Agenda item

Rebecca Sparks, Director Development and Partnerships; Michael Ridgwell, East Kent Primary Care Trust; Steve Phoenix, Chief Executive Officer and James Thallon, GP and Professional Executive Committee member for West Kent Primary Care Trust;

Lynne Selman, Director of Communications and Roger Pinnock, GP and Professional Executive Committee member for Eastern & Coastal Kent Primary Care Trust; Colette Glasson, Director of Communications, Heidi Shute, Community Cardiology Manager and Marion Dinwoodie, Chief Executive Officer for Medway Primary Care Trust

(Item 4 – Rebecca Sparks, Director Development and Partnerships, South East Coastal Strategic Health Authority; Steve Phoenix, Chief Executive, West Kent Primary Care Trust; Lynne Selman, Director of Communications and Dr Roger Pinnock, GP and Professional Executive Committee (PEC) member, Dr Robert Stewart, Medical Director, Eastern & Coastal Kent Primary Care Trust; Colette Glasson, Director of Communications, Heidi Shute, Community Cardiology Manager and Marion Dinwoodie, Chief Executive, Medway Primary Care Trust were in attendance for this item)

(1)       The Committee had among their papers a briefing note on commissioning.  It was recognised that there was not a concise definition of commissioning, since this term actually referred to a range of activities that had changed over time and were continuing to change as a result of major NHS reforms.  The briefing note referred to: the original NHS model; the internal market; commissioning and the new NHS; Payment by Results; patient choice; practice-based commissioning; the mixed economy of providers; the role of Foundation Trusts; expectations as regards PCTs undertaking commissioning and how that sat with practice-based commissioning and patient choice; how commissioning related to the reconfiguration of services; how commissioners could ensure access to services and tackle health inequalities.

(2)       Health colleagues then made a presentation to the Committee, which is attached as Appendix 2 to this set of minutes. 

Dental, Palliative and Respite Care

(3)       Following the presentation, Mr Godfrey Horne indicated that he liked the idea of the best care being available in the best place for the best value because he felt that it added meaning for the public and it was easier to understand.  He then asked a series of questions relating to how commissioning plans would improve services such as dental care, palliative care and respite care, recognising that there needed to be an holistic approach across the core agencies for delivering some of these services.  Mr Phoenix responded that there was an agreement between the Primary Care Trusts and local authorities that neither would take decisions that would impinge on, and place additional financial burdens on, the other side.  From a West Kent perspective, he said that there would be a review undertaken shortly on palliative care.  He acknowledged that dental-care provision was an issue across many parts of Kent and this was something that the Primary Care Trusts needed to tackle collectively. However, that work had not yet started. Marion Dinwoodie said that, in Medway, the Primary Care Trust ran the Wisdom Hospice; she actually had a surplus of hospice beds, because care in the community was working so well.

Patient Choice vis-à-vis Planned Hospital Care

(4)       Mr Phoenix said that there was clearly a possibility that Patient Choice would not deliver everything that was hoped.  He added that there might or might not be tensions between Choice and practice-based commissioning.  He said it was intended there would be a national set of standards, but the care pathways and the services offered would end up looking different in different areas.  He said that devolution often led to diversity. “Postcode lotteries” were seen as bad – but local involvement and local freedoms were regarded as good things; there was a tension here.  The national tariff meant that price would be standardised within the NHS market, so there could not be competition on price between providers. Choice of provider was currently still limited – but the policy was to allow the patient unlimited choice of provider, including within the private sector.  He acknowledged that the different facets of current health policy did not necessarily fit together very well and that they did, in some respects, tend to ‘rub up against each other’.

(5)       Dr Pinnock added that Choice was inevitably affected by patients’ ability to access different providers, but there was a stipulation that transport should not be a barrier to Patient Choice – transport should be provided where the patient was not able to travel independently. He agreed there was a tension between Choice and practice-based commissioning. There would need to be negotiation between the GP and the patient – if the GP explained to the patient what the best service was, the patient would choose that one. Ms Dinwoodie said that the choice presented to patients should be a choice between health services of the highest quality. Medway PCT had actually withdrawn a provider from their Choice menu because of concerns about quality.

Best Practice

(6)       Ms Harrison asked why, given that there were a number of good ideas in the NHS that could be copied, were not all Trusts across Kent good already?  She emphasised the need to treat patients holistically to achieve the best outcomes. She also expressed concerns about NHS Direct tending to err on the side of advising callers to attend their nearest Accident and Emergency Department, thereby placing unnecessary pressure on the service. She also felt there was a need to educate the public about what truly constituted an emergency, to ensure services were used appropriately.

(7)       Ms Harrison also raised concerns relating to: the shifting of services from acute hospitals into the community; the fact that Swale had for a long time been receiving a funding allocation below that stipulated by the weighted capitation formula; and the lack of GPs available, particularly on the Isle of Sheppey.

(8)       Dr Stewart said that there was already a great deal of co-operation and sharing of good practice; and there were several examples across the county where health colleagues were involved in national pilots. As regards ‘under-doctored’ areas, he said that problems in this regard in Shepway and Swale were being addressed.

(9)       Ms Sparks responded that there was much work already underway around cross-fertilisation and sharing of best practice to improve services.  She referred specifically to: the Institute of Innovation (formerly the NHS Modernisation Agency); the ‘Improvement Cabinet’, ‘Improvement Academy’ and ‘Clinical Champions’ established by the former Kent & Medway Strategic Health Authority; and the annual ‘Best of Health’ awards, hosted by the South East Coast Strategic Health Authority.  Regarding appropriate use of emergency services, Dr Pinnock suggested that many years of attempting to educate the public about this had not dissuaded some sections of the population from continuing to use A&E services as a substitute for primary care. He thought that the NHS should recognise this and address it by co-locating primary-care services with A&E departments. Ms Dinwoodie said that new services had to be signposted for the public when they were commissioned, to encourage people to use them – one way this was being done was through the insertion in the Yellow Pages telephone directory of a guide to local health services.

Emergency Care provided in a Primary Care setting, Mental Health, Inter-relationship between health services Provision and Deprivation

(10)     Mr Phoenix said that there were a number of emergency-care models operating across Kent.  For example, at the Darent Valley Hospital in Dartford, a new model of care had started on 2 January, with a nurse-led urgent care unit; this was already taking over 30% of the work away from the Accident & Emergency Centre.  A similar arrangement would be used at the new Pembury Hospital. In Gravesend, there was a Minor Injuries Unit at the Gravesham Hospital. 

(11)     £83 million was being spent annually on mental health – which represented approximately 11% of the budget.  Mr Phoenix said that, overwhelmingly, mental-health patients were being seen in primary care. He would like to see the balance of the service shifted more towards prevention of mental illness.

(12)     Mr Phoenix indicated that he would like to come back to the Committee at some stage to talk about preventive services in general and how they could be provided differently.  He said that general practice was a better approach to healthcare provision than the alternatives found in other health systems.  In the United States and France, secondary care could be accessed directly without going through a primary-care ‘gatekeeper’, and this worked less well than the system in the United Kingdom. Dr Stewart added that the interrelationship between health and deprivation was being taken very seriously.  He said that hospital was not the only option for providing healthcare – intermediate care was very important.  Marion Dinwoodie added that ‘top-slicing’ and ‘ring-fencing’ of monies in PCT budgets presented challenges as regards delivering services.  It was vital to have Service Level Agreements with acute providers that worked. PCTs were still ploughing money into acute care and they needed to make it clear to acute providers exactly what work they were being expected to do for that money.  At the same time, primary care needed to be re-engineered to reduce the number of patients being treated in the acute sector.

Patient Choice

(13)     Mrs Tweed asked what would happen to the William Harvey Hospital if too many patients chose to go to, for instance, the Medway Maritime Hospital instead. Marion Dinwoodie responded that the William Harvey would still have plenty of work, especially given the planned growth in Ashford’s population; she had no doubt that people would continue to choose it. The important thing was to re-engineer systems, map out patient pathways and plan for the future.

Neurology Services in East Kent

(14)     Dr Stewart said there was no plan to take neurology provision away from East Kent; the intention was simply for a few specialist cases to be dealt with at the Medway Maritime Hospital. 

Fit for the Future

(15)     Concern was expressed at the lack of a joined-up message coming from all the NHS bodies that were caught up in the ‘Fit for the Future’ review. Ms Sparks said the key messages had all been set out in the public discussion document relating to Fit for the Future.  The key drivers for Fit for the Future were those set out in the national health-policy framework.  There was a project board for Fit for the Future in Kent and Medway, which comprised representatives from the Primary Care Trusts, Acute Trusts, Patient and Public Involvement Forums and local-authority Social Services.  In addition, there was a steering group in each Primary Care Trust, in which acute Trusts and PPIFs were involved.

Choose & Book/Independent Sector Treatment Centre

(16)     Dr Pinnock said that a major challenge of the current funding system was that of unbundling the tariff – i.e. dividing the tariff up where a spell of acute care was dealt with partly by an acute provider and partly in primary care.  A question was asked about Independent Sector Treatment Centres receiving guaranteed full payment of their contract for five years, regardless of how much work they actually did – and how they were able to pick and choose which patients they would treat. Mr Phoenix said that PCTs were obliged to pay ISTCs in accordance with contracts that had been negotiated by the Department of Health centrally.  Mr Phoenix said that he was enthusiastic to re-negotiate the terms of the contract with the ISTC that had opened in Maidstone. Ms Dinwoodie said that the Will Adams ISTC in Gillingham was receiving a guaranteed income of £4 million a year from Medway PCT, and Eastern and Coastal Kent PCT under the terms of the ISTC’s contract.  The Centre was currently operating at 78% of capacity, and the fixed payment contract was a very strong incentive for her PCT to try and make as much use of the Centre as possible. She said that the Department of Health would be working on the issues of case-mix and pre-assessment of patients by ISTCs, in order to try and prevent the Centres from “cream-skimming” by excluding those patients they were reluctant to accept.

Choose & Book/Single-handed Surgeries/IT

(17)     Mrs Angell asked: about recruitment and retention of primary-care staff; about the high proportion of single-handed GP practices in Medway; how doctors could find the time during consultations to use the Choose & Book system; and whether the Minor Injuries Unit at Gravesham Community Hospital was being removed to the Darent Valley Hospital. Mr Phoenix responded that ‘Agenda for Change’ had addressed recruitment and retention in the NHS; and work was being done on the primary-care workforce.  Marion Dinwoodie confirmed that 37 out of 64 GPs in the Medway Towns were single-handed practitioners. She said practice-based commissioning was energising GPs and encouraging them to work together. Mrs Angell also asked whether limitations in information technology were preventing people accessing a national Choice menu. Mr Phoenix said that there was currently a restricted choice of provider, but there would in due course be full choice of any provider, anywhere in the country – the extent of the choice on offer was a matter of national policy and had nothing to do with IT issues.

Accountability of Foundation Trusts/Competence of Primary Care Trusts to commission

(18)     In response to several questions from Mr Daley, Mr Phoenix said that the establishment of Foundation Trusts within the NHS was a national policy.  Foundation Trusts were within the ‘NHS family’ but were legally distinct entities and not owned by the Secretary of State for Health, as ordinary Trusts were.  Monitor had been set up by the government to hold Foundation Trusts to account financially.  With regard to the claim that PCTs lacked the capability to commission effectively, Mr Phoenix said that was a matter of opinion. The former structure of PCTs had not been considered appropriate – hence the new PCTs had been created.  He did not think that PCTs would be done away with in the next two or three years. They would continue to be commissioning bodies, although they might take on new forms in future. What happened would depend on the success of practice-based commissioning.  It was possible that there would be no change in the NHS for another four or five years – although such a period of stability was not something he had ever seen before in his 27 years in the NHS.

RESOLVED that the Primary Care Trusts be thanked for their presentations on their Commissioning Plans.