Francesca is a freelance journalist who specialises in writing about health. She contributes to a wide range of healthcare magazines and websites, and is currently News Editor of Practice Nurse and The Practising Midwife journals
Decisions are currently being made about the future provision of community health services, which some primary care leaders fear could have a detrimental impact on care.
Primary care trusts (PCTs) in England have been instructed to separate their commissioning powers from their provider arm under a government programme called Transforming Community Services.(1)
This policy was drawn up two years ago to meet the aspirations of the NHS Next Stage Review, which set out new requirements for commissioning health services designed to promote high-quality standards of care.(2)
Initially, PCTs were expected to have agreed their intentions for the future structure of provider services by October 2009. Progress was slow, so this deadline was removed. Then, in December 2009, the NHS Operating Framework 2010/11 made it clear that by the end of March this year PCTs had to decide who was to be the preferred organisation to host their provider arm.(3)
It was originally intended that PCTs would find new organisations to host existing services via community foundation trusts, social enterprises, community interest companies, "vertical integration" with secondary care, "diagonal integration" with mental health trusts or with social services.
However, a number of organisations that were working towards community foundation trust status have been stopped from doing so, on the basis that the NHS does not want to create new organisations in the current financial climate that would inevitably lead to increased admin costs.
The choice is now largely between secondary care and mental health trusts. Some services, such as health visiting, may even be hived off to children's services run by local authorities.
There are no firm figures yet, as many strategic health authorities (SHAs) are still considering the plans submitted by their PCTs, but early indications are that more than half of community services will be moved to either acute or mental health trusts. Only eight community foundation trust bids have gone forward to the next stage, and just a handful of social enterprises are to be set up by NHS staff in places such as Kingston-upon-Thames, south London and Hull.
The question is: will this process turn out to be a transformation of community health services, which employ 250,000 staff and consume £10bn a year (roughly 10% of NHS spending)? Or will it turn out to be just a simple transfer of services from one organisation to another?
Supply and demand
The service needs transforming, the Department of Health (DH) argued, because it does not have the capacity to meet the rising demands it faces. More than half (57%) of those over 85 are currently in contact with a district nurse, and there will be a 31% increase in people over the age of 85 in the next 10 years; 15 million people have a chronic long-term condition, and obesity rates among children are rising.
Currently, says the DH, community health service outcomes are unmeasured, there is a lack of robust data or tariffs and a large variation in quality, care pathways productivity, costs and activity. The infrastructure – the technology, buildings and workforce – is outdated and there is limited innovation.
The potential benefits of transformation are substantial: an increased quality of life, health and wellbeing for many, a reduction in variations in quality and access, and more efficient use made of hospital and social care sectors. Productivity could be boosted by as much as 20%.
In a presentation to a Queen's Nursing Institute (QNI) workshop in September 2009, Viv Bennett, Deputy Chief Nursing Officer, said: "We have the best opportunity to clinically own and deliver change in community services for many years."
She said the prizes would be improved preventive care. Early wins could include a reduction of excess bed days for older people, better prevention and management of pressure ulcers and long-term conditions, and the establishment of end-of-life care pathways that reduced hospital admissions. Productivity could be boosted by providing more care closer to home.
"Community services are uniquely placed to major on prevention and the evidence base is growing," she said.
"Sudden change" criticisms
But the British Medical Association's (BMA) GPs' Committee (GPC), which has not been consulted on the changes, complains that the process is suddenly being pushed through with unseemly haste. It warns that moving community health services to new organisations risks fragmenting services, such as care of the elderly, child protection and terminal care. It also worries that shared goals will no longer be shared and that vital services could be destabilised.
GPC chair Dr Laurence Buckman says: "Practices will notice a sudden change in their community services and they may find it difficult to access the service they had before. Most GPs will find that it is harder to get hold of their district nurses and health visitors and they may well come from the hospital rather than be based in the community. The number of nurses may well be reduced.
"This is an opportunity to develop primary care and district nursing services – a lot of GPs would have wanted to be involved in that process and haven't been."
Dr Brian Balmer, Chief Executive of the Essex Local Medical Committees, and a member of the GPC, says there is great uncertainty about what is happening in his area.
"There was plan for a trust in West Essex, but staff voted it down and I'm not sure what the second plan is. Many community services will end up being integrated into foundation trusts, and we have serious concerns about that. Whatever trusts say, money is tight and this means they will retrench back inside the walls of the acute trust. When this happens, the community service always suffers."
Dr Balmer added: "If you keep the current system of Payment by Results and the acute trust also controls your community services, there is only one way the money is going to go – and that is not into primary care."
"Jury still out"
Rosemary Cook, Director of the QNI, is also worried about the changes, particularly at a time when the number of qualified district nurses is falling – their numbers fell below 10,000 for the first time this year.
She says one of the risks is that organisations taking responsibility for community health services will not have the experience of running them, so will not be best placed to develop them.
"Just doing what we have done before is simply not going to do in the future," she says. "These moves seem perverse at a time when we most need a focus on excellent community services. We must not end up with a service in people's homes largely run by inexperienced and non-community trained nurses. The jury is still out as to whether this is going to work."
Lynn Young, a primary care adviser for the Royal College of Nursing (RCN), says the BMA is scaremongering when it says that GPs will find it harder to get hold of district nurses and health visitors. "Nobody is saying we must reduce community nursing services," she said. "In fact, people are saying we need to find a way of investing in them. Who is providing the service and who is employing the nurses is frankly not that relevant.
"This is a wonderful opportunity to invest in community health services. But my concern, from the RCN perspective, is that the NHS has been told to make efficiency savings, so we are talking about less money and providing more effective services."
David Stout, Director of the NHS Confederation's Primary Care Trust Network, says GP practices will see few immediate changes to community services because all that is happening at the moment is a change of management of existing services.
In most areas, he says, it will take at least a year from making a decision about any changes to proceeding to actual implementation. Most PCTs will carry on managing community health services for another year and maybe even slightly longer.
He says GPs should not be worried about the changes. Moving community health services under the sole management of acute trusts could lead to improvements in the way services are delivered, because there would be better integration of services and better co-ordinated care. Mental-health trusts are also well placed to manage community services as they have experience of managing mental-health services in the community. Mr Stout says it is logical to reduce the number of organisations managing care.
But he does agree that GPs' concerns are valid and says they can play a role in checking what is happening in their area. "GPs should take seriously their role as practice-based commissioners, and should be making sure that whoever takes over, their specification of services are sufficiently clear to ensure that those services aren't asset-stripped. Practices should be keeping their eyes and ears out for what's happening on the ground so there aren't any surprises."
He added: "The aim of the Transforming Community Services Programmes is to improve services and not just leave them as they are. In a positive sense we would be looking for improvement, rather than making services worse."
Increased visits and costs
On 1 April, the first Community NHS Trust in the country was launched in Cambridgeshire. "Our aim is simple, we want to provide high-quality, innovative services that improve the lives of the people we serve," says the Cambridge Community Services Trust website. "Our vision is to transform services, wherever possible providing these in the community closer to people's homes."
But Mrs Samantha Clark, Practice Manager at East Barnwell Health Centre, Cambridge, says the change means they now have to share their district nurses with another practice.
"Our biggest gripe as a practice is that now we will only get help with a patient who is housebound if they are on the district nurses' caseload. This means we have to send our own practice nurses out to housebound patients to do blood and INR (anticoagulation) tests, and this is costing us more money. Our practice nurses don't usually see patients at home but at the same time we can't just abandon these patients. There is now a list of criteria for getting a patient onto the district nurses' caseload."
Not all the community services are affected. For example, health visitors continue to be based at the practice and end-of-life care provided by the district nursing team continues to excellent.
"We have written to voice our concerns about the service to Cambridgeshire Community Services, to the PCT and the LMC, and are still waiting for some kind of response. This change hasn't improved the district nursing service," says Mrs Clark.
1. Department of Health. Transforming Community Services [homepage on the internet]. Available from: http://www.dh.gov.uk/en/Healthcare/Primarycare/TCS/DH_100199
2. Department of Health. High quality care for all: Next Stage Review final report. London: DH: 2008. Available from: http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicati...
3. Department of Health. The NHS operating framework for England for 2010/11. London: DH; 2009. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...