Gerry and the GPs Panorama


Gerry and the GPs

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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,

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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

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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

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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

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

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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

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

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

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

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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.

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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.

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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.

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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

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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

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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

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

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

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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.

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