Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 720 - 739)



  720. I got the impression that what you were implying was that the cost to our system in respect of prescriptions is in the fact that a patient who is eligible for free prescriptions is required to see a GP to get that prescription, which means that they trouble the GP when they may not need to, rather than going straight to a pharmacist where they have to pay money for that.
  (Dr Fradd) Correct.

  721. So we need to look at that as an issue.
  (Dr Fradd) Newcastle has a model of it.

  Chairman: We should like to look at that, it would be very interesting.

Dr Taylor

  722. I am going to change the subject, although I think you have picked up an extraordinarily important point which we will obviously follow up. I have already declared that I am a member of the BMA, so my interest has been declared. I was delighted to hear you say that use of the private sector, although for some years to come, is a temporary expedient to use spare capacity up to help NHS patients. My understanding of this is that consultants will take people off their normal NHS waiting lists in order to put them onto the private sector. I should like to see the Government being a little prescriptive about how the recent large windfall of money which was announced on Tuesday is used. There are certain places where this could be targeted which would make a difference very quickly and one of them is exactly into this because one could make a difference on waiting lists by using spare capacity which exists at the moment. I hope in a way the BMA will be pushing for that because I certainly shall be as one of the users. That is perhaps not the most important. The most important is for extra pay for nurses to bring them back from agencies and the private sector. I must just stand up for the consultants, but coming to my question. Would the BMA and the NHS Alliance agree that one of the priorities for this vast amount of money which would produce an improvement almost immediately is to ask for some of it to go into funding for private sector operations as a temporary catchup expedient?
  (Dr Fradd) What I would say to that is that it ties in with what Mr Dowd was getting at. One of the problems we have with new resources is that they just go straight down through the system and then get swallowed up in secondary care. We have fought very long and hard for earmarked money and this year we had some money for primary care development and in many cases that got swallowed up in trying to deal with overspends in the secondary sector. I am not necessarily saying that I would at this time prioritise funds to go in that direction. It is a very worthwhile cause but there is a very good case for at least earmarking funds, if not ring-fencing them, so that we can move the NHS on and part of that is to make sure that we deal with the backlog and part of that is to move the agenda on and give us some seeding money with some headroom for freedom of development.

John Austin

  723. I can obviously see the attraction of commissioning services in the private sector or elsewhere in the patients' interests if it is going to reduce waiting time. In the area Dr Stanton represents, the pressures there are on the secondary trusts financially—and I think I am right in saying that several of the trusts you are responsible for have substantial deficits—
  (Dr Stanton) That is a very polite way of putting it.

  724. Is the commissioning of services elsewhere by the primary care trust likely to assist or contribute to the difficulties the hospital trusts are in?
  (Dr Stanton) Given that the trusts have a finite pot of money in their unified budget, in the circumstances you outline it will not make matters better. It will obviously reduce the number of people on the waiting list, which is a ministerial priority, but it will not fundamentally address the problem.

  725. In the short term you will have assisted some patients.
  (Dr Stanton) Yes.

  726. What are the long-term consequences for those trusts?
  (Dr Stanton) That is it and there is always an inherent tension for a GP in their day to day life between the needs of the individual patient, which clearly come first, and the needs of the system as a whole. This is a very, very difficult balancing act and it is one which causes a huge amount of stress in the day-to-day working lives of GPs who are well aware that if they do take routes to speed individual patients through the system, they are almost necessarily slowing down the system as a whole. That is the difficulty I think.

Julia Drown

  727. You were saying, Chairman, that in terms of devolving work to pharmacists it was about those people who have free prescriptions. But presumably, if someone were prescribing, whether the patient was entitled to free prescriptions or not you would be in favour of pharmacists being able to prescribe for everyone.
  (Dr Fradd) Absolutely.

  728. You said in terms of the change in the GP contract that you were concerned Ministers would interfere in the negotiations between yourselves and the Confederation and stop you delivering what you want to deliver for patients. What particular things do you think Ministers will not like?
  (Dr Fradd) We currently have a contract which came in in 1948; it is said to be the longest contract in the world. It is approaching the length of War and Peace. Those of us who live and breathe it find it remarkably difficult to find our way round it, so it is certainly time to have a change. That contract is based on high volume: pile `em high and sell `em cheap. One cannot help feeling that is something of the philosophy of the NHS in the twenty-first century. We want a very radical move away from that to a high quality service. There are difficulties with that because the capacity is not yet there. In order to increase capacity, there are necessarily going to be cost implications. We are going to have to make the nursing contract and the GP contract attractive enough both to keep people and attract new ones. It is the cost implications. I also think that there may be funnily enough an even stronger desire amongst Ministers to make primary care a managed service, even more than we feel that our Confederation colleagues who are in effect our managers seem much more confident at a local level to have a hands-off approach to it and to manage quality and monitor quality rather than necessarily to interfere in how the service delivery happens at a local level.

Mr Amess

  729. In my area there was a big falling out when primary groups and then primary care trusts developed as far as GPs were concerned; very, very different views on this. Would you first of all expand—we have heard a little from you—how you see your involvement in terms of commissioning health care? You did not go into much detail about this.
  (Dr Fradd) I would have to declare where I started from. I was very anti-fund holding and actually was one of the founding members of the Nottingham Non Fund Holders which was a commissioning group and very much the model on which the whole of the PCG/PCT was based. There were various problems. Firstly, when there were PCGs there was the difficulty that they were sub-committees of the health authority and did not have real powers so everything could be vetoed. Secondly, there was a very radical move to include the public in primary care groups, which certainly we welcomed at the BMA but some GPs felt very threatened by. This is why we made a stand to have a majority of GPs on primary care groups. I am very pleased to say that as they have evolved, my colleagues have become great fans of the lay input because they realised that actually they were very much on the same side and talked the same language. Now we are moving to PCTs there is the tension about being given the responsibility without the funding, which is what I was talking about earlier. There is another tension which is how we truly get public input into the development of the Health Service both at a national and a local level. The present structure does seem to me slightly bizarre where lay people are appointed; they put their names forward and they are appointed. There is no accountability back to their local community. That seems to me very disempowering and I have always maintained and the BMA has supported me, that we should actually have elections for lay input. I am quite happy to have greater lay input but there should be a line of accountability back to the local community which is empowering.


  730. This is music to my ears. The BMA are pleading for a democratic Health Service. The reason we do not have a democratic Health Service is that the BMA argued against it in the 1940s. Has there been a sea change? Have I missed something?
  (Dr Fradd) May I point out that I was born in 1950, so I am not prepared to take responsibility for my predecessors in 1948. I do think we have moved on. I do not know the details of what went on back in those days but I would say that the BMA is absolutely committed to an NHS which is free at the point of demand and which is funded out of central taxation. We produced a paper from our Council earlier this year which pre-empted the report we heard on Tuesday. We are absolutely delighted to know that it is going that way. It is the public's Health Service at the end of the day and the public should be able to decide what size it should be, what it embraces and how it is delivered and we are right behind that.

  731. So I can stand up in the next debate we have in the House of Commons and say that the BMA favours a democratic Health Service.
  (Dr Fradd) We do.
  (Dr Dixon) Important but possibly not relevant to the subject we are mainly debating today is this public involvement thing. It is absolutely crucial that primary care trusts are local people and professionals empowered and working together. We do not have the model quite right at the moment. We need to make sure we have the public properly represented inside the primary care trust, not an old-fashioned non-executive system which is the prescribed one at the moment. We need also to make sure that we have proper involvement of the public outside and some form of democratic input. I am not sure whether votes and things are necessary; something like the Newcastle system is good where they just choose a number from the 250 who meet four times a year from the local communities. There is an awful lot of work to be done on that, which Alliance is leading at the moment with the Department of Health to make sure that happens. You asked about commissioning and I come back to Richard's point which is the crucial bit. I too was a commissioning group but we did actually commission knee surgery from a private hospital at one point during our evolution five or six years ago and it comes back to this question of what we do with the extra money. At the moment commissioning is at a fairly immature phase for some of the reasons I have already outlined. At the moment acute trusts still have their own vested interests almost solely within the local health economy. This is a problem because some trusts are performing differently from others; some specialities locally are really committed to getting their waiting lists down, quality audit, all the things we all approve of, others simply are not. There is not quite that leverage in the system at the moment to make it happen universally and therefore quality is variable and so is access. We have not yet created the incentives to make sure that those who can deliver and can deliver quick services in the way we want are actually doing that. There is a danger that if we simply lob the money into trust deficits, if you simply put the money back into trust deficits, the money will be going where it has always gone, nothing happening and nothing changing. I would to some extent follow Richard's hypothesis that some of this has to go into just cutting off this tail end of the waiting list to begin with. Having spoken to the Secretary of the Cardio-thoracic Association last night, it was interesting to find that our views rather merged on this. We really need to cut these people off and either send them abroad or into private capacity in this country rather than suddenly do a quick ramshackle change within the NHS of importing resources, personnel, which may not be appropriate in the long term, and then finding another day we have not actually developed the Health Service in the way we want. The answer to this dilemma is yes, we probably do need to sub-contract in the short-term to get the patients the waiting times they want, because there is probably no other way of doing it within the NHS at the moment. In the long term what we must do is get our commissioning straight and make sure that local services really respond to local people and professionals in a way they are not yet.

  732. That is very helpful. We shall not follow this any more because you have given us your view, but very quickly, when you talked 15 minutes ago about moving the agenda on what did you mean?
  (Dr Fradd) It is a matter of moving it to a patient-centred service and one which is focused—

  733. How?
  (Dr Fradd) You can do that at three levels. You obviously have to have input at the one-to-one level and my colleagues have moved on enormously over the last two decades where the paternalistic aspect of care is no longer a model which is followed, where it is the patients' health care and they must as far as possible be informed in order to make an informed choice. The difficulty is that often choice is slightly restricted as to what you can offer.

  734. You can say that again.
  (Dr Fradd) At the second level, there is the input into primary care organisations of the public so they can have some effect. I believe in addition to what the basic guaranteed service of the NHS should be, rather than a complete free-for-all of what the structure of the service should be locally, there should be much more input at a national level, a truly lay input, as opposed to civil servants or ex Health Service managers and some public input into what the service should be. When you come down to the local level, there is this real potential for shifting the skill mix, to use a populist word, and allowing us to do far more in primary care to give services nearer the patient, which has enormous ramifications. If you look at something really simple like the management of anti-coagulation, we introduced this into general practice in Nottingham some years ago and in the first year alone we save £60,000 in transport costs. If you interpret that into what it meant for the patient, in terms of days sitting in cabs, going up to the hospital, waiting for the bus to take them home again, it absolutely transformed the service to one where you have an elderly person and the community nurse goes out and takes blood in their own home. You can transform it in such simple ways at a local level, but you do have to have the infrastructure support, you need more nurses, you need the powers of the pharmacist to take on some of the work, you may need additional space within your surgery to deliver the services.

Dr Naysmith

  735. Chairman, I was as astonished as you were to hear Dr Fradd, this suggestion about democracy. My recollection is that at the time of PCGs when PCTs were in prospect the medical profession just united and said they were going to have a majority on these committees or were not going to take part. A lot of what you are saying is very progressive and I am very much in favour of it. Are you actually now saying that doctors are prepared to give up some of the power they still have in order to encourage more patient participation? I should be very much in favour of that and I am sure the Chairman would as well.
  (Dr Fradd) Yes. I was sitting with the team which negotiated that potential majority of doctors on primary care group boards. The reason for doing that was to give the ownership of change in there. If you had gone in and said we should have seven lay people and four doctors, my colleagues would have been terrified by it and stood way back on it. The whole point of this was not in order to give us the power over the service but actually to say to people, which is what Alan Milburn who was then the Minister was saying, that this is to empower general practitioners to drive the NHS. I and my colleagues wanted GPs in general to feel that, to know it. It was a stepping stone, it was always a stepping stone and if you look at primary care trusts that majority is not there in the same way.

  736. So the BMA has recommendations to make on that in terms of involving more lay people.
  (Dr Fradd) We are very committed to the involvement of the public. I am the Chairman of the doctor/patient partnership which was founded by the BMA as an outcome to the out-of-hours problems we were getting.

  737. You were talking about the democratic—
  (Dr Fradd) It is more than that, it is the involvement of the public throughout the service. It is an ethos change.

  738. It is very easy to talk about involvement. To get people involved in the best and the most basic way is to give them a vote.
  (Dr Fradd) I accept what you say; there are limitations. I am doing some work with the King's Fund at the moment on patient centred care and it is very interesting. There is a point at which you cannot centre the care on the patient. We were talking about the limitations of choice. It is no good saying to the patient that they can have beta-interferon for multiple sclerosis if there is a national policy that beta-interferon is not going to be available within the NHS. There are constraints on what you can offer and it comes back very much to what Tony was saying earlier about the balance between the individual patient and the system. I believe if you get the structure right with public involvement at all levels, so the development of the service at the local organisational level, and being heard and informed as much as possible at the one-to-one level, then you get a much more patient-centred focus and I think you can make it democratic. There are limitations in the same way as I cannot—

  739. What does democratic mean in terms of what you have just said?
  (Dr Fradd) In exactly the same way as I have an input into saying what services I think should be available. It is the public's service and they should have a stronger voice. They cannot demand it, that is where the democracy ends; it is up to Parliament to decide what is going to be available in the global terms. They should have input, they can certainly have a majority, as they do on the PCTs in lay input if you include management and people as lay, but we have no problem with being in a minority on PCTs.

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