Select Committee on Health Written Evidence


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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