Memorandum submitted by the Continence
Foundation (PCT 4)
The Continence Foundation is a small UK-wide
charity concerned with bladder and bowel weakness. Our membership
includes members of the public as well as a wide range of health
professionals (clinicians, GPs, nurses, therapists etc.) We have
always maintained a close interest in NHS policy in our field
and sought to influence its development at both national and local
level.
SUMMARY
The Foundation does not understand the rationale
behind these changes: they are certainly not "patient-led".
We are not opposed to a reduction in the number of PCTs, provided
this is a development from existing forms of joint working: for
some services (such as continence) to function adequately, a population
base larger than that of most current PCTs is necessary. Practice-based
commissioning requires a level of strategic expertise and specialist
knowledge that most GPs are not interested in acquiring. There
is profound unease among staff in our field that could exacerbate
an existing shortage of qualified nurses. Yet another round of
major changes will produce planning blight: what most professionals
and voluntary organisations would like to see in the NHS is a
period of stability. Public consultation should have been undertaken
before so much work went into options for change, especially since
"no change" is not offered as an option.
1. We are at a loss to understand the rationale
behind the changes, since the amount of money to be saved is relatively
small in terms of the NHS total budget. Cynicism would suggest
that the motive is the introduction of private providers into
community health services. We also note that the proposals take
the system round in circles: many areas will end up with PCTs
that cover the same populations as the Health Authorities of the
1990s. The claim that that is "patient-led" cannot not
be upheld since the consultation on what ordinary people want
from non-hospital services only started after the structural changes
were announced, and in any case, the questions in Your health,
Your care, Your say are not about structures. Submissions
from some SHAs do show some consultation with Patient Forums,
but these were but a small part of the process.
2. However, the Foundation is not opposed
in principle to a reduction in the number of PCTs. Nevertheless,
is extremely concerned that any proposals should be based on evidence
regarding how services are already working across PCT boundaries.
It is possible that some SHAs have considered current joint-working
and SLAs between PCTs when deciding which PCTs should merge, but
this is not apparent from the submissions available.
3. Our evidence for the need for some services
to cover more than the population of the average PCT at present
is as follows. An important aspect of our research findings concerned
the number of PCTs that need to work together to have a sufficient
critical mass to justify employing nurses with the special interests
that need to exist within every community continence service if
they are to meet the needs of their population. These special
interests include children, men, learning disability, nursing
homes (a full list of all the special groups can be found in the
Guidance though not all on the same page.) Unless funding is available
for a team of at least four continence nurse specialists (and
support staff), it is not possible for them to have the necessary
special interests. The services that have achieved or moved close
to creating integrated continence services are working across
three to six Trusts: note that in some cases, an acute, mental
health or learning disability Trust is included to ensure smooth
transitions for patients across boundaries. The ideal population
appears to be at least 400,000 but most have gone for about 600,000—clearly
geographical factors and county boundaries are relevant considerations.
4. The proposal to move to Practice-Based
Commissioning could undermine everything that has been achieved
on a strategic level for continence services in the last five
years. It has been extremely difficult to get PCT Boards to take
an interest in developing integrated services. One of the problems
seems to be a lack of people with the ability to plan at a strategic
level. However, persistence by senior continence advisors (some
at nurse consultant level) backed up by consultants in acute trusts
has been effective in some places. At GP level, it is extremely
rare for individuals to have any interest in incontinence (Dr
Colin-Thome recognises that he himself is an exception). Thus
most practices will have insufficient knowledge to commission
a continence service and especially to understand how many practices
would need to co-operate to create a viable service. Various attempts
have been made over the last 15 years to get GPs more interested
in the design of services, but the results have always been patchy.
More in depth study into GP motivation would seem to be called
for, rather than another total redesign.
5. Continence services across the country
are already struggling to maintain a service. Part of the problem
is the shortage of qualified specialist nurses for the substantive
posts. This will not be helped by the general feeling of bewilderment
and even fear among continence advisors at present, generated
by the uncertainty about who will be their future employers and
whether they will still have NHS careers (almost all continence
advisors in the community are employed by a PCT). There is also
confusion about whether PCTs will be able to continue to be providers
as well as commissioners—it depends which document you read
or who you ask within the Department.
6. The consequences of yet another reorganisation
could produce planning blight: when the main change over to PCTs
took place in April 2002, many continence services had to put
a hold on previous plans for further integration and improvements
in "the patient journey" until they could sort out who
was responsible for what. Some actually found themselves landed
with contracts for the provision of continence products that had
been signed by Health Authorities that no longer existed and with
no mechanism for discovering who had authority to change them.
7. Consultation on the whole idea of yet
another reorganisation should have gone out to the public and
NHS stakeholders before so much work was undertaken by SHAs for
their submissions.
Dr Judith Wardle
Director, Continence Foundation
28 October 2005
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