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<title>"Commissioning - contracts, purchasing"</title></titleStmt>

<publicationStmt><distributor>BASE and Oxford Text Archive</distributor>


<availability><p>The British Academic Spoken English (BASE) corpus was developed at the

Universities of Warwick and Reading, under the directorship of Hilary Nesi

(Centre for English Language Teacher Education, Warwick) and Paul Thompson

(Department of Applied Linguistics, Reading), with funding from BALEAP,

EURALEX, the British Academy and the Arts and Humanities Research Board. The

original recordings are held at the Universities of Warwick and Reading, and

at the Oxford Text Archive and may be consulted by bona fide researchers

upon written application to any of the holding bodies.

The BASE corpus is freely available to researchers who agree to the

following conditions:</p>

<p>1. The recordings and transcriptions should not be modified in any


<p>2. The recordings and transcriptions should be used for research purposes

only; they should not be reproduced in teaching materials</p>

<p>3. The recordings and transcriptions should not be reproduced in full for

a wider audience/readership, although researchers are free to quote short

passages of text (up to 200 running words from any given speech event)</p>

<p>4. The corpus developers should be informed of all presentations or

publications arising from analysis of the corpus</p><p>

Researchers should acknowledge their use of the corpus using the following

form of words:

The recordings and transcriptions used in this study come from the British

Academic Spoken English (BASE) corpus, which was developed at the

Universities of Warwick and Reading under the directorship of Hilary Nesi

(Warwick) and Paul Thompson (Reading). Corpus development was assisted by

funding from the Universities of Warwick and Reading, BALEAP, EURALEX, the

British Academy and the Arts and Humanities Research Board. </p></availability>




<recording dur="00:47:44" n="7475">


<respStmt><name>BASE team</name>



<langUsage><language id="en">English</language>



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<item n="speechevent">Lecture</item>

<item n="acaddept">Postgraduate Medical Education</item>

<item n="acaddiv">ss</item>

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<item n="module">unknown</item>





<u who="nf1199"> i'm <pause dur="0.4"/> <gap reason="name" extent="2 words"/> <pause dur="0.2"/> you've met me before <pause dur="0.3"/> i used to work <pause dur="0.3"/> in a health authority <pause dur="0.6"/> i'm now working <pause dur="0.2"/> # <pause dur="1.2"/> providing practice management <pause dur="0.6"/> support to general practice <pause dur="0.4"/> and doing a range of other things including clinical governance <pause dur="0.3"/> coordination with the Department of Health <pause dur="0.6"/> and i've been asked to come here and do the session on <pause dur="0.4"/> commissioning contracting and purchasing <pause dur="0.4"/> which is actually a little bit <shift feature="voice" new="laugh"/>out <shift feature="voice" new="normal"/>of date now because we're don't we're not allowed to use those words <pause dur="0.4"/> with the new White Paper although the techniques are still the same <pause dur="1.6"/> what i thought i'd start off with doing is has anybody got any <pause dur="0.5"/> sort of commissioning or purchasing issues that they would like to have as a theme to <pause dur="0.2"/> to the session <pause dur="0.7"/> 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 <trunc>s</trunc> the <pause dur="0.4"/> the lecture round <pause dur="3.4"/> mm </u><u who="nf1200" trans="overlap"> the problem we've got is matching the data to the contracts <pause dur="0.2"/> the data that comes

across matching it to the services </u><u who="nf1199" trans="latching"> right okay </u><u who="nf1200" trans="overlap"> <gap reason="inaudible due to overlap" extent="2 secs"/> </u><u who="nf1199" trans="overlap"> so we need to <pause dur="0.4"/> look at <pause dur="0.3"/> one of the things we can do is explore a little bit detail in in the difficulties with <trunc>ob</trunc> obtaining information on contracting activity </u><u who="nf1200" trans="overlap"> mm </u><pause dur="0.4"/> <u who="nf1199" trans="pause"> fine <pause dur="1.3"/> what i'll intend to do then is just briefly do an overview <pause dur="0.2"/> of what <pause dur="0.6"/> N-H-S commissioning contracting and purchasing is all about <pause dur="0.7"/> and then i thought we'd take an example <pause dur="0.9"/> # a service delivery example <pause dur="0.3"/> where some of these issues come into play <pause dur="0.3"/> some of the variables that <pause dur="0.3"/> and the information that we need to address <pause dur="1.1"/> you're due to <trunc>fi</trunc> finish at five o'clock <pause dur="0.4"/> i'm happy to keep to that hour if you are 'cause you've obviously had a <pause dur="0.2"/> a long day and if you've # <pause dur="1.8"/> if you're anything like me by this time of the day <pause dur="0.4"/> start to <kinesic desc="mimics falling asleep" iterated="n"/> starting to wane </u><gap reason="break in recording" extent="uncertain"/> <u who="nf1199" trans="pause"><kinesic desc="overhead projector is on showing transparency" iterated="n"/> so now can everybody see that okay </u><u who="ss" trans="overlap"> yeah </u><pause dur="0.3"/> <u who="nf1199" trans="pause"> all right

let's start again <pause dur="3.7"/> are we ready <pause dur="0.9"/> just a quick <pause dur="0.5"/> overview of the new N-H-S which when i last spoke to you you <pause dur="0.3"/> should <trunc>r</trunc> now be really <shift feature="voice" new="laugh"/>aware of <shift feature="voice" new="normal"/><pause dur="0.4"/> to the back teeth <pause dur="0.6"/> # and the developing of primary care groups which actually means that the commissioning and purchasing and contracting role <pause dur="0.4"/> is gradually being devolved <pause dur="0.3"/> from what was the health authority responsibility <pause dur="0.4"/> and G-P fundholders' responsibility <pause dur="0.4"/> to primary care groups <pause dur="0.8"/> now it's going <pause dur="0.3"/> down at different levels <pause dur="0.3"/> primary care groups can go in <pause dur="0.4"/> to action at four levels <pause dur="0.7"/> most are opting in at level two which means that they can take the responsibility of some of the budget not all of it <pause dur="0.5"/> and they work in conjunction and accountable to the health authority </u><gap reason="break in recording" extent="uncertain"/> <u who="nf1199" trans="pause"> level four <pause dur="0.3"/> is when they become trust status is where they have the whole set of responsibilities as does as a health authority <pause dur="0.7"/> but at the moment nationally are <pause dur="0.3"/> they are tending to go in at level two

level one <pause dur="0.3"/> is where they just work on an indicative level <pause dur="1.5"/> so <pause dur="0.2"/><vocal desc="clears throat" iterated="n"/> that has changed things <pause dur="0.2"/> quite dramatically <pause dur="0.4"/> or will do <pause dur="0.4"/> in that the involvement of general practitioners in the <pause dur="0.3"/> purchasing commissioning focus is so much more <pause dur="3.7"/> <kinesic desc="changes transparency" iterated="y" dur="3"/> # around primary care <pause dur="2.0"/> primary care <pause dur="0.3"/> functions group main functions <pause dur="2.4"/> they have to contribute to what is called a Health Improvement Programme <pause dur="1.6"/> they have to look at the <trunc>p</trunc> and promote the health of their local population and the local population <pause dur="0.5"/> is <pause dur="0.5"/> # # based around <pause dur="0.5"/> geographical ward areas coterminous with social services <pause dur="0.5"/> so groups of practices will be brought together <pause dur="0.7"/> and they will be set <pause dur="0.3"/> # <pause dur="0.5"/> as a board <pause dur="0.5"/> looking at the individual needs of their local health <trunc>autho</trunc> health population <pause dur="1.6"/> they then have to look at how they're going to commission health <pause dur="0.2"/> services <pause dur="0.3"/> for that <pause dur="0.8"/> group of the population <pause dur="1.0"/> they also have to look at how they integrate that with the development of primary care <pause dur="1.1"/> community services <pause dur="0.3"/> and

gradually replace what is now known as fundholding <pause dur="1.8"/> presume everybody's aware of what fundholding is <pause dur="0.7"/> that they take a specific budget and they monitor that <pause dur="0.7"/> with primary care groups it is somewhat different in that they have to take those things <pause dur="0.4"/> in addition to fundholding <pause dur="0.4"/> that are not necessarily containable so they have <trunc>t</trunc> they can take <pause dur="0.5"/> <trunc>em</trunc> <trunc>i</trunc> levels of emergency activity they have to take that into consideration <pause dur="0.7"/> so it's not as contained as fundholding fundholding was very much a specific amount of money <pause dur="0.7"/> with very little external <pause dur="0.3"/> pressures and constraints on it <pause dur="1.0"/> unlike the health authority who had to manage winter pressures waiting lists <pause dur="0.4"/> emergency activity <pause dur="0.3"/> and other financial pressures on their budget <pause dur="0.4"/> primary care groups now gradually will have to start to take on board those issues <pause dur="6.5"/> <kinesic desc="changes transparency" iterated="y" dur="6"/> what is <pause dur="0.8"/> purchasing <pause dur="1.4"/> the definition of purchasing <pause dur="1.3"/> is the buying <pause dur="0.5"/> that's when you've decided <pause dur="0.4"/> what it is you need for your

local population <pause dur="0.3"/> you <trunc>g</trunc> actually go out and buy it <pause dur="0.6"/> that's still staying in the new N-H-S the purchaser provider split is still staying <pause dur="2.9"/> it <trunc>g</trunc> actually gives the primary care groups quite a lot of leverage <pause dur="0.2"/> because they will be determining <pause dur="0.2"/> what it is they want to buy <pause dur="0.4"/> based on the needs of their local population <pause dur="1.1"/> one of the things they have to get used to doing however <pause dur="0.6"/> is working with the providers because as an example if they suddenly decided <pause dur="0.4"/> that they'd no longer wanted to contract <pause dur="0.3"/> for a particular acute service in a main general hospital <pause dur="1.3"/> they then have to look at <trunc>wh</trunc> how that impacts on other services if we take <pause dur="0.3"/> paediatrics as an example <pause dur="0.3"/> paediatrics links in with SCBU <pause dur="0.3"/> it links in with maternity <pause dur="0.4"/> and other services around <pause dur="0.2"/> in primary care like child health services <pause dur="0.4"/> and and it's that sort of a domino effect if they remove one thing <pause dur="0.3"/> they actually can cause a ripple effect through an organization <pause dur="0.3"/> so there has to be <pause dur="0.4"/> a process of change management <pause dur="0.7"/> so they can change

purchasing decisions <pause dur="0.2"/> but it has to be done in a planned <pause dur="0.3"/> framework <pause dur="2.2"/> <vocal desc="clears throat" iterated="n"/> </u><pause dur="0.2"/> <u who="nm1201" trans="pause"> you you said about # <pause dur="0.6"/> you know there'll still be the commissioner and provider split </u><u who="nf1199" trans="overlap"> yes </u><u who="nm1201" trans="overlap"> but it may have become <gap reason="inaudible" extent="1 sec"/> when the <pause dur="0.4"/> primary care trusts come in <pause dur="0.7"/> because they'll be able to provide community care <pause dur="0.8"/> for that level as well won't they </u><u who="nf1199" trans="latching"> they will have to <pause dur="0.2"/> be responsible as a primary care <pause dur="0.2"/> trust <pause dur="0.4"/> still for the provision of services but that will be through contract still <pause dur="0.7"/> there may be some contracts within primary care <pause dur="0.4"/> but there will be a division between the board <pause dur="0.4"/> and the decision making process of what's actually provided <pause dur="1.0"/> the <pause dur="0.2"/> 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 <pause dur="0.4"/> but a primary care group will not actually themselves be providing the service <pause dur="0.3"/> they will be members of providers </u><u who="nm1201" trans="latching"> right </u><u who="nf1199" trans="overlap"> for example there will be a social worker <pause dur="0.3"/> a general practitioner <pause dur="0.3"/> an acute hospital <trunc>ru</trunc> member <pause dur="0.2"/> alongside up to seven

general practitioners <pause dur="0.2"/> so in <trunc>e</trunc> in essence they are providers <pause dur="0.5"/> but they will have as a primary care group board <pause dur="0.3"/> contracts as purchasers if you like <pause dur="0.3"/> with <pause dur="0.2"/> a range of providers </u><u who="nm1201" trans="latching"> mm </u><u who="nf1199" trans="latching"> does <pause dur="0.2"/> does that <pause dur="0.3"/> clarify </u><u who="nm1201" trans="overlap"> <gap reason="inaudible" extent="1 sec"/> providers could be then <gap reason="inaudible" extent="1 sec"/> shouldn't it </u><u who="nf1199" trans="overlap"> it <trunc>w</trunc> will definitely should be <pause dur="0.2"/> because the <trunc>r</trunc> the the aim is <pause dur="0.3"/> that <pause dur="0.3"/> all of those people sitting on the <trunc>pu</trunc> on the primary care group board <pause dur="0.2"/> will be aware <pause dur="0.2"/> of the capabilities weaknesses and change management issues <pause dur="0.4"/> around their own trust <pause dur="0.2"/> so if you're looking at somebody sitting on a primary care group from social services <pause dur="0.4"/> and the issue on the primary care group board agenda is elderly care <pause dur="0.4"/> it's very much their interest <pause dur="0.3"/> to have a voice in that group <pause dur="0.3"/> whereas at the moment it's not in an integrated forum <pause dur="0.7"/> there is <pause dur="0.2"/> there are a few areas that are under joint planning where we sit round the table as health professionals with social services

professionals <pause dur="0.4"/> but it's not part of the N-H-S structure <pause dur="0.2"/> before or it wasn't before primary care groups came in existence <pause dur="0.5"/> so i think the aim is to have an integrated approach <pause dur="0.4"/> of all the professionals <pause dur="0.4"/> involved in providing care <pause dur="0.2"/> for that designated area <pause dur="0.4"/> so whatever the whether it be a subject whether it be a client group <pause dur="0.3"/> or whether it be a specialty <pause dur="0.6"/> it will be discussed and each person will have a group there will be a practice nurse who will be able to speak <pause dur="0.3"/> on behalf of <pause dur="0.3"/> the practice nurse provision <pause dur="0.4"/> there will be <pause dur="0.5"/> as i said a social worker <pause dur="0.2"/> general practitioners all giving their views <pause dur="0.3"/> so it's going to fundamentally change because there's going to be a lot of tension because of people come <pause dur="0.4"/> in at different things in different ways <pause dur="0.8"/> when i was working with <gap reason="name" extent="1 word"/> <pause dur="0.2"/> <trunc>wh</trunc> who you've just <pause dur="0.2"/> met <pause dur="0.5"/> # we had to implement <pause dur="0.2"/> under the previous government <pause dur="0.4"/> # a White Paper called Changing Childbirth you're probably <pause dur="0.3"/> aware of that was that was

the change of maternity services <pause dur="0.4"/> from purely acute care <pause dur="0.3"/> and to more spread out into the community <pause dur="0.9"/> what you end up doing is <trunc>y</trunc> <pause dur="0.2"/> you have to start <pause dur="0.3"/> bringing in an awful lot of <pause dur="0.5"/> interest into that process but there's no formal <pause dur="0.6"/> # meeting place for that to happen and it was very difficult getting the midwives round the table alongside the health authority <pause dur="0.4"/> trying to drag a general practitioner in to give his view <pause dur="0.2"/> which one do you choose <pause dur="0.4"/> out of seventy-eight practices or however many practices <pause dur="0.3"/> which general practitioner do you actually choose to join you <pause dur="0.3"/> and is he <pause dur="0.2"/> is he or she seen <pause dur="0.2"/> as representative <pause dur="0.3"/> of their own profession in that area <pause dur="0.4"/> at least with primary care groups <pause dur="0.2"/> whoever they may be <pause dur="0.6"/> they will be accepted as the representative voice of that profession <pause dur="0.4"/> so whenever their changing services <pause dur="0.4"/> from a commissioning point of view <pause dur="0.3"/> they will be the guidance and they will be the reference point <pause dur="0.3"/> consultation point start point planning point whatever <pause dur="0.3"/> well they'll either go to

them to start a problem <pause dur="0.3"/> or they will make a decision to finish it <pause dur="2.5"/> the <pause dur="0.7"/> # <pause dur="2.3"/><kinesic desc="changes transparency" iterated="y" dur="2"/> commissioning <pause dur="0.9"/> definition that brings us on quite nicely to the is something entrusted to be done delegated authority <pause dur="0.5"/> # <pause dur="0.2"/> payment by percentage for doing something <pause dur="1.8"/> <shift feature="voice" new="laugh"/>that's a <shift feature="voice" new="normal"/><pause dur="0.2"/> a very lengthy <pause dur="0.4"/> # <pause dur="0.6"/> definition <pause dur="0.9"/> there are other definitions for commissioning <pause dur="0.3"/> which i actually prefer <pause dur="2.3"/> <kinesic desc="changes transparency" iterated="y" dur="4"/> which is looking at <pause dur="0.2"/> these key areas <pause dur="1.8"/> and that is looking at the skills <pause dur="0.6"/> oh dear <pause dur="2.4"/> skills and abilities of the people involved in providing the service i've got handouts for these so don't worry too much <pause dur="1.6"/> diagnosing the problem <pause dur="0.5"/> so if we're looking at changing a particular service as # <pause dur="1.6"/> around a client group <pause dur="0.4"/> we have to understand why we want to change it <pause dur="0.3"/> and that has to be backed up by <pause dur="0.3"/> evidence and the new White Paper says all the way through evidence based medicine <pause dur="0.5"/> R and D research and development <pause dur="0.6"/> clinical effectiveness they're all key words <pause dur="0.3"/> in the new White Paper <pause dur="0.2"/> so

whatever <trunc>w</trunc> <pause dur="0.3"/> primary care groups are changing <pause dur="0.4"/> they have to look for A the problem <pause dur="0.3"/> and then B <pause dur="0.3"/> underpinning it with reasons why <pause dur="0.3"/> or reasons for making changes in the commissioning process <pause dur="0.6"/> so from an information point of view it could well be activity data from contracts <pause dur="0.4"/> it could well be census data of age sex <pause dur="0.3"/> breakdown <pause dur="0.3"/> it could be <pause dur="0.3"/> <vocal desc="clears throat" iterated="n"/> epidemiological information about <pause dur="0.3"/> the structure and nature of that particular population that's causing the problem <pause dur="0.6"/> if there's a <trunc>prob</trunc> <pause dur="0.2"/> problem in <pause dur="0.7"/> a part of a county where there is high percentages of elderly and it is involved rehabilitation <pause dur="0.3"/> then there's an you know an underlying reason why rehabilitation is probably more of a problem there than it may be <pause dur="0.3"/> elsewhere <pause dur="1.8"/> 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 <pause dur="0.4"/> so commissioning the commissioning process is the <pause dur="0.3"/> the digging up <pause dur="0.2"/> all the research all

the evidence <pause dur="1.5"/> they have to look at it <pause dur="0.2"/> without taking sides so they've got to start and analyse that information <pause dur="0.9"/> # <pause dur="0.4"/> as a group of professionals without taking sides <pause dur="0.7"/> and that's going to be quite difficult 'cause obviously the doctors may well veer towards the medical <pause dur="0.6"/> angle <pause dur="0.3"/> nurses will be <shift feature="voice" new="laugh"/>protecting their <shift feature="voice" new="normal"/> own profession <pause dur="0.3"/> you'll have social services coming at it <pause dur="0.3"/> so there's going to be <pause dur="0.2"/> quite a lot of storming i think in relation to the group coming together initially <pause dur="0.6"/> but as the process takes 'cause as long as it's backed up by research and evidence <pause dur="0.3"/> they can't they won't be able to argue <pause dur="0.4"/> the decision making process in the longer term because it will be based on factual data <pause dur="1.4"/> so <pause dur="0.3"/> there's a lot of listening <pause dur="0.5"/> key in the White Paper is involving the local community <pause dur="0.5"/> focus groups <pause dur="0.4"/> # health economies i think they're being called in relation to involving those groups of individuals <pause dur="0.3"/> patients population <pause dur="0.4"/> in the decision making process <pause dur="0.4"/> so as part of the commissioning they

have <trunc>g</trunc> also got to demonstrate <pause dur="0.3"/> that not only are they underpinning it with <pause dur="0.3"/> evidence based <pause dur="0.3"/> research <pause dur="0.3"/> but they are actually going out on consultation <pause dur="0.3"/> to the people <pause dur="0.3"/> who actually <pause dur="0.5"/> <trunc>n</trunc> have to have the services <pause dur="0.4"/> delivered to them <pause dur="1.9"/> timing <pause dur="0.4"/> you cannot make change overnight it's not something that <pause dur="0.4"/> a group of professionals can suddenly make changes in within three to six months <pause dur="0.3"/> so there has to be a plan has to be a management plan <pause dur="0.4"/> involving the people <pause dur="0.4"/> involving the <pause dur="0.4"/> professionals involving the public <pause dur="1.7"/> 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 <pause dur="0.4"/> and independent <pause dur="0.2"/> sector <pause dur="0.2"/> development <pause dur="0.2"/> alongside a community hospital and actually integrate services <pause dur="0.3"/> and there was a public meeting with the health authority <pause dur="0.3"/> to the local population of the plans <pause dur="0.3"/> and encouraging people to put forward their views <pause dur="0.2"/> that's part of the commissioning process <pause dur="2.5"/> once you've done all of that <pause dur="0.9"/>

<vocal desc="clears throat" iterated="n"/> you then <pause dur="0.5"/> have to decide what you're going to buy <pause dur="4.0"/> <kinesic desc="changes transparency" iterated="y" dur="3"/> and that's then <pause dur="0.3"/> put into a contract <pause dur="1.3"/> that's where <pause dur="0.5"/> you've decided <pause dur="0.6"/> what it is you need <pause dur="0.5"/> you've based it around something that's tangible <pause dur="0.5"/> and then you've negotiated with the service providers <pause dur="0.3"/> to to to <pause dur="0.2"/> make that service available <pause dur="0.3"/> remembering that it may not be there now <pause dur="0.8"/> you may actually decide <pause dur="0.3"/> that you need a service that doesn't exist <pause dur="0.8"/> during the commissioning and consultation process <pause dur="0.3"/> out of that may arise <pause dur="0.3"/> that there is a need <pause dur="0.2"/> for a more <pause dur="0.5"/> say focus on domiciliary based <pause dur="0.3"/> rehabilitation <pause dur="0.4"/> that may not exist it may all be done in a <trunc>n</trunc> local acute hospital <pause dur="0.6"/> so there has to be agreement with the service providers <pause dur="0.3"/> as to how it can be moved <pause dur="0.4"/> from the acute setting <pause dur="0.3"/> out <pause dur="0.4"/> is it done in a building is it done in people's homes <pause dur="0.3"/> does it involve social services <pause dur="0.4"/> is the district nurse going to be involved all the different <pause dur="0.2"/>

tangibles have to be brought together <pause dur="0.8"/> when it's <pause dur="0.2"/> been decided how it will work <pause dur="0.2"/> we we then have to say well so much will be provided by district nursing <pause dur="0.4"/> that's a service that the local trust provides so we'll have a contract with them <pause dur="1.0"/> if it's about <pause dur="0.2"/> social services <pause dur="0.3"/> that's a social service area <pause dur="0.3"/> we need to have agreement <pause dur="0.3"/> with social services <pause dur="0.2"/> and how they will provide that and how we can have it written in contract <pause dur="1.2"/> the contract terms will dictate how often it takes place how many people can be seen <pause dur="0.4"/> what cost <pause dur="1.0"/> and it will actually define <pause dur="0.2"/> the nitty-gritty issues <pause dur="0.2"/> of financial management and control <pause dur="1.2"/> but it is very much a three stage process <kinesic desc="changes transparency" iterated="y" dur="3"/></u><pause dur="1.4"/> <u who="nf1202" trans="pause"> can i ask a question </u><pause dur="0.9"/> <u who="nf1199" trans="pause"> yes certainly </u><pause dur="0.2"/> <u who="nf1202" trans="pause"> about saying that <pause dur="0.5"/> that contracts are enforceable by law are they really in some sense are they <gap reason="inaudible due to overlap" extent="1 sec"/> </u><u who="nf1199" trans="overlap">

no they're not <pause dur="0.2"/> they're not legal agreements </u><u who="nf1202" trans="latching"> mm </u><u who="nf1199" trans="overlap"> they're <pause dur="0.6"/> it's what we hang everything round it's what we have an agreement with providers on <pause dur="0.7"/> but they're not <pause dur="0.2"/> <vocal desc="laugh" iterated="n"/> they're not a legal document </u><u who="nf1202" trans="overlap"> mm </u><u who="nf1199" trans="overlap"> because of they're in public sector <pause dur="0.6"/> however <pause dur="0.5"/> in contracting law <pause dur="0.3"/> the fact that somebody has agreed to provide something and and provides it over a period of time <pause dur="0.3"/> is actually a contract <pause dur="0.3"/> if i <trunc>en</trunc> if i started to pay you <pause dur="0.3"/> to deliver me a service <pause dur="0.3"/> <trunc>i</trunc> <pause dur="0.3"/> 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 </u><u who="nf1202" trans="latching"> mm </u><pause dur="0.5"/> <u who="nf1199" trans="pause"> but no they're not legal documents <pause dur="0.4"/> but they are some we have to have something <pause dur="0.6"/> to base <pause dur="0.2"/> all of this on <pause dur="0.4"/> against a strategic plan <pause dur="0.7"/> and the three stage process very much is <pause dur="1.1"/> <vocal desc="clears throat" iterated="n"/> <pause dur="0.7"/> commissioning <pause dur="1.3"/> purchasing <pause dur="0.5"/> and contracting <pause dur="1.8"/> when we first started working with general practitioners i remember

meeting with a group of doctors and they said <pause dur="1.6"/> well <pause dur="0.4"/> if i want to go out and buy oranges <pause dur="0.3"/> i'll go and buy oranges <pause dur="0.7"/> she was a G-P fundholder <pause dur="1.3"/> and i said <pause dur="0.8"/> fine <pause dur="0.6"/> # i said but <pause dur="0.5"/> the provider needs to know <pause dur="0.2"/> what sort of oranges you're going to want to buy <pause dur="0.6"/> do you want clementines satsumas <pause dur="0.4"/> jaffas <pause dur="1.0"/> and that's the <shift feature="voice" new="laugh"/>commissioning <shift feature="voice" new="normal"/> bit <pause dur="0.5"/> because if there aren't any satsumas and she specifically wants satsumas <pause dur="0.5"/> then the trust has to provide <pause dur="0.3"/> and we ended up talking in this analogy of oranges which <pause dur="0.3"/> <shift feature="voice" new="laugh"/>you know i thought <shift feature="voice" new="normal"/>here we are in the N-H-S talking about oranges <pause dur="0.3"/> but it actually gave quite a good example <pause dur="0.4"/> that you can say you want to buy elderly care <pause dur="0.8"/> 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 <pause dur="0.3"/> you know there there is a range of stuff around the elderly <pause dur="0.8"/> so it's about defining <pause dur="0.2"/> defining what you mean <pause dur="0.5"/> when you've defined it through need <pause dur="1.3"/> you then <pause dur="0.3"/> buy it <pause dur="0.3"/> and that's when you enter into agreement you say this is

how much money we've got <pause dur="0.6"/> and this is how we'd like it to be <pause dur="1.0"/> where do we buy it from <pause dur="0.5"/> if there's social care services social # services et cetera <pause dur="0.9"/> there was a a very difficult time when the internal market took over <pause dur="0.5"/> # <pause dur="0.2"/> <vocal desc="clears throat" iterated="n"/> being sensible i think at one point <pause dur="0.4"/> where we had two community trusts trying to provide <pause dur="0.4"/> counselling services one was a mental health trust <pause dur="0.3"/> and one was a community trust <pause dur="0.7"/> if a G-P referred to the mental health trust and it was a mental health referral that's <trunc>s</trunc> that's fine <pause dur="0.4"/> but if it was referred to the mental health trust and it was a general community <pause dur="0.4"/> <trunc>psycholi</trunc> psychological problem <pause dur="0.6"/> the mental health trust would be reluctant to pass it across because that would be income for them <pause dur="1.4"/> that would actually be income into their pot <pause dur="0.4"/> whereas now <pause dur="0.4"/> what we're saying is <pause dur="0.3"/> to <trunc>w</trunc> we should be dismantling all of that competition we should be assessing <pause dur="0.3"/> what it is we want to buy and who is the most appropriate provider <pause dur="2.2"/> then we purchase it

and we determine quantity <pause dur="0.2"/> quality et cetera <pause dur="0.8"/> and then we negotiate the contracts <pause dur="0.4"/> and that's really i was a contracts manager <pause dur="1.1"/> you have this pot of money <pause dur="0.9"/> that's it <pause dur="0.2"/> you have to monitor it then within those guidance and <pause dur="0.3"/> what you were saying <pause dur="0.2"/> which we'll go on to now <pause dur="0.5"/> was the difficulties <pause dur="1.3"/> and we'll just touch on <kinesic desc="changes transparency" iterated="y" dur="5"/> that briefly <pause dur="1.1"/> <vocal desc="clears throat" iterated="n"/><pause dur="5.5"/> activity <pause dur="9.4"/> you have to decide when you're managing a contract <pause dur="0.3"/> how you're going to monitor <pause dur="0.3"/> what's happening <pause dur="1.6"/> in acute hospitals it's fairly <pause dur="0.4"/> robust <pause dur="0.3"/> because <pause dur="0.2"/> the <trunc>c</trunc> # <pause dur="0.5"/> contract minimum datasets gives a record <pause dur="0.4"/> who comes in who goes out how long they stayed <pause dur="0.4"/> and what happened to them during that process <pause dur="1.0"/> so from a purchasing manager as i was then and probably in the future primary care group <pause dur="0.4"/> they will be <trunc>a</trunc> able to have from a local hospital <pause dur="0.3"/> each specialty <pause dur="0.6"/> and activity across the months across a quarter <pause dur="0.5"/> that will have a price attached to it <pause dur="0.7"/> and they can

work out by projecting forward whether they're actually within the <trunc>re</trunc> realms of their contract financially <pause dur="1.1"/> what is now being said nationally is that <pause dur="0.4"/> whereas you might get Solihull Hospital <pause dur="0.6"/> charges out <pause dur="0.3"/> # a hysterectomy at two-and-a-half-thousand pounds <pause dur="0.4"/> but Birmingham Heartlands may charge three <pause dur="0.8"/> there will be a national costing formula that will say a hysterectomy is always <pause dur="0.2"/> three-thousand pounds for an example or <pause dur="0.4"/> an acute general medical admission <pause dur="0.6"/> # <pause dur="0.2"/> <trunc>f</trunc> <pause dur="0.3"/> for whatever reason is <pause dur="0.4"/> and there will be a national pricing formula <pause dur="0.5"/> because that then gets away from the <trunc>compe</trunc> competition <pause dur="1.5"/> so the price will be linked to activity and it's it's activity times price <pause dur="0.3"/> that's the way the contract is monitored <pause dur="0.8"/> so it's based on <pause dur="0.4"/> # <pause dur="1.7"/> <vocal desc="clears throat" iterated="n"/> # locks lumps of activity <pause dur="1.2"/> in the community it's actually measured by contacts so at the moment <pause dur="0.6"/> if you contract as a large purchasing organization for something like district nursing <pause dur="2.6"/> a health authority would contract

that <pause dur="0.7"/> on how many people has that district nurse seen <pause dur="0.2"/> so how many contacts how many face to face contacts has an has been undertaken <pause dur="0.3"/> again during the quarter <pause dur="0.5"/> during a six month during a twelve month period <pause dur="0.4"/> and the trusts or the providers will put a price on that <pause dur="1.6"/> <trunc>i</trunc> <pause dur="0.3"/> the data <pause dur="0.2"/> and i'm sure from your experiences is less <pause dur="0.3"/> is less easy to analyse it's not as easy to interrogate <pause dur="0.4"/> and question what went on in that contact was it <pause dur="0.6"/> a lengthy contact of an hour did it last five minutes <pause dur="0.2"/> what happened to the patient <pause dur="0.4"/> # <pause dur="0.3"/> in that time <pause dur="0.6"/> so there's less sophisticated information in a community <pause dur="0.9"/> even less sophistication if you actually contract on a whole time equivalent basis which is what some of the fundholders did <pause dur="0.4"/> they actually said i don't want <pause dur="0.4"/> to have a contract on contacts i'm not interested <pause dur="1.0"/> i want to buy <trunc>e</trunc> either a whole <pause dur="0.2"/> district nurse <pause dur="0.3"/> time <pause dur="0.5"/> or <trunc>ho</trunc> <pause dur="0.3"/> nought-point-five whole time equivalent or whatever <pause dur="1.1"/> but the <pause dur="0.2"/> regional offices still want this activity measured by contacts <pause dur="0.8"/> because it can be <pause dur="0.5"/>

it's public <pause dur="0.7"/> # information that can be said <pause dur="0.3"/> this trust saw more <pause dur="0.4"/> than this <pause dur="0.3"/> you know <trunc>i</trunc> <trunc>i</trunc> <vocal desc="laugh" iterated="n"/> but <pause dur="0.3"/> really <pause dur="0.6"/> how <pause dur="0.3"/> <trunc>s</trunc> # <pause dur="0.7"/> robust that <pause dur="0.2"/> that statement would be <pause dur="0.4"/> is is to <pause dur="0.2"/> in my in my field is is actually dubious but <pause dur="0.7"/> contract minimum datasets is more robust <pause dur="1.2"/> so that's how we <trunc>c</trunc> we <pause dur="0.2"/> we go <pause dur="0.2"/> we go forward <pause dur="0.4"/> but <pause dur="0.5"/> a lot of <pause dur="0.2"/> G-P fundholders have actually <pause dur="1.3"/> questioned the activity that comes out of the hospitals because they have said <pause dur="0.3"/> that didn't happen <pause dur="1.4"/> and that without getting too engrossed in the way that activity's measured <pause dur="0.7"/> the <pause dur="0.3"/> formula for which they <pause dur="0.2"/> agree a price <pause dur="0.4"/> is usually on an average cost basis <pause dur="0.5"/> and i've had a general practitioner say to me <pause dur="0.7"/> this they want to charge me seven-thousand pounds or <pause dur="0.3"/> or the the whole package of care they won't be charging him # <pause dur="0.5"/> for this and they've read the # <pause dur="0.5"/> # activity that went on in the medical terms <pause dur="0.3"/> and they've actually said it was sort of a carpal tunnel <pause dur="0.6"/> insertion <pause dur="0.4"/> and they're saying but <pause dur="0.2"/> that isn't worth that much money <pause dur="0.4"/> but what <pause dur="0.2"/> the

trust will have costed up is any anaesthetic time <pause dur="0.4"/> any oh the theatre time the the nurse <pause dur="0.3"/> what time the heating <shift feature="voice" new="laugh"/>electric <shift feature="voice" new="normal"/>you know everything <pause dur="0.3"/> will have gone into that price so it's not <pause dur="0.5"/> it's not as <pause dur="0.2"/> cut <pause dur="0.3"/> and dry as what they actually do to that individual <pause dur="1.7"/> what what <pause dur="0.5"/> what particular question did you have on the <pause dur="0.7"/> data <pause dur="0.2"/> anything else </u><pause dur="0.4"/> <u who="nf1203" trans="pause"> well i think it's basically the problems we've had is # agreeing the electronic data that comes across from acute hospitals to <pause dur="0.5"/> # summary data that they send us in their reports </u><u who="nf1199" trans="latching"> mm-hmm </u><pause dur="0.2"/> <u who="nf1203" trans="pause"> and that's the <gap reason="inaudible" extent="1 sec"/> <pause dur="0.4"/> <gap reason="inaudible" extent="1 sec"/> problem </u><pause dur="0.7"/> <u who="nf1199" trans="pause"> and what <pause dur="0.2"/> where which side are <trunc>whe</trunc> are you from a trust or from a </u><u who="nf1203" trans="overlap"> no i'm from a health authority </u><u who="nf1199" trans="latching"> right so you end up in a <trunc>d</trunc> in a debate about what you feel has actually happened </u><u who="nf1203" trans="overlap"> mm </u><u who="nf1199" trans="overlap"> so you're looking at contract management terms </u><u who="nf1203" trans="latching">

yeah </u><u who="nf1199" trans="latching"> yeah <pause dur="0.3"/> yeah <pause dur="0.6"/> that very often happens well <pause dur="0.6"/> <trunc>w</trunc> the other thing that happens as well is <pause dur="0.3"/> trusts <pause dur="0.5"/> change their <pause dur="0.9"/> working practices so they might set up an emergency assessment unit <pause dur="0.7"/> so they start in the in in the acute unit # sorry in the emergency <pause dur="0.4"/> unit <pause dur="0.5"/> they then move either into a general medicine bed they're assessed in general medicine they move across to <pause dur="0.3"/> general surgery <pause dur="0.6"/> and they're <trunc>d</trunc> the health authority will have been charged <pause dur="0.5"/> an initial admission fee <pause dur="0.5"/> then <pause dur="0.4"/> they <pause dur="0.4"/> move the general medicine price <pause dur="0.2"/> and then the general surgical price <pause dur="0.4"/> there's like three episodes of care <pause dur="0.6"/> what the contract minimum dataset can do and you're probably well used to analysing that is actually do it by patient number <pause dur="0.4"/> and say but this patient only came in on Thursday <pause dur="0.4"/> they went out on Friday night okay they might have shifted round the hospital a bit but they certainly didn't have <pause dur="0.5"/> six or <shift feature="voice" new="laugh"/>eight-thousand pounds worth of <shift feature="voice" new="normal"/> care <pause dur="0.5"/> and you can actually interrogate that data <pause dur="0.3"/> that's less easy to do <pause dur="0.7"/> in community <pause dur="0.2"/> terms </u><u who="nf1203" trans="latching"> mm </u><pause dur="1.7"/> <u who="nf1199" trans="pause"> so the

role of <pause dur="0.4"/> 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 <pause dur="1.5"/> can anybody <trunc>e</trunc> think of other things that are going to cause a problem </u><pause dur="1.7"/> <u who="nf1204" trans="pause"> the problems we had #<pause dur="1.2"/> <gap reason="inaudible" extent="2 secs"/> i mean for the first few months of the contract you get # <pause dur="0.4"/> taken into account of course for like <pause dur="0.3"/> a few months but <pause dur="0.4"/> let's say eight or nine months into the year and you're experiencing the <trunc>co</trunc> you know the contract <gap reason="inaudible" extent="1 sec"/> quite a lot <pause dur="0.8"/> and actually going back to the trust and asking why <pause dur="0.7"/> this is happening what's happening with their <gap reason="inaudible" extent="1 sec"/> they don't actually have the answers </u><u who="nf1199" trans="latching"> mm </u><u who="nf1204" trans="latching"> you know because <gap reason="inaudible" extent="1 sec"/> getting to the bottom of that and <gap reason="inaudible" extent="1 sec"/> <pause dur="0.9"/> <unclear>always made it</unclear>

quite small but significant </u><pause dur="1.0"/> <u who="nf1199" trans="pause"> that's the importance of having general practitioners involved in the process </u><u who="nf1204" trans="overlap"> mm </u><u who="nf1199" trans="latching"> because from a primary care point of view <pause dur="0.5"/> # <pause dur="2.3"/> i have spoken with general practitioners and they have said <pause dur="0.5"/> either two things happen one is that there's an initial rush at the beginning of the year and they drag everything in <pause dur="1.2"/> and then they've run they've run out of the contract <pause dur="0.2"/> so there isn't any money left <pause dur="0.2"/> for when we know <pause dur="0.4"/> in the winter time general medicine's going to go through the roof or whatever it might be <pause dur="0.2"/> but they they look and think gosh if they were to continue at that rate of activity </u><pause dur="0.3"/> <u who="nf1204" trans="pause"> mm </u><u who="nf1199" trans="overlap"> they'd be well over the budget <pause dur="1.7"/> the trust <pause dur="0.4"/> can either play ball or not <pause dur="0.4"/> as the case may be <pause dur="0.2"/> and some local trusts round here have actually said okay <pause dur="0.3"/> we will profile the activity with general practices based on their budget and we will agree <pause dur="0.6"/> what we will treat <pause dur="0.2"/> over a twelve month period within that block

of money <pause dur="0.6"/> and set up <pause dur="0.3"/> care profiles <pause dur="1.1"/> others where <pause dur="1.0"/> the health authority or the what will be the P-C-Gs are not the host purchasers <pause dur="0.6"/> can actually say well so what <pause dur="0.7"/> as far as i'm concerned you've referred that patient to me <pause dur="0.3"/> for care and treatment i've got a bed i've got a slot <pause dur="0.3"/> i'll bring them in <pause dur="1.1"/> charge back to the general practitioner <pause dur="1.7"/> medical and legal implications of the G-P saying <pause dur="0.3"/> don't treat that person for six months <pause dur="0.6"/> there is not <pause dur="0.5"/> 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 <pause dur="0.4"/> when they actually <pause dur="0.4"/> feel <pause dur="0.3"/> they must have felt to refer them to a specialist <pause dur="0.4"/> that they should have they need <pause dur="0.2"/> the guidance of a consultant <pause dur="0.7"/> so <pause dur="0.4"/> they're in this dilemma financially <pause dur="0.5"/> they can't afford to have this patient treated <pause dur="0.2"/> immediately <pause dur="0.6"/> however they know <pause dur="0.3"/> that they need to be treated <pause dur="0.5"/> and as waiting lists expand <pause dur="0.4"/> there's <pause dur="0.2"/> usually we we have guidance on <pause dur="0.3"/> urgent emergency urgent and non-urgent <pause dur="0.4"/> which

spreads over a twelve month <pause dur="0.2"/> waiting list period <pause dur="0.3"/> they either bring them in within six weeks three months <pause dur="0.5"/> or the year <pause dur="0.8"/> as waiting lists expand to two years <pause dur="0.2"/> you'll need the urgent to be <vocal desc="laugh" iterated="n"/> you know the the # <pause dur="0.3"/> waiting from six months <pause dur="0.4"/> to eighteen months is not going to be acceptable so they all need to be reviewed <pause dur="0.9"/> but there is going to be this tension <pause dur="1.2"/> one of the the other things that is said is that for example dermatology <pause dur="1.0"/> general practitioners refer for a skin complaint <pause dur="0.4"/> and they find that the patient's going through this ever-revolving door <pause dur="0.4"/> every three months they go back they probably don't see the consultant but they see the senior registrar <pause dur="0.5"/> it's clocked up as an outpatient appointment <pause dur="1.9"/> the doctor says <pause dur="0.3"/> well unless he <pause dur="0.2"/> you know he's monitoring that carefully he <pause dur="0.2"/> has the patient come back to him and says <pause dur="0.4"/> i've been attending the hospital for the last <pause dur="0.4"/> twelve months doctor i still haven't had any <pause dur="0.2"/> it's not better <pause dur="0.6"/> the doctor looks back through his <pause dur="0.3"/> invoicing and thinks gosh it's cost me a fortune <pause dur="1.0"/> so the G-Ps are saying after three <pause dur="0.2"/> or after four <pause dur="1.5"/> visits <pause dur="0.2"/> can you

refer them back <pause dur="1.4"/> now what that consultants will say is <pause dur="0.4"/> well if you inform me as an individual general practitioner i will do that <pause dur="0.3"/> if you don't i will continue <pause dur="0.3"/> to manage their care as i see fit <pause dur="0.8"/> so it's back <pause dur="0.2"/> in the <trunc>ve</trunc> <trunc>ri</trunc> the responsibility of the general practitioner <pause dur="0.2"/> to say <pause dur="1.0"/> either in the practice flag up on their <pause dur="0.2"/> information systems <pause dur="0.3"/> after three <pause dur="0.3"/> outpatient appointments or however many it may be <pause dur="0.6"/> flag up and say ooh <pause dur="0.3"/> this let's review this case <pause dur="0.5"/> get on the phone to the consultant or ask for a letter <pause dur="0.3"/> find out what's happening what the position is and make a decision then as whether they continue to <trunc>ke</trunc> treat them in hospital <pause dur="0.3"/> or whether they <pause dur="0.2"/> <trunc>a</trunc> have them back <pause dur="0.2"/> within the realms of primary care <pause dur="0.6"/> the consultants will say well every general practitioner is different <pause dur="0.5"/> some will be happy to take the care and treatment back <pause dur="0.8"/> some <pause dur="0.2"/> will prefer once they've referred <pause dur="0.3"/> it's like <trunc>w</trunc> <pause dur="0.4"/> over to the consultant because that's their specialism <pause dur="2.4"/> and these are all <pause dur="0.6"/> you know things that <pause dur="0.4"/> got to be <pause dur="0.6"/>

addressed </u><u who="nm1201" trans="overlap"> <unclear>another</unclear> another pressure on # from the trust point of view <gap reason="inaudible" extent="1 sec"/> i worked within a trust <pause dur="0.5"/> as against <pause dur="0.2"/> fundholders of course is all the waiting list <pause dur="0.4"/> pressures that the trust have <pause dur="0.3"/> you must get your numbers below this <pause dur="0.6"/> well we can't have <pause dur="0.3"/> # equity of treatment and say well we'll only treat <pause dur="0.6"/> that fundholder 'cause he's willing to pay or that health authority 'cause they're willing to pay but not those patients </u><u who="nf1199" trans="overlap"> mm-hmm <pause dur="0.3"/> mm-hmm </u><u who="nm1201" trans="overlap"> because then you fall foul because somebody then waits over twelve months eighteen months </u><u who="nf1199" trans="latching"> mm-hmm </u><u who="nm1201" trans="latching"> so <pause dur="0.5"/> with the <pause dur="0.4"/> primary care groups coming along and the health authority and the HIMPs <pause dur="0.8"/> they will have to take that on board and realize that's part of their remit as well as just saying well <pause dur="0.3"/> i've sent that patient i can can forget it </u><pause dur="0.2"/> <u who="nf1199" trans="pause"> yeah </u><u who="nm1201" trans="overlap"> they just can't </u><u who="nf1199" trans="latching"> no <pause dur="0.6"/> no <pause dur="0.6"/> and somebody within the primary care group <pause dur="0.4"/> board <pause dur="0.3"/> has to have that remit that role of working

with the trust <pause dur="0.2"/> to say <pause dur="0.4"/> how are we managing activity how are we jointly <pause dur="0.5"/> going to meet waiting list initiatives which <pause dur="0.4"/> hopefully <pause dur="0.2"/> by bringing them all together <pause dur="0.2"/> in a management framework they will still be independent practitioners but by bringing their <pause dur="0.6"/> waiting list issues <pause dur="0.4"/> around a <trunc>sm</trunc> around a general focus <pause dur="0.4"/> will perhaps be easier for trusts because they can deal with say five primary care groups <pause dur="0.5"/> or seven depending how big the county is <pause dur="0.3"/> rather than <pause dur="0.4"/> two-hundred-and-something G-Ps <pause dur="0.3"/> or seventy-eight practices <pause dur="0.4"/> so <pause dur="0.5"/> 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 <pause dur="3.0"/> commissioning is actually going to affect primary care as well because <pause dur="1.2"/> at the moment <pause dur="1.6"/><event desc="turns off overhead projector" iterated="n"/> think we touched on this before <pause dur="0.3"/> but at the moment if a general practitioner wants to increase their practice nursing services in general practice <pause dur="0.4"/> they apply to the health authority they put a robust bid together <pause dur="0.4"/> and with general medical services money <pause dur="0.3"/> it's addressed <pause dur="0.5"/> usually with officers round the <trunc>lo</trunc> <pause dur="0.2"/> round the table from the

local medical committee health authority <pause dur="0.5"/> and <trunc>o</trunc> <pause dur="0.3"/> commissioning <pause dur="0.4"/> # representatives and they are either saying yes <pause dur="0.4"/> or no <pause dur="0.4"/> based on the bid <pause dur="1.0"/> they're going to have to take those bids shortly to <pause dur="0.6"/> their peers <pause dur="0.3"/> their primary care group <pause dur="0.8"/> and they are then going to have to argue <pause dur="0.5"/> across their locality <pause dur="0.7"/> why they should have extra nursing hours <pause dur="0.5"/> as opposed to another colleague <pause dur="0.3"/> because general medical expenditure of that nature is cash limited <pause dur="0.9"/> in respect of agreeing <pause dur="0.2"/> the amounts <pause dur="0.2"/> out to practices <pause dur="0.8"/> it's going to be a very interesting time because not only have they got all the host of <pause dur="0.6"/> H-C-H-S issues the hospital community and <trunc>h</trunc> # health <pause dur="0.2"/> # <pause dur="0.3"/> Hospital Community Health Service budget <pause dur="0.4"/> they've also got the G-M-S issues as well <pause dur="0.8"/> prescribing <pause dur="0.3"/> another interesting <pause dur="0.6"/> # the <pause dur="0.3"/> pharmaceutical profession are actually itching to get involved in P-C-Gs <pause dur="0.4"/> because they feel they've got a role in working alongside the P-C-Gs and saying <pause dur="0.6"/> what problems do you have how does that affect <pause dur="0.4"/> what you prescribe <pause dur="1.0"/>

and can we work through some rationale <pause dur="0.3"/> in relation to <pause dur="0.5"/> working alongside you with the industry <pause dur="0.6"/> and there's still very much a big gap i think <pause dur="0.2"/> between <pause dur="0.4"/> general practice the <trunc>d</trunc> <trunc>d</trunc> pharmaceutical companies are not necessarily seen <pause dur="0.4"/> as partners in that process yet <pause dur="0.6"/> # they're actually seen as <pause dur="0.3"/> the competitors out in the field <pause dur="0.8"/> perhaps the providers of a <pause dur="0.8"/> a few <pause dur="0.2"/> diaries and a <trunc>n</trunc> <vocal desc="laugh" iterated="n"/> <shift feature="voice" new="laugh"/>and a nice lunch <shift feature="voice" new="normal"/><pause dur="1.9"/> now it's # <pause dur="1.6"/> the <pause dur="0.4"/> contracting the purchasing and commissioning process is changing <pause dur="0.4"/> and it's going to continue to change <pause dur="0.4"/> through the proces of primary care group development <pause dur="1.4"/> buildings <pause dur="0.2"/> will be part of the commissioning process so again <pause dur="0.2"/> grants for primary care premises will come into the decision making process around a P-C-G <pause dur="0.9"/> everything around that locality <pause dur="0.4"/> that involves <pause dur="0.3"/> the health improvement <pause dur="0.4"/> of people in that area will be discussed <pause dur="0.4"/> and agreed through <pause dur="0.5"/> a planning process with the primary care group <pause dur="1.3"/> and then they'll be coming back out to you and saying as providers possibly <pause dur="0.5"/> can you provide

this </u><pause dur="0.8"/> <u who="nf1205" trans="pause"> will H-C-H-S # <pause dur="0.2"/> <gap reason="inaudible" extent="1 sec"/> separate </u><u who="nf1199" trans="overlap"> no </u><u who="nf1205" trans="overlap"> or a unified budget </u><pause dur="0.4"/> <u who="nf1199" trans="pause"> they're unified budgets <pause dur="0.6"/> and prescribing <pause dur="0.6"/> one of the things they have said is they've kept staff out in the White Paper it says staff out for twelve months <pause dur="0.4"/> but it then has a little word that says it will be reviewed <pause dur="0.8"/> so my guess is <pause dur="0.5"/> that in twelve months' time <pause dur="0.8"/> there will not necessarily be the protection of <trunc>s</trunc> <pause dur="0.3"/> # primary care staff <pause dur="0.4"/> i mean at the moment there's a practice manager <pause dur="0.6"/> <vocal desc="clears throat" iterated="n"/> they're fairly protected from this process because <pause dur="0.4"/> the G-M-S that's being included in primary care groups are things like <pause dur="0.4"/> the prescribing <pause dur="0.3"/> the new money <pause dur="0.2"/> around service provision <pause dur="0.2"/> but their staff budgets are being kept out of it <pause dur="0.6"/> but you once they review that <pause dur="0.3"/> my guess is that they will bring everything that G-M-S expenditure <pause dur="0.4"/> provides into the melting pot <pause dur="0.4"/> and they could start to say well we don't need thirty practice managers across thirty practices <pause dur="0.3"/> we

actually only need five or six or seven <pause dur="0.9"/> and start to actually rationalize like they've done in health authorities <pause dur="0.3"/> they've actually said we don't need such a robust management structure we can actually manage with less <pause dur="2.2"/> so <pause dur="0.5"/> in the past it's been health authorities and trusts that have suffered <pause dur="0.7"/> the changes in the N-H-S and primary care to a degree has been allowed to <shift feature="voice" new="laugh"/>rumble <shift feature="voice" new="normal"/>on <pause dur="1.1"/> all of a sudden working with practice managers they're beginning to realize <pause dur="0.6"/> that this is no longer the case for them <pause dur="0.2"/> they could well also be at risk in the future <pause dur="0.8"/> because the budget that <pause dur="0.2"/> they <pause dur="0.3"/> have at the moment that protects them and keeps their employment safe with their doctors <pause dur="0.4"/> will be <pause dur="0.2"/> will come under scrutiny as part of the general expenditure of a primary care group <pause dur="3.2"/> training and development is another issue that is funded <pause dur="0.3"/> for primary care in G-M-S <pause dur="0.8"/> we're fighting hard in primary care to have a career structure <pause dur="0.6"/> so people like yourselves can actually start to do academic studies <pause dur="0.3"/> and become

professionals in their own right <pause dur="0.3"/> and that money at the moment is approved through a health authority <pause dur="0.8"/> but for argument's sake if you had a primary care group that decided that <pause dur="0.5"/> they didn't necessarily feel their managers needed academic <shift feature="voice" new="laugh"/><trunc>profession</trunc> <shift feature="voice" new="normal"/><pause dur="0.3"/> professional qualification <pause dur="0.5"/> and they weren't going to support it <pause dur="0.3"/> it may not happen <pause dur="0.9"/> and hopefully <pause dur="0.9"/> the <pause dur="0.4"/> the voice from <pause dur="0.7"/> you know the consumer <pause dur="0.4"/> will actually # <pause dur="0.4"/> ensure that that doesn't happen but <pause dur="0.5"/> there's # going to be an awful lot of tension i think <pause dur="0.7"/> some good a lot of good because there's going to be conformity there's going to be focus less fragmentation <pause dur="0.5"/> unified agreement over services for a local population <pause dur="0.5"/> but alongside that is going to bring a lot of culture change a lot of changes to people <pause dur="0.4"/> in the way they work <pause dur="2.8"/> any comments </u><pause dur="3.4"/> <u who="nm1206" trans="pause"> is it <pause dur="0.3"/> intended that the <pause dur="0.2"/> amount of money spent on <pause dur="0.8"/> # you know <pause dur="0.5"/> # indirect patient care sort of the <trunc>administra</trunc> administrative cost <pause dur="0.5"/> don't you think that will # be reduced <pause dur="0.2"/> with <unclear>like</unclear> P-C-Gs </u><pause dur="1.2"/> <u who="nf1199" trans="pause">

at the moment they've set something like three pounds per head of population i think </u><pause dur="0.3"/> <u who="nm1206" trans="pause"> mm </u><u who="nf1199" trans="latching"> if i remember rightly which they said around P-C-G will be based around <pause dur="0.2"/> a hundred-thousand population so that gives three-hundred-thousand pounds <pause dur="0.7"/> that has to cover <pause dur="0.2"/> all of their admin management costs and expenditure <pause dur="0.6"/> locum fees for time out for general practitioners to get involved the works <pause dur="0.8"/> # <pause dur="0.8"/> and the target <pause dur="0.2"/> for reduction is around the fundholding staff <pause dur="0.4"/> that's being obviously got rid of <pause dur="0.7"/> # who knows really i think the P-C-Gs are going some have some difficult decisions ahead of them <pause dur="0.4"/> because the N-H-S is not getting any smaller the service demands are not getting any less <pause dur="0.5"/> and they're going <pause dur="0.2"/> to be forced to actually start to look at what they're buying <pause dur="0.5"/> where they're buying it from and how they're delivering the service <pause dur="0.4"/> and certain things have already fallen off the end haven't they <pause dur="0.4"/> service provisionwise <pause dur="0.4"/> and managers <pause dur="0.2"/> in health authorities have disappeared <pause dur="0.5"/> # and they're running on

a very <pause dur="0.3"/> slim management structure <pause dur="0.7"/> # my guess is they'll probably start off quite large <pause dur="0.4"/> and then gradually again <pause dur="0.3"/> will the financial pressure will mean that they will be having to put more money into service provision <pause dur="0.5"/> and look very hard at the management across the top <pause dur="0.8"/> on the other hand if they don't have <shift feature="voice" new="laugh"/>robust management <shift feature="voice" new="normal"/><pause dur="0.6"/> good I-T <pause dur="0.7"/> good general management skills good understanding of N-H-S good public health data research information of all sides <pause dur="0.4"/> they're not going to be able to make decisions <pause dur="0.4"/> commissioning decisions that we spoke on earlier that are actually going to mean something <pause dur="1.0"/> so it's you know it's balancing the two i think </u><pause dur="1.6"/> <u who="nf1341" trans="pause"> <gap reason="inaudible" extent="4 secs"/> <pause dur="0.4"/> really </u><u who="nf1199" trans="latching"> yes health action zones are <trunc>s</trunc> are sort of # <pause dur="0.7"/> in line with public consumer consultation so it's about looking at <pause dur="0.6"/> <trunc>he</trunc> <pause dur="0.2"/> health needs <pause dur="0.2"/> and taking action against that and involving local people <pause dur="0.5"/> i haven't been

involved in any myself and i think <pause dur="0.4"/> # <pause dur="0.4"/> currently people are so worried about getting the P-C-Gs up and running <pause dur="0.3"/> appointing chief officers <pause dur="0.5"/> losing fundholding staff and just keeping themselves going <pause dur="0.2"/> that </u><u who="nf1341" trans="latching"> mm </u><u who="nf1199" trans="overlap"> i think that activity at the moment is fairly dormant </u><pause dur="0.2"/> <u who="nf1341" trans="pause"> mm </u><pause dur="0.2"/> <u who="nf1199" trans="pause"> i mean it may well be active elsewhere in the country but certainly in the Midlands it's not <pause dur="0.6"/> # <pause dur="1.3"/> i mean there are people who've been having similar things to health action zones <pause dur="0.5"/> running for some time and i presume they're still continuing <pause dur="0.5"/> how <trunc>th</trunc> whether they're feeding into P-C-Gs yet <pause dur="0.3"/> is arguable 'cause <trunc>o</trunc> their P-C-G may not be <pause dur="0.6"/> # <pause dur="0.9"/> in in into its full <trunc>con</trunc> constitution <pause dur="1.8"/> but yes <trunc>o</trunc> it's it's going to be another sort of feeding in <pause dur="0.3"/> process really into the commissioning <pause dur="7.0"/> i sound a bit <pause dur="0.5"/> doom and gloom don't i really <pause dur="1.1"/> don't mean to <pause dur="0.4"/> 'cause i actually think that <pause dur="0.7"/> # <pause dur="0.6"/> it's quite a big there's quite a difference <pause dur="0.6"/> before <pause dur="0.4"/> i was using <pause dur="0.7"/> used to have a health authority <pause dur="1.0"/><kinesic desc="writes on flip chart" iterated="y" dur="59"/> that was responsible for purchasing care <pause dur="0.5"/> across five-hundred-<pause dur="1.6"/>thousand patients <pause dur="0.3"/>

so this is take Warwickshire <pause dur="1.1"/> then we had fundholding <pause dur="2.5"/> and health authorities <pause dur="0.5"/> which split that responsibility <pause dur="0.7"/> and at the beginning <pause dur="0.2"/> we had very few G-P fundholders <pause dur="1.6"/> and we had still the majority of care <pause dur="0.4"/> purchased by the health authority <pause dur="0.9"/> as G-P fundholding gathered momentum <pause dur="0.5"/> through the nineties <pause dur="0.6"/> we actually then started to have <pause dur="1.4"/> percentage of G-P fundholders in Warwickshire <pause dur="0.3"/> was around eighty-five per cent <pause dur="0.9"/> and <pause dur="1.2"/> the <trunc>gen</trunc> the the same amount of services that was within <trunc>h</trunc> health # was <pause dur="0.4"/> the balance <pause dur="0.2"/> however around that the health authority never lost <pause dur="0.3"/> things like learning disabilities <pause dur="0.6"/> mental health <pause dur="0.5"/> emergency care <pause dur="1.5"/> et cetera they they've always hung on to that <pause dur="0.3"/><vocal desc="clears throat" iterated="n"/> but in relation to the <pause dur="0.3"/> fund what inclusion exclusion of fundholding <pause dur="0.3"/> fundholding grew <pause dur="0.3"/> and the responsibilities of the health authority reduced <pause dur="1.0"/> the difficulty with that is <kinesic desc="writes on flip chart" iterated="y" dur="4"/> underneath the G-P fundholders you had <pause dur="1.7"/><kinesic desc="indicates point on flip chart" iterated="n"/> all these different practices <pause dur="0.2"/> all with different working ideas all with different views on how services

should be delivered <pause dur="2.3"/> forming a strategy <pause dur="4.5"/><kinesic desc="writes on flip chart" iterated="y" dur="4"/> and if we look at back at commissioning deciding <pause dur="0.8"/> from <pause dur="0.6"/><kinesic desc="indicates point on flip chart" iterated="n"/> this point of view <pause dur="0.5"/> what's best to buy <pause dur="0.5"/> how do you get all <kinesic desc="indicates point on flip chart" iterated="n"/> these different people to agree <pause dur="0.8"/> to change something <pause dur="0.3"/> very very difficult very very cumbersome <pause dur="0.5"/> so as a health authority officer <pause dur="0.7"/> we divided into <kinesic desc="writes on flip chart" iterated="y" dur="2"/> five groups <pause dur="1.3"/> which was the start of things to come in Warwickshire they started to say <pause dur="0.5"/> well let's start to <kinesic desc="writes on flip chart" iterated="y" dur="5"/> Nuneaton as one <pause dur="1.2"/> Nuneaton and Bedworth <pause dur="1.0"/> south Warwickshire <pause dur="0.2"/> et cetera so we started already to to focus our <pause dur="0.7"/> # view <pause dur="0.2"/> around local populations <pause dur="0.6"/> and involve <kinesic desc="writes on flip chart" iterated="y" dur="2"/> within those <pause dur="0.2"/> the G-Ps <pause dur="1.6"/> now what's happening with the White Paper <pause dur="0.3"/> is that actually takes that a step further <pause dur="0.3"/><kinesic desc="writes on flip chart" iterated="y" dur="8"/> and it makes them <pause dur="1.5"/> responsible <pause dur="1.4"/> but they're responsible <pause dur="0.5"/> for all <pause dur="0.6"/> the purchasing of that area <pause dur="0.7"/> so what it does do <pause dur="0.3"/> is it actually avoids the fragmentation <pause dur="0.8"/> it recreates the focus again <pause dur="0.3"/> and it ensures the involvement of doctors <pause dur="0.3"/> 'cause even when we were working <kinesic desc="indicates point on flip chart" iterated="n"/> here <pause dur="0.4"/> and we had a commissioning group <pause dur="0.7"/> it's only the <trunc>s</trunc> <pause dur="0.2"/> sort

of <pause dur="0.4"/> willing G-Ps <pause dur="0.3"/> that # would actually get involved <pause dur="0.2"/> here <kinesic desc="indicates point on flip chart" iterated="n"/><pause dur="0.4"/> they have a constitution that gives them the right to be part of the decision making process <pause dur="0.4"/> around it in in <trunc>k</trunc> # developing strategy <pause dur="0.4"/> purchasing and commissioning decisions <pause dur="0.5"/> so i actually think <pause dur="0.6"/> although i <pause dur="0.5"/> # <pause dur="0.5"/> it's going to be fraught with its problems it does actually bring back some cohesion <pause dur="0.8"/> and <shift feature="voice" new="laugh"/>we <shift feature="voice" new="normal"/> before long we'll be calling them <pause dur="0.4"/> well i remember a <pause dur="0.3"/> a consultant in public health that worked for the health authority saying <pause dur="0.3"/> why don't we call them <pause dur="0.4"/> discrete homogenous areas <pause dur="1.3"/> which is the same abbreviation as district <shift feature="voice" new="laugh"/>health authorities <vocal desc="laughter" iterated="y" n="sl" dur="1"/> <shift feature="voice" new="normal"/> so we've gone full circle <pause dur="0.6"/> so you know that <pause dur="0.3"/> that to me is an example of where we're moving it's trying to bring people back <pause dur="3.7"/> on that note <pause dur="0.8"/> unless there's something else <pause dur="1.3"/> i love this <pause dur="0.4"/> and i think i may have put it up before but i'm going to put <event desc="puts on transparency" iterated="n"/> it up again 'cause i actually think this sums up the whole process <kinesic desc="turns on overhead projector showing transparency" iterated="n"/> and it's from a report from

Buckinghamshire <pause dur="5.8"/> developing <pause dur="0.5"/> the <trunc>c</trunc> G-P commissioning role <pause dur="1.1"/> 'cause they want to know if they should buy sugar for the tea <pause dur="0.4"/> is that a clinical issue <pause dur="0.2"/> issue or do we take a vote <vocal desc="laughter" iterated="y" n="sl" dur="2"/> <pause dur="1.9"/> so <pause dur="0.6"/> it's probably a little bit # <pause dur="0.4"/> light-hearted but it is actually going to be quite a bit like that i think <pause dur="3.4"/> hence the need <pause dur="0.3"/> 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 <pause dur="0.3"/> who's very confident about what they're about <pause dur="0.3"/> from the clinical profession <pause dur="0.3"/> and public health or whoever they may be <pause dur="0.4"/> to say yes that decision is right <pause dur="0.4"/> because it's <pause dur="0.3"/> clinically effective <pause dur="0.6"/> or whatever <pause dur="1.3"/> and that's it <pause dur="1.2"/> right it is ten to five <pause dur="0.5"/> if you haven't got any other questions <pause dur="0.7"/> i will let you go