Examination of Witnesses (Questions 740
THURSDAY 29 NOVEMBER 2001
STANTON, OBE, AND
740. I am slightly concerned. We have skewed
in a direction I find very attractive and I could spend the rest
of the morning on this area. One other question on the commissioning
issue in respect of commissioning health care by one PCT. What
about the impact of the commissioning on neighbouring PCTs? How
do you deal with that?
(Dr Stanton) That is very important. It goes back
to what I think Mr Dowd was getting at earlier. You have to have
co-operation across a greater area than that served by a PCT.
In London very sensibly PCTs are configured on borough boundaries
with one or two small exceptions. Clearly the wish of a PCT in
the way it would wish to commission a hospital and other secondary
services cannot be allowed to destabilise the provision of heath
care across the sector as a whole. It is absolutely essential
that you have some overall commissioning structure greater than
the individual PCT.
741. One of the issues I raised with Alan Milburn
was an experience from the Yorkshire area which has interested.
Within Sheffield we have a private hospital which under the concordat
is now treating a series of streams of NHS patients. The question
I put to him, which to be fair he said he could not answer and
I understood the difficulties, was how we ensure, bearing in mind
the basic principles of our NHS which we hopefully we all still
subscribe to, that those patients coming from different streams
are treated in accordance with their clinical needs. In addition
to the NHS streams coming through the concordat from separate
purchasers, there are the NHS patients of those consultants in
the local Sheffield hospital to take into account. How do you
see that in respect of the arrangements between a purchaser and
the private sector? How do you see the basic principles of the
NHS being sustained?
(Dr Stanton) I am not sure I fully understand your
742. I have a concern. One of the worries for
me about the involvement of the private sector is that we may
well be, by virtue of having a series of separate purchasers in
a similar area like Yorkshire, sending streams of patientsI
believe cardio-thoracic is the specialismto one particular
private provider. I am not clear how we cross-prioritise the different
streams to ensure that those people on the several waiting lists
and the several purchasers' streams of patients are treated in
accordance with their genuine clinical needs; in other words,
the patient who needs urgent intervention receives it before somebody
who is less urgent.
(Dr Stanton) I am sure that the GP community would
wholeheartedly wish to sign up to that.
743. How do we sign up? That is the question
I am asking you. How would you ensure, if you were sending people
in those circumstances, that your people were not losing out compared
with your people from Nottingham or wherever?
(Dr Fradd) I do not think that is any different from
the NHS generally to be honest. If you have 20 GPs referring patients
to a single consultant within a NHS hospital, the consultant has
to make priorities according to the information you have given
him or her. It is no different whether they are working within
a private facility or within an NHS one. The only complicating
factor you have is of course that you still have the potential
for fast-tracking private patients through that system. I see
no new dilemma in terms of equating between the NHS and the private
facility you are working with. We have to have some faith in professional
colleagues that they have no vested interest and that they have
the skills to make the appropriate decisions.
Chairman: I am not sure I have fully explained
the concern I have. It struck me that there were serious questions
about how we ensured, with a range of streams, and obviously basing
decisions on information provided by the different purchasers,
that we were able to establish what is current practice I accept
on NHS waiting lists now in specialisms.
744. May I go back to Dr Stanton's point about
communication between PCTs? It is going to be absolutely crucial.
In my own county there will be three and they will have to share
out what happens. What arrangements have been made for that? The
only cross-PCT group that I know about will be the LMC and there
you have doctor participation but no patient participation. Going
back to the crucial bit about patient participation, how do they
get in on the communications between PCTs?
(Dr Stanton) Clearly they have to.
(Dr Stanton) I suppose the answer is: with very great
difficulty. Certainly the responses that the local committees
which I service in London have made to the consultation documents
for Lewisham and Wandsworth precisely make this point that there
will need to be co-operation between neighbouring PCTs. Dr Dixon
said that he chaired a commissioning group of three PCTs.
(Dr Dixon) Yes. It is a potential problem, but I am
not sure it is going to be an actual one. The way it is actually
turning out is that we have formed a commissioning college of
three PCTs and I chair the commissioning group for those three
PCTs so it is joined up and clearly has to be and almost has to
be because of the system. Though each PCT theoretically has its
budget and therefore theoretically could go off into the mist
and create all the problems which we have implied, that is not
actually going to happen because each PCT and the local health
economy has also to keep to various national standards and the
modernisation reviews cover numerous areas which have to be kept
within the NHS plan. That really is working between PCTs, so many
PCTs are working together in the modernisation reviews, looking
at how they are achieving things like the MS sufferer, coronary
artery disease and therefore having to work together anyway. When
it comes to commissioning they have already formed a group. I
do not see that happening. One of the problems with PCTs is that
they have become quite large. Although this was a potential problem
with PCTs at 50,000 to 100,000, the average size of PCTs is now
going above 150,000 so they are often large enough not to create
the fragmentation which we would not want to see.
746. Do you have citizen input into your commissioning
(Dr Dixon) We do not yet; we do not yet, I have to
(Dr Fradd) Michael is absolutely right about moving
to amalgamation of PCGs both into PCTs and using the same commissioning
group, but I take your point very much that there is a great tendency
to see the lay people left behind in this process. That is why
18 months ago we set up the National Association of Lay Members
for PCGs which is very much a going concern. You may well want
to contact them to see how they see organising lay people at a
more local level. That is a national organisation which we floated
off and let fly on its own.
(Dr Dixon) I do mean "yet". I know it is
going back a bit in the discussion but it is really important
as an example, coming back to this patient/public and professional
involvement. In my own practice last year we did an inventory
which most GPs will be doing in two or three years, where patients
scored us on our consultation performance, whether we gave people
time, listened to them, etcetera. We then formed a focus group,
not entirely democratic, selected to some extent, to look at those
and to give us some ideas on how we should develop the practice,
the commissioning decisions at micro level. What happened, and
this has been the most extraordinary finding for us, in spite
of the paranoia both of the clinicians and the managers within
the practice, was that this focus group turned out not only to
be very good on advising us what to develop and commission as
a practice, it has also been very much the arbiter in terms of
this division we have already discussed between an individual
patient and the population in terms of asking patients what sorts
of things we should be able to do ourselves and what sorts of
things should they not be coming to, the resource usage of the
practice. I know I have gone down to micro level there but that
seems to be the model for the patients and professionals operating
as a partnership and moving things and being perhaps friendly
critics in that relationship. That comes down to the commissioning
level and this might sound patronising but some of the things
we are discussing within the commissioning meetings at the moment
are so complex that it will take some time to get lay people up
to speed. However, we have to do that, without any doubt.
747. Picking up these points about how you deal
with one PCT's activities influencing another. The NHS Alliance's
memorandum talks about the strategic health authorities being
the arbiter of those disagreements, so it might be two PCTs both
wanting to set up a health centre next to each other at the boundary
not making sense, or one PCT wanting to put a lot of work into
the private sector which would then mean the other PCT was covering
all the fixed costs of the local hospital.
(Dr Dixon) Quite.
748. How would it work practically with that
health authority being the arbiter?
(Dr Dixon) There would have to be an appeal mechanism,
say in the situation you describe where a trust is suddenly finding
it is having to close beds by default because of the actions of
one PCT where the other PCT is actually trying to plan some .
. . There would have to be an appeal by the trust and the PCT
which felt their services were being compromised to the strategic
health authority and the strategic health authority would then
have to develop an arbitration procedure. In practice I am not
sure that is going to happen because PCTs are working together
and to some extent they see up there as the enemy and see themselves
as having to sort things out.
749. But ultimately the strategic health authority
should be able to say "Sorry. This is what has to happen".
(Dr Dixon) In the final event, yes, if there really
cannot be an agreement, but I am not seeing that happen in the
750. The other question is about clinical standards
and particularly in the light of Dr Fradd's comments about GPs
not having a majority on the PCT. How would you envisage ensuring
that appropriate services were commissioned, that were of a sufficient
clinical standard? What auditing processes do you think should
be there after the event? Or should there be some appeal mechanism,
if, for example, lay members of a PCT said the GPs said things
should be done in one way and they have this marvellous scoop
cheap offer from somebody else so they want to run with the other
one instead? What mechanism should be in place to ensure there
are clinical standards?
(Dr Dixon) We want a uniform mechanism. One of the
problems between the public and the private sector has been that
government systems are so entirely different. There should be
a principle that wherever a private service is commissioned, that
should fulfill the same government criteria as the public ones
which otherwise would apply. CHI, for instance should be involved
in assessing any private utility which is purchased by the NHS.
751. Would that be an after-event check?
(Dr Dixon) It would be a bit post hoc as far as CHI
was concerned, yes. The commissioning college or whatever, the
commissioning agency the PCT had would also to have to make sure
that it had standards which fitted both sectors.
752. Do you feel comfortable that the lay members
could as a majority overrule what the GPs on the PCT thought was
good clinical practice in terms of commissioning a particular
(Dr Fradd) I am comfortable with that. My experience
is that where lay and professional people get together, you actually
very rarely come into a situation where there is a division along
those lines. The divisions are normally elsewhere. In fact the
problems you face are the same. The doctor does not have a different
interest to the patient. I have no interest in doing anything
but getting the very best care for my patient; not only my patient,
but spreading that into the generality. The tension is not between
the professional and the lay person, it may be between the individual
needing care at a point in time and the needs of the community.
The split then is just as much between lay people as across that
other boundary. In terms of the quality issues, we should not
take our eyes off global developments. There is appraisal which
we believe, once we have sorted out the resourcing of it, is going
to be an extremely useful tool. That is going to lead into re-validation.
Those things must apply just as much to the private sector as
they do to the public sector. We are now getting some sort of
handle on outcomes data. You have probably all seen the Dr Foster
guides which have come out in the Sunday Times. They are still
fairly crude, but they are an enormous advance on what we had
historically and we have to work with these things. In the event
everything is historic. You cannot say what an outcome is going
to be; you can predict it but you cannot say what it is going
to be. You base that on what previous performance has been. I
think we have some very good mechanisms coming in. They will need
resourcing. It comes back to what I was saying about the contract.
Unless we get the necessary resources in there, how can we pull
doctors out of their practice for, say, ten days a year for continuing
professional development unless we make sure the resources are
there to provide the service?
(Dr Dixon) I agree. The people have to have the casting
vote at the end of the day. I may disagree slightly with Simon
because I think it is going to change the centre of gravity. Medical
evidence will not be as sacrosanct as it has been in the past.
Maybe the myopia we sometimes had in making global decisions about
local health and also about patient welfare as opposed strictly
speaking to clinical outcomes will be much more balanced. We are
going to balance the clinical with the human and the personal
with the medical so there will be a shift of gravity and we may
find a different use of evidence; NICE-type evidence on complementary
medicine may be reviewed differently in the future by a joint
lay/professional panel and not as it is today by a purely professional
753. Do you think the possible conflict between
PCTs having different commissioning patterns needs to be regulated
in some formal way above the PCT level, that there needs to be
an oversight to prevent threats to local acute units? Secondly,
could you say something about the amount of management time which
is being used by clinicians in managing PCTs which is taking them
away from clinical activities?
(Dr Fradd) I am wary of introducing any regulation
until we find it is necessary. One of the problems has been the
lack of freedom. I am not saying it will not prove necessary,
but I would rather see whether it becomes necessary. There is
enormous potential for solving such problems and you are much
better to solve them at the ground level. If it proves we are
constantly having to appeal back to strategic health authorities,
then we should re-visit that. In terms of the consumption of time,
it is considerable because it is not just the management function
of PCTs, but all sorts of other functions such as prescribing,
clinical governance. I am probably not the best person to give
the list but an enormous amount of time. What we have found is
that much more time has been needed than was predicted and not
just for getting these things up and running, even though you
start to get the structures and the decision-making process into
train, it is very consumptive of resources, of medical time, which
is a very rare commodity at the moment unfortunately.
(Dr Dixon) I agree with Simon, we do not want more
regulation. PCTs are meant to be risk-takers, they are meant to
be developing new things and if we handcuff them any more we find
they cannot deliver what they are meant to be doing. Professional
involvement? Yes, it is taking up rather a lot of professional
involvement but this has been the problem in the NHS in the past
because you have had professional devolvement from the services
and what is delivered. The exciting thing now is that people take
responsibility for the NHS and the use of public money as well
as the purely clinical decisions. It was the complete isolation
of those areas in the past which led to a lot of the problems
we have at the moment.
754. In your submission to the Committee, Dr
Dixon, it is really interesting when you are talking about health
centres being one of the benefits people hope to achieve from
primary care trusts. You say, "Health Centres, funded by
public money, failed to meet the expectation of those who advocated
them during the 1970s/80s and are now virtually extinct. If funding
by public money failed to produce the level of investment and
sensitivity to local population/professional needs (in comparison
to premises owned by GPs themselves) then the onus must be on
the private sector to prove that they can do better". There
are two things I want to take up on that. One is that in my experience
there was a health centre movement long before the 1970s and 1980s
and certainly in Bristol there are two which are still flourishing,
both of which started long before that. I know of a centre in
Liverpool and also in South London and probably more. Most of
them are still flourishing. Over the time you are talking about,
the 1970s and the 1980s, we have had regional health authorities
abolished and re-phased, area health authorities, district health
authorities, we have had trusts and budget holding and probably
numerous other things which I have forgotten, all of which might
have contributed funds which would have helped the health centre
movement to grow. Now we are going on to using private finance.
What do you think can now be contributed by private finance which
could not have been contributed before?
(Dr Dixon) In many ways my statements were personal,
as I shall explain shortly.
755. I am not criticising.
(Dr Dixon) Ideologically the health centre movement
was very much Alliance ideology and it has worked in many areas
just as you suggest. My own experience of a health centre was
having to work in a room eight by eight for seven years where
when the roof leaked no-one came to mend it and it was cold during
the winter months because nobody came to mend the radiators and
the complete relief eight years later of going into privately
owned by us building which met the specifications we wanted for
ourselves and our patients and a situation where, because I am
the one who puts the lights off as I leave the building, because
it is in my interest to do so, we end up with a much more sensitive
building to the incumbents and the people. I know that has not
been the general experience, but in actuality that is how it turned
out and I suppose some of the fears I have referred to which could
happen with LIFT or any third party agency, whether it is public
or private, is a problem of sensitivity to those working in the
building and the people coming in and out. We have to make sure
that we do not repeat those mistakes which were fairly widespread,
although it did depend upon your health authority or SPC as it
was in those days. It was very variable, you are dead right. It
is an ideal which after a while people just did not have their
hearts and souls behind which is why we ended up with leaky buildings.
756. You also say you want to concentrate on
areas of deprivation, which one suspects will not be the most
attractive to the private sector.
(Dr Dixon) Quite, but that is the added benefit. In
places like Devon where I practice, we do not really have a problem
with premises. It would be daft to start trying to improve things
which are more or less okay already. It is the inner deprived
centres where there is a desperate need for proper capital, not
only for buildings there, but also for proper infrastructure,
something along the lines of the primary care centres in the NHS
plan with locality resource and treatment centres which we described
in implementing the vision last year. There is a desperate need
for that sort of service in the inner cities because it is all
very un-joined-up and fractured. I suppose in our submission we
were saying that the big added benefit would be there, so let
us focus there and let us see if we can deliver there.
757. Mr Goldstone, what do you think your organisation
can contribute to these two problems we have just been talking
about? One is the trickle effect and the cutting off of funds
and the other one is the question of moving into deprived areas.
(Mr Goldstone) In terms of the description of health
centres leaking and being unheated, we are trying to develop an
approach which will require the private sector parties coming
in to deliver these facilities, to maintain a standard of accommodation,
a standard of facility which is what the practitioners and the
users of that building have specified at the start and actually
putting that responsibility for a life-cycle of condition, of
maintenance and repair on that provider. So even though we get
a suitable building built in the first place, it is not, as so
often has happened in the past, left to deteriorate over time
and not properly maintained because of shortage of resource for
758. Why should this continue? Why would it
not peter out?
(Mr Goldstone) Because what we are trying to do with
LIFT schemes, what the approach involves, is first of all a specification
which lists the standards required for new premises to meet and
putting the responsibility for the maintenance and sustaining
of that standard over the whole life of the accommodation on the
provider of that facility. So you are actually saying you will
only pay to the extent it meets that accommodation; you have the
facility not to pay. For example, if it is leaking and it is not
suitable for treating patients in then you would not pay for that
time. That is a very strong incentive on a commercial organisation
to make sure that standard is maintained.
759. What kind of practical assistance does
Partnerships for Health offer to LIFT?
(Mr Goldstone) I am sorry I did not answer your second
question about deprived areas. In terms of the localities where
we are taking LIFT schemes forward, we have six areas which are
working up the first such schemes and they were chosen by the
Department of Health through an appraisal and evaluation process.
Areas of relative deprivation as a big part of wider areas were
chosen. Part of the reason for that is that around the country
there are several new GP surgeries and in some cases more widely
used primary care facilities which have been developed by third
party developers on individual third party developer schemes.
Those tended to be in areas of higher affluence and where there
was a land value which a private sector organisation found attractive.
It has been much more difficult to do those sorts of things in
deprived inner city areas for reasons you are referring to. LIFT
areas are focusing on areas where effectively there has been no
effective alternative way of delivering these things and saying
to the private sector that we need them to come into this area
and be a long-term partner for the PCTs and the local health economy
which is in there and deliver these sorts of improved facilities
and certain accommodation which is at the required standard to
meet the practitioners' needs over its life. Then it is not just
about a land value, it is about a structure which is giving an
organisation a long-term right to be a partner in a long-term
business opportunity, in terms of providing, for example, leased
premises to GPs or other practitioners for health centres.