Read the full transcript of Pulse’s exclusive interview with the health secretary covering GP commissioning, PCT debts and checks on EU doctors.
Pulse reporter Gareth Iacobucci interviewed Mr Lansley on 28 October. To read the interview as it appeared in Pulse magazine, please click here.
You announced details last week of a £1m investment in pathfinders for GP consortia. How exactly will this £1m be spent and divided up?
The £1m across the whole country clearly isn’t necessarily the whole sum of money that will be needed in order to support the whole development of consortia. It’s specifically in relation to creating a national learning network. People have talked to me from various places across the country saying we want to be pathfinders, we want to make progress, we want ourselves to be able to work out the details of how we’re going to implement commissioning locally. At the same time, we think there are a lot of people who go along the same path as we do and we want to learn from them. So, creating a learning network. Individually in each area, as pathfinder consortia are established, we’ll be asking the PCTs locally to ensure that within their overall management cost, they make provision directly to support the developing commissioning activity of the individual consortia. The £1m is specifically about the learning network and in large measure, I think we’ll just have a conversation with the profession themselves about how they would like to see that learning network function.
How much funding will be set aside for shadow consortia to help with the transition? For example, will they receive half the budget they will have when they are fully fledged? And how will this compare to overall management costs at the moment?
Yes we are further forward. We’re not yet at the point where we can make announcements. It has in a way been sometimes as if months and years can go by and nothing happens. We’re now getting used to the idea that everything happens at real pace. But the truth of the matter is, once we’ve published the white paper, and in particular the document which was about the development of general-practice-led commissioning, we had a 3 month consultation and we’ve had responses to that and we’re working through those. I do hope quite soon we’ll get to a position where we can actually illustrate to the consortia and to PCTs how we see now, in light of the consultation, the distribution of functions inside PCTs. Some of course, through the legislation we will be able to dispense with, some of which will transfer to the national commissioning board, some will go as part of the transfer of public health and other responsibilities to local authorities. I think that will help to focus the consortia on what it is they are being asked to do.
There has been a tendency sometimes, some of the apprehension has been when people have looked at everything that a PCT does and the way they do it and assume they will have to do all those things and they will have to them in that way. Of course they don’t. We are creating not only a reduction in functions, we are focusing consortia on the thing, which from their point of view really matters, which is the commissioning of services for their patients, and, hopefully, we’re giving them the opportunity to do it in a less bureaucratic and restrictive framework. When you get to ‘what are the resources available for that’, once we’re clear about the distribution of functions, it will be possible for us alongside that to be clear about what the distribution of resources looks like. Now, in the intervening two financial years, 2011/12, and 2012/13, the general principle is, in the first year, not only does the PCT have legal responsibility but they will continue in the main to be exercising many of those functions themselves, even if GP consortia have moved strongly I hope into a position of taking the lead in designing services.
In the 2nd year, I would expect the consortia to be doing in pretty much the complete dry run, so we will then start to see resources and responsibilities being exercised by consortia even when we’ve got the legal structure in the PCT for the management of finance for this purpose. So to that extent management resources shifting into the hands of the consortia – we will I hope begin to see the pattern of initial development resources, in the 2nd year, resources to support that design process and establish relationships, to identify where their commissioning support will come from and that will therefore be a subset but not the majority of the management resources. Then the following year, they may well have, in many cases, control of the great majority of the management resources that in the long run will be the resources they have as fully-fledged consortia.
Has there been any discussion over how many functions GP consortia will take on?
We are working through that. I hope, because it’s very important, not least from the point of view of the organisational change itself. In response to the consultation, some people have said, isn’t this all very rapid? Well, if you’re living and working in a PCT, and you think you do a good job, and you think, that job is likely to continue, then you’d quite like to know that you’ve got the security that goes with that. And there will be some consortia that are keen for that to happen.
To the contrary, if there are circumstances where for example that role isn’t going to be continued, or is going to transfer to the NHS commissioning board, I think those people will want to know pretty rapidly whether that is the case. And organisational development practitioners pretty much tell us if you’re clear about the strategy, and people understand the values you’re working to, they would rather see these decisions made quickly, rather than slowly. But it does depend. We are going to hopefully get to the point where we can be clear about the shape of the transfer of functions, and the implications for human resources and financial resources that flows from that in about the timescale that matches the publication of the operating framework and the publication of the bill. Because these are in large measure the same sets of discussions that are taking place together. We don’t have a publication date for the bill but I’m very hopeful that we’ll publish it before Christmas.
You have had a chance to read consultation responses. Some GPs’ positive, some not so. One thing we’re consistently hearing from GPs is that they want more detail. How are your thoughts shaping up – particularly in terms of the specific contractual response GPs will take on, and how they will be held accountable on those?
Let me just say a word about the response to the consultation. There were a variety of views, that’s exactly what you’d expect. I said to the NAPC last week that I would characterise the response from general practice as enthusiastic but apprehensive. I can understand GPs wanting more answers to the questions. That’s very much in the framework of saying, we want to get on with it, and we want to know how we can get on with it. I think sometimes, it’s ‘we want to get on with it, and we want you to tell us how we do it’, which isn’t great. I think people are slightly getting out of that mindset now where more people I’m meeting are saying ‘we kind of get it now, this is actually about us deciding these things.
The classic illustration is how big should a consortium be? Well, we have said this has got to be developed from the locality circumstances the discussions between the practices and their colleagues. And I think people are starting to get that now, because I am seeing across the country quite different solutions being derived, including federated solutions like the ones that the Royal College have been recommending for sometime. Lots of solutions are coming forward without us having to prescribe them. I think this is very encouraging. But the frustration inevitably is, you can’t have a consultation and during the period of the consultation be telling people what the outcome of the consultation is. You have to wait and listen.
The consultation finished 10 days ago, I promise you we are not losing any time in trying to work through, in practice, not only the questions to which we know people need answers, before they can get on with it, but also taking account of the way in which they’ve responded to us. More generally, I would say about the responses. People who don’t know much about the NHS, kind of miss the point that the white paper was about a strategy.
Overwhelmingly, the responses to the white paper have been supportive of the strategy. They’ve just, perfectly understandably in many cases, being questioning the detail, the pace, the implementation plans and so on. Many of them adding to that, perfectly reasonable ideas and suggestions about it. But I think, from the point of view of the NHS as a whole, is the achievement of what I would say, with perhaps one major exception, is a consensus about the principles is pretty straightforward.
The exception is that the BMA and some others, Unison and so take a view that they do not agree with an any willing provide approach. They want to hark back to the idea that there are somehow bodies within the NHS and everybody else isn’t. I personally find it very difficult to understand. I say to you, are pharmacies NHS organisations or private organisations? Actually they are overwhelmingly private organisations. They might be quite large businesses. Do we somehow imagine that they shouldn’t be providing NHS services, that there is something inappropriate about that? We don’t. Our job is to focus on delivering the best possible services for patients through the NHS. To actually be prepared to accept that people can arrive with solutions from charities and the independent sector. Yes they can. From my point of view, we had a mandate to move to an any willing provider approach, it was in our manifesto and the Lib Dem manifesto.
I understand that some people cling to the idea that the NHS must be a protected organisation, immune from innovation and enterprise, but actually, I think innovation and enterprise is what we need. So there are some responses to the white paper that disagree with that in principle, and I’m sorry but I don’t agree with them. But actually, the same organisations like the BMA can say we are fully behind patient empowerment, we are fully behind the idea that we should have an outcomes focussed fundamentally on what we do. Fully behind the idea of devolution of responsibility to clinicians. So to that extent, some of the principles of the white paper are very well supported.
We’re working together with BMA and other general practice organisations. In addition to a range of developments in the GP contract, that flow from this, more particularly, what does the commissioning contract look like? Because the consortium will have its own framework. So if you can imagine having both the QOF, which is the responsibility of an individual practice, in relation to their population, and alongside that the consortium, for their registered population, and indeed for their resident population, having a consortium-wide responsibility which is then reflected into the commissioning outcomes framework. Essentially, the accountability of general practice is not fundamentally changed by this. The accountability of the consortium is a very new construct, and is essentially about propriety in the use of public money, and responsibilities. It’s aut financial control, these are public bodies living within a public budget. They can’t breach that budget. And delivery of outcomes. And we will in due course consult about what that commissioning outcomes framework looks like because I think that is pretty important.
A recent Pulse survey shows that about a quarter of GPs have an investment in a private company providing NHS services. Do you believe these conflicts of interest can be successfully overcome, and if so, how do you expect GP consortia to navigate them?
In the past, I have explained to people why what we’re proposing is quite different from fundholding. It’s only like fundholding in the sense that it is a belief that physician-led commissioning by those who actually exercise responsibility for care of patients is the only basis on which you can have effective health economies that deliver the best health outcomes. But it is very unlike fundholding. Commissioning is not being administered at the practice, it’s not being done on the basis of the money being able to be transferred between the commissioning budget and the practice’s own budget.
So to that extent, one of the major conflicts of interest has been removed. If general practice collectively through the consortium will be rewarded for doing well, but will be rewarded through the outcomes framework, not by saving money on the commissioning budget and reinvesting it into their own projects. Now, there is an issue, of course, one of the things that happened under fundholding is that GPs could refer patients to their own services, and make a profit. I think GPs, individual practices or collectively, should be able to provide additional services. I think we are in a better place than fundholding was.
Firstly because the consortium will have a responsibility for the commissioning and the contracting, not the individual practice. So any individual practice will be subject to the clinical and corporate governance of the consortium as a whole. Secondly, because when they do that referral, as part of the contractual obligation to provide patients with choice. So they can’t just say, ‘here you are, you want physiotherapy, I have a physiotherapy practice’.
They have to offer the choice and demonstrate that they’ve offered choice. But then thirdly, we’re also intending that by the time the legal responsibility transfers in 2013, to have extended tariff arrangements out into the community. So even if they do, perfectly reasonably, have patients that want a service, the general practice may well offer that service, patients can choose it, they won’t be able to take an excess profit on that because they will be transparently contracting within a tariff framework, where they would have to demonstrate for example that they have met the quality standards and the price that was otherwise available from other providers.
One of the key fears among GPs is that consortia will inherit in some cases huge debts from PCTs and that they will effectively be hamstrung before they start. Will consortia inherit these debts?
The legal responsibility will be transferred to the consortia in April 2013. So it is 2 and a half years from now. It’s 2 and half during which, I make no bones about it, we are going to have to deliver substantial efficiencies and secure the financial stability of the NHS. In some places, not everywhere, the NHS is not financially stable. We’re not in a happy place necessarily, despite the fact we’ve had 5.5% real terms increases in funding in the last couple of years. To that extent, we are going to have to deliver, I think, stronger productivity, stronger financial control in the short-run. But the object of that is that we arrive at the place in April 2013 where GP consortia are set up to succeed.
Asking them to start with legacy debts would mean they would be set up to fail. That does not mean that in their own health economy they can just carry on and the debts will be written off. It won’t work like that. So what we’ll do is, we have got an important period of time of transition, that transition has to be one that is not just about important issues about transfer of functions and what does the legal responsibility look like and who are the personnel. It is also about making sure we achieve a transition from, what in some cases might be current financial deficits and instability, to a position of financial stability.
What should a GP say to a patient if it’s at the end of the financial year and they can’t refer them because if they did they’d go over budget? Or should they go over budget?
The first thing is, we need to have much more transparent arrangements for managing risk. At the moment, individual PCTs carry all the risk themselves. Some PCTs carry all the risk in circumstances where they’re not actually that large. Now that doesn’t mean you have to have big consortia, what it means is you have to have good risk management arrangements. That includes, if anything more of the most costly and uncertain activity being managed by the NHS Commissioning board itself, and it also means the consortia thinking themselves about how they have a collective risk-management system. We will help with that, we will create a risk-pool. But a risk pool is not to enable people to breach budgets, and learning how to manage services within a budget is an essential task. But actually, I think people can rather over-estimate the ability of PCTs to do this, many have not, they can under-estimate the ability of GPs to manage this more effectively in the future. If you think about it, the essence of why PCTs don’t manage risk and demand at the moment is often because they are not actually the people who are living day-to-day with the developing problem. So instead of what you often experience now, which is GPs and patients making decisions, initiating referrals, undertaking prescribing and incurring cost, and then the PCT at some point in the year saying ‘stop, stop!’.
We have to be at a point where we can say, actually we can manage this, and that’s where some of the expertise of commissioning which ought to be available in PCTs hasn’t bee, or not sufficiently. It’s about understanding your population, its risk stratification and the way in which that risk is manifesting itself, and how you can manage it better.
We can never eliminate the point where the GP community collectively are going to have to set priorities on occasion to say, we must do this now, we will do that later, we agree that we should do this, and we shouldn’t do that. Those are decisions they will be able to take. They will not be able to take them arbitrarily, to exclude form the NHS whole categories of activity, because they would have the same legal duty that I have to provide a comprehensive health service. But they have to exercise a degree of priority setting. At the moment, if you’re in NHS Warwickshire at the moment, very often the GPs are saying to their patients, ‘we can’t refer you for this’ or ‘we’re not going to be able to offer that’. And they can sort of say, oh well, it’s the PCTs decision, and the public say, how I complain to the PCT. Who are they accountable to? The truth of the matter is, they are not. Strictly speaking, PCT is supposed to be accountable to me. But I can’t influence their decisions. The rigmarole says it’s a local decision. But we are going to have proper accountability.
If you’re sitting across the table from a patient and you’re saying I’m sorry we can’t do that now, the patient has a right to expect that their GP has been a participant in that decision. Not the individual decision, but a collective decision. So they are in a better place to explain why that decision has been reached. If they have a major problem about the structure of commissioning, the scrutiny role is in the local authority. The patient sitting across the desk is somebody who has a vote and the LA has a role within all this. What we are removing from the system is a body that exercises power without accountability.
Our recent story revealing the lack of language and competency testing for non-UK EU doctors has reignited the debate about the UK implementation of EU law. How close is the Government to resolving this, and ensuring that the law is implemented as such that it permits the testing of EU doctors?
I am determined and we have made it very clear to PCTs that they do have a responsibility in relation to GPs access to the performers list. And, I’m afraid, not only in relation to the Ubani case but the subsequent CQC examination of the performance of PCTs was not encouraging. So we have strengthened the messages to PCTs that at the moment they have the legal responsibility and they must do it. But it is not the best way of doing it.
Now, the GMC, I have talked to the GMC we are working closely with the GMC, it would be very straightforward from our point of view for the GMC alongside their responsibility to add EU doctors to the register, to undertake language tests. But the EC are very clear that in their view, linking it directly to entry onto the register is interfering with the ability of doctors to exercise the free movement principles of EU law. Because if you don’t put them on the register they can’t work at all, under any circumstances. They have said it’s got to be something separate from that. We are very keen on convincing the EC that we can be entirely compliant with EU law, we favour free movement principles, we don’t dispute them, but that we can be compliant with the law in spirit and letter if we then have a mechanism which is then geared to the employment of doctors rather than to the registration of doctors.
So it’s employment within the NHS. So when it comes to the performers’ list, we are looking at, it may not be possible until we’ve got the NHSCB established, the NHSCB being responsible for the language proficiency testing in relation to those who go onto the performers list. Of course, where other doctors are concerned working in the NHS, individual employers will continue to be responsible. So a hospital is responsible for the language competency as well as the other proficiency of the doctors they employ.
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