Commissioning further issues

UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE    To be published as HC 796-i

House of COMMONS

Oral EVIDENCE

TAKEN BEFORE the

 Health Committee

Commissioning: further issues  

Tuesday 8 February 2011

Councillor David Lines, Alyson Morley, Malcolm Alexander, Caroline Millar and Professor Jonathan Tritter

Dr Charles Alessi, Dr Clare Gerada MBE, Mike Sobanja and Dr Peter Carter OBE

Evidence heard in  Public Questions  1 - 81

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the  Health Committee

on  Tuesday 8 February 2011

Members present:

 Mr Stephen Dorrell (Chair)

Rosie Cooper

Nadine Dorries

Mr Virendra Sharma

David Tredinnick

Valerie Vaz

Dr Sarah Wollaston

 ________________

 Examination of Witnesses

Witnesses: Councillor David Lines, Deputy Chair, Audit and Scrutiny Panel, Local Government Association, Alyson Morley, Senior Policy Consultant, LGA, Malcolm Alexander, Chair, National Association of Local Involvement Networks Members, Caroline Millar, Partner, Moore-Adamson-Craig Partnership Ltd, and Professor Jonathan Tritter, Institute of Governance and Public Management, Warwick Business School, gave evidence.

Q1 Chair: Good morning, ladies and gentlemen. Thank you for coming. We have a very full agenda and a lot of ground to cover this morning. Could I ask you to begin by introducing yourselves and saying, very briefly, where you come from, starting with Alyson, please?

Alyson Morley : Good morning. I am Alyson Morley, Senior Policy Consultant with the Local Government Association. I am here to accompany our member representative.

David Lines: I am Councillor David Lines, representing the LGA and also The Centre for Public Scrutiny.

Malcolm Alexander: I am Malcolm Alexander. I am chair of the National Association of LINks Members.

Caroline Millar: My name is Caroline Millar. I am a partner in the MooreAdamsonCraig Partnership, which is a small independent consultancy which trains lay people. All our partners also act as lay people in various different capacities.

Professor Tritter: I am Jonathan Tritter. I am a professor at Warwick Business School. I set up and was the first chief executive of the NHS National Centre for Involvement during its existence.

Q2 Chair: Thank you very much for that. The first session this morning is focused on the arrangements proposed in the Health and Social Care Bill for patient and public accountability. The Government has said that it is a key aim of the NHS reforms to make "NHS services more directly accountable to patients and communities". It is timely that you are here to give evidence on this subject this morning because, as you are no doubt aware, there is a letter in The Times this morning from a group of voluntary organisations who state that "plans to make GP consortia accountable to the public are far too weak...we urge the Government to amend the Bill and insist on a strong independent scrutiny function led by democratically elected representatives." So we have the Government’s aspiration and we have a view expressed pretty trenchantly in correspondence in The Times this morning. I would like to ask each group, please, to open the session by telling us, relatively briefly, where you sit in terms of your view of the extent to which the Government delivers its objectives in the Bill as it is currently drafted and what proposals you might have to strengthen the meeting of this test to make NHS services more directly accountable to patients and communities.

Alyson Morley: If I say a little about GP commissioning consortia, Councillor Lines can then talk about Health and Well-being Boards. I heard about the letter on the radio today, and I think that is where there is a lack of symmetry in the Bill. We have a lot of specification about the membership of the NHS Commissioning Board and Health and Well-being Boards but very little on the constitutional and governance arrangements for GP commissioning consortia.

There are two ways of making GP commissioning consortia more accountable to the public. One is by having far greater accessibility from the public to those Boards, so you could have advisory members or you could have an advisory panel. In an awful lot of areas councils and PCTs have really good mechanisms for patient and public involvement and GP commissioning consortia need to build on what already exists rather than reinventing the wheel.

The second way of ensuring that GP commissioning consortia are more accountable to the public is the way they fit in with the other accountability mechanisms, most notably the Health and Well-being Board. You will know that GP commissioning consortia have to make reference and have regard to the joint strategic needs assessment, which lays out the needs, assets, resources and health concerns of the local population and the evidence of what will make effective health improvements. They have to have regard to that.

In our original submission to the Government, the LGA said that GP commissioning consortia should be required to sign off their commissioning plans with the Health and Well-being Board. While the NHS Commissioning Board will have responsibility for the financial rigour of those plans, it will be up to the Health and Well-being Board to sign off whether they were aligned to the JSNA. We still think that that would be really helpful. I will hand over to Councillor Lines.

David Lines: Thank you. Chairman, first of all, I would mention that when this first started it was in our remit of scrutiny and it has widened. I will be the first to say that my expertise is not in the health sector. My expertise is in governance and scrutiny. If I am asked a question on health, I shall pass to my much wiser colleague on that.

The background out of which both of us are coming, in the LGA, is the three themes of subsidiarity; in other words, localism, local decision making at the lowest appropriate level, transparency and everything else that falls away from that in terms of governance-if you shine a spotlight into dark crannies it is a good way of ensuring the right sort of disciplines come away in terms of governance-and best practice. We are not perfect. No one is perfect. Life is about evolution. We have to learn and we look for best examples.

If we turn to the Health and Well-being Boards, our view, fundamentally, is that they are executive boards and, as such, you shouldn’t mark your own homework. That is why the scrutiny role is very important. There is a debate there as to exactly how that should be developed. As this Committee is going through the process, the LGA is going through the process and, shall we say, there are plenty of minds made up but it has not come to a common view on how it will be best approached. The principal message is that it needs to be decided locally with less prescription from central government. If it is to go step in step with the Localism Bill, the makeup of these boards and the balance of political against specialist knowledge all has to be worked out. It will be horses for courses in that respect.

Q3 Chair: If I can develop that, you are content with a position where the precise form of local engagement by local authorities in the process is for local discretion rather than prescribed by statute.

David Lines: That is the way we are going. As I say, the LGA is moving towards a considered view on that, but that is the way it is going.

Q4 Valerie Vaz: Does that mean there are going to be differences throughout the country? Each part of the country will have their own Boards.

David Lines: That is inevitable. You are caught between a rock and a hard place. If you are devolving responsibility, you have to accept that people are going to do things a little differently. From my own experience in the private sector as a manager, delegating authority is the most difficult thing in the world. So many people put it down with one hand and take it back with the other. Keep it where it is but push it all down-responsibility and authority. Therefore, you have to have differences of view.

Q5 Rosie Cooper: I have one very quick question. Do you really believe that you have the ability, the resources and the expertise to hold people who have been commissioning, i.e. the managers, not the GPs necessarily, to account?

David Lines: Straight answer?

Rosie Cooper: No.

David Lines: No. The straight answer is "in a lot of cases", but I accept fully in such a wideranging organisation as local government that you are going to have the best and the worst. Is that a reason to throw localism into the bin? No, I don’t think so. I agree resources are important-in other words, support for this-and that is perhaps the Achilles’ heel or one of the Achilles’ heels in this and needs to be worked through. What will happen is that certain critical things will be looked at and studied and others will have to take a back seat. There is an inherent risk in that, and those that make this legislation and those that have to carry out this legislation must realise that.

Q6 Rosie Cooper: While you are getting the expertise, the system will be letting rip.

Alyson Morley: But this doesn’t come out of nowhere, and in an awful lot of places there is already really good joint commissioning between GP commissioning clusters and councils. You will know that in many areas there are joint arrangements now with PCTs and local government setting up as one organisation. There are probably about 18 councils and areas where this is happening. So we can build on what-

Q7 Rosie Cooper: But have they commissioned anything yet?

Alyson Morley: Yes, they are commissioning services. They are commissioning joint services as we speak.

Rosie Cooper: That is Torbay.

Alyson Morley: Joint commissioning has been going on since-I can’t remember which Health and Social Care Act it was. But there is good joint commissioning. There is also an incredibly strong business case for joint commissioning. GPs will realise that it is cheaper to pay for health and social care support at a low level which prevents later high intensity care. Not only is that better for their budgets, but it is better for the outcomes of their patients.

Chair: I am going to move on to Malcolm Alexander, please.

Malcolm Alexander: Thank you very much. My involvement with commissioning and public involvement goes back a number of years and the real issue is that for the community to influence commissioning it needs to have real influence, real power, resources and capacity. What has happened over the past few years is that that has been undermined and destroyed and we are in a situation now where we need to rebuild the capacity of LINks into HealthWatch organisations.

I would say that localism has been a disaster for LINks. It has meant that across the country we have absolutely fantastic LINks in one area and appalling LINks in other areas, which means that people really suffer from having organisations that cannot properly represent their interests. Culturally, GPs find it very, very difficult, in my experience, to collaborate with the community in terms of decision making. They love it when people come in and talk about the colour of the wallpaper and they love it when they come in and do little jobs for them-the helpmate approach-but collaboration between patients and GPs is rare. My colleague will tell you some very good examples, but I can tell you, from my experience over quite a lot of the country, that it is usually very weak.

What we badly need is to have the capacity. One, we desperately need lay involvement in the commissioning boards. Two, we need HealthWatch to be there, sitting, observing and participating in commissioning decisions. We need HealthWatch to be working actively with local authorities, but independence is the key. The proposals at the moment that make HealthWatch accountable to local authorities, we think, will be an absolute disaster. But the even bigger disaster at the moment is that the funding which has come from the centre for the development of HealthWatch, which is the same as last year with inflation, once it gets to the local authority is being cut in half. This means that many LINks are going to perhaps tumble over the next financial year and the capacity to develop HealthWatch will be infinitesimal in many parts of the country. We are facing a real disaster. Yesterday, talking to the Department of Health, that is number one on their risk register with respect to the development of HealthWatch for the next 18 months or so.

One more thing is that the relationship between the local HealthWatch and national HealthWatch will be crucial and elections from local HealthWatch up to the HealthWatch England body will be essential. Accountability and democracy must go side by side, both locally in HealthWatch and nationally in HealthWatch England. Capacity building has to be a function which HealthWatch England is able to carry on to make sure that every HealthWatch across the country reaches a certain level of capacity so that they can properly work with and represent the local community and also have real influence. That question of influence in commissioning is absolutely fundamental. It is, in my experience, one of the most difficult things a community can do and we need real power and influence to be able to do it effectively.

Caroline Millar: I would like to support what Malcolm Alexander has said. So far, we have talked a lot about structures, but the real question is where the lay people sit within these structures and how much influence they have. We have lay people on all sorts of committees-council committees, health committees-but it is my personal experience and the experience of the people we work with that the overriding feeling many of them have is one of frustration. They don’t feel they make a difference, and this is where the capacity-building element really comes in. It is about resources. It is also about attitudes and behaviours. Lay people very often get asked, at the end of the meeting, "So what’s the lay perspective on this?" There is one lay person sitting in the room and they are suddenly burdened with this responsibility. They may well be capable of giving a view, but their views are not built into the structure in such a way that they are given full attention.

We need to develop the capacity of individuals and also the capacity of groups, HealthWatch certainly, locally and nationally, but also all these other groups which exist out there. The voluntary sector has a huge wealth of experience and understanding of what people with particular conditions require and what local communities think and feel about things that are happening. I don’t see a proper route for those views to be aggregated and fed into commissioning decisions, which are the really crucial ones we are talking about, and I worry that lay people who currently sit on these groups will suddenly be given this responsibility for these vast amounts of money. Are they capable of making these decisions? Is it appropriate to ask these people to make these decisions?

Having said that, our preferred model is that there is a lot to be done down at the bottom. We need to do work in GPs’ practices, and again this is a capacity and skills issue. Most of the GPs’ practices we work with will tell you that they talk to their patients and know what patients want. Very, very few of them have any proper and effective ways of doing that. We know that patient participation groups can be very successful. But where we see them being successful is the result of a huge commitment from the practice itself, usually from one individual with a major input of resources, and it has to be an ongoing thing. This is not a question of just calling them up and asking, "What colour shall we paint the walls?" This is having an ongoing relationship where they can see the impact of what they have said to you. So if they are giving information, that information is passed on and fed up into the system. We want to see that aggregated up at consortia level so that consortia also understand what patients are thinking. Then, if there are individuals who can move up through the system with training support, through the HealthWatch or through other means, those individuals may be in a position to contribute to highlevel commissioning discussions. But we must not assume that just by sticking people on some committee somewhere we are going to get the lay input and public perspective. That is probably the most important aspect we need to think about.

Professor Tritter: I welcome the Committee’s inquiry into this area. I think it is incredibly important. I am concerned about the lack of patient and public involvement in commissioning, and particularly the dilution of the 2007 Act, the rewriting of section 221(2)(d) suggesting that HealthWatch is now far less about commissioning and far more about the promotion of choice.

I don’t think GPs are much closer to their patients. They have a patient list, but if you ask them what proportion of that patient list they see on an annual basis, it is about a third. Secondly, that patient list does not represent all those who need or utilise health services within that locality. Thirdly, the patient list is not representative of the community in any real way. GPs do not have any track record in terms of Joint Strategic Needs Assessment and absolutely no experience of doing public involvement. A study in 2006 looking at how GP surgeries were using PPGs-patient participation groups-found that less than twothirds of them had any experience of that despite 20 years of encouragement, and, further, that those surgeries which did have patient participation groups were more likely to be in affluent and less deprived populations.

The final thing I wanted to mention is that it is a shame HealthWatch is the name that was chosen, as this is the name of a charity established in 1991 looking at evidencebased medicine. It is essential that we find a way of having HealthWatch as a local basis for patient and public involvement engaging with the actual GP commissioning process rather than secured solely to the Health and Well-being Boards.

Finally, there needs to be a way to identify how local HealthWatches are working. One mechanism which might be used is that the annual reports they have to submit be subject to some external review which would identify how they have been doing involvement, what have been the outcomes and impacts of that involvement and what weaknesses could be identified to try and intervene to support their development. That is a very different mechanism. When LINks was introduced, I engaged with the Care Quality Commission to try and encourage them to do this and align their regulatory processes with the involvement that was supposed to go on at LINks. This never happened. I hope HealthWatch provides another opportunity for this kind of mechanism to be used.

Q8 Nadine Dorries: Isn’t there a slight difference between lay people, as in your lay patient, and the people who sit on organisations such as the Patients Association, the Alzheimer’s Society or the Stroke Association? When we talk about patient involvement, are we talking about those people who have made their life’s work being involved in organisations such as the Patients Association, or are we talking about the patient who just visits the GP once every few weeks? It seems to me as though the input from the two would be vastly different in terms of knowledge and ability to influence. Therefore, when we talk about patient involvement, what are we talking about? Are we talking about the patient who is involved, part of an association and incredibly informed on particular areas of commissioning, or are we talking about the retired lady who lives in Acacia Close who would just like to do a little more for her GP practice? Which one would provide the most input and which one should we be concentrating on?

Malcolm Alexander: It is all of those really. In terms of local public involvement work, it is about strategy. The strategy is probably that you would have a steering group, or the leading group in a LINk or a HealthWatch, which would be made up of lay people with some experience of the service-perhaps people who are in local voluntary sector organisations, so they have that kind of experience. For example, if somebody has MS and they are part of the MS Society, they know about local services and they bring that experience into the local body. Other people will have a range of different experiences that bring them there. Then there will be the outreach work, which is fundamental, which is about going into the communities, meeting with groups and talking about issues that concern them, perhaps campaigning issues. Sometimes it is about the closure of a clinic or a hospital which, actually, is the one thing that really mobilises people. If you want to get people going, you have to close a hospital. That is the tragedy of public involvement work in a way.

People will contribute at different levels of experience and knowledge. But how do you value those bits that people bring? It is like during your surgeries with people coming and bringing you a story. The weakness of the LINk and the Patients’ Forum is that it lost the capacity to listen to complaints because when CHCs closed complaints and advice went and it broke up the organisation. HealthWatch is an attempt to reunite the organisation and bring complaints back in. If you don’t hear the voice of the user, you can never build an organisation, in my view, in terms-

Caroline Millar: Could I just add to that? There is a tendency to forget the well people most of the time, and this may be part of the point you were making. We hear a lot from people who have longterm conditions, and it is very important that we do. But I know of examples of LINks who have not really made contact with their well populations. There are parts of London where there are lots of young, active working people and the issues for them may be completely different. They may be about sexual health or they may be about childbirth. They are quite different issues from the sort of people who are represented often through the voluntary sector groups that you are talking about. Often they are not heard. That is why the onus should be on HealthWatch, or whatever it is called, and also on local authorities to go out and find those people.

There are very good examples in local government of outreach work, of physically going out of the building, going to where the young mothers are, going to the day centres and talking to people. I see this happening in some of the provider services in Hackney, for example, where I am involved. Those kinds of approaches need to be used so that we can find out what patients, the generality of patients and the public, who may be separate from patients, think.

Q9 Nadine Dorries: I do take that, but you criticised patient involvement to an extent, or criticised GPs, rather, inasmuch as the people who get involved in GP services at the moment tend to talk about the colour or the pattern of the wallpaper. Isn’t it the case that if somebody isn’t a person who is involved with the MS Society or with the Alzheimer’s association, who has a specific singlefocus interest in a particular condition, what those lay people are concerned about when they become involved in their GP practice is the pattern of the wallpaper and is the experience that they are greeted with in their GP practice because they themselves do not feel qualified or knowledgeable enough to input on issues such as how young people’s sexual health services or how MS services are provided? They don’t feel qualified to comment on that. Therefore they become more involved in the GP experience that the patient receives when they arrive at their practice, such as opening hours and telephone helplines and that kind of thing, rather than actual commissioning for care.

Caroline Millar: Those things are extremely important.

Nadine Dorries: They are, of course, yes. I’m not saying they are not.

Caroline Millar: They are part of the picture of what happens when the service is being commissioned.

Malcolm Alexander: You can do an experiment. If you meet people inside a GP’s surgery, they are very placid. If they are sitting with GPs-

Q10 Valerie Vaz: Because they are sick.

Malcolm Alexander: No.

Valerie Vaz: I’m sorry. I go in there.

Malcolm Alexander: No, I don’t mean that. I mean patient groups. If you meet patient groups inside a GP’s surgery, they are very placid. They sit with the GPs and they are all patting each other on the back and being terribly nice to each other. If you have a meeting in the community and you say to people, "Tell us about your GP," it is a totally different story. They will tell you about their experiences of general practice and about the sort of services they receive. They will give you very, very rich information. It is fantastic. You just have to go to a community group and say, "Tell us about general practice," and people are full of ideas.

I have one more thing. If you then say to people, "Tell us what would make a really good service"-and I have done this many times, you get a group of people together and say to them, "How can we improve this particular service?"-there is a wealth of ideas that come out. A technique we have used is building up quality standards based on the views of patients-the public-and it is a fantastic technique.

Q11 Valerie Vaz: That is absolutely right. It picks up the point that Professor Tritter made about the GPs-

Nadine Dorries: I hadn’t actually finished, Chair.

Valerie Vaz:-seeing people who are ill and the people who they don’t see. That is the key point.

Malcolm Alexander: Yes.

Alyson Morley: One of the issues here, the challenge, is capturing all of this and everyone having access. What happens quite often with these consultations is you have an enormously rich tapestry of all sorts of information, demands and ideas on how to make the services better in a community, but what you don’t have is the putting together of that. The joint strategic needs assessment is a really good opportunity to put that together and for everyone to draw on that. So every single GP doesn’t have to reach out to every single member of their community. That is already done through tenants’ and residents’ associations, local assemblies and local mother and toddler groups, for example. They need to make the most of what already exists.

Chair: Nadine, you wanted to come back.

Q12 Nadine Dorries: Yes. I wanted to ask, just to complete my questioning, do you feel, up to now, that patients have had a bad shot at input and with defining how they input into services provided by GPs? Do you think it has been bad for them up to now? If you do, do you think that the Bill now provides patients with the platform to have their voice heard and have a greater involvement, as the Bill says in its statement, "better patient accountability"? Do you think that the Bill provides that opportunity? I know there are problems-and you have articulated those in your opening statements-but do you feel that, from where they are now to where the Bill puts them, the Bill puts them in a better place to have their voice heard?

Professor Tritter: The Bill does specify a requirement of the GP consortia to do patient and public involvement, which it never has had before. In that sense, GPs now have to do it and they never used to have to do it, so that is an improvement. Since most of them have not done it, and have not done it in relation to the array of services that are provided, it is a big challenge for them.

As to this issue of lay involvement, I think Malcolm is entirely right. The mode, the mechanism that one uses for engagement, is really important. There are things they do in southern Sweden around having an open forum where you bring together health providers and members of the public and patients to talk about health priorities. It is a very different context in which to discuss those things than sitting in the waiting room in a surgery and talking about the wallpaper or how services should be provided.

Q13 David Tredinnick: On this general point, I have one question. To what extent should the voice of the user extend to patients requesting specific treatments? A lot of us are being lobbied at the moment by the Chinese medical community and the acupuncturists about regulation, and a lot of people very often want to go down that route. How are we going to manage that in the general context of choice?

Malcolm Alexander: It is an interesting issue in terms of commissioning. I have done quite a lot of work with complementary therapies where we have had rooms full of people with PCTs. The rooms full of people have said, "We want complementary medicine" and the PCTs have just said, "We’re not interested. We’re not going to do it." This is one of the real challenges around commissioning. When people really want something as a community, they organise and they make the demands. What duty does that place on the commissioner to concede to those demands or to negotiate over those demands? There are two different things. One is what has been agreed and decided by those who are most actively involved and the other is those things which are wanted by the wider community. We have to try to deal with that issue in terms of what resources are available.

Q14 Chair: I am starting to feel giddy on behalf of these consortia. They have, on the one hand, to respond to the joint strategic needs assessment and the relationship with the local authority, they have to deal with consultation groups and HealthWatch direct patient involvement and they have to deal with the National Commissioning Board. Which way are they going to turn?

David Lines: And they have to look after their patients.

Chair: Occasionally the patient gets a look-in.

Professor Tritter: NICE, in some sense, is an adjudicating authority on what services are reasonable to be provided on the NHS. They weigh up evidence in terms of the existing efficacy, the cost and quality life year adjustments and involve patients and the public in their consultations. That is a mechanism to adjudicate between individual patient demands and those things that are deemed appropriate in terms of biomedicine.

Malcolm Alexander: Yes, but in terms of your question, of course, it is interesting the Bill does not actually place HealthWatch together with the consortia. The Bill keeps them separate, which is quite odd and difficult to understand. The answer is that general practice locally needs to develop good strong relationships with their patients and wider communities so that those relationships enable negotiation and discussion to take place about local issues. But we need quite a developed idea of how we can democratically get people involved with commissioning boards at a level where they can have real influence. It is a very poor model and GPs will be pulled and pushed in all sorts of different ways. It will only work from the point of view of the public if we can get the HealthWatch bodies properly working, supported and able to develop and grow to have the methods available to them to conduct a proper negotiation with the GPs in the consortia. If that happens, GPs won’t not be pushed and pulled in quite the same way.

Q15 David Tredinnick: I have a quick supplementary to Malcolm Alexander. You mentioned complementary and alternative medicine, and it just happens that I chair that group in Parliament and have done for many years.

Another point that is made to me by people demanding those services is they are less expensive. As we are trying to find an efficiency gap, isn’t that something else we should be looking at?

Malcolm Alexander: That is a point frequently made by people who choose complementary therapies. This is slightly outside the discussion, but I suppose the answer is that if patient choice is a genuine thing and people say, "This is what I choose" and the doctor says, "You can’t have it," we have a really serious problem. Patient choice, if it is a serious business, is not just about what other people choose for you or other people’s agendas. It is about the public’s right to be able to influence that agenda.

Q16 Chair: Though, as Professor Tritter says, presumably, if they are spending public money, there must be accountability for efficacy as well.

Malcolm Alexander: Yes, of course, there is, but are we to ignore the evidence of the patient who says, "This treatment has been very successful for me"?

Chair: No, certainly not.

Malcolm Alexander: Historically, many treatments have been used by the medical profession. We can go back to insulin therapy in mental health work, which was extremely dangerous. We should respect genuine patient choices.

Q17 Rosie Cooper: Basically following on from that, I am repeatedly saying that the Bill is high on autonomy and low on accountability and I am repeatedly told that patients will have a greater voice. I have yet to see one bit of evidence base for that and it drives me nuts.

In the Bill, the specified governance arrangements, for me, are virtually nonexistent, and those which are there I will categorically say I see as pathetic. It says that they will hold one public meeting a year and, beyond this, there is no requirement as to how they would conduct their business. Anyone involved in the Health Service who ever attends a trust AGM knows how ineffectual and ineffective they are. I used to bribe people to come to mine and if I found one genuine member of the public I was always very, very lucky. This is absolutely true. We would have to dragoon staff to come to make up the numbers so I wasn’t talking to myself. Maybe that is a reflection on me, but no. I understand all my colleagues have the same problem.

Looking at the governance arrangements, we really do need nonexecutive directors pummelled right through this, and perhaps a requirement that one of those nonexecutive directors should be of that particular area, representing the public. I do understand there is an argument that a group might get to be that person, but not if you have proper arrangements for interviewing and all the rest of it. I never ended up with one of those in my life and I always had a really good, strong local voice in there to fight with the rest of us who were trying to make a decision-a real voice. The truth is that is how I got involved in the Health Service. One AGM a year is not good enough and I believe that consortia meetings should be held in public, but I fear that this private and confidential or commercial confidentiality nonsense will mean that those meetings will be held in private. That, to me, is a game changer. You are not going to have real people on the board involved in making those decisions-no counterbalance.

What I am really saying is that I don’t think anyone has expressed a view that says what they have seen here is good enough. What is your view about nonexecutives, what is your view about meeting in private and what, in this scenario, would be a good model of governance for you? Remember that I used to be a local councillor. I don’t believe there is enough expertise in there to even remotely challenge the expertise of commissioners, former PCT people, who have been doing it for thousands of years and know the intricate detail. When you have Health and Well-being Boards challenging what may very well be a really good clinical decision made by a consortium and there’s a row, I’ve asked the Secretary of State who decides. We have got the answer, which is The Independent Reconfiguration Panel, which is no different to now.

Chair: I think that’s an essay question, Rosie.

Q18 Rosie Cooper: I am trying to summarise it because it is just so silly.

David Lines: My English master used to give us questions like that with the first foolscap page, and then you had to write another 10 after that. But, if I can pick up some of the themes there, I think-and this is more a personal observation from a governance point of view-this Bill is trying to be all things to all men and women. In other words, in layman’s terms, if I can use that expression, in governance terms, it is trying to micro-manage and macro-manage at the same level. That is a great mistake.

I would then move on to the Government’s arrangements. Yes, you have picked up one meeting, constitution. Why bother, because it won’t be effective? If you are serious about it, do it properly or don’t bother to do it at all. I am being equally as plain-speaking as you on this.

Q19 Rosie Cooper: No, it is good.

David Lines: That is my observation. I am a little bemused, just to go back to the original point, that scrutiny committees are not well equipped. I think possibly, maybe a hundred years ago, that was said about Select Committees, but I am scarcely going to be the one to level that criticism at a Select Committee. Scrutiny committees have only been in existence for 10 years. It is a growing process. Does that mean that they should stop? Then there is a discussion about lay people getting involved in providing choice. Actually, I am a layman.

Rosie Cooper: So am I.

David Lines: I am an elected layman, elected by laymen and women. Rather than bundle everything into an unmanageable ball of wool with bits and pieces everywhere, let us separate it out and say, "What do you want to do here?" "What do you want to do there?" and "What do you want to do there?" Why reinvent the wheel? We have a hundredsofyearsold system, parish councils. On that are built district councils, MPs, county councils. Yes, it is mind boggling and it is bureaucratic, but it is there. Let us reshape that. There is another Bill going through Parliament about localism. Let us reshape that and reshape this at the same time. In five years’ time I think you will find the best scrutiny committees will be as good as this Committee.

Q20 Rosie Cooper: Absolutely. Forgive me. I have obviously expressed myself really badly. It is not that they won’t get the ability do it. It is whether you have got it absolutely now to challenge the system over the next 18 months when it is going to race ahead.

David Lines: Could I pick up on the comments of my colleagues here? In effect, they said that no one has got there. We all, whether you want to do it down the public sector, the council way, or you want to do it through the voluntary sector, they all need support and that is the big-I repeat it-the big Achilles’ heel here.

Q21 Chair: Can I bring in Caroline Millar who has been sat patiently?

Caroline Millar: Perhaps the distinction that would be useful to make here is to distinguish between the public as the moral owners of the Health Service, if we like, and those people who are users of the Health Service. We need to be much clearer about these distinctions. We talk about patient engagement and patient involvement and we talk about public engagement and public involvement. They are different things and in those two different capacities people have different needs.

You are absolutely right, that in governance arrangements we need to acknowledge that the governance arrangements are there to serve the public as the moral owners of the Health Service. Therefore it is vital that in the structures those people have a voice-a substantial voice, not just the one voice in the room. It is not just about local councillors or democratic representatives. It is other people with other perspectives as well. If you take the example of nonexecutives on primary care trust boards or governors in foundation trusts, those are the sort of models you might look at. On paper they look like they could do the job, but I still think there is something very, very important about the status those people have within the organisation and the culture and the behaviours of the people who run the services, the GP commissioners or the local authorities, and those organisations to be able to hear and respond to the lay perspective, the public perspective. It is to do with power. really.

Q22 Rosie Cooper: Forgive me. That is why I believe there should be nonexecutives with a vote at the table. That is really important. I would not be misled about foundation trust governors. They are just an arm of management and never beyond that. There is a voice there, but they, again, aren’t strong enough to challenge. It is a great model and I totally believe in it. That is why my criticism is not that they can’t evolve to the point at which they will be great. I just don’t believe they are great now.

Caroline Millar: Your anxiety is about what is going to happen now. There are lots of nonexecutives on primary care trust boards knocking around and they are all going to be out of the picture. So where are the people and what is there to support the system now? There is some anxiety there.

Chair: Rosie, this is an evidence session, so can I-

Rosie Cooper: Forgive me. I did ask, what model of governance?

Chair: You did, and I was wanting to bring Malcolm in to answer that question, then Professor Tritter and then Alyson Morley.

Malcolm Alexander: I suppose behind this is, "Who is going to own the consortia?", in a way, because the involvement of the private sector in buying up practices is going to have a significant effect upon this whole system. Behind the GPs, who might be in the frontline, there might be companies who are employing them. Where our taxpayers’ money goes is fundamental.

There is an experiment in Scotland at the moment about electing the chairs of Health Boards. I can’t see any reason why 50% of the members of a commissioning board can’t be lay, and I can’t see any reason why some of those people, or all of them, couldn’t be elected locally. Certainly the chairs should be elected locally. We do need a huge amount of democracy in the system. Health has always been rather resistant to democracy and PCTs have not always been very inclusive. We need to acknowledge that. For example, in Hackney it has taken three years for us to get a lay observer seat on the PCT board. Just as they are about to close, they invited us to join them, which I thought was somewhat cynical.

In terms of openness, it is fundamental that they should always meet in public. We can’t understand why foundation trusts meet in private. All bodies making highlevel decisions about health care and about resources must meet in public. I don’t think it is negotiable. The onemeetingayear business is absolute nonsense. There should be the capacity for the public not only to elect some of the NEDs, or all of the NEDs, but HealthWatch should be there as lay observers and there should be constant interaction and participation in the work and the commissioning arrangements in the commissioning consortia.

Professor Tritter: I agree with a lot of what has been said. The accountability isn’t sufficient. I think that we get too caught up in this notion of "lay". The lay member of a research ethics committee is probably a professor of epidemiology. Most of us wear local hats simultaneously, so "lay" is not necessarily a useful way of conceptualising it. It might be better to think of diversity. What you want at any decisionmaking body is a diversity of voices reflecting a diversity of views within the community. If you are going to have nonexecutive directors, it might be worth specifying the different kinds of constituency you would hope that they were there to represent.

Q23 Chair: Can you have a diverse board without representatives from outside the health community on it?

Professor Tritter: I don’t think so, but it depends what you mean by "health community".

Q24 Chair: I guess by "lay" I might mean outside the health community.

Professor Tritter: You could, for instance, look at the Scouts and Guides, who have had a very bad role in terms of supporting LINks, but they are a different way of thinking about civil society within a locality. So there would be other constituencies. I live in Leamington Spa. In Kenilworth everything is run by the Lions Club. The Lions Club would be a really good place to go and look for people who have some sense of what that community wanted in health.

Alyson Morley: I want to respond to your concern about "How do we make it good now?" You are absolutely right. It is certainly incredibly patchy, but we know that in some areas things are working very well. For example, I was talking to a councillor from Westminster very recently who was saying that their Health Overview and Scrutiny Committee, and also in terms of joint commissioning, have a really good relationship with their local LINks. They feel that they are working really well and are getting into it. The LINks are making serious differences to the way commissioning works so that services really do work for people and they are commissioned from the point of view of those individuals rather than convenience for individual organisations.

What we don’t have is any systematic evaluation of that. The Local Government Association and many others have consistently called for some sort of evaluation of what we already have, and I would agree with all of the other panellists that the proposals aren’t sufficient. What also isn’t sufficient is our idea of what "good" looks like already. To try and do something about this, the Local Government Association and the Patients Association are going to be evaluating what LINks already do to identify where there is good practice already and seek to publicise that so we can build on the best. The problem at the moment, with the rhetoric around "building on the best", is that we don’t really know what "good" looks like.

We accept that there should be local variation, going back to Jonathan’s point that in his area the Lions Club is an organisation that is deeply rooted in the community. That will be different in different areas, but we will be able, if we evaluate things to see what is working now, to have a better chance of this. At the moment we are working in the dark.

Q25 Chair: Do you think that if we evaluated best practice we would find some constants that we could apply generally?

Alyson Morley: Yes.

Q26 Chair: Because at the moment the Government’s policy appears to be that this will be developed locally. Out of experience of good practice, is it possible to set out some parameters of good practice that still leave local flexibility but, none the less, deliver an assurance of standards across the system?

Alyson Morley: Yes, and that is certainly the LGA’s view, that localism should not mean that you have a wildly varying consistency in standards. The services you have-the how you do it or the what you do-should be based on values and those values are transparency. Another huge challenge with HealthWatch is we are doing a piece of research with the Patients Association about the awareness of LINks, and very few people, even visitors to the Patients Association site, are aware of LINks and don’t really know what they do. We have a real challenge there. So, one is transparency, communication, and another transparency challenge is that local authorities and GP commissioning consortia will be working to completely different populations, possibly. That is really confusing.

The other issue is inclusiveness, and absolutely your points that people need to be included as lay members. But there needs to be a broader inclusion of their voices in other ways. You can’t put everyone on a board. You need to find other ways.

Q27 Chair: It wasn’t really an invitation to draw out what those elements of good practice are here. It would be very helpful for the Committee to have thoughts from any of the panellists on what constitutes good practice in terms of patient and public accountability; the extent to which it is possible to preserve local variation while still applying consistent principles of good practice.

Caroline Millar: Could I say something?

Chair: Yes.

Caroline Millar: There is a lot of evidence that there are things which work and things which don’t work. There are a lot of examples of good practice and there are a lot of lists of principles of good practice out there. I have lost track of the number of times I have sat in rooms and people have said, "What is it? Is it transparency, accountability or what?" We know this stuff. My experience in the NHS-and this may change with more local government involvement-is that although people know what good practice looks like, they are reluctant or they don’t find the time to go outside and find out how it works and how it looks. It becomes a process that they have to do but they will try and find the cheapest and quickest way of doing it, and that is where it falls down so often. It is not that there are not wonderful beacons of excellent practice, but my concern is how you mainstream good practice across the whole plate without focusing on what it is you have to-The only way you can do this is by saying, "This is what you have to achieve". So it is looking at the ends rather than all the processes that go into it.

Q28 Mr Sharma: First, my apologies for arriving late. I just followed David’s last point, when Malcolm was responding to it, about patient choice of any alternative therapies, their own choice to go where they want to get help from. We get a lot of requests from those who are qualified doctors-maybe not in British standards, but certainly they have achieved their qualifications in other therapies from other countries like India, Pakistan and Bangladesh-in homoeopathy, Ayurvedic medicine and others. But when they request the doctors, the GPs, to find those alternatives they are refusing to do it. They are not supporting it. What do you think, Malcolm, is the best way for those people to get it because, within the system, it is not provided? I come from that background where it is very popular and a lot of people who came in the 1950s and 1960s are still very fond of those alternative therapies.

Malcolm Alexander: I suppose the only way for people to obtain those services is by trying to influence the commissioners and by campaigning. There are examples in Sefton, in Camden and other parts of the country where people have campaigned very hard to try to get the services they want locally, not Ayurvedic medicine but certainly homeopathy, which has been in the Health Service since 1948. It is an NHS service. There has been a kind of battle going on between people who were trying to access services which they have experience of as being very positive and successful and a medical establishment that rejects those services.

In terms of commissioning, it has been a huge battle for patients to convince commissioners and I don’t know whether it is going to change in terms of GP commissioning. I rather doubt it. The situation will be much more complex and I think there is a real tension between GPs as commissioners making decisions about what is appropriate for an area and patients wanting huge amounts of choice. There is a real problem, a real dilemma, in trying to find some accommodation between those two positions.

Q29 Mr Sharma: Do you think it is a prejudice, rather than providing the services, on one-

Malcolm Alexander: I think, yes, it is partly prejudice. But, in a way, to me it is more fundamental than that. The political support for patient choice and, at the same time, dismissing the choice of the individual is a fundamental flaw in the thinking of commissioning and the medical establishment.

Professor Tritter: There is an issue about the nature of the evidence. Thus far, there are not largescale trials that produce evidence around complementary and alternative therapies. Rather than simply lobbying for them to be provided, it would be better to lobby for the funding of those trials to generate the evidence, which is what we use in the system to justify what we spend public money on in the NHS.

Q30 Chair: There is inevitably a tension between the choice exercised by an individual patient and the requirement of somebody in charge of a public budget to determine priorities that will not always reflect the individual choice of the individual patient.

Malcolm Alexander: To expand the point, how on earth can a group of GP commissioners make decisions if there are so many choices available to the public? It is impossible. It is impossible for them ever to make sensible commissioning decisions if patients can choose whatever they want. There is an incompatibility there.

David Lines: Welcome to democracy.

Chair: Yes. There is no escape from that dilemma in a publicly funded health system. It is intrinsic in the system that we have established.

Q31 Dr Wollaston: It has been very interesting to hear the panel say that everybody knows what good practice looks like, but equally we know what bad practice looks like. The point that has been made about homeopathy also raises another issue. What happens if these participation groups are taken over by singleissue groups who are campaigning very vigorously and effectively for treatments that are not perhaps evidence based, or for treatments that then crowd out other important priorities? How do you feel we should get that balance right and not allow singleissue groups to take over?

Professor Tritter: That is a really important point. Voluntary sector organisations are wonderfully diverse, but they have a particular agenda. So Breast Cancer Care will be very in favour of breast cancer. They are not against kidney cancer or leukaemia, but they have a particular constituency of interests and those are the ones they promote. The only way around is to think about balance and diversity and ensuring there is also variation in timing, having term limits on the ways in which those representatives are able to have a particular kind of opportunity to express their voice.

Malcolm Alexander: Interestingly, I was the chief executive of the Association of CHCs for England and Wales and so I had a lot of experience about what happened across the country with CHCs. They weren’t taken over, you know. I never came across a CHC that was taken over by a singleinterest group and I don’t think I have come across a LINk that has been taken over by a singleinterest group. It is about good governance and it is about having a wide membership. It is about a wide membership that helps to determine priorities and agree a programme of work. If you have good governance in your organisation you don’t get these takeovers. It is extremely rare.

Dr Wollaston: That is reassuring.

Caroline Millar: And it is about outreach. It is about going and finding the people that you are not hearing from and finding out what their views are in a systematic way, using all sorts of different methods, and bringing that information back to the board or table. You will only hear the singleinterest groups if you don’t go out and find out what other people are thinking. But when you do you find a broader view.

Q32 Dr Wollaston: Yes, as Malcolm was saying earlier, going out there and canvassing people outside, so having diversity.

Malcolm Alexander: Yes. That is the experience, providing you keep bringing people in. If the steering group of an organisation allows it to be dominated by a single issue, clearly that is extremely damaging, but it does not happen, in my experience.

Alyson Morley: The best LINks have been networks of networks that bring in people who don’t necessarily want to sit on a LINk. For example, if you take young people, it is very unlikely that an average young person will want to be an active member of a HealthWatch. But groups of young people, whether they are youth councils in schools, members of youth clubs, members of faith groups or different tenants’ groups, may well have really strong views on health issues, especially around sexual health services, domestic violence and mental health services. If you can find ways of linking with existing groups, you don’t necessarily have to have everyone at the table all the time. The best LINks already do that, building on good community development strategies within councils.

Q33 Dr Wollaston: Thank you. Can I follow this up, because that has been very helpful? If there was a single amendment you could make to the Bill, have you thought about wording that you would like to have within the Bill to make all this good practice happen?

Professor Tritter: One of the things missing is the consequences of involvement. There is nothing in the Bill. You could put in a requirement to involve people, but unless you measure whether or not that involvement has led to some change of any activity it is almost meaningless. I worked with Northern Ireland to develop a framework for measuring the impact of involvement, and that is identifying both examples which did work and examples that did not work and how you might do them differently. Something which is about the impact of involvement is at least as important as providing the requirement to involve.

In the response to your last inquiry, the Government said that one of the things the NHS Commissioning Board might do is produce guidance on how to do involvement for the consortia. It seems to me a key part of that guidance should be about what should be measured, what should be documented, in terms of how involvement is taking place and what impact or influence that involvement has on their decisions.

Malcolm Alexander: I agree. The National Commissioning Board has a very important duty in promoting good practice in commissioning. In terms of amendments, the issue about lay involvement in the boards and elected lay members is fundamental. In terms of HealthWatch, elections to the local HealthWatch and HealthWatch England are fundamental. LINks and patients’ forums have been far too inward looking, and I absolutely agree with the point about community development. We need to get them outward looking, we need to make them democratic, we need them to be inclusive and we need the relationship between the public and the commissioning boards to be one where there is real accountability, real democracy and engagement. The past few years have been a very difficult time for effective public involvement and there may be an opportunity here to create something which is more profound. But unless we have elections to the different parts of the system, I don’t think it is going to happen.

Q34 Chair: Does anybody else want to come in on Sarah’s question?

Alyson Morley: I wanted to say that one of the areas we have not really focused on is the accountability of national bodies. Jonathan talked about the accountability of the NHS Commissioning Board. There are real issues about the accountability of Public Health England. At the moment there is almost nothing in the Bill about Public Health England. In fact, it is not mentioned because those powers are vested with the Secretary of State. There is also no relationship between Public Health England which will be responsible, we think, for commissioning, and provide planning for a lot of public health services, which, after all, are absolutely crucial in all of this, and no accountability framework between them and Health and Well-being Boards or between them and the NHS Commissioning Board or between them and HealthWatch. There is a vast gap in the Bill about how we hold Public Health England to account.

Professor Tritter: That is really important because 15% of the quality outcomes framework for GPs is going to be around commissioning public health interventions, but how does that come in to the ways in which GP consortia are supposed to be commissioning services? With the Health Protection Agency we have developed a people’s panel of a thousand people across England randomly, identified initially through MORI surveys. That provides you with one of the only attempts to engage with public rather than patient involvement around these kinds of issues. I do hope that when the HPA becomes integrated in Public Health England and the Department of Health they take the opportunity to move the people’s panel into that new body.

David Lines: In terms of an amendment-and this is not the LGA but the local politician speaking, if you like-I would like to see more emphasis on input rather than output. A lot of this is output based. The patient goes in. What do we do with them? Can we provide them with this, that, and the other? I am a great believer in "Sound body, sound mind". I would like to see the roles that the councils take, and districts and boroughs particularly, in terms of increasing opportunities for leisure and other activities like that.

I would like to give an example of good practice. Being chairman of the LSP, I invited the chief executive and the chairman of the local PCT to come along to our leisure centre, which we had upgraded, and already they were doing patient referrals. Essentially, I did a sales pitch. I went round the absolutely fabulous centre we have-full and really very impressive-and I said, "I am approaching you from three points of view: one, please continue referring your customers to us; two, you are a corporate entity and I wish to give you corporate membership", because I would have thought of all the organisations, private or public, you would expect that particular organisation to look after the health and wellbeing of their own organisation, "and, third, I want to approach you from a capital point of view", because they do have capital. We have one major centre and three satellites and I had wanted to develop the three satellites by putting our services closer to our clients. If I had the free will to put in an amendment, that is what I would like to see, because prevention, as they say, is better than cure.

Q35 Valerie Vaz: That quite neatly picks up the points I wanted to make. Given that we have this current system and we have the Health and Well-being Boards, which maybe are not as democratically accountable as we think they should be in terms of elected people, could each one of you give me your comments on the current makeup of the Health and Well-being Boards? And, secondly, given that we have the system, how would you, in the perfect world, make this system work and make it democratically accountable?

Chair: Who would like to go first? Professor Tritter.

Professor Tritter: Thank you so much. Some of the things you have already alluded to: the ways in which HealthWatch is represented; the role of public health and the director of public health on the way in which the Joint Strategic Needs Assessment would be carried out and, most importantly, that point I made last time, the need to be accountable for the impact of the involvement that takes place. Unless you do that, there is no way to identify weaknesses or think about developing the ways in which you are involving patients.

Malcolm Alexander: I would support that absolutely. There is no point in doing public involvement unless you can demonstrate that it has a real impact, not just because that is spending public money well, but also because the public will cease to want to be involved if they don’t have an impact and they can’t directly see the impact they are having at whatever level. There should be lots of councillors on Health and Well-being Boards, not just one, for the same reasons you were talking about to do with diversity. There also ought to be supported and trained expert lay people sitting there too who can hold them to account.

Malcolm Alexander: I would like to see more councillors on the boards. I am a bit dubious at the role of HealthWatch on the Health and Well-being Boards, in terms of their membership, and I am worried about their independence. They need to be more accountable. But there is something else, I think. We haven’t spoken about this, but participative budgeting and citizens’ juries are really important models that have been successful in bringing people in to look at complex decisions. That is a really important part of how we spend money locally, which is the participative budgeting part of it, and how we get people involved in really critical local decisions, and that is the citizens’ jury part of it. With that model, getting more accountability on the Health and Well-being Board, HealthWatch being a participating observer rather than a decision maker is important in terms of its ability to hold the body to account on behalf of the public. These methods of involving the public in more critical and more detailed ways in terms of decision making are fundamental.

Q36 Chair: It is striking that you focus your answer to Valerie on the Health and Well-being Board and not on the consortium, which is where the health-

Professor Tritter: I thought that was the question.

Q37 Chair: In terms of increased public accountability-and the question has been glossed over in this session so far-I am unclear where our witnesses actually stand and what your views are on the makeup of the consortium and the consortium board.

David Lines: You have hit the nail on the head, Chairman-clarity of role. We are trying to make GP consortia democratic bodies. We are trying to do different things to other different aspects. We should be very clear about what is going on. If we just address Health and Well-being Boards, I welcome the welcoming of local elected members on that. That is important because, as I said, what is the point in reinventing the wheel? You have a structure there. It may not be functioning well but it is structured and it is supported. It may not be supported well, but at least those things can be addressed rather than throw the whole thing up in the air.

There is a dilemma still with Health and Well-being Boards because there is a suggestion that we want to put it at a local level and you give choice. Having delegated that authority and that responsibility, some might go for proportional representation, and that could end up nonsensical. The big danger I see with Health and Well-being Boards is they become too cumbersome. I don’t know if people are fans or know of C. Northcote Parkinson and his observations on the British Cabinet system, but essentially, my observation in business and in my short political career is that, once they extend into double figures, committees tend to be exponentially less effective. That is what you don’t want. Health and Well-being Boards are executive, so, yes, have democratic representation there but have people in there who know what they are talking about as well from a specialist point of view. You are mixing your democracy and your specialism. The specialists, the NEDs perhaps, advise the executive directors to do that. I would say leave the poor doctors out of it. Let them get on with what they are good at.

Alyson Morley: We have had meetings with the BMA, the Royal College of GPs, the family doctor-all of the GP stakeholders, basically-who are very keen on this and they are pretty positive on some aspects, especially a closer relationship with local councils. We published a joint statement, but one of the things they did say about Health and Well-being Boards is, "If it’s a talking shop, we will come along because we have to, or a rep will come along, but we won’t pay any attention to it. They have to do things." There is a balance to be struck between not being a talking shop but being able to include all of those voices. At the moment, councils have advisory groups, reference boards and citizens’ panels. There is a whole range of hearing those voices without having to have them at every single meeting.

Q38 Rosie Cooper: How do you make a consortium listen to you? I think that is where the Chairman was going. What we are all doing is jumping into the bit we understand. Health and Well-being Boards are things we see, but this new consortium, this new commissioning body-this is the bit I was trying to get to earlier-is saying, "We’re not going to do hips any more. We’re going to do massive brain surgery," or "We’re not going to do this any more." They are really intricate decisions, clinicallyled decisions, but decisions a patient would have a view about. It is about all of this stuff that we have talked about-and I almost go right back to where we started. How do you make consortia listen or have a duty? I know it is there, but it is quite different to actually being around the table with a vote. Frankly, where is the cash coming from to support this patient involvement, even if you are just talking about Health and Well-being Boards, never mind where the real action is going to be going on behind closed doors making decisions that you will feel the effect of?

The final bit: in these constrained times, do local authorities see the NHS as a cashrich organisation that they can tap into, because we are all going to get into a real descending race to the bottom if this is where we are going?

Chair: Before you answer that, I am conscious we want to move on to the second session at 11.45. David wants to come in. Does any other member of the Committee want to put a final question?

Q39 David Tredinnick: Are there sufficient mechanisms in this Bill to encourage healthy living? If we are going to cut the costs of the Health Service, I believe strongly that we need to reduce demand. This has come up in very many meetings, and I do not get the feeling that there is enough of this. I also want to link this to a question about accountability. Under the Bill, local authorities will no longer be required to have Health Overview and Scrutiny Committees but will continue to have oversight and scrutiny powers which they may discharge how they see fit. Is this a strengthening or a weakening of local health scrutiny or will it make no real difference? Two questions: how do we cut demand for services and what about accountability? Is there a difference between requirements to act and scrutiny powers?

Chair: Can you answer that together with Rosie’s question about the consortia?

David Lines: That is just echoing what I said earlier. There seems to be a stunning logic, to me, that if you make people healthier, inevitably-and I am forthright in what I say-it will mean a reduced demand for services. Set that against a growing population-and we don’t want to get too complicated in our theoretical discussion, but if we accept that and you reduce your input-that is less contention for a lot of services, including alternative medicines and things like that. I am a lifelong advocate of that, that through healthy exercise, healthy lives, one can incorporate cultural things. This is a wellbeingtype of Bill as well and its impact on employment and on productivity has wider considerations. I would hope that Parliament will look at the bigger picture of what is going on.

It is a very detailed situation, and clearly this Committee has to attend to its portion, but this is part of a production line, if I may use that analogy. It is part of a production line and the unfortunate part of the production line is we are creating, not deliberately, unwell people and we are struggling now with how to deal with them. Surely, if you go further down the production line or back in the production line and actually reduce the input, then, hopefully, some of the problems you have will be reduced. That is my little speech on that.

Alyson Morley: To finish off on that, absolutely. To go back to what Sir Derek Wanless said, and that is to address your point about "Is the NHS just a source of cash?", clearly the NHS is not cash rich. It has to make £20 billion worth of savings and we all know that NHS inflation runs significantly higher than ordinary inflation. It is not cash rich. It is richer than councils, but that is saying absolutely nothing at the moment. We know, as Derek Wanless said, that the NHS in the long term is not sustainable if we carry on with these health patterns. What we need to do is to go back to public health interventions. We know that good housing, a good start in early life, educational attainment, community safety-all of these-have massive beneficial effects on people’s health and their need for health treatments. Talking to GPs, they do get this and they do understand it. The difficulty will be finding the evidence base for this in the short term, but certainly there is a growing evidence base that things like active walking groups can improve mental health, people’s risk factors for diabetes and heart disease in the short term as well as the long term. So GPs are willing to be convinced that there is a good public health case.

I wanted to say something about your point as to whether the change will make any difference with health overview and scrutiny. That is a tricky one which we are currently debating within the LGA. We have not come to any decisions, but when we do we will certainly give you our decision making. On the one hand, in some places health scrutiny has been somewhat marginalised because the powers reside in a committee that is subsidiary to the council and some would argue that giving that power to the council ups the profile of health scrutiny. On the other hand, you could say, as the council is a provider and a commissioner of services, it could be a conflict of interest for the council to be making decisions, but there are provisions within council constitutions already about conflicts of interest. When we have had those discussions amongst ourselves and come to an agreed decision, we will let you know.

Q40 Chair: Now the closing brief observations.

Malcolm Alexander: On the issue that David Tredinnick raised about reducing use of the Service, there is a big issue about continuity of care, especially in poor urban communities where care is not well integrated. That is when you get overuse and excessive use and excessive use of A&E departments and so forth. Good continuity of care is absolutely essential.

On the issue of Overview and Scrutiny Committees, there are lots of very, very good examples of successful Overview and Scrutiny Committees. I would be very sorry to see their role diminished. A lot of good reporting, a lot of good recommendations and good interaction with the community is often the case and I would like to see that role properly strengthened.

On the issue of the consortia, a lot of GPs are feeling they are not going to have very much influence in the consortia. But the issue that we raised before about the role, the lay presence in the consortia, is absolutely fundamental, and a democratic lay presence in the consortia is fundamental.

Caroline Millar: Very quickly, I absolutely agree that there is a role for scrutiny. Health and Well-being Boards need to be scrutinised somehow, and there are very good examples of where that has happened, where Overview and Scrutiny has worked well.

On the point of consortia boards, somehow the consortia have to be held to account for this public involvement, and there needs to be something structural in there to make sure they do it and that the evidence is out there so that the Health and Well-being Board can see what is happening within the consortia. We might have concerns that that information may not be easily available all the time.

Professor Tritter: On that last point, the Health and Well-being Boards have responsibility to do the Joint Strategic Needs Assessment and to develop a joint strategy for meeting those needs and that is then fed to the consortia to try and implement in terms of commissioning health. That is a very loose link. There is very limited accountability, and that needs to be strengthened. It may well be the guidance from the NHS Commissioning Board on how to do involvement provides one mechanism of holding them to account in the way that they do patient and public involvement. They also have a responsibility around the QOF
to do 15% on public health, and yet there is not a lot of evidence that the GPs know that much around public health. The role of the director of public health is not into the consortium but only into the Health and Well-being Boards, so where those services are going to be commissioned is unclear.

The final point is about choice and continuity of care. The evidence of Sweden, which has far more patient choice and has patient choice in terms of primary care for the last five years, shows that a lot of that has led to a loss of continuity of care and also a lot of patients receiving services outside of Sweden, going to Finland and Estonia. The implications of the EU Health Directive on patient mobility may have significant impact on how a local GP consortium actually ends up finding they have to spend more money than they thought they had to.

Chair: Thank you very much. You have given us, as ever, plenty of food for thought. Thank you very much.

Examination of Witnesses

Witnesses: Dr Charles Alessi, Kingston Pathfinder GP Commissioning Consortium, Dr Clare Gerada MBE, Chair, Royal College of GPs, Mike Sobanja, Chief Executive, NHS Alliance, and Dr Peter Carter OBE, General Secretary and Chief Executive, Royal College of Nursing, gave evidence.

Q41 Chair: Good morning. Thank you very much for coming. I am sorry to keep you waiting a little bit beyond the target time for this evidence session. Could I ask you to begin by introducing yourselves? There are some familiar faces, but, for the record, it would be useful to have an introduction. Thank you.

Dr Carter: Peter Carter, Chief Executive, Royal College of Nursing.

Mike Sobanja: Michael Sobanja, Chief Executive, NHS Alliance.

Dr Gerada: Clare Gerada, Chair of the Royal College of General Practitioners.

Dr Alessi: Charles Alessi, one of the leads in the Kingston Pathfinder and an executive member of the National Association of Primary Care.

Q42 Chair: Thank you. I would like to open the questioning, if I may, by focusing on the question of the relationship between GP commissioners in the new consortia and the rest of the clinical community. The Committee has expressed the view in the report we did on commissioning, on which this is a followup process, that we think it is important that while GPs can be the catalyst-indeed, should be the catalyst-for engagement of the clinical community in the commissioning process, as we see it, it is essential, if we are to get a highvalue commissioning process, that the entire clinical community feels its views, interests and specialisms are reflected in that commissioning process. I would like each witness to open the session by setting out your own views in reaction to that proposition which the Committee set out in its first report on this subject. Let us start with the Royal College of Nursing.

Dr Carter: Thank you, Chair. It is a very apposite way in which to open up our evidence to you, and thank you for inviting us. This is one of our strongest concerns. In many of our meetings with the Secretary of State we have consistently said that one of the flaws in the concept-because, as you know, we are supportive of many of the key principles of the Bill-was that it started off with general practitioner commissioning. We felt that, at the very least, it should have been general practice and everyone involved in general practice, or, if you like, clinical commissioning. We have severe reservations about the absence of, and in fact the Bill is silent on, the role of others. Not just nurses, but speech therapists, physiotherapists, pharmacists, the whole array of people in the multidisciplinary team, are feeling disaffected by the lack of a commitment to involve nurses and others. In relation to the Bill, one of the amendments that we would wish to see is a firm commitment that nurses and others will be involved.

Mike Sobanja: I happen to agree with Peter. A far better term would have been about clinical commissioning as opposed to GP commissioning, but recognising, as the Secretary of State has said on a number of occasions, that this basic, core role of a GP is about commissioning, whether it is treatment, referral or prescribing, and, in part, this is about aligning financial responsibility with that.

In terms of clinical commissioning, without going over the ground that Peter has set out, there is also a case for clinicians in secondary care and tertiary care to be engaged, because what we want to see is clinicallydriven commissioning and not for the Bill to introduce a degree of tribalism, which is GP alone. I was very struck by the previous discussions about engagement of local communities and so on. If I could pre-empt Rosie’s comments about that, yes, we do believe there should be independent directors on GP commissioning consortia, but that will not go far enough to ensure the public has an appropriate voice in the system.

Dr Gerada: Thank you very much for inviting me. I, too, agree with the fact that we must commission collaboratively with our specialist colleagues, our nursing colleagues and with patients. We, with the Royal College of Physicians, published Teams without Walls and will now go on to work on "Commissioning without Walls". Members of my organisation have also brought up the issue as to how, in a democratically elected country, that can be devolved just to one single professional group and whether that is going to be unrepresentative and unethical as things pan out.

Before I finish, we would also like to see a distinguishing between commissioning as in the use of resources in the consulting room, the husbandry of resources. The term "commissioning" always tends to get confused, but we consider commissioning to be about being a good clinician, understanding how you use your resources and understanding how you can use resources better as opposed to planning health services and all that that entails. With respect to planning health services, that absolutely needs to be done in collaboration with others. We cannot do this alone.

Dr Alessi: Thank you for inviting me too. It would be helpful to think in terms of the primary care home rather than general practitioners, because a lot of what the new Act is about is the treatment of patients in the context of a population. Anybody who accepts the fact that they have to treat a patient in the context of the population that is served and also of the resources that are available for that population clearly has a legitimate place at the table, be they a nurse, a speech therapist or anybody within primary care. That is fundamental to the way we work. I believe that the Act changes things from practising with a patient in front of one, whereby one treats a patient without a financial context, to treating a patient understanding that there is a responsibility to spend what we have in the most costeffective way we can and also to prioritise care effectively. This is not going to be easy, but unless everybody is involved I don’t think we are going to succeed.

Q43 Chair: Dr Alessi’s contribution, in a sense, was the test case, or was interesting coming from your particular perspective. It is therefore uncontroversial among all four witnesses that we need to have the whole clinical community engaged in the commissioning process. The followon question is: Should that, in your view, be written in in some way to the framework of the Bill from the point of view of the commissioning consortia, and, if you agree with that proposition, how would you like to see it done? Dr Gerada.

Dr Gerada: Absolutely, it should be written into the Bill that there should be a duty of collaboration, cooperation and shared working, with respect. You also need to be mindful of the fact that this may then be proven to be anticompetitive with the issue of "any willing provider". If you are getting groups of clinicians working together, it is inevitable that those groups of clinicians will be drawn from a local population, and it is inevitable that once you start to work together, clinicaltoclinical dialogue, you will be favouring your local clinician. So we need to be mindful of that.

Q44 Chair: Can I ask a probing question? If it is accepted that it is right for a consortium to have expertise from across the whole clinical community engaged in the commissioning process, that is a different proposition, is it not, from saying that it must be involved always with the local clinicians? Surely part of this ought to be about calling expertise from elsewhere in the system to call the local clinicians to account against the highest standards.

Dr Gerada: Yes, that is true. But when you are designing care pathways and where you are designing commissioning decisions around your local population, the de facto people that you will get involved with that will be your local clinicians because, one, they are there and, two, they are working with you. Whilst I accept that, you may well pull in organisations such as NICE and the Royal Colleges, because I think we play a very important role. On the ground it will be local people that do this together. In fact, good commissioning is about good clinical dialogue, so, again, in its simplest way.

Dr Alessi: We also need to remember that the choice is made by patient, not by the clinician. That is the challenge that is in front of us, to ensure that we really put the patient at the heart of everything we do. If we continue working in a way whereby we direct patients to where they should go, this system will not succeed. If, however, the choice is made by the patient, as long as-and I pick up on comments made in the earlier meeting-the care that is delivered is deemed to be of sufficient quality by the Care Quality Commission-because there are mechanisms to ensure that we commission what is of quality, and that decision does not need to be made by the clinicians themselves, there are bodies that have responsibilities to actually reach those decisions-I don’t see why we are going to get into such difficulty. Yes, there is-

Q45 Chair: I am sorry. Are you saying that you don’t think that a commissioning group should get involved in a quality question? They should simply assume that that is decided by the Care Quality Commission licence?

Dr Alessi: No, absolutely not. We should drive quality, otherwise we will end up with the lowest common denominator. But there is a flaw, and that flaw needs to be determined by somebody.

Mike Sobanja: On that particular point, the primary responsibility for quality rests with the commissioner and the regulator is secondary. One of the concerns that we would have about the way the current arrangements are described is that the regulator-and it may not be just CQC, it could be Monitor in this regard-might trump the commissioner and lead to a weakening of commissioning and then its links with the local community.

In answer to the Chair’s question, I am not convinced that writing that into the Bill would achieve a change in the culture and behaviour which is required. We see lots of things which are written into Bills which people then pay lip service to, although I can’t think of a ready example-

Chair: Or simply forget.

Mike Sobanja:-as if that job is then done. Personally, I am far keener to see the National Commissioning Board, in its relationships with local commissioning groups, make that a performance management and accountability issue which gets great prominence. That may be better, if not equal, to writing it into the Bill.

Dr Carter: I agree with Mike here, in that just because something is in a Bill, it doesn’t mean it is going to happen. It then requires behavioural change and commitment to make it happen. However, in relation to the nursing contribution, we would like to see this in the Bill. Whilst I don’t want to broaden this out too much at this moment in time, we do have serious reservations right from the top in terms of the role of the Chief Nursing Officer down through the various echelons where again it is wholly unclear at the moment as to where the nursing presence is going to be and where the nursing leadership is going to be. We have seen examples in different parts of the United Kingdom where, in the absence of that leadership, you do end up having serious issues to do with the quality of patient care.

Q46 David Tredinnick: I want to go back to the points Malcolm Alexander was making in the last session, this issue about the extent patients should be listened to in their request for clinical care. I raised the point about Chinese medicine and my colleague Mr Sharma touched on Ayurvedic medicine-both systems have been in operation for several thousand years-and also homeopathic medicine, which is very, very popular in India. How do we manage this in the future?

Dr Alessi: If we accept that there is a finite resource-and that is the first and most important thing that has to be accepted, because if one doesn’t accept that one doesn’t know where one starts-one can then use the mechanisms that exist, using a programme budgeting approach, for example, and using our colleagues in public health and their expertise around prevalence, to come up with indicative budgets that would be available for a condition. If that is accepted, then one can actually start to commission with local providers as long as one accepts that local providers also have a population responsibility. Perhaps if there is something which has not been as prominent as it should have been, it is that foundation trusts and acute hospitals also have population responsibilities. Their responsibility is not only to the patient that lies in front of them. If we get to that stage, then I think it is possible to prioritise care.

I will give you a little example from Kingston. There is a map of variability, which was published recently by Muir Gray, which looked at levels of things like major joint replacements. In Kingston, for example, we have one of the highest incidences of joint replacements in the country. So unless the population is markedly different-and having lived there all my life I have not noticed an enormous difference between there and here-or there is something special about that population, we are clearly devoting too much resource in that single area. By definition, we are devoting too little resource somewhere else. The decisions are never going to be easy, but this is the world we are in, and it is true of the whole of the western world. We are no different to anywhere else.

Dr Gerada: I would agree with most of what Dr Alessi says. I am a scientist at heart, I am doctor, and we have to be guided by evidencebased practice. We have to plan local health services and in a cashlimited budget we have to make decisions. I am far more concerned about decisions, if you like, for mainstream healthcare than I am for things that one could consider to be on the periphery, such as homeopathy. So I am concerned about the resources for our basic, everyday patients with chronic longterm illness, patients with Alzheimer’s, hip replacements, etcetera, but this is what public health will inform us is what a good health service decides and plans for.

Mike Sobanja: The only response I can give you is-and once in my career I was chief executive of a health authority, so I even predate PCTs, and it was the same then as it is now-these are judgments that have to be made. What I would observe is that what was missing in the judgments that we made at a healthauthority level is absolutely critical to getting the answer to your point about transparency and accountability to local communities. Charles’ point about starting with finite resources and opportunity cost we have to recognise. Choices have to be made. We have to invest authority in somebody to make those choices. I would rather it was local than national, but they have to be held to account and to give the reasons why they made those choices. This notion of free choice for every patient is cloud cuckoo land.

Q47 Chair: Can I come in here? I would be interested in the reflections of the four witnesses now in front of us, most of whom I think heard most of the last session, about how you think that accountability process is best discharged in the context of a GPled consortium because there was a lot of debate about relationship with local government, nonexecutive directors, elected members, etcetera. It would be interesting to hear the views of this panel about those questions.

Dr Gerada: I am going to raise a question because it is something that I do not understand. Local government will have a responsibility to its community. That is its responsibility. But GP consortia will have a responsibility to those registered on a GP list, which, with the abolition of practice boundaries, are no longer the same. In the first instance they may well be the same, but as this motors on and as commissioning organisations become much more mature and as patients become much more mature and move around, those two will divide. What I would like clarification on is that GP consortia are not responsible to their local community. The geographical responsibility is being removed, whereas with local government it remains. There is going to be a tension as things arise. So with the issue about planning for health services in Kingston-maybe Kingston might, because I suspect Kingston, and especially Surbiton where you work, is a very affluent area so people probably don’t move in and out-you may end up with folk moving in because the consortium offers different services or it hasn’t overspent its budget, or whatever. This confusion is one of the issues that is coming from through from my members. There are many confusions and paradoxes in the Bill, and I have to admit I have not read the Bill line by line, but of the bits that I have read it doesn’t all add up. Whilst we can say we are going to have a relationship with our Health and Well-being Board, who is going to have a relationship with the Health and Well-being Board? Is it going to be every consortium that has a patient that is served by that particular area or is it going to be just the majority of them? These are questions that I would like to pose because we do not have the answer for those.

Q48 Chair: There has been some clarification, hasn’t there, in the sense that each consortium, in addition to being able to accept members from out of area, will have a precise and a "monopoly" responsibility for a specific geographical community?

Dr Gerada: It is not clear because it is not clear who will mandate that. With the Secretary of State devolving responsibility now back down to GP consortia, who are in a sense going to be commercial organisations, it is not clear. Again, that is a clarification: Who is responsible for the healthcare of the entire population?

Mike Sobanja: If I can return to your original point-I am sorry, Peter-it seems to me that on the conversation I was hearing before, first of all we have to get arrangements in for both citizen involvement on priority setting, the opportunity cost issues, etcetera, and patient involvement in designing individual services. That seems to me to be a spectrum, and there is everything in between. I have already said that I believe there should be independent directors on GP commissioning consortia, decisionmaking bodies-boards, if you like, but we don’t know that they are going to have boards in every case-and I think that is important not only from a democratic legitimacy point of view but also from a governance point of view. External challenge is healthy on that.

What I was trying to say before about the holding to account is, again-and you will forgive me if I go back to my previous experience on a health authority-we had lots of process measures to do on public accountability and so on and, frankly, it wasn’t difficult to tick all the boxes. What would have been far more effective, in my view, in moving my own authority in engaging local communities, is if the then regional health authority had said to us "Demonstrate that you have meaningfully engaged your local community in your prioritymaking decisions. We are not going to tell you how to do it. Demonstrate it and we will hold to you account". I get quite concerned about people wanting to specify again and again how everything should be done as opposed to getting to the outcome in this matter as with health and saying, "It is your job. Do it, and we hold you to account."

Dr Carter: Can I go back to how this particular theme started and its relation to choice? You gave a very specific example of people wanting Chinese therapies. This is an area which is going to create some significant tension. The notion of patient choice has been highlighted quite significantly and I think it has raised expectations. This will not be new to GPs who have people coming into their surgeries, having read something, suggesting that this is what they would like. Of course, what happens time and time again is the GP will discuss that with the patient and, if it is not appropriate, persuade them that it is not appropriate. We know that.

However, in relation to people having their expectations raised, can I give an example of when the drug Aricept first came on the market, which is about 10 years ago? As people will know, Aricept is a drug in relation to helping with Alzheimer’s. When that drug first came on the market, there was a huge amount of comment in the media and there was a lot of enthusiasm that perhaps at last a cure had been found for this most debilitating of diseases. What happened in some areas was-at that time I was a trust chief executive and I had huge contrasts-for example, in the borough of Brent, in south Brent, the concept of Aricept just didn’t reach people, they weren’t tuned into it. In another part of the trust I was responsible for, South Kensington, almost immediately the good readers of the newspapers were hounding their GPs, for very understandable reasons, because they thought there was a cure for Alzheimer’s. Roll forward 10 years. What do we know? We know that Aricept is a very good drug for some people in the early stages of Alzheimer’s. What it doesn’t do is cure Alzheimer’s. But at that time some GPs were finding it very difficult to hold the line and it was very helpful that NICE took an approach to this, which was, if you like, as an arbiter. I think, in relation to these current arrangements, it will raise people’s view that they have a right to demand, and that is going to be very difficult for some GPs in some areas where you have a more informed community. GPs are going to find it very difficult to handle that.

Dr Alessi: It would be helpful to reflect on whether the present system we have at the moment is as perfect as people make it out to be. I am always amused by the fact that we are incredibly worried about the potential risks of introducing change and we suddenly all assume that the present system we have is so fantastic that any change may make it a little worse than it is at the moment. I am terribly sorry to disillusion you, but the present system we have doesn’t work very well. The fact is that we do need to change it.

In terms of how to change it and the accountability issues which were brought up, these are things we are going to have to feel our way along, certainly over the next few months, before we can come up with a final view as to how this should work. The Health and Well-being Board is particularly important because if you really believe in localism and moving away from a topdown management structure, this is where the action will take place. But it has to be meaningful and with teeth. Whether the consortium is accountable to a Health and Well-being Board or merely-and it is an improper use of English-accounts to the Health and Well-being Board is another matter altogether. That relationship has to be really quite strong but there is a balance somewhere and that balance is between allowing consortia to actually develop and putting coils of assurance around them. We are very good in the NHS at those coils. We have so many of them at the moment that the thought of having even more in the new world fills me with dread because I don’t think we will actually succeed if that happens.

Chair: I now have virtually every member of the Committee and the panel of witnesses wanting to contribute.

Dr Gerada: The panel may want to ask a question.

Q49 Chair: Yes, that’s right. They want to ask questions of each other probably. Mike, do you want to come in?

Mike Sobanja: Yes. I was going to make the point that the accountability of consortia is one thing. Once we have had a look at the accountability of general practice and practitioners to the consortia as well, and there is a key issue here about the resolution of the issues around section 24(d) of the Bill, as it is currently written, which basically confers a responsibility, as I read it, Chair-

Q50 Chair: You enlighten us.

Mike Sobanja: -on practices to act in a manner which is consistent with consortia policy, there is a need to rationalise that with regard to GMC requirements and also individual contracts which does not look entirely clear at the moment. What I am saying is there is an issue there, but accountability below consortia to practices is as important as above consortia to local communities and whoever else is involved.

Dr Carter: Very briefly, I wanted to make the point that we, too, see the need for change and we feel that commissioning has not worked. We want these reforms to work, but at the moment there are real gaps and real concerns about how it is hanging together. I will leave my point there.

Q51 Nadine Dorries: Dr Carter, last time you were here you were quite sceptical about the scope and the role that will be available for nurses within the new reforms. Having spoken, myself, to hundreds of GPs since you were last here, would you not agree that there is a huge amount of scope for developing the role of the nurse within the consortia? In fact, some the doctors I have spoken to have talked about having nurses being able to provide much more reactive sexual health clinics, mental health counselling and the things that they can’t provide at the moment, but being able to do that as consortia and focus on those areas where they see there is high cost and where there are few resources channelled at the moment. Do you get the feel yet from nurses that there are these exciting opportunities which will be presenting themselves?

Dr Carter: Absolutely. With the whole of the nurseled services, the integration, there are real opportunities here. We don’t want it left to chance and what we don’t want to see is a patchwork Health Service. That is why we think that more should be embodied in statute to ensure that nurses have adequate representation. What we don’t want to see is huge differentials in the performance of consortia and then playing catchup. Now would be the time to ensure that that happens.

Q52 Chair: Mr Sobanja was saying earlier less emphasis on writing it into statute and more on Commissioning Board guidance as the way of achieving that.

Dr Carter: As I have said-and I agreed with Mike-wherever it is embodied, it is then about behavioural change, and the last thing we want is tokenism. I do feel that the Bill really underestimates the significant contribution that nursing has to make right throughout the spectrum. Nurses are one of the few disciplines that follow the patient throughout the pathway. It is for those reasons, and it is not being parochial or nursecentric, we feel that consortia would be well advised to have nurses at the centre of it and, as the current arrangements are, it will be very much left to local choice.

Q53 Nadine Dorries: I totally agree with you, but I would take issue on your comment about patchwork provision. There is going to be patchwork provision because the needs of central Hackney are going to be very different from the needs of central Gloucestershire. There is going to be patchwork provision across the country because what will need to be applied and resourced is what the area needs and demands. So that will happen. To throw it back to you, can you give me a line that you would like to see, taking your words, in the Bill which would do this? I don’t see that you can actually write in the Bill a line which would give the assurances that you want because, if you do that, what you do then is exclude and restrict the amount of scope that nurses could have within consortia. I understand that it is not underwritten in statute, but you can see, surely, that the possibilities across the country are there.

Dr Carter: May I come back through the Chair? Of course I can see the opportunities. Currently there is a patchwork in the NHS, and whilst I am quite clear that with the previous Government there were some huge successes-and so there should have been with the amount of money that was put in-what we also know is that the health divide actually got wider. My fear is that that would increase the likelihood of that happening. In terms of the fragmentation of services and the gap in health inequalities, we don’t want to see that widening.

The Secretary of State is quite clear. He keeps saying "No more top down. Let us have bottom up". But in relation to the role of GPs, of whom I am a great fan-and I don’t mean that in a patronising way-the Secretary of State has no problem with prescribing on the role of GPs. We don’t see why he has such a problem in prescribing on the role of nurses and allied health professionals.

Q54 Nadine Dorries: What if it was mandated that there should be a nurse on the board of every consortium? Would that satisfy?

Dr Carter: It would.

Nadine Dorries: I feel an amendment coming on.

Chair: Does anybody else want to comment on that proposal, otherwise I think we might move on?

Q55 Dr Wollaston: I am very interested to hear from the panel how you feel about the arrangements under the legislation for picking up underperforming practices.

Dr Gerada: This is again one of those areas that is a little confusing within the Bill. At the moment the performance list sits with the PCT and if the expectation that the performance list and therefore the issue around performance is going to sit with the consortia, it needs to be clear that there will not be then inherent conflicts of interest. With the size of some consortia being little over the size of a large practice-my practice is 15,000 and the smallest consortium is about 16,000-you couldn’t possibly be assessing, or you could be assessing your own performance but I think there may be inherent conflicts of interest within that. What we would feel is that, wherever you sit on the performance assessment of GPs, it ought to be transparent. The individuals doing it, or the organisations doing it, need to have the respect of the GPs that are doing it. With large consortia, clearly, the 600,000 or 500,000, you can sit it within there, but with smaller ones you may need to do it with neighbouring ones.

The other issue is that they are also about "Performance for what?" because we have already picked up the requirement for practices to adhere to the commissioning decisions. This is again moving things away from clinical performance under the GMC, where our main role is responsibility to care for patients. There is going to be a tension, and already my members are sending me comments about the tension, of adhering to commissioning decisions that may, for example, not be in the patient’s best interest. For example, the mandatory use of referral management centres. For example, the competition, where competition and price are equal-so we are having competition based on price not just on quality. Those sorts of issues need, again, to be ironed out once we start to look at performance issues and once we start to roll this forward because they will inevitably create problems as this rolls out and as the funding that we have becomes squeezed and squeezed and squeezed so issues around stopping patients going to hospital will become the priority of commissioning consortia in order to release funds.

Dr Alessi: The reforms are not only about commissioning but are also about primary care itself, about making primary care more predictable in what it does, in its outputs in particular, and allowing for the overengineering that exists in secondary care to be reduced. Clearly if you know exactly how a patient journey is going to be managed, and one can rely on primary care to perform certain functions, perhaps that level of overengineering that exists doesn’t need to be there. In terms of managing underperformance within primary care per se, again there is a role for the Health and Well-being Board. This is perhaps left field, but clearly if a Health and Well-being Board is going to be satisfied with the results and with the commissioning decisions which are made by a consortium-and it has to be because if it is not, clearly, there is going to be significant difficulty in getting that Health and Well-being Board and the consortium to work together-it is going to have the ability to refer that consortium for remedials, if necessary, and that is at the end of a spectrum. The new world is about inclusion in practices. We have been in a world whereby it felt more like imposition, imposition of views of PCTs in many respects. The stick around performance management is something which we are going to have to use at some point, but this is a world whereby we all have to be part of the same and, as such, we have to help each other do that. Also-

Dr Gerada: I am sorry to cut across. Therefore, we need a robust measure of measuring performance. What I am concerned about is that what we hear about is performances-take away clinical performance, but, for example, on referral rates and on prescribing-and unless they are robust, and at the moment they are not robust, you can understand variation in performance. Clearly, there are some doctors who perform incredibly badly and we need to use the current systems which we have. We may need to look at some other systems, but we need to be absolutely clear what performance we are talking about. Otherwise, what we are going to end up with is GPs, such as myself, such as anybody, "over-referring" because I know more about a subject. We know that the more you know about a speciality area, the more you refer. If we use referral management centres and we stop patients being referred to the service of their choice, we may inadvertently delay cancer diagnosis and we may inadvertently cause underreferrals. We need to be absolutely clear. From the Royal College of GPs, of course, we look at this. This is part of our raison d’être. Standards of general practice and performance of GPs we have looked at in great detail and it is much more complicated than just saying somebody has got an unacceptable variation in antibiotic prescribing.

Dr Alessi: We are in a world, again, where we are assuming that we are perfect at the moment. We have situations arising now where parts of Birmingham are stopping patients being referred for musculoskeletal conditions because the money is running out, and that is affecting the whole population. We need to get better granularity and understanding as to how we manage the referral process as well. I will stop there.

Q56 Dr Wollaston: Clare makes a very important point, that if you look at our gate-keeping role, sometimes GPs can feel performance managed on the level of referrals they make, but we also know that underreferral for early diagnosis of cancer is just as bad. How you get that balance right is going to be crucial.

Dr Gerada: And to be mindful of it. Clearly, the Royal Colleges have a responsibility in this. We must, and through the Academy of Royal Colleges we will be looking at it, but we have to be absolutely careful that we are not performance managing GPs where patients are going to be put at risk.

Q57 Chair: Can I go back a stage? In that debate, the thing that was accepted between both Dr Gerada and Dr Alessi was the principle of performance management from the consortium, which is, itself, one of the controversial areas in these proposals.

Dr Gerada: If it is a large consortium. We have concerns where you have small consortia which are little more than practices performance managing. I would not like my performance to be controlled by the practice up the road.

Q58 Chair: No, absolutely. But can I just be clear whether, on both parts, you feel it is part of the job of the Commissioning Board, through some structure, to performance manage the delivery of primary care in this new world? That seems to me to be a very fundamental question.

Dr Gerada: Yes.

Dr Alessi: Yes, but at the very end of the spectrum. There is a lot of support-

Q59 Chair: Hang on a second. Performance management-

Dr Gerada: Yes.

Chair: -is it elimination of the dangerous or is it performance management across the bell curve? Which is it?

Mike Sobanja: Chairman, what you have to do here is think about the primary responsibility, and the primary responsibility goes with the contractual holding, for me. There are lots of other people to go in because this is Matrix, there’s CQC, there’s the colleges, there’s the local consortia and so on. But what we all want to know-what I want to know as a citizen and a taxpayer-is who should have acted when something went wrong in the system, and obviously went wrong in the system? I am thinking about Staffordshire. If you think about that, from my point of view, everybody sat round and looked at each other. I believe it is the commissioner you look at first and foremost because they have the contractual responsibility. There are lots of other things that have to feed into this, and what I would wish to avoid is the confusion or diffusion of responsibility for performance management, recognising there are lots of different players to put something into the pot.

Q60 Chair: Can I ask whether Dr Gerada and Dr Alessi agree with that or disagree with it?

Dr Alessi: I am very happy with that response.

Dr Gerada: I am very happy with that response. I was just thinking, whilst Mike was talking, that, of course, in the future consortia may not be your local GPs coming together because, under the Bill, if you have two or more people coming together to provide primary care services, they may well be a consortia. So you are absolutely right to question this. On the basis of that, I don’t know the answer, because if there is a corporation that is a consortia you might then get them not as willing to look at their performance as you might do, paradoxically, a group of GPs.

Q61 Chair: Mr Sobanja, it is not just about eliminating the case of Mid Staffordshire or any of the other highprofile examples, is it? It is also about taking doctors’ delivery of primary care across the whole range of practice in order to challenge the people who are at point 40 on the scale and who could be at point 60 on the scale if they simply observed better practice guidelines.

Mike Sobanja: There will be a curve of performance, and it is about moving the entire curve.

Q62 Chair: Where in this system does that responsibility lie? It is clear where it lies for secondary care. Where does it lie for primary care?

Mike Sobanja: I believe it should rest with the person who holds the contract, which is the National Commissioning Board, supported by the commissioning local consortia and others.

Q63 Dr Wollaston: The problem, as I see it, is that their contracts are all being held by the Commissioning Board, but it is unrealistic to think of the Commissioning Board in London actually being responsible for weeding out, if you like, poor doctors. There are two issues, are there not? There is the issue of the poor doctor individually that you want to protect patients from and the issue of performance as a whole as to how we control costs-the point that Dr Alessi was making about having the financial context to clinical decision making. I am very interested in what you feel about the role of the responsible officer that is currently with PCTs. Do you think that should be in the commissioning consortia or should that be at a more regional level or right up with the National Health Service Commissioning Board?

Mike Sobanja: Are we talking about the responsible officer or the accountable officer?

Dr Alessi: Both.

Dr Wollaston: I am sorry, when we are talking about how we actually-

Mike Sobanja: Because there is both.

Dr Wollaston: Yes. I am talking about responsible officer in terms of-

Chair: The GMC.

Dr Wollaston: -the GMCtype level.

Dr Gerada: There has been lots of debate about this, and it is passing backwards and forwards. The issue is because of the size of the consortia, because this is what we are always trying to marry up. The debate then is probably the responsible officer should sit at the National Commissioning Board devolved down to a more local level because if one assumes the National Commissioning Board is going to have regional outposts, that is probably the best place for that person.

Q64 Chair: Are we reinventing PCTs, or rather consortium clusters?

Dr Gerada: That is what we would like to ask the Secretary of State. They do feel very similar at some points.

Dr Carter: This is another area of concern, that there is a lack of detail and a lack of rigour. Whilst, of course, we want things to work and work well, you have to have contingencies as to when things do go wrong. Within the current arrangements, it is simply not readily apparent to us where the accountability and responsibility should lie. I agree with Dr Wollaston. There is a heck of a distance between people sitting in London and deep out into the community, even way down in Plymouth, with the lines of communication. That is where we would advise the Secretary of State and the Government to get some more rigour and some more detail into this.

Whilst I am on that theme, in relation to the financial management, we, like many others, saw Sir David Nicholson’s appearance before you and we do feel that there is a need for a plan B as to what happens if a consortium begins to get into financial trouble. You have to work in that that is a possibility. Goodness knows, I mentioned a few minutes ago, with all of the investment that was put in in the last Government, you still had trusts and PCTs getting into serious financial trouble. You marry that up with taking 4% out a year for four consecutive years-these are difficult financial times-and we would want to see, as I say, much more detail as to what the default position is.

Q65 Chair: There is another related subject, is there not, that we were talking about, performance management of primary care and how that is discharged in this new world, including some small consortia? There is a related question, which is where service is being reconfigured in a way that a particular practice or group of practices might have a good idea in which they are themselves engaged and how the commissioning process is seen to take place fairly but buying something beyond general medical services from practices that are members of a consortium. Mr Sobanja is nodding.

Mike Sobanja: I am only nodding because of the recognition that it is a very difficult area and tied up with "any willing provider", which I would like to say something about, if I may. The issue there, of course, is it would appear that Monitor would have a role in crying foul should the consortia indulge in anticompetitive behaviour, in the broadest sense. One of the issues there is, again, if the primary purpose of redesigning the service is about improving care to patients, improving integration, and so on, that, for me, would trump the issue of anticompetitive behaviour, recognising the statute to be complied with there. In that sense, to answer your question, Monitor ought to be a servant of good commissioning, not the determinant of good commissioning. The way the Bill is currently set up, it could be that the reverse would be true.

Equally-and "any willing provider" has been mentioned-if I may, "any willing provider" was introduced as a procurement mechanism, not as a policy. Its intention was, if my memory serves me correctly, to overcome a situation where we might be tendering left, right and centre with high transactional costs, etcetera. The issue is that the way in which "any willing provider" operates in the future, and at primary care as well as secondary care level, is key to this. If "any willing provider" is triggered by a commissioning desire, then it is satisfactory as an alternative to tendering, i.e. let us get it back into being a procurement mechanism. But if "any willing provider" is to operate at any time such that any provider can enter the market, with their licence from CQC and Monitor and must be given a contract and not in response to a commissioning trigger, then it undermines commissioning. What we have to do is put more weight behind commissioning, at both primary and secondary care, not undermine it.

Dr Gerada: It is a complex question. Of course, the greatest innovations have happened when clinicians get together and see a need and then design services to meet that need. Over the last 20 years, that is how change has happened, certainly in areas where I work, and we must encourage that. But at the same time, of course, we have to be mindful of the conflict of interest. We also have to be mindful that patients must not end up receiving secondrate services delivered by primary care practitioners just because that seems to be pragmatic at the time. My view is that this is where patients come in and where patient groups come in because patients are going to be our greatest advocates and the ones that will be there as the break to anticompetitive behaviour in its rounder sense. Patients will say, "Actually, doctor, I don’t want to come to your ENT service. I want to see a doctor who is a Royal College of Surgeons ENT." So if we are going to make any change within the Bill, it is actually using patients and patient groups to protect us. How it is going to be done, again is for yourselves to sort out because it is a question. We have all lived through fundholding. We saw fundholding and some of the issues that that threw up. Certainly, with GPs now holding £80 billion to £100 billion worth of public money, we want to make sure there is transparency but, at the same time, not stifle innovation.

Finally, before I finish, the Royal College of GPs have supported the use of federations, which is actually groups of GPs and others as provider organisations, so pulling in providers. As federations, putting yourself forward in a position to tender under an "any willing provider" or to put yourself up as an "any willing provider" in the mechanism is exactly the same as any other "any willing provider". We think that is probably the best way forward.

Dr Alessi: In an environment where resources are going to be ever more difficult to obtain, there is no option but to think in terms of us working with clinical colleagues to design new pathways. The duplication that exists within healthcare is enormous and we all know it. The handovers are the most problematic, and any system which develops into a process, which, instead of lobbing a patient over a wall, ends up with a warm handshake is something which we all would support because that is what we really should be about.

Clearly, there is going to be a degree of scrutiny that is going to be necessary to ensure we don’t enter into situations where there is a monopoly, but this is something we are going to have to feel our way through. There are significant concerns about this and significant debates about the transparency associated with this, but I don’t think they should stop people looking to reform pathways or develop new pathways with secondary care, to ensure that a patient gets perhaps a better service than they get at the moment. In the end, I agree with Clare-the patient will be the arbiter-for the first time.

Dr Gerada: The first time.

Dr Alessi: Today.

Dr Gerada: We are both from Malta.

Chair: We have found a source of agreement. That is good news. The way Dr Alessi answered that question is a good trigger for some questions David Tredinnick wants to ask about interface with social care, which is relevant in this area as well.

Q66 David Tredinnick: I don’t know whether the Malta GC end of the table want to answer these first or the other end of the table-and we will never forget those convoys.

The Bill contains provisions to make it possible for foundation trusts and commissioning consortia to be designated as care trusts. Do you expect this to work? They will have responsibility for commissioning both health and social care. Thank you.

Dr Alessi: Shall I start?

Chair: Yes, go on.

Dr Alessi: Absolutely, of course. This is the way of the future. Unless we start to work with social care in a far more constructive way, I don’t think we will succeed. In Kingston we have made significant advances in getting social care and health care jointly commissioned. We have a Health and Well-being Board already in existence. We have met twice and the second meeting was quite lively, which is good and positive. But these things are going to take a little time because if there is something we have learnt over the years, a lot of this is related to personal relationships and trust, and trust, unfortunately, is not something which can develop overnight. It takes quite a long time for that trust to develop between a leader of a council, the chief executive of a local authority and health. There are also the concerns about a local authority "stealing" health moneys-to use a health term. Having said that, I have fewer concerns about that, because we all know that the nonhealth determinants of health are probably at least as important as the health determinants of health.

Q67 David Tredinnick: As we are running out of time, let me be as unhelpful as I can. There is an issue here about these pooled budgets and, secondly, how are we going to work a system where we have not got coterminosity anymore between local authorities and the commissioners?

Dr Gerada: Absolutely.

David Tredinnick: What are we going to do with the fixed and the variable together?

Dr Gerada: Again, those are questions that we would like to have ironed out in the Bill, because the more I read the Bill, the more I look at this, I cannot marry up how the idea that we are abolishing practice boundaries is going to improve the situation for our local population and reduce health inequalities and in fact produce better quality of care for patients. That, added with the "any willing provider", is separating out the provider from the commissioner. There will be no relationship, let us be clear, when we have 2,000 "any willing providers". How can you have a local relationship with them when in fact what the Royal College of GPs would want is enough excellent providers, ideally from our local community, so that we can work together and form relationships for the complex chronic patients that we see every single day?

Q68 Chair: Dr Gerada’s view is that the principle of "any willing provider" entrenches the difference between commissioner and provider and between primary and other forms of health and social care.

Dr Gerada: Not just my view, the College’s view.

Chair: Okay, the Royal College’s view. I don’t think that is necessarily the view of every other witness on the panel. Either Dr Alessi or Mr Sobanja?

Mike Sobanja: No. The NHS Alliance policy is saying that commissioning should remain accountable to the public sector absolutely, and that is the benchmark; that it is perfectly possible for "any willing provider", in the way I described it before without going over that, to operate and for that to be in the interests of patients. My observation in some of the work I do in the commercial and the private sector is that they are actually very good at working and building relationships across supply chains in partnerships. It seems to me that that is the issue. If I can go back to the social work question and try to wrap that in, the Health Service and local authorities have to learn to work across boundaries, not to remove boundaries. The way I read that clause about care trusts is that where care trusts are working well now let us not dismantle them. That is fine. But I don’t believe that that is going to be mainstream in the future because we have to wrap in housing and education as well as social work on those nonhealth determinants, healthcare determinants of health, and make people work together across those boundaries. But certainly the concept of competition with providers, I believe, can be made to work in the public interest and the benchmark is one of commissioning remaining a public-sector accountability, not necessarily a provision.

Dr Carter: Can I come in?

Chair: Yes.

Dr Carter: We are totally committed to the concept of health and social care being integrated. There has been a lot of good work and examples of this in Northern Ireland over the years. In relation to my previous specialty in mental health, there were huge developments from the late 1990s onwards which has done so much to ameliorate many of the problems that we saw with homicide, suicides and serious incidents where health and social services were working together. That is the right direction of travel. But I agree with Clare. You now have a problem where you will not be having the coterminosity. That will provide a huge set of challenges. Marry that up with the "any willing provider" and the thing I would have said, if I had got in earlier, is we don’t have a problem with it but our concerns are that, in such economic testing times, we don’t want to see cost at the expense of quality and people going for the cheapest "any willing provider". That is something that is going to have to be watched very carefully.

We also think that yet another problem has opened up with the flexibility about choice of GPs, which, on the face of it, is a very attractive proposition, and from one perspective I couldn’t disagree with it. However, potentially, unless it is well managed, it will lead to a fragmentation of services. I commute in from Hertfordshire every day to central London and it would be very convenient for me to have my GP in central London. We don’t have the IT systems and the communication systems in order to get the loop back. Therein lies a set of difficulties. Also the Bill is absent on the kind of detail which I think perhaps people think doesn’t have to be in the Bill, but it will have to be somewhere. How many times can someone change their GP-once a year, once a month? It is simply silent on these things. Whilst the critical mass of people will continue, I believe, with their local surgery, it is actually around the edges that has the potential to destabilise things. It is not what you do with 95% of the money, it is what you do with 5% of the money that can tip you into an over or under spending situation.

Q69 Valerie Vaz: Apologies for going slightly offpiste, but I am asking very simple questions. It is very good to have you here, Dr Alessi, because you are a pathfinder, so I am quite concerned and I just need to find out how it is all working. Presumably it is, is it? Apologies to all my other colleagues who are very well versed with the Health Service, but I suppose I am the lay person on the Clapham omnibus. I would really like to know, just to pick up the coterminosity point, are you aligned with your local authority?

Dr Alessi: We are aligned with our local authority. Prior to the publication of the legislation, we had already moved towards a one Kingstontype approach, which actually brought the local authority and all the GPs within the borough into one organisation. To a degree, we are living in sin, which is always fun anyway, so we are part of the PCT but the PCT devolved its responsibilities to us. We are going through quite a difficult phase at the moment because, clearly, we are going to have to moderate that through the journey over the next 18 months and the challenge is to ensure we don’t lose the momentum that we have already developed. Our aircraft has taken off. We don’t want to go back, start again and start assembling a new aircraft. That is the debate, between allowing us to continue and levels of assurance that are perhaps deemed to be necessary in terms of delegated responsibility.

Q70 Valerie Vaz: In terms of budget, because presumably you were given a budget to do this, how much were you given and who are you accountable to for the budget?

Dr Alessi: Because we are living in sin, the budget is the PCT’s budget. The methodology we have used is that we have used groups of GPs and other professionals, including nurses, and physiotherapists in some cases as well, to determine exactly how that money would be spent. The practitioners have been very much more involved in clinical commissioning. What this has shown already is that there was a level of incoherence in terms of the contracting that existed before. The contracts which the NHS are using are exceptionally complex and they are basically standard contracts with codicils upon codicils added to them. In the end, they contradict themselves so many times that, in many respects, they are a licence for the providers rather than for the commissioners. We need to change that.

Q71 Valerie Vaz: Do you, as the pathfinder, have the budget, or is it still with the PCT?

Dr Alessi: We cannot legally hold the budget until we become a consortium-it is with the PCT-but in actual fact we are as one. It is quite an extraordinary situation. Somebody fell off a horse on the way to Damascus. I am not quite sure who it was.

Q72 Valerie Vaz: Exactly. In terms of what you do, how do you balance the individual patient need with population need? How are you going to do that and how do you do that?

Dr Alessi: Again, public health is really important. We keep on going back to public health, in terms of "Are we spending enough in respiratory medicine? "Are we spending too little in a condition?" "Why are we spending so much more to treat macular degeneration than its prevalence would suggest that we should be spending?" "What is going wrong?" Those are the challenges we are trying to grasp at the moment.

Q73 Valerie Vaz: As a pathfinder, how do you do that now? How are you balancing your individual patient needs with the wider needs of the population?

Dr Alessi: What we are spending most time doing at the moment is engaging with all the practitioners in Kingston. A lot of this is not about big meetings but onetoones, very small meetings, and for us all to understand what we are supposed to be doing. The moment that happens we are starting to come up with indicative budgets for conditions, and I think that is the direction it will take. At the moment, we are not doing it, clearly, because we have just started. A little bit of time and a little bit of space.

Q74 Valerie Vaz: You talked about quality and enhancing quality, because that is the key thing. What levers do you have, as the pathfinder, for enhancing quality?

Dr Alessi: It is certainly in our interests to have the highest quality primary care that exists because clearly the less activity that is referred out, potentially the better use we will make of the resources we have for our population. There is a vested interest for us all to manage that quality together as long as we have public health again to make sure that we don’t undersell health to a population, and the new world is not about saving out of a budget but spending that budget as wisely as possible.

Q75 Valerie Vaz: What levers do you have then?

Dr Alessi: These are levers we are developing. You are talking about managing the recalcitrant practice within a system, I think, are you not?

Valerie Vaz: Yes.

Dr Alessi: We do not have a good system at the moment for doing that. We are trying to develop perhaps a more supportive way of doing that in the future and in the present.

Chair: I am conscious that we are running out of time. Rosie wants to come in, so could you ask your question and then perhaps each of the witnesses have a final opportunity to respond to you and say anything else they would like to say.

Rosie Cooper: I wanted to take bigger part in this part of it but I have not been able to.

Chair: Apologies.

Q76 Rosie Cooper: No. I didn’t want to just jump in this time because it is developing. Frankly, when we were talking about the health and social care interface and the way we go forward, people listening will be thinking "If only". What is actually happening out there is health and social care, delivered locally, will be starting to mesh. The reality is that, with the financial constraints, local authorities are delivering care at different levels and it is reducing. That is really frightening. People moving house will suddenly find that care they have taken as normal has disappeared.

To go back to a little bit about the Commissioning Board, it is going to delegate, or possibly delegate, some of its responsibility for managing GPs down to consortia. I wondered how wise you think that is. Who will hold the contract? The Commissioning Board. Will that come down to consortia in part as well? The reason I ask that question is, there is a huge question about how you manage your colleagues. How do people performance manage you? In essence, I am saying if you have a difficult doctor or practice, how do you, as a consortia, think you will performance manage them? And, for example, things like overseas locum GPs practising in this country, as an example of where you already are, how are you going to manage that out and who is going to be responsible?

Dr Gerada: Do you want me to go first? The question is a very complex one, but practices will have layers of clinical governance, so I do not think all of this has to be devolved to a National Commissioning Board. We need to make sure, at practice level, and this is what, through the Royal College of GPs, we are talking about-practice accreditation, and embedding clinical governance that’s live-you start to address performance as you go on day by day. Above that, clearly you need some sort of performance management, and we would say the NHS Commissioning Board, devolving that down to a reasonable geographical area. I don’t know what the answer is. I would imagine about 400 GPs, that sort of an area-a natural larger community than a commissioning consortium.

In terms of how you deal with the overseas doctors-it is the EU doctors because others will be bound by different rules-again that needs to be through the Royal College of GPs. We have sent guidance out to every single PCT and to Strategic Health Authorities about this, but that has to be a responsibility of the National Commissioning Board, I think. Again, the devil is going to be in the detail and where that is going to be determined still needs to be sorted out.

Q77 Rosie Cooper: I appreciate we are all looking for a black cat in a dark room and I am praying someone will switch the light on.

Mike Sobanja: If I came at that from a slightly different point of view, the National Commissioning Board can delegate authority. It can’t delegate responsibility. That is one thing we have to be crystal clear about. If I go back to the question before, the notion that this National Commissioning Board is going to be sitting in London and there will not be anything else, other than all of these consortia, does make me smile because the certainties of life are life, death and an intermediate tier in the NHS. I do believe that they will be there long term and there will be lots of them, and a lot more than people actually think.

Dr Carter: Strategic Health Authorities maybe.

Mike Sobanja: But there difference here-

Q78 Rosie Cooper: Where’s the money coming from? Hang on. We are all describing how we think it will pan out. Where is the money coming from?

Dr Carter: And where is the detail?

Dr Gerada: That is again over to yourself and the scrutiny of the Bill.

Q79 Rosie Cooper: No, we are chasing it just as much as you are.

Dr Gerada: There will be no money. In a sense, the GP commissioning consortia cannot be as many because you have all the transaction costs of just keeping many, many more GP consortia going than we have currently got PCTs, but the money will no doubt have to be taken out of the management structures of those.

Q80 Rosie Cooper: So it will come out of patient care in the end.

Chair: Order.

Dr Gerada: It probably will come out of patient care in the end.

Rosie Cooper: It will come out of patient care.

Dr Gerada: Transactions will have to come out of patient care.

Rosie Cooper: Services will be reduced by this. It is ridiculous.

Chair: Mr Sobanja was about-

Mike Sobanja: I was about to say my belief is that the commissioning of outofhours services, if that is where you were directing your comments to, will rest with consortia and they will have a fundamental responsibility, of course aided by the various regulators and supporters and all of that particular mechanism. But I go back to this absolutely fundamental point. The National Commissioning Board can delegate what it likes, but it cannot delegate the responsibility and nor should it be allowed to do so, and that is why David Nicholson will have a direct line to the Public Accounts Committee in terms of value for money and quality of service.

Q81 Chair: Concluding comments-and to my two colleagues, we have to all sit here because otherwise we are not quorate.

Dr Alessi: A very quick comment. There is a balance to be had between the levels of assurance that are going to be designed and operational issues in the NHS. Clearly we are moving into a world whereby there is going to be less resource, hence we are going to have, as a nation, to accept there may be an element of risk which is greater and that element of risk may be worth paying if the delivery is going to be so much greater. That is a debate we are going to have to all have.

Rosie Cooper: "If" is a very big word.

Dr Alessi: I know it is a very big word and I am very happy to come back and talk about it again. Thank you.

Chair: You might well find you are taken up on that.

Dr Gerada: We need to learn from pathfinders. Many of the pathfinders such as Dr Alessi have been doing it for many years. They have put systems together but what we must not do is fall into the trap that what works in Surbiton is going to work in Southwark.

Dr Alessi: Indeed.

Mike Sobanja: I like the direction of travel. Perhaps slightly different to Peter, I don’t want to see everything written into the Bill. My past experience of Bills, which are hugely detailed-and heaven knows this one is detailed enough in terms of size and so on-is that that is unhelpful. I would like some answers to some of the questions about secondary legislation about directions and regulations which will colour in some of the detail that we are all looking for. I am not convinced that it should be in the Bill.

Dr Carter: Very briefly, the issue to do with evaluating Pathfinders is something that is very important to us. The RCN were at the forefront of wanting pilots, and Pathfinders is a euphemism for pilots, and we would like that evaluated because that is key to this.

There is something else which at some stage I would ask, if I may, that you and your colleagues could look at, and if there had been more time today we would like to have. It is the issue to do with if a consortium has a surplus. What happens to that? We feel very strongly that any surplus should be reinvested back into healthcare and should not be part of a profit for the consortia to then be converted to salaries, even if that went to nurses and others. So, to be crystal clear, if people are doing a good job, they make better use of the money and there is a surplus, that is taxpayers’ money. It should be spent on healthcare not on salaries.

Chair: In the legal profession, it is known as the clients’ account. It is a fairly simple proposition. It is not difficult to police in reality. Thank you very much.