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commissioning contracting and purchasing which is actually a little bit out of 
date now because we're don't we're not allowed to use those words with the new 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