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Commissioning - Health Committee Contents
Examination of Witnesses (Questions 399 - 419)
DR PAULINE BRIMBLECOMBE, MS MAUREEN DONNELLY, DR PAUL ZOLLINGER-READ AND MR STEPHEN GRAVES
Q399 Dr Naysmith: Good morning everybody. Welcome to the Health Select Committee. You have all, I think, been sitting in on the first session, so you pretty well know the score. What I want is fairly sharp answers, if you can, and not too much repetition and we will get through quite a long agenda. Could you, first of all, introduce yourselves for the record and say who you are representing?
Ms Donnelly: I am Maureen Donnelly; I am the Chair of NHS Cambridgeshire. I have been the Chair for just over three years.
Dr Zollinger-Read: Paul Zollinger-Read; I am the Chief Executive of NHS Cambridgeshire; I have been doing that now for nearly two weeks.
Dr Brimblecombe: I am Pauline Brimblecombe; I am a Cambridge GP and I am Chair of our local Practice Based Commissioning Consortium.
Mr Graves: Stephen Graves; I am Director of Corporate Development at Cambridge University Hospital, locally known as Addenbrooke's.
Q400 Dr Naysmith: We have invited you all here this morning to explore how a local health economy works. Can I start off by asking you how you see your organisations working in the relationships with each other?
Dr Zollinger-Read: NHS Cambridgeshire is clearly a commissioning organisation. The role of commissioning is to work with public health colleagues to understand the need of the local population and then, with patients and clinicians, to implement actions that deliver for that need, ensuring that we drive up quality. Clearly, partners within that are local authorities, primary care and our acute colleagues and ensuring that we commission correctly depends on collaboration between all those organisations.
Dr Brimblecombe: Just to explain what our Practice Based Commissioning Consortium is, it was formed very early on when PBC first came in. It is called CATCH (Cambridge Association to Commission Health) and it presently consists of 31 practices and the city itself and actually Hertfordshire and Bedford as well. Basically the consortium built itself around Addenbrooke's, because Addenbrooke's is really our only acute trust provider. Patients in Cambridge actually do not want choice, because they have a very good acute hospital on their doorstep. We built the consortium to improve collaboration between GPs and we thought we would be powerful enough to perhaps influence our acute provider, who, being a foundation trust, we regarded as being very powerful and perhaps influencing our spend rather more than we wished. Actually what we have achieved over the last four years more than anything is engagement of the clinicians. I think, if I am going to emphasise anything, the health reforms have come in and everybody at the top understands them, but the clinicians take a while to get on board and it has taken us four years for the GPs to really become engaged. They now understand particularly the health economics locally, and, as you probably know, NHS Cambridgeshire has its problems—it still has a historical deficit to pay off. As far as practice based commissioning savings go we have very few, but we do have the GPs engaged now—they at least understand the problem—and they are accepting that it is part of their role, and the fourth principle of medicine of distributive justice, which I think clinicians have great difficulty in understanding, they are just about coming on board with.
Q401 Dr Naysmith: We will explore that more later on. Stephen, how do you see your relationships with your commissioners?
Mr Graves: I think they are absolutely fundamental. I think from the data you will see that we have a very large income stream from our local commissioners, but we have an income stream in terms of acute care which is about the same size from other commissioners and specialist services. As a large player locally, we understand fully that we have a fundamental role in terms of the health (in every sense of that word) of the local system, very different, I think, to a number of years ago. I think we fully understand that we have to live within the means of the local system and play our role in managing that system so the funds available to us can be used to best effect, and that, as Pauline has said, is now something that is fully understood by the lead clinicians as well as the management team.
Q402 Dr Naysmith: Pauline and Paul, you both have commissioning functions. Could you, please, describe what commissioning you each do? You do not do exactly the same sort of commissioning, do you?
Dr Zollinger-Read: The Primary Care Trust is responsible for the overall commissioning. That will only work if PBC and Primary Care Trust work together. In my view, PBC and Primary Care Trust need to agree what is the commissioning agenda for the year coming. What is it we are jointly going to do and how are we going to do that? Within that you will have elements that the PBC groups are particularly interested and want to push forward on, and then there will be other areas that they are not particularly interested in and want the PCT to lead on. Pauline, do you want to come in?
Dr Brimblecombe: A lot of the things we have done, we have put our strategy in with the PCT's strategy. Developing a community geriatrician role was something that PBC savings actually were used for to try and help a central frame of what we want to do, which is to improve the care of our elderly populations.
Q403 Dr Naysmith: Are there any services, Pauline, that you are better at commissioning than the commissioners in the PCT would be?
Dr Brimblecombe: Are there better ones?
Q404 Dr Naysmith: Are there any services that you think it is better for you to commission?
Dr Brimblecombe: On a day-to-day basis, because we know what our patients actually need—and I think there is a problem there with what they want what they need—looking at the pathways is something that we think that we can actually help develop much more effectively. Our plan in the future is actually to look at the pathway rather than just a service or provider. If you ask me what my role as a commissioner is, I commission every time I sign a prescription and every time I send a referral off. The problem is at the moment that our referrals are actually a blank cheque, and that is something that we really want to change.
Dr Zollinger-Read: The main plank of our strategy is really now engaging with PBC across the patch to enable PBC to fully commission. I have met with all the different clusters and there is a strong appetite for taking forward real budgets in clusters of varying size with support from the PCT. I believe that if you devolve that, first of all, you get clinical leadership, which is crucial for any commissioning, secondly, you are more likely to get the joining up of primary and secondary care working together on pathways and, thirdly, you will get local patient involvement as well; so I think that devolution is definitely the way that we are moving in NHS Cambridgeshire.
Q405 Dr Naysmith: Is everyone clear about their different roles in the health of your local communities?
Ms Donnelly: Yes.
Q406 Dr Naysmith: Maureen, are you happy with that?
Ms Donnelly: Yes, I am.
Q407 Dr Naysmith: Pauline, you know exactly what you are meant to be doing and you do not feel confused?
Dr Brimblecombe: I think there is going to be confusion because of the statutory role of the PCT with the budget at the moment. I think that has still got to be ironed out, whether we are going to be handed real money or whether it is still going to be just notional budgets. I think, probably, a lot of my colleagues are going to say, "Hang on, do we really want the responsibility to break even at the end of the year?" I know that a lot of my GP colleagues are very anxious about that, because if they cannot manage the budget at the moment, do they want to take on that whole risk? It is very easy for GPs at the moment to be able to hand off the risk to the PCT, and I think that is one of the challenges.
Q408 Dr Naysmith: We will explore some of that in more detail later on. Stephen, are you quite happy that everyone in your health community understands what they should be doing?
Mr Graves: I think, as has been said (and the word "journey" has been used a lot), if you take this particular example, we are moving from something that has been more led by the PCT to something that is being more led by local groups of GPs. If I had some of my doctor colleagues here, I am sure they would say, "I want greater clarity", but we are betwixt one and the other. The reality, I think, is that there need to be services where the core principles are the same across the whole area but that the way it is delivered will be more locally focused. Like many of the people coming in, Cambridge is a small city of 120,000 people, there is a ring of villages around the outside which are roughly another 100,000 odd people and then you move to the north in Cambridgeshire into some much more remote areas of the fens, and so the principle has to be the same, but the way that it is delivered in detail will be different. For people in Cambridge, maybe their local physical provider is the hospital for some services, whereas in the middle of the fens 20 miles away it may be a community hospital that that clinician in secondary and primary care needs to go to in order to provide it, but the principle of how it works needs to be the same.
Q409 Dr Naysmith: What you cannot say at the moment is anyone calls the shots. As to who calls the shots, actually, in different circumstances different organisations will call the shots.
Mr Graves: No, I think that the joint work between PCT and primary groups, GP groups, is starting to play out, and these are complex worlds, so I think we understand that we have all got to work between everybody as opposed to one person calling the shots in that way.
Ms Donnelly: May I add a comment to that? The way we are trying to think about it is we look, with the clinicians, at the service pathways, we then try to stop ourselves thinking about the walls of the current organisations and think: how do we get the most expert help and the most appropriate help for that patient to that person in a way that suits them? Whether it is within a hospital, outside a hospital, whether it is an expert consultant or a local clinician, can we get them to work in different ways that suits the clinical pathway?
Q410 Dr Stoate: Pauline, you put it very well when you said your aim is to achieve distributive justice, and I entirely agree with you there, but in your evidence, which is also very well put together, you say that the bulk of health expenditure is spent in the acute sector, yet delivers care only to the top 10% of the health pyramid and care in the community is mainly theoretical. What would you do to address that obvious imbalance?
Dr Brimblecombe: Somehow we have got to shift the care. It is the resource we need, and that is the conundrum we all have. We know what we want to do but we have not got the resource to be able to put the investment in community care. All the health reforms over the last three or four years have been directed towards acute care, so the focus has been totally on the acute sector, which has delivered very good outcome with the 18-week targets but, of course, it has consumed a lot of the resource. Now we are suddenly saying, "Whoops, we had better look at long-term conditions because if we manage those much better and patients with long-term conditions better, we would then have some savings." The problem is we have spent the savings first and now we need to try and recoup it to invest in things that we know actually down the line will benefit everybody.
Q411 Dr Stoate: The Audit Commission recently said that PCTs have made little or no inroads in 2008-09 for transferring care from hospitals into the community or in dampening demand either in investment or activity. What would you do as a GP commissioner to try and address that? You have already said what the problem is, but what would you do to try and put it right?
Dr Brimblecombe: I think we would specifically start looking at employing, particularly if you look at long-term conditions, our own specialist nurses, liaising much more specifically with an individual consultant to come and support us. We would try and change the way we deliver care. Choose and Book has driven, again, a carthorse through the individual relationship between the GP and the clinician in secondary care which has developed over a period of years so that you learn to trust each other, and that is really what has been lost. We want to get back the trust so that consultants can come and support us to look after our patients actually right there in the surgery. We need their expertise, but we need their support rather than actually taking over the problem.
Q412 Dr Stoate: You mentioned that your 37 practices were very slow to come on board. Why was that? Do you think they are being sufficiently incentivised? Are they interested in coming on board? Would they rather someone else did? What is the reason why it has taken four years for you effectively to engage with your 30-odd practices?
Dr Brimblecombe: Because, as you know, GPs are very busy people. They go to work, they see the patients in front of them and that is their main focus. That is what we have all been trained to do, to actually do the best for that patient in front of you and to block out everything else. I know in other countries they would feel that it was iniquitous for a clinician to actually be thinking about distributive justice and the use of resources in a different way.
Q413 Dr Naysmith: We are empowered to do that all the time, are we not, and in practice as well.
Dr Brimblecombe: Yes, but you can understand that now, but with most GPs it takes a while before you come on board and see that you have got a wider remit than the person in front of you. The strength of general practice is that individual relationship and individual care, but you do have to put it into context, and GPs have been slow in coming on board because we have not had to have budgets to look after. Before we did not know how much we spent. We would prescribe a drug and had no idea how much it cost. Now we do—it flashes up on our computers in front of us—we know exactly what it is costing us, and that has, therefore, changed our behaviour. You cannot change behaviour unless you know what you are doing.
Q414 Dr Stoate: Is there a future then for GP commissioning or do you think David Colin-Thome may have got it right when he said, "I think the corpse is not for resuscitation"?
Dr Brimblecombe: I think that was slightly misquoted. It was rhetorical, I think, is what he says. It is like everything else, we are on a journey, and it was just totally unrealistic to expect that clinicians were going to understand what the big vision was when they had not actually been involved in developing it. Once they become involved, once they understand the problem, they come up with the solution. That is the real skill of clinicians because that is what we do in every day life: patients come with a problem and we help them to solve it.
Q415 Dr Stoate: Stephen, is the truth of the matter really that the acute hospitals are simply too powerful in relation to GP commissioners and, therefore, it is an unequal struggle?
Mr Graves: It is quite an interesting position listening to the debate. I guess, over the last few years we have seen Payment by Results as a huge opportunity for people referring and in the past, I think, as earlier colleagues said, people argued about what the level of marginal cost was for extra activity, whereas if you get the whole value of an extra patient coming in you, equally, save the whole value of a patient not coming in. Ironically and interestingly, for some time, I think, most secondary care providers have actually worried about the threat of all that money stopping coming in and yet the overheads were always going to remain. The interesting position, certainly from our position (and I do not think we are on our own), is that we day in, day out, say to colleagues in primary care and in the PCT we need to find ways of reducing the extra activity. Pauline has described from a GPs' point of view how they know what the cost is. We started three years ago to understand what our costs were. We can now, in effect, produce a patient bill, so we know what per patient it costs very easily by HRG, and we start to understand that the extra over-activity that we have been seeing—putting on Saturday morning clinics, putting on Saturday operating lists, working later into the evening—if you look at the pure finances of it, loses money per patient.
Q416 Dr Stoate: I understand all that. We have looked into this in the past. I am not so worried about your income stream. We know what those are. I am more worried about the power relationship between you and the GPs, which seems to me hopelessly imbalanced. As Pauline has pointed out, 90% of the work is done in general practice in terms of patient numbers and yet virtually all the money actually goes to the acute trusts.
Mr Graves: We would say we want to reduce the number of referrals coming in, and I appreciate there will be some consultants that do not think that is a great idea. Many of our consultants actually, quite the opposite, say, "We want fewer patients coming in around diabetes, we want fewer patients coming to us around COPD because we have experienced different ways of delivering those services."
Q417 Dr Stoate: But they are still putting you back in control; it all comes from you. What I am trying to get at is you are saying, "I do not want all these patients", you are saying, "I do not want all these diabetics with complications coming in." I am more concerned about the power structure. The relationship seems to be, "We are the acute trust, we do not want all these patients because we think they should be managed elsewhere." I am much more concerned in the equality of the relationship between you. There does not seem to be any.
Mr Graves: If you take diabetes, one of our lead diabetologists has gone out to the fenland area and sat down with groups of GPs and started the debate, and what one finds about this is that people need to get to know each other and trust each other on both sides, if there are two sides of this clinical debate, and to start to say, "We do not believe it is right for these patients to come here; you do not believe it is right for them to come here. These are the skills that you may or may not have, these are the resources, in terms of specialist nurses, these are the clinical parameters that we think trigger somebody needing to come into hospital or ringing us as secondary care clinicians", and that is actually really starting to have some debate.
Q418 Dr Stoate: That is helpful. I want to ask Paul the same question. Do you think that basically the hospitals are too powerful, or do you think it is about right?
Dr Zollinger-Read: I think we have got more levers now to manage that. I do not see it as a power issue. I think PBC has not been as successful and now we need to look at what we can do to make that work. Sitting on the other side of the fence, I also work as a GP and the frustration is that we in PCTs have not been quick at putting through business cases. I think that is a very fair comment; so we have frustrated PBC. If we can speed that up and liberate PBC, you then start to get changes. The other significant issue, and you mentioned the National Audit thing which I have not seen, but we have put in place lots of these Tier Twos, GPs with special interests, community clinics, and what we have not been good at is managing the demand, and so we have got an alternative over there but what we have not done is stopped that pathway over there. We have got the patients going over here, but they are still pouring into the hospital. We have got to crack that issue, and that is a primary care issue which I would put back to the clusters: "We can give you the tools but you have now got to start to manage that properly."
Q419 Dr Stoate: Are you powerful enough to do it?
Dr Zollinger-Read: Yes.
Prepared 8 April 2010