Examination of Witnesses (Questions 189-239)
Q189 Q189 Chair:
Ladies and gentlemen, thank you very much for coming. Welcome
to the Committee and welcome in particular, if I may say so, to
Dr Colvin. We visited Hackney, enjoyed the visit and look forward
to hearing what you have to say further, as well as your colleagues
on the panel. Could I ask you briefly to introduce yourselves
and then we will get the evidence session underway?
Dr Colvin: I am
Deborah Colvin. I am a GP in City and Hackney PCT.
Christopher Long:
My name is Chris Long. I am the Chief Executive of NHS Hull. I
am now—since last Thursday—the Chief Executive of
the Humber cluster of primary care trusts.
Dr Lovett: I am
Margaret Lovett. I am a GP and acting chair of the NHS Hull consortium.
Dr Weaving: I am
Peter Weaving, cochair of the Cumbria Senate consortium.
Q190 Q190 Chair:
Thank you. I should have said to you, Dr Weaving, welcome back
to your second session with the Committee.
I would like to open the discussion, if I may, with
a fairly general question which relates to the three health economies
represented here. I would ask you to identify what you think are
the key differences, and equally the key similarities, in the
world before this Bill process started and the world that will
result from the implementation of the various proposals that are
now being worked through. In other words, what difference is
all of this going to make in the context of your own local health
economy? If I may, I would like to start with Hull and then move
to the other two. What are the key differences and similarities?
Christopher Long:
Thank you. We have got a bit of phasing, haven't we? The first
phase is how we move between now and 2013. The real challenges
there, as we manage that transition, are, first of all, the loss
of quite significant numbers of staff in the primary care trusts.
I am losing about one quarter of my staff over the next four weeks
to redundancies, to achieve the management cost reduction targets,
and we are going through an exercise that feels like we are getting
rid of the bureaucrats but we are not minimising the bureaucracy
as a consequence of that. So I have some concerns about how we
manage upwards as we move through the transition.
Then there is how we work with general practitioners
locally to develop them to get ready to take this over, and I
have confidence in that because we have a good group of engaged
GPs working on that particular agenda. And then there is the macroclimate
we are working in. Pressures are starting to emerge in providers
due to reductions in the tariff and some of the inflationary pressures
and the fact that our local authority has had to reduce its budgets
by £76 million this year, nearly 25% of its total revenues.
There is a real challenge there as we move through.
The next bit, having got to 2013 and the point where
the GPs are leading, is: what is the net difference going to be
on top of if we hadn't done anything? That is the great unanswered
question. I will be looking forward to watching that as we move
through into the next election.
Q191 Q191 Chair:
That is, in a sense, the core question I am asking, trying to
separate out the changes that are coming because of resource pressures—which
we refer to as the "Nicholson challenge", which is something
quite outside the legislative process—and how much is changing
as a result of the legislative process. One thing you said that
I latched on to was that we are reducing bureaucrats without reducing
bureaucracy.
Christopher Long:
Yes.
Q192 Q192 Chair:
That is not necessarily good news. The other was your comment
about your work with the GP community, and I wondered as to the
extent that was work going on anyway and whether it is going to
end up in a different place from where it would have done if this
legislation had not been proposed.
Christopher Long:
Yes. Inevitably, as we move through change in a period like this,
we are going to see an increasing and tightening central grip
on things. That is completely understandable. There is a huge
amount at stake as we move through the transition. We had very
good engagement with GPs anyway; we had very good GP leadership;
we had a devolved locality model in Hull, where we had three localities
chaired by general practitioners—and Margaret was one of
those—and we had a lot of clinical involvement, in both
primary and secondary care, in terms of designing the goals and
our actions for our strategies. I don't think we are going to
see a significant increase in the amount of clinical engagement
in the short to medium term as a consequence of these changes
over and above where we were already. I accept that Hull might
have been a bit further ahead of some others in that particular
regard, but by no means all. Where we see a range of performance
across 152 primary care trusts now, I think we will see a range
of performance across 200 to 300 commissioning consortia in four
or five years' time.
Q193 Q193 Chair:
Would Dr Lovett like to comment?
Dr Lovett: Yes.
The change that there might be is more interaction between primary
and secondary care, which there hasn't really been, for the simple
reason that, if we are going to make any changes, it is that communication
between primary care and hospital doctors which will make the
difference.
Dr Weaving: I would
like to start by going even further back. Ten years ago I was
the executive chair of a PCT, a PEC chair, and there we basically
ran community services. We did no realistic commissioning. In
Cumbria we have had a journey of three or four years of realistic
clinical engagement in commissioning, gradually increasing over
that time. We are now at the situation where, in a way, I don't
want to see big changes occurring in the next year or two. I want
to see a continuation of the journey we have made whereby I can
sit down with colleagues in secondary care and say, "This
is the patient pathway. This will get us the best deal. What do
we need to do to put in place this commissioned service?",
and then do it.
For me, that has been the real improvement over the
last three for four years and that is what I want to see continuing—clinical
engagement on both sides, primary and secondary care, with appropriate
input from patients in terms of their experiences and also their
preferences. That is how I would like to see this evolving in
the future. The systems and structures, as described, provide
a framework within which that can happen, but, at the end of the
day, it is the engagement and the active participation of those
clinicians which will be key to making it happen.
Dr Colvin: We have
also been engaging very closely with secondary care and we have
been able to make some changes. I don't know whether you noticed,
in the Health Service Journal we were one of five PCTs
in London that has reduced outpatients this year, whereas with
most PCTs the GPs have increased outpatient referrals. We have
done that through working extremely closely with secondary care
and it has been a lot of hard work. My worry is that this process
is going to start to slow that down. As foundation trusts feel
more threatened—as, no doubt, they will with decreasing
resources—it is going to be harder for them to work with
us. We are already beginning to see signs of that. Clinicians
are saying, "I quite agree we could do this better this way,
but what impact will it have on our income as a foundation trust?"
I am worried that all the close clinical working may start to
slow down, and that would be a huge loss to everybody.
My other worry, in relation to three or four years'
time, is that I am very concerned about equity. In City and Hackney
we will have two separate consortia. What are we going to do when
the patients of those consortia have different quality services?
I can't see how the general public are going to understand this
and I can't quite see how it is going to benefit anybody. It is
a National Health Service and all patients should have the same
service.
Q194 Q194 Chair:
Why would the emergence of two consortia lead necessarily to different
levels of quality of care for their patients?
Dr Colvin: I have
no doubt that different consortia will have different ideas about
the best way to do things for their patients—and they may
have very good reasons behind that—but if you have two people
living in the same street and one consortia has a different offering
on the plate it is going to cause a lot of difficulty.
Q195 Q195 Rosie Cooper:
If I may, I will ask a general question of you all and then a
particular question of Dr Weaving. How satisfied is each of you
that your local health economy will be in financial balance by
2013 and that the consortia will not inherit debt?
Christopher Long:
Hull will be in financial balance by 2013. There will be no inherited
debt for the consortia.
Q196 Q196 Rosie Cooper:
You are absolutely sure. What do you think generally? Do you think
there will be a PCT, or clusters and consortia that are in difficulty?
Christopher Long:
I think there will be difficulties. The fine line between being
in recurrent balance and in recurrent balance because you have
had to take extraordinary nonrecurrent means to get you
to recurrent balance on a yearbyyear basis is going
to be where the debate is. The focus is very much on ensuring
people are in financial balance and—not in Hull, I am pleased
to say, but in one or two other places—they might have to
do some fairly unpalatable short-term things to achieve that.
Dr Colvin: We have
a £30 million gap to reconcile in City and Hackney,[1]
and that is going to mean some dramatic changes in what we can
offer. We are in a better position than some neighbouring PCTs,
but, again, I worry about the effect of PCTs with big hospitals
that have been built with PFI and have those huge costs to deal
with. I don't quite see how that is going to pan out and how the
citizens living in those boroughs, if we are going to get rid
of the overspend, will get the same level of health care as those
where there isn't a PFI going on.
Q197 Q197 Rosie Cooper:
I am putting you on the spot, but I don't wish to be difficult.
How do you see that £30 million in terms of the difference
in patient care? How do you think you are going to really address
that?
Dr Colvin: We are
going to have to address it by looking very closely at the things
perhaps people can't have. That is what worries me every time
you hear politicians talk about "patient choice". If
you are somebody with problems of infertility and you want to
have as many goes as you can for treatment, that is your choice.
But how are we going to fund that? We are not going to be able
to. We are going to have to say, "No. You can have two goes."
We are going to have to make those decisions.
Q198 Q198 Rosie Cooper:
Are there any other others you can think of that would probably
be at the forefront of that rationing?
Dr Colvin: Personally,
I think we should look very closely at prescribing. Probably we
could save quite a lot of money on prescribing.
Q199 Q199 Rosie Cooper:
Saving money on prescribing is not necessarily a bad thing, is
it?
Dr Colvin: No,
it isn't, but, again, it is having that public debate with the
nation and saying, "What is important to us all?" We
can't all have everything all the time. We have to make choices.
Patient choice doesn't mean getting what you want. It means getting
what is important.
Q200 Q200 Rosie Cooper:
From a narrower field.
Dr Colvin: I think
generally.
Dr Weaving: We
will have a gap at the end of this year, not a big one but a definite
gap. We have a plan that we will have no gap by 2013. For me,
the more important question is why the gap has arisen rather than
starting 2013 with a level playing field of financial balance.
That is no use to me if the issues within the organisations that
are going to take me back into financial deficit are still there.
I would be more concerned about finding out what the underlying
issues are rather than what the balance sheet says at the end
of the year.
Q201 Q201 Rosie Cooper:
Have you any idea what that imbalance will be at the end of the
year?
Dr Weaving: At
the end of this year it will probably be about £6 million.
Q202 Q202 Rosie Cooper:
Dr Weaving, if you look back, Cumbria has done really well. Can
I ask you where you think the Cumbrian economy would have been
if you had not had what I would see as considerable external support
in the past? Could you have got to where you are today without
that influx of cash?
Dr Weaving: Almost
certainly not. That influx of cash, right at the beginning, enabled
us to put in place some fairly radical plans for a whole closeathome
plan for improving the health economy. The challenges of Cumbria,
as I am sure you are well aware, are about rurality and deprivation
and the diseconomies of scale in trying to provide district general
hospital services from three sites for a population which would
support one. If you want to make ends meet and provide good quality
services for patients, you have to make it run extremely efficiently.
That means quite small, very effective, efficient DGHs and very
good community services to provide as much outofhospital
care as possible. You also have to make sure that your primary
care services are very focused on admission avoidance, good prescribing
and sensible referring. What we have seen over the years, with
that support, is reductions—
Q203 Q203 Rosie Cooper:
You are making my point really. Cumbria is considered to be superb.
It is wellquoted and all the rest of it. For that to happen,
you had external support. But in the health economy generally,
other areas are being asked to do that under the weight of the
Nicholson challenge and everything else which will not have that
external financial support. How are they going to do it?
Dr Weaving: I would
say our Nicholson challenge arrived four years earlier and that
is because of the diseconomies we have.
Q204 Q204 Rosie Cooper:
But you had that financial support to help you do it.
Dr Weaving: Yes.
How the—
Q205 Q205 Rosie Cooper:
Everywhere else is not going to get that pump priming, if you
like, to get them going.
Dr Weaving: Agreed.
To go back to Deborah's point about "Where is the money in
the system?", the money is in the system. It is not in management
costs. It is in what we already do in terms of our health spend—the
prescribing, the admitting emergencies and the referring of patients.
There are huge sums of money within that.
Q206 Q206 Rosie Cooper:
I don't disagree. The problem is how other parts of the health
economy are going to get to the point where you are without that
input of money. At the moment everybody is struggling, money is
coming out and they will not get that pump priming. But I would
also like to go on to ask you this: you are in a reasonably good
position now, with a possible £6 million gap at the end of
the year, what do you think will happen in Cumbria if GPs take
more and more work out of the acute sector without having an agreed
plan with the hospitals so that you can sustain what is acute
care, essentially?
Dr Weaving: If
you did it in an unplanned way, without complete signup
with your secondary care colleagues, it would fall over.
Q207 Q207 Rosie Cooper:
We are already hearing that foundation trusts and people are very
worried about income. You may have almost a willingness to achieve
an aim in the future with the trust not able to engage in the
way they would like because, if they do, there will be continuing
costs being taken away from them and they will fall over.
Dr Weaving: Yes.
It is a very adult conversation between primary and secondary
care and the public about "This is the amount of money that's
available. For you to survive as an organisation"—a
hospital or whatever—"you need this amount of money
coming in. We want these services to be provided from you."
The discussion, which is the core of this whole process, is about
how you make that work. I have that discussion with my colleagues
in secondary care with appropriate expertise, in terms of financial,
intelligent support and so on, and with the full understanding
of the public.
Q208 Q208 Rosie Cooper:
With an acute trust, the system is designed so that it will be
there and be financially viable, ergo Monitor, or it will not
be. If it isn't, it will either be taken over or it will not be
there for the people. Are you really saying to people, "Choose.
You can have me, your GP, or an acute hospital which is not 20
miles away but 40 or 50 miles away"? Is that what you are
really saying?
Dr Weaving: No.
What I have said to the people of Cumbria is that I guarantee
that, as a GP commissioner in Cumbria, they will have their district
general hospital where they want it, which is in Carlisle and
is in Whitehaven. I have said that.
Q209 Q209 Rosie Cooper:
But what if the money doesn't add up?
Dr Weaving: The
money does add up and the closetohome plan takes us
there.
Q210 Q210 Rosie Cooper:
You are sure that you have an agreed plan for the future of acute
services in Cumbria.
Dr Weaving: Indeed,
and I sit down on a regular basis with my secondary care colleagues.
Rosie Cooper: That's cool.
We will revisit that one.
Q211 Q211 Valerie Vaz:
The picture that is emerging so far is that there is lots of good
work going on, and you don't really need this disruption as GPs
and commissioners, et cetera. My specific question—and
I have heard from Dr Weaving and I met Dr Colvin—is really
designed for Hull. You must be doing something right because you
came top of the league in World Class Commissioning in 200910.
Why have you not joined the pathfinder process?
Dr Lovett: As a
consortium, we didn't see that there were any advantages to being
a pathfinder. There certainly weren't any advantages to patient
care to make us be a pathfinder. Ours is a fairly disparate group
of GPs with not everybody jumping, waving their flag about and
wanting to sign up and do things. The GPs leading the consortium
want to do it in a very considered fashion and let somebody else's
patients be the guinea pigs first.
Q212 Q212 Valerie Vaz:
The other specific question to all of you is: in this brave new
world that we are heading for—we don't know what is going
to happen at the end of it—who is making the decisions about
population medicine versus the individual patients?
Dr Colvin: That
is a very good question. It is a question I am sure we all think
about a lot because, of course, we are constantly faced with the
dilemma of what benefits the population as a whole. The benefits
to the person sitting in front of you may be so tiny that you
could argue whether it is beneficial or not. We have to make those
decisions all the time with patients and I'm not sure we always
do it very well. I'm not sure how you marry the two up because
if you ask the public—if you ask the person in front of
you, "Do you want this for yourself or not?"—their
answer will be very different from what public health tells us
would be good for the nation. It is a very difficult dilemma.
As GPs who have always worked with the patient in front of us,
and are their advocate, shifting to saying, "That might be
good for you, but for all of you in this area it's not good"
is going to be hard. The way we are going to have to do it is
to make sure we have the public working with us on this so that
these decisions are shared.
Christopher Long:
I will give a slightly different answer. World Class Commissioning,
at one level, didn't have a lot of fans. But what it did do was
bring an awful lot of structure and rigour to the way we work
that I thought was quite helpful. We worked very closely with
our colleagues in primary care, and indeed in secondary care,
as we identified what the big killers are in Hull and how we address
those. We also established a membership model, which is like but
better than the foundation trust membership model, for people
in Hull. We have about 8,000 people signed up as members out of
the city at the moment. We went out and did a very big consultation
with them. We went to one in six households across the city to
find out what their priorities and aims were. That helped us to
build a strategy in Hull, which, for those of you who don't know,
is an area of very uniform, high levels of deprivation. We are
the eleventh most deprived local authority in the country, which
is not a badge I wear with any pride.
If you look at the pathway we are commissioning,
which is about prevention, detection, diagnosis, treatment and
ongoing care, we were able to target our investments in those
areas in a way that will bring about a good impact. It is an impact
that people told us they wanted, that was coherent to professionals
and practitioners, both in primary and in secondary care, and
which had some science behind it in terms of the lives it would
save and the morbidity it would reduce.
As I say, in that respect, by bringing rigour to
the way that we worked, World Class Commissioning has been helpful.
You don't need to revisit that every year because you have a fiveyear
strategy lined out which has an accompanying investment plan to
make it work. That is one thing I would hate to see lost in this
change. In particular, I would hate to see that lost in the kind
of fragmentation of commissioning that we are going to see, with
some of it going to local authorities, some to the Commissioning
Board, some to Public Health England and some staying with the
GP consortia. It is about how you can continue with that incoherence
in the future.
Dr Lovett: I agree
with Chris. We have fairly common problems that extend across
the patch with regard to deprivation—people dying early
from things like cancer and ischaemic heart disease—and
most of our planning is done on those public health terms.
To get back to what happens when the patient is in
front of you, you make a decision each time. Usually there are
indicators you can call upon that would make you think, "Is
this person exceptional and therefore exceptional treatment is
required?", and not just for things like cosmetic surgery.
GPs do tend to make that decision bearing in mind the individual
patient that they are dealing with and tailor the treatment to
that individual patient. Unless somebody's demands are totally
unreasonable, GPs can fit patient demand in with the greater public
health initiative.
Q213 Q213 David Tredinnick:
I want to ask this to Mr Long. When you did your patient survey,
which is very interesting, and you came up with this preventative
care programme, did you ask them what types of treatment they
would like or did you just ask them what their problems were,
please?
Christopher Long:
It was more focused on what their problems were and what they
saw as the priorities. The thing that emerged, and the thing we
always have to balance when we ask that, is that we all know there
is a great fear of cancer in the community but the number one
killer in Hull is coronary heart disease. There is something about
how we tease out those answers and how we then balance that across.
In terms of the treatments, we didn't go down the
line of "Would you rather we fluoride the water or have seven
cycles of IVF?" We didn't think that was appropriate for
the work we were trying to do, which was fundamentally about reducing
mortality in the city.
Q214 Q214 David Tredinnick:
The Government has put some emphasis on choice, and I wondered
how you were addressing that. That is my last question.
Christopher Long:
It is about choice of who treats you rather than choice of where
you go. Hull is a very isolated community. We have about 32 square
miles of city surrounded by thousands and thousands of square
miles of green. People don't want to go anywhere else. They want
to have high quality services on their doorstep that are accessible
to them and suit them. That is the main choice they would exercise.
Q215 Q215 Dr Wollaston:
Could I return to the wider issue of clinical engagement, which
the panel have touched on at some point? I am wondering if all
of you could clarify whether, in your local area, practicebased
commissioning has engaged with nurses and secondary care and,
if so, what benefits that has brought. Furthermore, are the provisions
under the Health and Social Care Bill going to help or hinder
that engagement in each of your areas?
Dr Colvin: Practicebased
commissioning made us engage enormously. The work we have done
within our PBC organisation has been very exciting. We have involved
members of the public, nurses and practice managers and we have
a liaison committee with the hospital. We have done an enormous
amount of work with them. As you know, we have rewritten a lot
of pathways and we have consultant advice lines. It has been very
constructive.
We are just setting out on a piece of work to look
at urgent care and GPs working in A&E alongside the consultants
and learning from each other. It has been wonderful. But, as I
said to you before, my real anxiety now, as the foundation trusts
feel the pinch and become threatened, is how easy it is going
to be for them to continue. We had a very interesting discussion
with the gynaecologists about the value of some of their followup
appointments and whether or not they needed to see the patients
after certain procedures. We discussed whether it was necessary
or not, but they did then say, "If we stop, what is going
to happen to the department? How much can we take?" I know
we can think creatively about it and we can think around, "If
we freed up resources from this area you could move that money
into something more effective", and that is absolutely true.
I think that is what you were saying, that there is money in the
system and we just need to use it better.
To a certain extent, what politicians have not said
out loud to people is, "If you do this—if we are really
careful about how we use the money and we use it appropriately—there
has to be a loser somewhere." If our local hospital stops
doing lots of unnecessary outpatients and things like that, and
they can offer their services more widely to other boroughs, somewhere
out there is going to be another hospital which is losing. Somewhere
out there, eventually, one hospital is going to become financially
unable to continue. That may be appropriate. It may not. But that
is the consequence. We have to be honest about where it is going.
There is money in the system but we need to spend it in a better
way and there will be winners and losers.
Dr Lovett: With
regard to engagement of other partners, in the localities we had
practice nurses, optometrists, dentists and pharmacists. They
all had a say on things that went on in the locality. As a small
consortium, we did work with longterm conditions to reduce
the COPD readmissions. That worked quite successfully. It
was mainly, obviously, working with secondary care clinicians,
but the COPD thing was run by the longterm conditions nurses.
We also set up a community DVT service to reduce emergency admissions—just
for DVT. That was run by a nursing team. Obviously, we work very
closely with the nurses for palliative care so that people can
choose to die at home, with support.
Q216 Q216 Dr Wollaston:
To summarise, there is a wide range of clinicians involved at
the moment. In the future, do you see that getting worse or better?
Dr Lovett: I would
hope it would get better. Certainly, on the consortium board we
are going to have a practice manager and a practice nurse and
invite in other clinicians as required for specialist topics.
A lot of it is working more with the consultant. We have tended
to all be in our silos busily getting on with what we have to
get on with. It is that—communication—which has created
the problem and that is why pathway development is important.
It is hospital doctors and GPs getting their heads together that
is the key.
Q217 Q217 Dr Wollaston:
You see it happening on an informal basis, that, as a consortium,
you would invite secondary care colleagues and consult with them
but not have them—under the arrangements you can't have
them—on the board with you.
Dr Lovett: We haven't
firmly decided if there will be a hospital representative on there,
but we would invite them to do pieces of work in a specific area.
Dr Weaving: Before
answering the question about clinical engagement, could I return
to the very important point about the potential loss of public
health in GP commissioning? What I have learnt over the last few
years—and we are blessed with Professor John Ashton who
has turned us, the GP commissioners, into a group of very public
health-minded commissioners—is the old adage about "The
swamp is full of crocodiles. Keep shooting the crocodiles."
The crocodiles in Carlisle are that one person every other day
dying of lung cancer. You can continue to fail to treat those
or you can go upstream, in a public health sense, and do something
about smoking cessation and other issues.
If anything, GP commissioning has driven me closer
to public health and not further away. I appreciate that there
might be a separation of organisational structures around public
health but, very definitely, we see the future as being very closely
aligned with the public health agenda. Basically, the lifestyle
choices we make are the most significant factors that we need
to influence to improve our health in the future. We will still
need some hitech medicine, but, realistically, if we want
to improve health it will be at the preventative end of the agenda.
As to clinical engagement, none of this works, as
I said before, without clinical engagement. We have had two years
of largely GPfocused clinical engagement, with developing
links with secondary care which have become strong. In spite of
quite significant organisational changes, between us we have maintained
very good clinical links with our secondary care colleagues. On
a locality basis, we have opened the fold wider and we now have
the other health professionals involved. We have learnt, to our
cost, that if you don't involve a practice manager it doesn't
matter what the GPs say about what their practices will do. You
need the practice manager, the practice nurses and the community
staff and you need to have a dialogue and realistic involvement
with all of those in the way you are planning services and taking
the agenda forward. Clinical engagement is key and it does need
to be in a broad church.
Q218 Q218 Dr Wollaston:
The Royal College of Physicians is calling for mandatory involvement
of secondary care clinicians in commissioning. I am wondering
whether you see there are advantages and disadvantages in that.
Dr Weaving: I would
say, almost by definition, you will not get mandatory engagement.
If you legislate for it, people might tick the box. But it will
not happen.
Q219 Q219 Dr Wollaston:
Do you think it is best to do as you are all suggesting already
happens, that, de facto, no one is going to be able to commission
without involving them?
Dr Weaving: Yes.
Everybody needs do it but it needs to be realistic, people sitting
together saying, "These are the best clinical pathways",
"This is the most cost effective", "This gives
the best patient outcomes." How you put that into legislation
to make people do it, I don't know.
Dr Colvin: I would
also say to the Royal College of Physicians, "In that case,
let's have mandatory GPs on foundation trusts."
Dr Wollaston: Yes.
Q220 Q220 Chair:
Would it be fair to regard this as part of the standard operation
of a good consortium for which the consortium should be held to
account by the National Commissioning Board?
Dr Colvin: Yes.
Q221 Q221 Chair:
I say that with the representatives of the emerging Commissioning
Board sat behind you, but is that a fair description of how you
think the consortium relationship should evolve or not?
Dr Weaving: They
need to demonstrate realistic engagement.
Q222 Q222 Dr Wollaston:
Do you think that is something that should be looked at by the
Commissioning Board when they are reviewing performance?
Dr Weaving: Yes.
Dr Colvin: I absolutely
agree and we have done that, but I would also say that for many
years there has been a balance of power which has been very much
on the secondary care side. GPs do need to be able to make their
voices heard and secondary care needs to work with us, not feel
that they are running the show.
Q223 Q223 Chair:
Do you think there is a risk in these arrangements, which clearly
put primary care in the driving seat of the clinical engagement
process, in some parts of the primary care community that that
would lead them to place inadequate importance on their relationship
with the rest of the clinical community?
Dr Colvin: Yes,
I do.
Q224 Q224 Chair:
If so, how do you think that should be addressed?
Dr Colvin: I do,
absolutely. It is difficult, isn't it? How are we going to make
sure that we are safe and appropriate? At the end of the day,
always, you have to think about patient safety and them getting
the care they need. That has to be at the centre of everything,
and I know it is for everybody. But, you are talking about GPs.
GPs are like anybody else. They are like MPs. There are good ones
and bad ones.
Chair: It's nice to know
there are some good MPs.
Andrew George: Yes. Perhaps
we could name them.
Dr Colvin: We have
to have some system to make sure that consortia can't go wild
and harm patients. We do need secondary care looking in and helping
us do that.
Dr Weaving: There
is no harm in having the GP at the centre of that conversation
because they are quite useful in the sense that they know what
happens to their patients. People talk to them all the time about
their experiences of services. If I am going to change a service,
let us say, a cardiology service, I would want the advice of a
cardiologist. I would also want the advice of a financial expert
and a public health expert. But in terms of sitting in the middle,
it's not a bad place to be.
Q225 Q225 Dr Wollaston:
But how are you going to prevent the rogue consortia, if they
do emerge, from not consulting? How would you write that into
the Bill?
Dr Weaving: I would
say that a consortium which did not consult would not work. It
would not be able to operate.
Q226 Q226 Chair:
It comes back to the relationship with the Commissioning Board—quaere?
Dr Weaving: It
depends what the Commissioning Board puts in place to monitor
things which, in some ways, are as soft as professional relationships.
Christopher Long:
It comes back to how the whole regulatory framework is going to
operate in this regard. To talk about clinical engagement is important
but, in terms of secondary care, those clinicians are employees
of a business entity called "The Foundation Trust" or
something else. There has to be a mutual relationship, not just
on a cliniciantoclinician basis but organisation-to-organisation
as well, so that commissioners are aware of the impacts of their
actions on their supply chain. There has been quite a lot of debate
about the impact of the market—is it good or bad?—in
terms of this, but I think it is much more about supply chain
management than market management when you are a commissioner.
If you are an effective supply chain manager and you are working
with your supply chain to develop it to ensure that you are getting
a good quality product and to ensure you are getting productivity
gains out of your system, you are not working just to screw them
down to the last penny. Unless you have the willing signup
of the organisations and of those working in them who are responsible
for those pathways, it will not work. There is something not only
about how the Commissioning Board regulates the commissioners
but about the relationship between the Commissioning Board and
Monitor, where the early warning signs are in that too so that
we can have this mutual alert system going on across the entire
system, as opposed to in segments of it.
Q227 Q227 Chair:
Thank you. We need to move on, but Andrew has one question to
ask about referral.
Q228 Q228 Andrew George:
I am interested about a practical nutsandbolts aspect.
When you are referring patients on, to what extent is that informed
by the budget that is available?
Dr Lovett: Basically,
if a patient comes to see you and they need referring, you will
refer them. If you don't, you risk being sued. You don't refer
people for fun.
Q229 Q229 Andrew George:
No. Okay. I wanted an indication as to what kind of signals there
are to GP practices with regard to the available budget and your
general referring patterns. I wanted to find out to what extent
those referrals, those decisions, are informed by the financial
consequences of those decisions taken, because they are decisions
to refer and not, if you like, automatic actions, are they?
Dr Colvin: It is
slightly more complicated than that. You could refer the patient
on or you could say, depending on what the problem was, "I
will work this patient up. I will do the work." That is what
is difficult. There is a whole grey area of conditions where,
traditionally, GPs referred patients to hospital that they were
perfectly capable of looking after themselves. There are things
which, as you said, absolutely you have to refer to hospital because
they need to be looked after in hospital. I don't think cost would
come into it and it would never enter my mind to think about it.
But there are a number of cases where I think, "I could do
this myself" and it takes a lot of time and resources. What
we have been trying to do with our work in our PBC consortium
is to develop ways of doing more in the community so that we are
referring less. But somebody has to do the work. We are not saying
to the patient, "We will just do nothing." The decision
for me, sometimes, is almost, "Have I got the energy to do
what I need to do?" "Does it make sense for my practice
for me to be spending all this time doing this when I could refer
them?" It is quite complicated.
Q230 Q230 Andrew George:
Do the existing referral management arrangements that most PCTs
have in place, as well as the choose and book systems that exist,
help? Do you think that that helps GPs to inform them in terms
of the decisions that they are taking, because often you are overruled
by that management system?
Dr Colvin: We don't
have referral management systems.
Q231 Q231 Andrew George:
You don't have them?
Dr Colvin: No,
we don't. We have reduced our referrals without that.
Q232 Q232 Andrew George:
None of you?
Dr Weaving: We
don't run a referral centre where a GP cannot refer a patient
to a consultant specialist without going through a separate system.
What we have put in place is a very robust system of education,
best practice and evidencebased referrals. We have support
in each practice so that each practice is aware of how it behaves
as a practice using the finite resource that is available. It
is basically trying to make clinicians aware of the financial
consequences of their actions and also to get the best practice
in place. We benchmark practices against each other. They know
how they perform in this arena, as with everything else they do,
whether it is emergency admissions or prescribing behaviour. There
are reasons, some of which are driven by the needs of their patients
and some of which are driven by clinician behaviour. My role as
a GP commissioner is to tease out which are the ones which represent
good practice and which are the ones which indicate an area that
needs more support.
Q233 Q233 Andrew George:
In terms of the referral process itself—both now and presumably
as you see it in the future—it is one in which the only
way the budget comes into play is purely in retrospect. You have
retrospective information which informs you and which guides you
as to what would be an appropriate pattern of referral if you
are to meet your budget target. Is that right?
Dr Weaving: Yes.
Almost by definition, you have to measure it retrospectively.
Demand and behaviour are remarkably static, so you can see relatively
early on where the hot spots are going to be and take appropriate
steps to try and improve that situation. The intelligence is already
there. The key is to take it back to the individual clinician
because, as Dame Barbara said 10 years ago, it is the doctors
that are spending the money. They are making the referrals, prescribing
the drugs and admitting the emergencies and they need to have
a good understanding, and the GMC now specifies that it is a requirement
of a good clinician that they make appropriate use of resources.
All we are doing is giving them the information and the intelligence
and benchmarking them against their peers in a nonanonymised
way so they can see how they are doing.
Q234 Q234 Andrew George:
Does the existence and availability of patient choice to any extent
at all interfere or destabilise that process?
Dr Weaving: We
are looking at the number of referrals going wherever. We are
not interested in where the patients have chosen in that aspect
of the commissioning.
Q235 Q235 Andrew George:
What proportion overall, from your experience, take advantage
and become assertive in respect of their own entitlement to patient
choice? Is it a perishingly small proportion or is it used to
a large extent, in your experience?
Dr Weaving: I have
no problem with people asserting their authority on behalf of
their patient. Being a patient advocate is absolutely their role.
Q236 Q236 Andrew George:
No. I mean the patient themselves asserting their entitlement
to patient choice.
Dr Weaving: It's
a spectrum of human nature.
Q237 Q237 Andrew George:
Does it happen a great deal?
Dr Lovett: It does
happen, but certainly in Hull it is only a small percentage of
people who come in and say, "I want referring for x, y and
z."
Q238 Q238 Andrew George:
Is it less than 5%?
Dr Weaving: Yes.
I would say less than 5%.
Dr Colvin: Yes.
Dr Weaving: Indeed,
one of our referral criteria is either extreme anxiety or concern
from the patient that they wish to see a particular specialist
even if it is not clinically indicated. That is a reasonable reason
for referral.
Q239 Q239 Chair:
Could I ask, as a question of fact, whether Hull uses centralised
referral management, or do you rely on similarly decentralised—
Christopher Long:
It is similar to the Cumbrian model.
Chair: Thank you very
much. I would like to thank all four witnesses for your attendance.
We have a lot to think about. You have contributed some more.
Thank you very much.
1 Note by witness: I want it to be made clear
that this is £30 million over the next three years, not just
for this year. I'm sorry I didn't make that clear at the time. Back
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