Editor's blog 14th January 2009: Transform over content?

Good morning. You will probably already have seen the DH’s new Transforming community services: enabling new patterns of provision (www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_093197), which emphasises “quality and enabling transformational change”.

The document states that “to secure modern, high quality community services we also need to ensure that the organisations providing them are fit for purpose. We need modern organisations, which enable and empower front-line staff to innovate and free up their time to care for patients. Organisations which empower all clinicians to shape the future of community services, and provide them with the support and resources they need to be world class practitioners. Organisations which have a robust business infrastructure, capable of contracting with commissioners and effective business planning.” The lack of verbs at the end of this is pure Tony Blair.

However, policy-wise, it is saying nothing we don’t already know about the direction of travel: getting PCTs largely out of the provision business. “The aim of this enabling document is to help providers of community services to meet these challenges by considering what type(s) of organisations would best meet the needs of patients and local communities (informed by a thorough needs analysis), and how such change can be managed well to support the transformation of services to patients.”.

No national blueprint
The documenty states that “There is no national ‘blueprint’. Decisions will be taken locally by PCT Boards as the responsible statutory authorities, with processes and decision-making assured by Strategic Health Authorities.” It then lists a series of what look suspiciously like criteria for a national blueprint, or as the document puts it, “guiding principles to support local change”.

It goes on to state, “One of the reasons for producing this guidance is the current highly variable pace of organisational change to services directly-provided by PCTs. Decisions should be led locally, but it is in everyone’s interest that change is managed coherently, to high standards, and reflects the consistent application of common guiding principles and criteria”.

So do we like local decision-making? Only when it happens at the pace the DH wants, and produces the correct results, apparently. The long echoes of 2005’s Commissioing A Patient-Led NHS still linger.

Time to sell assets
The document does come clean on one significant aspect: “Control of current PCT property should be protected in the interests of taxpayers and to ensure that commissioners have sufficient leverage to drive change and improve quality. As a rule, property will not be transferred to providers and PCTs will be encouraged to develop strategic partnerships that make the best use of estate”.

Here is your timetable
Noting the 2009-10 Operating Framework’s requirement for PCTs to ‘create an internal separation of their operational provider services, agree SLAs, based on the same business and financial rules as applied to all other providers’, the report gives deadlines that “by April 2009 all PCT direct provider organisations should have moved into a contractual relationship with their PCT commissioning function, using the national contract for community services in 2009/10. This means ensuring sufficient separation of roles within the PCT to avoid direct conflicts of interests.

It further adds, “it is anticipated that, by October 2009, PCT commissioners, working closely with their practice-based commissioners, will have developed a detailed plan for transforming community services, including how they intend to enhance patient choice, for agreement with their SHA. To the same timescale, PCT provider services should review (in consultation with local staff and trade unions) and assure themselves that they have the best governance arrangements to sustain high quality community services that best suit local need and circumstances, and whether to declare an interest in establishing new governance arrangements, such as a social enterprise or Community Foundation Trust”.

The chapter on implementation is four pages long. The document is 103 pages. Business as usual, then.

So will it work?
The question  is not whether it will happen – we know that it will, and we have a timetable. It will happen. The question is, will it work?

Well, very little has been heard from the initial batch of Community Foundation Trust pilots, other than that a couple dropped out – the silence on the others is deafening. Social enterprises are arising, but not in significant numbers.

What is the problem this is trying to solve? That of the conflict of interest between commissioning and provision. The conflict of interest is a real one, but it must also be considered to be manageable – otherwise we would not have the policy of GP practice-based commissioning.

Provision of community services has long been criticised as a data ‘black hole’. If the debate becomes about organisational forms, then we are in danger of repeating previous mistakes. Instead, the first organising principle should surely be about organising integrated services that fit around patient care and patient pathways – with all conflicts of interest around provision carefully recorded, publicised and managed. The language and tone of this document do not appear to perceive this - the buzz-words and phrases – transformational change, fit for purpose, modern – are ones we have heard before, many times.

What the statements say
In a statement, NHS Alliance chairman Dr Michael Dixon said: “PCT provider services can’t go from pillar to post. The Department of Health is saying this is really important and we need to get it right, but simply following departmental guidelines is not enough. We need to make it sustainable and adopt a holistic approach to service provision.”

His colleague, Alliance chief executive Michael Sobanja added: “We need to bear in mind that integrated service delivery is more important than integrated organisations. Our main focus should not be on the organisational shape or design, but on the values that will underpin them. At heart, PCTs should be organisations that are built around the needs of the patients and the wider communities they serve, overcoming the fault lines between general practice and community health services, primary and secondary care and health and social care.”

Media round-up
BBC News has a fairly sane piece from Kings Fund research fellow Tammy Boyce on public and media attitudes to MRSA (but have the BBC looked through their own archive? The irony!). Not much in this on handwashing, though:
http://news.bbc.co.uk/1/hi/health/7772871.stm

They also mention a case in NHS Scotland, where nurses face police questioning over 18 C Diff-related deaths at the Vale Of Leven Hospital
http://news.bbc.co.uk/1/hi/scotland/7826260.stm

A touching story about success of a retiring social worker in  helping Clare Allan, author of Poppy Shakespeare, with her recovery from mental health problems:
www.guardian.co.uk/society/2009/jan/14/mental-health-clare-allan-social-worker

The Times has noticed the issue of social care (note which section of the paper in which the report appears):
http://women.timesonline.co.uk/tol/life_and_style/women/the_way_we_live/article5511395.ece

Intelligent commentary about inequalities, including health:
www.independent.co.uk/opinion/commentators/hamish-mcrae/hamish-mcrae-social-mobility-requires-more-than-breaking-down-barriers-1334120.html