John Hutton -2004 Speech on Practice Based Commissioning

Below is the text of the speech made by John Hutton, the then Minister of State for Health, on 7 December 2004.

Can I first of all thank the HSJ for giving me the opportunity of saying a few words at this very important gathering.

This is a decisive moment for the future of primary care in the NHS. Last year we saw agreement on the new contracts for GPs and the first tranche of new investment to go in alongside it. Next year we will see the introduction of the new practice based commissioning arrangements. Both of these changes have the potential to fundamentally change the quality, capability and capacity of primary care services. We need to take full advantage of these opportunities if we are to maximise the benefits of both. We need to do this for one very obvious reason.

The NHS was built on the foundations of primary care and primary care remains central to its future. Nearly all of our patients begin and end their treatment in a GPs surgery. Primary care continues to enjoy the highest satisfaction rates of any part of the National Health Service. It has a proud record in public health and health promotion. And despite all of its detractors, NHS primary care is still the envy of every other developed health care system and a model admired right across the world. If primary care is the cornerstone of the NHS then it is clear that the ambitions we have for the NHS can never be fully realised unless primary care has the tools to do its job properly.

But I believe we have every reason to be positive and optimistic about what lies ahead for both primary care and the NHS.

There are more GPs and nurses working in primary care than at any time in the history of the NHS. More doctors than ever before want to work in general practice. As a result, people can see their GPs more quickly and there are more services available to patients. Many GP surgeries have been improved and modernised – creating a better environment in which both to work and to treat patients. And there is a steady increase in resources going in to primary care. Helping to build up capacity and capability even further.

So we’ve come a long way. But clearly not everything is perfect. Not every part of primary care in our country has seen all of these improvements. The pressures are still there and they are experienced every day by hundreds of dedicated staff and thousands of increasingly frustrated patients. So it is not my argument today that every problem in primary care has been solved. We all know that isn’t true. Nor am I saying that primary care cannot improve further still, because we all know that it can. My argument today is that primary care has an extraordinary opportunity to build for the future. To play a leading role in shaping our definition of healthcare. To make Britain a healthier place to live for me the most important thing is the health of the poorest of all.

If we are going to take advantage of these opportunities there needs to be further significant investment and change in primary care. Not change for changes sake. But reform with a very clear purpose. To strengthen primary care and to improve the service it provides helping, in the process, the NHS to become the service we all want it to be.

Advances in technology and in our understanding of illness and disease together with an expanded workforce and greater resources will allow us to provide more services to a higher quality. So in the future more surgery, testing and diagnostics will be performed in primary care settings.

GPs with a special interest will take on new roles that have, until now, always been the exclusive preserve of hospital consultants – particularly in the area of chronic long term illness. Nurses and other health care professionals working in primary care will similarly see their responsibilities expand as they enter into new partnerships with GPs to deliver GMS and PMS.

New contractual frameworks will, for the first time, allow both for improvements in the quality of services to be properly rewarded for the first time as well as encourage new providers to enter primary care and help deliver a wider range of NHS services. Expanding choice as well as accessibility for patients.

The introduction of new information technology applications in primary care through the National Programme I hope too will herald further improvements to the quality, safety and convenience of the service we provide to the public.

All of these changes are designed to improve the service available to patients in primary care and are going to be backed up higher investment in primary care – up by a third over the next few years. And who better to lead this process of change than our family doctors and our primary care staff who have always been at the forefront of innovation in the NHS.

That is why I believe the engagement and involvement of front line professionals themselves is going to be essential to the success of these reforms.

Thousands of doctors and nurses are currently engaged in designing new ways of working and are hoping therefore to reshape the boundaries between primary and secondary care.

I want this to be the norm everywhere in England. I want GPs and their practice staff to be properly enabled and encouraged to fashion services around the needs of patients. Where we do look critically at all of the care pathways patients follow to ensure we offer the best possible configuration of expertise and resource.

To make this happen, I don’t think we need another re-organisation. But we will require a new balance of responsibilities in primary care, with new powers for general practices to work creatively with their local NHS partners in taking the key decisions that affect the delivery of frontline services.

We set out in July our plans for practice led commissioning. Next week we will publish the final guidance. There won’t be any major changes. From next April, every practice will have the right to hold a practice level commissioning budget. From elective care to prescribing, from chronic care to diagnostic screening, practices will be better able I think to help determine the future shape of the NHS.

There will be no new targets. No one will be forced to do anything they don’t want or choose to do. Instead, we will set out what practices are entitled to receive as a budget and how any disputes about the budget can be easily resolved. We will set out the ground rules about how any savings can be re-deployed into developing better services. And we will highlight many of the local success stories from around the country where practice led commissioning is already making a major contribution to the work of our NHS.

Within this framework, people will be free to determine their own pace of travel. They will be free to develop their own local preferences. They will be free to do it their own way. Because here there is no one size fits all model and therefore we will not be imposing one.

So this will be a bottom-up process. Led by GPs and their practice staff and working alongside PCTs and NHS Trusts to deliver the best possible services that we can provide. We want to see local innovation resulting in flexible high quality services for patients. And, if innovation leads to money being freed up, which I believe it will, then it will be ploughed back into patient care to further improve the services that patients receive.

We have always been clear about the need to fully involve GPs and practice staff in local decision making in the NHS. In our very first White Paper on the NHS in 1998, we made clear that we wanted to:

“Extend to all patients the benefits, but not the disadvantages of GP fundholding”

That is what practice based commissioning is all about. It is not a return to the fundholding arrangements of the past.

Unlike fundholding, there will be no extra resources going to those practices who take up PBC. There will be a level playing field for all practices whether they want to take advantage of PBC or not. No patient will be unfairly disadvantaged if their practice decides not to take up these new opportunities to have more say over how local services are designed. That wasn’t true under the policy of fundholding.

Secondly, PBC, unlike fundholding, will not usher in a huge expansion in bureaucracy as PCTs will still retain legal responsible for the contracting process.

And finally, there will be no return to the situation under fundholding where it frequently came down to which hospital could provide a service at the lowest possible price. The single national tariff will prevent this from arising. PBC will instead focus on quality and efficiency. This will put the interests of patients first. As it should be.

So we remain clear that it was right to end fundholding because it unfairly discriminated against the patients in those practices who chose not to take it up and because it spawned a giant bureaucracy. So we won’t be repeating these mistakes with PBC.

But clearly in return for the significant new freedoms that PBC will bring I do believe that it is fair and reasonable for PCTs to expect that primary care services will operate to the appropriate level of customer service and convenience. For example, patients should be able to take advantage of electronic booking systems that connect GP surgeries to hospital admission systems. And patients should also be guaranteed prompt and fast access to GPs and their practice staff.

There will also be effective safeguards to ensure value for money and the proper use of public funds. Practices will have the responsibility of balancing their budget over three years and PCTs will have the right to intervene if public money is being used inappropriately. In balancing rights and responsibilities, we want to encourage PCTs and practices to work in a mature partnership to ensure the best outcomes for their patients.

We are not promoting Practice Based Commissioning at the expense of commissioning at a locality level by groups of practices. For the correct size for commissioning care varies for different services.

And we should aim high. I hope that all practices will be involved in Practice Based Commissioning by 2008. Within that context, people can decide their own pace of change. We will actively support those practices and PCTs who want to take advantage of the possibilities that practice led commissioning provides. Next year, we will be offering support to the NHS in the form of further technical guidance and IT support, which I think will be essential. This will give practices the tools they need in order to take the fullest advantage of these new opportunities. The rest will be down to you. You will write the next chapter in the history of NHS primary care. That is how it should be, because there is no one better placed to do that than Britain’s family doctors.

The ultimate test of any new policy must be what benefits it brings for patients. I believe Practice Based Commissioning will be particularly advantageous for people with long-term conditions, allowing their doctors to commission integrated care that ensures holistic treatment of a condition. Diversity of provision and more use of primary care should also reduce waiting times. In North Bradford PCT, which has been using Practice Based Commissioning for 4 years, waiting times are well below six months. And Practice Based Commissioning will give GPs and their patients greater choice in how services are provided and should lead to more varied and more local services. For instance, East Devon PCT has used Practice Based Commissioning to reduce reliance on secondary care. Patients that would have gone to the Royal Devon & Exeter Hospital for Ear Nose and Throat complaints are now being treated in a primary care setting by practitioners with special interests.

These are a just a few examples of the benefits that Practice Based Commissioning offers. It will be for those who work in the NHS to explore the full potential.

Practice Based Commissioning is part of a journey to improve the NHS and make it the service we all want it to be. Focused absolutely on the needs of patients. On managing referrals into secondary care efficiently and effectively. On providing services in the most appropriate setting possible and as close to the patient as we can. That journey is not over yet. We still have a great deal to do. But even our most sternest critics would, I think, be prepared to acknowledge that there are now real and tangible signs of progress right across the country. Shorter waiting times. Reduced mortality from cancer and coronary heart disease. Newer hospitals and better GP premises. Faster access to the latest drugs, treatments and equipment that can help us improve our ability to diagnose and cure our patients. This is down to the hard work of people like you in the NHS.

So I want to conclude my remarks by expressing my own appreciation for your commitment to the NHS and for the values it stands for. Those values have never been more relevant to our society than they are today.

Our challenge is simple. It is to make these values meet the aspirations of the British people for the best possible healthcare that money can buy. Work with us to meet those aspirations. Help us to make the NHS the service we know it can be.