Annex A > Chapter 8 - Management and Culture of the UBH and the UBHT > The purchaser-provider split and the establishment of the UBHT
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The purchaser-provider split and the establishment of the UBHT
29 The Government's plan for the reorganisation of the Health Service was set out in the 1989 White Paper `Working for Patients'. [37] The main thrust of the change:
`... lay in the creation of a competitive environment through the separation of purchaser and provider responsibilities and the establishment of self-governing NHS trusts and GP fundholders.' [38]
30 The UBHT formally came into existence on 1 April 1991. Thereafter, the UBHT was the `provider' of healthcare services at the BRI and the BRHSC (and elsewhere) and the B&WDHA (later the Bristol & District Health Authority, B&DHA) was the purchaser of that healthcare. [39] Dr Roylance described his responsibility in these changes:
`In 1991 it was my responsibility as District General Manager to divide the District into a continuing District Health Authority, which became the purchasing authority for the District.' [40]
31 Dr Roylance told the Inquiry that, in relation to cardiac services:
`The people who decided [what] the pattern of cardiac disease treatment should be ... were the purchasing health authorities, not the providers and not the Trust Board.' [41]
`The decision of whether cardiac services should be increased and that money should be allocated to it at the expense of the allocation of the same money to other services is the sole responsibility of the purchaser.' [42]
32 Ms Deborah Evans [43] explained the position in the District at the time of the purchaser-provider split:
`There were many challenges. I think that there was an enormous technical change in the Health Service at that time, which was to do with being able to track all the patients that were resident in a particular Health Authority and to follow them through hospital care and turn all of that into service agreements; but also, looking at the public health side of it, health authorities had a responsibility for the first time only to look at the needs of their local populations and not to be involved in running services. So I think the changes gave rise to an increased and more particular focus on local health needs from a public health point of view, which was helpful, and I think the other side of the separation from the provision of services meant that managers and clinicians had to go through a huge cultural change in getting used to huge organisations working together on the planning of healthcare.' [44]
33 Dr Roylance expressed himself a keen supporter of the purchaser-provider split. [45] However, Dr Roylance emphasised that a trust, as a provider unit, could not dictate what services the health authority should purchase. He said that at times this made strategic planning difficult. Dr Roylance mentioned the split site cardiac service in this context. He told the Inquiry:
`There is another strategic plan ... and that was to rebuild and reprovide the Children's Hospital. We had to do that on no more than an understanding that the purchasers would continue to purchase children's services from us and indeed some children's services which are currently purchased from others.
`Q. ... I was going to ask you, if it was the case that strategic planning meant no more than being able to respond to that which other people had determined and their strategic plans, how on earth does one plan a major development such as the development that is just taking place?
`A. I have to say, with difficulty, and I was very pleased that before I left, plans had reached an achievable position and the Children's Hospital is being built, but I would not like to minimise the very substantial difficulties with that.
`Q. So put another way, the planning for the future of the Trust and the hospitals within it may depend upon the reaction of other people, but on the other hand, the reaction of purchasers may to an extent be anticipated and plans placed, formed, on that basis?
`A. I think that is right. ...
`Q. So there is scope for strategic planning, notwithstanding that whether the plans ultimately come to fruition may depend upon the co-operation of others who hold the purse strings?
`A. If you strategically plan a new unit like the Children's Hospital and then do not get contracts for it, I think somebody ought to have the situation discussed with them. I mean, what I am saying here is that the cardiac disease was a major cause of death and demand in the regional services is high and so on, and this is an issue that we are not meeting the demand for cardiac services and we were not committed to developing the service. Of course the Trust is and was committed to developing the service, but only as far as the purchasers were committed to buying that service.
`Q. ... it would no doubt be helpful, would it not, ... for the Trust Board or the Trust to have a strategic plan, if it wished to do so, to encourage purchasers to behave so that investment and development of cardiac services might take place?
`A. That is usurping the purchaser role. That is the provider saying that we, as providers, would like to provide this service. [46]
`Q. ... is there anything intrinsic in the system which means it is the usurpation of the purchaser's role for the provider to encourage the purchaser to make a particular purchase and anticipate that he might do so?
`A. Yes. In the decision of the purchaser to place contracts, there is a negotiation. The negotiations, by necessity, are specialty by specialty. What is needed is to influence the purchaser in their determination of the balance of resources they wish to put to each service. ... What I think I am trying to say in great detail is that the provider trust has a very real and challenging problem of being in a position to provide whatever service the purchasers in their wisdom decide they need. But it is not the role of the provider as a trust. It may be as members of the public, but as a trust it is not their role to decide the pattern of care that the purchasers should provide. ...
`Q. ... then the provider must necessarily anticipate to some extent the demands which a purchaser is likely to make upon it?
`A. Yes, and it is for the directorate who are entering into that sort of conversation to advise the Trust Board what he believes the purchaser might buy.' [47]
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Footnotes
[37] `Working for Patients'. London: HMSO, 1989. (Cm 555)
[38] INQ 0038 0006 - 0007 ; Ham/Smith paper
[39] See Chapter 6 for a further explanation of the purchaser-provider split
[40] WIT 0108 0005 Dr Roylance
[43] Associate Director, and latterly Director, of Contracting for B&WDHA from April 1991, and Director of Contracting for B&DHA from October 1991