BMA response to proposed changes to Primary Care Trusts following the Health Committee inquiry
2 November 2005
The BMA is pleased to submit written evidence to the above inquiry and would be happy to provide additional information for the Committee's deliberations should this be appropriate.
We welcome the Committee’s focus on this issue because there has been too little discussion around the far reaching changes set out in Sir Nigel Crisp’s letter of 28 July 2005. Subsequent clarifications, such as John Bacon’s letter and announcements from the Secretary of State have only added to a general feeling of confusion.
While we would agree that some reconfiguration is necessary, doctors and others are increasingly frustrated by the process of implementation, which is neither clear nor engaging. The whole process has added to an already uncertain climate about the direction of health policy.
The BMA’s comments on the proposed changes are provided below, under headings that were suggested for the inquiry. We have added one more – ‘thinking across the spectrum of healthcare’ – because, given the huge change agenda that has been set in place, it is necessary to think about change across health and not only in primary and secondary care. This is particularly important in relation to developing care pathways for patients and strengthening commissioning.
- The rationale behind the changes
- The likely impact on commissioning of services
- The impact on the provision of services
- The impact on PCT functions, including public health
- Consultation about proposed changes
- The likely cost and cost savings
- Thinking across the spectrum of healthcare
The direction of change and the rationale for changes are not clear. There is no overarching explanation from the Department of Health of how the wide-range of changes proposed - of which Commissioning a patient-led NHS is part - will improve healthcare for patients.
There seem to be two major drivers behind the changes proposed to PCT structures. The first is to help achieve the target of a 15% reduction in management costs. The second, as the NHS ceases to be the sole provider of health care, is to create a framework in which PCTs can act as “market managers”. By moving to divest the provider role, the theory is that PCTs will become more effective commissioners.
The likely impact on commissioning of services
One way in which PCTs can improve commissioning is by effectively working with local professionals to better engage them in the process. Among the suggestions in Nigel Crisp’s letter that we welcome is a commitment to better engagement with local clinicians. We would like clarification on how this will be achieved.
Practice-based commissioning is an important vehicle for the development of care pathways and the strengthening of teams of professionals to provide more community based care. One of the negative consequences of the uncertainty in the direction of current policy is that its development is not being taken forward in the way it should. The lack of clear guidance is that it is adversely affecting the day-to-day functioning of many PCTs and their ability to implement key areas of government policy. Until the likely reconfiguration of PCTs is set out clearly at a local level, it will not be possible for PCTs to determine what their role will be in practice-based commissioning.
In addition, there appears to be an assumption that local clinicians are solely general practitioners, but whilst GP engagement is absolutely critical, especially in taking forward practice-based commissioning, there are also consultants in a range of specialties working in the community as well as public health that need to be involved in the redesign of health services. Whilst many consultants are largely hospital-based, they are also ‘local clinicians’ and have a valuable contribution to make to the debate, particular on the development of care pathways and the medium-term ambition of moving more specialist-led services into the community.
The impact on the provision of services
The Nigel Crisp letter indicated that PCTs should only act as a provider as a last resort. A subsequent letter of clarification from John Bacon said plans to do this should be developed over a longer time-frame. Despite this supplementary letter, we are concerned that some PCTs are still making detailed plans to divest themselves of their provider functions with no clear thinking about who will take over these roles.
We are concerned that even though there has been some back-tracking on the plans to divest PCTs of provider functions, the 28 July letter still represents a policy ambition. This will see the eventual transfer of more than a quarter-of-a-million staff (mostly nurses, but also doctors and other professionals) move to new providers –such as GP practices, private providers, secondary care providers, or perhaps new consortiums. This level of uncertainty is not conducive to successful implementation of such a large change agenda. In addition, the managers that are being asked to take change forward inevitably worry about their own roles and whether they will still exist following reconfiguration.
The BMA has advised doctors to discuss with local SHAs and PCTs any issues that they would wish to see addressed as a result of possible PCT reconfiguration and also, in future, to seek information on how the PCT provider role is likely to change. But this can only be done if PCTs and SHAs show a greater willingness to work in partnership. We believe that PCTs should not be rushing to change their commissioning structure or shed their provider status without consultation or before they can demonstrate that there will be no detriment to the delivery of services and patient care.
Over the last several years there have been several changes that have seen community staff move to new employers. In addition to the financial costs (which have never been quantified) the critical relationships between teams of professionals which have taken time to strengthen and make effective are at once undone and have to be recreated within new structures.
The impact on PCT functions, including public health
In paragraph 10 of Nigel Crisp’s letter it is indicated that ‘the Department will test proposals’ submitted by PCTs regarding organisational reconfiguration. We would like clarity on the bases by which these proposals will be tested and whether professional associations, like the BMA and patient representatives will be given the opportunity to influence this ‘testing’ process.
The BMA would like to see doctors represented on the panel that will assess proposals.
A key concern for the BMA, in the changes proposed, is that public health is not at the forefront of local managers’ minds in responding to central demands for reconfiguration. There is a danger that this focus is being lost in the wider programme of “system reform”. The current review of NHS structures presents a valuable opportunity for improving arrangements for Public Health, in particular that commissioning teams should include Public Health trained clinicians, and that local Public Health departments should be coterminous with Local Authority boundaries whenever possible The BMA supports the appointment of a Director of Public Health (DPH) to the population of a management unit of a local authority. Also that where a PCT covers a group of unitary authorities then we feel that a separate DPH should be appointed for each of the authority areas and conversely where a large local authority is divided into several PCTs a DPH should be shared.. Public health is critically important to the development of multi-disciplinary care pathways, to the success of disease-management initiatives and in providing a strategic focus to commissioning.
The BMA has sent a paper to all Strategic Health Authorities and the Department of Health, which sets out the contribution of public health and the role it should play in the future. This is attached as an appendix.
Consultation about proposed changes
The BMA has received a number of reports about PCTs rushing into the merger process with little or no consultation with local stakeholders including GPs, consultants and their representative bodies, and patients.
The Nigel Crisp letter was addressed to Strategic Health Authorities and professional groups were not invited to offer their views, likewise patient representatives. In response to unhappiness with the changes, the Secretary of State has belatedly said there will be local consultation on proposed changes from December. An important question is whether this will involve a fundamental review of what is needed locally and how policy strands can be used to support these needs or whether it will be a consultation designed to “sell” a pre-identified solution.
There are two fundamental reasons why the lack of consultation needs to be addressed. Firstly, change will not be successful without meaningfully engaging doctors and other professionals. The current change programme is wide-ranging and local professionals, managers and the public need to come together to make sense of how policy can be fitted together locally. These changes include new entrants to the provision of healthcare, choice of provider offered to patients, an ambition to overcome some of the divide between health and social care, a new payment system which will threaten provider stability, and changes in the commissioning structure.
Some liken the change strands to different pieces of a jigsaw, but these pieces can only be put together locally if groups are given the opportunity to construct a picture of what they want to create locally.
A second and important reason consultation is a critical issue is because current Government policy – particularly Payment by Results – unleashes competitive forces that mean service configurations are likely to change. This necessitates some kind of local forum in which these changes can be explained to local people and be influenced by them.
The likely cost and cost savings
As noted above, one of the main drivers for change is to use resources more effectively. There is an explicit ambition to cut management costs by 15%.
Nigel Crisp’s letter states that a focus in taking changes forward will be on ‘internal capacity and capability to discharge new functions, and particularly leadership ability’. We would agree that one of the needs of the NHS is more effective management and leadership in some areas and would hope that it will be made a priority to involve clinicians in meaningful management and leadership roles. However, we are concerned that this focus on leadership (and the Government’s stated aim of enhancing clinical leadership) may be diluted if the reconfiguration process is required to ‘deliver at least 15% reduction in management and administrative costs’, as it states in paragraph 3. Whilst administration may be reduced, higher calibre management may require further investment.
Resources could be used more effectively, but it is important that a strategic view is adopted. Cutting back costs now without looking ahead to what is needed could end up being more costly in the future.
As noted above, one key ambition that should not be forgotten in the huge change agenda that has been set in motion is the aim to improve the management of long-term conditions, which necessitates better care of people in the community. It will mean the movement of some specialist services from hospital settings into the community. This will take time and resources.
A key vehicle is practice-based commissioning. Moving this function closer to patients with more clinical involvement has the potential to produce more innovative and patient-centred services, as well as creating pathways that enable more care in community settings. But while this will achieve savings over time, it will also require some investment in developing expertise among new commissioners. We are concerned that the requirement to reduce management costs may impede the development of such skills within PCTs.
Thinking across the spectrum of healthcare
The BMA is positive about the potential for practice-based commissioning to draw together and strengthen care pathways. Public health has a key role to play in providing strategic support for changes. There is also potential for new ways of working across primary and secondary boundaries and a key role for consultants in contributing to service improvements.
The Government’s changes to the NHS have introduced a deliberate tension between secondary and primary care, in the hope, we assume, that this tension will be creative. However, we are concerned that co-operation within and between health sectors will be reduced and potential benefits to health and healthcare from closer co-operation could be lost.
For example, it is possible that while a hospital doctor might want to work with colleagues in community settings to design new care pathways they will be prevented from doing so by hospital managers who are understandably concerned about the loss of income to their institution that will result. In this submission we do not have the space to expand on solutions to this problem, but more thought needs to be given to the establishment of care pathways that cut across traditional settings. Achieving this requires important changes to the financial system (Payment by Results) to allow tariffs to be apportioned to different providers – a process known as “unbundling”.
It is critical that discussion of these changes does not only concentrate on primary care. The redesign of care pathways and the aim of moving more care into the community cannot be done discretely, but must involve discussions across the spectrum of health care and doctors in a variety of settings.
The BMA would be happy to expand on any of the issues raised in this. Please contact Sue Marks, Head of the BMA’s Parliamentary Unit, should you require any further information
Email: parliamentaryunit@bma.org.uk