nf1199: i'm [0.4] namex [0.2] you've met me before [0.3] i used to work [0.3] 
in a health authority [0.6] i'm now working [0.2] er [1.2] providing practice 
management [0.6] support to general practice [0.4] and doing a range of other 
things including clinical governance [0.3] coordination with the Department of 
Health [0.6] and i've been asked to come here and do the session on [0.4] 
commissioning contracting and purchasing [0.4] which is actually a little bit 
out of date now because we're don't we're not allowed to use those words [0.4] 
with the new White Paper although the techniques are still the same [1.6] what 
i thought i'd start off with doing is has anybody got any [0.5] sort of 
commissioning or purchasing issues that they would like to have as a theme to 
[0.2] to the session [0.7] anybody they can think of that's going on in their 
organization that they think we've got a particular problem of that we can base 
the s-, the [0.4] the lecture round [3.4] mm 
nf1200: the problem we've got is matching the data to the contracts [0.2] the 
data that comes 
across matching it to the services 
nf1199: right okay 
nf1200: 
nf1199: so we need to [0.4] look at [0.3] one of the things we can do is 
explore a little bit detail in in the difficulties with ob-, obtaining 
information on contracting activity 
nf1200: mm [0.4] 
nf1199: fine [1.3] what i'll intend to do then is just briefly do an overview 
[0.2] of what [0.6] N-H-S commissioning contracting and purchasing is all about 
[0.7] and then i thought we'd take an example [0.9] er a service delivery 
example [0.3] where some of these issues come into play [0.3] some of the 
variables that [0.3] and the information that we need to address [1.1] you're 
due to fi-, finish at five o'clock [0.4] i'm happy to keep to that hour if you 
are 'cause you've obviously had a [0.2] a long day and if you've er [1.8] if 
you're anything like me by this time of the day [0.4] start to starting to wane 
nf1199: so now can everybody see that okay 
ss: yeah [0.3] 
nf1199: all right 
let's start again [3.7] are we ready [0.9] just a quick [0.5] overview of the 
new N-H-S which when i last spoke to you you [0.3] should r-, now be really 
aware of [0.4] to the back teeth [0.6] er and the developing of primary care 
groups which actually means that the commissioning and purchasing and 
contracting role [0.4] is gradually being devolved [0.3] from what was the 
health authority responsibility [0.4] and G-P fundholders' responsibility [0.4] 
to primary care groups [0.8] now it's going [0.3] down at different levels [0.
3] primary care groups can go in [0.4] to action at four levels [0.7] most are 
opting in at level two which means that they can take the responsibility of 
some of the budget not all of it [0.5] and they work in conjunction and 
accountable to the health authority 
nf1199: level four [0.3] is when they become trust status is where they have 
the whole set of responsibilities as does as a health authority [0.7] but at 
the moment nationally are [0.3] they are tending to go in at level two 
level one [0.3] is where they just work on an indicative level [1.5] so [0.2] 
that has changed things [0.2] quite dramatically [0.4] or will do [0.4] in that 
the involvement of general practitioners in the [0.3] purchasing commissioning 
focus is so much more [3.7] er around primary care [2.0] primary care [0.3] 
functions group main functions [2.4] they have to contribute to what is called 
a Health Improvement Programme [1.6] they have to look at the p-, and promote 
the health of their local population and the local population [0.5] is [0.5] er 
er based around [0.5] geographical ward areas coterminous with social services 
[0.5] so groups of practices will be brought together [0.7] and they will be 
set [0.3] er [0.5] as a board [0.5] looking at the individual needs of their 
local health autho-, health population [1.6] they then have to look at how 
they're going to commission health [0.2] services [0.3] for that [0.8] group of 
the population [1.0] they also have to look at how they integrate that with the 
development of primary care [1.1] community services [0.3] and 
gradually replace what is now known as fundholding [1.8] presume everybody's 
aware of what fundholding is [0.7] that they take a specific budget and they 
monitor that [0.7] with primary care groups it is somewhat different in that 
they have to take those things [0.4] in addition to fundholding [0.4] that are 
not necessarily containable so they have t-, they can take [0.5] em-, i-, 
levels of emergency activity they have to take that into consideration [0.7] so 
it's not as contained as fundholding fundholding was very much a specific 
amount of money [0.7] with very little external [0.3] pressures and constraints 
on it [1.0] unlike the health authority who had to manage winter pressures 
waiting lists [0.4] emergency activity [0.3] and other financial pressures on 
their budget [0.4] primary care groups now gradually will have to start to take 
on board those issues [6.5] what is [0.8] purchasing [1.4] the definition of 
purchasing [1.3] is the buying [0.5] that's when you've decided [0.4] what it 
is you need for your 
local population [0.3] you g-, actually go out and buy it [0.6] that's still 
staying in the new N-H-S the purchaser provider split is still staying [2.9] it 
g-, actually gives the primary care groups quite a lot of leverage [0.2] 
because they will be determining [0.2] what it is they want to buy [0.4] based 
on the needs of their local population [1.1] one of the things they have to get 
used to doing however [0.6] is working with the providers because as an example 
if they suddenly decided [0.4] that they'd no longer wanted to contract [0.3] 
for a particular acute service in a main general hospital [1.3] they then have 
to look at wh-, how that impacts on other services if we take [0.3] paediatrics 
as an example [0.3] paediatrics links in with SCBU [0.3] it links in with 
maternity [0.4] and other services around [0.2] in primary care like child 
health services [0.4] and and it's that sort of a domino effect if they remove 
one thing [0.3] they actually can cause a ripple effect through an organization 
[0.3] so there has to be [0.4] a process of change management [0.7] so they can 
change 
purchasing decisions [0.2] but it has to be done in a planned [0.3] framework 
[2.2] [0.2] 
nm1201: you you said about er [0.6] you know there'll still be the commissioner 
and provider split 
nf1199: yes 
nm1201: but it may have become when the [0.4] primary care trusts come in [0.7] 
because they'll be able to provide community care [0.8] for that level as well 
won't they 
nf1199: they will have to [0.2] be responsible as a primary care [0.2] trust [0.
4] still for the provision of services but that will be through contract still 
[0.7] there may be some contracts within primary care [0.4] but there will be a 
division between the board [0.4] and the decision making process of what's 
actually provided [1.0] the [0.2] the it's it's not as you say it's not as 
clear-cut as now where you've got an N-H-S trust [0.4] but a primary care group 
will not actually themselves be providing the service [0.3] they will be 
members of providers 
nm1201: right 
nf1199: for example there will be a social worker [0.3] a general practitioner 
[0.3] an acute hospital ru-, member [0.2] alongside up to seven 
general practitioners [0.2] so in e-, in essence they are providers [0.5] but 
they will have as a primary care group board [0.3] contracts as purchasers if 
you like [0.3] with [0.2] a range of providers 
nm1201: mm 
nf1199: does [0.2] does that [0.3] clarify 
nm1201: providers could be then shouldn't it 
nf1199: it w-, will definitely should be [0.2] because the r-, the the aim is 
[0.3] that [0.3] all of those people sitting on the pu-, on the primary care 
group board [0.2] will be aware [0.2] of the capabilities weaknesses and change 
management issues [0.4] around their own trust [0.2] so if you're looking at 
somebody sitting on a primary care group from social services [0.4] and the 
issue on the primary care group board agenda is elderly care [0.4] it's very 
much their interest [0.3] to have a voice in that group [0.3] whereas at the 
moment it's not in an integrated forum [0.7] there is [0.2] there are a few 
areas that are under joint planning where we sit round the table as health 
professionals with social services 
professionals [0.4] but it's not part of the N-H-S structure [0.2] before or it 
wasn't before primary care groups came in existence [0.5] so i think the aim is 
to have an integrated approach [0.4] of all the professionals [0.4] involved in 
providing care [0.2] for that designated area [0.4] so whatever the whether it 
be a subject whether it be a client group [0.3] or whether it be a specialty [0.
6] it will be discussed and each person will have a group there will be a 
practice nurse who will be able to speak [0.3] on behalf of [0.3] the practice 
nurse provision [0.4] there will be [0.5] as i said a social worker [0.2] 
general practitioners all giving their views [0.3] so it's going to 
fundamentally change because there's going to be a lot of tension because of 
people come [0.4] in at different things in different ways [0.8] when i was 
working with namex [0.2] wh-, who you've just [0.2] met [0.5] er we had to 
implement [0.2] under the previous government [0.4] er a White Paper called 
Changing Childbirth you're probably [0.3] aware of that was that was 
the change of maternity services [0.4] from purely acute care [0.3] and to more 
spread out into the community [0.9] what you end up doing is y-, [0.2] you have 
to start [0.3] bringing in an awful lot of [0.5] interest into that process but 
there's no formal [0.6] er meeting place for that to happen and it was very 
difficult getting the midwives round the table alongside the health authority 
[0.4] trying to drag a general practitioner in to give his view [0.2] which one 
do you choose [0.4] out of seventy-eight practices or however many practices [0.
3] which general practitioner do you actually choose to join you [0.3] and is 
he [0.2] is he or she seen [0.2] as representative [0.3] of their own 
profession in that area [0.4] at least with primary care groups [0.2] whoever 
they may be [0.6] they will be accepted as the representative voice of that 
profession [0.4] so whenever their changing services [0.4] from a commissioning 
point of view [0.3] they will be the guidance and they will be the reference 
point [0.3] consultation point start point planning point whatever [0.3] well 
they'll either go to 
them to start a problem [0.3] or they will make a decision to finish it [2.5] 
the [0.7] er [2.3] commissioning [0.9] definition that brings us on quite 
nicely to the is something entrusted to be done delegated authority [0.5] er [0.
2] payment by percentage for doing something [1.8] that's a [0.2] a very 
lengthy [0.4] er [0.6] definition [0.9] there are other definitions for 
commissioning [0.3] which i actually prefer [2.3] which is looking at [0.2] 
these key areas [1.8] and that is looking at the skills [0.6] oh dear [2.4] 
skills and abilities of the people involved in providing the service i've got 
handouts for these so don't worry too much [1.6] diagnosing the problem [0.5] 
so if we're looking at changing a particular service as er [1.6] around a 
client group [0.4] we have to understand why we want to change it [0.3] and 
that has to be backed up by [0.3] evidence and the new White Paper says all the 
way through evidence based medicine [0.5] R and D research and development [0.
6] clinical effectiveness they're all key words [0.3] in the new White Paper [0.
2] so 
whatever w-, [0.3] primary care groups are changing [0.4] they have to look for 
A the problem [0.3] and then B [0.3] underpinning it with reasons why [0.3] or 
reasons for making changes in the commissioning process [0.6] so from an 
information point of view it could well be activity data from contracts [0.4] 
it could well be census data of age sex [0.3] breakdown [0.3] it could be [0.3] 
epidemiological information about [0.3] the structure and nature of that 
particular population that's causing the problem [0.6] if there's a prob-, [0.
2] problem in [0.7] a part of a county where there is high percentages of 
elderly and it is involved rehabilitation [0.3] then there's an you know an 
underlying reason why rehabilitation is probably more of a problem there than 
it may be [0.3] elsewhere [1.8] so they have to look for the underlying causes 
but they can't just make a judgement and say we think it's because they've got 
to start to back it up [0.4] so commissioning the commissioning process is the 
[0.3] the digging up [0.2] all the research all 
the evidence [1.5] they have to look at it [0.2] without taking sides so 
they've got to start and analyse that information [0.9] er [0.4] as a group of 
professionals without taking sides [0.7] and that's going to be quite difficult 
'cause obviously the doctors may well veer towards the medical [0.6] angle [0.
3] nurses will be protecting their own profession [0.3] you'll have social 
services coming at it [0.3] so there's going to be [0.2] quite a lot of 
storming i think in relation to the group coming together initially [0.6] but 
as the process takes 'cause as long as it's backed up by research and evidence 
[0.3] they can't they won't be able to argue [0.4] the decision making process 
in the longer term because it will be based on factual data [1.4] so [0.3] 
there's a lot of listening [0.5] key in the White Paper is involving the local 
community [0.5] focus groups [0.4] er health economies i think they're being 
called in relation to involving those groups of individuals [0.3] patients 
population [0.4] in the decision making process [0.4] so as part of the 
commissioning they 
have g-, also got to demonstrate [0.3] that not only are they underpinning it 
with [0.3] evidence based [0.3] research [0.3] but they are actually going out 
on consultation [0.3] to the people [0.3] who actually [0.5] n-, have to have 
the services [0.4] delivered to them [1.9] timing [0.4] you cannot make change 
overnight it's not something that [0.4] a group of professionals can suddenly 
make changes in within three to six months [0.3] so there has to be a plan has 
to be a management plan [0.4] involving the people [0.4] involving the [0.4] 
professionals involving the public [1.7] if anybody's aware in Warwickshire at 
the moment there's a major project going on around Alcester Hospital where 
they're trying to bring together a social services [0.4] and independent [0.2] 
sector [0.2] development [0.2] alongside a community hospital and actually 
integrate services [0.3] and there was a public meeting with the health 
authority [0.3] to the local population of the plans [0.3] and encouraging 
people to put forward their views [0.2] that's part of the commissioning 
process [2.5] once you've done all of that [0.9] 
you then [0.5] have to decide what you're going to buy [4.0] and that's then 
[0.3] put into a contract [1.3] that's where [0.5] you've decided [0.6] what it 
is you need [0.5] you've based it around something that's tangible [0.5] and 
then you've negotiated with the service providers [0.3] to to to [0.2] make 
that service available [0.3] remembering that it may not be there now [0.8] you 
may actually decide [0.3] that you need a service that doesn't exist [0.8] 
during the commissioning and consultation process [0.3] out of that may arise 
[0.3] that there is a need [0.2] for a more [0.5] say focus on domiciliary 
based [0.3] rehabilitation [0.4] that may not exist it may all be done in a n-, 
local acute hospital [0.6] so there has to be agreement with the service 
providers [0.3] as to how it can be moved [0.4] from the acute setting [0.3] 
out [0.4] is it done in a building is it done in people's homes [0.3] does it 
involve social services [0.4] is the district nurse going to be involved all 
the different [0.2] 
tangibles have to be brought together [0.8] when it's [0.2] been decided how it 
will work [0.2] we we then have to say well so much will be provided by 
district nursing [0.4] that's a service that the local trust provides so we'll 
have a contract with them [1.0] if it's about [0.2] social services [0.3] 
that's a social service area [0.3] we need to have agreement [0.3] with social 
services [0.2] and how they will provide that and how we can have it written in 
contract [1.2] the contract terms will dictate how often it takes place how 
many people can be seen [0.4] what cost [1.0] and it will actually define [0.2] 
the nitty-gritty issues [0.2] of financial management and control [1.2] but it 
is very much a three stage process [1.4] 
nf1202: can i ask a question [0.9] 
nf1199: yes certainly [0.2] 
nf1202: about saying that [0.5] that contracts are enforceable by law are they 
really in some sense are they 
nf1199: 
no they're not [0.2] they're not legal agreements 
nf1202: mm 
nf1199: they're [0.6] it's what we hang everything round it's what we have an 
agreement with providers on [0.7] but they're not [0.2] [laugh] they're not a 
legal document 
nf1202: mm 
nf1199: because of they're in public sector [0.6] however [0.5] in contracting 
law [0.3] the fact that somebody has agreed to provide something and and 
provides it over a period of time [0.3] is actually a contract [0.3] if i en-, 
if i started to pay you [0.3] to deliver me a service [0.3] i-, [0.3] no piece 
of paper may exist between us but it would be deemed in law that we would have 
had a contract because i'd have been paying and you'd have been delivering 
nf1202: mm [0.5] 
nf1199: but no they're not legal documents [0.4] but they are some we have to 
have something [0.6] to base [0.2] all of this on [0.4] against a strategic 
plan [0.7] and the three stage process very much is [1.1] [0.7] commissioning 
[1.3] purchasing [0.5] and contracting [1.8] when we first started working with 
general practitioners i remember 
meeting with a group of doctors and they said [1.6] well [0.4] if i want to go 
out and buy oranges [0.3] i'll go and buy oranges [0.7] she was a G-P 
fundholder [1.3] and i said [0.8] fine [0.6] er i said but [0.5] the provider 
needs to know [0.2] what sort of oranges you're going to want to buy [0.6] do 
you want clementines satsumas [0.4] jaffas [1.0] and that's the commissioning 
bit [0.5] because if there aren't any satsumas and she specifically wants 
satsumas [0.5] then the trust has to provide [0.3] and we ended up talking in 
this analogy of oranges which [0.3] you know i thought here we are in the N-H-S 
talking about oranges [0.3] but it actually gave quite a good example [0.4] 
that you can say you want to buy elderly care [0.8] but what do you mean by 
elderly care do you want acute general medical beds do you want domiciliary 
rehabilitation do you want social care [0.3] you know there there is a range of 
stuff around the elderly [0.8] so it's about defining [0.2] defining what you 
mean [0.5] when you've defined it through need [1.3] you then [0.3] buy it [0.
3] and that's when you enter into agreement you say this is 
how much money we've got [0.6] and this is how we'd like it to be [1.0] where 
do we buy it from [0.5] if there's social care services social er services et 
cetera [0.9] there was a a very difficult time when the internal market took 
over [0.5] er [0.2] being sensible i think at one point [0.4] where we had two 
community trusts trying to provide [0.4] counselling services one was a mental 
health trust [0.3] and one was a community trust [0.7] if a G-P referred to the 
mental health trust and it was a mental health referral that's s-, that's fine 
[0.4] but if it was referred to the mental health trust and it was a general 
community [0.4] psycholi-, psychological problem [0.6] the mental health trust 
would be reluctant to pass it across because that would be income for them [1.
4] that would actually be income into their pot [0.4] whereas now [0.4] what 
we're saying is [0.3] to w-, we should be dismantling all of that competition 
we should be assessing [0.3] what it is we want to buy and who is the most 
appropriate provider [2.2] then we purchase it 
and we determine quantity [0.2] quality et cetera [0.8] and then we negotiate 
the contracts [0.4] and that's really i was a contracts manager [1.1] you have 
this pot of money [0.9] that's it [0.2] you have to monitor it then within 
those guidance and [0.3] what you were saying [0.2] which we'll go on to now [0.
5] was the difficulties [1.3] and we'll just touch on that briefly [1.1] [5.5] 
activity [9.4] you have to decide when you're managing a contract [0.3] how 
you're going to monitor [0.3] what's happening [1.6] in acute hospitals it's 
fairly [0.4] robust [0.3] because [0.2] the c-, er [0.5] contract minimum 
datasets gives a record [0.4] who comes in who goes out how long they stayed [0.
4] and what happened to them during that process [1.0] so from a purchasing 
manager as i was then and probably in the future primary care group [0.4] they 
will be a-, able to have from a local hospital [0.3] each specialty [0.6] and 
activity across the months across a quarter [0.5] that will have a price 
attached to it [0.7] and they can 
work out by projecting forward whether they're actually within the re-, realms 
of their contract financially [1.1] what is now being said nationally is that 
[0.4] whereas you might get Solihull Hospital [0.6] charges out [0.3] er a 
hysterectomy at two-and-a-half-thousand pounds [0.4] but Birmingham Heartlands 
may charge three [0.8] there will be a national costing formula that will say a 
hysterectomy is always [0.2] three-thousand pounds for an example or [0.4] an 
acute general medical admission [0.6] er [0.2] f-, [0.3] for whatever reason is 
[0.4] and there will be a national pricing formula [0.5] because that then gets 
away from the compe-, competition [1.5] so the price will be linked to activity 
and it's it's activity times price [0.3] that's the way the contract is 
monitored [0.8] so it's based on [0.4] er [1.7] er locks lumps of activity [1.
2] in the community it's actually measured by contacts so at the moment [0.6] 
if you contract as a large purchasing organization for something like district 
nursing [2.6] a health authority would contract 
that [0.7] on how many people has that district nurse seen [0.2] so how many 
contacts how many face to face contacts has an has been undertaken [0.3] again 
during the quarter [0.5] during a six month during a twelve month period [0.4] 
and the trusts or the providers will put a price on that [1.6] i-, [0.3] the 
data [0.2] and i'm sure from your experiences is less [0.3] is less easy to 
analyse it's not as easy to interrogate [0.4] and question what went on in that 
contact was it [0.6] a lengthy contact of an hour did it last five minutes [0.
2] what happened to the patient [0.4] er [0.3] in that time [0.6] so there's 
less sophisticated information in a community [0.9] even less sophistication if 
you actually contract on a whole time equivalent basis which is what some of 
the fundholders did [0.4] they actually said i don't want [0.4] to have a 
contract on contacts i'm not interested [1.0] i want to buy e-, either a whole 
[0.2] district nurse [0.3] time [0.5] or ho-, [0.3] nought-point-five whole 
time equivalent or whatever [1.1] but the [0.2] regional offices still want 
this activity measured by contacts [0.8] because it can be [0.5] 
it's public [0.7] er information that can be said [0.3] this trust saw more [0.
4] than this [0.3] you know i-, i-, [laugh] but [0.3] really [0.6] how [0.3] s-,
er [0.7] robust that [0.2] that statement would be [0.4] is is to [0.2] in my 
in my field is is actually dubious but [0.7] contract minimum datasets is more 
robust [1.2] so that's how we c-, we [0.2] we go [0.2] we go forward [0.4] but 
[0.5] a lot of [0.2] G-P fundholders have actually [1.3] questioned the 
activity that comes out of the hospitals because they have said [0.3] that 
didn't happen [1.4] and that without getting too engrossed in the way that 
activity's measured [0.7] the [0.3] formula for which they [0.2] agree a price 
[0.4] is usually on an average cost basis [0.5] and i've had a general 
practitioner say to me [0.7] this they want to charge me seven-thousand pounds 
or [0.3] or the the whole package of care they won't be charging him er [0.5] 
for this and they've read the er [0.5] er activity that went on in the medical 
terms [0.3] and they've actually said it was sort of a carpal tunnel [0.6] 
insertion [0.4] and they're saying but [0.2] that isn't worth that much money 
[0.4] but what [0.2] the 
trust will have costed up is any anaesthetic time [0.4] any oh the theatre time 
the the nurse [0.3] what time the heating electric you know everything [0.3] 
will have gone into that price so it's not [0.5] it's not as [0.2] cut [0.3] 
and dry as what they actually do to that individual [1.7] what what [0.5] what 
particular question did you have on the [0.7] data [0.2] anything else [0.4] 
nf1203: well i think it's basically the problems we've had is er agreeing the 
electronic data that comes across from acute hospitals to [0.5] er summary data 
that they send us in their reports 
nf1199: mm-hmm [0.2] 
nf1203: and that's the [0.4] problem [0.7] 
nf1199: and what [0.2] where which side are whe-, are you from a trust or from 
a 
nf1203: no i'm from a health authority 
nf1199: right so you end up in a d-, in a debate about what you feel has 
actually happened 
nf1203: mm 
nf1199: so you're looking at contract management terms 
nf1203: 
yeah 
nf1199: yeah [0.3] yeah [0.6] that very often happens well [0.6] w-, the other 
thing that happens as well is [0.3] trusts [0.5] change their [0.9] working 
practices so they might set up an emergency assessment unit [0.7] so they start 
in the in in the acute unit er sorry in the emergency [0.4] unit [0.5] they 
then move either into a general medicine bed they're assessed in general 
medicine they move across to [0.3] general surgery [0.6] and they're d-, the 
health authority will have been charged [0.5] an initial admission fee [0.5] 
then [0.4] they [0.4] move the general medicine price [0.2] and then the 
general surgical price [0.4] there's like three episodes of care [0.6] what the 
contract minimum dataset can do and you're probably well used to analysing that 
is actually do it by patient number [0.4] and say but this patient only came in 
on Thursday [0.4] they went out on Friday night okay they might have shifted 
round the hospital a bit but they certainly didn't have [0.5] six or eight-
thousand pounds worth of care [0.5] and you can actually interrogate that data 
[0.3] that's less easy to do [0.7] in community [0.2] terms 
nf1203: mm [1.7] 
nf1199: so the 
role of [0.4] primary care groups in all of this is going to be fascinating 
because at the moment they they don't have a structure to set up to do exactly 
what you're saying [1.5] can anybody e-, think of other things that are going 
to cause a problem [1.7] 
nf1204: the problems we had er [1.2] i mean for the first few months of the 
contract you get er [0.4] taken into account of course for like [0.3] a few 
months but [0.4] let's say eight or nine months into the year and you're 
experiencing the co-, you know the contract quite a lot [0.8] and actually 
going back to the trust and asking why [0.7] this is happening what's happening 
with their they don't actually have the answers 
nf1199: mm 
nf1204: you know because getting to the bottom of that and [0.9] always made it 
quite small but significant [1.0] 
nf1199: that's the importance of having general practitioners involved in the 
process 
nf1204: mm 
nf1199: because from a primary care point of view [0.5] er [2.3] i have spoken 
with general practitioners and they have said [0.5] either two things happen 
one is that there's an initial rush at the beginning of the year and they drag 
everything in [1.2] and then they've run they've run out of the contract [0.2] 
so there isn't any money left [0.2] for when we know [0.4] in the winter time 
general medicine's going to go through the roof or whatever it might be [0.2] 
but they they look and think gosh if they were to continue at that rate of 
activity [0.3] 
nf1204: mm 
nf1199: they'd be well over the budget [1.7] the trust [0.4] can either play 
ball or not [0.4] as the case may be [0.2] and some local trusts round here 
have actually said okay [0.3] we will profile the activity with general 
practices based on their budget and we will agree [0.6] what we will treat [0.
2] over a twelve month period within that block 
of money [0.6] and set up [0.3] care profiles [1.1] others where [1.0] the 
health authority or the what will be the P-C-Gs are not the host purchasers [0.
6] can actually say well so what [0.7] as far as i'm concerned you've referred 
that patient to me [0.3] for care and treatment i've got a bed i've got a slot 
[0.3] i'll bring them in [1.1] charge back to the general practitioner [1.7] 
medical and legal implications of the G-P saying [0.3] don't treat that person 
for six months [0.6] there is not [0.5] any G-P i wouldn't have thought in the 
land that is actually going to say that because what they're then having to do 
is take back the management of that patient [0.4] when they actually [0.4] feel 
[0.3] they must have felt to refer them to a specialist [0.4] that they should 
have they need [0.2] the guidance of a consultant [0.7] so [0.4] they're in 
this dilemma financially [0.5] they can't afford to have this patient treated 
[0.2] immediately [0.6] however they know [0.3] that they need to be treated [0.
5] and as waiting lists expand [0.4] there's [0.2] usually we we have guidance 
on [0.3] urgent emergency urgent and non-urgent [0.4] which 
spreads over a twelve month [0.2] waiting list period [0.3] they either bring 
them in within six weeks three months [0.5] or the year [0.8] as waiting lists 
expand to two years [0.2] you'll need the urgent to be [laugh] you know the the 
er [0.3] waiting from six months [0.4] to eighteen months is not going to be 
acceptable so they all need to be reviewed [0.9] but there is going to be this 
tension [1.2] one of the the other things that is said is that for example 
dermatology [1.0] general practitioners refer for a skin complaint [0.4] and 
they find that the patient's going through this ever-revolving door [0.4] every 
three months they go back they probably don't see the consultant but they see 
the senior registrar [0.5] it's clocked up as an outpatient appointment [1.9] 
the doctor says [0.3] well unless he [0.2] you know he's monitoring that 
carefully he [0.2] has the patient come back to him and says [0.4] i've been 
attending the hospital for the last [0.4] twelve months doctor i still haven't 
had any [0.2] it's not better [0.6] the doctor looks back through his [0.3] 
invoicing and thinks gosh it's cost me a fortune [1.0] so the G-Ps are saying 
after three [0.2] or after four [1.5] visits [0.2] can you 
refer them back [1.4] now what that consultants will say is [0.4] well if you 
inform me as an individual general practitioner i will do that [0.3] if you 
don't i will continue [0.3] to manage their care as i see fit [0.8] so it's 
back [0.2] in the ve-, ri-, the responsibility of the general practitioner [0.
2] to say [1.0] either in the practice flag up on their [0.2] information 
systems [0.3] after three [0.3] outpatient appointments or however many it may 
be [0.6] flag up and say ooh [0.3] this let's review this case [0.5] get on the 
phone to the consultant or ask for a letter [0.3] find out what's happening 
what the position is and make a decision then as whether they continue to ke-, 
treat them in hospital [0.3] or whether they [0.2] a-, have them back [0.2] 
within the realms of primary care [0.6] the consultants will say well every 
general practitioner is different [0.5] some will be happy to take the care and 
treatment back [0.8] some [0.2] will prefer once they've referred [0.3] it's 
like w-, [0.4] over to the consultant because that's their specialism [2.4] and 
these are all [0.6] you know things that [0.4] got to be [0.6] 
addressed 
nm1201: another another pressure on er from the trust point of view i worked 
within a trust [0.5] as against [0.2] fundholders of course is all the waiting 
list [0.4] pressures that the trust have [0.3] you must get your numbers below 
this [0.6] well we can't have [0.3] er equity of treatment and say well we'll 
only treat [0.6] that fundholder 'cause he's willing to pay or that health 
authority 'cause they're willing to pay but not those patients 
nf1199: mm-hmm [0.3] mm-hmm 
nm1201: because then you fall foul because somebody then waits over twelve 
months eighteen months 
nf1199: mm-hmm 
nm1201: so [0.5] with the [0.4] primary care groups coming along and the health 
authority and the HIMPs [0.8] they will have to take that on board and realize 
that's part of their remit as well as just saying well [0.3] i've sent that 
patient i can can forget it [0.2] 
nf1199: yeah 
nm1201: they just can't 
nf1199: no [0.6] no [0.6] and somebody within the primary care group [0.4] 
board [0.3] has to have that remit that role of working 
with the trust [0.2] to say [0.4] how are we managing activity how are we 
jointly [0.5] going to meet waiting list initiatives which [0.4] hopefully [0.
2] by bringing them all together [0.2] in a management framework they will 
still be independent practitioners but by bringing their [0.6] waiting list 
issues [0.4] around a sm-, around a general focus [0.4] will perhaps be easier 
for trusts because they can deal with say five primary care groups [0.5] or 
seven depending how big the county is [0.3] rather than [0.4] two-hundred-and-
something G-Ps [0.3] or seventy-eight practices [0.4] so [0.5] it should avoid 
some of that fragmentation and you get one practice being very different to 
another and yet they're next door to each other wouldn't they [3.0] 
commissioning is actually going to affect primary care as well because [1.2] at 
the moment [1.6] think we touched on this before [0.3] but at the moment if a 
general practitioner wants to increase their practice nursing services in 
general practice [0.4] they apply to the health authority they put a robust bid 
together [0.4] and with general medical services money [0.3] it's addressed [0.
5] usually with officers round the lo-, [0.2] round the table from the 
local medical committee health authority [0.5] and o-, [0.3] commissioning [0.
4] er representatives and they are either saying yes [0.4] or no [0.4] based on 
the bid [1.0] they're going to have to take those bids shortly to [0.6] their 
peers [0.3] their primary care group [0.8] and they are then going to have to 
argue [0.5] across their locality [0.7] why they should have extra nursing 
hours [0.5] as opposed to another colleague [0.3] because general medical 
expenditure of that nature is cash limited [0.9] in respect of agreeing [0.2] 
the amounts [0.2] out to practices [0.8] it's going to be a very interesting 
time because not only have they got all the host of [0.6] H-C-H-S issues the 
hospital community and h-, er health [0.2] er [0.3] Hospital Community Health 
Service budget [0.4] they've also got the G-M-S issues as well [0.8] 
prescribing [0.3] another interesting [0.6] er the [0.3] pharmaceutical 
profession are actually itching to get involved in P-C-Gs [0.4] because they 
feel they've got a role in working alongside the P-C-Gs and saying [0.6] what 
problems do you have how does that affect [0.4] what you prescribe [1.0] 
and can we work through some rationale [0.3] in relation to [0.5] working 
alongside you with the industry [0.6] and there's still very much a big gap i 
think [0.2] between [0.4] general practice the d-, d-, pharmaceutical companies 
are not necessarily seen [0.4] as partners in that process yet [0.6] er they're 
actually seen as [0.3] the competitors out in the field [0.8] perhaps the 
providers of a [0.8] a few [0.2] diaries and a n-, [laugh] and a nice lunch [1.
9] now it's er [1.6] the [0.4] contracting the purchasing and commissioning 
process is changing [0.4] and it's going to continue to change [0.4] through 
the proces of primary care group development [1.4] buildings [0.2] will be part 
of the commissioning process so again [0.2] grants for primary care premises 
will come into the decision making process around a P-C-G [0.9] everything 
around that locality [0.4] that involves [0.3] the health improvement [0.4] of 
people in that area will be discussed [0.4] and agreed through [0.5] a planning 
process with the primary care group [1.3] and then they'll be coming back out 
to you and saying as providers possibly [0.5] can you provide 
this [0.8] 
nf1205: will H-C-H-S er [0.2] separate 
nf1199: no 
nf1205: or a unified budget [0.4] 
nf1199: they're unified budgets [0.6] and prescribing [0.6] one of the things 
they have said is they've kept staff out in the White Paper it says staff out 
for twelve months [0.4] but it then has a little word that says it will be 
reviewed [0.8] so my guess is [0.5] that in twelve months' time [0.8] there 
will not necessarily be the protection of s-, [0.3] er primary care staff [0.4] 
i mean at the moment there's a practice manager [0.6] they're fairly protected 
from this process because [0.4] the G-M-S that's being included in primary care 
groups are things like [0.4] the prescribing [0.3] the new money [0.2] around 
service provision [0.2] but their staff budgets are being kept out of it [0.6] 
but you once they review that [0.3] my guess is that they will bring everything 
that G-M-S expenditure [0.4] provides into the melting pot [0.4] and they could 
start to say well we don't need thirty practice managers across thirty 
practices [0.3] we 
actually only need five or six or seven [0.9] and start to actually rationalize 
like they've done in health authorities [0.3] they've actually said we don't 
need such a robust management structure we can actually manage with less [2.2] 
so [0.5] in the past it's been health authorities and trusts that have suffered 
[0.7] the changes in the N-H-S and primary care to a degree has been allowed to 
rumble on [1.1] all of a sudden working with practice managers they're 
beginning to realize [0.6] that this is no longer the case for them [0.2] they 
could well also be at risk in the future [0.8] because the budget that [0.2] 
they [0.3] have at the moment that protects them and keeps their employment 
safe with their doctors [0.4] will be [0.2] will come under scrutiny as part of 
the general expenditure of a primary care group [3.2] training and development 
is another issue that is funded [0.3] for primary care in G-M-S [0.8] we're 
fighting hard in primary care to have a career structure [0.6] so people like 
yourselves can actually start to do academic studies [0.3] and become 
professionals in their own right [0.3] and that money at the moment is approved 
through a health authority [0.8] but for argument's sake if you had a primary 
care group that decided that [0.5] they didn't necessarily feel their managers 
needed academic profession-, [0.3] professional qualification [0.5] and they 
weren't going to support it [0.3] it may not happen [0.9] and hopefully [0.9] 
the [0.4] the voice from [0.7] you know the consumer [0.4] will actually er [0.
4] ensure that that doesn't happen but [0.5] there's er going to be an awful 
lot of tension i think [0.7] some good a lot of good because there's going to 
be conformity there's going to be focus less fragmentation [0.5] unified 
agreement over services for a local population [0.5] but alongside that is 
going to bring a lot of culture change a lot of changes to people [0.4] in the 
way they work [2.8] any comments [3.4] 
nm1206: is it [0.3] intended that the [0.2] amount of money spent on [0.8] er 
you know [0.5] er indirect patient care sort of the administra-, administrative 
cost [0.5] don't you think that will er be reduced [0.2] with like P-C-Gs [1.2] 
nf1199: 
at the moment they've set something like three pounds per head of population i 
think [0.3] 
nm1206: mm 
nf1199: if i remember rightly which they said around P-C-G will be based around 
[0.2] a hundred-thousand population so that gives three-hundred-thousand pounds 
[0.7] that has to cover [0.2] all of their admin management costs and 
expenditure [0.6] locum fees for time out for general practitioners to get 
involved the works [0.8] er [0.8] and the target [0.2] for reduction is around 
the fundholding staff [0.4] that's being obviously got rid of [0.7] er who 
knows really i think the P-C-Gs are going some have some difficult decisions 
ahead of them [0.4] because the N-H-S is not getting any smaller the service 
demands are not getting any less [0.5] and they're going [0.2] to be forced to 
actually start to look at what they're buying [0.5] where they're buying it 
from and how they're delivering the service [0.4] and certain things have 
already fallen off the end haven't they [0.4] service provisionwise [0.4] and 
managers [0.2] in health authorities have disappeared [0.5] er and they're 
running on 
a very [0.3] slim management structure [0.7] er my guess is they'll probably 
start off quite large [0.4] and then gradually again [0.3] will the financial 
pressure will mean that they will be having to put more money into service 
provision [0.5] and look very hard at the management across the top [0.8] on 
the other hand if they don't have robust management [0.6] good I-T [0.7] good 
general management skills good understanding of N-H-S good public health data 
research information of all sides [0.4] they're not going to be able to make 
decisions [0.4] commissioning decisions that we spoke on earlier that are 
actually going to mean something [1.0] so it's you know it's balancing the two 
i think [1.6] 
nf1341: [0.4] really 
nf1199: yes health action zones are s-, are sort of er [0.7] in line with 
public consumer consultation so it's about looking at [0.6] he-, [0.2] health 
needs [0.2] and taking action against that and involving local people [0.5] i 
haven't been 
involved in any myself and i think [0.4] er [0.4] currently people are so 
worried about getting the P-C-Gs up and running [0.3] appointing chief officers 
[0.5] losing fundholding staff and just keeping themselves going [0.2] that 
nf1341: mm 
nf1199: i think that activity at the moment is fairly dormant [0.2] 
nf1341: mm [0.2] 
nf1199: i mean it may well be active elsewhere in the country but certainly in 
the Midlands it's not [0.6] er [1.3] i mean there are people who've been having 
similar things to health action zones [0.5] running for some time and i presume 
they're still continuing [0.5] how th-, whether they're feeding into P-C-Gs yet 
[0.3] is arguable 'cause o-, their P-C-G may not be [0.6] er [0.9] in in into 
its full con-, constitution [1.8] but yes o-, it's it's going to be another 
sort of feeding in [0.3] process really into the commissioning [7.0] i sound a 
bit [0.5] doom and gloom don't i really [1.1] don't mean to [0.4] 'cause i 
actually think that [0.7] er [0.6] it's quite a big there's quite a difference 
[0.6] before [0.4] i was using [0.7] used to have a health authority [1.0] that 
was responsible for purchasing care [0.5] across five-hundred- [1.6] thousand 
patients [0.3] 
so this is take Warwickshire [1.1] then we had fundholding [2.5] and health 
authorities [0.5] which split that responsibility [0.7] and at the beginning [0.
2] we had very few G-P fundholders [1.6] and we had still the majority of care 
[0.4] purchased by the health authority [0.9] as G-P fundholding gathered 
momentum [0.5] through the nineties [0.6] we actually then started to have [1.
4] percentage of G-P fundholders in Warwickshire [0.3] was around eighty-five 
per cent [0.9] and [1.2] the gen-, the the same amount of services that was 
within h-, health er was [0.4] the balance [0.2] however around that the health 
authority never lost [0.3] things like learning disabilities [0.6] mental 
health [0.5] emergency care [1.5] et cetera they they've always hung on to that 
[0.3] but in relation to the [0.3] fund what inclusion exclusion of fundholding 
[0.3] fundholding grew [0.3] and the responsibilities of the health authority 
reduced [1.0] the difficulty with that is underneath the G-P fundholders you 
had [1.7] all these different practices [0.2] all with different working ideas 
all with different views on how services 
should be delivered [2.3] forming a strategy [4.5] and if we look at back at 
commissioning deciding [0.8] from [0.6] this point of view [0.5] what's best to 
buy [0.5] how do you get all these different people to agree [0.8] to change 
something [0.3] very very difficult very very cumbersome [0.5] so as a health 
authority officer [0.7] we divided into five groups [1.3] which was the start 
of things to come in Warwickshire they started to say [0.5] well let's start to 
Nuneaton as one [1.2] Nuneaton and Bedworth [1.0] south Warwickshire [0.2] et 
cetera so we started already to to focus our [0.7] er view [0.2] around local 
populations [0.6] and involve within those [0.2] the G-Ps [1.6] now what's 
happening with the White Paper [0.3] is that actually takes that a step further 
[0.3] and it makes them [1.5] responsible [1.4] but they're responsible [0.5] 
for all [0.6] the purchasing of that area [0.7] so what it does do [0.3] is it 
actually avoids the fragmentation [0.8] it recreates the focus again [0.3] and 
it ensures the involvement of doctors [0.3] 'cause even when we were working 
here [0.4] and we had a commissioning group [0.7] it's only the s-, [0.2] sort 
of [0.4] willing G-Ps [0.3] that er would actually get involved [0.2] here [0.
4] they have a constitution that gives them the right to be part of the 
decision making process [0.4] around it in in k-, er developing strategy [0.4] 
purchasing and commissioning decisions [0.5] so i actually think [0.6] although 
i [0.5] er [0.5] it's going to be fraught with its problems it does actually 
bring back some cohesion [0.8] and we before long we'll be calling them [0.4] 
well i remember a [0.3] a consultant in public health that worked for the 
health authority saying [0.3] why don't we call them [0.4] discrete homogenous 
areas [1.3] which is the same abbreviation as district health authorities 
[laughter] so we've gone full circle [0.6] so you know that [0.3] that to me is 
an example of where we're moving it's trying to bring people back [3.7] on that 
note [0.8] unless there's something else [1.3] i love this [0.4] and i think i 
may have put it up before but i'm going to put it up again 'cause i actually 
think this sums up the whole process and it's from a report from 
Buckinghamshire [5.8] developing [0.5] the c-, G-P commissioning role [1.1] 
'cause they want to know if they should buy sugar for the tea [0.4] is that a 
clinical issue [0.2] issue or do we take a vote [laughter] [1.9] so [0.6] it's 
probably a little bit er [0.4] light-hearted but it is actually going to be 
quite a bit like that i think [3.4] hence the need [0.3] for good and robust 
information 'cause if i'm making a decision as a manager and not a clinician 
i'm going to need somebody [0.3] who's very confident about what they're about 
[0.3] from the clinical profession [0.3] and public health or whoever they may 
be [0.4] to say yes that decision is right [0.4] because it's [0.3] clinically 
effective [0.6] or whatever [1.3] and that's it [1.2] right it is ten to five 
[0.5] if you haven't got any other questions [0.7] i will let you go