Gerry and the GPs Panorama


Gerry and the GPs

In this special edition of Panorama, troubleshooter and businessman Sir Gerry Robinson examines the government's plans for the biggest shake-up of the NHS in its history.


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Transcript


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I'm Gerry Robinson. I have been in business all my life. I have turned

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around failing companies, and I've managed billion-pound budgets.

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Three years ago I spent months inside a hospital for a BBC series

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trying to work out how to make the NHS run more smoothly. Now, as it

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faces its biggest transformation Since the Government announced the

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Health and Social Care Bill last year, there's been fear and anger

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amongst the public about where our Health Service is headed. If you

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have money driving your decisions, they won't be the best decisions

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for the patients. The reforms aim to save �20 billion over three

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years, but are GPs the right people to put in charge? What

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qualifications do people have to manage something of that scale?

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What qualifications do you have to... That's an extremely good

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question and one that I often ask myself in the middle of the night

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when I'm not sleeping very well. I'll find out where our Health

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Service is failing... So you think procedures are happening either

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carelessly or deliberately that don't... Deliberately. That don't

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need to happen? Correct. I meet the man who is staking his political

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reputation on these reforms. We've opened the Pandora's box, you know.

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Every worry about the NHS is now coming in to be part of the

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question of how do we deal with it I've never seen an organisation

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like the NHS, as dysfunctional as it is loved. I don't know what

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these reforms are going to do to the Health Service, so I think it's

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important that I get out there and meet the people who, you know, when

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the dust settles are going to have to put these reforms into practise.

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As the Government's health reforms have generated debate, I have been

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travelling around the country to form my own view on the Bill. I

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think these plans have been very poorly communicated. It's -

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everyone is confused by it, and that confusion is simply not

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helpful. Despite the Government's listening exercise as the Bill goes

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back to Parliament, the key aims remain the same, from what I can

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see - most important is a bigger role for GPs. They'll be at the

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heart of the new bodies that will replace Primary Care Trusts in

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making decisions on behalf of us, the patients.

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And there's one GP who our Prime Minister wants us all to know is

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right behind the plans. Calm down, dear. Calm down. Calm down.

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LAUGHTER Listen - calm down and listen to

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the doctor. Howard Stoate GP a says this, "My discussions with fellow

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GPs reveal overwhelming enthusiasm for the chance to help shape

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services for the patients they see daily."

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Will you tell me how you have been, George? Fine, absolutely fine. I

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have been having physiotherapy, physiotherapy treatment. Tell me

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how you found the physiotherapist? Very good indeed. Howard Stoate has

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been a GP for 29 years and was a Labour MP for 13 of those. Here in

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the commuter belt of Bexley, the PM's poster boy for the reforms and

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his fellow GPs have had control over patient care since 2008.

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morning, Gerry. Welcome to the Albion. How does it work in

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practise? Instead of GPs saying what services are available to this

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patient, and say this hospital provides this service that hospital

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provides that service - that's actually - we think - the wrong way

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around. If you start with a blank piece of paper, how would you best

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design a service, not pick a service off a menu of a service

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that exists, - how would you design a service from scratch that meets

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the patient's needs, and you start from there. The NHS budget for,

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butly alone is �350 million a year, and up till now, while GPs here

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have been making the decisions, the Primary Care Trust has still been

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signing the cheques. In future, Clinical Commissioning Groups led

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by GPs like Howard will control the money.

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I have managed budgets of this size, and I know what it requires. I

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can't help wondering if GPs are the right people to take control.

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What qualifications do people have to manage something of that scale?

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What qualifications do you have to - to... That's an extremely good

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question, and one I'll ask myself often in the middle of the night

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when I'm not sleeping very well because it is a great concern to me.

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What I would say in my defence is that GPs are very good at what GPs

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do. GPs are very good at understanding patient needs. GPs

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are very good at talking to their patients to know exactly what their

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needs are. To prove to me just how well GP commissioning can work,

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Howard sent me to look at a local cardiology scheme that's won

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countless awards. It's the brainchild of one of Howard's

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colleagues who felt his local hospital had him and his heart

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patients over a barrel. When we tried to get a breakdown of

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the Bill we used to get for cardiology, it took us 18 months to

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find out why we're paying the money. GPs should have the power to look

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at the books and see where every penny of taxpayers' money is going

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to. Kosta used to refer his heart patients to his local hospital,

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where consultants usually ordered an angiogram, an expensive,

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sometimes painful, test where dye is injected into a vein.

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So Kosta used his new commissioning power to bypass the old system. Now

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he has a top cardiologist from a London teaching hospital come to

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Bexley to examine his patients on the spot and decide what tests are

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needed. It's meant fewer costly angiograms, but that's not the only

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change. When the consultant sees the patient, he decides whether he

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needs further investigations, and if he needs angiography, instead of

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sending them to the hospital, he sends them to Harley Street with

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the transport provided by the service. Welcome to the weekly

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heart bus to Harley Street courtesy of Kosta. I caught the bus to meet

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the specialist who decides who gets on - cardiologist Dr David Brennand

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Roper. He's convinced the scheme's better for the patients and better

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for NHS finances. When they analysed the costs of sending a

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patient to the chest clinic, they found that the average saving

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versus the average cost of a journey through the hospital

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including various tests, they saved about �1,000 a patient.

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So what do the patients make of it? Are you surprised to be going to

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Harley Street or not on the NHS? It's a nice surprise. I didn't

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expect that I was going to Harley Street, but yeah, it will be

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interesting. And there's also bonus for patients like Angela. Unlike

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the hospital, the Harley Street clinic has a high-tech low-

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radiation CT scanner which makes invasive angiograms unnecessary.

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I'm just going to move you into position. The clinic's scanner can

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scan a heart in a single heartbeat while giving a fifth of the

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radiation dose of Angela's local hospital version. But it means NHS

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revenue going out of the system to a private provider simply because

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they've got better kit. I don't really understand why we

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can't have similar facilities available within local hospitals

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within local hospitals within the NHS itself. We spend �100 billion a

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year on the NHS. A few million here or there is hardly noticeable.

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Savings could be made in other territories. It seems to me

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extraordinary that we haven't got more of them because we're still

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sending patients for these unpleasant angiograms when this it

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can is available to do it a lot more pleasantly.

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For the hospitals, it might be worse than just having inferior kit.

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The way they process heart patients might need examination too. With

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the transparency that's come with gaining control of patient care,

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Kosta claims to have found some alarming hospital practise. He

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believes angiograms were routinely ordered at the local hospital

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partly because they're a source of income. You know full well that

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that bill is artificially boosted. So you think procedures are

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happening either carelessly or deliberately that... Deliberately.

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That don't need to happen? Correct. Angiograms - they used to do

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angiograms in your local hospital. And when you look at the figures,

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500 angiograms of which 180 were actually necessary. The rest was

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just to create revenue. So when - when we talk about the potential

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for saving, you think there's a huge potential for saving in the

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NHS... Billions. Without harming the patient? Yes. The Secretary of

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State for Health and architect of the new reforms, Andrew Lansley,

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agrees with Kosta that the current system can encourage this sort of

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wastage. Well, it can happen, and it happens because of the way the

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payment system in the NHS works at the moment because it pays for

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activity so, of course, if you incentivise somebody just to do

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more work, they'll do more work. What I'm talking about is us

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getting to the point where what the payment system focuses on is

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delivering quality and the results for patients, and that's a

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different matter, of course. Currently, PCTs pay hospitals a set

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tariff for most of the procedures they carry out, so if hospitals

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aren't rigorous in weeding out anything unnecessary, the potential

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for waste is huge. The South London Healthcare Trust

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told us they refute the allegation that unnecessary angiograms were

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carried out, and at the time, coronary angiography was an

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accepted normal investigation for suspected heart disease throughout

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the UK. The Trust is working closely with local GPs to continue

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to improve services. Back in Harley Street, it's good

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news for Angela. Her scan is clear. If this scheme is anything to go by,

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then clearly GPs are likely to go private if they feel their local

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NHS services are inefficient. The reforms have been changed so that

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private providers can't undercut NHS rates, so they'll have to win

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on quality, not price. That seems pretty straight forward.

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Yes. But it's still attractive to those like Paul Jenkins who runs

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the Harley Street Clinic. Does the opening up of the central

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- or the attempt to open up the NHS - does that represent a business

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opportunity for you? Yes, I think it does because we have

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demonstrated with this project with Bexley that the model works, and

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we're very keen to expand it to other, you know, care trust GPs,

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commissioners, and in discussions with a number of them. Even Howard

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Stoate, who is a fan of GP commissioning, has concerns for how

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local hospitals will fare in the brave new world. What happens if a

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local hospital can't or won't or is for whatever reason not able to

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deliver the service the GPs decide to buy, and they are forced to go

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to other providers because there is no alternative? Now, that's the

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controversial bit. So will hospitals need to close? And if

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they do, who makes the decision? What it means is that may be

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significantly fewer people in hospital beds. There may still be

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very much, you know, visiting their hospital for the outpatients'

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appointment visiting their hospital for diagnostics, visiting their

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hospital as a day case. Now, all of those things means hospitals change,

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of course it does. It doesn't mean they necessarily close. If it does

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need those decisions to be made about hospital closures, who will

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make those decisions? But you don't. You don't in the business world.

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You don't. You need to decide, you know, how many stores you're going

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to have on the basis of somebody sitting there with you in - you

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know, head office with a big map moving things around. You do. You

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got three Tesco stores within - and one of them is not working. You

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don't - you certainly don't build another one, and you certainly

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close one. If the people who are commissioning the service want the

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service to be there, if the public want the service to be there, if it

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is transparent that the service is in demand it doesn't make sense to

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shut it down. But the reality is that not all GPs

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are happy with what their hospitals are providing, and I feared for

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some hospitals. For me it was the first sign that GP reform would

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affect the rest of the NHS especially if no-one is managing

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from the centre, so how will it affect patients? Like the I -- I

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travelled from Bexley to hackney East London, one of the country's

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poorest neighbourhoods and home to Dr Deborah Colvin's practise. If

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you have money driving your decision, they won't be the best

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decisions for the patients. If we agree together as a society, OK.

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These are the outcomes we want. Let's get together and work out how

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to make them happen, then people will be driven by wanting to do the

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best for the patient. Like the heart scan project, the GPs here

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have devised a scheme that joins up a lot of agencies really

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effectively. It's for patients with diabetes. But unlike the Bexley

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doctors, in Hackney, they're keeping it all within the NHS.

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beauty of the scheme is that diabetes is a complex illness, and

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there are lots of problems, and you need lots of people working

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together, and if you can bring everybody together, you can work

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out the best path for them because everybody's different. What works

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for one person doesn't work for another. Central to the new reforms

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is patient choice - the mantra is, "No decision about me without me."

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But for Deborah, the choice between private provider and NHS could

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If she said I want to see a dietician from this company and a

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nurse from that company, it would make my life a nightmare.

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Contacting different people, different payment systems, forms,

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phone numbers. I would never get everybody together to talk together.

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If the service wasn't working for me then, I would need to sit down

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with the people that were working with me and then we could discuss

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what was going wrong. I wouldn't just necessarily come out and say,

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well, I need to change this service. In a sense, the informed choice,

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whether we like it or not, it's true for me, has to be made by the

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medical expert. I think Debra is really impressive. She's totally

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committed to doing the right thing for her patients and totally

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committed to doing it within the health service. She's not happy

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with outside providers. I've got some sympathy with that. There is a

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place for outside providers, but it needs to be very, very carefully

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managed. Private health care providers come from a wide and

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varied background. Circle are one of them. They run three hospitals

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already and plan to open another 25. Ail Parsa, a former Goldman Sachs

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investment banker, is their co- founder. Do you think that these

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changes will present an opportunity for the private sector to come in

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and do things, make things happen? Yes, I do. I think that it's health

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care professionals, social entrepreneurs, they will come up

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with new ideas, new solutions. Web those ideas and solutions will only

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work if patients choose to go there. He passionately believes private

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providers will improve the NHS. years ago we used to spend �37

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billion in health care. Today we're spending 127 billion in health care.

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We tripled the cost of delivery. This country can't afford three

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times as much in another ten years. We need to look at different

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solutions. The solution being proposed now is that patients will

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choose their own treatments from a list of qualified providers, NHS

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and private. That makes the NHS lift its game. To me, this is a

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total cop-out. Get the system better with management not with the

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threat of outside providers. I have absolutely no objection to using

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outside providers and I've no objection to their making a profit.

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What I hate is the idea of using outside providers as a way of, you

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know, making efficiency changes in the health service itself. That's

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straightforward cowardlyness. If there are savings to be made within

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the health service, it needs to be managed within the health service,

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by a central system, which sets out what it wants in a strategic way

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and follow it's through. It's cowardly. It's wrong. It doesn't

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actually work. It ends up destroying the organisation itself.

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I have a strong sense that you're trying to use external competition

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to make the internal market or the internal service work better.

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really. My experience of the NHS is actually there is more than

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sufficient competence, enterprise, innovation in the service. We just

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have to let it out. Back in May, when the reforms were

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being debated, the anger out there was incredibly powerful. Do you see

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this as the beginning of the end of the NHS, do you? I think it's just

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going to be a brand, a logo, stuck onto a corporate machine,

:18:45.:18:48.

disgusting. These measures affect everyone in our society and the

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people who are making them and the people who can afford them with

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private health care, that's fine for them.

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I think the NHS stands for something quite important. It

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unites everyone in this country, the NHS. We all have this amazing

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access to health care. The NHS has been described as the closest the

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British have to a religion. Many here clearly believe what's

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proposed is sacrilege. If you're going to change the NHS you need to

:19:26.:19:30.

do it extraordinarily carefully. And the feeling here is that

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actually this is the beginning of the end. People find change

:19:36.:19:40.

incredibly difficult. Sometimes they have concerns and they want to

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know those concerns have been heard and responded to. A lot of that was

:19:44.:19:48.

about saying, well, you know, it's going to mean privatisation of the

:19:48.:19:52.

NHS and it won't. But it wasn't about involving the private sector

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more. It was actually about getting the best possible services for

:19:56.:20:04.

patients. The big driver for these changes is savings. With increased

:20:04.:20:08.

demand and an ageing population, soon the NHS is simply going to

:20:08.:20:13.

cost too much money. Do you know it's horrifying how much money this

:20:13.:20:17.

organisation chews threw and ongoing it's just not sustainable.

:20:17.:20:22.

So it's vital that we make the right changes to make sure that we

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do have an NHS around over the coming years. It's just crucial.

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Near the top there. That's it. move this, does it hurt? Andrew

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Lansley's confident that getting rid of Primary Care Trusts will

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bring big savings for the NHS. Where the reforms are yet to be

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agreed, it's already happening. Back in Hackney, Dr Deborah

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Colvin's local PCT has gone, merged with two others. It's causing chaos.

:20:57.:21:01.

Things are coming apart. We don't know next month where we're going

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to get our IT support from, because half of it's gone, 50% of the PCT

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have gone. She took me to her derelict old PCT building. Some of

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the team were moved from here. But many have been made redundant.

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Horrible, isn't it? Yes. Those teams don't exist any more and all

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their memories, all their knowledge of the local area and what patients

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need and how things work and Who's Who... All gone. All gone.

:21:36.:21:40.

It's estimated that 20,000 redundancies will occur, as PCTs

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are dissolved at a cost of �1 billion in redundancy payments.

:21:46.:21:50.

I've been involved in any number of changes in large organisations, but

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this is easily the strangest one that I've ever seen. It's already

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started. People are being made redundant. Things are changing, but

:21:59.:22:03.

we don't actually know what the end game is. And there's another worry

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about these reforms, in order to run the commissioning process

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effectively, GPs are going to have to band together into bigger units.

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Does that mean we risk losing something special about our GPs?

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Tuck add way in the Lincolnshire Wolds, I meet Ajay Vora, a country

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doctor with a thriving practice. Nice to meet you. Welcome to the

:22:27.:22:32.

practice. Thank you. Essentially a single handed practitioner, but

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we're in a rural area, covering approximately 100 square miles. I

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work with my wife, who's a nurse practitioner. It's very much a

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couple-driven practice. We've been here 20 years. We hopefully have

:22:47.:22:51.

got to know our patients very well. I'm excited that I might now, forts

:22:51.:22:55.

first time, have a say in how some of these funds are directly spent.

:22:55.:23:01.

Tell me the patient we're going to see? It's a lady who is house bound

:23:01.:23:11.
:23:11.:23:12.

now. He took me on a home visit to meet one of his patients. How long

:23:12.:23:18.

is it since you had the fall? when the snow was on the ground.

:23:18.:23:23.

couple of months. When you hear all this stuff about the NHS not

:23:23.:23:28.

working well and all the reforms, what does it make you think? Well,

:23:28.:23:35.

first of all, how fortunate we are to not have the problem. You can

:23:35.:23:40.

hardly believe that they can ring up to make an appointment and being

:23:40.:23:46.

told that we can't see you for a week. When we go to our doctor, we

:23:46.:23:50.

don't get that. Somebody will always see you. It's been nice

:23:50.:23:58.

seeing you Joyce. Yes, I'm pleased to see you.

:23:58.:24:04.

Some independent GPs like Ajay also have concerns. They will be asked

:24:04.:24:08.

to join with local practices to commission as a unit. Where he now

:24:08.:24:13.

has sole control of his budget, he will find himself part of a large

:24:13.:24:20.

group having to make joint decisions. I'm told I have to refer

:24:20.:24:23.

Pat to a certain hospital with a certain consultant because a

:24:23.:24:27.

contract has been put in place that make it's work better, maybe

:24:27.:24:30.

financially. Suddenly now, she doesn't know whether I'm saying

:24:30.:24:35.

that because there's a background motive or because it is the best

:24:35.:24:41.

for her. Now there's doubt put in a patient's mind. I really think he's

:24:41.:24:46.

right. There is a danger that the purity of that patient -GP

:24:46.:24:51.

relationship could be threatened by a financial motive injected into

:24:51.:24:55.

the decision-making process. What really concerned me was who was

:24:55.:24:59.

going to manage and coordinate these GP commissioning groups. I

:24:59.:25:02.

can understand why the power to commission has been centred around

:25:02.:25:05.

GPs. I think it makes a lot of sense, these commissioning groups.

:25:05.:25:10.

But you know, who will hold the commissioning groups responsible?

:25:10.:25:16.

This lack of accountability, which to me, has never been in the NHS,

:25:16.:25:20.

isn't in the NHS and I see nothing in these reforms that will change

:25:20.:25:27.

that. There's got to be a set of people in each part of the country

:25:27.:25:31.

who are responsible. That's for clinical commissioning groups.

:25:31.:25:35.

There is a line, the NHS commissioning board is responsible

:25:35.:25:38.

for allocated resources. They're accountable to the public through

:25:38.:25:43.

the Secretary of State who sets a mandate for the ambitions for the

:25:43.:25:48.

service as a whole. These reforms affect only England. In Scotland,

:25:48.:25:53.

they're moving in the opposite direction. I headed 400 miles north

:25:53.:25:59.

to Glasgow, where they have health boards, instead of PCTs and trusts.

:25:59.:26:02.

Here hospitals and GPs work together much more closely and

:26:02.:26:11.

there is a central report ing structure. Lovely to meet you.

:26:11.:26:15.

Margaret McCartney's practice is in the west of the city. She is

:26:15.:26:17.

genuinely worried for her colleagues across the border.

:26:17.:26:21.

have a sense of impending doom. What's happening in England is

:26:21.:26:24.

horrendous. I do not see any way that patients are going to get a

:26:24.:26:29.

better deal out of this. I think doctors are going to be moved to

:26:29.:26:32.

doing more management, accountancy. Their best interests should be

:26:32.:26:36.

served by the patient in front of them. It's placing doctors in an

:26:36.:26:39.

untenable situation where the patient in front of them is going

:26:39.:26:43.

to be thinking, "Is my doctor deciding not to give me this

:26:43.:26:46.

because there's no evidence for it or because they're not willing to

:26:46.:26:50.

fund it?" On my journey round the country, I've met believers in

:26:50.:26:54.

these reforms and been convinced by them that GPs are probably the best

:26:54.:26:58.

people to handle commissioning. I've also met doubters, deeply

:26:58.:27:04.

worried about the role of private providers and I share their concern.

:27:04.:27:09.

And those who simply aren't sure what the reforms will lead to. I

:27:09.:27:17.

think the stakes here are huge, the very existence of the NHS could de-

:27:17.:27:20.

- depend on getting this right. Who's managing that big picture?

:27:20.:27:25.

For me, that's the question that remains. Unless somebody really

:27:25.:27:29.

does grab this thing at the centre and actually have the courage to

:27:29.:27:33.

make the decision that's are right, but unpopular, I think it could be

:27:33.:27:38.

the end of the NHS. This is my view, but the Health

:27:38.:27:41.

Secretary disagrees, believing the reforms will ensure the NHS is safe

:27:41.:27:46.

in his hands. With a service the size and

:27:46.:27:49.

significance of the National Health Service, you've got to take people

:27:49.:27:53.

with you. You've got 50 million patients who, for whom it's always

:27:53.:27:56.

going to be an important thing. They've got to know that, where

:27:56.:28:00.

they hear noise about is the service going to be fragmented, is

:28:00.:28:03.

it going to be safe in the future? They need to know it's going to be

:28:03.:28:06.

safe. They need to know that the people who work in it are confident

:28:06.:28:10.

it will deliver a better service in the future. I think everyone wants

:28:10.:28:14.

the health service to survive these reforms. If I've taken one thing

:28:14.:28:18.

from my journey, it's that the British love affair with the NHS is

:28:18.:28:21.

alive and strong. I just hope that these changes aren't the end of the

:28:21.:28:29.

affair. Next week on Panorama, remarkable

:28:29.:28:32.

In this special edition of Panorama, troubleshooter and businessman Sir Gerry Robinson examines the government's plans for the biggest shake-up of the NHS in its history. Sir Gerry travels the country, taking the temperature on support for the reforms and talking to GPs with opposing views. He finds how change has already started with the closure of many Primary Care Trusts, and asks Health Secretary Andrew Lansley if the future of the NHS is at risk should his reforms fail.


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