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Waverley Borough Council Committee System - Committee Document

Meeting of the Executive held on 11/10/2005
COMMISSIONING A PATIENT-LED NATIONAL HEALTH SERVICE



Summary & Purpose
The report outlines proposals for restructuring Primary Care Trusts to improve commissioning of health services and to achieve greater efficiencies. These proposals have wide-ranging implications for patients, staff of the NHS, inter-organisational relationships and the structure of the health economy nationally, regionally and locally.

Quality of Life Implications
Natural Resource Use
Pollution Prevention and Control
Biodiversity and Nature
Local Environment
Social Inclusion
Safe Communities
Local Economy
Natural
Resource Use
Pollution
Prevention and Control
Biodiversity
and Nature
Local
Environment
Social
Inclusion
Safe, Healthy
and Active
Communities
Local
Economy
N/A
N/A
N/A
N/A
Positive
Positive
N/A


APPENDIX G
WAVERLEY BOROUGH COUNCIL
EXECUTIVE – 11th OCTOBER 2005
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Title:

COMMISSIONING A PATIENT-LED NATIONAL HEALTH SERVICE
[Wards Affected: All ]

Summary and purpose

The report outlines proposals for restructuring Primary Care Trusts to improve commissioning of health services and to achieve greater efficiencies. These proposals have wide-ranging implications for patients, staff of the NHS, inter-organisational relationships and the structure of the health economy nationally, regionally and locally.

This is a complex issue. This report seeks to provide the policy context through which changes are being initiated and comment on the local implications of the proposed changes. Once the recommendations of the Surrey and Sussex Strategic Health Authority are made to the NHS and have been considered, there will be a formal 90-day formal consultation exercise on the proposals for change that are being put forward by the NHS. In effect, therefore, this report is an ‘early warning’ of potential changes to the local health organisation.
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Quality of life implications – social, environmental & economic (sustainable development):

Natural Resource Use
Pollution Prevention and Control
Biodiversity and Nature
Local Environment
Social Inclusion
Safe, Healthy and Active Communities
Local Economy
N/A
N/A
N/A
N/A
Positive
Positive
N/A

E-Government implications:

There are none arising from this report.

Resource and legal implications:

There are no immediate resource or legal implications for Waverley arising from this report.
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Background

1. As part of its ‘Modernising Agenda’, the Government is seeking to create a ‘Patient-led NHS’. The NHS has issued a paper entitled “Commissioning a patient-led NHS”, which sets out the process of change required for effective commissioning of health services. Government guidance aims to create a step-change in the way in which services are commissioned by front-line staff, to reflect patient choice. Effective commissioning is considered to be a prerequisite to making patient choice real and is part of the strategy to improve the health of the whole population. This requires:

Faster, universal roll-out of Practice Based Commissioning;
Better engagement of local clinicians in the design of services;
Developing Primary Care Trusts (PCTs) to support Practice Based Commissioning.
Practices taking on the responsibility for performance management through contracts with all providers;
Reviewing the functions of the Strategic Health Authority to support commissioning and contract management.

2. The changes are also aimed at bringing about closer working with local authorities in line with the Choosing Health Agenda, and at making national savings of 250 million in overhead costs.

3. Furthermore, it is hoped they will help prepare the NHS to implement the White Paper on improved care outside of hospital, which the DoH will be consulting on throughout the autumn.

4. These changes herald a reconfiguration of PCTs and SHAs in an attempt to streamline commissioning, achieve greater efficiencies and reduce administrative costs. There is some desire to align health boundaries with those of Government Offices, where this is currently not the case.

5. The Strategic Health Authority is required to undertake a review, through consultation with stakeholders in their local health economy. The process falls into two stages:
engaging PCTs, other stakeholders including local government and NHS staff; enhancing the ability of Practices, PCTs and SHAs to do their new job.

6. Any proposals arising from the consultation process will be assessed against a set of criteria including:

secure high quality, safe services;
improve health and reduce inequalities;
improve the engagement of GPs and rollout of Practice Based Commissioning;
improve public involvement;
improve commissioning and effective use of resources;
manage financial balance and risk;
improve co-ordination with social services through greater congruence of PCT and local government boundaries; and
deliver at least 15% reduction in management and administrative costs.

7. The timetable that has been set by the NHS for changes to structures is as follows:

March 2006: all statutory consultation completed.
By October 2006: all reconfigurations undertaken.
October 2005: commissioning development support programme launched (2 year programme).
March 2006: first wave of enhanced Practice Based Commissioning implemented.
December 2006: PCTs have in place arrangements for universal coverage of Practice Based Commissioning.
April 2007: SHA reconfiguration complete.
December 2008: Changes in PCT service provision complete.

8. The agenda being set by the NHS will result in significant changes to how health services are both commissioned and provided. At present the Guildford and Waverley PCT, for example, both commissions services and is a provider of services, as well as having Public Health responsibilities. It seems that PCTs will become commissioners of services and their provider role will diminish, if not cease altogether.

9. Whilst the changes to organisational structure have captured much attention – particularly in where the new PCT(s) boundaries may be located, perhaps of greater importance to constituents is how are services to be provided into the future and by whom?

10. There are examples of other service providers emerging; private companies being commissioned to provide primary care practices, and certain foundation trusts have expressed an interest in taking on ‘out of hospital’ health care provision. It has also been reported that voluntary organisations could be given national contracts to provide services to NHS patients and one SHA is considering the viability of setting up a Public Health Trust.

Proposals for Change in Surrey

11. The PCT Chief Executives who work across Surrey have considered the agenda presented to them by Sir Nigel Crisp, the NHS Chief Executive. They produced a range of options viz:

Option 1 – maintain the status quo

12. Current configuration consists of five organisations, each of which has a significant population base, with the largest (East Elmbridge & Mid-Surrey) covering 275,000 people. Two of the five PCTs (East Elmbridge & Mid-Surrey, and North Surrey) cross local borough council boundaries. Significant patient flows to London, along with an acute trust whose catchment area spans Surrey & Sussex, create major boundary issues for a number of PCTs, particularly in the East of the County. This option does not address the coterminosity issue, or the imperative to realise management cost savings. Further, five PCTs in Surrey may not provide sufficient critical mass with which to ensure robust arrangements to deliver the new commissioning agenda. Option 2 – two PCTs with an East/West split

13. This configuration reflects previous health authority boundaries. It retains a split borough boundary and may not realise the required savings in management costs or provide a large enough catchment area to provide critical mass for commissioning leverage. Ultimately, this option does not represent any gain over current configuration. Option 3 – two PCTs, broadly North/South

14. This configuration ensures coterminosity with borough boundaries. Again, reduction to two PCTs may not realise sufficient savings in management costs or represent a large enough catchment area to provide critical mass for commissioning leverage. Option 4 – four PCTs to reflect children’s services boundaries.

15. This configuration ensures coterminosity with borough boundaries but does not reflect the reality of patient flow into acute services and would split commissioning arrangements to major acute trusts between PCTs. It is unlikely that the management cost saving imperative could be realised by retaining this number of organisations. Option 5 – a single Surrey-wide PCT 16. This option would includes proposals for a strong locality base of potentially 5 (reflecting current PCT boundaries) or 4 (reflecting children’s social care boundaries). This is the favoured configuration of the PCT since it offers the critical mass necessary to ensure maximum commissioning leverage, and is most likely to realise the necessary management cost savings. Whilst being coterminous with the County Council, a strong locality infrastructure will ensure partnerships with clinicians, boroughs and communities, as well as clinical alliances are maintained at local level.

Presentation by the Interim Chief Executive of the Guildford and Waverley PCT

17. Jane Dale, the Interim Chief Executive of the Guildford and Waverley PCT was specially invited to make a presentation to Waverley members on Wednesday 28th September 2005.

18. Ms Dale reported that the recommendation of the Surrey PCT Chief Executives was that the option of one PCT to cover the whole of Surrey was their preferred way forward, so long as it was underpinned by strong locality partnership working. It was considered that this option best fulfilled the assessment criteria and would help achieve cost savings.

19. Ms Dale reported that the Surrey and Sussex Strategic Health Authority had met that day and had considered the issues and would be making recommendations to the NHS on the basis of the information they had before them.

20. Once the Department of Health had received advice from the Strategic Health Authorities across England, proposals would be forthcoming – towards the end of this year – about PCT re-configuration and there would be, at that stage, a full 90-day formal consultation period. It would be during this period that the Council would be consulted on any proposals for change.

Surrey County Council’s View

21. As members will be aware, County Councils and Unitary authorities hold the statutory role in relation to health scrutiny. Surrey County Council’s Health Scrutiny Committee has therefore considered the issues surrounding PCT re-organisation.

22. Surrey County Council’s Health Scrutiny Committee considered this issue in September and concluded that its favoured option was for the model of a single commissioning PCT, coterminous with Surrey County Council boundaries.

Officer Comment

23. There have been many changes to the structure of the NHS and service delivery over the past decade. The South West Surrey Health Authority was replaced by the West Surrey Health Authority. This in turn was superseded – in Waverley’s case – by the East Waverley Primary Care Group and the West Waverley Primary Care Group. These subsequently merged to form one PCT, which was then followed by mergers to create the Guildford and Waverley Primary Care Trust.

24. Many of these changes were inspired at national level with a view to creating more locally responsive NHS services that included GPs and patients in greater involvement in decision making and, indeed, to provide efficient and effective management structures.

25. Evermore management/organisational restructuring within the NHS is not at all appealing. Whether constant structural reorganisation will lead the local health economy meeting the Government’s objectives is questionable – previous re-organisations/restructuring has not given rise to the cost savings and efficiencies that were hoped for. Indeed, given the levels of indebtedness of organisations such as the Guildford and Waverley PCT and the demands being made on health services locally, it is difficult to see how the current proposals can lead to financial stability.

26. Of all the forms of health organisation we have seen over the last decade, perhaps the most successful in terms of inter-organisational relationships has been the creation of the Guildford and Waverley Primary Care Trust.

27. This PCT has the advantages of enjoying largely co-terminous boundaries with other public sector partners. It is small enough to understand local needs and issues, and be able to make real contact with its service users and yet of a scale to be able to manage a range of services.

28. As a local authority, Waverley has particularly valued the PCT’s ability to work as part of the Local Strategic Partnership (LSP), to be partners in joint initiatives, and to be able to share issues that are a common challenge to us in the public realm. Were PCTs to become very much larger, what the Council actually value as partners might be lost.

Recommendation

It is recommended that the Executive notes:

1. the intention of the NHS to reconfigure PCTs across the country and the potential implications locally; and

2. asks officers to invite the PCT Chief Executive to return to Waverley when the formal consultation exercise begins on the new proposals being made by the Department of Health.

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Background Papers (DoH)

There are no background papers (as defined by Section 100D(5) of the Local Government Act 1972) relating to this report.
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CONTACT OFFICER:

Name: Mr J Swanton Telephone: 01483 -523375
E-mail: jswanton@waverley.gov.uk





Comms/Executive/2005-06/126
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