditions and the development of community services. It's not
just access to services for people in the community; it's their
ability to have the right care at the right place at the right
time, as well as reducing avoidable and unnecessary hospital admissions
and high-cost procedures, and so on. In the QIPP process, that
is a substantial part of what needs to be done, and I think the
development of GP-led commissioning consortia is central to that.
One of the criteria that all the pathfinder consortia were asked
to meet when coming forward in the first wave was that they were
already engaged in developing that.
Q496 Valerie Vaz:
I am really sorry to interrupt you; I know that time is short,
and I am trying to keep my questions as brief as possible. Did
I understand you correctly when you said of the £15 billion
to £20 billion Nicholson challenge that nothing had been
delivered yet, nor is it intending to be?
Mr Lansley: Well, the point is
Q497 Valerie Vaz: Is that yes
or no?
Mr Lansley: You can either have
a proper answer, or you can have a yes or no answer. The answer
is
Q498 Valerie Vaz: Is that not
a proper answeryes or no?
Mr Lansley: It was only ever intended
to start
Q499 Valerie Vaz: You either know
or you don't know.
Mr Lansley: The point is that
it was only ever intended to start on 1 April 2011. That does
not mean that in 2010-11 there is no efficiency gain.
Q500 Valerie Vaz: But I
thought you said the QIPP process was getting it going. You said
it started under the previous Government.
Mr Lansley: But if you want a
formal answer to the question, "Has it begun?", no,
technically it has not begun. It starts on 1 April 2011.
Q501 Valerie Vaz: So let's move
on to the cost of reorganisationthe Lansley challenge.
I have tried a number of times to ask you this question on the
Floor of the House. Do you have a figure for the cost of the White
Paper reorganisation?
Mr Lansley: When we were here
last, we said two things. First, we said that we know that there
are certain associated costs, not least with redundancy and the
reduction of management inside the NHS, and that that is nearly
£900 million. We know that the recurrent savings to the NHS
are such that that cost is more than recouped within two years,
and subsequent recurrent savings flow from that. To that extent,
we have made that clear. Beyond that, there will be further costs,
but they will be reflected in total in the impact assessment that
we publish at the time of the Bill's publication.
Q502 Valerie Vaz: Okay, pretend
I'm stupidand I am this morning because I woke up really
earlybut just give me a figure. Other people have put it
between £2 billion and £3 billion.
Mr Lansley: I don't recognise
that figure.
Q503 Valerie Vaz: So what figure
do you recognise?
Mr Lansley: As I said, we will
publish an impact assessment when the Bill is published.
Q504 Valerie Vaz: But surely you
must know now.
Mr Lansley: We will publish an
impact assessment. I am not going to publish a single figure now
on the basis of
Q505 Valerie Vaz: You must have
a clear idea of how much it will cost.
Mr Lansley: I have a very clear
idea, but I will publish an impact assessment when the Bill is
published.
Q506 Valerie Vaz: How do you knowyou
are asking people to make savings, and you don't know what the
figure is?
Mr Lansley: I'm not asking people
to make savings on the basis of that figure
Q507 Valerie Vaz: You are.
Mr Lansley: The QIPP programme
is asking people to make savings. We are very clear about the
reduction in management costs that we are looking for, and we
are very clear about the policy and the basis on which people
will make progress. Once the policy has been published, the task
of the Department is to publish a full impact assessment that
looks at all those impacts and measures them. And we will publish
that when the Bill is published.
Q508 Rosie Cooper: So when will
we get the Bill?
Mr Lansley: It will be introduced
in January.
Q509 Rosie Cooper: It will definitely
be introduced in January.
Mr Lansley: A written ministerial
statement today says that we plan to introduce it in January.
Q510 Mr Virendra Sharma: After
how long will you give us the figures?
Mr Lansley: I intend to publish
an impact assessment when the Bill is published.
Q511 Valerie Vaz: Just going on
to something very important, I know that people do not like the
National Audit Office, but there is an obligation
Mr Lansley: Who doesn't like the
National Audit Office?
Q512 Valerie Vaz: I have heard
on the Floor of the House that people think thatwell, it
has been abolished anyway.
Mr Lansley: No, that is the Audit
Commission, which is going to be abolished.
Q513 Valerie Vaz: Oh, yes; sorry.
Well, yes, it's going to be abolished. So there is a duty
Mr Lansley: I actually have the
greatest respect for the health work of the National Audit Office.
Q514 Valerie Vaz: Can I finish
my question? You always interrupt me. I'm sorry; I hope I don't
interrupt you, but we don't often get a chance to talk like this.
There is a duty, and I think it's clear that this is a significant
reorganisation of the health service, isn't it?
Mr Lansley: It is a significant
reorganisation in the management of the health service, yes.
Q515 Valerie Vaz: A significant
reorganisation with £80 billion going to GPs, and there wasn't
actually an electoral mandate for that, but anyway.
Mr Lansley: Sorry, am I allowed
to interrupt you?
Q516 Valerie Vaz: No, you're not,
until I have finished my sentence. Have you actually presented
anything to Parliament indicating what the outcomes will be in
terms of the positive outcomes of the reorganisation, so that
there can be some sort of measure?
Mr Lansley: Two things. First,
I have explained to the Committee previously that the shape of
the NHS reforms was indeed the product of the coalition coming
together and bringing together with benefit to the reforms overall
our Liberal Democrat colleagues' intention that there should be
stronger democratic accountability in the NHS. I think we have
not only incorporated that, but used it positively to engage local
authorities more fully strategically in integrating health, social
care and health care. That is very much to the benefit of the
reforms overall.
Strictly speaking, from the Conservative party's
point of view, it is not true to say that there is no electoral
mandate for GP-led commissioning consortia. There is an explicit
mandate set out in our manifesto to do that.
Q517 Valerie Vaz:
It's not a Conservative Government; it is a coalition Government.
Mr Lansley: No, no; I did just
say that. The reform process as a whole combines elements of what
we said in our manifesto and elements of what the Liberal Democrats
said in their manifesto, and indeed the working out of those collectively
differs from those two component parts.
Valerie Vaz: Okay,
in terms of the National Audit Office.
Mr Lansley: In terms of the outcomes,
from my point of view, the outcome that matters is the outcome
for patients. We have already made clear in The Operating Framework
how we want to see further improvements today for the next year
in some aspects of the priority quality of services for patients.
We will set out before Christmas the draft outcomes framework,
which we hope, in 2011-12, will be a basis on which the NHS begins
to orientate progressively towards those results. From the point
of view of how the commissioning consortia interact with that,
we will need to go through a further process of consultation as
to how this structure of outcomes for the NHS as a whole is also,
in particular, related to a structure of outcomes that supplements
what is in the quality and outcomes framework for general practice.
Q518 Valerie Vaz:
So you didn't present it to Parliament, and we don't have the
benefits by which we can measure how good it is.
Mr Lansley: We published a draft
Valerie Vaz: I mean, it may be good.
The Lansley challenge may be good; we don't know. But is there
anything we can measure it by that has been presented to Parliament?
Mr Lansley: As I say, The Operating
Framework sets out some specific intentions in terms of continuing
improvement in the service to patients. The outcomes framework
we will publish before Christmas will go further in that direction.
Chair: Can I interpose in this dialogue?
Mr Morris.
Q519 Grahame M. Morris: Thank
you very much indeed, Chair. Arising out of those questions that
my colleague has just asked in relation to the documents that
have been published on The Operating Framework and your
earlier statement, clearly huge organisational changes are being
implemented. There are concerns that that might have a destabilising
impact on the service, which in turn may well adversely affect
outcomes. I have heard it said that destabilisation of the system
is the enemy of reform and, clearly, it is not in anyone's interest
to see that happen.
We have seen reports as well, Secretary of State,
about the fact that Oliver Letwin has been drafted in and asked
to review the reform plans. We have heard reports that there are
mounting concerns at the Treasury, and possibly in Downing Street,
over the implementation. I would be interested in your views on
what Mr Letwin's role is and what impact that's likely to have
in terms of the timetable and the plans that are before us.
Mr Lansley: Well, Oliver Letwin
is the Minister for Government policy. This policy is one of the
most significant and hopefully most beneficial and impactful of
Government policies. So he is engaged in the process of the formulation
of Government policy; it would be surprising were he not. Today
we have published, in Liberating the NHS: Legislative framework
and next steps, a document on behalf of the Government that
sets out the Government's further intentions in relation to the
reform process.
Q520 Grahame M. Morris: Is Mr
Letwin's appointment, or the announcement of his appointment and
the work that he is doing in relation to the health reforms, significant
at this stage?
Mr Lansley: I'm sorry; I'm not
aware of any announcement.
Grahame M. Morris: Well, it was a report
in the Financial Times on 30 November.
Mr Lansley: Oh I see. Ah, so that
won't be an announcement, then?
Valerie Vaz: Well, you didn't announce
anything else.
Mr Lansley: When we shape Government
policy, we do it collectively. I seem to be in a position where
on the one hand people are saying, "Oh, but it's the Lansley
challenge." It's not; it's the Government's challenge. It's
not me alone; it is the Government, together. We are not only
a coalition Government
Q521 Valerie Vaz: The Prime Minister
said he didn't want any reorganisation.
Mr Lansley: We made it very clear
that we weren't going to have a major top-down reorganisation.
That was not our intention. But actually when we looked as a coalition
at how we could deliver in all these circumstances the reforms
that were required, including the authority and the responsibility
in the hands of clinical leadersand with our Liberal Democrat
colleagues genuinely empower local government in a way that we
hadn't, from our point of view as Conservatives, intended originally
to doI think that strengthened the process. I think it
strengthens the reforms. The response from local government to
the White Paper has been overwhelmingly, almost without exception,
very positive both in relation to the public health and their
role in NHS commissioning. It has taken us to a new place.
It is very easy to overstate the impact on the
NHS. When you think about people working in general practice,
community services or hospital services, the processes of NHS
reform that impact on them are processes that already existed.
It is just that we are making them consistent and impactful where
they weren't before. Practice-based commissioning existed, but
it didn't really have the benefits or the impact it was intended
to have. We are going to make that happen. Transforming community
services was a process started under the Labour Government, but
we are going to make it happen. The translation of all NHS trusts
into foundation trust status was something that was announced
by a Labour Government in 2005 and was intended to be implemented
by December 2008. We are going to make it happen.
I make no bones: there is a reorganisation of
the management of the NHS. That, frankly, would have had to happen
anyway. When you look at the finance of the NHS, we cannot carry
on spending £5.1 billion on administration. Some of what
Mr Morris says is destabilisation is, frankly, simply the inevitable
consequence of reducing the management overhead to the NHS by
45%.
Q522 Grahame M. Morris: It's rather
more than that, isn't it? The switch to GP commissioning as a
method of commissioning services is rather more than a tweak that
would have happened anyway. There is an argument for a more evolutionary
system in relation to the existing PCTs; this is quite revolutionary.
It was interesting yesterday; I was at the seminar
on cancer services, "Backing Cancer". It was very well
attended, with more than 350 delegates. Just as a bit of feedbackbecause
I am not sure whether you were present for the earlier sessionwhen
delegates, from a wide range of charities and specialist patient
groups, were asked whether they thought that the new commissioning
arrangements with GPs would assist in improving outcomes, I would
suggest that three quarters of them thought that it wouldn't.
I thought that that was quite significant. There wasn't any kind
of doubt in their minds. There is quite a job to do to persuade
people that it is going to improve outcomes for patients.
Mr Lansley: Well, perhaps I'll
ask my colleagues to add a bit on this. Let me just say, because
I was there to hear some of the sessionindeed, not all
of itand spoke to the Britain Against Cancer conference
yesterday, that I have been to those conferences previously and
one of the central issues, including the report of the National
Audit Office, was that cancer services suffered not least from
weaknesses in commissioning. So we are not in the place we need
to be. We are not in the place we need to be in terms of outcomes
for cancer, and I won't go on about that, but I was actually very
surprised at people there yesterday. Positively, they said that
they overwhelmingly supported the focus on outcomes and the structure
of the outcomes framework that is in the White Paper. They clearly
don't understand how the clinical leadership of general practice
coming together locally can actually give us a stronger place
in terms of managing care on behalf of patients, including cancer
care. I think they understand that specialised commissioning is
the responsibility of the NHS Commissioning Board. It is worth
my colleaguesBarbara first, then Davidspeaking about
how GPs, collectively, can improve the quality of commissioning.
Dame Barbara Hakin: I've gone
round the country talking to a lot of patient groups and other
stakeholders about the changes. One of the things that struck
me, perhaps, is the misconception about how the system worked
before, which actually makes some of this look more radical. I
think that people did not understand that primary care trusts,
which are based on primary care and have clinicians involved as
part of them, actually received the vast majority of the funding
for all NHS services, and that those organisations were responsible
for working together and not only doing the clinical design of
services, but then going on and contracting them. So I think that
there are a lot of people who have been anxious because they felt
that the money went directly to the hospitals and that now it
is going via the GPs.
I have talked to a lot of people who have that
view, particularly patient groups. They start to understand that
this is just a more clinically oriented way of doing things with
the people who will be more responsible. GP consortia will have
really strong and good managers supporting them in the same way
that PCTs had good clinicians helping them. The clinical leaders,
who understand the needs of their patients, will have much more
of a say in the clinical design of those services and the pathway
from primary care to secondary care for patients with all sorts
of conditions.
Q523 Grahame M. Morris: I don't
necessarily agree with your analysis. Yesterday, I participated
in the all-party cancer group, where it was identified that in
2007 the cancer strategy made a quantum leap forward with the
design of the clinical pathways, the establishment of the cancer
care networks and so on. We were moving along the right track.
This isn't a conversion on the road to Damascus; the general consensus
is that we were moving positively in that regard. There is an
acceptance that, generally, the outcomes are not as good as they
should be. I accept that, and there is work for the Committee
to do on that.
Mr Lansley: The truth of the matter,
and we know it, is that in the period since the introduction of
the cancer reform strategy, important and beneficial as the improvements
have been, the improvement in cancer survival rates in this country
is still no different in trend terms than that which preceded
it, and it is no better relative to other European countries than
in the past. To that extent we need to close the gap in terms
of outcomes, and we know that there are a number of things that
we need to do.
I have talked to the Committee about the cancer
drugs fund, but, as I said yesterday, we also have to be much
more aware of the signs and symptoms of cancer. We have to be
much better at early diagnosis and have much better access to
treatment at an early stage. Yesterday's meeting of the all-party
parliamentary group significantly understated the importance of
general practice in doing that.
Taking one example, lung cancer, when I have
talked to lung cancer physicians, as I have done at Papworth in
my constituency, they feel very strongly that there is a difference
in practice between, for example, ourselves and France. The point
at which patients are referred to X-ray or other scans for signs
and symptoms of cancer is, on average, significantly earlier in
France than in this country. The essence of that is changing the
practice in the community and having people identifying those
symptoms. General practitioners can make an enormous step forward
in educating their patients and making such referrals at the right
time.
Dr Colin-Thomé: Could I
just say two things? One of the reasons for the poor outcomes
in this country is the delay between symptoms and diagnosis, which
is longer than most and has a big effect on outcomes. That may
be about the public's awareness, but it may also be that primary
and community services require better access to diagnostics to
improve. The second point is that you can't give all of the credit
to commissioning, because those were national strategies and the
national directives are still continuing with those guidelines.
We are still doing poorly in cancer outcomes,
despite our improvements, and for care of the elderly we are actually
going the other way; we are getting worse. As some 70% of people
with cancer are over 65, that is an indictment of our present
system, which isn't doing the trick. We need to have a much greater
clinical focus. We have a lot to do, despite the improvements,
most of which came from central approaches, rather than local
commissioners.
Q524 Grahame M. Morris: I don't
want to drive the agenda away, but I want to make one point that
came out of yesterday's conference, particularly from patient
groups. GPs are perhaps diagnosing, on average, eight or nine
cases a year. So there are issues there that need to be seriously
addressed.
Mr Lansley: I think that, strictly
speaking, they said that on average there are 250,000 new diagnoses
of cancer a year and there are 35,000 GPs. So there will be some
eight new diagnoses per GP across the country; it is not that
they necessarily make the diagnosis. The point we were making
yesterday was that, on average, those GPs might see 200 patients
who have potential signs or symptoms of cancer. To that extent,
it is the response to those signs and symptoms that is most significant.
Dame Barbara Hakin: Can I make
it very clear that GPs will be the co-ordinators of commissioning
and all clinicians will be involved in the clinical pathways?
This is not about GPs determining the clinical aspects of the
complexity; it is about GPs using their relationships with their
colleagues and using their clinical skills to bring that together
in a much more clinically based system.
Chair: I am conscious that we are trying
to get away for the beginning of Question Time at 11.30. We have
an hour and a half left, and we haven't yet started seriously
questioning the commissioning structure. Rosie wants to come in,
and then I would like to move on.
Q525 Rosie Cooper: Could I go
back to what Dame Barbara said about talking to patient groups
about the scale of change? You imply, and the Secretary of State
is reported to have implied, that concerns over time scale are
exaggerated. As you just said, Dame Barbara, people woefully overestimate
the scale of change, because practice-based commissioning, choice
of provider, NHS price list and foundation trusts already exist.
If that is all so exaggerated, why, after seven years, have so
many NHS trusts that have got off to a flying start compared with
the consortia that you are trying to establish in a very short
time scale not become foundation trusts? If you have all the building
blocks and they can't do it in seven years, how are you going
to get commissioners off the
Mr Lansley: To be fair, Barbara
is responsible for commissioning development and the question
you ask is about the development of provider services within the
NHS. We are shaping ourselves in the Department in relation to
the future in the same way as we are asking people to do throughout
the country, and that is divided between the provider services
and the commissioning services. Barbara is responsible for the
development of commissioning services.
Let me answer that. You're right: in 2005, a
Labour Government said that every NHS trust should be a foundation
trust by December 2008. That did not happen. There were a number
of reasons for that, but some of them were policy reasons. The
foot literally came off the accelerator and in 2009 it went on
the brake. You can see more than 20 FTs going through the pipeline
year after year until 2009, and then suddenly it was a handful.
We have restarted the pipeline and are working hard on it. There
are about 120 existing NHS trusts. To some extent, we are adding
to the number of NHS trusts, because community services are turning
into NHS trusts, so the numbers will be slightly misleading. None
the less, we have about 120 NHS trusts. I wrote to the chair of
every NHS trust in late September and asked them all to respond
to me by the end of November with their own timetable, milestones
and challenges in moving to foundation trust status. We are working
through that, but I can tell you, roughly, that at least a third
of those are clear about the timetable and will do it. They are
confident that they will be able to do so before 2014; some quite
quickly.
Another third feel confident that they will
be able to do that, but they have specific challenges that they
need to meet. They will come through towards the end of that period,
because we need to tackle those. There is probably another third
where we need to make significant changes in the configuration,
management or functioning of those NHS trusts in order to make
that happen. I won't, for reasons of time and otherwise, go into
detail about how we will do that, but much of it is literally,
I promise you, about facing up in individual NHS trusts to problems
that have been allowed to go on for too long.
Q526 Rosie Cooper: So why do you
not think you are going to face that sort of scale of problem
with consortia? Why do you think you will just drive it through?
Mr Lansley: Well, consortia are
a completely different point. I think that the essence of the
development of consortia is that people talk about commissioning
as though it is something that GPs collectively don't currently
come together and do. They do do this.
Rosie Cooper: Of course they do.
Mr Lansley: So why would they
not be able to? Frankly, there is a whole range of support available
to the new commissioning consortia as they establish themselves.
We will assign staff to the consortia from within primary care
trusts to enable them to establish themselves. They can seek to
use existing primary care trust staff. From our point of view,
there is absolutely no intention that the reduction in staffing
in primary care trusts should be so widespread that it excludes
managerial and expert staff in primary care trusts from continuing
to be responsible, but within the context of clinical leadership
rather than managerial control.
Q527 Rosie Cooper: So you would
say that the NHS is not facing its Ark Royal moment where you
have taken a calculated risk that leaves the NHS without air cover
and, I believe, risks the financial stability of the system. At
this crucial time, what are you doing? You are making massive
reductions in management costs. People are leaving all over the
place. You have your headlines of train wrecks et alsomeone
else is going to ask about that. There is grave concern that you
expect this to be driven through by people who aren't there.
Mr Lansley: I don't think that's
true for a minute. This is Barbara's responsibility, so she might
like to add to this, but make no bones about it, we intend to
reduce the number of management staff. We have been clear. We
talked to you before about the mutually assured resignation scheme,
and I think 2,200 staff have left under the scope of that scheme.
Because we published the Command Paper today and The Operating
Framework, it will also enable Sir David Nicholson, Barbara
and their colleagues to make clear how the transition is to be
managed. David will issue a letter to the service alongside The
Operating Framework that helps on that and the human resources
consequences.
Essentially, it means that there are staff who
will leave, and we accept that they will leave. That will enable
us to reduce the overall administration cost, the management cost
and the number of managers. The number of managers in the NHS
has been declining since earlier this year, and it is declining
at a rate of some 600 or 700 over the course of the past six months,
which will continue.
We will, however, maintain the quality-critical
and service-critical staffing. We will maintain them through the
PCT clusters so that we don't have to have 152 teams all over
the country. We will create space for the GPs. That will allow
us then to assign staff to support the commissioning consortia.
There are many staffyou should not underestimate the extent
to which there are staff and leaders inside primary care trusts
who see their role in future as being alongside the GP-led commissioning
consortia, with management, yes, but with clinical leadership
and management working together rather than the separation between
clinical decision making and managerial decision making that has
so characterised the service in the recent past.
Q528 Rosie Cooper: A very final,
quick statement; almost yes or no would be okay. What you are
saying is that you can provide assurances that changes to management
arrangements at strategic health authorities and PCTs won't lead
to increased financial difficulties and that, for example, waiting
times will be as good as they were when the coalition Government
came into power.
Mr Lansley: Well, I encourage
you to look at The Operating Framework, which is absolutely
clear.
Q529 Rosie Cooper: Waiting times
won't increase?
Mr Lansley: The Operating Framework
is absolutely clear that the service will not only maintain financial
control, but continue to improve measures of service.
Q530 Rosie Cooper: Waiting times
are currently increasing all over the place. How can you give
that assurance?
Mr Lansley: Have a look at The
Operating Framework. It talks about continuous improvement,
including in waiting times.
Q531 Rosie Cooper: But the fact
is that waiting times are increasing nowtoday.
Mr Lansley: No, they're not.
Rosie Cooper: Yes, they are.
Mr Lansley: No, they're not.
Q532 Rosie Cooper: The evidence
is that that is true.
Chair: Evidence can't proceed on the
basis of, "Yes, they are," and, "no, they're not."
Mr Lansley: We have published
the data.
Rosie Cooper: The patients you're supposed
to be listening to will tell you it is increasing.
Q533 Andrew George: We had previously
agreed an orderly process of questioning, and we seem to have
lost that to a certain extentthat is not a criticism of
you, Chair, I hasten to add.
The role of Parliament ultimately, when the
Bill comes before us next year, in making the big decisions about
proceedingor potentially notand deciding whether
there should be any amendment to the Bill as it is presented,
is clearly going to be critical. In that regard, what we have
before us is a product of a White Paper so far, leading to a Bill
that has been variously describedby you as a logical reform.
I think it is acknowledged as a challenge, and we have also had
reference to one PCT chief executive referring to it as a "bloody
awful train crash" about to happen. I'm sure you know about
that particular chief executive and he's not alone, which I think
is the important pointwe are not talking about someone
who is talking alone. Certainly, evidence to this Committee, suggesting
that that is widely reflected, is that it will inevitably cause,
as he claims, organisational upheaval and staff demoralisationI
think that has been coveredand it will also undermine the
focus on patient care and financial control. In respect of that,
how do you respond to the fear that this will result in some awful
catastrophe about to happen as a result of having to save lots
of money and achieve efficiencies, while at the same time going
through very significant reorganisation?
Mr Lansley:
Well, I think it would be sensible for Barbara to add, but, from
my point of view, I of course never expected that when we make
changes, and in particular when we make changes that involve a
reduction of 45% in the number of managers and senior managers
in strategic health authorities and primary care trusts, those
senior managers would all express themselves delighted at the
prospect. It would be unreasonable to expect that to be the case.
What I would simply say to you is that Sir David
Nicholson and his colleagues in the NHS have set out very clearly
how we can manage the transition effectively. There will be people
who don't want to be a party to the management structures in the
future, and we will make arrangements for them to be able to leave,
which would be part of the overall reduction in management cost.
There will be many others, however, who want to be part of that
transition. I think that Mr Creighton, who said those things,
wants to be part of the transition. He wants to be chief executive
of one of the north-west London PCT clusters. There are others
who actively and positively want to be part of the new shape of
commissioning in the future, and we will make arrangements for
them to be able to do that, too, through assignment and the commissioning
consortia having a financial allowance to enable them to take
on some critical staff to enable that to happen.
What I would just say to you is that I have
visited a number of the pathfinder consortia. There is energy
and enthusiasm among not only GPs, but the whole staff, including
often the primary care trust staff who are working with them to
make that happen. This is true. You can go to Cumbria, and Sue
Page is working with the GP consortia to make it happen. You can
go to Bexley, as I did last week, and Anthony McKeever and the
PCT staff are critical to making this happen. The energy and enthusiasm
being generated in those places where the new consortia are being
established is, in my experience, far in excess of the energy
and enthusiasm for commissioning that was generated inside primary
care trusts.
I have to sayI'm sorry, but it is a simple
truththat there is a world of difference between clinical
leadership and a focus upon how we can deliver improving care
for patients, and the enthusiasm that is generated by people being
given the freedom and the authority to do that, as distinct from
people who are going through what is essentially more of a managerial
and bureaucratic process. The allying of those resources and responsibilities
to this clinical enthusiasm for delivering positive change is
instrumental in making commissioning work more effectively.
Q534 Chair: The Committee visited
Hackney yesterday, which, as I understand, isn't a pathfinder
consortium, but there was similar enthusiasm for the process.
Other issues will arise as well.
Mr Lansley: Barbara and David
will have seen many other examples.
Dame Barbara Hakin: Absolutely.
I would like to refute the reflection of what I said earlier.
I said that we need to ensure that we help the public, stakeholders
and patients to understand what exactly is happening in the reforms,
but, in terms of the management through the transition, this is
a significant transition period for management change. It would
have had to have been that level of change, because we are reducing
management costs, and we have to find a great deal of money actually
to improve outcomes for patients without an enormous uplift in
the NHS budget and with ever-increasing need.
In order to do that, The Operating Framework
and David Nicholson's transition letter will make it clear that,
in forming PCTs into clusters and in the way that we work with
PCTs to take us through from the middle of next year through to
13 April, when the new system is much more established, we will
actually have a much more robust system working through the cluster
units and on to their PCTs. I think that the PCT chief executive
in question has subsequently said that he feels that his words
were ill chosen to relay what he meant, which was that it was
absolutely necessary that we create a transitional infrastructure
to ensure that we have really good grip through that period.
Dr Colin-Thomé: Can I just
say quickly that you will always get siren voices whenever there
is change? Of course, this particular group feels more embattled.
You don't get that much noise from clinical areasincluding
not only GPs but othersabout the demise of PCTs. There
are plenty of PCTs, as Andrew has said, which have been very positive
about the changes, as we have described, because I have also been
to other places around the country such as Tower Hamlets, Cambridge
and Peterborough. Those have been doing it already, so you would
expect the odd siren voice.
If you look, for instance, at your waiting times,
we have always driven these in the past by top-down, 18-week programmes,
and so on. However, if you could engage all clinicians, including
primary care who are often not involved, most of the care that's
done with our patients could be done completely differentlyclinically,
rather than a top-down approach. There are something like 40 million
follow-up appointments a year, which doesn't seem to be the best
use of resources. Those redesigns will tackle some of the targets,
because of clinical involvement rather than some mechanistic top-down
approach to some of these changes.
Chair: Mr George has a follow-up question.
Q535 Andrew George:
Yes, it's a follow-up question to the question about it being
Parliament which will decide, because the Bill will come before
Parliament. The issue is that a lot of this change is already
happeningthe pathfinders have already been announced. The
Bill will be coming before us towards the end of January or February,
and then it will be scrutinised by Parliament. Parliament will
be making its decisions after the event. On most of the decisions,
it will be a trainwhether it is a crash or not is a debating
pointthat has already left the station and is way down
the track before Parliament has the opportunity to begin the process
of expressing a view.
On this issue, it is quite important to note
that, Secretary of State, you say that the Government are making
these decisions collectively. Well, collectively, they went into
the coalition agreement saying that there would be no major top-down
reorganisation. That is precisely what this is, and therefore,
it should be subject to significant parliamentary scrutiny. That
scrutiny should be ahead ofinstead of afterthe event
itself, particularly in relation to the geographical upheaval
in terms of the boundaries. I don't think anyone has any love
for the quangos themselvesthe PCTs, the unelected boards.
Putting it in the hands of clinicians is fine, but only one sector
of clinicians will be driving this commissioning process. There
are a lot of debating issues, but we as a Parliament will be invited
to take part in the debatein spite of the scrutiny nowvery
much after the event.
Mr Lansley: I think that the criticism
would be valid if we were not, in truth, taking what is essentially
an evolutionary process at the moment. We're not actually anticipating,
strictly speaking, in any sense the introduction of the legislation;
we are reorganising primary care trusts under existing legislation.
Q536 Andrew George: But the pathfinders
have been announced. The train has left the station.
Mr Lansley: With delegated powers
under existing legislation, we are creatingand I think
we will demonstratethe opportunity for the development
of general practice-led commissioning. That willI hope
and I thinkdemonstrate how the general practice-led commissioning
consortia can take responsibility, improve commissioning and improve
the services for patients. We are doing that under existing powers.
Of course, under existing legislation, if we went down that path,
we end up trying to have all three things: strategic health authorities,
primary care trusts and the GP commissioning consortia. That was
why we ended upI was very clear, so I won't repeat what
I said beforewith what was effectively a managerial reorganisation
of the NHS. I don't think that it is a reorganisation at the front
line, but it is a managerial reorganisation in order to empower
the front line.
We had to make a decision about that but, strictly,
Parliament will make a decision on whether to leave all these
bodies in place or to accept, which I believe Parliament will
do, that it is better to devote resources to supporting the front
line. It is better to give more responsibilities to local authorities
for democratic accountability than to leave them with unelected
primary care trust boards. The Liberal Democrat manifesto proposed
the abolition of strategic health authorities, and we are proposing
that in the legislation. These are things that I think will be
the consequential decisions made by Parliament, not least because
we are demonstrating, over the course of the coming year, how
the new shape of commissioningand provision, for that matteris
capable of achieving benefits for patients in the future.
Q537 David Tredinnick: Apropos
train crashes, I am sure that we are all hoping that we will see
the light at the end of the tunnel and not the headlamp on the
express train as it comes towards usthat's the old joke.
I would like to ask you a few questions about
PCT clusters and commissioning, but, if I may, I want to pick
up on something that you said earlier. You're very keen on the
devolution of commissioning, but is there not a contradiction
here in that you've got this Commissioning Board that will be
more powerful than any other commissioning board we've ever had?
Do you think that's a fair statement?
Mr Lansley: Of course the NHS
Commissioning Board has considerable powersand necessarily
so. In a national health service, we need clear national standards
and there needs to be a body that holds the contracts with the
individual practices across the country, and that would be the
Commissioning Board's responsibility. GPs themselves take the
view that this is the right way for it to happen. Strictly speaking,
does it have more power than the Department of Health under the
current system? No, of course not, because the Department of Health,
as things happen at the moment, pretends that there is devolution
of responsibility in different places across the country, but,
strictly speaking, it can control it all.
Q538 David Tredinnick: On the
PCT clusters, which are comingthis is going down to the
devolved partis there not, in a sense, a safety net as
the primary care trust organisation dissolves? Some parts of the
country may lose a lot of employers. Is it not, in a sense, a
circle of wagons to ensure that you can get through this phase
in some sort of shape?
Mr Lansley: If I may say so, I
think that that is an entirely negative way of seeing what we
regard as a very positive way of approaching this. We're managing
organisational development by concentrating resources in primary
care trusts, so that the management resource is effective at delivering
financial and quality control, while creating space. That is space
in terms of resources, commissioning responsibilities and budget
management, so that the commissioning consortia can establish
themselves.
Q539 David Tredinnick: Yesterday
at Hackney, I got the impression that there were savings that
could be made through restructuring, certainly in the primary
care trust areas. At the end of the transition period, do you
think the clusters are going to be redundant? I think Sir David
said that at the end of the transition it would be a matter for
the Commissioning Board, "because the board get them from
1 April" 2010I am quoting him exactly.
Mr Lansley: 2012. The clustering
of primary care trusts is a transitional measure. Subject to the
approval of Parliament, primary care trusts will be abolished
on 1 April 2013. We intend to establish the NHS Commissioning
Board in shadow form during 2011, so, to that extent, the primary
care trust clusters will be a basis on which the NHS Commissioning
Board exercises its responsibilities as part of the transition.
From 1 April 2013 onwards, the NHS Commissioning Board will be
able to make its own decisions on how it manages its relationship
with commissioning consortia across the country.
Q540 David Tredinnick: Going back
to my safety net, isn't the reality that the board could quite
conveniently say, "Actually, we're not going to dismantle
this framework", so you'll still have a primary care trust
skeleton report network going up to the Department? They won't
be disposed of and, probably, quite rightly, because you've got
a lot of skills there. The second part of my question is, are
they going to be able to support these new GP consortia? Is there
not a role for them to provide support services to doctors who
really don't want anything to do with administration?
Dame Barbara Hakin: Absolutely.
The clusters are a transition vehicle and a way in which we can
both support the GP consortia and also support the NHS Commissioning
Board as it comes into being. PCTs are currently accountable to
strategic health authorities, which will be abolished and disappear,
and then all PCTs for the year of 2012-13 will accountable to
the NHS Commissioning Board. By that time, the NHS Commissioning
Board will, through the creation of clusters, have a more appropriate
way to relate to PCTs.
The board at that time will have to determine
how it chooses to discharge its functions. Obviously, some of
its functions are national and are done once, but some of its
functions are about relating to consortia. Some of its functions
are the direct commissioning that it undertakes itselfsay,
of primary care. After it's formed, the board can determine what
shape it needs to best discharge those functions.
The clusters will be there, in the board's early
days, to ensure that we have the rigour and grip that we need,
but it will be for the board then to choose whether the cluster
shape and the cluster distribution is something that it would
want to use for the future. That will hugely depend on the size
of the consortia, of course. Until we see the size and shape of
the consortia, it will be very difficult for the board to determine
what's the right shape for it.
Q541 David Tredinnick: You talk
about the board choosing. Sir David, when he came before us, said
that there would be a need for central Stalinist controls during
the transition period, and he didn't sound like a very consensual
individual. I got the impression that they were going to be told
to get on with it. Do you think that's fair? "Stalinist controls"
was the phrase he used.
Mr Lansley: If Barbara wouldn't
mind my adding to her comments, from my point of view, we have
always been very clear, and clear with the Committee, that during
the transition, we are going to create space for the GP-led commissioning
consortia to establish themselves, and give them support to do
so and engage them directly in improving quality and delivering
on the challenge in relation to quality, innovation and productivity.
But at the same time, we have to maintain financial control. We
are asking the NHS, notwithstanding a 3% increase in cash next
year, to enter a period during which the increases in resources
for the NHS are not what they have been previously. We are entering
a period when there is going to have to be continuing improvement
in the quality of service in a time of financial constraint. To
that extent, we've always been very clear. There is a combination:
the service will experience tight controls of financial management
and performance management, while at the same time building the
capacity of the front-line commissioning consortia effectively
to take over responsibility.
Q542 David Tredinnick: So we've
got the Nicholson effect; we've got the Letwin effect; and now
we've got the Joseph Stalin impact. Is that right?
Mr Lansley: The Committee seems
very keen on attributing names to these things. It is the Government's
policy, and the Government are collectively responsible for it.
Q543 David Tredinnick: I have
one last serious question, which is about the strategic health
authorities' role. The White Paper says the SHAs have "a
critical role during the transition in managing finance and performance",
but they are to be abolished in 12 months, before the new system
is operational. Why is this, and which body, if any, will take
on this role in 2012-13?
Dame Barbara Hakin: The NHS Commissioning
Board will come into being as the SHAs are abolished and will
take on responsibility for overseeing the PCTs, which will be
accountable to it, and the growth of the consortia during the
year, at the end of which PCTs will be abolished. The final state
is a devolved situation with a lot of local leadership and freeing
up of the front line to make the changes that we know it wants
to make, but it is clear that as you go through the transition,
it is really important to be very clear and to have clear direction.
That was what Sir David was sayingparticularly over the
next year, we need to be very clear about how the system operates
in the transition in order to put the NHS Commissioning Board
and the new structures in the right place when they come into
being in 2012.
Mr Lansley: And, to be fair, the
enthusiasm of the GP commissioning consortia is very much focused
on being able to engage with clinical services, being able to
design services and being able to improve services. They have
a concern, which we completely understand, in that they don't
want to be in a position where they are given control of finance
at a point where they can't understand the nature of what they're
commissioning and how they're commissioning it, and where they
can't shape it, they can't shape the contracts. From the general
practice point of view, the process is to think about clinical
care and improve that, shape the contracts with providers so as
to be able to have the framework of commissioning that you're
looking for, and then put a financial control mechanism alongside
it. We're trying to make sure that through the transition, they
are confident that that financial control mechanism is in place
and is available for them to see at the point at which they take
responsibility.
Chair: We will now have a short question
from Nadine and then go to Dr Wollaston.
Q544 Nadine Dorries: This question
is on the back of the SHA question and is probably for Dr Colin-Thomé.
Can I first say this to you: Liverpool, Runcorn1980?
Dr Colin-Thomé: Yes, I
was a GP in Runcorn.
Q545 Nadine Dorries: We knew each
other in a different life. This question is for you, then. Where
will Jim Easton's responsibilities for driving quality, innovation,
productivity and prevention reside? And will GPs be expected to
pick up the cost of this, particularly in terms of new technologies
and innovation?
Dr Colin-Thomé: Once the
NHS Commissioning Board is, it will have to decide who is going
to be within that board, including some of the QIPP work. But
if you look at the GP organisation, consortia and the pathfinders
we've put in place alreadyand there is more to comethat
redesign is at the basis of their enthusiasm. They feel that the
present structures have not allowed that enthusiasm to flourish
and reshape care, because it is clinicians and especially doctors
who spend the money, as I said before. The GP leaders have lots
of ideas, all of them, about how we can reshape care around the
varying lengths of stay we have in hospitals or the follow-up
outpatients, and the need to actually refer in the first place.
That fundamental reshaping will make a difference to financial
control. That is what QIPP is about. I think you will find that,
with GP leadership, they'll have a good vehicle out there that
maybe the present architecture hasn't been so good at.
Q546 Nadine Dorries: And will
the financial provision be available within that vehicle? Will
they be able to afford to do this?
Dr Colin-Thomé: If we are
going to be allowedas we are, and that's not just the 3%
growth but the fact that, whoever's challenge this is, we can
reinvest the £15 billion to £20 billionthen it
is up to us to release resources for that. The 3% growth, especially
if consortia and pathfinders are allowed to flourish as we think
they will, will mean that we can use that growth much more imaginatively
now. There is lots of money in clinical care, around ineffective
care, care of lower value and the way that we organise care, which
is hugely inefficient at the moment. Clinicians have never had
a vehicle, until now, to be able to challenge what we do and to
make it for the better. We will be able to release the money as
we go along, because we know there is lots of money that we are
not spending as appropriately now.
Mr Lansley: I understand that
you won't have had an opportunity to read The Operating Framework,
but if I could just draw to your attention that we are clear in
the transition that there will be a small allowance for the pathfinder
consortia during the course of 2011-12. Creating space will include
generating management savings through primary care trusts that
are available to the consortia.
We said in the revision in June that we will
set out how resources will be released from the infrastructure
and running costs of strategic health authorities and PCTs in
order to provide a running cost allowance for GP consortia. The
Operating Framework , in paragraph 5.16, goes on to say that
our "expectation is that GP consortia will have an allowance
for running costs that could be in the range of £25 to £35
per head of population by 2014/15. We will not determine the exact
amount until further work has been undertaken with pathfinders".
So we will use 2011-12 to identify what is required in order to
be the support for the commissioning consortia. I quote: "This
work will explore the optimal balance between insuring sufficient
investment in organisational sustainability with maximising resources
for front line services. Before this, during their development
phase, the running costs will be locally agreed within the running
cost envelope for each region."
Dr Colin-Thomé: And currently
in London, for instance, the idea of clustering PCTs has released
money to allow the pathfinders to have a bit of money, even now,
to develop the ways that we were talking about. I believe that
the clinical challenge of the way we organise our care will make
a significant difference, especially if those clinicians are helping
commissioning.
Chair: I am going to restrain Sarah,
if I may, just for one more time, because I know Chris wants to
come in on management first.
Q547 Chris Skidmore: I wanted
to bring that up. I managed to pick that up from The Operating
Framework. In a previous session, Kingsley Manning from Tribal
told us that he thought a maximum management allowance could work
on £5 to £7 per head. We have also known from previous
experience that primary care groups have operated on £3 per
head for a management allowance. Do you not feel that £25
to £35 is actually, in the words of Sir David Nicholson,
"remarkably generous and
that people will be shocked
by the size of it"? The Government are attempting to reduce
management costs
Mr Lansley: Sir David hasn't said
that about this figure.
Chris Skidmore: He has, on 18 November,
to the NHS Alliance conference.
Mr Lansley: No, no. This figure
is published in The Operating Framework, so he won't have
been referring to that then.
I understand the point you're making. There
is a fundamental discontinuity between the way in which people
have expressed the figure for management costs in the NHS, which
was used widely but actually only ever measured the salary cost
of managers and senior managers. What I am referring to is not
that management cost; it is a running cost total, so it is in
effect the total cost of administration of an organisationeverything
that is not the provision of services to patients. So, to that
extent, it is a different calculation.
At the moment, therefore, what are we comparing
with? What's the baseline? The baseline on running costs across
the Department, arm's length bodies, strategic health authorities
and primary care trusts is £5.1 billion. I'll happily let
you knowI think, broadly speaking, about £3.5 billion
of that would be the running costs of primary care trusts at the
moment. So the figure, the range that we've expressed in The
Operating Framework, is entirely consistent with bringing
the administration cost of commissioning down in exactly the way
that we previously said in the spending review.
Q548 Chris Skidmore: You don't
think it can be cut any further.
Mr Lansley: No, to be fair, the
point we've made in The Operating Framework is that we
set a range that is consistent with reducing the overall administration
cost very dramatically, from where it is with primary care trusts
at the moment; but the actual figure will be built up from the
bottom up, rather than top down.
Chris Skidmore: On that point, I see
in paragraph 5.17 that you've said that "in line with NHS
foundation trust reporting, NHS trusts will no longer be required
to report on management costs." Will GP consortia be required
to report on management costs?
Mr Lansley: On running costs,
yes, they will.
Q549 Chris Skidmore: And will
that be in part of the constitution?
Mr Lansley: The commissioning
organisations willbecause they are using public fundsat
every point in the system, on the commissioning side, in their
use of public funds have a running cost limit directly applied
to them. Hospitals, of course, have a budget to provide a service,
and it's up to them how they use their budget.
Q550 Chris Skidmore: But if they
undercut that limit will those figures be published annually?
I notice in your written statement you're requiring all GP consortia
to have a published constitution. Will that be part of that constitution?
Mr Lansley: Yes, as part of the
accountability, they will publish their use of resources, including
their running cost total for that year.
Dame Barbara Hakin: Plainly, if
they wish to use less on running costs and more on patient care
then that would be within their gift.
Q551 Chris Skidmore: The discrepancy
between someone like Tribal, saying they could do it for seven
quid a head, compared to
Mr Lansley: I think, to be fair
to Tribal, when Kingsley Manning was saying that to you he would
have been using the comparison with management costs that was
used in the NHS, not the total running cost.
Chair: Sarahmuch delayed.
Q552 Dr Wollaston: Yesterday,
we visited City and Hackney NHS at the Lawson practice and met
a number of commissioners and other representatives from the PCTs.
There were several issues that they raisedin fact, four
that I think are crucial. I'd just like to run through some of
those until the Chair loses patience with me.
The first one was around the choice agenda.
They made the very important point that they spend a great deal
of time commissioning very careful care pathways which deliver
better care and save money for the NHS, with Homerton hospital,
addressing all the issues, like David raised, about the number
of outpatient follow-ups and so forth. The trouble is that's completely
undermined when patients exercise their choiceand often
these are not the most needy patients but patients who perhaps
don't need to. They exercise their choice to go to University
College hospital, where the costs are not controlled and there's
no evidence of better outcomes sometimes. They make the point
that they can spend a lot of time commissioning very good care
pathways, but often they're in a position where those then are
undermined by foundation trusts, perhaps that have high PFI costs,
that charge a great deal of money; and they're not in a position
to have the levers of power to alter that. So that's one issue.
The second issue around choice and about practice
boundaries, and indeed about the boundaries for commissioning
groups, is the fact that they are concerned that patients will
exercise their choice to register in fancy, smart practices in
the City, when in fact they will then be left with patients who
have high dependency and high costs. I wonder whether that's an
issue you could perhaps refer to.
Then, again, with the issue of boundaries, I
know I asked you the last time you came about the issue of commissioning
boundaries, and you said that this would be very much bottom-up
and something that you would leave GP practices to determine.
But will you be in a position to step in if some of those commissioning
groups follow entirely illogical boundaries and people find themselves
having to commission care for patients, but there are entirely
separate geographical areas? That will affect their ability to
work closely with local authorities and deliver the best quality
care.
On the purchaser-provider split, we have discussed
before the make-or-buy decisions. I know many GPs who are keen
to roll up their sleeves and get on with commissioning, but I
don't know any who want to face the risks of facing European procurement
rules and, potentially, face legal challenge. We've heard evidence
from witnesses in this Committee from the private sector, telling
us that that will happenthat they will face legal challenge.
Finally, how to address failing practices? One
of the great scandals in the NHS is not that nobody knew that
doctors and practices were sometimes failing, but that everybody
knew and nobody was able to step in a take appropriate action.
One area that PCTs are able to address at the moment is failing
practices. It's happening too slowly, but it is happening. Who
will step in, in this new organisation? Will it be the Commissioning
Board or will GPs be able to directly identify, exclude and take
action against failing colleagues and practices? That is the end
of my list.
Mr Lansley: That is such an excellent
list that I will ask Dame Barbara to start with care pathways
and choice.
Dame Barbara Hakin: Yes, interestingly,
I visited City and Hackney pathways group a few weeks ago as well.
We need to rememberI discussed this with themthat
the tariff is designed to create, at the moment, a consistent
cost for services. Therefore, the cost of a specific service,
whichever secondary care provider is involved, is the same. We
have said that we want to give patients a choice. I think that
none of us in this room would want to deny patients the choice
of where they went to receive their care.
One issue on my visit was that, actually, the
strength of commissioning and contracting to ensure that the way
that they operated with the two hospitals was consistent. They
were making the point that they had a better relationship with
one than the other and were therefore able to design care pathways,
but hopefully in the new system they will be able to strengthen
the clinical commissioning, so that they can work with both hospitals
equally to ensure that the costs are not driven up by inappropriate
treatments that GPs don't want to see because they feel that they're
not as effective and not in the best interests of their patients.
But that can't be at the expense, in the final analysis, of allowing
patients to choose where they want to have a specific treatment.
They also raised the pointit is important:
we listened when we went to see themabout the funding issues,
particularly for deprived areas. In terms of looking, over the
next few years, at the allocations and how those work, the Secretary
of State has specifically asked us to look at the funding allocation
to ensure that practices and consortia serving deprived areas
get the right income to allow them to deliver the care that those
specific patients need. But we need to do that in a way that doesn't
deny the choice of patients who want choice, which would be the
other option.
Q553 Dr Wollaston: But will you
facilitate that choice? We all know that some patients find it
difficult to exercise their choice.
Dame Barbara Hakin: Absolutely.
And there's a broad range of areas in the reforms where we will
hopefully be able to improve, and empower patients. The central
tenet of the White Paper is that, somehow or other, we have to
support all patients to be in a much better position to understand
the services that are offered to them and for timely information
to be presented in a way that they can really understand. That
means an extra effort for certain groups of patients, so that
they can then make informed choices, because we need to be in
a position whereby all patients can make really well-informed
choicesnot just a certain cohort.
Q554 Dr Wollaston: And will we
have the ability to stop hospitals initiating inappropriate follow-up
appointments themselves?
Dame Barbara Hakin: I believe
that that ability is there and has been there for some considerable
while. Commissioners currently have been differentially competent
at managing that. We'll see that continue. The wherewithal is
in the contracting mechanism at the moment.
Q555 Chair: Can I come in on that?
From my understanding of what Dame Barbara has just said, the
answer to the core point being made to us yesterday is that there
should be no economic difference to the commissioning consortium.
If a patient chooses to go to one hospital or another, they should
both be performing on the tariff; therefore, there should be no
economic difference or difference to the rest of the patients
in that consortium. If that is not the resultthat is certainly
what they were saying to us yesterdaythat is the result
of weakness of commissioning, not weakness of the system.
Dame Barbara Hakin: Yes. Absolutely.
Mr Lansley: On that thought, as
far as I can see, one of the ways in which we ought to develop
payment by resultsthe tariff structureis to increasingly
be able to commission and use a tariff along a care pathway. The
way in which GPs are describing to you that they want to construct
their local commissioning along care pathways should also be the
basis upon which they construct their contracting. That would
not close out UCL from offering that, but it would be perfectly
legitimate for it to say, "You can offer a service to our
patients, but you have to offer the whole care pathway. You can't
just pick bits and pieces to make that happen."
Dr Colin-Thomé: It is an
opportunity, I think, for providers to be much more helpful in
commissioning in this way. You could commission a provider to
be the leading or principle provider of a pathway with urgent
care. At the moment, I think we have separated commissioning and
provision far too much. We obviously need to do that in the procurement
phase, but in designing care we need the clinical input from providers.
I think you'll find that GP commissioners, even though it is about
GPs, will engage a lot of the clinicians in doing that.
The other thing about City and HackneyI
have been there as wellis that they feel the power of the
big beast compared with the local hospitals, which is what they
were worried about. I would say that you have to be more flexible.
If you feel that, you need to band together with your other PCTs,
or consortia in the future, to have a bit more leverage. I think
that how you organise yourself in future, rather than being rigid
about your own boundaries, will be key. We are being too frozen
by our structures rather than what the heck we are for. Even on
practice boundaries, it sounds like the GPs want to be a bit too
controlling. Whose health service is this? If a patient wants
some choice, they should damn well have some choice.
Q556 Dr Wollaston: As long as
they are adequately remunerated if they are left with higher-risk
patients who have greater needs. I think that is important.
Dr Colin-Thomé: Sure.
Mr Lansley: Can I comment on that,
because I though you made an interesting point? It is particularly
true that in some of the more urban areas people can exercise
choice between practices. In my area, for example, plenty of people
commute to London and register with a GP practice there or, more
often, they register with a practice in the middle of Cambridge,
even though they might live some way away. There is a discontinuity
between where they live and where they are registered.
To some extent, we are very clear that, although
patients can exercise choice, GPs can't cherry-pick patients.
They have to be open to the patients who put themselves forward
to their practices. A lot of this depends on us being very clear
as we develop which we have begun to do in the allocations
to primary care trusts for the next yearthat we seek to
relate the resources that are provided to general practice to
the prospective burden of disease. For example, we are increasing
the weighting for age and deprivation next year. We are trying
to focus the resources for the NHS to be more accurately reflective,
including, I hope, as time goes by, in relation to individual
practices. People who live in Hackney might be registered with
a brand-new practice close to them in the middle of the city,
but if it mainly consists of patients who aren't ill, the level
of resources that flows from it will be modest.
Q557 Dr Wollaston: That is great
and it is good news, because at the moment it is mostly capitation
based, so it is very difficult.
Mr Lansley: It will still be capitation,
but a very clearly weighted capitation reflective of the prospective
burden of disease of the demographic characteristic of the population.
Q558 Chair: But that impliesdoesn't
it?an ability to link the resource to an individual rather
than to a polling district or traditional structures?
Mr Lansley: At some point, it
would probably be helpful for you to hear about not only the work
that we are doing, but the work that is being done on the Department's
behalf by, for example, the Nuffield Trust on seeking to arrive
at much better information about the prospective burden of disease
of particular populations. Until now, it has not really been possible
to disaggregate below PCT level and to accurately reflect that,
but it is increasingly possible. Those data are being generated
partly through the quality and outcomes framework and the disease
registers that go with it and partly through the development of
the tariff systems, too. Soon we will arrive at the point at which
there will be robust data that would not only enable us to be
clear about the appropriate level of allocation to consortia when
the Commissioning Board takes that responsibility, but enable
the consortia themselves to have access to those data so that
they can make, and the board can make, very clear, robust allocations
down to practice level.
Q559 Andrew George: Does that
mean that the Advisory Committee on Resource Allocation, given
all of its work in recent years, is going to be ignored and you're
starting with a blank sheet of paper?
Mr Lansley: No, on the contrary.
Today, I have separately published my correspondence with the
Advisory Committee on Resource Allocation, in which I asked it
to do this work. This is where it wants to be, and this is the
work it wants to do.
Q560 Andrew George: The advisory
committee has been doing that, and it has been looking at disease
prevalence, demographic issues and deprivation.
Mr Lansley: Yes, and we are going
to help it to go further in that direction. In the overall allocation
today, we are devoting more weight to what is, through age and
deprivation, reflective of need for health care services. You
have asked what is being derated. At the end of the process, the
ACRA told Ministers that they could allocate an amount of money,
which might be 10, 15 or 20%, on the basis of inequalities in
health outcomes. We are very clear that we are moving in due course
towards separate allocations for NHS services and for public health.
It is clear that the public health allocation will not exceed
10%, although we have not determined what it will be. So we as
Ministers have said to the ACRA that we will set the allocation
for relative health outcomes at 10% and allow, consequently, additional
weight to be given to the factors, such as age and deprivation,
that directly relate to health care need. That will impact on
the balance of allocations in 2011-12.
Dr Colin-Thomé: Could I
just say
Q561 Chair: Sorry. I think Sarah
asked five questions, and so far we've got to number two.
Mr Lansley: Failing practices
are very important, if Barbara would kindly address that.
Dame Barbara Hakin: Failing practices
are key, and it should be understood that under the new commissioning
architecture we will not have a board that is completely distant
from consortia. There will be a lot of interchange and sharing
of the way we do business between the two. The board will have
the overall responsibility for the primary care contracts. We
are talking about practices that are failing in their provision,
but if you are a poor provider, you are also a poor commissioner,
because good husbandry of resource is a responsibility of a good
practiceensuring that the whole of your population get
the best possible services is the duty of an individual GP and
their practice.
We see this as a joint relationship, with the
board having the final sanctions, because the board will hold
the contract with the individual consortium. The board, probably
through its outposts, will be able to intervene where there are
serious issues. The consortia leaders have very clearly said to
us that, to get the most out of this new system, they feel that
consortia need to have a role in driving up the quality of primary
care through peer pressure. Consortia need to be able share learning
across practices by demonstrating to some practices that what
they are doing is significantly different from their peers. I
see the role in managing failing practices as a joint venture
between the consortia and the board.
Mr Lansley: I have one additional
point on that. From April 2012, the Care Quality Commission will
also be registering general practice, which I know is not wholly
regarded in general practice as without burdens. I hope that we
can do that with as little burden as possible by also bringing
to bear the Royal College's practice accreditation process. The
CQC, in those circumstances where there are failings in GP practices
that prejudice levels of quality and safety, will have additional
powers to intervene that are not currently available.
Q562 Dr Wollaston: The point was
made yesterday that often clinical audit, particularly in the
form of notes review, is a very effective way of picking up failing
practices, rather than raw data through the QOF, which can be
fraudulently altered and so on. Would the responsibility for the
registration process sit with the Care Quality Commission, with
the board or with the consortia?
Mr Lansley: As it happensBarbara
will correct me if I'm wrongI actually think what you're
describing is likely to be part of the integral process of a consortium
looking at the clinical governance arrangements in its area.
Dr Colin-Thomé: There is
a thing called the global trigger tool, where you go through case
records that have been deposited in hospitals, which would have
picked up something of the hospital, and the institute has been
doing some work with general practice on that particular thing.
You get a lot of information from a random selection of notes.
Chair: Before we move off that subject,
Yvonne has a question.
Q563 Yvonne Fovargue: I want to
take that a bit further. As a last resort, if a practice within
a consortium is failing, will it be possible to expel that practice?
If so, what happens if that practice cannot go into any other
consortium? If no one else will accept them, what will happen
to the patients within that practice?
Mr Lansley: The NHS Commissioning
Board will have a responsibility to ensure that there is a continuing
service to patients. It will be possible for a consortium to say,
"We can no longer support this practice in its current form."
But, essentially, under those circumstancesBarbara will
correct me if I'm wrongwe are proposing that they wouldn't
be able to take a practice out of their area, because remember
there is an area responsibility, as well as a commissioning responsibility,
and not only for their registered patients, but for their resident
population. To that extent, I think the consortium would have
to ask the Commissioning Board to intervene in relation to that
practice, because it will have the intervention powers.
Dame Barbara Hakin: Yes. In answer
to your question, it was in the White Paper, and certainly in
the response, that the consortia have to have a geographical basis.
Therefore, I think that answers your point, but it leads us into
your question, which I think is a very good one, because it would
be very difficult for a practice that is right in the middle of
a consortium to be anywhere else. It is important to remember
the difference between provision and commissioning, and the board
has responsibility for provision. A consortium that was not playing
an enormous part in commissioning would probably remain in the
consortia, with the board working with the consortium to improve
that. If a practice
Mr Lansley: A practice not playing
a part.
Dame Barbara Hakin: Yes, sorry.
A practice that was not playing a part. I am getting the words
wrong.
If a practice is really so poor that it is are
having an impact on the commissioning at the consortium, that
practice is really poor at provision. Therefore, there are methods
that occur now that are currently available to PCTs who hold the
contract, but will, in time, be with the board that holds the
contract, actually to deal with that poor provision, which would
be initially perhaps through clinical governance, as you've talked
about, but, in the final analysis, would be through the provision
contract.
It is important to remember that practices are
not going to be told that they cannot provide services for patients
because they are not playing a big part in the consortium that
is commissioning. They will be supporting the practices to play
more of a part in commissioning with the consortium, but their
ability to provide services would still be there.
Chair: I don't think that we can get
totally bogged down in this, but there is some interest in failure
regime for practices.
Q564 Valerie Vaz: Just as a follow-up,
the consortia will have geographical boundaries but the GP practices
won't. Is that right?
Dame Barbara Hakin: The majority
of GP practices have a practice boundary.
Q565 Valerie Vaz: But they don't
have to under these proposals, do they?
Mr Lansley: No. They don't.
Q566 Valerie Vaz: So how will
that work?
Mr Lansley: Because there is a
combination of responsibilities. The consortia will have a responsibility
to commission services for the registered population of the practices
that are their members as well as for the resident population
in the area that they cover. The individual practices will be
open to receiving applications to register as patients with them
from wherever people happen to live. One of the things that the
previous Government said was that they wanted to abolish practice
boundaries, but they hadn't, which I think is necessary, put in
place a clear understanding that that doesn't mean that individual
practices must undertake, as it were, home visiting in any part
of the country. GP practices must be able, through their prospectus
as a practice, to be clear about where they will visit and where
they won't.
Separately, part of the development of commissioning
is that we're looking for that area responsibility of consortia
to be a responsibility for the provision of unscheduled care in
their area. A practice might be part of another consortium, but
if it has registered patients who are living in the area of another
consortium and if they access that unscheduled care there will,
of course, beas there is at the moment between PCTsa
transfer of resources into that consortium to provide their unscheduled
care, even though the patients happen to be registered with another
practice.
Q567 Chair: So in plain English
there will be a map.
Mr Lansley: Yes.
Q568 Chair: And a consortium will
have a map of an area where it has a geographical responsibility.
Mr Lansley: Yes.
Q569 Chair: And no part of the
country will not be allocated to one consortium and no part will
be allocated to two consortia.
Mr Lansley: That's right.
Q570 Valerie Vaz: But the GPs
don't. As a patient, am I going to be told that my GP is part
of consortium A and consortium B?
Dame Barbara Hakin: No. The practice
will be part of a consortium. One imagines that still the vast
majority of patients registering with a practice will live locally.
But in exactly the same way as now, if you are part of a PCT,
through being part of a practice, and you need urgent care because
you happen to be somewhere else in the country, you would still
have access to that urgent care and the charge would go back to
your PCT. In the same way, significant numbers of patients aren't
registered with a general practice and every consortiumthey
will cover the whole countrywill have to be responsible
for the care of all the patients who live within their geography.
Mr Lansley: Technically, it's
a simplification relative to where we are at the moment. For example,
I have a constituency surgery that is a branch surgery of a practice
in Hertfordshire. That practice, technically, now has to be both
in Hertfordshire and in Cambridgeshire PCT areas. In future, for
the whole of its practice area, it can choose to be in consortium
A or consortium B, let's say.
You'll find that, to some extent, the consortiums
will tidy up what are at the moment rather awkward boundary issues
for GP practices, which are created by the fact that the PCTs
have boundaries. But you as a patient are registered with a practice,
and that practice is responsible for your service. The fact that
it has commissioning arrangements through a consortium is not
something that, from your point of view, would necessarily be
the central issue. The issue for you is that your practice is
responsible for your care.
Q571 Chair: I thinkif I
may say sothat that's relatively clear and we've still
got two of Sarah's questions to answer.
Mr Lansley: We did boundaries.
Make or buy, and European procurement rules, which we can't escape
Q572 Dr Wollaston: No, but it
is a big issue for practices, which have financial responsibility,
and personal responsibility, in some cases. For some GPs, that
is acting as a deterrent to getting on board, because some of
them tell mesome have told the Committeethat they
would be put off by the thought of having their shoulders constantly
looked over by Monitor and facing the threat of legal challenge
on their commissioning decisions. Could you comment on that?
Dame Barbara Hakin: We're clear
that we want a situation whereby practices can deliver better
primary care and general practice in a more unfettered way than
at the moment and then reduce resources and secondary care. However,
it is equally important that if a group of practices or a consortium
wants to offer a service that could be offered by someone else,
we abide by the law, so those services would appropriately be
tendered or would follow European lawthe Secretary of State
says that we can't get away from that.
Over the next few weeks and months, we need
to get through to practice, and give them the comfort that there
will be a lot of commissioning support around them and they will
have a considerable running-cost resource to have the people with
them who can advise them which services they need to tender so
that, if tender is necessary, they can do that complicated process
of procurement. The idea is that we will, through the clusters,
create quite comprehensive commissioning support arrangements
that consortia could draw on so that, if they felt that they wanted
to create a new service, they would get the right legal advice
on European law saying, "Is this something that you can simply
go ahead and do or do you need to tender it, otherwise Monitor
will view this as anti-competitive?" If they need to move
to the process of undertaking that complex tendering process,
they will have managers to support them within their individual
consortium, or they can buy in help to do it.
Q573 Dr Wollaston: So, in other
words, every commissioning pathway that they designsay
through Homerton hospital; we met the commissioners yesterdaywon't
be subject to legal challenge and they won't have to put it out
to competitive tender. They'll get clear advice.
Dame Barbara Hakin: They will
get clear advice. Certainly they will not all be subject to competition.
There is a broad range of times when they would not be subject
to competition, but they will have access to advice that will
help them to understand whether what they were proposing could
be deemed as anti-competitive.
Dr Colin-Thomé: And their
personal money won't be put at riskthat is a fear that
GPs often express to me, toobecause there is quite a separation
between their provision and their commissioning responsibility.
Mr Lansley: I won't read them
out to you, but paragraphs 6.87 to 6.90 of the Command Paper specifically
address how we will think about the process of regulating for
competition on the commissioner's side. Monitor will have a responsibility,
and the Secretary of State will have a power to issue regulations
setting out how that works. We will consult about that in due
course.
I would just say this: our intention is that
Monitor will have a concurrent competition jurisdiction in health
and social care. Clearly, we cannot leave commissioners out of
it because they may behave in an anti-competitive fashion, but
we will be clear that the focus should be on significant breaches
where there is a significant risk of anti-competitive behaviour.
There will not be high levels of ex-ante regulation of purchasing;
it will be specifically about addressing abuse. People behaving
in a reasonable fashion should not really be having the competition
authority looking over their shoulder.
Q574 Dr Wollaston: So we won't
see a race to the bottom, with everyone chasing the lowest cost.
Mr Lansley: Absolutely not, because
from the patient's point of view and the commissioner's point
of view, quality is the principal criterion on which they will
be seeking to commission. The reward, not least to patients and
to the commissioners, is in delivering better outcomes.
Q575 Rosie Cooper: Secretary of
State, are you saying that there won't be a more litigious climate,
and that private providers won't take action if they don't think
that they are getting enough of a bite of the cherry? Are you
really saying that?
Mr Lansley: They can't take legal
action to get, as it were, a bite of the cherry. They can go to
Monitor as the competition authority, as we propose, as they can
now go to the Office of Fair Trading. They could go to the competition
authority and say that there is an abuse of competition, and the
authority would have a responsibility to investigate and take
action if there was an abuse, but that is no different from now.
Q576 Chair: Can we move on? Grahame
Morris wants to ask questions on the timing of the Commissioning
Board.
Grahame M. Morris: Actually, some of
that is covered in the framework
Chair: You have the advantage of having
read it. Do you want to pass in that case, Grahame?
Grahame M. Morris: I wanted to raise
the issue of wider determinants of health, and whether that will
be reflected, but we have covered that, in essence.
Chair: Fine. Do you want to go there?
Grahame M. Morris: No, we have already
covered it, Chair.
Chair: Fine. Rosie wants to talk about
local authorities.
Q577 Rosie Cooper: I am not sure
where we are, but let me, if I may, ask a question about consortia
and holding meetings in private or public. Will the commissioning
boards be placed under a statutory duty to meet in public? If
not, why not?
Mr Lansley: We are not proposing
that we should prescribe in detail how the commissioning consortia
conduct their own activities internally. We are requiring them
to be transparent. For example, they will have to publish a constitution,
and act in response to it. They will be accountable for the outcomes
that they achieve. Clearly, they will be accountable for financial
control and the use of public money, and there will be clear accounting
rules about how that is exposed.
Their own internal management will not be accountable
on a day-to-day basis. There will be specific proposals in legislation
for them to publish their commissioning plan each year, and for
them to publish through their annual report how they have gone
about doing their business. The conclusion that we have reached
is that they must be prospectively clear about their commissioning
plan, which must be in line with the joint health and well-being
strategy and available to the public and to the local authority
through the board. That is prospectively the right way to do it.
Retrospectively, as it were, through their annual report, we want
them to be clear about what they have done, how they have achieved
it, and what they are accountable for. If we try to intrude large
amounts of prescription about the way they manage themselves internally,
we will end up with primary care trusts.
Q578 Rosie Cooper: Obviously,
I would not share that view. What you have described has patients
nowhere near the heart of decision making, or having any great
influence on that.
You have described HealthWatch. How will that
be able to influence commissioning? If patients are not going
to be at the heart of it, who will really be there to ensure it
does happen?
Mr Lansley: First, I think your
characterisation is completely wrong. What we will do, through
commissioning consortia, will give patients much greater involvement
in commissioning. Let us be clear about that. How many patients
across England think that the primary care trust is an organisation
that at the moment responds to local patient voice? I have not
been inundated with people explaining to me how great is the patient
involvement in primary care trusts.
Q579 Rosie Cooper: It's all pretty
dreadful; I get that. This is not going to make it any better.
Mr Lansley: We are going to put
the board and the consortia under a legal duty to involve patients
and the public in their commissioning. As I explained, the Command
Paper says how we are going to strengthen the role of HealthWatch
locally and nationally. That will give patients and the public
a real champion locally and nationally. We are where we are. The
last Government abolished community health councils; they set
up patients' forums and then abolished them; and they set up LINks.
We have to do something that is stronger in the long run, as a
basis for health representation and health and social care on
behalf of patients and the public. HealthWatch will do that. The
linkage directly into the local health and well-being board is
important; they will be able to do that locally. The use of statutory
powersfrankly LINks have few statutory powerswill
strengthen their role in the future using, if need be, the powers
of CQC for quality enforcement.
Q580 Rosie Cooper: You have described
the patient as the best person to know, and yet you are not allowing
the patient to be at the table taking partas would be bestor
holding meetings in public so that the patient can see the decisions
being made at the consortium. I think it is flawed at the core.
We disagree yet again, Secretary of State, because we spoke before
about people waiting longer on the waiting list and you disagreed
with me. NHS information centre data show that the number of people
waiting 18 weeks for treatment in the NHS has increased by 15%
since the coalition Government abandoned the 18-week target. That
is 6,000 more people waiting.
Mr Lansley: That was the August
figure. It is all to do with the summer. That's ridiculous.
Q581 Rosie Cooper: I beg your
pardon.
Mr Lansley: That is all to do
with the summer. You have to do a seasonal adjustment on that.
Q582 Rosie Cooper: Forgive me,
you are going to get a reputation not for the Lansley challenge
but the Canute challenge: "It is not because I say so."
When will the facts get in your way?
Dame Barbara Hakin: Just for interest,
City and Hackneywhich has had a long-standing group of
practices doing some work, which you and I have visitedhas
an excellent way of involving patients and the public in what
it does. It has grown that from the bottom up; I would be happy
to let you have details. It is not specifically about one individual
board meeting. It has a comprehensive system for trying to involve
patients and the public.
Q583 Rosie Cooper: If you really
believe that, make the board meetings open to the publiclet
them see it happen. If you really believe it, walk the walk and
let them see.
Dame Barbara Hakin: It is about
ensuring that these organisations have a way of ensuring the patients
and the public are involved.
Rosie Cooper: What are you hiding? Why
has it got to be in secret? What on earth is going on?
Q584 Andrew George: Can I come
back to the issue of looking forward to the consortia themselves
and how they relate to local accountability? In your statement
today, you say that there will be a "joint health and wellbeing
strategy" for local authorities and the consortia to work
on together. I welcome that as an important step forward from
what might otherwise have been a relative fracturing of local
accountability on the one hand, relating only to social care,
and the consortia that commission NHS services. It seems to me
that you're moving back towards the coalition agreement by doing
that. In other words, to establish joint health and well-being
strategies, it's inevitable that local authorities and consortiums
will have to work very much hand in glove. You're bringing the
two back into what is, if not a joint commissioning board, almost
a joint planning board for their geographic area. Would you say
that is a fair reflection of where you're going with this?
Mr Lansley: I think that's an
entirely fair summary. Indeed, it is dreadfully underestimated
how important this is in the White Paper. For example, on the
day the pathfinder consortiums were published, I went to see the
GPs in Bexley. It was no surprise I went to see them. They were
working with their primary care trust. The chief executive was
there, and so were the chief executive and the leader of the council.
That is because they are all working together. This
is happening now.
Q585 Andrew George: Okay. That's
good. That's my interpretation of where it's going. That's very
encouraging, and I welcome that. What then concerns methis
is partly reflected by the different populations being served
by the 52 pathfinders, which range from 17,000 to 650,000is
the lack of coterminosity between the consortiums and the local
authorities. Shouldn't you be not micro-managing and therefore
instructing, but encouraging the consortiums, wherever possible,
to establish coterminosity with their local authorities? That
seems to be the direction in which it is going.
Mr Lansley: The direction in which
it's going is being determined by the groups of GPs coming together.
They are clearly making judgments themselves. They are making
different judgments in different places, and I think that's often
for good reasons. SometimesI am only illustrating the point,
and these are not the exclusive reasonsthey are doing that
for reasons of coterminosity. For example, I was in Widnes talking
to the Runcorn GPs among others. It is not a big area, but if
I recall correctly, the GPs in Runcorn said, "We have 65,000
patients and we want to have a consortium, or at least a cluster
within a consortium, that is coterminous with the local authority,
because we're working with the local authority." That is
fine.
There are other places where a group of GP practices
that is coming together feels that it wants to construct a consortium
that broadly reflects the catchment of a particular hospital.
That may be a judgment that is perfectly reasonable to make. In
the way that Dr Wollaston said, GP practices might be thinking
about having a range of contracts, and they want to feel that
they are the dominant commissioner in relation to a set of health
care providers so that they can establish through their contracts
the structure of care pathways that they are looking for and have
real weight when they do so.
These are differing factors. We've always been
clear on the experience of primary care trusts. When there were
304, or whatever it was, the geography wasn't right. Then we moved
to 152, and the geography wasn't right. We'll go to clusters,
and people will argue about the geography. The point is not to
prescribe this; the point is to let it be governed by circumstances
and, in truth, to have a flexible structure, which the Bill will
provide, so that if commissioning consortia feel that the geography
is not right, they can shift and they can do that easily.
Q586 Andrew George: But the logic
of that statement is that it would make sense for coterminosity
to exist
Mr Lansley: No.
Dr Colin-Thomé: Except
that in all the years I've spent in the health service, coterminosity
hasn't produced anything unless there are good relationships and
good leadership. What we're trying to tap into in these reforms
is about going with the energy of people, rather than rigid structures.
Mr Lansley: My experience is that
people are building relationships at a local level around the
White Paper and that those relationships are the basis on which
you really best structure this.
Dr Colin-Thomé: All the
GP leader organisations meet the Local Government Association
to discuss this at a national level, too.
Chair: I was going to say there are seven
minutes left to deal with conflicts of interest, but there are
now six. Valerie and David both have questions.
Q587 Valerie Vaz: Before that,
I just have a factual question. Did you do your own survey of
GPs to establish whether they wanted to go down this road?
Mr Lansley: Before?
Q588 Valerie Vaz: Before the White
Paper. Did you do your own survey of GPs? A number of surveys
have come out about whether GPs want this, or want to handle this
£80 billion.
Mr Lansley: After the election,
but before the White Paper, no.
Q589 Valerie Vaz: Going on to
conflicts, 25% of GPs have a stake in private companies or have
their own private companies. Do you see this happening more? What
safeguards are there for patients in terms of conflicts of interest?
Mr Lansley: I have no view about
whether it is going to happen more or less.
Q590 David Tredinnick: Can I add
my question? I am concerned that with all this extra money GPs
are not going to be properly accountable, that there won't be
any checks or balances on the services that they buy, and that
they can buy from providers with whom they may have special relationships.
There are no checks to prevent that.
Mr Lansley: We knew this was a
problem when there was fundholding in the mid-1990s. GPs were
in a position where they had a conflict of interest, in the sense
that they could spend less on treatments for patients and have
a financial benefit to the practice by spending the money on their
own practices. They had a conflict of interest because they could
send patients to a connected provider. We are dealing with those
conflicts of interest. It will not be possible for GPs to save
money on their commissioning budget and for that to become money
in their pocket. It just doesn't work like that. The only way
they can benefit themselves is if they improve the outcomes for
patients by the value for money that they achieve with their commissioning
budget.
In terms of having contracts, we are in a much
better place. They can have contracts with providerswith
themselves as provider or a connected interestbut they
can do so only through the consortium. To that extent, it will
be transparent. We touched on it earlier; if there is an abuse,
there will be a competition regime, the purpose of which is to
investigate and, if necessary, to act against any such abuse.
Q591 David Tredinnick: One of
the most impressive aspects of going to Hackney yesterday was
the doctors saying that under the new structure, "We are
not setting up a business, we are not going to form ourselves
into business, we are going to be a co-operative." There
is a danger here: if doctors form into a commercial unit, and
if there are no inducements, it is certainly convenient at times
to be influenced by the fact that it is a commercial organisation
rather than one that isn't. Certainly doctors yesterday expressed
that view. They said, "We're not going down that route. We
want to be a non-profit-making organisation." Perhaps Valerie
can help me on that.
Mr Lansley: I am not aware of
anything in the White Paper that, in itself, leads to any differenceany
greater likelihoodthat general practitioners individually
or collectively would engage in an additional commercial practice.
They can do it at the moment; they can do it in the future.
Q592 Valerie Vaz: What about safeguards?
They could send the patients to their own company, couldn't they?
Mr Lansley: Well, the safeguards
are partly that that is safeguarded against by the fact they will
have a legal duty and a contractual duty to maximise patient choice.
They can't just refer patients into their own connected interests.
They must give patients access to choice. To that extent, if they
own an additional provision and it is clearly contracted for on
a basis that is competitive, I don't have a problem with it. If
they are trying to do it in a way that is anti-competitive or
that deliberately seeks to restrict competition, it is anti-competitive.
We're going to have a proper competition regime, which at the
moment the NHS doesn't really do. There are limitations on the
proper application of measures to combat abuse of competitive
situations.
Dame Barbara Hakin: I think there
are three or four other safeguards. The first is that the paper
makes it very clear that they have to conduct their business in
an open and transparent way and in line with principles of the
public service. That should mean that under circumstances where
practitioners find themselves acting in a commissioning environment
and making commissioning decisions where they had an interest
in the provision, they would need to declare that interest and
stand aside from that decision. You've then got the Commissioning
Board, which oversees and authorises.
Q593 Valerie Vaz: Every decision?
Dame Barbara Hakin: Not every
decision, but it oversees and authorises the way that the organisations
do their business. We've got the safeguarding of patients, as
the Secretary of State said, because they will have choice. The
final safeguard is that where there is clear anti-competitive
behaviour, there will be a body that can intervene. That is four
levels of safeguards against what is a reasonable thing for us
to be concerned about.
Q594 Valerie Vaz: So your view
would be to have lots of providers, and that that would make it
more competitive and better?
Mr Lansley: I hope that there
will be plurality of provision, certainly.
Q595 Valerie Vaz: So more down
the privatisation road, then?
Mr Lansley: No, absolute provision
is not the same thing as privatisation.
Chair: And it's fair to say that these
conflicts of interest are not new.
At this pointrather against my expectationat
precisely 11.30 am, the Committee has concluded its agenda. I
thank you all for coming and answering our questions.
1 Note by witness: It was on
21 October. Back
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