Examination of Witnesses (Questions 334-390)
Q334 Chair: Good
morning. Thank you for coming to the Committee. In the first half
of this morning's session, we want to focus on the effect of the
changes proposed by the Government in the Health and Social Care
Bill on the management of reconfiguration of services within the
NHS. That is the main focus of this session. Could I ask the witnesses
to introduce themselves, briefly?
Alwen Williams:
Shall I start?
Chair: Yes. Thank you
very much.
Alwen Williams:
I am Alwen Williams. I am the Chief Executive for the inner north-east
London cluster of PCTs.
John Black: John
Black, President, Royal College of Surgeons.
Dr Hobday: Paul
Hobday. I have been a full-time GP in Kent for 30 years and—a
slight correction to the order paper—I am an ex-chair of
the local BMA.
Seán Boyle:
I am Seán Boyle. I am a Senior Research Fellow in LSE Health
at London School of Economics.
Q335 Chair: Thank
you very much. Could I ask you to begin the session by setting
out for the Committee, in general terms, your view, first, about
the importance, or lack of importance, possibly, if that is the
case you wish to argue—the relative importance—of
reconfiguration of services in delivering good value and high
quality health care? Is that something that ought to be a priority?
Secondly, whether or not it is a priority, what do you think is
the impact of the changes currently going through Parliament on
the ability and the methods the Health Service will use to manage
the reconfiguration of health care delivery? Shall we move from
left to right and start with Alwen Williams? Thank you.
Alwen Williams:
Thank you. My personal view, and very much from personal experience,
is that the reconfiguration of services is a priority. It is a
priority for a number of reasons, but principally to ensure the
delivery of effective clinical outcomes, good quality patient
experience and, in some cases, that NHS resources are used optimally.
In north-east London we have a number of examples where we have
transacted a reconfiguration of some specialised services, for
example, a heart attack centre, hyper acute stroke services and
trauma services. There is a clear evidence base in relation to
the impact of that reconfiguration in terms of patient outcomes.
In terms of the impact of the reforms, there will
be an issue as to how the functions of GP commissioning consortia
are transacted collectively around reconfiguration issues. Often
they are issues that require very close collaboration and partnership
across a range of commissioners. That depends on the nature of
the services being addressed, but one of the issues will be the
way in which GP commissioning consortia work together across broader
population bases and are held to account for the delivery of high
quality, effective and cost-efficient services on behalf of their
populations.
Q336 Chair: Do
your current responsibilities include Chase Farm?
Alwen Williams:
No.
Chair: In that case, I
won't ask you to comment on it.
John Black: The
reconfiguration of services is constantly with us as patient treatments
change. My college would take an attitude that if there is a clear
evidence base we would strongly support it—where there is
a clear evidence base. There are often, of course, very difficult
conflicts, politically, with providing a National Health Service
with some of the reconfigurations and centralisations of service
and we have to recognise that reconciliation of these two may
be exceedingly difficult. Remember Kidderminster.
The other point we would make is that if reconfiguration
has to be done on cost grounds—we are all grown ups and
we all recognise this—it should be made completely open
that a reconfiguration is being done on cost grounds and not on
improvement of service grounds.
Lastly, we would bitterly oppose reconfigurations
brought about by artificial outside influences, such as the European
Working Time Directive.
Dr Hobday: I would
fully agree with a lot that has been said. As GPs we feel—and
I feel from my own personal experience, particularly in Maidstone
where I practise—that we have been very much left out of
the process completely. It is only in recent days, since Mr Lansley's
announcement that we were to take the commissioning driving seat,
that the PCTs and the acute trusts woke up to consult us. Obviously
I would say that is a good thing. I feel GPs are in a position
to give good evidence for the value of the reconfiguration, considering
we see 90% of patients in the NHS and have over 300 million consultations
every year.
Locally, as to the four rules that Mr Lansley has
imposed, I have a very good example where all four rules have
been broken and GPs' opinions have been totally ignored. I would
hope that that would not continue to be the case.
Q337 Chair: Could
I ask you to comment on what Alwen Williams said, that there are
questions in the new world about the ability of GP consortia to
be large enough to look across the range of services required
to plan a large scale reconfiguration?
Dr Hobday: The
size of the consortia is one of the major questions I don't think
anybody has an answer to. Clearly, everybody knows that if they
are too small they have no influence and if they are too big they
lose the local value. In my years as a GP, having seen a dozen
or so reorganisations, from Family Practitioner Committees to
FHSAs, et cetera, they have continually followed this cycle
of starting off small, merging and then breaking up again. When
PCGs were first introduced, as a policy, that seemed favourable
because, initially, GPs were on board. But when they became PCTs,
they became far too large and lost their local influence. I really
have no answer to how big consortia ought to be.
My local example is that we have worked fairly
well in a local PBC group of about 112,000 patients and 70-something
GPs. We have had a little bit of influence in tinkering but, of
course, we had no great power against a giant local acute trust.
We have now merged with two other consortia to produce a group
of 361,000 patients and 252 GPs. We have already lost our local
"feel" and the people that are running these are self-selected
because no GPs have come forward yet to want to run them, apart
from the enthusiasts.
Q338 Nadine Dorries:
You just said that if consortia are too small they are not effective
and if they are too large they lose their local influence. That
conjures up a mental image of all the GPs practising in one place
and we know that they are going to be, still, in their individual
practices. Could you define what you mean by large consortia losing
local influence?
Dr Hobday: Locally,
I can give the best answer by quoting what has happened in Kent.
Our local trusts and the local area merged because it needed the
size to build a new PFI hospital. But it produced real divisions
in the whole area between the two main towns in our PCT group,
Maidstone and Tunbridge Wells, where there was almost warfare
between the two ends. Without decent co-operation, you cannot
produce decent services because people were coming from completely
different directions. That was when it was too big.
Q339 Nadine Dorries:
That is not exactly losing local influence, though, is it? That
implies something else. The GPs in those two groups were still
practising as GPs and I am sure the patients didn't receive any
better or lesser treatment because of what happened.
Dr Hobday: No,
but in the long run it influenced the services provided. For instance,
Maidstone has lost its consultant-led maternity unit against the
wishes of local GPs because they were put together with the Tunbridge
Wells GPs who had no interest in Maidstone.
Q340 Nadine Dorries:
And that is as a direct result of that?
Dr Hobday: That
is the direct result of the group getting too big and not local.
Chair: Could I bring in
Seán Boyle in answer to the original question?
Seán Boyle:
Yes. I don't think we should say that reconfiguration is necessarily
a good thing in itself. What we always need to do is look at the
case for reconfiguration and the case for change. That should
work in the best interests of the populations concerned. What
we should be doing is ensuring that businesses cases are presented
on a case-by-case basis with the clear evidence underlying each
part of the case. You need to look at a financial case but also
at access for populations as well as clinical quality and at deliverability,
if there are going to be major changes. This is a process which
we have had in the NHS for some time now and that is key to delivering
good change.
In terms of the country as a whole, we have
different practices in different parts of the country. That is
often a good thing, but you also have to recognise that, over
time, there are technological changes which mean you have to change
the way you do things. Colleagues on my right have said that,
and that is important. Always—and I suppose I would say
this—the evidence has to be clearly presented and it has
to be presented to the public so that people will feel they are
properly consulted on what is being proposed and will understand.
Often the public are treated like fools, but they do understand
a lot of the technical side of this. They can see what a trade-off
between access, cost and quality might mean. They also know when
they are not being given the real story.
Q341 Chair: There
are two different models here, aren't there? One is that the commissioner
is responsible for planning a reconfiguration of services and
the other is that the commissioner directs the patient to where
the patient is best treated and it is for the provider to plan
services in response to the referrals by GPs. Do you have an instinctive
preference for one of those routes or the other and do you think
that the Bill currently going through Parliament changes the balance
of that argument?
Seán Boyle:
To take the first point, I don't have a preference one way or
the other. I believe you need to present the case in a way which
makes clear the choices being made by professionals on behalf
of patients and then bring it back to patients for their view
to be taken account of.
I have been involved in a number of issues around
reconfigurations over the last 20 years in different parts of
England. The sort of choice I mean is that it may be, in order
to keep a maternity unit open or an A&E department open, you
need to spend another £1 million or £2 million. If you
present that as a choice to the public, that if you are going
to spend that on keeping local access then you are going to lose
something else, and make people aware of that, then the public
are making those choices. They are deciding whether or not their
local unit should close. They may well say, "No. We can see
the need to do that."
As to the changes, it remains unclear to me
what is going to happen in the future. Often, what is being proposed
is very similar to what we are doing already in terms of business
cases, consultation and changes round the edges about who is actually
doing things. You may come on in later questions to discuss the
structure of commissioning and these sorts of decisions and the
way in which local authorities will influence this.
Chair: That is exactly
where Mr George wishes to take us.
Q342 Andrew George:
That is good, yes. Could I begin by refining the term "reconfiguration"?
I am not aware of any community being up in arms or petitioning
against having a dialysis service closer to their home or having
a CT scanner in their local hospital whereas it was 50 miles away
or having an ophthalmic service in a smaller hospital closer to
them. When you are reconfiguring and bringing services closer
to people, those are pretty uncontentious. If we can refine the
term "reconfiguration" to the contentious side, which
is the concentration, the centralisation and the reduction in
numbers of centres providing those services, could you say how
you think the dynamics of centralising the services are best managed
under the new GP consortia arrangements? In other words, how will
decisions, as you see them, be made by GP consortia when we are
talking about the centralisation of services? To what extent will
they have a say in terms of that type of reconfiguration?
John Black: We
are slightly concerned about the gap between the National Commissioning
Board and the GP consortia about services that are not nearly
big enough for national commissioning, which is rare diseases
with two centres in the country, and areas where the average general
practitioner will often not see a patient. I can only speak with
any understanding of surgical services, but there are many surgical
specialties, such as cardiac surgery, paediatric surgery and neurosurgery,
which seem to work best when they are commissioned considering
the needs of a population of about 5 million people. I am not
saying there should be retention of any of the regional bureaucracies,
which most people would be quite pleased to see the back of, but
I do think there has to be some commissioning element looking
at it between the national basis and the GP consortia basis.
The model for this, of course, is cancer services
which have been centralised and we have seen improved outcomes
from that. Again, that was more or less done on that population
set-up. Cornwall have had that number of population. It is a point
that was made by Paul Hobday earlier.
Q343 Andrew George:
Yes. Can you see how that dynamic of the kind of grey area between
where the scale at which the GP consortia will be operating and
the management of national services by the NHS Commissioning Board
is going to be covered? Is that something in which you—any
of you—have had any kind of engagement in this process so
you can be clear about how those services are serving populations
of 1 million or more where you need to have that operating because,
clearly, there are not going to be any GP consortia at that scale.
A lot of them—and even in Cornwall, one pathfinder is 16,000.
John Black: There
is no reason why there should not be that sort of arrangement
in place. It doesn't have to be, physically, in any one place
and the clinician involvement is particularly important at that
sort of level. I see this as a gap we have been asking to be filled,
and not necessarily with a formal structure, but either at the
bottom end or the top end there should be some arrangements put
in place.
Q344 Andrew George:
How do you manage the dynamics between the clinical governance
issues that you are covering and local loyalty to one's hospital
and much loved local clinicians who, no doubt, people believe
can do almost anything? This is going to be made worse, is it
not, by a GP consortia structure which is at a very local scale?
There will be many more GP consortia than there are PCTs.
John Black: Yes.
Q345 Andrew George:
Therefore, they will be much more bound in to the aspirations
of their local community, perhaps.
John Black: This
is true. We saw this with fund holding, that the more distal based
commissioning is, i.e. the nearer it gets to the patient, the
more the local hospital is defended.
Q346 Andrew George:
Do any of the rest of you wish to comment?
Dr Hobday: Yes,
briefly, to add that, when the choice agenda appeared, my patients
said to me, "I don't really want choice. I want a good, local
district general hospital that is safe, clean and will produce
the basic services", which obviously includes maternity,
some general surgery, et cetera. We know that every district
general hospital won't be able to produce vascular surgery, cardiac
surgery, et cetera. On the GP commissioning basis, considering
when we refer one in 20 of our patients to secondary care and
most of those referrals are basic bread-and-butter stuff—they
are not for neurosurgery, et cetera—the majority
of our work relates to a local district general hospital. Clearly,
we have got to have contracts, or whatever it may be, to deal
with the supra specialist field. That is a small proportion but
it is one that may distort all these arguments if we are not careful.
Q347 Andrew George:
Do you feel that you and your colleagues are qualified to make
those kinds of judgments about the scale and the clinical governance
issues with regard to some services where the level of intervention
is perhaps a level above where the DGH will be?
Dr Hobday: We won't
be making those decisions on our own, of course. Our role as GPs
is to know when to consult and when to refer on when we have passed
our limit of expertise.
Q348 Andrew George:
But as a consortia what is the formal structure? Where will you
get that advice and when do you know when you need to seek that
advice?
Dr Hobday: From
experience, there will be a constant dialogue with our secondary
care colleagues.
Q349 Andrew George:
But would it not be better to have your secondary and tertiary
care colleagues on your commissioning board to help you make those
decisions?
Dr Hobday: Yes,
and I can't see any reason why not.
John Black: We
would strongly support that. In fact, if you called it clinician-led
commissioning rather than GP-led commissioning and merged the
secondary care sector and the primary care sector—and it
is already beginning to happen, which is slightly encouraging—
Q350 Andrew George:
I am sorry, can you explain more?
John Black: I was
told of a case recently in a town where the local GPs have arranged
to meet the local physicians prior to the new arrangements to
discuss how they are going to cut the number of emergency admissions
to hospital. That is just the sort of dialogue we would all wish
to see, with the sectors working together and the clinicians providing
the same advice.
Q351 Chair: Mr
Tredinnick wants to come in but, before you do, David, Alwen,
do you want to comment on these points?
Alwen Williams:
The points I would like to make are these. It feels to me that
where we have achieved success in terms of consensus around reconfiguration
goes back to John's earlier point about a very strong evidence
base. Where we can encourage and find ways of GPs and secondary
and tertiary care clinicians working well together in looking
at the whole system of care with a strong evidence base, certainly
my experience is clinicians will come out of their institutions
to look at the whole system and what is the best design of services
to produce the best clinical outcomes—the best use of NHS
resources.
We have examples in north-east London where we have
just been through a significant consultation on reconfiguration
of services. It has been very strongly clinically led and clinically
driven with strong patient involvement. When I talk about "clinically
led" it has not just been the GPs. It has been acute clinicians
as well. The outcomes that we have secured as a result of that,
building a consensus of what "good" would look like
for the health community but, again, clinicians engaging with
patients and patient groups in that process, feels to me to be
a sound model. We then need to think about how, potentially, we
could get that to work with the new commissioning and indeed provide
a landscape that is being developed.
Q352 David Tredinnick:
I wanted to take you up, Mr Black, on the point you made about
specialist services needing a catchment of 5 million people and,
also, that the links with commissioning structures are already
starting to happen. If you are going to have one neurosurgery
hospital serving 5 million people how do you get down to all these
different commissioning groups? Do you have a formal structure?
Have you got a representative or does each commissioning group
nominate a doctor who is responsible for talking to the neurosurgery
hospital? How does it actually work? I see a very hazy tree there
or inadequate coverage.
John Black: I see
a very hazy tree, too. There are two ways. The consortia themselves
could work as a group with those involved in providing the 5 million
size service or it could, of course, be done centrally on a virtual
level. The services that are required to be commissioned at that
level could be all organised centrally in a virtual way. For example,
if you look at the reconfiguration of children's cardiac surgery
that is going on at the moment, with support from us because there
is an evidence base, the location of the centres should have been
decided on a level playing field nationally, I would say.
Q353 David Tredinnick:
If you have different commissioning structures bidding for scarce
resources, who is the gatekeeper going to be? Do you decide that
this tumour is worse than another tumour? How do you evaluate
the actual pitch that different commissioners are making? You
might get a multiple application, like the Olympics, and you have
to say, "I will pick and choose one of those." I don't
want to be facetious. Maybe it is difficult to answer.
John Black: The
answer is you want clinician involvement from the appropriate
clinicians. I fully support the point. By "clinicians"
I don't mean doctors. I mean clinicians of all specialties. Nurse
clinicians are particularly important in various safety measures
such as setting nursing levels. One mechanism might well be for
that to happen nationally with clinician advice rather than coming
from two directions. But I share with you in that I am not at
all clear how that is going to work.
David Tredinnick: Thank
you.
John Black: But
it is not rocket science to produce some mechanism whereby it
could work.
Q354 Dr Wollaston:
With reconfigurations it is always difficult to persuade the public
of their case. Take an example in the south-west of reconfiguring
upper GI cancer services, which was initially unpopular but has
now been accepted. Subsequently, the evidence is clear and people
now accept that that was the right thing to do. I am interested
to hear from the panel how many reconfigurations in future will
be financially driven rather than clearly clinically led and how
difficult you think it will be to persuade the public of the need
for that to happen, say, in London which is over-provided with
hospitals.
Chair: Who would like
to go first? Dr Hobday.
Dr Hobday: Following
on, I would like to make a point that we refer to people not buildings.
The medical world is quite a small world, so I know the neurosurgeons
even though it is a big district, for instance.
On the arguments about whether it is financially
driven or not, we have a good example in the last 10 years again
in Maidstone. There was always total denial that the reconfiguration
of the surgical and orthopaedic services, and, later, the maternity
and the paediatrics, was a financial decision. But it has turned
out that it clearly was a financial decision and there was no
transparency for people to scrutinise it. The consequence is that,
in our area, there is now immense suspicion that the policy is
made and then the evidence is looked for, rather than the other
way round. That is widespread in my area. Transparency has got
to be there.
Q355 Dr Wollaston:
You think transparency is the key to this, being open with people
that this is a tough financial decision but "This is why
we are doing it".
Dr Hobday: Yes.
Locally, this reconfiguration may go to judicial review because
it is so contentious and there are so many faults in it, as far
as we can see. But when the trust has gone it is the same as when
the trust goes with the doctor-patient relationship. We have to
be incredibly careful there because the suspicions of the patients
will always be, "Are you doing this for financial reasons
rather than for my clinical good?" That is the small example
extended to the reconfiguration process.
Q356 Chair: Surely
the reality, in most of these decisions, is that it is a balance
of clinical and financial questions. It is a question of how you
get the best value for the money that is available, which will
always be limited.
Dr Hobday: Absolutely,
but admit that. In our local area that was not admitted. It was
always, "This is not a financial decision." It became
obvious, eventually, that it was.
Q357 Dr Wollaston:
Do you think it is going to be something that GPs, as commissioners,
will find easy to do—easier to do than perhaps has been
the case for PCTs?
Dr Hobday: That
is a very good question, of course, because PCTs were fairly impotent,
as they were in our area, to tackle the acute trusts. I don't
see how GP consortia will be much stronger, unless we go back
to the size issue and we have so much clout that, again, it covers
vast areas and vast population numbers.
Seán Boyle:
The issue about whether it is financially driven is often key
in terms of looking at changes and reconfiguration to services.
My view is that clinical arguments have often been used to mask
what have really been financial considerations in the past. I
know we are looking to the future now but you can learn from how
things were done in the past. If things were not done well in
the past, in terms of being transparent and in terms of your arguments,
which is what my colleague has been referring to, we should learn
from that and the Government should go forward committed to laying
out the arguments in a clear way.
The problem for me, always, has been that I
have never seen really good financial arguments put forward in
business cases in the NHS. I am not aware of major changes in
services—reconfigurations of services—that have resulted
in large savings or any savings within health economies. I have
not seen the evaluations of change that show you this. In fact,
if you look at what the National Audit Office does, it often looks
at changes which are supposed to realise benefits and they don't
realise benefits. Why is that? I don't believe business cases
are put forward in a way which is honest in the sense of saying,
"We are going to make these savings, we are going to improve
quality and we will be tested against this in the future."
Q358 Chair: It
is a very important point you are making. If it is true that service
reconfigurations are routinely carried out in order to achieve
better use of resources and you are saying, in the event, they
fail against that test, then that must undermine the case for
these reconfigurations as we consider them going forward, doesn't
it?
Seán Boyle:
I think they did fail that test. I have not seen evaluations which
show otherwise, is perhaps the way I should put it. I have seen
individual changes taking place where the NAO has shown some evidence
to this effect.
Going back to this notion of consortia, if we
think back to strategic health authorities, they drove a lot of
the reconfigurations. That is true. That is the way it worked.
PCTs were working locally but the framework within which they
were working was determined by the strategic health authorities.
The Commissioning Board is in a similar position, in a sense.
From my reading of the Bill, it will be determining whether or
not the plans of consortia will work for local populations, to
put it very crudely, and whether the way in which they interact
will work.
I personally believe that a Commissioning Board at
a national level cannot do that. I know, from the evidence of
David Nicholson last week, that he has hedged his bets a bit.
He said that the Commissioning Board will not be involved in reconfiguration
but, at the same time, that the Commissioning Board will have
people at local levels. I would predict that, within a couple
of years, what we will have are regional bodies as part of the
commissioning boards which might not be called anything but "Commissioning-Regional".
But they will be there to ensure that things are working appropriately
on the ground. Whether or not we go back to the command and control
system that we had under the previous Government depends on whether
the current Government wants to use the Commissioning Board in
that way. That is their choice. I will be interested to watch
what develops.
Q359 Chair: Would
any other member of the panel like to comment on that prediction?
John Black: I would
like to say that, where there is an evidence base, clearly bodies
such as the Royal College should be prepared to defend it. Sarah
has mentioned upper GI reconfigurations, of which we have made
certain recommendations. In that event, we should be prepared
to stand up and say so to the local population. Indeed, I remember
getting out of Rugby only just with my head on my shoulders a
few years ago. But that is a very good point because the history
of trust mergers in the National Health Service is that they don't
save money.
Q360 Chair: But
do they achieve better clinical standards? There are two justifications,
one is clinical and the other is financial. Do they achieve either
of their objectives? If they don't, then taking local patient
groups with us is going to be impossible because they are right.
John Black: You
could argue that in the City about all these mergers that go on
there. Do they actually improve anything for anybody? Pass.
Q361 Chair: Can
I ask Alwen Williams' views on this?
Alwen Williams:
Going back to the issue of whether this is financially led, I
would want to emphasise the point that this is about the best
use of NHS resource. Looking at the focus, that trusts and commissioners
and GPs are looking at efficient systems, we risk having too much
capacity in certain hospitals that would then not, in my view,
warrant a good use of NHS resource. Again, it is about how the
system plans that to ensure that, indeed, NHS resources are best
deployed.
There is also a link to increasing quality.
To a certain extent, a key driver for us has been increasingly
consultant-delivered services rather than consultant-led services—that
is key to improving the quality of patient outcomes—and
if we can achieve that within a best value approach, as opposed
to an incremental cost approach, when we know the reality is that
there are real constraints in terms of the financial allocations.
Again, I would say it is looking both at how you best choose NHS
resources in terms of the application to front-line services and
how you can also, at the same time, drive up the quality and cost-contain
for the future.
Q362 Dr Wollaston:
Can I come back to you on that point about consultant delivered
as opposed to consultant led and bring in John Black, who is sitting
next to you, because you also, earlier, touched on the issue of
the Working Time Directive? How effective do you think the new
arrangements will be in enabling primary and secondary care to
work together to deliver those outcomes?
Alwen Williams:
It is how we design the system. My concern is that one could design
a system that is pretty fragmented. You have touched on small
scale, potentially, GP commissioning consortia, in a set of relationships
that may be more about transactional contracting with NHS trusts
and foundation trusts. My view is that isn't going to deliver
the best NHS. It is very much about how commissioners play their
role and how providers play their role but we need to ensure that,
as we design the system, the system needs to be an integrated
offer. Only by doing that, I believe, are we going to continue
to improve quality of patient care, make the best use of financial
resources and not create, inadvertently, a system that is, in
a sense, at loggerheads with itself or, in a sense, so fragmented
it is unable to achieve large scale service change.
John Black: We
strongly support a consultant-delivered service where the service
is delivered by trained specialists assisted by people trained
to be consultants. It is inevitable because we now have enough
doctors coming out of UK medical schools to supply our own needs.
Like every other first world country, medical graduates will want
to have been properly trained to specialist level and to work
at that level. GP consortia commissioning with that stipulation
would be very valuable and, indeed—sorry I am going on a
bit—the old fund-holding practices sometimes used to stipulate
that they wanted their patients seen by consultants. The patient
group really do. The trouble is the patients do not know if they
are seeing a consultant or not, which is yet another issue we
might take up one day.
Q363 Valerie Vaz:
I want to fast forward. You have mentioned this elephant in the
room or the person looking over your shoulder in the shape of
Sir David Nicholson. I wondered, in terms of GP commissioning
in the future, whether you think it is going to be easier or more
difficult to drive through reconfigurations.
John Black: It
has always been difficult and will remain difficult. One of the
stresses in the Bill, which we were very pleased to see, was a
stress on measuring outcomes. If you measure outcomes, there should
be more evidence on which to base reconfigurations. Hard fact
is very difficult to argue against. For example, if all commissioners
had to insist that outcomes are measured as best they could, that,
in surgery, would be the biggest single measure you could do to
improve patient care.
The classic example of that is the cardiac database
where every cardiac operation, 10 years ago, with a bit of kicking
and screaming at first, was entered into a national database.
What happened? The outliers looked at themselves and there were
various reconfigurations driven by the profession, not by commissioners
or managers. The profession said, "We've got to reconfigure."
The outliers were eliminated and we now have the best cardiac
surgery results in Europe—probably the world. That could
be replicated, with proper outcome measures that could be put
into the Bill, if commissioning is absolutely based on outcomes.
The difficulty is that it is relatively easy in surgery but, of
course, very difficult in other areas. It is easy for me.
Dr Hobday: I would
add that, yes, we all fully agree with what John said about outcomes.
It is very easy, or easier, to measure in surgery but in mental
health and dermatology and all the other specialties how do you
measure outcomes? There is this over-emphasis, I believe, on outcomes
although we have to measure it somehow.
Q364 Valerie Vaz:
Do you think it is going to be easier or more difficult? You are
in the driving seat as GP commissioners. There may not be an answer.
It may be something else.
John Black: If
they were persuaded to make a condition of commissioning that
you measure the outcome, that would drive standards up inevitably
and I would hope to see that. In fact, the Bill does say "outcomes,
outcomes, outcomes" all the way through, which is good.
Dr Hobday: I believe
the devil is in the detail. When the White Paper on the Bill was
first published, a lot of GPs were in favour of it because there
was a simple statement that GPs were going to be put in the driving
seat of commissioning. As soon as the detail was looked at, now
there are polls that say the vast majority of GPs are against
it because of the conflicts of interest, et cetera. It
purely depends on the mechanics and nuts and bolts of how it is
going to be put into operation. If it is put into operation properly,
I believe reconfigurations and commissioning will be easier.
To add a further point, yes, referrals to consultants
are the sort of things that must be written into contracts. We
now have a situation, and have done for some years, where, as
I said earlier, we seem to be referring to buildings rather than
people. If we try to refer to named consultants we find our patients
in front of a nurse specialist. That sort of thing, in my opinion,
is one of the first things that will be stamped on if we ever
get the reins of commissioning.
Chair: Mr Boyle was shaking
his head.
Seán Boyle:
On that simple point, it doesn't have to be stamped on. Why should
it be stamped on?
Dr Hobday: For
choice—I am sorry.
Seán Boyle:
There are things which nurse specialists can do which they do
very well.
Dr Hobday: But
not without our saying so.
Seán Boyle:
What we are looking at here is a situation where we can deliver
the same quality of care more cheaply through using different
types of people. I think there will be no argument from the specialists,
from doctors, that they should be doing what they are specialised
in doing and that other professionals should be doing things which
they can do. That is why I was shaking my head, because a lot
of people are quite pleased to go to a nurse specialist rather
than to a consultant. That was my point.
Q365 Chair: Dr
Hobday's point, as I heard it, was that if you are referred to
see a consultant then it should be the original decision by the
GP rather than by the institution they are referred to.
Dr Hobday: Yes.
If I can clarify, I have no intention of knocking nurse practitioners
and nurse specialists because they do a good job when they have
the appropriate patient in front of them. I have nurse practitioners
in my practice and the skill is making sure that the right person
is seen by the right type of professional. But when, for instance,
I, myself, might refer somebody, after 30 years of experience,
and find that they are seen by a nurse practitioner who is aged
25 and has not got any experience, I would think, "I won't
bother referring in future." But the patient is then denied
a choice. Their choice is obviously that we are wanting to consult
somebody. That is where the phrase came from, "a consultant".
Q366 Valerie Vaz:
Do you see yourself doing it over a wide geographical area or
would it just be your local patch?
Dr Hobday: Mainly
within the patch but I do not see why, as long as we know the
specialist and know the reputation, people should not go further
afield. Again, when I first started practising there was no restriction
to where I referred patients. I could have sent somebody to Newcastle,
if I wished. In 1990 that was taken away so we had difficulty
referring to people of our choice. Then it became more generic.
We were referring to hospitals and to a named consultant but it
was all watered down and that patient was seen by whoever was
thought appropriate by the managers.
Q367 David Tredinnick:
Do you think the Commissioning Board is going to be out of touch
because so many services dealt with by the strategic health authority
are going to go out? I think Mr Boyle referred to the possibility
of command and control—they are just my notes—and
waiting to see how the Board operates. What is your instinct?
Do you think it is going to be way up there in the clouds and
a non-responsive body or do you think it will be a strong body
that oversees?
Seán Boyle:
My instinct is that it is going to operate strongly at a local
level. At the higher level we are talking, maybe, about £3.5
billion worth of activity—at a really specialised level.
Where the action is in terms of money is at a lower level in terms
of specialisation. My instinct is that the Commissioning Board
will be operating at that more local level. If it doesn't do that,
then it will not be able to work effectively, I would suggest.
I am not putting that forward as a model that
I would say, "This is the best model." I am saying I
think that that is the way it will work because that is what comes
out of the culture of the NHS eventually. There is a way that
things often fall back into an almost natural position in terms
of the management of things.
Alwen Williams:
It is early days, but as a cluster chief executive I can certainly
see the benefits of having a degree of a sub-regional structure
for the National Commissioning Board. That may need to be for
a transitional period when we look at the functions of the National
Commissioning Board in relation to direct commissioning in terms
of ensuring that GP consortia are developed and are transacting
their responsibilities fully. I can see in my role now, for example,
as a cluster chief executive with five GP commissioning consortia
in situ, that the cluster does play a role in brokering relationships
in the GP commissioning consortia coming together with acute clinicians
looking at how the system can be best managed. I am not, for one
minute, saying that necessarily has to be replicated in terms
of that geography but that approach, certainly in the medium term,
I can see working well, and particularly with the direct commissioning
responsibilities of the NCB.
Q368 Rosie Cooper:
What powers do you have? You talk about bringing people together
and getting them going but what powers, in your current role as
chief executive of a cluster, do you really have to knock heads
together to make something work?
Alwen Williams:
For the next two years—
Rosie Cooper: Please don't
use the word "influencing".
Alwen Williams:
My role as, in a sense, the accountable officer for—
Chair: You hold the chequebook.
Alwen Williams:
—the deployment of NHS resources, the contract held with
NHS trusts, and clearly a responsibility for the development of
GP commissioning consortia and an ambition to ensure that the
legacy handed over in 2013 is a good one from the cluster, means
that we have a range of current accountabilities and responsibilities
that enable us to do things in the way that we think is right
for patient care and in a way that enables strong clinical leadership
of that agenda.
Q369 Rosie Cooper:
Can I ask a quick question? The Secretary of State is saying that
some commissioning boards are coming together now and the inference
is that they are "commissioning". If, between now and
2013, you have boards which are moving towards, perhaps in 2012,
beginning to pull together a commissioning plan and you hold the
purse-strings, as we have just been told, could you veto any of
those plans? If so, what would that do to the emerging consortia?
How would they feel? What confidence would they have in themselves?
Alwen Williams:
I would say it is a sign of failure of my system if I got to a
position of having to veto a plan. There is a huge reliance on
good working relationships, trust and confidence and the GP commissioning
consortia having confidence in the management team of the cluster
to give strong advice to provide high quality commissioning support
services. Certainly in my experience of over 10 years as a PCT
and, latterly, a cluster chief executive, I have never been in
that position because you have to broker. You have to problem-solve
together and broker solutions together and a system that ends
up, in my view, either voting at a PCT board or vetoing someone's
plans feels, to me, a system that is clearly not working as well
as it should be.
Q370 Chris Skidmore:
A key part of a discussion we have had this morning has been to
look at laying out the argument for reconfiguration, whether that
is on the basis of cost or on the basis of clinical output. I
would be interested in what Mr Black had to say about that. But
I was also interested in to what extent Government can drive principles
of reconfiguration. The previous Government set out, in 2006,
that there should be a clinical case for change. I can't remember
what the mantra was but it was something like "localised
where possible, centralised where necessary". Since the coalition
Government has come in we have obviously seen Andrew Lansley's
four tests for the reconfiguration of services that were placed
under a moratorium and to what extent those tests will carry on
through will influence future programmes of reconfiguration. I
would be interested in your views on that. When it comes to outcomes,
which are not always empirically measurable, to what extent can
we have principles set by Government that can then be applied
over a wide geographic area where, obviously, there is a huge
degree of variation?
John Black: As
I said at the very beginning, reconfiguration is always going
to be with us because medicine changes. The way, where—the
place—and how patients are treated is fundamentally different,
even from 30 years ago. Defining principles is all that can be
done but it is never going to be easy because there is always
this conflict. We have a National Health Service and yet we want
to centralise the most important services, which doesn't mean
it is not national. Patients hate to travel.
I wish I knew the answer to this dilemma. It
is always going to be a dilemma and it is always going to be difficult.
As I keep saying—sorry—at least it should be done
on looking at outcomes on evidence rather than on finance and
politics. I think probably finance and politics are always going
to be with us.
Dr Hobday: The
trouble is that principles that start off at the DOH end up down
at the PCT being interpreted in amazingly imaginative ways and
in a way that suits the local PCT, perhaps. I don't want to go
on about Maidstone, but there is no trust in any trust around
Maidstone any more because certain things were interpreted and
used in a way that did not work or suit patients. Our experience
with the small PBC groups was that a lot of the good ideas were
blocked at that local level, despite the fact that it was in line
with what started off at the DOH as a good idea.
Seán Boyle:
There is not a standard—
Q371 Chris Skidmore:
Do you think those four key tests that Lansley set for the moratoria
of previous reconfigurations were effective? Some of them were
quite broad. I think only one of them was empirically measurable.
Seán Boyle:
They were a continuation of what was there already, really. Support
from GP commissioners. PCTs were always expected to support plans
and GPs were encouraged to become part of that support network
in order to put reconfigurations forward. Clarity on a clinical
evidence base. Who is going to say that you should not be clear
about that? Nobody. Strengthening public and patient engagement.
What does that mean? Not very much. If you look at what anybody
said over the last 20 years, everybody said that you are to involve
the public and often people have not done it very well. I am thinking
of that chap from the west country who did reviews.
Chair: Carruthers.
Seán Boyle:
Yes. Carruthers was called in to make recommendations. His recommendations
were, basically, "Do what you are supposed to do." Again,
the final one, consistency with current and prospective patients.
In my view, I would translate that as, "Analyse what the
historic patterns are and analyse what you think future patterns
of activity should or will be and try and match your services
to those." That is not rocket science but I was glad to see,
at that point, that quite a few were being reiterated but it was
a reiteration.
Q372 Chris Skidmore:
There is also an important difference, from now on, with any future
reconfiguration. That is, with the progress of the Bill, we will
have new providers entering the market and to what extent reconfiguration
will have to reflect that. I was wondering if you had any views
on whether future reconfigurations will necessarily have to reflect
the fact we have these new providers and that possible reconfigurations
in the future will be, in essence, breaking down large incumbent
providers and allowing new providers to enter into the market
and facilitating that with ease. Do you think that is a concern
or a reality in the new system?
John Black: There
is a level playing field for Any Willing Provider which means
they have to provide a comprehensive service. Certainly in surgery,
which is not by any means the whole of the NHS, I don't really
see many new providers coming in if they have to provide training,
education, audit, research, full emergency cover, measure their
outcomes and feed them back. It is unlikely, if cherry-picking
is stopped and the same standards are applied, that we would see
providers in surgery but there will be others on the panel who
will tell of other services where this could indeed happen.
Dr Hobday: Absolutely
crucial.
Q373 Chair: Could
you enlarge on that comment "absolutely crucial"?
Dr Hobday: The
worry of cherry-picking, frankly. We have seen plenty of examples
in Maidstone of outsourcing, as it is called: psychology and the
cataract service. The tick-box selection of patients by one of
the services was so annoying. They could say that they had seen
and dealt with a patient that needed counselling by ringing them
up and suggesting that they went off to Waterstones and bought
a book on stress management, and that qualified. The rump of the
NHS service was trying to deal with the really difficult psychiatric
cases. That is one example. The patient of mine that wanted a
hip replacement at one of the local providers was told that he
cannot because his BMI was over 25—like the rest of us here.
If all that cherry-picking is stopped then we would have more
confidence in the system. But, as John said, which private provider,
otherwise, is going to employ a newly qualified houseman? What
is the value for them if they are not actually made to and they
can save money that way? Therefore, it would not be a level playing
field unless the same rules are applied in every area, in education,
training, et cetera.
Q374 Andrew George:
A moment ago John Black said that we now have the best cardiac
surgery outcomes, arguably in the world.
John Black: Certainly
in Europe.
Q375 Andrew George:
That seems to contradict what the Secretary of State appears to
be saying about the failure of the NHS in a whole swathe of areas
and a lot of statistics are being brought forward to show how
outcomes are poorer than many comparable countries in the rest
of the world. To what extent, given that that has apparently been
achieved in the area of cardiac surgery, and cardiology, presumably,
will these reforms help or hinder the development of similar improved
outcomes across other specialties?
John Black: I hope
we would see that the stress on outcomes would improve outcomes
where they are measurable. But that is the great difficulty. It
is easy for surgery. It is relatively easy for cancer. Of course,
the trouble with international comparisons is that every patient
in this country goes into a national cancer registry. You can't
compare results with France where 10% go into a registry. International
comparisons are difficult unless we know they are valid. The cardiac
results were valid. Everyone was measuring it in the same way.
Q376 Andrew George:
But my question was: to what extent will these reforms help or
even hinder these improvements? You are saying this has been achieved
before the reforms.
John Black: Yes.
Q377 Andrew George:
Will the reforms make it easier for you to improve outcomes or
more difficult?
John Black: If
the reforms could be done in such a way that what was done in
cardiac surgery was done for every form of not just surgery but
procedure with a clear outcome, it would undoubtedly improve outcomes.
That could be put into the commissioning process. It could be
put into the present-day commissioning process as well.
Q378 Andrew George:
But you have done this before the reforms?
John Black: Yes.
It was done before the reforms.
Q379 Andrew George:
What lessons have you learned which you could now apply to a reformed
NHS with GP commissioning and in an environment where any other
willing provider is also providing the services and competition
law will be applied?
John Black: I think
I said that. Everybody should have a level playing field and a
condition of providing the service should be that they measure
the outcome. What has been done in cardiac surgery, and is happening
in other specialties where the results are not quite so mature,
is a model to which any commissioning system should aspire. They
should look at what was done and insist that this goes in to their
commissioning from now on. So-called world class commissioning—I
cringe when I hear that word—would measure outcomes and
insist that those outcomes are fed back in to changing the services.
Q380 Andrew George:
So the Royal College supports the reforms.
John Black: We
support the stress on outcomes. As a college, we would not have
an attitude per se. We think how health care is delivered is for
Government and Parliament and the people of this country. But
we thoroughly support the stress on outcome measures and we would
push for more clinician involvement.
Q381 Andrew George:
In the commissioning process?
John Black: In
the commissioning process.
Alwen Williams:
To answer your question—and again, today, we have discussed
structures and size of consortia—what we need to inject
into the debate, whether this comes as part of the authorisation
process, is that commissioning competencies are key requirements.
My view, having worked in the NHS for over 30 years, is that we
work with different structures as long as those structures work
in an integrated way. It feels to me that the competence of commissioners
as well as the competence of providers is absolutely key. As somebody
who went through world class commissioning on a few occasions,
relatively successfully, I have to say—and I know maybe
it is the terminology "world class"—I think the
fundamental framework which was about how you measure commissioning
competence, how you make sure you have a clear strategy and how
you ensure you have very good transparent governance, which goes
to your point on reconfiguration, was a very good framework. My
answer to your question is that it would largely depend on how
competent the future commissioners and commissioning support services
are to ensure that the right commissioning processes and decision-making
processes are put in place for the benefit of patients.
Q382 Andrew George:
Do you share the same confidence?
Dr Hobday: I am
worried that the upheaval will slow down the improvements that
we have seen in trends and I recommend John Appleby's paper in
the BMJ a month ago from the King's Fund who, I am afraid,
discredited a lot of these claims of how poorly our Health Service
is doing. If trends continue, for instance, as they are, next
year we will have equally if not better myocardial infarction
survival rates than France. It was not pointed out that France
spends 29% more on health than we do, so there was a bit of selection
and cherry-picking among the statistics there, I am afraid. The
paper produces a lot more examples about how the cancer care in
this country is much better than Mr Lansley is making out. I could
give you the reference for that in the BMJ, if you wish.
Q383 Chair: Could
you write to us with that?
Dr Hobday: Yes,
I can.
Chair: Just to emphasise
that point. It would be helpful.
Dr Hobday: Yes,
certainly. If things are left as they are the trends would continue
in the right direction and we would be doing very well and on
a par with most European countries, if not better. I worry that
the upheaval of the changes will sabotage a lot of those trends.
Q384 Rosie Cooper:
Could I first ask Alwen how Government policy on reconfiguration
has changed since the coalition came to power and how you think
GPs will play a role in that reconfiguration process? Then, if
I may, I will put that to other members of the panel.
Alwen Williams:
We were in the throes of a reconfiguration process as the new
Government came into power and introduced the four tests. So we
have been a bit of a guinea pig in north-east London in terms
of reviewing the processes. The measure of success has to be strong
clinical engagement—I would say GP commissioners as well
as acute clinicians—in ensuring that the reconfiguration
proposals are based on good evidence and clinically led. That
feels to me, certainly from our experience in north-east London,
looking at a dialogue that then ensues between clinicians, patients
and, indeed, local government is a much more powerful dialogue
and set of conversations than, I would suggest, between an NHS
manager like myself, and local government with GPs and clinicians
being towed along.
I think the way in which we design reconfiguration
processes to be very strongly clinically-led is absolutely key.
We have certainly worked through the four tests and, as a result,
from external validation we were enabled to go through to a joint
decision making of the joint committee of the PCTs on those reconfiguration
proposals. They have since been referred to an IRP process as
a result of a referral from one of the overview and scrutiny committees.
One of the tensions in the systems, to me, is that if there is
a strong clinical evidence base and a strong financial base, and
I don't think we should kid ourselves to say that absolutely everybody
will agree because that is not going to be the case, but if there
is a substantial degree of consensus in relation to "This
is the right thing to do", there is something about the current
process taking so long that it mitigates against securing the
optimum result as a result of a reconfiguration process. One of
my pleas going forward is not only to continue to sustain very
strong clinical leadership but to see whether there is a degree
of streamlining some of the processes in terms of construction
of the case and the decision-making processes. What we absolutely
do not want is, having made a very strong business case around
clinical quality and patient outcomes, to find that there is significant
delay in enabling delivery of that as a result of the processes
that are currently in situ.
Q385 Rosie Cooper:
I will come back to accountability of that in a minute, if I may.
I would like to ask Dr Hobday: how is that working in practice?
Dr Hobday: I am
sorry, accountability?
Rosie Cooper: How is the
policy working in practice? You had an example before.
Dr Hobday: Going
back to the Maidstone example, yes. In practice, for conditions
locally, they were totally ignored. They really were. This is
one of the reasons why the trust has completely gone.
Seán was mentioning about how you can measure
these. We had a survey in our area that was audited correctly
and showed that 97% of GPs were against the closure of a consultant-led
maternity unit but it was ignored. We had a clinical evidence
base ignored and genuine public opinion ignored. The interesting
thing was that GPs, in this reconfiguration process that started
in 2003, were not asked their opinion once until July last year
when Mr Lansley produced his four conditions.
Q386 Rosie Cooper:
Now you have been asked and ignored.
Dr Hobday: Absolutely.
Q387 Rosie Cooper:
So that makes it better.
Dr Hobday: I was
going to say that the commissioning side, as far as the GPs are
concerned, is only going to work if the GPs are listened to a
little bit at least. But there should be a reversal of this policy
of diluting the GP role. How can we become gatekeepers and look
after the commissioning side if people can squeeze round the side
of the gatekeeper, whether it is because they are going to walk-in
clinics or Darzi centres and all the sorts of things over the
last 10 years which have diluted the GPs role? I am not saying
that they are necessarily bad things but it will sabotage or not
make the commissioning easier.
My main concern with whether the commissioning
can work well is that worry I have of the interference with the
doctor-patient relationship—bringing rationing into the
consulting room—and, therefore, all the people that have
self-selected themselves on to the boards of these groups really
ought to be producing declarations of interests before they put
themselves forward. In our area, the board has been elected because
there were so many places and not many people came forward. So
they were a self-selected group.
Q388 Rosie Cooper:
Accountability, as something that I have followed right through
this process, worries me greatly. On reconfiguration, for example,
in the very early days when we had the Secretary of State before
us, I asked the question, "What happens if clinicians make
a decision pursuing a reconfiguration, the consortium then believe
that is the best course of action, yet the Overview and Scrutiny
Panel or the Health and Well-Being Board, as it will be, the local
population, were against that clinical decision which led to a
reconfiguration?" I asked the Secretary of State what would
happen in that instance. There is no real level, for me in my
understanding of this, of accountability anywhere. We can't see
anybody on the consortia—no patient or external people—there
at the table with a voice involved in the decisions. Health and
Well-Being Boards will not sign off the plans of the consortia.
There is a lot of consultation, there is a lot of influencing
but no actual being there at the centre of decision making. What
would happen, I put to the Secretary of State, if we had the populus,
if you like, against a clinical decision? He said exactly that,
it would go to the Reconfiguration Panel. That is exactly the
same as we have now without the pretend of consulting and ignoring
clinicians.
I suppose I would like to ask the panel generally
where you really think you are today. I understand that it is
at Chase Farm, in north London, where a reconfiguration of A&E
services has been going on, as I think we heard before, for 17
years. That is now on hold yet again. If that is going to happen,
where are you going? Does anyone want to pick up that point?
Chair: This needs to be
a wrap-up question, if I may. Where are you going?
John Black: If
clinicians in professional bodies give clear advice that something
should be done to provide higher standards they should stand by
that decision and they should become involved in the processes
to persuade the patients that it is in their interest to do so.
If you don't do that, you are shirking your duty. But it has always
been difficult, it is always going to be difficult and it will
never be easy. But if someone like my college says, "We think
this service would be safer if it moved from A to B", we
should stand up and say so and try to help the local population
understand why this should be done.
Q389 Andrew George:
But, finally, who is making the decision, is the point I am trying
to get to? Is it the clinicians, is it the population or is it
the Secretary of State?
John Black: I don't
know—I am not an expert in parliamentary governance—but
it is going to land on the desk of the Secretary of State, isn't
it? It is like a planning thing. What is the Secretary of State
for but to make the ultimate decision?
Seán Boyle:
I will try to answer some of your questions. I agree completely
that what we are looking at in terms of the way the process is
working, at the moment, is one where the Reconfiguration Panel
will look at cases on an individual basis and make recommendations.
I would recommend a report from them which I pulled out, Learning
from Reviews, which I can let your clerk know the reference
for. If you look at that, all that we have been talking about
today is contained in the way of the problems of presenting a
case for change that will work effectively for patients. That
is one thing.
I said, just now, that this is the situation
at the moment when we are in a position of transition. What will
be interesting—and it is difficult to forecast—is
what will happen if we are in a situation where we have independent
foundation trusts who should be making decisions themselves about
how they are going to reconfigure services and presenting an array
of services to commissioners who will then be thinking about how
to negotiate with these trusts on the basis of price, quality,
et cetera—things which have always been there anyway?
At this point can the Secretary of State intervene and say, "Barnet,
Edgware, Chase Farm and North Mid, you might be one trust but
I am not going to let you close this one down" or is the
legislation going to be such that the Secretary of State will
have to stand back and say, "You are an independent body.
You might not get the business and you might get the business.
It is up to you to see what happens"? That is a crucial question.
I can't tell you what will happen in the future. I have given
you a bit of a forecast. That one is much more difficult to judge
but that is crucial.
Alwen Williams:
Your point highlights that the NHS is a complex system and making
change to that complex situation requires a degree of resilience,
focus and real passion to ensure that we get the very best for
patients whatever structures and processes we have in place. We
have probably rehearsed with you today what we believe to be some
of the key ingredients of success. Often the success is in the
execution rather than in a set of principles or a kind of diagnostic.
It is how you execute well a plan that involves clinicians, the
public and local politicians. In a sense, some of the elements
of that, which we have articulated today, are very much related
to a strong clinical base.
I think strong relationships are important and I
think strong clinical leadership and more sophisticated ways of
engaging our local communities with clinicians being much more
visible in that process feels, to me, not a recipe for guarantee
but perhaps a recipe for success in terms of ensuring that we
are able, as we reconfigure, to reconfigure effectively as opposed
to reconfiguring in ways that either do not happen because they
get stuck in bureaucratic systems or reconfiguring for the wrong
reasons.
Chair: Dr Hobday, and
then we really need to move on.
Q390 Rosie Cooper:
Forgive me. Before Dr Hobday comes in, there is a real flaw in
here which is that we can do all that consultation and everything
else but the financial base of a foundation hospital or a local
general hospital will depend on what is being commissioned and
if those conversations do not involve the hospital and consultants
and their financial base is challenged then, when the hospital
is threatened, you will see that debate will change pretty rapidly.
Alwen Williams:
Our experience, in north-east London, is that you absolutely need
your clinicians across the system to engage in that. We have had
very strong clinical leadership from the medical directors of
the acute trusts who see that some of their services are not sustainable
and that it is not a good use of NHS resources and that health
inequalities persist. I would not underestimate the potential
of acute clinicians as well as mental health clinicians as well
as GP commissioners to want to do the very best for their health
economies and their health systems because many of them have worked
in those areas for many years and really have a commitment to
high quality patient care.
Dr Hobday: You
will only take the public with you on a certain policy produced
locally—we have bad experience in Maidstone of this—if
there is total honesty, transparency and no vested interests with
the policies, as has happened in Maidstone, and if declarations
of interests are there.
Chair: On that note, we
need to move on. Thank you very much for your contribution. We
shall reflect on what you have said. Thank you.
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