In 2009 a shake-up of primary care services will see PCTs officially split into purchaser and provider branches. Richard Staines considers the benefits and disadvantages for nursing.
By April 2009, the government’s drive to create an internal market within the NHS will be almost complete.
PCTs will be effectively split into two branches - purchasers and providers.
In theory, the purchasing side of the trust will commission services from its provider branch, but it will also have the option of using other types of provider to cover all of its services, thus creating an internal market.
The idea is that the creation of a market in primary care will raise standards by introducing competition. It will also mean that commissioning organisations will be able to react quickly and design services to suit local needs.
The government’s vision is for a vast array of different types of provider organisations, some owned by the NHS itself, others by independent sector companies and, in some cases, social enterprise schemes.
According to senior commentators, there could be opportunities for nurses in both commissioning and providing services.
With their expert knowledge of patient care, nurses are expected to play a vital role in designing services and deciding which organisations carry them out.
Increasingly, primary care nursing is focusing not just on hands-on care but also on more strategic planning around treatment pathways. Specialist nurses are increasingly playing a central role in shaping how care is delivered and the move to a market in primary care promises to maintain this trend.
Nursing Times has contacted all 10 strategic health authorities in England to find out how nurses will be able to commission services in the future. Leading nurses at the SHAs said they expected to have a frontline role in commissioning, not least because this was recommended by health minister Lord Darzi in his NHS Next Stage Review.
Jane Cummings, director of nursing, performance and quality at NHS North West, said that the emphasis on commissioning for quality and improving services would mean ‘huge opportunities’ for nurses.
‘There is a lot of opportunity for nurses in making sure PCTs have quality outcomes in terms of patient experience,’ she said.
‘Lord Darzi’s next stage review said that in many cases staff will be contributing and lending expertise in terms of design.’
Susan Osborne CBE, director of nursing for NHS East of England, added that the introduction of ‘patient budgets’ could give nurses opportunities as advisers - the Next Stage Review recommended the piloting of budget allocation to allow people with long-term conditions to purchase and design their own support.
‘If you are going to go down the route of having personalised budgets, which we hope to become a pilot for, the whole commissioning process is going to change significantly if you are going to have patients who have their own money,’ she said.
‘They will need a lot of advice and will need a lot of information at PCT level. Senior nurses will be talking to providers looking at how services are being provided and talking to users,’ she added.
A separate document drawn up by Lord Darzi - A Framework for Action - set out plans for community services in London. This promised greater levels of involvement for clinical staff in the commissioning process.
Trish Morris-Thompson, chief nurse at London SHA, said: ‘There will be 31 local borough commissioners, five second-tier commissioning bodies and one central commissioning body for London. I see nurses involved at all of these levels
But Howard Catton, RCN head of policy, warned that nurses have been omitted from the commissioning process in some places where the split has begun.
‘When you look at what commissioning is - in terms of assessing needs and planning how you are going to meet that need - that is at the heart of what nursing is,’ he said.
‘But, to be frank, it is a mixed picture. There are some places where nurses are heavily involved with decisions about identifying what commissioning needs are. But there is still scope for improvement.
‘We have done some early work into the nursing involvement at PCT executive level and there is variation in the level of involvement,’ he added.
Architects of the changes are keen to point out the opportunities the commissioner-provider split will provide. The Department of Health’s vision for a diverse range of provider organisations promises to provide new employment opportunities for nurses.
Central Surrey Health, a social partnership created from East Elmbridge and Mid-Surrey PCT in 2006, is a positive example of a successful social enterprise.
These are not-for-profit companies that provide services to the NHS under specialist provider of medical services (SPMS) contracts.
They can obtain funding from sources outside the health service - as long as this funding goes towards patient care - as well as from conventional NHS sources. Staff hold a share in the company, which cannot be bought or sold.
This model is being heavily pushed by the DH as the future of primary care in the NHS Next Stage Review, with nurses in particular being encouraged to set them up. A number of schemes led by nurses or likely to have heavy nurse involvement are either already up and running or planned (see map).
However, there are drawbacks. Staff who transfer to social enterprises can remain members of the NHS pension scheme. But the DH quietly announced last month - at the end of a document on social enterprises - that they would no longer qualify for early retirement or injury benefits. Also, new staff employed by social enterprises after their creation are not guaranteed as good a pension as an NHS one.
Social enterprises can also become insolvent and go out of business altogether.
While Nursing Times has found that some PCTs, such as Kingston, favour a social enterprise strategy, some have rejected it. Proposals to create a social enterprise at Sefton PCT have been shelved, while Havering PCT has opted to become a community foundation trust (CFT).
John Cowman, acting chief operating officer at Havering PCT, said this could offer many benefits of a social enterprise without leaving the NHS.
CFTs are allowed to reinvest profits into services they deem to be a priority and a system of elected governors makes them more locally accountable.
‘If you look at social enterprises, they are not actually very different from community foundation trusts - it is just that funding streams of social enterprises are different,’ Mr Cowman said.
‘A lot of the freedom we wished to gain from being a social enterprise can be expected from a community foundation trust,’ he added.
However, Tricia McGregor, managing director of Central Surrey Health social enterprise scheme, rejected the idea that leaving the NHS was a negative move.
Her new-look organisation is about focusing on patients, who are in effect its ‘customers’. ‘It is about becoming more patient focused. But we are not for sale and we do not have any outside shareholders,’ she said.
Even more controversial is the notion that services previously provided by PCTs may be contracted out to private or voluntary sector organisations.
None of the SHA directors of nursing contacted by Nursing Times said they were currently intending to tender out existing services to the independent sector - but none would rule it out in the future. Nursing Times revealed last week that a private firm, Clinicenta, has won a£27m contract to provide additional end-of-life care in north-west London.
Nurses working in primary care in 10 years’ time are likely to find themselves working for a variety of providers.
Many unions remain ideologically opposed to independent sector involvement in the NHS and are suspicious of initiatives that break away from the traditional model.
But Liz Redfern, director of patient care and nursing at South West SHA, said: ‘Even if a service is taken over by a third-sector organisation, there are still opportunities for nurses. They need to wake up to this rather than thinking it is going to mean they will lose their jobs.
‘Nurses can run social enterprise programmes and can lead on some of these issues,’ she added.
‘They need to recognise there are more ways than being an employee of the NHS.’