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


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


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


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


faces its biggest transformation Since the Government announced the


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


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


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


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


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


qualifications do people have to manage something of that scale?


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


making decisions on behalf of us, the patients.


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


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


LAUGHTER Listen - calm down and listen to


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


GPs reveal overwhelming enthusiasm for the chance to help shape


services for the patients they see daily."


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


have been having physiotherapy, physiotherapy treatment. Tell me


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


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


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


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


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


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


patient, and say this hospital provides this service that hospital


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


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


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


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


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


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


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


signing the cheques. In future, Clinical Commissioning Groups led


by GPs like Howard will control the money.


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


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


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


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


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


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


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


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


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


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


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


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


colleagues who felt his local hospital had him and his heart


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


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


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


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


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


where consultants usually ordered an angiogram, an expensive,


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


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


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


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


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


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


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


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


the transport provided by the service. Welcome to the weekly


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


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


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


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


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


versus the average cost of a journey through the hospital


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


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


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


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


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


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


radiation CT scanner which makes invasive angiograms unnecessary.


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


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


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


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


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


can't have similar facilities available within local hospitals


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


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


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


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


sending patients for these unpleasant angiograms when this it


can is available to do it a lot more pleasantly.


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


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


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


Kosta claims to have found some alarming hospital practise. He


believes angiograms were routinely ordered at the local hospital


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


that bill is artificially boosted. So you think procedures are


happening either carelessly or deliberately that... Deliberately.


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


for waste is huge. The South London Healthcare Trust


told us they refute the allegation that unnecessary angiograms were


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


accepted normal investigation for suspected heart disease throughout


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


significantly fewer people in hospital beds. There may still be


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


appointment visiting their hospital for diagnostics, visiting their


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


Contacting different people, different payment systems, forms,


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


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


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


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


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


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


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


committed to doing the right thing for her patients and totally


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


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


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


managed. Private health care providers come from a wide and


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


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


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


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


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


care professionals, social entrepreneurs, they will come up


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


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


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


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


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


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


solutions. The solution being proposed now is that patients will


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


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


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


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


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


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


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


straightforward cowardlyness. If there are savings to be made within


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


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


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


actually work. It ends up destroying the organisation itself.


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


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


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


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


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


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


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


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


disgusting. These measures affect everyone in our society and the


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


private health care, that's fine for them.


I think the NHS stands for something quite important. It


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


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


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


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


do it extraordinarily carefully. And the feeling here is that


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


incredibly difficult. Sometimes they have concerns and they want to


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


about these reforms, in order to run the commissioning process


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


Pat to a certain hospital with a certain consultant because a


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


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


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


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


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


relationship could be threatened by a financial motive injected into


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


going to manage and coordinate these GP commissioning groups. I


can understand why the power to commission has been centred around


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


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


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


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


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


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


There is a line, the NHS commissioning board is responsible


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


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


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


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


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


Here hospitals and GPs work together much more closely and


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


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


genuinely worried for her colleagues across the border.


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


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


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


doing more management, accountancy. Their best interests should be


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


untenable situation where the patient in front of them is going


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


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


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


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


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


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


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


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


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


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


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


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


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


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


in his hands. With a service the size and


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


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


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


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


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


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


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


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


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


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


affair. Next week on Panorama, remarkable


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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