POLICY AND POLITICS

Policy paradox and political neglect in community health services Bob Hudson

Visiting Professor in Public Policy, School of Applied Social Sciences, University of Durham   

In 1972 the Conservative Government, with Sir Keith Joseph as Health Minister, published a white paper (Department of Health and Social Security, 1972: para. 1) that began with a clear statement of the government’s belief in the principle of unification:

‘The National Health Service should be a single service. Its separate parts are intended to complement one another, not to function as self-sufficient entities...The administrative unification of hospital and community services will make a firmer reality of the concept of a single service.’ This was the justification for transferring control of community health services (CHSs) from local authorities to NHS Area Health Authorities on 1 April 1974. During the passage of the Bill, MPs from both sides of the house expressed their reservations about the reduced role of local authorities, notably the former Health Minister, Enoch Powell, who complained of ‘the nationalisation of com-

ABSTRACT

Community health services (CHSs) have never had a settled organisational existence but the turmoil has intensified since the publication of Transforming Community Services in 2009. CHSs are now beset by three dilemmas: ongoing organisational fragmentation; the extension of competition law and the spread of privatisation; inadequate workforce development and lack of clarity on the nature of CHS activity. This has left the services in a position of policy and political vulnerability. The solution may be for the service to be part of horizontal integration models such as the accountable care organisation, with a focus on locality and multiprofessional teams wrapped around patient pathways.

KEY WORDS

w Community health services w Organisational fragmentation w Privatisation w Activity measurement w Models of integration

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munity health services’ (Ottewill and Wall, 1990). On the due date a raft of services transferred, including school health, district nursing, health visiting, domiciliary midwifery, chiropody, health education and ambulance services. CHSs accounted for 10.6% of NHS expenditure in 2012–13—a relatively small amount given the current emphasis on increasing out-of-hospital care but an increase on the 6.7% of 30  years ago (Health and Social Care Information Centre, 2014). With around 100 million community visits taking place each year, CHSs undertake a vital role, but the 1972 model of CHS as a robust link in a national chain of coordinated care now looks fanciful. Rather the picture is one of increasing fragmentation, confusion and unaccountable neglect. This article explores the main dilemmas facing CHSs in England today and outlines options for change. Three dilemmas are identified: w Organisational fragmentation w Competition law and privatisation w Workforce development and activity

Organisational fragmentation The organisational uncertainty surrounding CHSs arises from the pursuit, by all recent governments, of an ever more ‘pure’ purchaser–provider split. With acute hospitals under increasing pressure to become semi-autonomous foundation trusts, CHSs have been left marooned with commissioning agencies—most recently primary care trusts (PCTs). Even before the abolition of PCTs under the NHS and Social Care Act (2012), the previous Labour Government sowed the seeds of confusion with the publication of Transforming Community Services (Department of Health, 2009) which required PCTs to divest themselves of their remaining provider role. A range of options was said to be available for reconfiguring CHSs: w Remaining within the PCT but at ‘arms-length’ w Community foundation status w Social enterprise status w Integration with acute trust

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Introduction

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w Primary-care-based alliances w Care trust w Partnership arrangement with the local authority. In the event, around 25% of CHSs went to acute foundation trusts, 28% to mental health trusts and 26% to new aspirant community foundation trusts. Of the remainder, about 10% went to social enterprises, while GPs, independent sector providers and local authorities managed around 4% each. Forty years on from the white paper, the 1972 leitmotif of a ‘single service’ has been replaced by a complex organisational maze. This in turn has given rise to two dangers—acute sector asset-stripping and the strangulation of community foundation trusts (CFTs). The danger, for CHSs, of being part of a vertically integrated system is that a corporate focus on the acute business results in financial raids on community services. As early as July 2011 it was being suggested that acute trusts could inherit community services assets worth around £2.7 billion, creating the possibility that property would be offloaded to hit short-term savings targets rather than create more rational service configurations (Lewis and Williams, 2011). Such suspicions were confirmed by Monitor’s review of the situation in the same year which found (Monitor, 2011: p. 2):

‘very very few foundation trusts were able to clearly articulate in detail the strategic rationale for undertaking the transaction, and for many trusts it was an opportunistic rather than a strategic move’. In the meantime, the alternative ‘single service’ model— the 17 aspirant CFTs—have been strangulated by the acute sector authorisation requirements imposed by Monitor. A confidential review of the situation commissioned by the Department of Health in 2013 was said to be positive about CFTs but critical of the application of an acute FT-style authorisation (Lintern, 2013a). CFTs, the report concluded, were vulnerable to large-scale contract changes, while their ‘asset-light’ nature and small executive teams made it difficult for them to meet Monitor’s authorisation requirements for FT status. The uncertain fate of CFTs remains in the hands of the obscure NHS Trust Development Authority.

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Competition law and privatisation The fragmentation and confusion arising from Department of Health (2009) has been further complicated by the arrival of private-sector companies. The Section 75 Regulations arising from the NHS and Social Care Act 2012 require all NHS services to be put out to competition unless the commissioners can prove there is only one provider capable of delivering them. CHSs will be unlikely to meet this demanding requirement, and attempts to award contracts without tender could be exposed to costly legal challenges (Hudson, 2013a). With little in the way of capital requirements and the possibility of moving staff off the Agenda for Change (the current NHS grading and pay system for all NHS staff with the exception of doctors, dentists and some senior

managers) on to lower-cost terms and conditions, CHSs are an attractive prospect for private companies. As early as 2011, private-sector market analysts Laing & Buisson predicted that community nurses would increasingly find themselves working for private-sector companies outside of national pay contracts over the next 5  years (Dowler, 2011). Private-sector companies have since gone on to win some substantial contracts—for example, Virgin Care with a £500 million contract to run CHSs in Surrey for 5 years, and Serco to manage Suffolk Community Healthcare. The most recent analysis of this situation comes from the Nuffield Trust (2014), who report that one pound in every five spent by the former PCTs on CHSs in 2012–13 was accounted for by independent sector providers—an increase of 34% in a year alone. Overall, around one third of NHS spending on CHSs is now with non-NHS providers, and this cannot be accounted for by the creation of a handful of ex-NHS social enterprises. Moreover, the high mark of private-sector CHS provision is yet to come, once the bulk of Transforming Community Services contracts come up for renewal. Many of these agreements were due to expire at the end of 2013–14 but had an option to extend for a further 2 years and are yet to be re-tendered by many clinical commissioning groups (CCGs). What happens at this point will shape the future position of CHSs, but there is little public information on CCG contracting activity. The biggest CCG in England, Northern, Eastern and Western Devon, has said it intends to award the bulk of its community services without competition in defiance of the Section 75 regulations (Calkin, 2014a). Other CCGs will watch from the sidelines with interest but will do so under the firm gaze of the competition watchdog, Monitor, which has shifted from saying it will be watching procurement decisions closely (Calkin, 2014b) to announcing a formal investigation into CCG intentions with this health sector (Williams, 2014). Early research suggests legal compliance with CCGs awarding around two thirds of contracts to non-NHS providers (Davies, 2014).

Workforce development and activity In principle. the need for an increase in the numbers and skills of the CHS workforce—especially district nursing— is evident: the population is ageing; there is a growing number of people with lifestyle-related conditions such as type 2 diabetes; there is intense pressure on hospital beds; and the major policy focus is on a model of out-of-hospital care. There also exists no shortage of wishful thinking on the matter. In 2013 the Department of Health published its New Vision and Model for District Nursing, which was

‘to provide clarity regarding the role and responsibilities of district nurses to ensure wider stakeholders understand and appreciate the scope and complexity of the service’ (Department of Health, 2013: p. 22) and in the same year the Care Quality Commission pub-

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inevitably fall upon CHS professionals and will significantly shape their practice. It would, however, be unfortunate if the dominant metric was solely that of price. There is an even more crucial measure of which we know little: patient experience and outcome. Huge effort is being expended on attempting to measure patient feedback in hospitals, but much less on patient experience of CHSs, even though those receiving care at home are among the most vulnerable in society.

Where next for CHSs? All of this adds up to a parlous policy and professional context for CHSs. Edwards (2014) sums it up by arguing that that ‘years of initiatives, policy ideas and fads have left a legacy of highly complex, narrowly focused and often poorly coordinated services’. Part of the problem, argues Edwards, is that CHS professionals and managers lack control over the key points of the patient pathway—referrals, admissions, discharges, etc—and have few powerful advocates within the system. The dilemmas outlined above indicate the key issues that need to be addressed—proper funding, addressing workforce supply and development and developing activity data to understand the cost of moving complex cases from the acute sector to the community. In terms of funding it is clear that the spending allocation for NHS services is insufficient to meet increasing demand and there is now growing recognition that significant decisions about future funding will have to be made (Roberts et al, 2012). In organisational terms, the problem is that CHSs have become everyone’s distant relative but nobody’s baby, and it is vital that this marginalisation is brought to an end. The experience of vertically integrated systems is one of reduced investment in CHSs, when what is needed is horizontal integration—patients (and staff) moving freely along coordinated pathways between acute and community services. This means partly returning to an old, but neglected, agenda of multi-disciplinary teams for people with complex needs (Hudson, 2007). In the current policy context, the best vehicle for progress could be the fashionable Accountable Care Organisation (ACO) model (Shortell et al, 2014), whereby a commissioner contracts one lead provider to ensure the delivery of an agreed domain of activity. The key features are as follows: w A lead provider takes on the budget and responsibility for selected groups of patients or for resolution of a cross-cutting issue w Commissioners offer financial rewards for reaching agreed outcome-based quality goals w Service duplication will be diminished or eliminated, care will be better coordinated and preventive activity will be boosted. It is very early days for the ACO model, though the current Health Secretary, Jeremy Hunt, seems to be pushing for its adoption (West and Welikala, 2014). Indeed, the idea seems to have wide political appeal. In his recent speech on future Labour health policy, for example, the

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lished its new methodology for inspecting community health services (Care Quality Commission, 2013). In the meantime, there is a workforce crisis at the front line. Although there is now a strategy to reverse the steady decline in the numbers of health visitors, the number of district nurses has continued to fall (by 44% since 1999) as the numbers trained is increasingly exceeded by those leaving and retiring—27% of the workforce is aged over 50 (Ball et al, 2013). This situation has now reached the point at which the Royal College of Nursing has claimed that district nurses ‘face extinction’ as a ‘critically endangered’ type of health professional (Royal College of Nursing, 2014). All of this is ratcheting up the pressure on the remaining workforce. The King’s College survey (Ball et al, 2014) reports heavy workloads, with community nurses more likely than hospital nurses to say they feel under too much pressure. A total of 75% say they leave at the end of home visits without having undertaken some necessary tasks or answering all of a patient’s questions, and the same constraints limit their time to liaise with other professionals such as GPs and social workers. It is not evident that a strategy is in place to respond to this situation. Rather, attention is being focused on pinning down the nature of community nursing activity and then putting a price on it—crucial ingredients in the commodification and marketisation of health services. Relatively little is known about the precise nature of CHS activity and there is little in the way of a methodology to assess appropriate workloads. In the absence of such measurements, activity tends to be expressed as a ratio such as the number of district nurses per 1000 head of population or through average caseload size (Shortell et al, 2014). A Monitor (2013) research paper reported that most local contracts for CHSs are block contracts based on poorquality data that do not reflect the true cost of provision. In the absence of robust data, Monitor and NHS England are proposing to fund a CHSs tariff some 20% below that paid to acute providers on the grounds that CHS providers are unaffected by the cost of implementing the Francis Report (2013) improvements. This position looks set to change, with commissioners, providers and regulators all looking to validate activity. CFTs are working on a national programme to develop indicators to benchmark their performance and value, and this could underpin a national CHS tariff payment system that enables commissioners to see the quantifiable value derived from activity (Lintern, 2013b). This work could cover a swathe of activities not currently part of the national tariff payment model, including district nursing, health visiting, audiology, school nursing, wheelchair services and diabetes services. Meanwhile, Monitor has commissioned the management consultancy, Deloitte, to undertake a study evaluating the costing of community and mental health-care services to ensure money paid from CCGs to CHSs accurately reflects activity. The burden of recording the necessary data will

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Shadow Health Secretary, Andy Burnham, referred to ‘one service coordinating all of one person’s needs’, with the district general hospital ‘evolving over time into an integrated care provider from home to hospital’ (Hudson, 2013b). The incentive for the acute sector is to restabilise its business as it moves away from a bed-based service model—with CHSs being an integral partner in a shift to horizontal integration. In all of this, the notion of ‘place’ is important. Using localities as service lines, rather than defining service lines in terms of specialties, would support attempts to integrate services around people’s needs. Context is also critical. There is a growing body of evidence that an intervention that succeeds in one locality does not deliver the same results elsewhere (Health Foundation, 2014). Alongside the importance of what is done (the intervention) and how it is done (the implementation), the context within which it is done also matters—it is the interaction between these three elements that makes for success. The message here is that what works in one CHSs locality cannot simply be transplanted elsewhere. Each partnership will have its own distinctive characteristics that will shape local events. In this respect, Enoch Powell’s plea for localised but integrated community health services may turn out to be correct.  BJCN

KEY POINTS

w Community health services (CHSs) have been subject to organisational change and political marginalisation for several decades

w Although the need for CHSs is increasing, the future of the service is uncertain

w Evidence is growing that private companies are winning more CHS contracts

w The evidence base for what is achieved and at what price by CHSs is still weak

w The future lies in an integrated single service system such as the Accountable Care Organisation mode

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Policy paradox and political neglect in community health services.

Community health services (CHSs) have never had a settled organisational existence but the turmoil has intensified since the publication of Transformi...
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