I wonder whether you feel that you have been given sufficient time to read the Future Forum’s report and the Government’s response, to listen to what various people have said, to read 180 amendments and to consult your members in the two working days that have been made available to you. Will you comment on that before giving any further evidence?
Dr Gerada: As you know, I am Clare Gerada. I am a general practitioner and chair of the Royal College of General Practitioners, which has 42,000 members looking after 60 million people across the United Kingdom.
The short answer to your question is, no, we have barely had time to read the Future Forum’s report. We have not had time to look in depth at the Government’s response to that report, and we certainly have not had time to consult on the 160 pages, the 34 amendments and the documents that arrived in our inbox last night.
By the bye, we had a brief consultation with our members over the weekend. A survey went out with my blog, and we have had a number of responses and continue to receive responses. To test the water, because I am giving evidence today, I asked our members to give me a steer. We have our formal structures, but I asked them to give me a steer on what they feel post-Future Forum and what they feel having seen some of the deliberations in the Government’s response. I am happy to share those early responses with you as and when.
I do not believe that any of your organisations have been able to put in a written submission, so, when answering the question, will you confirm whether you will be in a position to give us anything in writing in furtherance of the evidence that you give today when you have had an opportunity to read through everything?
Michael Sobanja: I am Michael Sobanja, chief executive of the NHS Alliance.
I am in a similar position to Dr Gerada, particularly on being able to consult the 216 commissioning groups that the NHS Alliance represents on the detail. We intend to submit written evidence to the Committee.
I would only add that the Bill is one thing; the culture and behaviours of the organisations that are envisaged as operating and applying the Bill are another. With the greatest of respect to the Committee and the parliamentary process, one might be concerned about the level of centralisation that could come about if, for example, the national commissioning board behaved in a particular way, irrespective of the way in which the Bill is written. There are two levels of concern but, no, we have not had the opportunity to consult members fully on every clause.
Dr Paynton: I am Dr David Paynton. I am a practising GP in Southampton. I was a commissioning director in a PCT, and I now work for the centre for commissioning at the RCGP. There have been a number of responses to the survey, as Clare has indicated. It is fair to say that many members are still looking for further assurances from the Government on the direction of the reforms. They are not wholly opposed to them, but it is fair to say that many are still expressing some concern.
I suggest to you all that it is probably rather hard to consult on something that you understand only imperfectly in a fair or objective way, so it may be a few days or even weeks before you are able to get the full flavour. However, I ask Dr Gerada to tell us about the different nuances of response to the Future Forum, rather than what people have heard about the legislation. Given that everybody agrees that greater integration is the way forward—it is the bottom line for everyone—what are the obstacles, if any, or opportunities, if any, in doing that under the Bill?
Dr Gerada: What a long question. Indeed, there are two questions.
The first is about the Future Forum and what our members feel about it. I shall not address the Future Forum itself because it is important that we say what is the Government’s response to it. We were reassured that the Prime Minister should have spoken so positively about the NHS, and so positively at Guy’s hospital about the values and principles of the NHS. We were particularly reassured by his response to the Future Forum, when he upheld the 2006 duty of the Secretary of State to provide a comprehensive health service, and by his reassurance that it would be in the Bill. We note that it is not in the revisions, but we are not lawyers and I suspect that lawyers will be picking over the exact wording. We have had discussions with the Department of Health, which tells us to be reassured about it, but my simple mind as a GP says that if it does not matter why not resort to the original wording? That is the first thing.
Secondly, we all talk about integration as if it is some sort of magic bullet, but everybody has different views on what it means. I run a shared-care mental health service that has within it professionals from psychiatry, psychology and the third sector, and GPs and nurses. To me and to GPs, integration is about shared care, where the professionals maintain their professional autonomy, where you work across professional boundaries, ideally with shared budgets and using the GP electronic record that everybody writes in.
That is what integration means to us. We need it absolutely for the big issues that face us, such as end-of-life care, certain mental health services and services for the frail and elderly. That is what we mean by integration, and that is what the Royal College of General Practitioners will be promoting.
I did ask what obstacles remain in the Bill that would hinder that.
Dr Gerada: I am not a lawyer but a GP, and it takes me enough to read our “British National Formulary”, let alone the Bill and the amendments. The obstacles to integration in the Bill are particularly to do with competition and the fact that we now need to have responsibility for looking after all our patients within a geographical boundary. Questions on purchaser-provider split and the market act as a disincentive and a barrier to that.
These are not in the Bill. They have been in the NHS for quite some time.
Dr Paynton: As Clare has indicated, the biggest problems that we face in the NHS are frail, elderly vulnerable adults and long-term conditions. Those conditions require care across a number of organisational pathways. I hope that GPs leading the clinical commissioning groups can help bring that together and make it work on the ground for local patients, without the fear that they will somehow compromise competition law—or that they will not be able to it because it might result in their being accused of not following competition law. There is something about the spirit—
May I press you a little on that, because it was a point made about the initial legislation? Clearly, the initial legislation has been changed—and changed in the direction of making that less rather than more possible, would you agree? Without actually abolishing competition altogether, what further changes to the legislation are you looking for that would do the trick?
Assurance, not legislation?
Dr Dixon: I think the legislation already supports integration, simply through clinical commissioning groups. As David says, the issue is about how you get front-line primary care clinicians to redesign services for the 80% of patients we see who get a totally unintegrated service at present. Intrinsically, the legislation supports integration.
The changes to the role of Monitor are very welcome, because it should be as concerned about integration as it is about competition—you need both. Therefore, to get this right, we need to ensure that the clinical commissioning groups are themselves sovereign. Our concerns with NHS Alliance are now mainly around the autonomy of those groups to determine the services that their local patients need. Now they are responsible to quite a lot of organisations, from senates to the health and well-being boards and the NHS commissioning board, and we must ensure that these are lean organisations, owned by the local practices, fuelled by the local population and able to make the innovative changes needed. Tying them up in knots will not allow for that.
Michael Sobanja: A thing that the Bill might have addressed is the mechanism of payment by results. PBR does not necessarily promote integration between primary and secondary care, often known as vertical integration, but one thing that we want to promote is integration across primary and secondary care. If your question is, “What is in the existing Bill that could be changed to do that?” I am not sure what the answer is. What might have been in the Bill would be something to address some of the frailties of PBR.
The role of the Secretary of State and how it is defined in the Bill has been mentioned. I have seen various wordings, some of which has been rather confusing. What operational difference do you see, as far as the NHS is concerned, with one wording rather than another? Do all of you see a big operational difference or is it just an issue for Dr Gerada?
Michael Sobanja: I think there is a difference. The original provisions envisaged that the Secretary of State would be required to secure a comprehensive health service, which is slightly different from how it was a few years ago when they had to provide a comprehensive health service; there is a substantial difference between the two in terms of ideology. The major point is that the Secretary of State is still obliged to secure a comprehensive health service within the resources available. I do not see that as being any different from the 2006 Act or previous legislation in practice.
Thank you all very much for coming today. I did not manage to ask a question at the end of the previous witness session, so I will ask it of you now. The briefing that the NHS Confederation has provided says:
“The role of the NHS Commissioning Board has been extended, which means decision-making and financial control are more centralised than previously anticipated and far more than is the case in our current health system”.
It also says that the NHS commissioning board will commission services on behalf of any clinical groups that are not ready to do so and will run the clinical senates and clinical networks, and have powers to determine how else commissioning groups get their advice, how frequently your governing bodies meet and so on. What do each of you think about those extra powers being given to the commissioning board? Perhaps we can start with Dr Dixon.
Dr Dixon: It is a concern, for the reasons I gave. You can have all sorts of laudable things that en masse can have an erosive effect and straightjacket hopefully innovative clinicians. I am concerned by the move in the language from assumed responsibility, which the NHS Alliance has always said that there must be. There must be trust in front-line clinicians and people to do these things, rather than earned autonomy, which has a slightly childish feel to it in that it has to be earned.
On the point about the board with its PCT clusters signing off those consortia and being able to commission on their behalf, I suggest that we need to ensure that there is a proper incentive arrangement for those clusters to sign off to commissioning groups in 2012 and make them ready for purpose, and not delay the process and end up with groups that are not ready for all sorts of reasons.
With such things as the senates, we must not return to the Darzi-type scenario, where we had a lot of secondary care input into how services were commissioned. There was, therefore, a linear look at different diseases rather than in the round, which is what clinical commissioning groups need to do—they need to look horizontally and adjust priorities. As far as the senates are concerned, I would suggest that rather than their seeming to hand the tablets to the commissioning groups, they should be co-owned by the groups and by the national board, so that clinical input is not something that seems to be another imposition on clinical groups.
My feeling is that in the Government’s response, it is clear why, for political reasons, more responsibility for governance has been put on commissioning groups, but that could, as a whole, stop the groups from being as free-moving as they need to be.
Dr Gerada: The bureaucracy with the new Bill, post-pause, means that we have gone—we have calculated this—from 163 statutory organisations to a proposed 521, not counting the commissioning support organisations. Clearly, we have massively increased the bureaucracy, if one calls it that, within the new, post-pause NHS. With respect to the national commissioning board and whatever, the current, post-pause Bill seems to be very incoherent. No matter what one felt about the pre-pause Bill, it was coherent. This is not. It is neither liberating nor controlling. It neither allows for GPs to be innovative, nor does it give them tight restraints.
I cannot really answer the question, except to plead that we are talking about the health of our patients and our population. If the national commissioning board sees fit to control vast sums of taxpayers’ and NHS resources until consortia are fit to be able to do it, so be it. This is not unimportant; it is the most important thing for my patients whom I see every day, and it is the most important thing for the 60 million patients whom my members see every year.
Dr Paynton: While we obviously support the role of the national commissioning board in holding the ring, there is a danger, particularly with the PCT clusters—this may an operational issue, rather than a legislative one—that if we are not careful and there is no clear plan of shifting authority and autonomy to clinical commissioning groups over a period of time as they are ready, we could see an ossification of the system, rather than a liberation of it.
Michael Sobanja: Put simply, the Bill puts too much potential power in the hands of the national commissioning board, to address your issue head on. Clinical commissioning groups should have the right to appeal to the Secretary of State, potentially, or some other body, which I think is suggested in the revised Bill, to avoid the national commissioning board from becoming too directive and to ensure that it focuses on its true role of holding the commissioning groups to account. There is a substantial difference between the two.
The message we have heard so far today is that the biggest challenge facing the NHS, as you have also all said, is an ageing population and the need to meet their care needs through integrated services. Dr Gerada, we had a very clear example of your view of integrated services. My question to each of the panel is whether we need legislation for you to be able to deliver that.
Dr Gerada: No. Let me also say that we have to ensure that commissioning is done by the right people with the right skills across the right population. Where we will make phenomenal changes is in provider reform. Where the Royal College of General Practitioners comes in is to ask, “How do we tackle those big challenges?” Where doctors get excited, really excited, is when we start talking about delivering key services, innovation, joining together across federations—integrated care with the model that I mentioned and removing the perverse incentives.
I will give you an example. Hospitals are designed to make money, which means that they increase their activity because that is how they make money. GPs are performance managed. They have to reduce money and therefore stop patients going into hospital. You have two opposing systems working. Somehow, in the second decade of the 21st century, we have to ensure that we do not continue to have those perverse incentives. We need to look at tackling those big issues through provider reforms, and sensible commissioning should enable us to do that.
Dr Paynton: There is one other aspect to this. If we are serious about wanting to shift the focus of care into the community, that requires everyone to support that direction of travel. It also requires us to consider, as Clare has said, provider reform and how we can enhance the capabilities of primary and community services to provide the care in the community that our population is looking for.
Dr Dixon: I think we need legislation because we have tried to introduce clinical commissioning for the past 15 years and have failed. Each time, we have not changed the environment sufficiently. We have not given them statutory responsibility and we have ended up with fundholding primary care groups and, latterly, practice-based commissioning, which all folded because there has never been that power and responsibility with the front-line clinicians and local people. Without that, it will not happen.
You need to have a means whereby you can say, “These clinical commissioners are leading the health service and, for the first time, the spending decisions that I make in surgery for my patients, in terms of referrals, prescribing and diagnostics, are aligned with my responsibility to the outer world and population. I am no longer responsible just for you—the patient in front of me—but in future for the whole of the population and for the best good of the greatest number.” Unless you bring general practice and other clinicians into that role and responsibility—but you have got to empower them as well—you will not get the integration that you want.
Dr Gerada: Can I clarify? The Royal College of General Practitioners has discussed this issue. Our primary responsibility must always be the patient in front of us. I have always said that good commissioning is about the good use and husbandry of resources and that we must never muddy the water between commissioning across a population and the patient in front of us. Once we do that, we stop the trust. It is the trust between the doctor and the patient—the fact I am doing something in their best interests and not to save money—that defines the national health service.
You are both agreeing that the doctor-patient relationship is so important. What do you think—first in terms of that relationship, but also in terms of the efficiency drive in the NHS—of the power for the national commissioning board to make bonus payments to clinical commissioning groups? How do you think that impacts?
Dr Gerada: Clearly, as the representative of a national organisation that represents 42,000 GPs, I can answer that. We are well against making bonus payments to GPs that are predicated on stopping patients going to hospital. By all means use those payments for patients or give them to charity, but we must not be rewarded for preventing people going to hospital. That is a perverse incentive that will backfire on us.
Michael Sobanja: I have a slightly different view. The truth here is between those two views. It is entirely justifiable to give an incentive to clinical commissioning groups as long as the caveat is that that money can be spent only on improved patient care. I understand where Dr Gerada is coming from, but somebody has got to take a population view. It is a hard fact of life that doing something for the patient in front of you every time may disadvantage the patient who is not in front of you. So there has to be a balance in this. I would suggest that it is appropriate to incentivise the groups, not GPs and practices, with the caveat that that money can only be spent on improved patient care.
Dr Paynton: Speaking for the RCGP, we are absolutely clear that decisions by clinical commissioning groups have got to be made with the support of the population and the public they serve. Doctor-patient relationships are very good. The vast majority of patients trust their doctor. I would like to see the same degree of trust being established by the clinical commissioning groups and the local population as exists between the GP and the individual patient. We need to try to ensure that whatever difficult decisions need to be made by the clinical commissioning groups are supported by the public they serve. That way, we will retain the trust.
Dr Dixon: David is absolutely right. We have to be courageous; we have to take on this population role as well as our individual role. After all, when you see me in my consultation, if we have devised a better menu of services that you can have—that are more local and appropriate—and they are more cost-effective, and if we are mutually geared to making sure that they are used cost-effectively, there will be more to go round.
But Dr Dixon, what you and David said was that you were not just thinking about me; you are thinking about the next person to walk through the door. I am alarmed, because I have never sat in front of my GP thinking for one minute that they were not absolutely focused on my needs, but were thinking about the next person to walk through the door. I am living in a different health system.
I could not possibly comment on that.
Dr Paynton: Perhaps there is a misunderstanding. When I see an individual in front of me, that is what I am focused on. If I need to make a commissioning decision collectively and corporately, I would wish to ensure that that decision was respected by the population I serve. It is a challenge for GPs to see themselves in those two different roles, but I think it can be done.
Dr Gerada, I have a question about new clause 4. I will read a bit of it to you, because I heard you say earlier about not having enough time to do so. It is a clause in which the Government are trying to alleviate fears that there is a danger that we will see the NHS privatised. They have highlighted this as ruling out privatisation. It says, in effect, that the Secretary of State will no longer in future be able to promote the interests of any one group. He will not be able to promote the interests of a private provider over another group.
It also says, equally, that the new clauses would prevent the Secretary of State from deliberately promoting the growth of state providers over voluntary sector or private ones. Is it your view that that is another perverse consequence in the Bill? In a tax-funded and still overwhelmingly publicly owned NHS, the Secretary of State would be so hidebound by competition law as to stop him protecting publicly owned bits of the NHS.
Dr Gerada: We have surveyed our members on that. I will give you evidence of why I think you are correct: the Future Forum’s own consultation process on choice and competition. I urge you to look at it. There were more than 800 responses from members of the public, patients and some professionals. Of those 800 responses, and pulling out only the ones that relate to choice, about 597 of them were against choice. They actually used words such as, “We want a good local provider”, “We want our NHS service next door”, “We want to be able to choose the treatment we get in the consultation, but basically we don’t want a multiplicity of providers and choice.” Seventeen of those who expressed a preference were pro-choice, and one of them lived in France, so that can be reduced to 16.
I think, and our members feel, that it is important that the Government are partial to and protect the NHS on behalf of our patients. The NHS is there because it provides a totality of service, universality and services that do not come and go. Our patients with long-term illnesses do not have illnesses that last for three to five years. That is how long contracts are for now, and I run many contracts. We have won, as GPs, many contracts where we run GP practices, and now we are coming to the end of the tender process and we have to go out to tender again. Patients with long-term diseases have them for more than five years. If what you say is the case, I and the college would feel that we are entering a difficult space.
Michael Sobanja: It is true to say that significant parts of the health service are not part of the nationalised industry view of the NHS now. There is community pharmacy, to give you one example. My own view would be that it is actually much more important for those who are providing a service to sign up to NHS values—I absolutely agree with Dr Gerada in that sense—rather than there having to be some form of state provision of which the Secretary of State is the non-executive chairman. Also, rather pointedly, I cannot avoid pointing out that general practice isn’t that anyway.
Order. I am afraid I must announce that that brings us to the end of the time allocated to the Committee to ask questions of our witnesses. I thank you on behalf of the Committee.