In order to be able to identify those costs, there is going to be an enormous amount of work and it is going to be contested as well.
: David and Adrian may want to say more about the skills, but certainly Monitor and the National Commissioning Board will need a very different set of skills, I think, than the traditional NHS manager skills, whether that be in actuarial risk pooling. There are all sorts of new terms that we are going to get a lot more familiar with. Yes, to set efficient prices we are going to need more than the current number of civil servants sitting in Skipton House working out the national tariff.
I am going to bring in Dr Singer, and then perhaps Dr Bennett would like to comment on the armies of accountants point.
: We are beginning to discover that what was offered to the GP body was they would have 80% of the budget and control of the NHS. This is simply not viable. Consortia can be more than two practices-6,000 patients-and we are talking about reconfiguring, in the case of A&E, for a population base of 500,000 to 1 million. A& Es have to have 24 hour access, 365 days a year, to everything. There is no point in having an A&E if you have no orthopaedic surgeon on call 24 hours a day. That is obvious.
It is not clear at all how consortia, even if they have a 500,000 population, are going to manage this because we have lost the next tier up. I don’t know who is going to do that job and I don’t know how a hospital with the local A&E is going to be able to survive if there are failing departments within that hospital and that is not attended to or there is a better tender. This is a big issue. A&E is obviously crucial to everybody’s feeling about the NHS, and we know about trolley waits. It is absolutely crucial that that bit works, and I don’t see how it can do unless you designate the whole lot, which, of course, is exactly what this is designed not to do.
: On the armies of accountants point, Anna is right that one of the things that is needed is a more detailed and even clearer understanding of the costs of all these different services and how they interact and so on. There is an element of that done by the Department at the moment through the PbR and tariff setting, but there is a lot more that should be done. We, in Monitor, will be responsible for that. Indeed, we will need analysts capable of doing that analysis, but obviously, in the belief that by having that clearer and deeper understanding you can then promote greater efficiency in the way the services are delivered.
: I don’t think that is in our remit, no, but you are getting to the question that Anna raised and Dr Singer picked up on as well, which is about issues like reconfiguration and how you do the strategic commissioning. It clearly has to be in there. It is very much an issue for the Commissioning Board and not for Monitor. But, in some way, the new system has-with the combination of the GP consortia, the support provided to those consortia as commissioners and the NHS Commissioning Board collectively-to be able to do that sort of strategic commissioning.
: Designation has to come in because you have to have the A&E open. My problem is everything around it.
: On the designation question, the issue there is what happens if the provider of the service is the only provider of that particular service that is available to its local community but the provider gets into difficulty. Designation is all about making sure that there is continuity of the provision of the service even if the provider themselves gets into difficulty where there is no alternative provider.
On the integrated care for A&E, yes, there are similarities. I think the critical issue is where you draw the boundaries. If you finish up in a situation where you define the boundaries around A&E as being the whole of the DGH, then you have somewhat frustrated the policy, but I don’t think that should be necessary.