the hsj interview: Dr Peter Smith

Published: 16/01/2003, Volume II3, No. 5838 Page 22 23

For National Association of Primary Care chair Dr Peter Smith, frontline service doesn't mean primary care trusts.His idea of a devolved health service is the involvement of doctors and managers at practice level

Devolution of power and influence to a local level is one of the most hotly debated topics in the NHS. From prime minister Tony Blair down, everyone appears to agree that, in principle, it is a good thing.

However, ask a representative cross-section of NHS staff what 'a local level' actually means and you are likely to get a wide range of answers.

Dr Peter Smith, chair of the National Association of Primary Care, has a very clear idea what it means - or rather what it does not.

'The words 'front line' have often been applied to primary care trusts. Primary care trusts are not the front line.'

The 'front line', in Dr Smith's eyes, is represented by the medical professionals and managers working at practice level.

This view, of course, is hardly surprising. NAPC was formed in 1998 following a merger between the National Association of Fundholding Practices and a splinter group, the Association of Independent Multifunds.

Over recent years, NAPC may appear to have lost out in the battle for influence to the NHS Alliance, whose genesis lay in opposition to fundholding during the early 1990s.

But policy appears to be flowing back in NAPC's direction. Indeed, NAPC says it has been consistently influential in shaping government policy - it has simply tended to keep quite about it.

Dr Smith claims, for example, that NAPC was 'able to bring influence to bear' in shaping the recent priorities and planning framework document.

1A quick glance at the framework gives weight to his boast: 'The planning process [undertaken by the NHS] itself will need to involve all the relevant organisations and, most importantly, the frontline staff who must make the vision happen. For example, staff in general practices must be actively involved through improved engagement with PCTs.'

Dr Smith believes NAPC has few battles left to fight on policy, but that giving an impetus to implementation is now key.He says he is looking forward to a 'wonderfully exciting year', but he warns that 'if there is no movement now, people will permanently disengage'.

Arguably the biggest test of the 'improved engagement' required by the priorities and planning framework will be the commissioning arrangements that PCTs put in place.

Some have caricatured NAPC as wanting to return to the days of fundholding. Not so, claims Dr Smith, although he says recent commissioning arrangements, which have largely been a case of 'demand and divi', with 'the person who shouts the loudest getting the most money', are hardly anything to get excited about either.

NAPC's vision for commissioning during 2003 is a steady growth in engagement as set out in the priorities and planning framework, with a number of practices and PCTs operating personal medical services contracts forming the leading edge.

Dr Smith says he is realistic enough to know that during the next year there are going to be a lot of pressures on PCTs and that 'to expect them to set up a new commissioning service which involves detailed discussion with every individual player would be unreasonable'. But he expects every PCT to be 'working towards re-engagement'.

Involving practices in commissioning 'has to become part of the way the NHS works', he says. 'We know It is never going to be the top priority, but we need regular reminders to PCTs of their responsibilities. The framework shows the government means business.'

This kind of central diktat is essential, says Dr Smith, 'in a service which is still sadly very tied up with command and control'.

There is a question mark over 'what sort of hard evidence' PCTs must provide to demonstrate their compliance, but Dr Smith has no doubt that the Commission for Health Improvement should examine how well PCTs involve practices in commissioning during its forthcoming reviews.

For the average GP practice, NAPC believes it is an improved flow of information that could and should make the biggest, earliest impact.

There is another part of the framework that appears to bear NAPC's fingerprints: 'It is important that there is a local sharing of performance and financial data [particularly between PCTs and providers of healthcare such as acute hospital trusts and GP practices] to inform local planning.'

The online system for comparison analysis or reporting - Oscar - is a web-based version of the performance analysis toolkit. It contains regularly updated information on, for example, length of stay, waiting times and readmission rates by PCT, provider, specialty or health resource group.

PCT chief executives can also get the same information for individual practices.As a 'very basic minimum', Dr Smith believes the chief executives should ensure that this information is available as a matter of course on GP desktops.

By doing this, Dr Smith believes that GPs will better be able to understand the care patients are receiving and conclude how commissioning power should be used to improve it. This will be made easier as indicative budgets for services are added to the system.

Dr Smith sees no reason why the actual 'buying process' needs to happen at practice level.

'Experience in multifunds and commissioning groups showed you do not have to do that, ' he says.

However, the 'specification of how resources are used' is a different matter. 'You need to have a clear link between activity and the commissioning process. They're divorced at present. There is no link to the people actually generating activity.'

Dr Smith says that, in time, 'there is no reason why a significant proportion of the resources used for secondary care services should not be specified at practice level. 'GPs have to know what resources are associated with that activity to make a sensible judgement, 'he says.

Providing this kind of information could also make it easier to move services out of secondary into primary care. 'The problem with getting services out of secondary care is identifying the resources associated with it. In the past, secondary care has cried foul and said if you take this activity out, you're going to destabilise it.'

Having access to the Oscar data will be the first step in determining whether it is a good idea, for example, for a group of GPs or practices to undertake 'lumps and bumps' surgery or outpatient clinics. 'I do not see any reason at all why most outpatients services are delivered within hospitals - most can be delivered in primary care settings, ' adds Dr Smith.

Of course, he points out, commissioning decisions taken by practices need to be 'within a strategic framework'. But this should also be 'defined locally'.

Dr Smith believes that access to the kind of information provided by Oscar will also be vital if patient choice is to work.

He points out that the GP consultation room will be where the patient 'interfaces with the commissioning process'. He adds: 'A very significant percentage of GPs, nurses and primary care management feel they have no influence over the commissioning process. Unless that changes, I can't see them being particularly interested in influencing the way patients make decisions. They also, of course, need the data to help patients make those decisions in an informed way.'

He continues: 'Many PCTs may feel they will lose control [because of patient choice], but devolving power to GPs will help them retain it.'

In the days of fundholding, Dr Smith says patients would often 'want to go to the hospital with the machine that went 'ping' which they'd seen on television', regardless of the appropriateness for the individual or the impact on commissioning arrangements.

An engaged and informed GP can help patients make choices that are good for them and the local health economy.

'Where a patient is making a choice, It is the individual that interfaces directly with them that has the greatest influence, ' observes Dr Smith.

Giving practices and individual GPs more say over commissioning is also the secret to tackling the growing disillusionment among primary care clinicians over the NHS reform process, he believes.

GPs, he says, are having to deal with 'a lot more complaints from individual patients who feel they are being lost in the system'.Access to information and the influence over the commissioning system will allow GPs to deal with complaints more effectively.

This, together with a greater sense of ownership of the commissioning process and the ability to respond to patient needs will produce 'a far greater level of [job] satisfaction'.

NAPC expects to see the greatest strides on commissioning being made during this year in practices which operate under PMS, particularly PMS Plus, which offers the opportunity to provide enhanced services, and especially where such contracts are PCT-wide.

Already under PMS, community services are 'there to be effectively commissioned' by practices and it is under PMS that indicative practice budgets are likely to emerge. This, of course, would give practices the effective control over resources that NAPC believes is so important.

Dr Smith says PMS practices and PCTs are likely to take different routes and move at different speeds on indicative budgets. The more cautious are likely to restrict budgets to individual services, while the more ambitious may use them on a much wider front.

However, for this to happen, he believes there has to be much greater encouragement for practices to explore the PMS model.

He says NAPC regularly comes across numerous examples of practices being told by their PCT that PMS Plus schemes are 'not in our strategy'.And though the government has made it clear that it wishes PMS to be a permanent option, NAPC is still having to deal with situations in which practices are cautioned by PCTs that the contract 'has a limited lifespan'.

'It reminds me of a joke, ' says Dr Smith, 'about the guy walking into a bar and asking for a pint of real ale, and the barman replying, 'Sorry we do not have any. You're the 30th person today to ask for real ale and I've told them all that There is no call for it round here'.'

The government, he says, should remove the contract's pilot status as quickly as possible to make it clear that PMS is here to stay.


1Improvement, expansion and reform: the next three years' priorities and planning framework 2003-06, www. doh. gov. uk/planning2003-2006/