Memorandum submitted by Basildon PCT (PCT
11)
1. INTRODUCTION
1.1 We note that the Health Select Committee
has decided to undertake an inquiry into potential changes to
primary care trusts' functions and numbers arising from the Department
of Health's recent paper, Commissioning a Patient-Led NHS.
We note that the Committee will be examining:
(i) The rationale behind the changes.
(ii) The likely impact on commissioning of
services.
(iii) The likely impact on provision of local
services.
(iv) The likely impact on other PCT functions,
including public health.
(v) The consultation process on the proposed
changes.
(vi) The likely costs of change and subsequent
possible cost savings.
1.2 As a PCT we welcome the decision of
the Select Committee to look into these matters and submit the
following evidence for your consideration. This evidence is submitted
to you on behalf of Basildon Primary Care Trust in Essex, by the
non-executive directors of the Trust and signed by the Chairman.
1.3 Basildon Primary Care Trust serves one
of the most deprived communities in Essex, as measured by most
indices of social deprivation. In particular we would draw the
Committee's attention to the low education attainment, which is
one of the lowest in the country. The population served by the
PCT is 109,000 and is contained within the "New Town"
part of the Basildon District Council area, and within the large
shire County of Essex (1.6 million people). Basildon PCT is one
of the most underfunded PCTs in the country. We will gain in real
terms through the NHS financial allocations announced for the
next two years, having suffered the disadvantages of being more
than 9% distance from target allocation at the establishment of
the organisation on 2001. This year's budget of £122 million
budget will, we have been told, increase to circa £135 million
in 2006-07 and circa £151 million in 2007-08. For the first
time since establishment this will give Basildon PCT the money
to make major investment in improving primary care services and
tackling the real local health inequalities.
1.4 We set out our evidence the Select Committee
below under the Select Committees terms of reference.
2. RATIONALE
BEHIND THE
CHANGES
2.1 Strengthening commissioning
We positively welcome and support the policy
direction which strengthens commissioning and empowers local clinicians
to procure locally appropriate services through practice-based
commissioning (PbC). But we are puzzled at the suddenness of the
announcement and publication by the DoH of the paper Commissioning
a Patient Led NHS in July, during the holiday period, and
the compressed timetable within which the informal consultation
on reconfiguration of PCTs, Ambulance Trusts, and SHAs took place.
Although we have no argument with the overall policy direction
we do not believe this required the wholesale reconfiguration
of PCTs. In our case, which is not uncommon in the NHS, we have
already set up strong partnerships with neighbouring PCTs for
commissioning, modernisation of services, risk sharing, and the
implementation of PbC and capability is being strengthened daily.
Our partnership is called the South West Essex Health Management
Partnership and we have identified a top five shared commissioning
priorities for the area:- Emergency Care, Management of Long Term
Conditions, Planned Care, Children's Services and Mental Health.
As a group the PCTs in this area have almost two years experience
of being a commissioner of a first wave Foundation Trust (Basildon
and Thurrock University Hospitals NHS Foundation Trust) within
the enhanced Payment by Results (PbR) financial regimen.
We believe we would have achieved fitness for
purpose ourselves over a relatively short period of time, bringing
local stakeholders with us, rather than being "victim"
of what is now perceived as a top down process.
2.2 Saving money
With regards to the saving £250 million,
the NHS has had to find considerable savings over the years and
we believe that if we had been asked to find our share of this
we would have done so, reconfiguring locally to meet the challenge.
Like other PCTs in Essex we are not only expected
to make the necessary savings to break even ourselves, but also
to help balance the books Essex-wide by finding an additional
£750,000 surplus.
2.3 Co-terminosity
Achieving co-terminosity with social services
authorities in a large shire County like Essex sacrifices District
Council or Borough co-terminosity where most of the partnership
work actually happens, and where true public sector integration
around community strategy/LSP priorities is possible. In addition
the factor of two smaller unitary councils in the south of Essex
needs to be considered.
3. LIKELY IMPACT
ON THE
COMMISSIONING OF
SERVICES
3.1 The reconfiguration debate will inevitably
take people's "eye off the ball" of what we all believe
is the most important factor, the successful implementation of
PbC. Our commissioning processes, essential for getting Local
Delivery Plans (LDPs) in place for April 2006-07 onwards will
be seriously compromised if Chief Executives and Directors, the
key leaders in this process, are insecure about their futures.
Of course as professionals they are hard at work constructing
business continuity plans to make sure all the essential work
is co-ordinated and delivered during this critical time, but this
in itself takes energy away from the true and complex commissioning
task, especially in the context of PbR and PbC.
3.2 PbC implementation is, we believe, the
"arrowhead" of the commissioning reforms and is likewise
in danger of being undermined or delayed. Local clinical engagement,
the key to the success of this process, has already been compromised
by the speculation about what the new organisations will look
like, and who will be the new key players.
4. LIKELY IMPACT
ON PROVISION
OF LOCAL
SERVICES
4.1 Staff in provider services, particularly,
community nursing (Health Visiting, District Nursing), therapy
services ( Physiotherapy, Occupational Therapy, Speech and Language,
Dietetics and Nutrition, Chiropody and Podiatry), community paediatric
medicine and nursing etc, have been deeply unsettled by the July
statement that provider services will separate from PCTs by 2008,
with no clarity about where they will go or who will manage them.
Some new light has been given in the recent announcement by the
Secretary of State, which appears to say this is now a matter
for the new PCTs to decide and not a directive, but there is still
lack of complete clarity. This is causing unsettled staff to lose
focus and sometimes vote with their feet by moving to organisations
perceived as being more stable. In this time this will be the
acute sector of the NHS or mental Health Trusts, ie those perceived
to be unaffected by reconfiguration. This is highly counter productive
at a time when Government policy, through patient choice and good
medical practice is focusing on admission avoidance and managing
long term conditions in the community. At any time PCTs can ill
afford to lose the skills of their primary care and community
workforce .
5. LIKELY IMPACT
ON OTHER
PCT FUNCTIONS INCLUDING
PUBLIC HEALTH
5.1 It is unclear what has happened to the
"Choosing Health" White Paper and delivery plan in this
debate about the size and shape of PCTs. There is a risk that
unless mechanisms to implement this vital part of policy are explicit,
the very thing that can have the most impact on health, especially
in a deprived community like Basildon Town, is lost in an organisation
that is too large to relate to local communities and too involved
in strategic commissioning to really put in the investment that
is needed to promote healthy living.
5.2 Impact on PCTs ability to deliver PbC
has been addressed above.
6. CONSULTATION
ON PROPOSED
CHANGES
6.1 The Essex SHA adopted a rapid informal
consultation process as requested in DoH document in July. This
necessitated a very short time scale for consultation as draft
submissions had to be in to DoH by 15 October, and most key players
were away in August and could not respond. Consequently insufficient
time was available to collect vital data to inform a complete
option appraisal of the various possible configurations. The SHA
submission, by their own admission is lacking in essential information,
especially financial data, and they are only now commissioning
work to carry out these essential investigations. Yet they have
made a recommendation to the DoH that they consult on a preferred
option of two PCTs, one North, one South for Essex which many
according to their own public consultation report feel is not
sensitive enough to address vital local issues of health inequalities
and service integration.
6.2 Basildon PCT's preferred option is to
be merged as part of one South West Essex PCT, as part of a configuration
that would give five PCTs across Essex. Our rationale being that
collaboration already exists amongst PCTs that share a main acute
provider. In our own case this is particularly strong with the
jointly appointed Director Commissioning and joint programmes
addressing many common needs. Our clinicians are already fully
engaged with this process that is designed to achieve stronger,
clinically led commissioning. In particular our clinicians and
our patient representatives are concerned that our new resources
next year and the year after are safeguarded for the most deprived
communities they serve. The rationale for five PCTs in Essex seems
at least as strong as the rationale for two until costs are considered.
We understand that detailed costings are being undertaken and
note that costs may need to be completely reconsidered if the
management costs of provider services are not necessarily to be
channelled into other organisations.
6.3 In the formal consultation stage we
would like assurance that real weight is given to local views
including those of the PPI forum and District Council.
6.4 In our original submission to the SHA,
we made the following additional points in support of a SW Essex
PCT option.
6.4.1 The combination of the impact of the
population increases in the South West of Essex associated with
Thames Gateway (additional 32,100 households by 2021) and the
enhanced financial allocations over the next few years (eg an
estimated budget of over £450 million by 2007-08) a SW Essex
PCT is clearly a viable unit.
6.4.2 A SW Essex PCT reflects a natural health
economy around a first wave Foundation Trust. A similar natural
health economy has developed in the South East of Essex. A South
Essex single PCT configuration would artificially pull together
two separate, functioning, natural health economies.
6.4.3 Children are a high priority in Basildon
and neighbouring areas. There are a high number of children on
the child protection register, and children suffer significantly
poorer educational achievement compared with most parts of the
country. A SW PCT will be more effective in protecting and developing
the work of our very active District Council level local Children's
and Young People's Strategic Partnerships (CPSYPs).
6.4.4 Bringing these two natural health economies,
SW Essex and SE Essex together gives absolutely no guarantee that
in a South Essex budget, the interest of the deprived Basildon
communities would continue to be served and that Basildon people
would continue to benefit from the increased allocations per capita
they have waited so long to receive.
7. LIKELY COSTS
AND COSTS
SAVINGS
7.1 We would refer you to our comments
in paragraphs 2.2 and 6.2.
8. CONCLUSION
8.1 We would respectfully ask the Select
Committee to consider the evidence we have presented. Our aim
is not to oppose change but to make the case for form to follow
function. The current proposals risk widespread system instability
at the very time, when the "arrowhead" of reform, PBC,
requiring close local clinical engagement and considerable local
management capacity, is being implemented.
Alwyn Hollins, Chairman
Basildon Primary Care Trust
31 October 2005
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