Examination of Witnesses (Questions 41-81)
Q41 Chair: Good
morning. Thank you very much for coming. I am sorry to keep you
waiting a little bit beyond the target time for this evidence
session. Could I ask you to begin by introducing yourselves? There
are some familiar faces, but, for the record, it would be useful
to have an introduction. Thank you.
Dr Carter: Peter
Carter, Chief Executive, Royal College of Nursing.
Mike Sobanja: Michael
Sobanja, Chief Executive, NHS Alliance.
Dr Gerada: Clare
Gerada, Chair of the Royal College of General Practitioners.
Dr Alessi: Charles
Alessi, one of the leads in the Kingston Pathfinder and an executive
member of the National Association of Primary Care.
Q42 Chair: Thank
you. I would like to open the questioning, if I may, by focusing
on the question of the relationship between GP commissioners in
the new consortia and the rest of the clinical community. The
Committee has expressed the view in the report we did on commissioning,
on which this is a followup process, that we think it is
important that while GPs can be the catalyst—indeed, should
be the catalyst—for engagement of the clinical community
in the commissioning process, as we see it, it is essential, if
we are to get a highvalue commissioning process, that the
entire clinical community feels its views, interests and specialisms
are reflected in that commissioning process. I would like each
witness to open the session by setting out your own views in reaction
to that proposition which the Committee set out in its first report
on this subject. Let us start with the Royal College of Nursing.
Dr Carter: Thank
you, Chair. It is a very apposite way in which to open up our
evidence to you, and thank you for inviting us. This is one of
our strongest concerns. In many of our meetings with the Secretary
of State we have consistently said that one of the flaws in the
concept—because, as you know, we are supportive of many
of the key principles of the Bill—was that it started off
with general practitioner commissioning. We felt that, at the
very least, it should have been general practice and everyone
involved in general practice, or, if you like, clinical commissioning.
We have severe reservations about the absence of, and in fact
the Bill is silent on, the role of others. Not just nurses, but
speech therapists, physiotherapists, pharmacists, the whole array
of people in the multidisciplinary team, are feeling disaffected
by the lack of a commitment to involve nurses and others. In relation
to the Bill, one of the amendments that we would wish to see is
a firm commitment that nurses and others will be involved.
Mike Sobanja: I
happen to agree with Peter. A far better term would have been
about clinical commissioning as opposed to GP commissioning, but
recognising, as the Secretary of State has said on a number of
occasions, that this basic, core role of a GP is about commissioning,
whether it is treatment, referral or prescribing, and, in part,
this is about aligning financial responsibility with that.
In terms of clinical commissioning, without going
over the ground that Peter has set out, there is also a case for
clinicians in secondary care and tertiary care to be engaged,
because what we want to see is clinicallydriven commissioning
and not for the Bill to introduce a degree of tribalism, which
is GP alone. I was very struck by the previous discussions about
engagement of local communities and so on. If I could pre-empt
Rosie's comments about that, yes, we do believe there should be
independent directors on GP commissioning consortia, but that
will not go far enough to ensure the public has an appropriate
voice in the system.
Dr Gerada: Thank
you very much for inviting me. I, too, agree with the fact that
we must commission collaboratively with our specialist colleagues,
our nursing colleagues and with patients. We, with the Royal College
of Physicians, published Teams without Walls and will now
go on to work on "Commissioning without Walls". Members
of my organisation have also brought up the issue as to how, in
a democratically elected country, that can be devolved just to
one single professional group and whether that is going to be
unrepresentative and unethical as things pan out.
Before I finish, we would also like to see a distinguishing
between commissioning as in the use of resources in the consulting
room, the husbandry of resources. The term "commissioning"
always tends to get confused, but we consider commissioning to
be about being a good clinician, understanding how you use your
resources and understanding how you can use resources better as
opposed to planning health services and all that that entails.
With respect to planning health services, that absolutely needs
to be done in collaboration with others. We cannot do this alone.
Dr Alessi: Thank
you for inviting me too. It would be helpful to think in terms
of the primary care home rather than general practitioners, because
a lot of what the new Act is about is the treatment of patients
in the context of a population. Anybody who accepts the fact that
they have to treat a patient in the context of the population
that is served and also of the resources that are available for
that population clearly has a legitimate place at the table, be
they a nurse, a speech therapist or anybody within primary care.
That is fundamental to the way we work. I believe that the Act
changes things from practising with a patient in front of one,
whereby one treats a patient without a financial context, to treating
a patient understanding that there is a responsibility to spend
what we have in the most costeffective way we can and also
to prioritise care effectively. This is not going to be easy,
but unless everybody is involved I don't think we are going to
succeed.
Q43 Chair: Dr
Alessi's contribution, in a sense, was the test case, or was interesting
coming from your particular perspective. It is therefore uncontroversial
among all four witnesses that we need to have the whole clinical
community engaged in the commissioning process. The followon
question is: Should that, in your view, be written in in some
way to the framework of the Bill from the point of view of the
commissioning consortia, and, if you agree with that proposition,
how would you like to see it done? Dr Gerada.
Dr Gerada: Absolutely,
it should be written into the Bill that there should be a duty
of collaboration, cooperation and shared working, with respect.
You also need to be mindful of the fact that this may then be
proven to be anticompetitive with the issue of "any willing
provider". If you are getting groups of clinicians working
together, it is inevitable that those groups of clinicians will
be drawn from a local population, and it is inevitable that once
you start to work together, clinicaltoclinical dialogue,
you will be favouring your local clinician. So we need to be mindful
of that.
Q44 Chair: Can
I ask a probing question? If it is accepted that it is right for
a consortium to have expertise from across the whole clinical
community engaged in the commissioning process, that is a different
proposition, is it not, from saying that it must be involved always
with the local clinicians? Surely part of this ought to be about
calling expertise from elsewhere in the system to call the local
clinicians to account against the highest standards.
Dr Gerada: Yes,
that is true. But when you are designing care pathways and where
you are designing commissioning decisions around your local population,
the de facto people that you will get involved with that will
be your local clinicians because, one, they are there and, two,
they are working with you. Whilst I accept that, you may well
pull in organisations such as NICE and the Royal Colleges, because
I think we play a very important role. On the ground it will be
local people that do this together. In fact, good commissioning
is about good clinical dialogue, so, again, in its simplest way.
Dr Alessi: We also
need to remember that the choice is made by patient, not by the
clinician. That is the challenge that is in front of us, to ensure
that we really put the patient at the heart of everything we do.
If we continue working in a way whereby we direct patients to
where they should go, this system will not succeed. If, however,
the choice is made by the patient, as long as—and I pick
up on comments made in the earlier meeting—the care that
is delivered is deemed to be of sufficient quality by the Care
Quality Commission—because there are mechanisms to ensure
that we commission what is of quality, and that decision does
not need to be made by the clinicians themselves, there are bodies
that have responsibilities to actually reach those decisions—I
don't see why we are going to get into such difficulty. Yes, there
is—
Q45 Chair: I am
sorry. Are you saying that you don't think that a commissioning
group should get involved in a quality question? They should simply
assume that that is decided by the Care Quality Commission licence?
Dr Alessi: No,
absolutely not. We should drive quality, otherwise we will end
up with the lowest common denominator. But there is a flaw, and
that flaw needs to be determined by somebody.
Mike Sobanja: On
that particular point, the primary responsibility for quality
rests with the commissioner and the regulator is secondary. One
of the concerns that we would have about the way the current arrangements
are described is that the regulator—and it may not be just
CQC, it could be Monitor in this regard—might trump the
commissioner and lead to a weakening of commissioning and then
its links with the local community.
In answer to the Chair's question, I am not convinced
that writing that into the Bill would achieve a change in the
culture and behaviour which is required. We see lots of things
which are written into Bills which people then pay lip service
to, although I can't think of a ready example—
Chair: Or simply forget.
Mike Sobanja:—as
if that job is then done. Personally, I am far keener to see the
National Commissioning Board, in its relationships with local
commissioning groups, make that a performance management and accountability
issue which gets great prominence. That may be better, if not
equal, to writing it into the Bill.
Dr Carter: I agree
with Mike here, in that just because something is in a Bill, it
doesn't mean it is going to happen. It then requires behavioural
change and commitment to make it happen. However, in relation
to the nursing contribution, we would like to see this in the
Bill. Whilst I don't want to broaden this out too much at this
moment in time, we do have serious reservations right from the
top in terms of the role of the Chief Nursing Officer down through
the various echelons where again it is wholly unclear at the moment
as to where the nursing presence is going to be and where the
nursing leadership is going to be. We have seen examples in different
parts of the United Kingdom where, in the absence of that leadership,
you do end up having serious issues to do with the quality of
patient care.
Q46 David Tredinnick:
I want to go back to the points Malcolm Alexander was making in
the last session, this issue about the extent patients should
be listened to in their request for clinical care. I raised the
point about Chinese medicine and my colleague Mr Sharma touched
on Ayurvedic medicine—both systems have been in operation
for several thousand years—and also homeopathic medicine,
which is very, very popular in India. How do we manage this in
the future?
Dr Alessi: If we
accept that there is a finite resource—and that is the first
and most important thing that has to be accepted, because if one
doesn't accept that one doesn't know where one starts—one
can then use the mechanisms that exist, using a programme budgeting
approach, for example, and using our colleagues in public health
and their expertise around prevalence, to come up with indicative
budgets that would be available for a condition. If that is accepted,
then one can actually start to commission with local providers
as long as one accepts that local providers also have a population
responsibility. Perhaps if there is something which has not been
as prominent as it should have been, it is that foundation trusts
and acute hospitals also have population responsibilities. Their
responsibility is not only to the patient that lies in front of
them. If we get to that stage, then I think it is possible to
prioritise care.
I will give you a little example from Kingston. There
is a map of variability, which was published recently by Muir
Gray, which looked at levels of things like major joint replacements.
In Kingston, for example, we have one of the highest incidences
of joint replacements in the country. So unless the population
is markedly different—and having lived there all my life
I have not noticed an enormous difference between there and here—or
there is something special about that population, we are clearly
devoting too much resource in that single area. By definition,
we are devoting too little resource somewhere else. The decisions
are never going to be easy, but this is the world we are in, and
it is true of the whole of the western world. We are no different
to anywhere else.
Dr Gerada: I would
agree with most of what Dr Alessi says. I am a scientist at heart,
I am doctor, and we have to be guided by evidencebased practice.
We have to plan local health services and in a cashlimited
budget we have to make decisions. I am far more concerned about
decisions, if you like, for mainstream healthcare than I am for
things that one could consider to be on the periphery, such as
homeopathy. So I am concerned about the resources for our basic,
everyday patients with chronic longterm illness, patients
with Alzheimer's, hip replacements, et cetera, but this
is what public health will inform us is what a good health service
needs and help us plan for.
Mike Sobanja: The
only response I can give you is—and once in my career I
was chief executive of a health authority, so I even predate
PCTs, and it was the same then as it is now—these are judgments
that have to be made. What I would observe is that what was missing
in the judgments that we made at a healthauthority level
is absolutely critical to getting the answer to your point about
transparency and accountability to local communities. Charles'
point about starting with finite resources and opportunity cost
we have to recognise. Choices have to be made. We have to invest
authority in somebody to make those choices. I would rather it
was local than national, but they have to be held to account and
to give the reasons why they made those choices. This notion of
free choice for every patient is cloud cuckoo land.
Q47 Chair: Can
I come in here? I would be interested in the reflections of the
four witnesses now in front of us, most of whom I think heard
most of the last session, about how you think that accountability
process is best discharged in the context of a GPled consortium
because there was a lot of debate about relationship with local
government, nonexecutive directors, elected members, et
cetera. It would be interesting to hear the views of this
panel about those questions.
Dr Gerada: I am
going to raise a question because it is something that I do not
understand. Local government will have a responsibility to its
community. That is its responsibility. But GP consortia will have
a responsibility to those registered on a GP list, which, with
the abolition of practice boundaries, are no longer the same.
In the first instance they may well be the same, but as this motors
on and as commissioning organisations become much more mature
and as patients become much more mature and move around, those
two will divide. What I would like clarification on is that GP
consortia are not responsible to their local community. The geographical
responsibility is being removed, whereas with local government
it remains. There is going to be a tension as things arise. So
with the issue about planning for health services in Kingston—maybe
Kingston might, because I suspect Kingston, and especially Surbiton
where you work, is a very affluent area so people probably don't
move in and out—you may end up with folk moving in because
the consortium offers different services or it hasn't overspent
its budget, or whatever. This confusion is one of the issues that
is coming from through from my members. There are many confusions
and paradoxes in the Bill, and I have to admit I have not read
the Bill line by line, but of the bits that I have read it doesn't
all add up. Whilst we can say we are going to have a relationship
with our Health and Well-being Board, who is going to have a relationship
with the Health and Well-being Board? Is it going to be every
consortium that has a patient that is served by that particular
area or is it going to be just the majority of them? These are
questions that I would like to pose because we do not have the
answer for those.
Q48 Chair: There
has been some clarification, hasn't there, in the sense that each
consortium, in addition to being able to accept members from out
of area, will have a precise and a "monopoly" responsibility
for a specific geographical community?
Dr Gerada: It is
not clear because it is not clear who will mandate that. With
the Secretary of State devolving responsibility now back down
to GP consortia, who are in a sense going to be commercial organisations,
it is not clear. Again, that is a clarification: Who is responsible
for the healthcare of the entire population?
Mike Sobanja: If
I can return to your original point—I am sorry, Peter—it
seems to me that on the conversation I was hearing before, first
of all we have to get arrangements in for both citizen involvement
on priority setting, the opportunity cost issues, et cetera,
and patient involvement in designing individual services. That
seems to me to be a spectrum, and there is everything in between.
I have already said that I believe there should be independent
directors on GP commissioning consortia, decisionmaking
bodies—boards, if you like, but we don't know that they
are going to have boards in every case—and I think that
is important not only from a democratic legitimacy point of view
but also from a governance point of view. External challenge is
healthy on that.
What I was trying to say before about the holding
to account is, again—and you will forgive me if I go back
to my previous experience on a health authority—we had lots
of process measures to do on public accountability and so on and,
frankly, it wasn't difficult to tick all the boxes. What would
have been far more effective, in my view, in moving my own authority
in engaging local communities, is if the then regional health
authority had said to us "Demonstrate that you have meaningfully
engaged your local community in your prioritymaking decisions.
We are not going to tell you how to do it. Demonstrate it and
we will hold to you account". I get quite concerned about
people wanting to specify again and again how everything should
be done as opposed to getting to the outcome in this matter as
with health and saying, "It is your job. Do it, and we hold
you to account."
Dr Carter: Can
I go back to how this particular theme started and its relation
to choice? You gave a very specific example of people wanting
Chinese therapies. This is an area which is going to create some
significant tension. The notion of patient choice has been highlighted
quite significantly and I think it has raised expectations. This
will not be new to GPs who have people coming into their surgeries,
having read something, suggesting that this is what they would
like. Of course, what happens time and time again is the GP will
discuss that with the patient and, if it is not appropriate, persuade
them that it is not appropriate. We know that.
However, in relation to people having their expectations
raised, can I give an example of when the drug Aricept first came
on the market, which is about 10 years ago? As people will know,
Aricept is a drug in relation to helping with Alzheimer's. When
that drug first came on the market, there was a huge amount of
comment in the media and there was a lot of enthusiasm that perhaps
at last a cure had been found for this most debilitating of diseases.
What happened in some areas was—at that time I was a trust
chief executive and I had huge contrasts—for example, in
the borough of Brent, in south Brent, the concept of Aricept just
didn't reach people, they weren't tuned into it. In another part
of the trust I was responsible for, South Kensington, almost immediately
the good readers of the newspapers were hounding their GPs, for
very understandable reasons, because they thought there was a
cure for Alzheimer's. Roll forward 10 years. What do we know?
We know that Aricept is a very good drug for some people in the
early stages of Alzheimer's. What it doesn't do is cure Alzheimer's.
But at that time some GPs were finding it very difficult to hold
the line and it was very helpful that NICE took an approach to
this, which was, if you like, as an arbiter. I think, in relation
to these current arrangements, it will raise people's view that
they have a right to demand, and that is going to be very difficult
for some GPs in some areas where you have a more informed community.
GPs are going to find it very difficult to handle that.
Dr Alessi: It would
be helpful to reflect on whether the present system we have at
the moment is as perfect as people make it out to be. I am always
amused by the fact that we are incredibly worried about the potential
risks of introducing change and we suddenly all assume that the
present system we have is so fantastic that any change may make
it a little worse than it is at the moment. I am terribly sorry
to disillusion you, but the present system we have doesn't work
very well. The fact is that we do need to change it.
In terms of how to change it and the accountability
issues which were brought up, these are things we are going to
have to feel our way along, certainly over the next few months,
before we can come up with a final view as to how this should
work. The Health and Well-being Board is particularly important
because if you really believe in localism and moving away from
a topdown management structure, this is where the action
will take place. But it has to be meaningful and with teeth. Whether
the consortium is accountable to a Health and Well-being Board
or merely—and it is an improper use of English—accounts
to the Health and Well-being Board is another matter altogether.
That relationship has to be really quite strong but there is a
balance somewhere and that balance is between allowing consortia
to actually develop and putting coils of assurance around them.
We are very good in the NHS at those coils. We have so many of
them at the moment that the thought of having even more in the
new world fills me with dread because I don't think we will actually
succeed if that happens.
Chair: I now have virtually
every member of the Committee and the panel of witnesses wanting
to contribute.
Dr Gerada: The
panel may want to ask a question.
Q49 Chair: Yes,
that's right. They want to ask questions of each other probably.
Mike, do you want to come in?
Mike Sobanja: Yes.
I was going to make the point that the accountability of consortia
is one thing. Once we have had a look at the accountability of
general practice and practitioners to the consortia as well, and
there is a key issue here about the resolution of the issues around
section 24(d) of the Bill, as it is currently written, which basically
confers a responsibility, as I read it, Chair—
Q50 Chair: You
enlighten us.
Mike Sobanja: —on
practices to act in a manner which is consistent with consortia
policy, there is a need to rationalise that with regard to GMC
requirements and also individual contracts which does not look
entirely clear at the moment. What I am saying is there is an
issue there, but accountability below consortia to practices is
as important as above consortia to local communities and whoever
else is involved.
Dr Carter: Very
briefly, I wanted to make the point that we, too, see the need
for change and we feel that commissioning has not worked. We want
these reforms to work, but at the moment there are real gaps and
real concerns about how it is hanging together. I will leave my
point there.
Q51 Nadine Dorries:
Dr Carter, last time you were here you were quite sceptical about
the scope and the role that will be available for nurses within
the new reforms. Having spoken, myself, to hundreds of GPs since
you were last here, would you not agree that there is a huge amount
of scope for developing the role of the nurse within the consortia?
In fact, some the doctors I have spoken to have talked about having
nurses being able to provide much more reactive sexual health
clinics, mental health counselling and the things that they can't
provide at the moment, but being able to do that as consortia
and focus on those areas where they see there is high cost and
where there are few resources channelled at the moment. Do you
get the feel yet from nurses that there are these exciting opportunities
which will be presenting themselves?
Dr Carter: Absolutely.
With the whole of the nurseled services, the integration,
there are real opportunities here. We don't want it left to chance
and what we don't want to see is a patchwork Health Service. That
is why we think that more should be embodied in statute to ensure
that nurses have adequate representation. What we don't want to
see is huge differentials in the performance of consortia and
then playing catchup. Now would be the time to ensure that
that happens.
Q52 Chair: Mr
Sobanja was saying earlier less emphasis on writing it into statute
and more on Commissioning Board guidance as the way of achieving
that.
Dr Carter: As I
have said—and I agreed with Mike—wherever it is embodied,
it is then about behavioural change, and the last thing we want
is tokenism. I do feel that the Bill really underestimates the
significant contribution that nursing has to make right throughout
the spectrum. Nurses are one of the few disciplines that follow
the patient throughout the pathway. It is for those reasons, and
it is not being parochial or nursecentric, we feel that
consortia would be well advised to have nurses at the centre of
it and, as the current arrangements are, it will be very much
left to local choice.
Q53 Nadine Dorries:
I totally agree with you, but I would take issue on your comment
about patchwork provision. There is going to be patchwork provision
because the needs of central Hackney are going to be very different
from the needs of central Gloucestershire. There is going to be
patchwork provision across the country because what will need
to be applied and resourced is what the area needs and demands.
So that will happen. To throw it back to you, can you give me
a line that you would like to see, taking your words, in the Bill
which would do this? I don't see that you can actually write in
the Bill a line which would give the assurances that you want
because, if you do that, what you do then is exclude and restrict
the amount of scope that nurses could have within consortia. I
understand that it is not underwritten in statute, but you can
see, surely, that the possibilities across the country are there.
Dr Carter: May
I come back through the Chair? Of course I can see the opportunities.
Currently there is a patchwork in the NHS, and whilst I am quite
clear that with the previous Government there were some huge successes—and
so there should have been with the amount of money that was put
in—what we also know is that the health divide actually
got wider. My fear is that that would increase the likelihood
of that happening. In terms of the fragmentation of services and
the gap in health inequalities, we don't want to see that widening.
The Secretary of State is quite clear. He keeps saying
"No more top down. Let us have bottom up". But in relation
to the role of GPs, of whom I am a great fan—and I don't
mean that in a patronising way—the Secretary of State has
no problem with prescribing on the role of GPs. We don't see why
he has such a problem in prescribing on the role of nurses and
allied health professionals.
Q54 Nadine Dorries:
What if it was mandated that there should be a nurse on the board
of every consortium? Would that satisfy?
Dr Carter: It would.
Nadine Dorries: I feel
an amendment coming on.
Chair: Does anybody else
want to comment on that proposal, otherwise I think we might move
on?
Q55 Dr Wollaston:
I am very interested to hear from the panel how you feel about
the arrangements under the legislation for picking up underperforming
practices.
Dr Gerada: This
is again one of those areas that is a little confusing within
the Bill. At the moment the performance list sits with the PCT
and if the expectation that the performance list and therefore
the issue around performance is going to sit with the consortia,
it needs to be clear that there will not be then inherent conflicts
of interest. With the size of some consortia being little over
the size of a large practice—my practice is 15,000 and the
smallest consortium is about 16,000—you couldn't possibly
be assessing, or you could be assessing your own performance but
I think there may be inherent conflicts of interest within that.
What we would feel is that, wherever you sit on the performance
assessment of GPs, it ought to be transparent. The individuals
doing it, or the organisations doing it, need to have the respect
of the GPs that are doing it. With large consortia, clearly, the
600,000 or 500,000, you can sit it within there, but with smaller
ones you may need to do it with neighbouring ones.
The other issue is that they are also about "Performance
for what?" because we have already picked up the requirement
for practices to adhere to the commissioning decisions. This is
again moving things away from clinical performance under the GMC,
where our main role is responsibility to care for patients. There
is going to be a tension, and already my members are sending me
comments about the tension, of adhering to commissioning decisions
that may, for example, not be in the patient's best interest.
For example, the mandatory use of referral management centres.
For example, the competition, where competition and price are
equal—so we are having competition based on price not just
on quality. Those sorts of issues need, again, to be ironed out
once we start to look at performance issues and once we start
to roll this forward because they will inevitably create problems
as this rolls out and as the funding that we have becomes squeezed
and squeezed and squeezed so issues around stopping patients going
to hospital will become the priority of commissioning consortia
in order to release funds.
Dr Alessi: The
reforms are not only about commissioning but are also about primary
care itself, about making primary care more predictable in what
it does, in its outputs in particular, and allowing for the overengineering
that exists in secondary care to be reduced. Clearly if you know
exactly how a patient journey is going to be managed, and one
can rely on primary care to perform certain functions, perhaps
that level of overengineering that exists doesn't need to
be there. In terms of managing underperformance within primary
care per se, again there is a role for the Health and Well-being
Board. This is perhaps left field, but clearly if a Health and
Well-being Board is going to be satisfied with the results and
with the commissioning decisions which are made by a consortium—and
it has to be because if it is not, clearly, there is going to
be significant difficulty in getting that Health and Well-being
Board and the consortium to work together—it is going to
have the ability to refer that consortium for remedials, if necessary,
and that is at the end of a spectrum. The new world is about inclusion
in practices. We have been in a world whereby it felt more like
imposition, imposition of views of PCTs in many respects. The
stick around performance management is something which we are
going to have to use at some point, but this is a world whereby
we all have to be part of the same and, as such, we have to help
each other do that. Also—
Dr Gerada: I am
sorry to cut across. Therefore, we need a robust measure of measuring
performance. What I am concerned about is that what we hear about
is performances—take away clinical performance, but, for
example, on referral rates and on prescribing—and unless
they are robust, and at the moment they are not robust, you can
understand variation in performance. Clearly, there are some doctors
who perform incredibly badly and we need to use the current systems
which we have. We may need to look at some other systems, but
we need to be absolutely clear what performance we are talking
about. Otherwise, what we are going to end up with is GPs, such
as myself, such as anybody, "over-referring" because
I know more about a subject. We know that the more you know about
a speciality area, the more you refer. If we use referral management
centres and we stop patients being referred to the service of
their choice, we may inadvertently delay cancer diagnosis and
we may inadvertently cause underreferrals. We need to be
absolutely clear. From the Royal College of GPs, of course, we
look at this. This is part of our raison d'être. Standards
of general practice and performance of GPs we have looked at in
great detail and it is much more complicated than just saying
somebody has got an unacceptable variation in antibiotic prescribing.
Dr Alessi: We are
in a world, again, where we are assuming that we are perfect at
the moment. We have situations arising now where parts of Birmingham
are stopping patients being referred for musculoskeletal conditions
because the money is running out, and that is affecting the whole
population. We need to get better granularity and understanding
as to how we manage the referral process as well. I will stop
there.
Q56 Dr Wollaston:
Clare makes a very important point, that if you look at our gate-keeping
role, sometimes GPs can feel performance managed on the level
of referrals they make, but we also know that underreferral
for early diagnosis of cancer is just as bad. How you get that
balance right is going to be crucial.
Dr Gerada: And
to be mindful of it. Clearly, the Royal Colleges have a responsibility
in this. We must, and through the Academy of Royal Colleges we
will be looking at it, but we have to be absolutely careful that
we are not performance managing GPs where patients are going to
be put at risk.
Q57 Chair: Can
I go back a stage? In that debate, the thing that was accepted
between both Dr Gerada and Dr Alessi was the principle of performance
management from the consortium, which is, itself, one of the controversial
areas in these proposals.
Dr Gerada: If it
is a large consortium. We have concerns where you have small consortia
which are little more than practices performance managing. I would
not like my performance to be controlled by the practice up the
road.
Q58 Chair: No,
absolutely. But can I just be clear whether, on both parts, you
feel it is part of the job of the Commissioning Board, through
some structure, to performance manage the delivery of primary
care in this new world? That seems to me to be a very fundamental
question.
Dr Gerada: Yes.
Dr Alessi: Yes,
but at the very end of the spectrum. There is a lot of support—
Q59 Chair: Hang
on a second. Performance management—
Dr Gerada: Yes.
Chair: —is it elimination
of the dangerous or is it performance management across the bell
curve? Which is it?
Mike Sobanja: Chairman,
what you have to do here is think about the primary responsibility,
and the primary responsibility goes with the contractual holding,
for me. There are lots of other people to go in because this is
Matrix, there's CQC, there's the colleges, there's the local consortia
and so on. But what we all want to know—what I want to know
as a citizen and a taxpayer—is who should have acted when
something went wrong in the system, and obviously went wrong in
the system? I am thinking about Staffordshire. If you think about
that, from my point of view, everybody sat round and looked at
each other. I believe it is the commissioner you look at first
and foremost because they have the contractual responsibility.
There are lots of other things that have to feed into this, and
what I would wish to avoid is the confusion or diffusion of responsibility
for performance management, recognising there are lots of different
players to put something into the pot.
Q60 Chair: Can
I ask whether Dr Gerada and Dr Alessi agree with that or disagree
with it?
Dr Alessi: I am
very happy with that response.
Dr Gerada: I am
very happy with that response. I was just thinking, whilst Mike
was talking, that, of course, in the future consortia may not
be your local GPs coming together because, under the Bill, if
you have two or more people coming together to provide primary
care services, they may well be a consortia. So you are absolutely
right to question this. On the basis of that, I don't know the
answer, because if there is a corporation that is a consortia
you might then get them not as willing to look at their performance
as you might do, paradoxically, a group of GPs.
Q61 Chair: Mr
Sobanja, it is not just about eliminating the case of Mid Staffordshire
or any of the other highprofile examples, is it? It is also
about taking doctors' delivery of primary care across the whole
range of practice in order to challenge the people who are at
point 40 on the scale and who could be at point 60 on the scale
if they simply observed better practice guidelines.
Mike Sobanja: There
will be a curve of performance, and it is about moving the entire
curve.
Q62 Chair: Where
in this system does that responsibility lie? It is clear where
it lies for secondary care. Where does it lie for primary care?
Mike Sobanja: I
believe it should rest with the person who holds the contract,
which is the National Commissioning Board, supported by the commissioning
local consortia and others.
Q63 Dr Wollaston:
The problem, as I see it, is that their contracts are all being
held by the Commissioning Board, but it is unrealistic to think
of the Commissioning Board in London actually being responsible
for weeding out, if you like, poor doctors. There are two issues,
are there not? There is the issue of the poor doctor individually
that you want to protect patients from and the issue of performance
as a whole as to how we control costs—the point that Dr
Alessi was making about having the financial context to clinical
decision making. I am very interested in what you feel about the
role of the responsible officer that is currently with PCTs. Do
you think that should be in the commissioning consortia or should
that be at a more regional level or right up with the National
Health Service Commissioning Board?
Mike Sobanja: Are
we talking about the responsible officer or the accountable officer?
Dr Alessi: Both.
Dr Wollaston: I am sorry,
when we are talking about how we actually—
Mike Sobanja: Because
there is both.
Dr Wollaston: Yes. I am
talking about responsible officer in terms of—
Chair: The GMC.
Dr Wollaston: —the
GMCtype level.
Dr Gerada: There
has been lots of debate about this, and it is passing backwards
and forwards. The issue is because of the size of the consortia,
because this is what we are always trying to marry up. The debate
then is probably the responsible officer should sit at the National
Commissioning Board devolved down to a more local level because
if one assumes the National Commissioning Board is going to have
regional outposts, that is probably the best place for that person.
Q64 Chair: Are
we reinventing PCTs, or rather consortium clusters?
Dr Gerada: That
is what we would like to ask the Secretary of State. They do feel
very similar at some points.
Dr Carter: This
is another area of concern, that there is a lack of detail and
a lack of rigour. Whilst, of course, we want things to work and
work well, you have to have contingencies as to when things do
go wrong. Within the current arrangements, it is simply not readily
apparent to us where the accountability and responsibility should
lie. I agree with Dr Wollaston. There is a heck of a distance
between people sitting in London and deep out into the community,
even way down in Plymouth, with the lines of communication. That
is where we would advise the Secretary of State and the Government
to get some more rigour and some more detail into this.
Whilst I am on that theme, in relation to the financial
management, we, like many others, saw Sir David Nicholson's appearance
before you and we do feel that there is a need for a plan B as
to what happens if a consortium begins to get into financial trouble.
You have to work in that that is a possibility. Goodness knows,
I mentioned a few minutes ago, with all of the investment that
was put in in the last Government, you still had trusts and PCTs
getting into serious financial trouble. You marry that up with
taking 4% out a year for four consecutive years—these are
difficult financial times—and we would want to see, as I
say, much more detail as to what the default position is.
Q65 Chair: There
is another related subject, is there not, that we were talking
about, performance management of primary care and how that is
discharged in this new world, including some small consortia?
There is a related question, which is where service is being reconfigured
in a way that a particular practice or group of practices might
have a good idea in which they are themselves engaged and how
the commissioning process is seen to take place fairly but buying
something beyond general medical services from practices that
are members of a consortium. Mr Sobanja is nodding.
Mike Sobanja: I
am only nodding because of the recognition that it is a very difficult
area and tied up with "any willing provider", which
I would like to say something about, if I may. The issue there,
of course, is it would appear that Monitor would have a role in
crying foul should the consortia indulge in anticompetitive behaviour,
in the broadest sense. One of the issues there is, again, if the
primary purpose of redesigning the service is about improving
care to patients, improving integration, and so on, that, for
me, would trump the issue of anticompetitive behaviour, recognising
the statute to be complied with there. In that sense, to answer
your question, Monitor ought to be a servant of good commissioning,
not the determinant of good commissioning. The way the Bill is
currently set up, it could be that the reverse would be true.
Equally—and "any willing provider"
has been mentioned—if I may, "any willing provider"
was introduced as a procurement mechanism, not as a policy. Its
intention was, if my memory serves me correctly, to overcome a
situation where we might be tendering left, right and centre with
high transactional costs, et cetera. The issue is that
the way in which "any willing provider" operates in
the future, and at primary care as well as secondary care level,
is key to this. If "any willing provider" is triggered
by a commissioning desire, then it is satisfactory as an alternative
to tendering, i.e. let us get it back into being a procurement
mechanism. But if "any willing provider" is to operate
at any time such that any provider can enter the market, with
their licence from CQC and Monitor and must be given a contract
and not in response to a commissioning trigger, then it undermines
commissioning. What we have to do is put more weight behind commissioning,
at both primary and secondary care, not undermine it.
Dr Gerada: It is
a complex question. Of course, the greatest innovations have happened
when clinicians get together and see a need and then design services
to meet that need. Over the last 20 years, that is how change
has happened, certainly in areas where I work, and we must encourage
that. But at the same time, of course, we have to be mindful of
the conflict of interest. We also have to be mindful that patients
must not end up receiving secondrate services delivered
by primary care practitioners just because that seems to be pragmatic
at the time. My view is that this is where patients come in and
where patient groups come in because patients are going to be
our greatest advocates and the ones that will be there as the
break to anticompetitive behaviour in its rounder sense. Patients
will say, "Actually, doctor, I don't want to come to your
ENT service. I want to see a doctor who is a Royal College of
Surgeons ENT." So if we are going to make any change within
the Bill, it is actually using patients and patient groups to
protect us. How it is going to be done, again is for yourselves
to sort out because it is a question. We have all lived through
fundholding. We saw fundholding and some of the issues that that
threw up. Certainly, with GPs now holding £80 billion to
£100 billion worth of public money, we want to make sure
there is transparency but, at the same time, not stifle innovation.
Finally, before I finish, the Royal College of GPs
have supported the use of federations, which is actually groups
of GPs and others as provider organisations, so pulling in providers.
As federations, putting yourself forward in a position to tender
under an "any willing provider" or to put yourself up
as an "any willing provider" in the mechanism is exactly
the same as any other "any willing provider". We think
that is probably the best way forward.
Dr Alessi: In an
environment where resources are going to be ever more difficult
to obtain, there is no option but to think in terms of us working
with clinical colleagues to design new pathways. The duplication
that exists within healthcare is enormous and we all know it.
The handovers are the most problematic, and any system which develops
into a process, which, instead of lobbing a patient over a wall,
ends up with a warm handshake is something which we all would
support because that is what we really should be about.
Clearly, there is going to be a degree of scrutiny that is going to be necessary to ensure we don't enter into situations where there is a monopoly, but this is something we are going to have to feel our way through. There are significant concerns about this and significant debates about the transparency associated with this, but I don't think they should stop people looking to reform pathways or develop new pathways with secondary care, to ensure that a patient gets perhaps a better service than they get at the moment. In the end, I agree with Clare—the patient will be the arbiter—for the first time.
Dr Gerada: The
first time.
Dr Alessi: Today.
Dr Gerada: We are
both from Malta.
Chair: We have found a
source of agreement. That is good news. The way Dr Alessi answered
that question is a good trigger for some questions David Tredinnick
wants to ask about interface with social care, which is relevant
in this area as well.
Q66 David Tredinnick:
I don't know whether the Malta GC end of the table want to answer
these first or the other end of the table—and we will never
forget those convoys.
The Bill contains provisions to make it possible for foundation trusts and commissioning consortia to be designated as care trusts. Do you expect this to work? They will have responsibility for commissioning both health and social care. Thank you.
Dr Alessi: Shall
I start?
Chair: Yes, go on.
Dr Alessi: Absolutely,
of course. This is the way of the future. Unless we start to work
with social care in a far more constructive way, I don't think
we will succeed. In Kingston we have made significant advances
in getting social care and health care jointly commissioned. We
have a Health and Well-being Board already in existence. We have
met twice and the second meeting was quite lively, which is good
and positive. But these things are going to take a little time
because if there is something we have learnt over the years, a
lot of this is related to personal relationships and trust, and
trust, unfortunately, is not something which can develop overnight.
It takes quite a long time for that trust to develop between a
leader of a council, the chief executive of a local authority
and health. There are also the concerns about a local authority
"stealing" health moneys—to use a health term.
Having said that, I have fewer concerns about that, because we
all know that the nonhealth determinants of health are probably
at least as important as the health determinants of health.
Q67 David Tredinnick:
As we are running out of time, let me be as unhelpful as I can.
There is an issue here about these pooled budgets and, secondly,
how are we going to work a system where we have not got coterminosity
anymore between local authorities and the commissioners?
Dr Gerada: Absolutely.
David Tredinnick: What
are we going to do with the fixed and the variable together?
Dr Gerada: Again,
those are questions that we would like to have ironed out in the
Bill, because the more I read the Bill, the more I look at this,
I cannot marry up how the idea that we are abolishing practice
boundaries is going to improve the situation for our local population
and reduce health inequalities and in fact produce better quality
of care for patients. That, added with the "any willing provider",
is separating out the provider from the commissioner. There will
be no relationship, let us be clear, when we have 2,000 "any
willing providers". How can you have a local relationship
with them when in fact what the Royal College of GPs would want
is enough excellent providers, ideally from our local community,
so that we can work together and form relationships for the complex
chronic patients that we see every single day?
Q68 Chair: Dr
Gerada's view is that the principle of "any willing provider"
entrenches the difference between commissioner and provider and
between primary and other forms of health and social care.
Dr Gerada: Not
just my view, the College's view.
Chair: Okay, the Royal
College's view. I don't think that is necessarily the view of
every other witness on the panel. Either Dr Alessi or Mr Sobanja?
Mike Sobanja: No.
The NHS Alliance policy is saying that commissioning should remain
accountable to the public sector absolutely, and that is the benchmark;
that it is perfectly possible for "any willing provider",
in the way I described it before without going over that, to operate
and for that to be in the interests of patients. My observation
in some of the work I do in the commercial and the private sector
is that they are actually very good at working and building relationships
across supply chains in partnerships. It seems to me that that
is the issue. If I can go back to the social work question and
try to wrap that in, the Health Service and local authorities
have to learn to work across boundaries, not to remove boundaries.
The way I read that clause about care trusts is that where care
trusts are working well now let us not dismantle them. That is
fine. But I don't believe that that is going to be mainstream
in the future because we have to wrap in housing and education
as well as social work on those nonhealth determinants,
healthcare determinants of health, and make people work together
across those boundaries. But certainly the concept of competition
with providers, I believe, can be made to work in the public interest
and the benchmark is one of commissioning remaining a public-sector
accountability, not necessarily a provision.
Dr Carter: Can
I come in?
Chair: Yes.
Dr Carter: We are
totally committed to the concept of health and social care being
integrated. There has been a lot of good work and examples of
this in Northern Ireland over the years. In relation to my previous
specialty in mental health, there were huge developments from
the late 1990s onwards which has done so much to ameliorate many
of the problems that we saw with homicide, suicides and serious
incidents where health and social services were working together.
That is the right direction of travel. But I agree with Clare.
You now have a problem where you will not be having the coterminosity.
That will provide a huge set of challenges. Marry that up with
the "any willing provider" and the thing I would have
said, if I had got in earlier, is we don't have a problem with
it but our concerns are that, in such economic testing times,
we don't want to see cost at the expense of quality and people
going for the cheapest "any willing provider". That
is something that is going to have to be watched very carefully.
We also think that yet another problem has opened
up with the flexibility about choice of GPs, which, on the face
of it, is a very attractive proposition, and from one perspective
I couldn't disagree with it. However, potentially, unless it is
well managed, it will lead to a fragmentation of services. I commute
in from Hertfordshire every day to central London and it would
be very convenient for me to have my GP in central London. We
don't have the IT systems and the communication systems in order
to get the loop back. Therein lies a set of difficulties. Also
the Bill is absent on the kind of detail which I think perhaps
people think doesn't have to be in the Bill, but it will have
to be somewhere. How many times can someone change their GP—once
a year, once a month? It is simply silent on these things. Whilst
the critical mass of people will continue, I believe, with their
local surgery, it is actually around the edges that has the potential
to destabilise things. It is not what you do with 95% of the money,
it is what you do with 5% of the money that can tip you into an
over or under spending situation.
Q69 Valerie Vaz:
Apologies for going slightly offpiste, but I am asking very
simple questions. It is very good to have you here, Dr Alessi,
because you are a pathfinder, so I am quite concerned and I just
need to find out how it is all working. Presumably it is, is it?
Apologies to all my other colleagues who are very well versed
with the Health Service, but I suppose I am the lay person on
the Clapham omnibus. I would really like to know, just to pick
up the coterminosity point, are you aligned with your local authority?
Dr Alessi: We are
aligned with our local authority. Prior to the publication of
the legislation, we had already moved towards a one Kingstontype
approach, which actually brought the local authority and all the
GPs within the borough into one organisation. To a degree, we
are living in sin, which is always fun anyway, so we are part
of the PCT but the PCT devolved its responsibilities to us. We
are going through quite a difficult phase at the moment because,
clearly, we are going to have to moderate that through the journey
over the next 18 months and the challenge is to ensure we don't
lose the momentum that we have already developed. Our aircraft
has taken off. We don't want to go back, start again and start
assembling a new aircraft. That is the debate, between allowing
us to continue and levels of assurance that are perhaps deemed
to be necessary in terms of delegated responsibility.
Q70 Valerie Vaz:
In terms of budget, because presumably you were given a budget
to do this, how much were you given and who are you accountable
to for the budget?
Dr Alessi: Because
we are living in sin, the budget is the PCT's budget. The methodology
we have used is that we have used groups of GPs and other professionals,
including nurses, and physiotherapists in some cases as well,
to determine exactly how that money would be spent. The practitioners
have been very much more involved in clinical commissioning. What
this has shown already is that there was a level of incoherence
in terms of the contracting that existed before. The contracts
which the NHS are using are exceptionally complex and they are
basically standard contracts with codicils upon codicils added
to them. In the end, they contradict themselves so many times
that, in many respects, they are a licence for the providers rather
than for the commissioners. We need to change that.
Q71 Valerie Vaz:
Do you, as the pathfinder, have the budget, or is it still with
the PCT?
Dr Alessi: We cannot
legally hold the budget until we become a consortium—it
is with the PCT—but in actual fact we are as one. It is
quite an extraordinary situation. Somebody fell off a horse on
the way to Damascus. I am not quite sure who it was.
Q72 Valerie Vaz:
Exactly. In terms of what you do, how do you balance the individual
patient need with population need? How are you going to do that
and how do you do that?
Dr Alessi: Again,
public health is really important. We keep on going back to public
health, in terms of "Are we spending enough in respiratory
medicine? "Are we spending too little in a condition?"
"Why are we spending so much more to treat macular degeneration
than its prevalence would suggest that we should be spending?"
"What is going wrong?" Those are the challenges we are
trying to grasp at the moment.
Q73 Valerie Vaz:
As a pathfinder, how do you do that now? How are you balancing
your individual patient needs with the wider needs of the population?
Dr Alessi: What
we are spending most time doing at the moment is engaging with
all the practitioners in Kingston. A lot of this is not about
big meetings but onetoones, very small meetings, and
for us all to understand what we are supposed to be doing. The
moment that happens we are starting to come up with indicative
budgets for conditions, and I think that is the direction it will
take. At the moment, we are not doing it, clearly, because we
have just started. A little bit of time and a little bit of space.
Q74 Valerie Vaz:
You talked about quality and enhancing quality, because that is
the key thing. What levers do you have, as the pathfinder, for
enhancing quality?
Dr Alessi: It is
certainly in our interests to have the highest quality primary
care that exists because clearly the less activity that is referred
out, potentially the better use we will make of the resources
we have for our population. There is a vested interest for us
all to manage that quality together as long as we have public
health again to make sure that we don't undersell health to a
population, and the new world is not about saving out of a budget
but spending that budget as wisely as possible.
Q75 Valerie Vaz:
What levers do you have then?
Dr Alessi: These
are levers we are developing. You are talking about managing the
recalcitrant practice within a system, I think, are you not?
Valerie Vaz: Yes.
Dr Alessi: We do
not have a good system at the moment for doing that. We are trying
to develop perhaps a more supportive way of doing that in the
future and in the present.
Chair: I am conscious
that we are running out of time. Rosie wants to come in, so could
you ask your question and then perhaps each of the witnesses have
a final opportunity to respond to you and say anything else they
would like to say.
Rosie Cooper: I wanted
to take bigger part in this part of it but I have not been able
to.
Chair: Apologies.
Q76 Rosie Cooper:
No. I didn't want to just jump in this time because it is developing.
Frankly, when we were talking about the health and social care
interface and the way we go forward, people listening will be
thinking "If only". What is actually happening out there
is health and social care, delivered locally, will be starting
to mesh. The reality is that, with the financial constraints,
local authorities are delivering care at different levels and
it is reducing. That is really frightening. People moving house
will suddenly find that care they have taken as normal has disappeared.
To go back to a little bit about the Commissioning
Board, it is going to delegate, or possibly delegate, some of
its responsibility for managing GPs down to consortia. I wondered
how wise you think that is. Who will hold the contract? The Commissioning
Board. Will that come down to consortia in part as well? The reason
I ask that question is, there is a huge question about how you
manage your colleagues. How do people performance manage you?
In essence, I am saying if you have a difficult doctor or practice,
how do you, as a consortia, think you will performance manage
them? And, for example, things like overseas locum GPs practising
in this country, as an example of where you already are, how are
you going to manage that out and who is going to be responsible?
Dr Gerada: Do you
want me to go first? The question is a very complex one, but practices
will have layers of clinical governance, so I do not think all
of this has to be devolved to a National Commissioning Board.
We need to make sure, at practice level, and this is what, through
the Royal College of GPs, we are talking about—practice
accreditation, and embedding clinical governance that's live—you
start to address performance as you go on day by day. Above that,
clearly you need some sort of performance management, and we would
say the NHS Commissioning Board, devolving that down to a reasonable
geographical area. I don't know what the answer is. I would imagine
about 400 GPs, that sort of an area—a natural larger community
than a commissioning consortium.
In terms of how you deal with the overseas doctors—it
is the EU doctors because others will be bound by different rules—again
that needs to be supported through the Royal College of GPs. We
have sent guidance out to every single PCT and to Strategic Health
Authorities about this, but that has to be a responsibility of
the National Commissioning Board, I think. Again, the devil is
going to be in the detail and where that is going to be determined
still needs to be sorted out.
Q77 Rosie Cooper:
I appreciate we are all looking for a black cat in a dark room
and I am praying someone will switch the light on.
Mike Sobanja: If
I came at that from a slightly different point of view, the National
Commissioning Board can delegate authority. It can't delegate
responsibility. That is one thing we have to be crystal clear
about. If I go back to the question before, the notion that this
National Commissioning Board is going to be sitting in London
and there will not be anything else, other than all of these consortia,
does make me smile because the certainties of life are life, death
and an intermediate tier in the NHS. I do believe that they will
be there long term and there will be lots of them, and a lot more
than people actually think.
Dr Carter: Strategic
Health Authorities maybe.
Mike Sobanja: But
there difference here—
Q78 Rosie Cooper:
Where's the money coming from? Hang on. We are all describing
how we think it will pan out. Where is the money coming from?
Dr Carter: And
where is the detail?
Dr Gerada: That
is again over to yourself and the scrutiny of the Bill.
Q79 Rosie Cooper:
No, we are chasing it just as much as you are.
Dr Gerada: There
will be no money. In a sense, the GP commissioning consortia cannot
be as many because you have all the transaction costs of just
keeping many, many more GP consortia going than we have currently
got PCTs, but the money will no doubt have to be taken out of
the management structures of those.
Q80 Rosie Cooper:
So it will come out of patient care in the end.
Chair: Order.
Dr Gerada: It probably
will come out of patient care in the end.
Rosie Cooper: It will
come out of patient care.
Dr Gerada: Transactions
will have to come out of patient care.
Rosie Cooper: Services
will be reduced by this. It is ridiculous.
Chair: Mr Sobanja was
about—
Mike Sobanja: I
was about to say my belief is that the commissioning of outofhours
services, if that is where you were directing your comments to,
will rest with consortia and they will have a fundamental responsibility,
of course aided by the various regulators and supporters and all
of that particular mechanism. But I go back to this absolutely
fundamental point. The National Commissioning Board can delegate
what it likes, but it cannot delegate the responsibility and nor
should it be allowed to do so, and that is why David Nicholson
will have a direct line to the Public Accounts Committee in terms
of value for money and quality of service.
Q81 Chair: Concluding
comments—and to my two colleagues, we have to all sit here
because otherwise we are not quorate.
Dr Alessi: A very
quick comment. There is a balance to be had between the levels
of assurance that are going to be designed and operational issues
in the NHS. Clearly we are moving into a world whereby there is
going to be less resource, hence we are going to have, as a nation,
to accept there may be an element of risk which is greater and
that element of risk may be worth paying if the delivery is going
to be so much greater. That is a debate we are going to have to
all have.
Rosie Cooper: "If"
is a very big word.
Dr Alessi: I know
it is a very big word and I am very happy to come back and talk
about it again. Thank you.
Chair: You might well
find you are taken up on that.
Dr Gerada: We need
to learn from pathfinders. Many of the pathfinders such as Dr
Alessi have been doing it for many years. They have put systems
together but what we must not do is fall into the trap that what
works in Surbiton is going to work in Southwark.
Dr Alessi: Indeed.
Mike Sobanja: I
like the direction of travel. Perhaps slightly different to Peter,
I don't want to see everything written into the Bill. My past
experience of Bills, which are hugely detailed—and heaven
knows this one is detailed enough in terms of size and so on—is
that that is unhelpful. I would like some answers to some of the
questions about secondary legislation about directions and regulations
which will colour in some of the detail that we are all looking
for. I am not convinced that it should be in the Bill.
Dr Carter: Very
briefly, the issue to do with evaluating Pathfinders is something
that is very important to us. The RCN were at the forefront of
wanting pilots, and Pathfinders is a euphemism for pilots, and
we would like that evaluated because that is key to this.
There is something else which at some stage I would ask, if I may, that you and your colleagues could look at, and if there had been more time today we would like to have. It is the issue to do with if a consortium has a surplus. What happens to that? We feel very strongly that any surplus should be reinvested back into healthcare and should not be part of a profit for the consortia to then be converted to salaries, even if that went to nurses and others. So, to be crystal clear, if people are doing a good job, they make better use of the money and there is a surplus, that is taxpayers' money. It should be spent on healthcare not on salaries.
Chair: In the legal profession,
it is known as the clients' account. It is a fairly simple proposition.
It is not difficult to police in reality. Thank you very much.
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