As PCTs draw up plans to outsource community services provision, we asked our expert panel what developments are likely in the future.
PCTs have drawn up their plans to outsource the provision of community services under the Transforming Community Services (TCS) agenda and an exclusive survey by our sister publication Pulse suggests most propose to vertically integrate with acute trusts. We asked a group of practice-based commissioning experts how they saw the future for community services.
Is it fair to say vertical integration will be the norm for most areas?
NW: I think that's right. It's the most expedient route for PCTs given the tight deadline. Very few areas are looking at the social enterprise route and I haven't heard of any going down the commercial route, so that leaves mental health trusts or vertical integration with acute trusts. There's huge scepticism about NHS pensions. I don't think hospitals understand what's going on in the community and GPs could end up losing the community staff they currently have inside the hospital.
DJ: Yes, vertical integration will be the norm because it's quick and easy and the unions will be happy. In any reorganisation, the most important players are the unions – in this case Unite and the Royal College of Nursing. Their key is to make sure that their members are looked after. When you ask the staff, they want to keep their NHS pensions. But here is a big unanswered question: do we need to do it at all? Either we move away from the market model or stick with it. But if you can control the budget via PBC, the need to integrate becomes a lot less.
JA: I think there are parts of the NHS that will naturally lend themselves to the vertical integration system, building on the good relations between primary and secondary care. But we see PBC as retaining an important role because of our insight into the community. From our perspective, there is still room for PCTs and PBCs – and for wider providers in the health economy. The only difference is that the trust would have a different role.
MD: It seems that vertical integration is the preferred option in around 50% of PCTs. Mental health trusts are the next most popular option and the rest are proposals such as community foundation trusts, arm's-length PCT provider units and some community services teaming up with local general practices or out-of-hours services.
PCTs are between a rock and a hard place because they have had to meet the 31 March deadline. Most have been unable to discuss vertical integration in sufficient detail with their front-line clinicians or local people (or even practice-based commissioners) and therefore acute trusts have presented the easiest position, especially for staff concerned about their pensions.
Vertical integration with acute trusts is the norm on pragmatic grounds and not because it is likely to improve patient care or productivity. Indeed it is likely to have a negative effect on both, contradicting the rhetoric of a primary care-led NHS, and strengthening local clinical leadership and putting the NHS clock back 30 years.
How will the transfer of community services to acute trusts affect GPs as commissioners?
MD: I think it is likely to depress GP commissioners in those areas where they have had little say in the outcome and make them question how effective they can be. Vertical integration with acute trusts will increase the monopoly position of local acute trusts and put the provider in an even stronger position beside the commissioner than they already are. So it will present GP commissioners with a challenge.
They will need to show their strength either in confronting acute trusts who appear to be serving their own ends rather than all patients or in developing a co-operative commissioning relationship as equal partners. GP commissioners will also need to ensure that these new providers do not selectively cut community services rather than acute ones, as their finances are squeezed by the current economic situation.
NW: It could be an absolute disaster. There are lots of areas where the acute trusts can hardly manage as they are. I'm not against vertical integration per se but we need some evaluation and perhaps pilot schemes. Every GP I speak to is concerned that continuity of care might diminish or disappear. The GPC wouldn't like to see it happen just like that – imposed for ideological reasons. We'd like the forced march to change to end and to have significant national debate.
DJ: I think it's a real possibility that GPs could have more power under such a system. But given the current political climate, large-scale organisational reform is probably less likely than more subtle and covert limitations on budgets. PCTs don't actually have to put these plans into operation. They have met the 31 March deadline and come up with firm plans, but it's highly likely that we´ll go to the polls again within a year. My prediction is that the politicians have already got their minds set on the next general election and won't want to take on hot issues like reforming the hospital sector.
JA: From what I've seen on the ground, it doesn't matter whether the workforce is part of the PCT or integrated into an acute trust; the same type of services have to be commissioned. And the overall thread is community accountability, which GPs will need to be involved in.
Has the horse bolted in terms of PBC being able to influence community services?
MD: PBC will still have a vital role in ensuring that the services are appropriate and productive and in exerting challenge as commissioners when they are not. Their service specifications should prevent some of the fragmentation that might otherwise occur when community services are hived away from general practice, social services and the rest of primary care.
Nor should they consider TCS a ‘done job'. They should challenge local ‘stitch-ups' that are not in the best interests of local people. They should be vocal where necessary now as it is very possible that the Government will want a thorough review of TCS as vertical integration may challenge its own views on monopolies and the role of primary care as a provider.
JA: From our perspective, we think PBCs will still be able to influence community services. There may still be groups who want to take it on and some PCTs are in favour of it. We have done some work with a group of PCTs within an SHA exploring how this would work and we´ve uncovered some real strengths of PBCs running community services. We actually came up with a specification for running such a service in PBC. It's about trying to improve patient care and making best use of resources.
It's a challenge, but there always needs to be a robust commissioning response.
NW: You have got to have clinical leadership, so absolutely, there is a role for practice-based commissioning, perhaps on community boards or more directly. I know of some PBC groups who want to take it on as a social enterprise but their PCTs don't feel they have the capacity. And some PBCs don´t want to take on that number of staff. We'll see what happens if the new Government picks this up.
Interviews by Alisdair Stirling, a freelance journalist
Dr David Jenner (DJ) - PBC co-lead for the NHS Alliance and a GP in Cullompton, Devon
Dr Nigel Watson (NW) - chair of the GPC's commissioning and service development subcommittee, CEO of Wessex LMCs and a GP in the New Forest
Jeff Anderson (JA) - director of primary care at Tribal Consultancy
Dr Michael Dixon(MD)- chair of the NHS Alliance and a GP in Devon
Where next for community services?