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Andrew Lansley Q&A: Part 1

Andrew Lansley Q&A: Part 1

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When the time came to give his first trade interview, following the passing of the health Bill, Andrew Lansley decided that there was only one publication to do it with.

Of course, there was plenty to discuss when the Health Secretary caught up with GP Business Editor-in-chief, Victoria Vaughan - and we'll be bringing you the best bits from the interview over two parts this week.

In part one of our interview with Andrew Lansley, he tells GP Business why it's so important that GPs are part of the commissioning process, why he's happy to live with the criticism that's come his way, and what he did to celebrate the passing of the Bill.

Victoria Vaughan (VV): First of all, how did you celebrate the passing of the Bill?

Andrew Lansley: I think on that evening, actually I think it was two nights in a row, the team got together for a small celebratory drink when it secured passage in the Lords, and then the following day when we secured the final passage, as it were. I think we have not had a formal celebration; I think we are planning a formal celebration at some point.

(VV): Like a dinner out, that kind of thing?

Andrew Lansley: No, a bit larger –because there are a lot of people involved, when you actually got down to it. I got together with the policy teams who supported the Bill team for a meeting, I think, two or three days after the Bill went through, and there were about 60 people there so it is quite a big deal.

(VV): Were there any kind of things you would have done differently, looking back at the Bill and how it did not go, perhaps, as quickly?

Andrew Lansley: Yes. If you recall we published the White Paper and had a consultation period in the way that government normally does –I think what really became obvious by about February, although we had responded to the consultation, set it all out in a command paper in December of 2010, is that publishing a document and then asking for responses to the document does not really engage many of the people who really need to be engaged. It engages, as it were, some of the formal organisations who are sort of geared up to think about it in policy terms, but it does not engage people who think about it in practical terms.

What became obvious in February was that, firstly, lots of people had not really read any of this and, secondly, that even if they had read it they had not really understood it or engaged with it. And if they had engaged with it, they had practical issues they wanted to be reassured about, which actually we had not necessarily got to; we had not reassured them sufficiently, or in some cases, even made changes which would give them confidence. So the whole listening exercise, which is, as you know, just over a year ago now, in an ideal world would have happened earlier; it would have happened three or four months earlier. We have learnt that lesson so that, for example, where social care is now, when we published the initial consultation we said, ‘Look, we are not going to publish a document and then just put it out there, we are actually going to have engagement works streams that have independent leaders that will look at some of the issues. So when we actually write the White Paper we do it on the basis of some of this engagement’.

The listening exercise got us to a good place; I think it actually identified the issues. If you really look at it, since the conclusion of the future forum listening exercise – with the exception of some specific issues we followed up on, like information governance and use of information to drive patient choice, the education and training development, which of course was never formally part of this Bill – it got us to a very good place in terms of identifying where the key issues were and enabling us to make some amendments that dealt with that.

That is why, I think, when we went through the Lords, although we made further amendments, in truth, a lot of those amendments were practical things in order to give further reassurance. They did not really fundamentally change the principles at all.

(VV): There was a lot of criticism over communication of the Bill –where do you think the fault lies for that?

Andrew Lansley: People always criticise these things. I think there was a big issue about the lack of engagement at a practical level in the service in the first six months. The truth of the matter is that there is a big gap between what is happening in the service, and has been happening for some considerable time, and what commentators and part of the Westminster political system is talking about.

(VV): Are you referring there to the kind of discussion around competition?

Andrew Lansley: It is a lot of those things. If you were to say things like fragmentation, there are organisations, trade unions and the Labour Party and some others, who were talking about the risk of fragmentation. If you actually talk to the clinical commissioning groups about what they are doing, who are going to be responsible for commissioning services, they are saying, ‘Well, hang on a minute, we are, for the first time now tackling some of the issues where these services have been divided between primary and secondary and where things did not join up, where social care was not involved’.

I was with the West Hampshire commissioning group and in the course of that conversation there were two interesting remarks. One, Nigel Sylvester, I think, was saying, ‘Look, we have just got together with the orthopaedic consultants from the hospital and we explained to them what we are looking for and talked to them about what they are doing’. And they said to him, ‘Well, why didn’t you tell us?’ And this had just never happened. Of course, what had happened in the past was that the GPs were not formally part of the commissioning process.

Even if they said things to the Primary Care Trust, the Primary Care Trust was actually driven by the operating framework and the targets that it was having to pursue, and they were talking in any case to the managers in the hospital and not directly to the consultants.

So everybody was kind of structured around the bureaucratic process; manager talking to manager, not clinician to clinician. So that tells you immediately you are going to integrate the service more effectively as a consequence of those conversations.

The other was one of the other CCG members said we are working with a social worker who has said –the social worker has been in the profession for 20 years and had had more contact with general practice in the last nine months than in any of the previous 20 years.

(VV): Do you think, then, that the CCG doctors could have been more outspoken about the progress they are making, because all we have heard is criticism? Yet when you speak, like you say, to CCG doctors, they are actually making changes and doing quite well, but their voice has not been as strong. Do you think they should...

Andrew Lansley: No, their voice, and they like me, might well take the view, which I do, is that part of the thing people criticise communications for and say, ‘Why didn’t you say this and why didn’t you say that?’ And they say, ‘Well, we have been; we have been saying that, it is they have been ignoring us’. And the reason is sometimes because many of the national trade unions and the Labour Party and so on, they do not want to hear that anyway, so why would they? They do not repeat that. I will excuse GP Business from this, but basically the media is interested in the row, so they look for the row. The voice of clinical commissioners was not really part of that; they were not particularly interested in that. So you could go back to February and there would have been, for example, a front page story about one clinical commissioning group that said we are not happy with the Bill...

(VV): So how do you square that with the recent BBC survey where GPs have –I think it is 22% down to 12% confidence that the Bill will make things better for patients. Does that concern you, and are you going to embark on a hearts and minds campaign?

Andrew Lansley: Yes, but the issue is not about trying to tell GPs what to think; the issue is about GPs themselves realising that they now have the power, responsibility and freedom to make things better.

(VV): Yes, but what if they do not want that?

Andrew Lansley: I think they do think that, and I think actually, ask that question at this moment with all this row going on, why would they express confidence because everybody is telling them it is going to be a problem? Their own organisations, the BMA and The Royal College are telling them it is all going to be terrible. It is not, and actually the BMA and The Royal College of General Practitioners have themselves been supporters of clinical commissioning. So if you said to them, ‘Do you think clinical commissioning will improve services in the NHS?’ Their answer is, ‘Yes’. What we have to do is to get beyond the rows to the place where we all work together in the same direction because the principle of clinical commissioning has been subscribed to even by organisations that chose, for broader political reasons, to oppose the Bill.

(VV): What are you priorities now to get everyone beyond the row and start really working with the group?

Andrew Lansley: The first priority has always been the same, which is to focus on the outcomes, because if you focus on the outcomes you will not get things wrong fundamentally; you will get things in the right place. We have got the NHS outcomes framework for the NHS purposes; I think it is terrifically important now to focus on those and say, ‘Look, how are we going to move those positively?’ The second thing is, from my point of view, to make sure that the clinical commissioning groups get the support they need. I have written to them, I have just written to Malcolm, who is the Chair of the NHS Commissioning Board, with, in effect, the summary of our conversations about this period leading up to the first mandate. That is about a number of things but one of them is about ensuring that commissioning groups get not only delegated responsibility this financial year –and they will; we will see precisely what they have but it is probably going to be of the order of £35 billion, maybe even £40 billion delegated responsibility –but that they are supported to go through the authorisation process and to do that effectively so that they are really setup and running, and feel confident about what they are doing from 1st April next year.

That is not just a bureaucratic process, that is about redesigning services. I think the third thing is to make sure that we are on track with delivering greater improvements with efficiency; with the QIPP programme we are on track. We always knew that with the QIPP programme, the early part consisted of a lot of work on central budgets, on work in acute hospitals, of efficiency gains in the acute sector, and the benefit of the pay freeze and the like.

As time goes on more of the QIPP efficiency has to be derived from service redesign and clinically led service redesign. I know from conversations all over the country, that it is what clinical commissioning groups are doing, that is why they need support now. It is not just about a formal transfer of responsibility; it is about the business of having clinical leadership designing services more effectively.

For more from our interview with Andrew Lansley, read the Spring issue of GP Business - out now.

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