The following interview with Andrew Lansley, secretary of state for health, is reproduced with the kind permission of the Royal College of Physicians. The interview was first published in Commentary, October 2010, the RCP membership magazine, and is based on questions submitted by RCP fellows and members.
Q. Given the additional strains on clinicians’ time resulting from the proposals in the white paper, Equity and Excellence: Liberating the NHS, what will you do to enable us to find the time for carrying out the revalidation process?
A. I want a system of revalidation that works for patients and for the medical profession - a system that is robust, efficient and cost effective. That’s why we have extended the current revalidation pilots for another year - we want to get it right. I understand that there are many pressures on clinicians’ time, and we will use the pilots to ensure that the benefits of revalidation really do outweigh the costs for the medical profession and patients.
Q. I warmly welcome the re-engagement of clinicians in healthcare planning, but we do not want to risk duplicating lots of bureaucratic time negotiating new contracts for small numbers of patients from several local practices or consortiums. How will relatively small consortia of GPs be knowledgeable enough to commission services for low-volume, high-cost disorders such as adult cystic fibrosis?
A. GP consortia will help us bring together the management of care with the management of resources - and that’s vital for a more effective and efficient healthcare system. There are practical challenges we will need to face, not least the skills challenge around commissioning. However, consortia will have access to expert support if they feel they need it and the NHS Commissioning Board will provide expert commissioning guidelines to further support them.
And we are also currently consulting on how the NHS Commissioning Board and GP consortia can best work together to ensure effective commissioning of low-volume services. I would welcome the RCP’s views on how we can get the right skills in the right places to support consortia arrangements.
Cystic fibrosis is an interesting case where we can improve on current commissioning. My discussions with the Cystic Fibrosis Trust have shown how their work has helped identify the key factors in individual trusts, and they are working on a more effective tariff. With clear quality indicators and a better tariff structure to incentivise quality and more patient input I am sure we can do better.
Q. Should hospital consultants hold positions within the commissioning consortia so that they can contribute their knowledge and experience to the task of commissioning such models of care?
A. Given their key role in coordinating care, GP practices are well placed to lead on commissioning care for patients. But clearly we would expect consortia to involve relevant health and care professionals from all sectors in helping design care pathways or care packages that achieve more integrated delivery of care. Working between GPs, specialists and other providers is instrumental to service improvement.
Q. How is the secretary of state planning to handover to primary care in England such a large responsibility of healthcare when most general practitioners at present do not take responsibility for their patients after 6 pm on weekdays and at the weekend/bank holidays?
A. Their responsibility was taken away through the 2004 contract. GPs, in my experience, want to be involved. Through the GP consortia, we are putting general practice in its rightful place - at the very heart of the healthcare system. GPs are closest to their patients and are best-placed to secure the right services for them at the right time.
We are currently working with GP organisations to sort out the detail of what this means in practice. But I’ve been clear that the consortia will be required to take over responsibility for commissioning out-of-hours care, which will form part of a 24/7 high-quality, urgent-care system.
Now this doesn’t necessarily mean a return to the old days, where GPs were individually legally responsible to offer out-of-hours services themselves - though some may choose to do so. Instead, we are expecting local GPs to commission the best out-of-hours service for their patients and to be clearly accountable for the standard of care received - whether that’s during the day or at night.
Q. Would the secretary please re-consider the penalty charge for readmission as the current one may make consultants reluctant to discharge and lead to prolonged lengths of stay?
A. I think the statistics tell a story. Over the last 10 years, emergency re-admissions have increased by 50%. I don’t believe this is because patients have become more frail but because hospitals have been incentivised to push people out early. It’s a classic case of process targets creating risks for patients.
Our proposals are about sending a powerful signal to the NHS - that it is outcomes, not activity, that matter. By withdrawing payment for re-admissions we are making it absolutely clear that patient care doesn’t end when patients walk out of the hospital door.
I don’t see this as a fine or a penalty charge, but as a way of ensuring hospitals discharge patients when it is best and safe for them to do so; and we will ensure that the resources are provided to reflect these additional responsibilities. It may be earlier - if the hospital can be sure they have the right team in place. This will also stimulate the NHS to forge meaningful connections with community services to ensure patients are fully supported in recovery.
I also recognise that some re-admissions are appropriate - for instance it may be in the best interests of a child with a long-term condition to be sent home, although there is a risk of re-admission. We plan to adjust the tariff prices for initial admissions to take account of such ‘appropriate’ re-admissions.
Q. There was little related to the education of trainee doctors in the white paper. What changes does the secretary of state see in the delivery of education to trainee doctors? Who will commission education and training?
A. Training and supporting the next generation of doctors is essential for the long-term future of the NHS. I want to make sure we’re attracting the brightest and best, and that we’re planning appropriately for new demands as our healthcare needs change.
We’ll be publishing a consultation on how education and training needs to evolve later this year. Certainly it’s clear to me that we need to make the system simpler, more efficient and more employer-led. But I also want to make sure the professions, the royal colleges and the NHS contribute to this process, and I hope as many of you as possible will get involved in the consultation.
Q. Will the new government be advised to take a firm stand with the European Commission and say that the EWTD does not work in England and should be modified?
A. Practising medicine is a 24/7 business and I’m conscious there are significant problems associated with limiting doctors’ hours in line with EWTD.
We cannot - and will not - go back to a situation where doctors are working 100-hour weeks. I consistently supported our New Deal for Junior Doctors to ensure we stopped excessive hours. But it’s also clear that the directive isn’t working for patients or the profession in its current form.
I will support the business secretary in taking a robust approach to future negotiations on the revision of EWTD. It is essential that the opt-out is retained, and that a workable solution is found.
In the meantime, I’ve asked Medical Education England to work with the profession, the service and the medical royal colleges, including the RCP, on proposals to improve training practices and support greater continuity of care under the current system.
Q. Given that there are increasing numbers of trained specialists coming through the system and a shortage of new consultant posts, how are the current expectations of the medical workforce to be met?
A. You are absolutely right to say that medical training posts need to meet future demand for specialists rather than current service demand for junior doctors.
There were some reductions made in training post numbers in 2009/10 and we need to build up the evidence to match specialty training to future needs.
That’s why the Centre for Workforce Intelligence has been commissioned to provide initial recommendations on medical specialty training numbers for 2011 by specialty - this will give us a solid foundation for planning the clinical workforce of the future.
Q. Will the coalition’s determination to encourage clinical audit be backed up with continuity funding for mature audits as well as help for start-ups?
A. I’ve been clear that good information is a catalyst for better performance. I want to encourage clinicians to examine what they do against explicit criteria and by comparison with their peer group. I have, in opposition, been very much aware of the way in which the Myocardial Infarction Audit Project and the Sentinel Stroke Audit have helped drive improvements.
That’s why we will continue funding the National Clinical Audit and Patient Outcome Programme (NCAPOP) this financial year, and will also extend national clinical audits to support clinicians across a much wider range of treatments and conditions.
Funding for NCAPOP is there to get more clinical audits off the ground and we are looking at how we can encourage the NHS to use a range of funding options for established audits more effectively. We are also keen to put more information from clinical audits into the public domain and develop clear outcome measures.
What is important is that the local NHS grasps that good information is integral to quality and patient safety, and makes the right investment.
Q. Does the government have any plans to revise the rules and regulations surrounding recruitment of international medical graduates (IMGs) to ease the lack of locum doctors?
A. We want to attract the very best doctors into the NHS - and that includes drawing on talent from abroad where appropriate. There are now far more doctors working in the NHS than ever before and the NHS is now more self-sufficient in the training and development of our own doctors.
However, we are open to bringing in outstanding doctors from abroad, and if no suitable UK or European doctor is available to fill a post, the current immigration rules do allow fast-tracking to secure an IMG.
Q. Since its introduction in 2007, smoke-free legislation has already had a positive impact ‘at the coalface’ of medicine. What plans do you have to protect people, specifically children, further from smoking and smoke?
A. Public health is about striking the right balance between regulation and responsibility. Certainly, we know that the smoke-free legislation is improving health and saving lives, and so we have no intention of rolling back legislation in this area.
But we need to be aware of the continuing prevalence of smoking so, in terms of going further on tobacco control, we need to look carefully at the evidence of what actually works. We will say more about our plans when we publish our public health white paper later this year.
