Kings Fund - Shaping PCT Provider Services: The future for community health - 23 April 09

Source

Primary care trusts (PCTs) provide a broad and complex range of community-based services. However, the commissioning and management of these services have been a challenge for the NHS and in particular for PCTs. As PCTs provide community health services, there is a potential conflict of interest for their role as commissioners. The government is clear that PCTs need to separate their provider and commissioning functions. This report examines the issues surrounding the placement of community health services, the options proposed for their reorganisation, and the steps that must be taken to deliver the desired transformation in community health services.

In brief

• The way in which community health services are provided has changed little since the NHS was established in 1948. Community health services have suffered from many years of inattention and underinvestment. As a consequence, the services provided vary widely in terms of performance and productivity, and the necessary facilities and support, both managerial and technical, are often lacking.
• Yet the challenges faced by community services are increasing significantly: care is shifting from hospital to community settings, the population is ageing and the number of people with long-term conditions is growing. There is a compelling case to modernise services and to improve the degree of co-ordination with other services, particularly in primary and social care.
• Lord Darzi’s NHS Next Stage Review put the organisation of community health services firmly back on the agenda, and as part of the drive to turn PCTs into world class commissioners PCTs need to separate their provider and commissioning functions. PCTs must now come up with a strategy to modernise their community services and identify future organisational options for the separated services.
• The Department of Health requires PCTs to lay out a strategic vision and organisational options for the community health services that they currently manage. This provides PCTs with an opportunity to address many years of neglect in these services and to prepare for the growing health care needs of a population that is ageing and has rising rates of chronic disease.
• It was against this backdrop that The King’s Fund produced the report Shaping PCT Provider Services: The future for community health. It examines the issues faced by PCTs in determining the future pattern of provision and opportunities for service improvement.

Approach
The King’s Fund is examining the issues faced by PCTs in determining the future pattern of provision and opportunities for service improvement. 

The project team is looking at:

• evidence on current community health service provision – its strengths and weaknesses
• the lessons that can be learnt from previous reconfigurations of community health services
• the evidence on the key ingredients for success when developing integrated care models including the experience in community mental health services.

The project findings also draw on the output from an expert seminar held jointly by The King’s Fund and Ernst & Young and attended by senior policy-makers, academics, and professional and NHS representatives.

Findings
The Department of Health requires primary care trusts (PCTs) to lay out a strategic vision and organisational options for the community health services that they currently manage. This provides PCTs with an opportunity to address many years of neglect in these services and to prepare for the growing health care needs of a population that is ageing and has rising rates of chronic disease.

Our report Shaping PCT Provider Services: The future for community health, published in April 2009, draws on a range of evidence about community services and health care service development. It aims to help PCTs to develop a service and organisational strategy that addresses key performance issues as well as to configure services to meet the changing needs of their local population.
 

Addressing performance issues
The evidence suggests that community health services, particularly community nursing services, urgently need to address a number of performance issues. There are opportunities to enhance the quality of services if they:

• clarify roles and responsibilities
• introduce more systematic approaches to caseload management
• move towards a service that is driven by needs not demand.

If some community services are to provide a genuine alternative to hospital care they need to be able to provide 24/7 support, with close working between all those offering support in the out-of-hours period.

Successful reconfiguration
The report suggests possible reasons why previous attempts to locate community health service provision better within the health care system have failed:

• each reorganisation has focused on structural change and not challenged the way in which services are delivered or staff work
• services have remained separate from primary care despite the importance of close working relationships
• aside from the attempts to reorganise, community health services have not been the focus of national or local attention and have struggled to attract investment or effective leadership.

Better integrated care
The experience of integrated care models reinforces a number of these messages and suggests that if primary care trusts wish to deliver more patient-focused and integrated care through their new community services structures, they need to:

• focus on process as much as on structure
• take account of the dynamics of new ways of working
• focus on the patients
• actively engage GPs to ensure strong co-ordination of  primary and community services.

Conclusion
In reviewing options for reconfiguration, our report suggests that there is no single ‘right’ way of working; different solutions will suit different circumstances. The use of outcome measures, and contracting with networks of providers for more integrated models of care can help PCTs to overcome inherent weaknesses in any organisational solution.

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