Yesterday we published part one of our Andrew Lansley Q&A with GP Business Editor-in-chief, Victoria Vaughan. The interview was his first with the trade press, following the passing of the health Bill.
In part two of our Q&A with the Health Secretary, he addresses the challenges that CCGs will face going forward, offers his views on the quality premium and reveals how he'll know when it's time to leave his job.
Yesterday we published part one of our Andrew Lansley Q&A with GP Business Editor-in-chief, Victoria Vaughan. The interview was his first with the trade press, following the passing of the health Bill.
In part two of our Q&A with the Health Secretary, he addresses the challenges that CCGs will face going forward, offers his views on the quality premium and reveals how he'll know when it's time to leave his job.
Victoria Vaughan (VV): You will have in a strategic health authority area, 30 to 40 CCGs working with the budget, and service redesign on a small scale can extract savings, but do you think that CCGs should be getting together in federations to manage the large sums of money that have not really made these big savings?
Andrew Lansley: I think absolutely it is not my job having, as it were, disarmed the central direction to CCGs to tell them exactly how they do their job. They have all the flexibilities they need. They can work at a local level as an individual CCG, they can come together, and will, I know, in practice come together with their colleagues. For example, when I was in Leicestershire the three CCGs in Leicestershire said, ‘Actually, there is a lot we are doing individually, but we are working together as three, we have a collective operation for contracting with the university hospitals of Leicester because there is a very close relationship between our total population and their catchment population; so we are contracting with them as one organisation’. That kind of thing is going to happen.
In particular, they’re going to use clinical networks. I do not see any prospect that CCGs are going to do other than collectively use the clinical network, the cancer networks and the stroke networks and the developing neurology networks and so on, and maternity networks – so it will be a basis upon which they design their services.
(VV): How can you maintain a universal standard of care with all this kind of different local innovation going on? Is that realistic?
Andrew Lansley: Innovation – in a sense you are asking the $64,000 question because the NHS, like any organisation, there is an expectation on the part of the public that the National in the National Health Service equals a uniform standard of care; the job of the NHS Commissioning Board, with the commissioning groups, is to ensure that those quality standards are met. The quality standards published through NICE are important to that; the commissioning guidance produced through NICE and the Commissioning Board is important for that.
If it is done on an evidence base I think it will not be something that the commissioners themselves find inherently objectionable in any way. They want to be able to deliver those standards. The point about their flexibility, their freedom, is it creates space for innovation for improvement, and we have got to give them that space because if we do not allow them to innovate, it will not happen. I am afraid, and I can think back to a few years ago –I was talking to Stephen Thornton probably five years ago, who had been at the Health Foundation for a while, and he said, ‘We have asked people to do a project looking at innovation in Primary Care Trusts’. The trouble is that was not enough, and that is the big difference.
We are looking for clinical service redesign, we are looking for evidence-based improvement; it is not going to come from the endless production of documents from the Department of Health. We have been down that path in the past. The risk of political interference is that you end up simply trying to focus the whole system on a small number of process measures, rather than something which is actually using innovation. So, by freeing people up to focus on the outcomes, we give them the space to innovate in processes and service configuration, but also we give the clinical commissioning groups, with clinical leadership, the opportunity themselves to innovate. Now, from the patient’s point of view, that will mean that services are not uniform across the country, but they should always meet the quality standards that are evidence based and produced by NICE.
(VV): What about the quality premium? When are we going to get details on that, and how do you think it should be administered? Should it be a local thing?
Andrew Lansley: We have not published the proposed regulations on that, and we will do so, and will consult with the commissioning groups and the Commissioning Board about how they think this is best structured. What the legislation is very clear on is that it forms part of, as it were, the overall resources for the commissioning groups administration, but it is a part which is a specific incentive for the delivery of commissioning outcomes –so it is outcomes focused. In that sense, it is not an incentive to manage or to deliver a surplus on your budget or anything like that, it is about outcomes in the same way as the quality and outcomes framework is about outcomes.
At a collective level these resources should then be available, the legislation should be available to the clinical commissioning groups to spend as they see fit. I do think, although clearly during the course of the legislation, a lot of time was spent trying to deal with –let me explain it like this. Legislation sometimes feels a bit like when you are trying to agree a contract in law. The people you are working with are constantly thinking of everything that could go wrong, and it is like in a PFI contract, you have to think of everything that could go wrong for the next 25 years, and legislation is a bit like that too; everything that could go wrong for the next 25 years, and they want to write into the legislation what happens under every set of circumstances. So, an awful lot of effort went in to trying to remove every aspect of any freedom, anywhere in the service, but I think we have protected in the quality premium, the ability of the clinical commissioning groups to decide how they deploy those additional resources. They have to earn them, but having earned them they should have the freedom to deploy them in the way they think best to improve quality and services.
(VV): Will the GP contract need to change, do you think?
Andrew Lansley:Well, the GP contract is the subject of annual negotiation. From our point of view, the principle change in the GP contract negotiated for 2012/13 was the contractual requirement for practices to be part of a clinical commissioning group. I think one of the things that we were clear was the right decision right at the outset, was that the clinical commissioning groups would be a statutory body, with statutory public accountability, and of course by extension, although clinical commissioning groups comprise GP practices collectively, they are not legally the same. So the GP contract, in that sense, is separate from the contract with the clinical commissioning group that the NHS Commissioning Board has.
To that extent, the GP contract needs to change in the way that it has always needed to change, which is to adapt in order, for example, to give us efficiency gains, in order to deliver on improvements in the quality and outcomes framework, so it is better focused on quality and outcomes, that it responds better to the evidence base and so on. Those are the issues we are going to keep coming back to. And of course, what I am looking for also is for the pilot schemes in terms of GP choice, to inform positive changes in the GP contract to support patient choice in future.
(VV): There was a Department of Health, there is going to be a lot more organisations with Public Health, England; Health Watch, England.
Andrew Lansley: Actually, technically not particularly.
(VV): No?
Andrew Lansley: Well, there has always been, and you can do this in various ways, but we are going to remove 150-something Primary Care Trusts in strategic health authorities –there were 900 or something practice-based commissioning groups –so actually in that sense we have become very focused on basically two sets of things. One is the national organisations, NHS Commissioning Board –for NHS purposes – and monitoring the care quality commission. Obviously, there is Public Health, England, in the same way, but which in itself includes, for example, the Health Protection Agency and the Biological Standards Board and so on. So, in a sense, it is not more bodies, it is just to bring it together. In that sense we are much more focused. There are the national responsibilities and there are local clinical leaders, and, in-between, they can configure it however they wish to.
(VV): So you definitely do not think there is going to be an increase in bureaucracy because complexity is something that some organisations are talking about at the moment?
Andrew Lansley: You see, I do find this a bit strange because sometimes the same people who say how complex it is going to be in the future, if I ask them to explain how the NHS used to work in the past they had no idea. Sometimes the same organisations and the same people who complained about the bureaucracy of the NHS in the past are not quite realising that this is actually, strictly speaking, pretty straightforward. The NHS Commissioning Board is responsible for commissioning. The commissioning groups locally lead commissioning locally. The NHS organisations that are provider organisations are still the provider organisations. What is so complicated about that?
(VV): You know the 50 PCT clusters that will be there, how do you ensure that the CCGs do have the space to breathe, and they are not caught up because they do not necessarily know about managing within the context of the NHS, that they are not again tied up with red tape and they do not get disenfranchised in any way?
Andrew Lansley:Well, firstly because we are pressing down on running costs across the system as a whole. So, for example, the NHS Commissioning Board may have an operating budget of £300 million or something, but when you look at the functions that it has taken on board it has gone down from £800 million to £300 million or something, in terms of running costs –so there is a big reduction in its running costs.
Across the whole system we are reducing running costs, compared to 2010/11, by a third in real terms. If you go back to 2009/10 it is bigger than that; it is more like a 45% reduction. So in that sense, if you have less administration and less costly administration, you have less bureaucracy. The second thing is, of course, this is part of what the legislation is about. The people who said, ‘Oh, you could have done it without legislation’, they are talking bunk because actually if you had not had legislation you could have pretended that the practice-based commissioning groups could somehow been magically turned into the new commissioning organisations, but they would not be. The Primary Care Trusts would still be controlling them, and the Primary Care Trusts would still be controlled by the strategic health authorities, and the SHAs would still be controlled by the department –that is how it always used to be, and it is how it would have continued to be.
The clinical commissioning groups are statutory bodies; they will receive their own resources. We are intending that the authorisation process is a route to the establishment of clinical commissioning groups, but our intention, and indeed the Commission Board’s intention, is that we should get all the CCGs to this place, and that while there may be transitional conditions they will not be enduring conditions. To that extent they arrive at a place where they have the statutory responsibility and their own budget, and that is different, and their duties are laid out in legislation.
So, like other parts, like the relationship I, as the Secretary of State, will have with the NHS Commissioning Board it should essentially be that you deliver on improvements in outcomes within your budge, and as long as you do those two things and you do it in a way that meets your proper public accountability –you involve the public, you report to the public, you are transparent about what you are doing in the way the Nolan Principles require, etc –as long as you do those things we will not be interfering with you.
(VV): Is it realistic to expect that CCGs can have whoever they want to provide their commissioning support organisation, when it is likely that former PCT commission support organisations are going to be able to do it more cheaply?
Andrew Lansley: I think, clearly, the commissioning support organisations that are being hosted through the Commissioning Board will be depended upon, to a significant extent, by CCGs to start off with. We are very clear with the Commissioning Board that this should not extend beyond 2016; this is a transitional process. Now, the commissioning support organisations they host in the transitional process may have substantial, enduring responsibilities and the commissioning groups may well contract with them those for a longer term, but they do not have to contract with them. There will be a number of commissioning support organisations and they will be in competition with one another, because one of the things people say is, ‘Where is your competition?’ Well, the competition often does not apply in services directly to patients, but actually, if you are looking for support organisations as a commissioning group you probably do want competition because it is actually going to drive value to you from the commissioning support organisations who are looking for your contracts.
(VV): What is your feeling on co-payments, in terms of a patient topping up for their treatment, to be able to get it quicker?
Andrew Lansley: Well, the legislation does not permit it and we are not proposing any changes to the current rules. Mike Richards, of course, did a piece of work for my predecessor, Alan Johnson –actually, I was involved in it. I met Mike at the time, and I had conversations with Alan Johnson at the time because the issue arose in relation to, I think, complex cancer treatments. The rules that were published at the time, following my research report, are still the rules that apply and they will continue to be the ones that apply.
The legislation, of course, does not permit an extension of charging in the NHS, so a commissioning group legally could not say, ‘Well, this service used to be free and now it has to be paid for’. They cannot do that.
(VV): Two questions –in your vision of the future of the NHS what is the optimum role that private sector should be playing, because there has been a lot of concern that the private sector are going to put NHS Trusts out of business, that kind of thing? What is the realistic kind of hope that the private sector will have?
Andrew Lansley:I think Patricia Hewitt had a target for private sector activity and I do not. The legislation does not –actually it precludes having a target; it says it cannot advantage the private sector relative to the NHS. So, from that point of view I have no optimum view about that. Indeed, actually what I think has been rather curious, is some of the people or organisations –like some of the trade unions in particular who claim to be most in favour of the NHS as a publically managed institution –appear to have the least faith in NHS organisations to be the service of choice of patients.
Now, my view is if you give Foundation Trusts, and obviously the NHS Trusts who come through and acquire Foundation Trust status, if you give them the ability to provide services on a level playing field with others, I cannot see any reason why you would expect there to be large numbers of additional private sector services being offered. Not least, actually, in the acute sector because the capacity is there; if it is used well the capacity is there so it is very unlikely you have large additional investments.
I think in community services you might well have private investment, but actually more often maybe social enterprises, and we are starting to see that kind of social enterprise really building in the community sector. We talked about commissioning support organisations –I think the private sector clearly has a role to play in that; it has done for Primary Care Trusts in the past, probably in a more competitive framework in the future than they did in the past. PCTs had, I think in the year before the elections, something like £250 million worth of contracts with Primary Care Trusts, most of which, frankly, were in order to enable them to tick all the boxes on world class commissioning. Well, I do not want to be in that place; if they are providing services it is because they are providing exceptional value.
You can look at things at a company like Experian in Nottingham, for example, where frankly, if you want to do population-based data analysis for public health purposes, why would the NHS want to invent something new when you have got a data management company that for a range of private sector reasons is able to manipulate far more data, far more effectively. You would not want to recreate all of that, would you? So, there is a role for the private sector but they are going to have to prove that they can really add extra value.
(VV): What do you say to a GP who says, ‘I just want to be a clinician; I am not interested in this’?
Andrew Lansley: Yes, that is absolutely fine, and they can do. There will be, let us say, 220 clinical commissioning groups –I am looking for clinical leadership in those groups. But by no stretch would I expect that every GP is going to be required to do anything in those CCGs, and most CCGs in my experience, probably one in ten of the GPs in any given area, are actively engaged in this process.
Now, what I think sometimes that same GP might ignore, is they might say, ‘Well, I want to be involved, I am very interested in mental health issues, and I want to be involved in the team that is thinking about mental health’. The other week I was sitting around a table with GPs and consultants and nurses who were planning dermatology services –well, you might be a GP who has a special interest in dermatology so you go to that and you say, ‘Right, we are designing what the commissioning pathway, what the referral pathway for dermatology looks like’. And then they will say, ‘But I’m not involved in the clinical commissioning group’. Well, actually they are because that is the critical task. The essence of the task is bringing the clinical knowledge of patients and the population you look after to the table to make resource decisions about how services are structured and funded, and they will do that. They will not think they are doing clinical commissioning because they will think that is something that happens in a theoretical abstract committee room somewhere else, but actually they will be doing it.
(VV): You have stayed Health Secretary or Shadow Health Secretary for a long time; other people tend to move around a bit. Why? Why do you like it?
Andrew Lansley: Actually, not as much as you might imagine, and personally, I think it is to David Cameron’s credit that in opposition and then in government he has said, ‘Look, I want people who get to know what they are doing, who have a very clear idea about how we can change things for the better, and who are held to account for the delivery on that’. Now, from my point of view it is not just about the legislation; it was never just about the legislation. It is all about arriving at a place where outcomes in the NHS are improving and the service is sustainable for the future because it is tough; the financial challenges are significant and the NHS needed to change in order to match up to those challenges.
I think, from my point of view, in any walk of life, in any senior position in any organisation, there is sort of a limit; you should not do it forever because, like anybody else at some point, I will start finding the same solutions to problems that are presented, and I ought to be finding new ones. Hopefully, I am not at that place yet by any means – I am at a place where, I think now, I have the opportunity to demonstrate that the changes, the modernisation in NHS is going to make a big difference. It is not just going to be clinical commissioning groups; it is going to be about public health, big time. It is going to be about things like the reform of social care. It is going to be about bringing local authorities in the NHS much closer together so we integrate care and health services more effectively. Things like the Three Million Lives Telehealth systems, it will be things like the 111 Urgent Care system.
I can imagine, if you were to look a few years down the line and say, ‘Well, you have done those things’, it is actually now time to say, ‘Well, you have done that and what we do not need is a lot of political interference in the NHS anymore’. So, from my point of view maybe I should be concentrating on the public health side and much less on trying to think any new thoughts about the NHS. I am open about that; I am very clear. Part of my objective is to get beyond the reform processes that we had to bring in place, get comprehensive reform for the NHS so that it does not have to go through a set of further changes for, hopefully, a long time in the future. So we get to what is a stable and a sustainable structure for the NHS in the future.
