Oral evidence: Primary care, HC 408Tuesday 8 December 2015

Oral evidence, 8 December 2015.

Witnesses

Rosamond Roughton, National Director of Commissioning Development, NHS England, Professor Sir Bruce Keogh, National Medical Director, NHS England, Julie Wood, Chief Executive, NHS Clinical Commissioners, and Dr Steve Kell OBE, Co-chair, NHS Clinical Commissioners and Chair, NHS Bassetlaw CCG, gave evidence.

Chair

Thank you very much for coming this afternoon. Could you start by introducing yourselves to those following outside this room, starting with Rosamond?

Rosamond Roughton

Hello. I am Rosamond Roughton. I am the director of NHS Commissioning at NHS England. I have oversight of the services that we directly commission that are not specialised. That includes primary care services.

Professor Sir Bruce Keogh

I am Bruce Keogh. I am the national medical director.

Julie Wood

Hello. My name is Julie Wood. I am chief executive of NHS Clinical Commissioners, which is the membership organisation of clinical commissioning groups across England.

Dr Kell

My name is Steve Kell. I am a GP, chair of Bassetlaw CCG in Nottinghamshire and co‑chair of NHS Clinical Commissioners.

Chair

Thank you.

Mr Bradshaw

Thank you. How is co‑commissioning going? Not very well by the sounds of it.

Dr Kell

In terms of how it is going, co‑commissioning is still in the early days but there is a lot of interest in it. The whole background behind co‑commissioning was that the CCGs were keen to support primary care. We saw primary care struggling around us, and in general practice particularly we saw the opportunity to link up some of those pathways. It did not make sense that we were commissioning nursing homes—which is a good example, I think—without being able to commission general practice, which provides so much support for those patients. We have already had a significant number of CCGs in co‑commissioning with a significant amount of difference being made. We have a huge level of interest for 2016‑17—a significant increase. Over 50% of CCGs will have delegated commissioning if they are approved. It is important that we do not see this just as CCGs doing it on their own—that we are still working closely with NHS England, with our lay members and with our member practices. It has strengthened the patient engagement that we have built up in CCGs.

Mr Bradshaw

What about the CCG and NHS England perspective?

Julie Wood

It is going well. As Steve said, it is fairly early days but we are beginning to see CCGs making a real difference. We see across the country different examples where CCGs are beginning to join back-up pathways of care so that they are looking at primary care and community services and can do things differently. They can bring forward some flexibilities in how they bring resources from their wider commissioning budget to increase the level of investment in primary care, and that is a good thing too. The appetite is increasing. This year, in the first year, we saw 30% in delegated commissioning. As Steve says, we are looking at over 50% for 2016‑17, and we see examples such as where the member practice in a CCG—a neighbour to one another—in year 1 thought, “This is not for us,” and in year 2 they are saying, “This is absolutely for us. This is the way in which we can transform out‑of‑hospital care.” So I think it is going well.

Rosamond Roughton

From our perspective, we have seen three big benefits. First, it is about improved real insight about what is going on in general practice, because CCGs are just closer to the reality of general practice life than we can be, given the scale at which we operate. Secondly, to emphasise the point that Julie has made, the future for general practice is part of a much more integrated, wider set of services. Those are services that CCGs are responsible for commissioning. We can see with some of the CCGs with delegated responsibilities that they are better able to try and shape a strategy for a local place rather than having this boundary. Thirdly, it is about public involvement. We heard earlier about the strengths and the limitations of big national survey work, and some of that patient engagement and public involvement needs to happen at a local level. We can continue to build on local engagement processes that perhaps already exist, not just bespoke for general practice. Those are three things from our point of view that we think are helping to create a better system.

Mr Bradshaw

There were a couple of issues. There was the line of accountability issue, which could be seen to be blurred now as far as the patient and the public are concerned as to who is responsible for performance-managing their GPs, and the issue that was raised at the time of the Lansley legislation, which is why you were given responsibility originally, which is the conflict of interest potential. How are both of those areas being resolved in practice and are they being resolved to the satisfaction of the patient and the public?

Rosamond Roughton

I will take the conflicts of interest first. We recognise that there were heightened issues with the delegation. As a result, we published some statutory guidance on it for the first time in December. We have invested in training the lay members who sit on CCGs. We have not just left it to a piece of paper but have followed that up with training to support the lay members on CCGs in doing this. We are commissioning an independent audit so that we get some insight into how it is working in practice and be confident that we are still discharging our bit of the responsibilities adequately. On the issue of blurred responsibilities, we have set out the things for which we do remain accountable, such as management of the list that determines whether a doctor is safe to practise in general practice—the national performers list. We have a clear distinction operationally about what we remain accountable for and what is the responsibility of CCGs. It probably is quite a technical list, but we know between us from a public point of view that we would see the CCG as the local leader on the ground and we would work with the CCGs if there were issues that were being raised by the public that they felt were not within the purview of their immediate accountabilities.

Julie Wood

Absolutely. I would add, in terms of conflicts of interests, that getting that clear was very important to our members. NHS Clinical Commissioners has worked with the BMA, the GPC and the RCGP to develop some shared principles on conflicts of interest when CCGs are commissioning from member practices. The three organisations that have a professional interest are together coming up with a single document about those important principles for how CCGs need to operate in that space.

Dr Kell

Can I come to the accountability question because it is really important? For a patient, when I see them as a GP I am accountable, and the whole reason I got involved in clinical commissioning was because I felt accountable for decisions that were made once they had walked out of my surgery door. I wanted to know that the services that got built around them were adequate, safe and sustainable and so on. That is why I got involved. The accountability technically has not changed. CCGs are there to support practices. We can do that in a much better way through co‑commissioning. Actual individual performance issues are still the responsibility of NHS England. It is helpful sometimes to have that clear separation.

Mr Bradshaw

Are you pushing amalgamation or a more federated service provision? Who would take the lead on that?

Rosamond Roughton

Just last week the Royal College of GPs and Nuffield said about two thirds of practices are now reporting that they are in some kind of network. We would very much respect that these are independent providers, but working at scale is probably one of the solutions to both some of the demographic challenges and the financial position for the NHS at the moment.

Mr Bradshaw

You are satisfied, Julie, are you, that—given the history of commissioning, not just now but under PCTs as well, which was not a particularly happy one in terms of quality—you have the capacity and the money to do it?

Julie Wood

One of the risks for CCGs in taking forward co‑commissioning was about the capacity to do it. They recognised that it was important that they did it—to join back-up care pathways—but they also recognised that they were doing it with less running costs than they had had in their predecessor PCTs and indeed less running costs than NHS England had got to support primary care co‑commissioning. They have gone ahead in spite of those risks. They are finding ways of bolstering up the management capacity to deliver things. For example, across Gloucestershire CCG they have created a team of people who are working with their localities, so very close to their member practices, who understand the issues across the different parts of Gloucestershire, to deliver that commissioning responsibility in a different way. But it has put them under stress and strain because the CCGs have not seen their running costs increase; in fact, they have seen them decrease from when they started in their first year to their second year. It was one of the factors that the CCGs had to take into account, but they felt that the improvements that they could make to the pathway for patients and the outcomes for patients outweighed the risks that were in place that they needed to cope with in taking on responsibilities.

Chair

Can I ask a supplementary on the conflict of interest? We have seen some concerns about, for example, pharmacy advisers having outside interests. What is the guidance to those who are involved as doctors commissioning—that they keep a transparent register of financial interests?

Dr Kell

This is important too. All clinical commissioning groups have a register of interests within the governing body, for example, so the GPs, lay members and everybody else who make the decisions, but then each member practice—there is quite clear guidance about this—have publicly available conflicts of interest as well.

Chair

You are happy across the board that the public can have confidence that it is transparent what those conflicts would be.

Dr Kell

Yes. The important bit is that we are assured that we have the correct processes and systems within CCGs but that we also are allowed to harness that level of innovation that is out there, to define new pathways. We are in danger of creating a system sometimes that inhibits that and how we are going to move forward. I think the processing system is key.

Chair

We have the level of not discouraging people with expertise but making it transparent what their interests are. Are you happy we have the balance right, Dr Kell?

Dr Kell

Yes. We have learned as we have gone along to become more and more used to declaring interests and leaving rooms. Sometimes it makes it more difficult to harness that innovation, but we have developed robust processing systems, overseen and authorised by NHS England.

Professor Sir Bruce Keogh

May I add two other points to that? As part of our assurance process, CCGs have to report quarterly as to where they are in terms of conflicts of interest—any that have arisen in the last quarter. They also have to update their public register and have to indicate in that quarterly self‑certification what action they have taken with respect to any conflicts that have arisen. The second point is that, in April, we will be publishing some updated statutory guidance, which will have come out of this debate, on how we handle conflicts of interest across the commissioning system as a whole. We will be going out to consultation on that shortly.

Chair

Thank you. With the rest of the Committee’s permission, I am going to come to Philippa next because she has to leave for an all‑party group.

Dr Whitford

Thank you, Chair. We have talked about the pressure on general practice and starting to change the shape of the team. What responsibility do CCGs take to encourage the development of a true multidisciplinary team, not as some kind of second‑class primary care but able to bring a much broader range of services to the patients?

Dr Kell

One of the beauties of my job as a GP is that I am used to working as part of a team and it is really important that we see the role of the GP in primary care generally as part of a wider system. A lot of the commissioning work that I have been doing for the last three years or so has been around support for patients in the community, which in itself is support for general practice often. If I think about my most vulnerable patients who have severe dementia, in nursing homes, for example, commissioning specialist dementia nurses to support general practice—but most importantly to get better patient outcomes—has made a huge difference. We heard Don talk about social prescribing. Not everything that we see now in the GP surgery is dealt with by the NHS or by a prescription; it is dealt with by referring people to mental health counselling, to Citizens Advice or to befriending services. These things that may seem soft—they are not about referrals or numbers—are the things that are making a real difference. Co‑commissioning has enhanced and accelerated that.

Dr Whitford

Sometimes we talk about physicians’ assistants and other people as someone who can step in, whereas people like physios, counsellors and social workers are bringing in a totally different set of skills. Are there barriers to that? Is there anything that is stopping that development within commissioning?

Dr Kell

Some of it is about incentive. I have personal experience of the benefits of employing a pharmacist, which makes a huge difference both to the quality of prescribing and to workload within a practice. That has made a real difference. Physio is a good example where in a lot of areas you can now see an orthopaedic surgeon quicker than you can see a physio. That is not good for the patients or for hospital care. But the incentives are not necessarily there in the system for a practice to go out and employ a physio, because that is a completely separate budget and way of financial funding. I think there is work yet to be done around breaking down budgets, because I think the future is about multidisciplinary working.

Julie Wood

That is one of the real opportunities of co‑commissioning because you are bringing together around a place, if you have delegated commissioning, the budget for primary care with the budget for community services, and then you can look very differently at how you bring in people like clinical pharmacists, physiotherapists, OTs and all those people. GPs naturally, as leaders of local health systems, as CCGs, think in that way. It is fairly natural for them to think they can do this differently and get a broader primary healthcare team looking after the patients, who will make the very best of the skillset that you have around the place to improve care and healthcare outcomes.

Dr Whitford

Are there any other comments on that?

Rosamond Roughton

When we put the investment into the Prime Minister’s Challenge Fund about improving access, we were struck by the fact that every single one of those schemes redesigned their workforce. It has generated for the system some really powerful case studies about the contribution that the wider workforce can make. Last month we backed that with some extra investment to support a faster roll‑out of bringing clinical pharmacists into general practice. We are funding about 400 pharmacists—match funding for practices—in about 700 practices across England. That will allow us to test the kind of training and best way of making the most of that expertise. There are other things like that, but, given the nature of the population health challenge of the future, I would see the need for us to look at the primary care team and the wider extended services in the round and not just think about the medical workforce.

Chair

Julie, you had a wider point on the pharmacy issue.

Julie Cooper

Yes. Acknowledging the role of other health professionals, including pharmacists, in the primary care team I have first‑hand experience of seeing a minor ailments scheme running in the community and have heard first hand from GPs how much they valued that and how much it eased their workload. Why is this not rolled out in commissioning nationally?

Rosamond Roughton

We looked to see whether a national minor ailments service would be something we would do, but we were not able to reach an agreement with the pharmacy bodies on a price that we felt delivered good value for money for the taxpayer. Instead, we have produced some material to help CCGs negotiate our local teams a better price locally. We can see now that about a third of the country is covered by local minor ailments services.

Julie Cooper

Presumably the negotiations at local levels have been successful because pharmacies have agreed to run these schemes. I suppose it is building on that good practice and seeking to make sure that is spread nationally.

Dr Kell

This comes back to national problems but local solutions. There are very few examples where a single national solution has solved the problem in every locality. It depends very much on how many patients pay for prescriptions, the state of pharmacy locally and GP access. There are different ways of achieving the same outcome. What is really important is that we have that local knowledge. I work closely with local pharmacists, as I think CCGs do. How do we harness those relationships and see what the local problem is before we find a solution together, if that makes sense?

Julie Cooper

It does. There is a case, is there, for grouping similar areas? I take the point that, in areas where there are a lot of patients who do not pay for prescriptions, many would seek to access a GP to get a free supply of medication rather than going to the pharmacist. Maybe you could intercept that and provide cheap and effective medicines via the pharmacy. I suppose there could be some sort of encouragement for similar demographic areas to work together. If it worked in one of those, it is probably going to work in another one. Thank you for that.

Helen Whately

Over the last few weeks we have heard from other witnesses who said that primary care needs to have a greater share of NHS funding, as it used to apparently, but it has had a declining share. I would be interested to know if any of you have a particular perspective on that; and if you think the answer is, “Yes, it should have a greater share,” what that should be spent on, albeit we are tight on time, so I am not asking for an extensive answer.

Rosamond Roughton

From NHS England’s point of view, we have set out in our evidence the recognition that we think the facts are clear. In general practice, in particular, in more recent years the level of investment has not increased at the same level of hospital services at a point when we are saying strategically that we want to see greater investment in out‑of‑hospital services and potential for more to be done. If you look over the last two years, the data shows a much bigger increase. We had a 3.6% increase in 2013‑14 and a 2.7% increase in 2014‑15. This time last year, when our board was making allocations, it made a very deliberate and conscious decision that there was a 4.1% increase in allocations for primary care compared with the 3.4% uplift in CCG allocation. There is a bit of a shift towards a greater level of investment in primary care. That is why the delegation and co‑commissioning is so important. We need to try and make sure we think not just about general practice on its own but primary and wider community services together in thinking about what the balance of investment is between the different parts of the health system. We need to make that decision in light of what the local strategy is. That is why we have both made some moves towards that, but the delegation of commissioning is an important step.

Dr Kell

Co‑commissioning is an opportunity here but not the answer. We have recently held a members’ meeting for CCGs. One of their main concerns was the sustainability of general practice. It is very difficult, as a commissioner, to actively increase out‑of‑hospital care and to shift funding or support from hospitals towards community services, mental health and general practice at the moment for a number of reasons, including financial incentives, tariff and the fact that provider deficit is so high. It is very difficult to do that. It challenges within the Five Year Forward View how we meaningfully get that shift that is talked about into better support in nursing homes, which is a good example. How do we better get that shift of support, with more and more focus on hospitals, referral activity, provider deficit, four‑hour wait and so on? It is as much about focus as a real shift in funding. If we are going to go to member practices and ask them to take on more work, or work in different ways, they need that space and the funding to take on extra staff to do it.

Julie Wood

The money is absolutely important, as is the workforce. If we get the shift of the funding and if part of the solution is about more people, in terms of a broader range of people but more provider services in the community, we need to make sure they are there to pick up the additional services that are needed. For a number of our CCGs, our members will say it is not about giving them more money at this point, because even if we did they could not find the people to do the work. We need to have the workforce strategies aligned to the primary care strategies and aligned to the funding flows together to transform and improve health outcomes.

Dr Kell

I have one quick point that I forgot to make about the cycles of funding that are really important. General practice is often based on annual changes in funding or priorities. As commissioners, it is important that we work together with NHS England to create longer cycles of certainty around what our priorities are, to fund those shifts and to enable people to take staff at risk, but with a longer certainty in how our future is going to be investing in care homes, and let’s get the staff in to do it.

Helen Whately

How well does the Carr‑Hill formula allocate funding to practices, particularly those with atypical patient populations?

Rosamond Roughton

I will take that one. We think the Carr‑Hill formula, which determines the distribution of a significant proportion of money to general practice, is a little outdated now. We have begun some work with the British Medical Association to review whether it is still fit for purpose. That review is under way at the moment. In terms of atypical practices, we are having discussions about whether there are some particular population groups that no formula will ever be able to account for. For example, we may find it hard to have a national formula that sufficiently reflects the needs of a practice with a predominantly student population. We are also looking at whether there are some particular groups where, if a practice largely has that group, the national formula will not adequately reflect the needs and workload that that practice experiences.

Helen Whately

So there is a review of the formula ongoing. One answer we have heard that has been given to practices that are worried about this is that co‑commissioning will mean there are flexibilities and CCGs will be able to mitigate the impact of changes in funding, particularly for the withdrawal of PMS funding. That is the answer they have been given, but in practice they are very worried that that mitigation will not work. Do you have a view on that problem?

Rosamond Roughton

Yes. We are carrying out PMS reviews—reviews of practices that have personal medical services contracts—for two reasons. The first is that these practices get more money than a GMS practice and we want to be sure, first, that we are getting value for money for that and, secondly, that this does not mean we have one particular bit of the population benefiting and not others from whatever is on offer. Those reviews are under way, and we completely recognise that in some cases some practices are saying this has the potential to destabilise their funding. We have set down three principles. The first is that that money must not be lost to general practice services; that is not money that is going to go into a different bit of the NHS. I think that has been really important. Secondly, it stays locally. It is not money that goes outside the local health system; we are not moving large amounts of money around the country. Thirdly, this is managed over a period of time so that, if a practice is losing money, it can prepare and think about how it adapts its business model to continue to deliver services for similar funding levels to those practices surrounding it that will have been delivering services at that funding level in the past. I have not seen it so much with the PMS reviews but more with the removal of a minimum practice income guarantee, which was some transitional funding that was introduced over a decade ago now, but I have seen that some CCGs have taken steps to commission additional services from some practices that have been losing money through the withdrawal of the minimum practice income guarantee, which has helped stabilise those practices.

Helen Whately

As a counterbalance to providing funding, do the commissioners, whichever model they are following across the spectrum you are talking about, have the levers needed to make sure that practices are providing value for money and consistent levels of service? I say this partly reflecting on some of the things I have seen in my constituency.

Dr Kell

One of the challenges with commissioning general practice is that, apart from some outputs such as the Quality Outcomes Framework and patient satisfaction, there is relatively little known about services within general practice itself, in terms of number of consultations offered and capacity, for example. CCGs have been increasingly collecting through their member practices that level of information so that, for example, when we are planning future services, we know what the level of capacity is within practices for the week in advance and can spot surges in activity earlier. That leads to a true commissioning of general practice in a way that does not just focus on hospitals, where we look at A&E activity all the time. The intelligent commissioning of general practice will evolve, but it is about collecting the data and understanding it first before we rush in and do stuff.

Julie Wood

Through their co‑commissioning arrangements—and pre‑dating them, so some do go back to PCT days—a number of CCGs have dashboards or a range of metrics that they have developed with their member practices that help look at activity and some measures that they can then work over with their practices to help them drive forward improvement but on a comparative basis. That is being rolled out across different parts of the country in different ways, but the important thing is that it is being developed bottom‑up by the member practices within the CCG so it is seen as having the indicators that do demonstrate high-quality care and high-quality outcomes.

Dr Kell

We have those metrics running in Bassetlaw. In Liverpool, they have commissioned a certain amount of activity from general practices per 1,000 patients per week. There are different models, but it is interesting that this work is happening.

Helen Whately

That is interesting. Thank you.

Chair

Can I ask a supplementary question? When we visited Page Hall medical centre on our visit to Halifax and Sheffield, it was the degree or the scale of the shift in funding that they were going to see that they felt would have very serious implications for them. Are you seeing practices around the country expressing real concern about what they see as a cliff edge?

Julie Wood

It is interesting that we are likely to see it first as part of the PMS reviews.

Rosamond Roughton

Yes. We are about halfway through the PMS reviews. Bear in mind that none of them has been included. We are working with our local teams to understand if we are going to get that kind of cliff edge and what the mitigations are for that. Our No. 1 concern is that patients continue to get a high-quality service. If there are particular places, then I would need to follow that up.

Chair

Can you give us an indication of the number of practices that have indicated to you around England that they would be in severe financial distress as a result of the changes? Do you have an idea of the numbers?

Rosamond Roughton

No, I do not. We are doing a stock‑take at the moment about where we are with all the reviews, but we do not have that kind of data. One thing we will look at is the ratio of things like expenses to earnings and average earnings as well in taking account of to what extent, if practices think that there is a cliff edge, that is something that will impact on patients, or whether this is a practice business model issue, which is what we have seen in some places—but a very small minority, I hasten to say. It is not the majority.

Chair

It is too early for you to say.

Rosamond Roughton

Yes.

Chair

Thank you very much. We will come on to James.

Dr Davies

Representations have been made to us in terms of the benefits of GPs federating. What national support is available for GP practices that wish to federate?

Rosamond Roughton

This year at the moment and last year we have offered support to practices that were successful in bidding for money for the Prime Minister’s Challenge Fund, which was about improving access. In doing so, we set a minimum population size. That has led, in effect, to incentivising practices about coming together to work to provide a network of care. We have provided support to about 1,000 practices in the first instance in the 20 schemes and now the current 37 schemes. We have also commissioned some work from the Royal College of General Practitioners and the Nuffield Trust to support developing networks. Just last week they published their initial set of findings and the areas on which people want support. But there is also support from other bodies as well as ourselves.

Professor Sir Bruce Keogh

It might be fair to say that there are other models that are beginning to emerge other than federations. Models of single organisations with a single‑board modality in Birmingham would be an example. I would imagine that, as the new models of care programme begins to emerge, we will start to see a small but significant number of different models, some of which will have advantages over others, particularly relating to geography and demographics and so forth. We need to be careful not to get into a place where once again we start to think that one size fits all.

Dr Kell

The GP networking, or federation, has various forms, from the informal working together as joint support to a contractual or merger change. The role of commissioners is to facilitate that, to make sure it makes sense for the local population. It is also important that we have a clear narrative as to why practices would be working together. It is important that that is hopefully done in a proactive way, which improves patient quality, access and sustainability. I am more concerned when I think it is because of the financial need to do so, because then we lose some of the benefit that might happen. If it is because of changes to funding and so on that forces practices into that, we will get less benefit as commissioners. Our members as CCGs see practices working together more and more and tell us that, but they are also very worried about sustainability.

Julie Wood

The key is having a locally developed primary care strategy that underpins the future direction, but then having the enablers that get underneath that, so the business models—federations or different models of care. Also, you have to get enablers like premises, plant and IT right and operating together so that we can deliver a transformed out‑of‑hospital service in a way that makes sense to local people and local populations.

Dr Davies

If CCGs have delegated commissioning responsibilities, would they be in a position to commission a new type of care about bringing in secondary care outside the GMS contract?

Julie Wood

Yes, they would. The key thing is how that is enabled to happen and, if that requires resource shifts from secondary care to primary care, how you ensure that you are able to transact that through your various contractual responsibilities and levers through commissioning—but, yes, absolutely.

Dr Kell

I want to talk about working jointly, so I will come back to my work as a GP and working as part of a team. We are in natural health systems, so we work with community services, mental health teams, hospital providers and general practice looking at things as a whole, and that is really important. We are seeing more shift from hospitals coming out into the community, and I think that is essential. Having the whole budget to either commission jointly or commission and delegate arrangements gives us more flexibility to do that, but we have to keep the purpose right, which is improving patient care. That health system approach is crucial. We all have responsibility for the patients in our system.

Dr Davies

Thank you.

Maggie Throup

Coming back one step, I have a supplementary about federations. One barrier I have come across to federations is when you have individual practices that are obviously registered with the CQC. Then you have federations forming that perhaps want to provide the seven‑day service and they find they have to register with the CQC again. What can be done about that?

Rosamond Roughton

We have talked to the CQC about how we can make sure that its registration requirements match the developing models of care. It is very responsive to that and, certainly in the schemes that we are supporting from NHS England’s point of view, it has agreed to provide a go‑to person that can guide them through the process. We need to make sure where we are putting on these new services that we are confident that the CQC regime—the registration is there for a reason, which is around public safety—is not compromised. We think there are ways in which we could start speeding up that process. It is not just about the federations; it is also about the programme of work we have on developing new care models as part of the NHS’s Five Year Forward View. That is another area where we want to work with the regulators to ensure the regulatory regime keeps up to speed with the different ways that care is developing.

Maggie Throup

There are no more comments. That is fine. Still sticking on federations, could federations be commissioned to provide care on the basis of a capitated model of care?

Professor Sir Bruce Keogh

Yes; we are looking at that under the new models of care programme. We see that as offering quite an exciting opportunity. It is not unrelated to Dr Davies’s question.

Maggie Throup

They are connected, yes.

Dr Kell

It is a particular opportunity to improve community services and their link again with general practice. We did have this but it got lost along the way a few years ago. If you talk to a lot of GPs and district nurses—matrons—they will talk about that teamwork having been lost a few years ago; and to bring that back, which is what CCGs are doing, is crucial. Patients expect that we work together, particularly out of hospital, that we communicate, that we share records and that their pathway will be a joined‑up one, and sometimes the reality is different. Our role as commissioners, and sometimes through capitated budgets as a tool, is to bring that back together.

Maggie Throup

We are getting towards the end now. Do you anticipate that the most ambitious general practice federations will seek to develop their own MCP-type models of care?

Julie Wood

Yes.

Rosamond Roughton

That is the ultimate goal.

Professor Sir Bruce Keogh

Not just that—we would encourage it.

Chair

I have a couple of follow‑up questions. One of the barriers that we have heard about so far in our inquiry is the issue around continuing professional development for other members of the healthcare team. Is that something that you think should be commissioned by the commissioners or should we leave that to individual practices? We have heard it is sometimes not happening when individual practices have to pay for it.

Rosamond Roughton

It is not something that has been raised with me previously. My initial reaction is that in the rest of NHS services the responsibility sits with the employer for continuing professional development. That is the approach that we have been taking since the NHS’s inception with general practice. In terms of what we are trying to do about stimulating new workforce models in general practice, we are looking at some investment. When I talked about bringing pharmacists into general practice—because we are trying to kick-start some of that—we are paying for the training costs in that scheme, but that is a protected scheme at the moment. It is certainly something for us to think about.

Chair

But what about in the future, if we have physician associates and extended roles for nurses? At the moment one of the problems we have heard about is that nurses within practices often do not get access to the same continuing professional development that, say, GPs do. That is why I was asking the question whether you see that being more of an issue down the line and a case for it being commissioned more centrally.

Dr Kell

We see commissioning as being part of a health assistance system. A lot of CCGs have started to take a responsibility for education beyond the practice team. For example, nursing home nurses can often work in isolation or under great stress with low numbers and an increasingly complex caseload, so a lot of areas have brought together nursing home nurses with practice nurses and hospital nurses, often led by the hospitals on some occasions. There is that system view of, “Is it good for a hospital to improve the care within nursing homes and within general practice?” Absolutely, it is. That is the future model and that is what CCGs are working to in a lot of areas, seeing education as a whole around the system rather than educating silos of workers.

Chair

Thank you. I have one final question. Do you see the issue of devolution of health and social care—the Devo Manc model and the various other models that are being proposed around the country—as a positive thing or as something that will create more system churn just as these new models are starting to bed in?

Julie Wood

Our members very much see localism as key. Localism can be delivered in a number of ways. Devolution in its various forms is one of those, but it is not the only one. The critical thing is that there is a local conversation that goes on about what we want to have greater control of locally and who then across our place needs to lead on that. It could well be different organisations for different things, what is in the scope of us wanting greater local flexibility, and then bringing all that together. We need to be clear about the rules of the game in relation to devolution. One of the things that we are keen to understand is the devolution legislation as it develops and the existing Acts and legislation around the Health and Social Care Act: one says you can do away with public bodies and the other says you have to have them. It is important that we are clear about the implications of the devolution legislation on the footprint of local public bodies within that place.

Chair

Do other Committee members want to ask anything further? In that case, can I finish by asking if there are any questions that you have not been asked that you feel are important points you would like to make for this inquiry at all?

Dr Kell

I have one very quick thing, which is to stress the importance of workforce planning. I know you have taken some evidence on workforce, but, as a commissioner, I get increasingly concerned that we stretch things too far and that we, for example, lose part of the system that is out-of-hours, for example, in terms of GP capacity. That is a constant challenge for us, whether we are NHS England or clinical commissioning groups and I think it is something that we need to keep at the forefront of our minds when planning services.

Chair

Yes. It is certainly something that Philippa was touching on; we have heard that having dual systems is undermining out-of-hours. Is that your view?

Dr Kell

We certainly hear from a lot of our members in quite a few areas that that is a challenge.

Professor Sir Bruce Keogh

May I say something that is not really a question or anything that I necessarily would have wished you to ask? I would like to pay some credit to the people who work in primary care. It seems to me that, through a number of routes, there has been quite a lot of criticism of primary care in the recent past. There is a risk of over-criticism at our peril. Both general practitioners and their associated staff are having to deal with tricky issues of increasing demand and rising expectations, and in particular in the face of increasing complexity of the patient workload that they have to see. In my view, it is a really hard job. They have to be clinically, intellectually and emotionally strong. I can say this as a cardiac surgeon, where all our patients come to us kind of worked up. I do not want to downplay that, of course. But day in, day out, general practitioners are having to sort out the wheat from the chaff, to identify major clinical problems masquerading as minor ailments, and it is utterly relentless. It requires quite a lot of intellectual flexibility and people have to be very tolerant individuals. It is one of the hardest jobs in medicine. It is important to say that at a time when general practice is going through quite a lot of turmoil.

Chair

I am sure that will be deeply appreciated and it is a very good note to end on. Thank you very much. Oral evidence: Primary Care, HC 408 21