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Redesigning community care

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Six community foundation trust pilots are under way. Simon Ellery looks at their progress and how they are helping to improve care

The government vision of how the acute sector should run is on track.

More than 100 foundation trusts – out of a total of 270 general acute hospitals – are up and running and able to set their own local health priorities free from central government control.

Community foundation trusts (CFTs), which extend this idea to wider community services, are also being established to bring patient care ‘closer to home’. Under this programme, PCTs are split into a provider, which supplies the health services to the community, and a commissioning wing, which contracts those services.

An arm’s-length board of governors is elected from the local population, patient groups and staff, who then direct the running of the CFT and determine local priorities. They in turn appoint a chairperson and non-executive directors – often nurses – to a management board.

The government wants providers, including those from the voluntary sector and joint ventures with independents, to grow in number, widening patient choice in the process. Last month health minister Ben Bradshaw said that the Department of Health would support organisations ‘that best underpin the development of flexible, responsive community services’.

But while the government has pledged to back the development of innovative community services, support on the ground has been mixed.

Six pilots are in operation at the moment (see box, below) but two of the first wave of eight decided to withdraw from the programme last October.

The six CFT pilot sites

  • Ashton, Leigh and Wigan PCT

  • Cambridgeshire PCT

  • Liverpool PCT

  • Middlesbrough PCT and Redcar and Cleveland PCT

  • Oldham PCT

  • South Birmingham PCT

Newcastle PCT shelved the move as it felt that provider services should continue to be managed by the NHS; and Southampton City PCT pulled out, blaming a lack of support from the DH and the local strategic health authority.

Despite some PCTs’ lack of confidence in the initiative, a spokesperson for the DH emphasises that it ‘continues to support the CFT pilot programme’.

The pilots have also provided invaluable information. In its report Towards Autonomy, published in May, the NHS Confederation identified key issues such as governance concerns and developing new cultures and relationships at non-executive and executive levels. Concerns have been raised about the fact that CFTs’ arm’s-length management boards are chaired by a non-executive director who is on the PCT board and the provider board.

It is this management structure that Jo Webber, policy manager of the NHS Confederation, says creates a conflict
of interest.

She says that the benefits of CFTs are that staff remain within the NHS, opportunities for public engagement are strong and the model is flexible enough to allow local changes.

The report concludes that the CFT model represents ‘one of the potential models for separation’ of provider services from
the PCT.

‘It is by no means the only answer and there are many lessons still to be learnt from the pilot sites,’ the report says.

Howard Catton, head of policy at the RCN, says the college has never opposed CFTs but that it is concerned about the foundation model’s two-tier set-up.

The biggest concern was that foundation hospitals, instead of raising standards across the board, would improve their own performances and leave ‘sink’ hospitals in their wake. ‘But we saw that there was potential for better public and patient involvement and staff engagement,’ says Mr Catton.

The RCN introduced a ‘scorecard’ for members to rate key facets of the CFTs, such as governance and whether there is a nurse executive on the board of directors. Nurses can then assess each application against key criteria.

Mr Catton adds: ‘We are not going to come out and say CFTs are a bad thing. We will take the scorecard approach and adapt it for individual CFT applications.’

He says the RCN is worried that having a number of providers, including voluntary and third-sector bodies, will make it harder to provide joined-up, seamless services.

Having two large, powerful organisations ‘out there on their own’, on the other hand, can mean that they are less responsive to local needs.

Good commissioning, he points out, requires a strong understanding of providing services and should not be done in a vacuum. Some nurses complain that this has been one of the problems with CFTs.

But so far the six pilots are delivering results. At Liverpool PCT, which operates four nurse-led walk-in centres and a 72-bed nurse-led intermediate care unit, nurses believe that autonomy has brought abouta fresh focus on innovation.

Lead nurse and managing director Bernie Cuthel says the pilot has enabled it to redesign community nursing, including its district nursing. ‘We believe it has resulted in a reduction in hospital admissions and greater patient choice,’ she says.
Liverpool PCT has a strong legacy of innovation in nursing and Ms Cuthel sees ‘a real opportunity to optimise the role
of nurses in developing career pathways in primary care and community services’.

Blood transfusions are already being delivered at home and the team is now working with care homes to drive up standards through increased access to community matrons.

‘Community nurses in Liverpool already have opportunities to operate autonomously and we believe that the CFT model will strengthen the involvement of nurses both in their engagement with service improvement and development,’ says
Ms Cuthel.

Access to services has been improved with the introduction of treatment rooms – dotted across the city and open seven days a week – and patient ‘choose and book technology’. Such innovations have helped to keep patients out of hospital, says Ms Cuthel, citing a woman who was spared a wait in A&E.

‘A lady from a care home was admitted with severe dehydration to the nurse-led community clinical assessment unit by a community matron. She was assessed and treated over a 48-hour period and returned to the care home,’ she says. In
the past, the patient would have been admitted to A&E and probably into an acute medical bed.

Nurses have also gained a certain amount of ‘corporate clout’ through governance roles, which allow them to operate autonomously. With senior nurses on the board, nurses on the ground feel more able to feed through comments and suggestions and to shape how services are provided.

Graham Nice, lead nurse and assistant director for clinical governance at Cambridgeshire PCT, thinks clearly defined business units and service lines have empowered clinicians to run services in partnership with management colleagues.

‘If the organisation knows what it does, how it does it, for whom and at what value, it gives a much more robust framework for clinicians to work with,’ he says.

Cambridgeshire’s pilot has increased its understanding of the business – and identified strengths and weaknesses.

‘It has been really challenging but we were prepared to stick our heads above the parapet. We felt that the CFT process would bring discipline along with support from the other pilots,’ says Mr Nice.

The pilot has also completed the first stage in a three-stage process of separation from the PCT so that it has the appropriate delegated authority to operate while still being accountable to the PCT.

The CFT has delegated responsibility from the PCT board to run its services with a dedicated board of officers and lay members who are empowered to run the provider arm. The PCT remains ultimately accountable.

The next step is for the autonomous organisation to become a legally constituted organisation and the final stage is to become a foundation trust.

Mr Nice says productivity has increased, releasing more time for direct care in district nursing, health visiting, intermediate care and occupational therapy. The plan is to cut the amount of time clinicians spend on managing systems and increase the time devoted to individual patients.

Another achievement has been the creation of new pathways of care for patients, such as end-of-life care, child health promotion and long-term conditions that Mr Nice says ‘will improve efficiency, reduce waste and improve job satisfaction’.

‘We believe that this model is the best solution for community services in the long term as it offers new financial flexibilities to invest in the development of services and shifts accountability to the communities we serve. Creating a CFT enables the staff to create the culture and behaviours necessary to deliver on the Darzi vision.’

One senior nurse at the Liverpool pilot believes CFT status has brought new dynamism to her work. ‘Nurses feel enabled to challenge the system and do what is best for patients,’ says Claire Heneghan, head of nursing for long-term conditions. ‘If there is a block in the system they are empowered and supported to “shift” that block, keeping the patient at the centre of care.

Nurses understand and own the “out of hospital” agenda and the challenges placed in primary and community care.’
Pilot sites are also seeing relationships overhauled. Stephen Childs, lead nurse and chief operating officer at Middlesbrough, Redcar and Cleveland PCT, says there is a ‘heightened awareness of customer value’ with the CFT viewing both the patient and commissioner as the customer.

‘There is much more disciplined business practice, such as financial management leading to sharper and more sustainable cash-releasing efficiency initiatives,’ he says. ‘This in turn is leading to better service planning and better use of resources, which gives better value for commissioners and better service for patients.’

Nurses are freed up to work more closely with commissioners to inform pathway redesign and identify unmet needs. At the same time incentives help target efficiencies and productivity gains with significant revenue released that can be reinvested in staff development.

Mr Childs adds: ‘As we become more and more attuned to what the customer values, we will be providing services that really are meeting their needs in a way that is tailored to their circumstances.’

So, is your PCT likely to become a CFT?

The regulator of foundation trusts, Monitor, has specified that only CFTs with an annual turnover of £30m would have ‘the level of governance and financial expertise associated with the foundation trust model’.

As the pilots continue it is becoming clear that moving towards a CFT is not easy. Two have pulled out and not all organisations – or communities – can successfully adopt the model.

What is also clear is that any change requires backing from the DH and the SHA as well as strong assessment of local
health needs.

Ministers are determined to test the foundation model in community settings.

If lessons are learnt and the model adapted, it may yet provide a valuable template for responsive services up and down the country.

What is a CFT?

  • A CFT is a provider organisation with no commissioning function

  • Foundation trusts (including CFTs) are free from central government control and can decide how to improve services

  • They are accountable to their local communities through their governors and members and they can keep surpluses to invest in improved (and new) services for patients, and can borrow to support these investments


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