Transforming Community Services was launched earlier this year. Helen Mooney reports on UNISON’s concerns over separation of the commissioning and provider functions
As part of the government’s renewed drive to force PCTs to separate their commissioning and provider functions, the Department of Health published a series of documents in January 2009 under the heading ‘Transforming Community Services’.
One key document, Enabling New Patterns of Provision, sets out how PCTs can go about separating their functions, outlining timetables and models PCT provider arms might take.
When creating new provider organisations, PCTs have several options. These include retaining services through arm’s-length organisations, setting up community foundation trusts (CFTs) or integrating with other NHS organisations. However, a further option - transferring provider services to the private sector or social enterprises - is causing disquiet among unions and staff.
UNISON is concerned that such a move could result in staff losing out on their NHS employment rights and pension. Another issue for consideration is that in the current financial climate, private sector organisations and social enterprises may not be sustainable.
In principle, PCTs should have moved their provider services arm into a contractual relationship with their PCT commissioning function by now. The government wants the degree of separation to be great enough to avoid potential conflicts of interest.
PCTs must review the operation and governance of their provider services by October to ensure they are the most appropriate to meet local needs. They must also declare whether or not they are interested in establishing a social enterprise or CFT for any of their services and agree a development and management plan with their strategic health authority.
Although the DH has stressed it is not prescribing any ideal form for provider organisations, health unions are worried that PCT boards will try to push staff into social enterprises or contract-out services.
While PCTs have a duty to consult with staff and trade unions on the available options for provider organisations, unions want to ensure that staff are engaged from the start of the process. There are concerns that, in some areas of the country, this is not happening.
UNISON’s concerns about Transforming Community Services
- Many staff want to continue to be employed within the NHS rather than transfer to social enterprises or private companies.
- In some PCTs, consultation and staff involvement are poor.
- The DH has introduced a Cooperation and Competition Panel, raising concerns that the focus is more on competition than patient care.
- Some PCTs are unsure about whether they are allowed to become community foundation trusts - UNISON wants clear guidance from the DH that this is an option for all PCTs.
- In this financial climate, there are concerns about the longevity of social enterprises and private companies providing health services.
- It is unclear whether services will be sustainable, particularly those set up to deliver niche or specialist clinical services, and the programme could undermine local innovation.
UNISON national officer Celestine Laporte, who leads on primary care, says that they have received reports that some PCTs have not been holding consultations at all.
Enabling New Patterns of Provision makes it clear that staff and unions should be fully informed and consulted about how any changes to the pattern of provision might affect the workforce. However, because decisions are made locally there seems to be no central system for monitoring whether or not this is happening.
Ms Laporte is also apprehensive about how the changes will affect primary care as a whole.
‘This is about the fragmentation of primary care services,’ she says. ‘Introducing more competition into the market will be detrimental to the NHS and flies in the face of joining up community services. It will create a less cooperative environment.’
The programme is being conducted ‘under the political radar’, she adds, with most of the public and many MPs unaware it is happening.
The government, however, hopes it will help to create ‘secure modern, high-quality community services’ - a public commitment it made as part of the NHS Next Stage Review: Our Vision for Primary and Community Care.
Therefore, in addition to improving primary care provision, key aims of the Transforming Community Services programme are to promote community engagement and eliminate health inequality. However, it recognises that to achieve this the organisations providing the services must be fit for purpose.
Modern organisations are needed, it says, which ‘enable and empower frontline staff to innovate and free up their time to care for patients’. Provider organisations must empower healthcare professionals to shape
the future of community services, giving them the support and resources they need to be world-class practitioners.
A Cooperation and Competition Panel has been set up to ensure that PCTs commission from organisations and services that best suit patient needs. However, Ms Laporte says many NHS managers and government officials have begun to refer to this as the ‘Competition Panel’, ignoring the vital issue of cooperation.
‘The overall strategy is a good thing but policy seems to contradict that and simply calling it the Competition Panel seems to have over-stepped the mark,’ she says.
Pam Barr, an occupational therapist and staff side UNISON representative at Ashton, Leigh and Wigan PCT, agrees. Transforming Community Services is leading to increased competition among service providers, she says, but rather than being a positive thing it is creating real division.
‘There is a lot of fragmentation because services have been put in to competition even if they don’t want to be,’ she says.
Ms Barr says the effect is that services that once worked in cooperation are finding it increasingly difficult to do so, and this is creating obstacles for patient care pathways.
Ultimately, it will be up to PCTs to consider how separation of their functions and the consequent loss of control will affect their ability to implement innovation in care pathways and integrated services. However, losing large sections of their workforce into the provider organisations could leave skills gaps in the commissioning arm and create tension.
Among the ‘guiding principles’ of the programme is that decisions about how services are provided must be made according to local needs, and that this should be part of an open, transparent process. ‘Clear and robust’ assurance, approval and authorisation processes, it says, are essential at both regional and local levels.
The principles also state that new providers must be able to meet agreed employment standards, and that staff and unions must be ‘substantially involved’ before any decisions are made. However, many individual community services will be rigorously costed for the first time, and the absence of national tariffs could cause difficulties for providers - at least in the short term - particularly in relation to the transfer of NHS pensions and TUPE rights.
David Stout, director of the NHS Confederation’s PCT Network, is concerned about how PCTs will interpret Transforming Community Services.
‘The policy itself is fine, it’s fairly permissive and it is for local PCTs to determine what services they need locally,’ he says. ‘The worry is that the NHS will focus on the organisational form services should take, with the structure becoming the end rather than the means…there is a risk that they will lose sight of services and focus on the organisation.’
Mr Stout points out that the majority of PCT provider arm services have so far expressed the wish to remain part of the NHS, with scant interest in establishing social enterprises or forming partnerships with the private sector.
‘This is because of issues around the transfer of NHS pensions and being able to convince staff it is a good idea,’ he explains. ‘There is also the issue of losing clinical negligence cover if services are no longer part of the NHS.’
Many PCTs have expressed an interest in pursuing the community foundation trust model in a bid to become competitive and yet remain part of the NHS.
Ms Barr says her PCT, one of the pilot sites for community foundation trust status, chose this as the ‘least worst option’. And PCT staff favoured the model because they would remain within the NHS.
‘I have worked in the NHS for 25 years because I believe in it,’ she says. ‘I would certainly rather stay employed by the NHS - at least if we are a community foundation trust any profit we make will go back into the NHS.’
Both Mr Stout and Ms Laporte want the government to clarify the situation with regard to community foundation trusts as there is currently a cap on the number of PCTs that can apply. Mr Stout questions why the numbers have been ‘artificially constrained’.
How Transforming Community Services will ultimately affect primary care is still unclear. But if it is to achieve the government’s goals of improving services while increasing community engagement and reducing inequality, PCTs must actively involve both staff and patients in deciding how services will be run.
What the Department of Health says
‘There is no national blueprint. Decisions will be taken locally by PCT boards, with processes and decision-making assured by strategic health authorities. To help support local decision-making, a set of guiding principles should underpin this change. These include:
- The interests of patients and carers must be paramount;
- Quality is the organising principle - organisations must provide safe, effective, personalised care. This will require transformational service change;
- PCTs must have a clear commissioning strategy, with improving quality and reducing inequalities at its core;
- Proposals must also be able to deliver value for money for tax-payers;
- Decisions about how services are provided should be led and made locally, with robust consultation processes;
- Recognition that services differ in their characteristics and the people they serve, and therefore that different solutions may suit different services, even within the same locality;
- The early and continued involvement of staff, trade unions and stakeholders before any decisions are made is essential;
- High standards of human resource management should be followed;
- Assurance, approval and authorisation processes must be clear, robust and transparent;
- Proposals must enable integrated care, including with local authority services where appropriate, world-class commissioning and patient choice;
- Proposals must fit with the department’s Principles and Rules for Cooperation and Competition;
- That options are equality impact assessed;
- The provision of safeguards for service continuity, assets and staff pensions.
A dedicated section on the UNISON website offers information and advice on Transforming Community Services. It contains up-to-date information including a Q&A on what options PCTs face in the coming months and what they will mean for staff terms and conditions. www.unison.org.uk/pct/tcs.asp