The money makers at the BMA

Posted on February 12, 2010. Filed under: Journals |

Health Service Journal | Richard Vize | 12 February 2010

The BMA campaign Look After Our NHS is a highly distorted portrayal of the health service.

The first distortion of the campaign is for the BMA to portray itself as representing the interests of patients. That is not its purpose. It is an excessively powerful trade union which exists to further the interests of its members. It is a union which has exploited its power to obstruct improvement. At its worst the BMA can make Arthur Scargill sound like a passionate advocate for flexible working.

The slogan accompanying the campaign is “Publicly funded, publicly provided”. This is not what the BMA actually wants. The vast majority of the GPs which the BMA represents are self-employed. The union’s GPs’ committee could comfortably become part of the Federation of Small Businesses.

Primary care trusts should have much more power to terminate the contracts of the GP businesses which provide an inadequate service to patients. In the absence of such freedom, competition from services in modern premises run by doctors who have grasped the basics of 21st century communication tools such as websites and who open at times to suit working people are vital to shake the poorer GP services out of their complacency.

The campaign’s website features a somewhat childish drawing of a doctor holding up a placard saying “Stop big business profiting from our NHS!”. Presumably this doctor is not a consultant who sells his services to private patients.

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Build a virtual polyclinic

Posted on November 30, 2009. Filed under: Journals, Polyclinics |

Health Service Journal | BY MARK CAULFIELD | 30 November 2009

Streamlined care cannot be delivered unless clinicians are able to share information easily. Mark Caulfield describes how Tower Hamlets solved the problem with integrated IT.

As the repository for vital patient information, IT systems are at the heart of rethinking services in the post-Darzi era.

It is impossible to redesign more streamlined care pathways – with the patient, not the provider, at the centre – without also considering how different healthcare teams can share information to deliver a joined‑up approach.

This is particularly important for patients with long term conditions, who rely on the support of many different healthcare practitioners, who in turn work in a wide range of settings.

Without shared information – for example, details of recent interventions or current medication – consultations become more time consuming and less effective, not to mention frustrating for the patient.

At NHS Tower Hamlets, we have adopted an ambitious IT programme to support the restructuring of our services into eight new networks. In effect virtual polyclinics, the networks combine clusters of GP practices aligned to local community health services.

The aim is to deliver better and more integrated care, closer to home, in one of the most deprived boroughs in the UK.

To support this new way of working, we needed an integrated IT system that was flexible enough to be used by a wide range of clinicians and that would support comprehensive, PCT-wide data reporting.

We decided to continue our history of collaborative work with healthcare systems supplier EMIS to develop its EMIS Web system into a structure that would work across the whole primary care trust.

Single record

The system allows us to create bespoke consultation templates for different healthcare teams – each feeding data into a single patient record, which can be viewed by different practitioners.

We worked closely with different practitioners to create the right template for their particular service and to agree which other professionals could access the data recorded.

For example, we worked with the community matrons to create templates for patients with long term conditions, based on the templates used in general practice. More recently, we worked with the child protection nurse specialist to create a template to record data for vulnerable children.

Both of these templates can be viewed by GPs and community teams – providing a vital overview of care – and the system automatically captures data from different practitioners’ consultations.

Two years into the project and the system is now widely used by 300 community practitioners, from health visitors to district nurses, and will be implemented across all community teams by the end of 2009.

The benefits of this include:

  • Patients’ electronic records are now more comprehensive, with data entered by different practitioners, giving a rounded view of their care.
  • Data capture to support performance reporting is done in seconds, not weeks, and we can now produce electronic 18-week referral reports.
  • Using the system’s powerful search and reports module, we can track all childhood immunisations across the whole PCT and manage call and recall to improve vaccination rates.
  • Services are being delivered more efficiently. For example, by using a streamlined appointment booking service which has removed duplicate data entry, our physiotherapy admin team is saving seven hours a week.
  • We are developing sophisticated care pathways that will allow us to generate tariff information as well as relating this activity to episodes of care defined by specific problems or conditions.
  • Clinicians have adopted the new system with great enthusiasm – far from having to persuade them to change, we are fighting off requests to extend the roll-out of the system.

Integrated patient care does not stop with the PCT. We plan to implement data sharing with a local hospital trust and with the council’s social care services.

How to deliver joined-up IT

  • Involve clinicians from the outset: listen to their needs and take time to understand how services work before you start to think about IT.
  • Focus on the end result: our focus was not on management information but on using IT to help support new care pathways.
  • Don’t assume that different clinicians need different systems: we identified core similarities in how different practitioners approached a consultation, enabling us to develop a central module that could be adapted to meet service-specific needs.
  • Develop rigorous data sharing agreements: GPs in particular need reassurance about who will access the patient record, how and why
  • Retain flexibility: interoperability with other IT systems is essential if you are to link information with other providers, for example in secondary care.
  • Work closely with your IT supplier: having a direct relationship with those designing the system is a tremendous benefit – saving time and ensuring clear communication of users’ needs.
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Camden PCT shelves plans to give contract to private company for new GP led health centre

Posted on November 26, 2009. Filed under: GP-led health centres, Journals, Providers | Tags: |

British Medical Journal | By Clare Dyer | News | 26 November 2009

A primary care trust’s controversial decision to award a £20m [{euro}22m; $33m] contract for a GP led health centre in London to a private company has been put on hold after campaigners threatened legal action.

NHS Camden has now shelved its plan to give Care UK Ltd a contract to open the big health centre in Hampstead Road near Euston station and has agreed to consult the public on whether the centre should go ahead.

Tony Stanton, joint chief executive of the Londonwide LMCs (local medical committees), which represents NHS GPs and their practice teams in London, said, “There has been a lot of unhappiness about the way in which Camden PCT conducted the procurement process for their GP led health centre. The LMC is very pleased that there is to be a proper public consultation.”

Lawyers for Camden Keep Our NHS Public and the former Labour Camden councillor . . . [Full text of this article]

Published 26 November 2009, doi:10.1136/bmj.b5025
Cite this as: BMJ 2009;339:b5025

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GP spending role debated

Posted on November 25, 2009. Filed under: Journals | Tags: |

Health Service Journal | By Steve Ford | 25 November 2009

Practice based commissioning should be replaced by consortia with “real” budgets but comprising clinicians from both primary and secondary care, according to a think tank report.

The Nuffield Trust and the NHS Alliance this week called on the government to consider “radical alternatives” to GP commissioning to engage frontline clinicians in service design.

While the Conservatives have said they will give GPs“real budgets” to incentivise commissioning, the Nuffield Trust and NHS Alliance have suggested a more major shake-up is needed.

Their joint report Beyond Practice-Based Commissioning: the local clinical partnership calls for new organisations made up of groups of clinicians based in hospitals and in the community. These would be known as local clinical partnerships and would typically be led by a GP but with the active involvement of specialists, nurses and pharmacists.

The two organisations based their conclusions on workshops with clinicians, managers, academics and other stakeholders.

The report said: “With PBC apparently unfit for purpose in its present form, and [primary care trust] commissioning frequently cautious and tentative, further thought is urgently needed as to how to boost commissioning, and specifically how to nudge or evolve clinically led commissioning into life.”

Nuffield Trust head of policy and report lead author Judith Smith said: “If clinicians are going to play a key role in designing and changing services during this uncertain period radical action will be necessary.

“PBC has shown patches of promise but we need a more far reaching alternative that re-engages GPs and other clinicians in this agenda. We believe groups of clinicians working together in local clinical partnerships could not only revitalise local commissioning but also improve the quality of care patients receive and potentially save the NHS money at this critical time.”

PCT Network director David Stout said: “We welcome the emphasis in this report on local clinical leadership and better integration across historical primary and secondary divides.”

But he added that “further discussion and testing” was needed on the significant practical and policy changes needed to implement the local clinical partnership model.

The Commons health committee is carrying out an inquiry into commissioning, including practice based commissioning, which held its first oral evidence session last month.

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NHS London suspends private care service

Posted on November 19, 2009. Filed under: ISTC, Journals, News stories |

Health Service Journal | By Clare Lomas | 19 November 2009

Out of hospital services run by the independent company Clinicenta have been suspended by NHS London following concerns over the company’s performance.

The strategic health authority is now conducting an investigation into the services provided by Clinicenta in 20 north London boroughs.

A spokesperson for NHS London said the decision to suspend the services was made following “a number of performance issues and incidents prior to the death of a patient”.

“Our first priority is patient safety and this decision has been taken as a precautionary measure while NHS London conducts a full investigation into the concerns that have been raised,” he said.

All patients currently being treated by Clinicenta are having their care transferred back to an NHS provider, and no new referrals for treatment are being accepted.  

Private health scheme suspended

BBC | 18 November 2009

A scheme which provides private health care on the NHS has been suspended following the death of a patient.

NHS London, the strategic health authority for the capital, has begun an investigation into the fatality and some other incidents.

The out-of-hospital services are run by Clinicenta in 20 boroughs across north London.

The company said it was co-operating fully with the NHS London investigation.

£144m contract

A spokesman for NHS London said: “Our first priority is patient safety and this decision has been taken as a precautionary measure while NHS London conducts a full investigation into the concerns that have been raised.”

About 51 patients currently being treated by Clinicenta are being transferred back into NHS-run clinics and no new referrals for treatment are being accepted.

Clinicenta had been awarded the Independent Sector Treatment Centre (ISTC) contract eight months ago.

As well as the day surgery centres, it includes some services carried out in GP surgeries and patients’ own homes.

A spokesman for the company said: “We are aware that NHS London has concerns and we will co-operate fully with the investigation.”

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HSJ50 2009 – Major Shifts of Power

Posted on November 12, 2009. Filed under: Journals |

Health Service Journal | BY RICHARD VIZE | 12 November 2009

This year’s HSJ50, the ranking of the 50 most powerful people in NHS management policy and practice in England, again reveals major shifts in who is wielding power.

It was drawn up by an expert panel in association with our partners, recruitment consultancy Harvey Nash, and management consultancy Ernst & Young.

This is the fourth year we have published the HSJ50. A total of 18 of this year’s most powerful people are new entries, with three re-entries.

The list is controversial and we do not expect everyone to agree with the judges’ decisions. We give details of the judging panel and how they came to their decisions.

As well as managers, politicians and government advisers the rankings include clinicians, civil servants, strategic health authority chief executives, trade unionists, a journalist, policy experts and regulators.

The ministerial team had a poor showing, with only health secretary Andy Burnham making the cut. Regulators are still big beasts in the health jungle, while factors such as swine flu and the financial squeeze have advanced the fortunes of several key players.

The NHS senior management team is still the dominant force, while the SHA chief executives are resurgent.

Despite being out of formal government circles there were strong rankings for Lord Darzi and former director of commissioning Mark Britnell.

Among those who didn’t make this year’s list but are hot prospects for 2010 are Jim Easton, recently appointed national director for improvement and efficiency, Jennifer Dixon, director of the resurgent Nuffield Trust, and Steve Barnett, who took over permanently this year as chief executive of the NHS Confederation.

One of the difficulties the panel faced was reflecting the growing power of the Conservatives as the NHS prepares for a change of power. In the end two Tories made the rankings, but it is arguable that others should have joined them. Note the panel always excludes the prime minister and chancellor and their shadows.

  • 01 David Nicholson
  • 02 Lord Darzi of Denham
  • 03 David Flory
  • 04 Sir Bruce Keogh
  • 05 Andy Burnham
  • 06 Bill Moyes
  • 07 Sir Liam Donaldson
  • 08 Baroness Young of Old Scone
  • 09 Sir Michael Rawlins
  • 10 Andrew Lansley
  • 11 Mike Farrar
  • 12 David Behan
  • 13 Steve Smith
  • 14 Cynthia Bower
  • 15 Andrew Dillon
  • 16 Mike Richards
  • 17 Mark Britnell
  • 18 Ruth Carnall
  • 19 Steve Bundred
  • 20 Oliver Letwin
  • 21 Sir Robert Naylor
  • 22 Niall Dickson
  • 23 Sophia Christie
  • 24 Laurence Buckman
  • 25 Peter Carter
  • 26 Bob Ricketts
  • 27 Jeremy Heywood
  • 28 Steve Field
  • 29 Nick Timmins
  • 30 Dame Sally Davies
  • 31 Sir Ian Carruthers
  • 32 Nigel Edwards
  • 33 Mark Goldman
  • 34 Elisabeth Buggins
  • 35 Hamish Meldrum
  • 36 Richard Barker
  • 37 David Fillingham
  • 38 Stuart Bell
  • 39 Helen Bevan
  • 40 Lord Carter of Coles
  • 41 Sian Thomas
  • 42 Dame Carol Black
  • 43 Nicolaus Henke
  • 44 Robert Chote
  • 45 Stephen Thornton
  • 46 Dame Barbara Hakin
  • 47 Ben Page
  • 48 Karen Jennings
  • 49 Sue Slipman
  • 50 Ben Goldacre
  • HSJ50 2009 – the judging process
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    David Colin-Thomé on practice based commissioning

    Posted on November 12, 2009. Filed under: Journals | Tags: |

    Health Service Journal | BY DAVID COLIN-THOMÉ | 12 November 2009

    I feel I need to contribute further to the debate generated by my recent choice of words – used while attempting to raise the profile of practice based commissioning implementation.

    Practice based commissioning is very much here to stay and remains a key plank of the Department of Health’s primary and community care policy. Indeed, health minister Mike O’Brien said in a recent speech: “As the national director for primary care, Dr David Colin-Thomé has said of GPs and GP practices – ‘We spend most of the money, commit most of the resources, who best to challenge where clinical quality is poor and to always improve on the best.’

    “Now some of you may have read David’s reported description of practice based commissioning in last week’s HSJ as being like a ‘corpse’.

    “Well, reports of its death have been greatly exaggerated!

    “It is certainly true that it has not taken off everywhere, and we need to change that, but, and as indeed David Colin-Thomé actually said in his speech, where it has, the results have been truly impressive.”

    Back to my thoughts – I am, as always, deeply committed to practice based commissioning. Aligning budgetary responsibility to the clinicians who commit the resources should be an important design principle for the whole NHS but only if those very same clinicians have the skills, aptitudes and capabilities to take on that responsibility. We need to find ways of involving clinicians who do not possess those attributes if we are to systematise practice based commissioning. When, as in primary care, that budget can be deployed to aid population health, the potential of practice based commissioning is even more enhanced.

    I did use the words reported but went on to say – as was also reported – that there are many examples of excellent practice based commissioning implementation – so it is very much alive, well and kicking. If my words have confused or de-motivated the excellent, please accept my apologies.

    But it is interesting to note that some GP leaders have welcomed my raising the profile by citing many examples where practice based commissioning has not ‘taken off’. Many PCTs and clinicians report an ever increasing involvement of clinicians in commissioning – which is excellent news, but many of the innovative and capable have not been offered devolved hard budgets. And that is the extra dimension that practice based commissioning offers and which is necessary if we are to deliver on the imperative of better quality, innovation, productivity and prevention. QIPP is our protection against a temptation to make arbitrary cuts when budgets appear to tighten.

    To quote Mike O’Brien again: “Our challenge is how to achieve the vision of High Quality Care For All set out by Ara Darzi while finding new ways of releasing funds for frontline care from within existing budgets.

    “Let me be clear, what I do not want to see are PCTs or trusts making their own, unprompted slash and burn hacks at budgets, second guessing the chancellor or the outcome of the general election and making drastic cuts.

    “This simplistic, knee-jerk reaction will only undermine the incredible progress that a decade of investment has made and will only take us further from realising our collective vision for the health service.”

    It is my belief that practice based commissioning is the vehicle most suited to achieving this vision. And I would add that implementation must be faster, more comprehensive and devolving if we are to succeed.

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    Andrew Lansley warns against ‘chilling’ preferred provider policy

    Posted on November 11, 2009. Filed under: Journals, News stories | Tags: |

    Health Service Journal | By Charlotte Shantry | 11 November 2009

    A Conservative government would return to an “any willing provider” model, the shadow health secretary has said.

    Addressing delegates at last week’s NHS Employers conference in Birmingham, Andrew Lansley said all primary care trust providers should be encouraged to request to become social enterprises or apply for community foundation trust status.

    But he said the government’s new policy of treating the NHS as the preferred provider would damage social enterprises. “[Government policy] will have a very chilling and damaging effect on social enterprises [that] think they can provide services within the NHS,” he said.

    “I want to make it absolutely clear that we’re committed to an any willing provider policy. We must look for whoever is best able to deliver the care and services we want for patients,” he said.

    Mr Lansley said the social enterprise model offered PCTs the chance to improve employee engagement while remaining within the NHS.

    The shadow health secretary also said he wanted the foundation trust regime simplified and defended his plans to cut by a third the administrative costs of PCTs, strategic health authorities, quangos and the Department of Health.

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    PBC is alive and real budgets a ‘maybe’, says tsar

    Posted on October 26, 2009. Filed under: Journals | Tags: |

    Pulse | 26 October 2009

    Primary care tsar, Dr David Colin-Thome has set the record straight about reports he called PBC a ‘corpse’.

    He told Practical Commissioning: ‘I asked a rhetorical question – I can’t remember the exact words, but it was essentially, are we reinvigorating a corpse? I then went on to say that actually there is plenty of good practice which is hardly saying there’s a corpse. And actually all the press reported that I was saying that there’s good in parts. What I’m saying is we need to get those energetic (PBC groups) to have more influence and power and maybe (real) budgets and need to be even more ambitious about what we can do in re-shaping care.’

    He added real budgets were ‘always part of our policy if people were confident enough. And that’s a local decision.’

    Primary care tsar, Dr David Colin-Thome has set the record straight about reports he called PBC a ‘corpse’.
    In his speech to the NHS Alliance conference this week, health minister, Mike O’Brien, said: ‘Some of you may have read David’s reported description of practice- based commissioning as being like a ‘corpse’..

    Well, reports of its death have been greatly exaggerated.’

    ‘It is certainly true that it has not taken off everywhere, and we need to change that, but, and as indeed David Colin-Thomé actually said in his speech, where it has the results have been truly impressive.’

    Click here to find out more!Primary care tsar backs PBC

    Pulse | 23 October 2009

    National primary care tsar Dr David Colin-Thomé has insisted that he continues to support Practice Based Commissioning – just days after describing the troubled initiative as a ‘corpse not for resuscitation’.

    Speaking at the NHS Alliance conference in Manchester, Dr Colin-Thomé said: ‘Of course I don’t think the darn thing’s dead.’

    His remarks at a conference in London earlier this month had been misinterpreted, he claimed but he added: ‘I’m certainly disappointed with the impact PBC is having.’

    Health minister Mike O’Brien also moved to defend the under-fire initiative in his keynote address to delegates, insisting ‘reports of its death have been greatly exaggerated.’

    He said: ‘It’s certainly true that it’s not taken off everywhere and we need to change that. But as David also said in his speech, where it has taken off results have been truly impressive.’

    Primary care czar jokes about PBC ‘corpse’ blunder

    Healthcare Republic | 22 October 2009

    Primary care czar Dr David Colin-Thome has said his description of practice-based commissioning (PBC) as a ‘corpse not for resuscitation’ was misunderstood and even joked about the blunder.

    Addressing the NHS Alliance annual conference in Manchester on Wednesday, Dr Colin-Thomé said: ‘Perhaps the C in (my initials) DCT should stand for corpse, not Colin.’

    Dr Colin-Thomé, England’s clinical director of primary care, made the controversial comment last week and it has been the talk of the NHS Alliance conference this week.

    Health minister Mike O’Brien also took advantage of his appearance at the conference to defend PBC.

    Mr O’Brien maintained that Labour’s drive to improve quality could deliver enough efficiency savings to reign in NHS finances.  ‘The only way forward in these times is to continue on the reform path we are on,’ he told delegates.

    Earlier, shadow health secretary Andrew Lansley set out his vision of a drastically different NHS, where GPs commission all local health services for their population, including urgent and emergency care.

    Mr Lansley said patients wanted GPs to make difficult rationing decisions about the care available to them. 

    ‘There will always be rationing in the NHS because we have finite resources. But ask people who they trust to make these difficult judgements – it’s not the secretary of state, it’s not PCT managers. The public are looking for someone they can look to, to manage their care.’

    GP commissioning shows little sign of life – David Colin-Thomé

    Health Service Journal | By Steve Ford | 14 October 2009

    The government’s primary care tsar has admitted that efforts to “resuscitate” the “corpse” of practice based commissioning have had little effect.

    National clinical director for primary care David Colin-Thomé said last week that the Department of Health is “hard at work trying to reinvigorate” practice based commissioningbut said it “isn’t really taking off, in any systematic way”.

    He told delegates at the Wellards annual conference in London that it was hard to say why this was. “But it’s certainly not seen as a major vehicle for change,” he said.

    The DH published extra guidance in March intended to mark the start of a new push to get practice based commissioning “working to its full potential” – five years after the policy was first launched. 

    The document, Clinical Commissioning: our vision for practice based commissioning, included various ideas intended to try to “reinvigorate” the stalled policy.

    It set out entitlements that commissioners could expect, including that primary care trusts should make decisions on practice plans and business cases within a maximum of eight weeks, and that PCTs would be held to account for the quality of their support.

    Dr Colin-Thomé said: “We thought we’d try and reinvigorate it, and we had all sorts of ways of doing it – entitlements and things like that.

    “But I think the corpse is not for resuscitation. There doesn’t seem to be much traction,” he said.

    “We’re struggling to make it systematic,” he added. “There’s a lot of support around it but it’s not really taking off out there.”

    However, Dr Colin-Thomé insisted that clinicians do need to have some form of budgetary responsibility in order to “reshape how clinical care is provided and challenge inappropriate and ineffective interventions”. “Clinicians, doctors especially, we spend the money,” he said.

    The apparent failure of practice based commissioning has not deterred the Conservative Party from sticking to its policy of giving GPs “real” budgets if they win the election.

    Writing in HSJ earlier this month, shadow health secretaryAndrew Lansley said: “We will hand them real budgets to manage the costs of their patients’ care. They will have a direct incentive to buy the most efficient services on behalf of their patients, because they will be able to keep any savings and use them to reinvest in care.”

    Speaking at the Wellards conference last week, NHS Confederation director of policy Nigel Edwards said the Conservatives were “basically betting the ranch on hard budgets for GPs as a mechanism for change”.

    “I’m torn on this,” he told delegates. “There are some big questions.”

    Mr Edwards said he would have no concerns about GPs he had met who already do practice based commissioning and “do this well”. But he said: “There are some really interesting questions about what to do with the people who don’t want to do it or don’t have the skills or the capacity.”

    He added: “The other issue of course is that GPs are also providers. If you want to bring new providers in, which is also part of Conservative policy, then it’s quite hard to do that if the commissioner is one of your potential competitors.”

    Birmingham East and North PCT chief operating officer Andrew Donald said: “I tend to agree with the principle of giving GPs hard budgets because actually they are the ones who create most of the cost. They write referrals, they write prescriptions, their patients got to A&E, their patients have emergency admissions.”

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    Public-private partnerships: getting NHS finance that adds up

    Posted on October 23, 2009. Filed under: Journals | Tags: |

    Health Service Journal | BY STEPHEN LANSDOWNSHELLEY THOMAS | 23 October 2009

    Public-private partnership arrangements can be the right alternative to PFI for some trusts’ equipment upgrades, say Stephen Lansdown and Shelley Thomas

    The need to balance finances, manage risk and drive efficiencies are common themes in today’s NHS. Delivering high quality, safe patient care while achieving the 18 week target is a constant demand.

    Technology in radiography, diagnostic imaging and nuclear medicine is developing fast. Indeed, the NHS’s electronic system PACS demands hospitals have up to date equipment, training, and support and maintenance services to achieve the Department of Health’s objective of joined up, modern healthcare provision.

    But such equipment is often costly, expensive to maintain and quickly superseded by newer technology.

    A trust considering an equipment upgrade might implement a managed replacement project. Nothing new there. New medical equipment has been procured through largerprivate finance initiative schemes for some time. Trusts which have engaged specialist contractors for this have been able to call on private sector expertise.

    Expected constraints on capital expenditure budgets beyond 2012-13 will reduce the amount of PFI. And for some trusts that is not in any event the right solution.

    A standalone managed equipment replacement project based on a public-private partnership allows a trust to manage the cost and spread it across the life of a contract with an external provider (typically 15-20 years). The project is “stand-alone” in the sense that it is procured without a larger private finance scheme.

    Radiology and diagnostic imaging are where the equipment is most suitable for this type of project, but the principles can be applied elsewhere in the trust’s operations, such as anaesthetics, patient monitoring, ophthalmics and endoscopy.

    In essence, the contractor takes on responsibility on an outsourced basis for supplying, maintaining, repairing and ensuring the operation of the equipment, for a regular payment from the trust. Typically the contractor will fund the equipment replacement programme using asset finance.


    The public-private arrangements typically involve the contractor, as well as bearing the capital cost of the required upgrade, providing services such as maintenance, support and training to the trust.

    Some new or replacement equipment is usually installed at the start of the project and then, working around the life cycle of the current equipment, other equipment is replaced on a pre-agreed rolling basis.

    Benefits include:

    • delivering cost savings;
    • removing unpredictability in long term capital expenditure;
    • offering certainty as to equipment uptime and service quality (most payment mechanisms in these projects are based on equipment availability times and monthly performance measurements);
    • providing new and up to date equipment at regular, pre-agreed intervals;
    • reducing capital charges (if off balance sheet treatment can be secured).

    Despite the introduction of international financial reporting standards, carefully structured managed equipment replacement projects which transfer significant technology, financial and other risks to the contractor may still be off the NHS balance sheet. Some examples of major risks that the trust should expect a contractor to bear include:

    • supply, maintenance and repair of the equipment
    • equipment downtime
    • technology updates
    • equipment obsolescence
    • changes in maintenance and support charges, interest rates and other costs
    • removal of the equipment on expiry or earlier termination.

    Case study

    Southport and Ormskirk Hospital trust entered into a 20-year managed equipment replacement project in 2007.

    The contract involves the diagnostic imaging equipment at the trust’s two main hospitals being replaced and refreshed with the latest technology, following a pre-agreed phased programme. Service and training are included, and significant technology, financial and other risks are transferred from the trust to the contractor. New equipment in the initial phase includes: digital, general and mobile X-ray; fluoroscopy; digital mammography; ultrasound and mobile C-arms. At the end of the lifecycle of the current equipment, the trust’s CT scanners, MRI scanner and direct digital chest X-ray will also have been replaced.

    This contractor financed programme is allowing the trust to reorganise services and improve the patient experience.

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    Andy Burnham extends preferred provider vow

    Posted on October 22, 2009. Filed under: Journals, Providers | Tags: |

    Health Service Journal | By Steve Ford | 22 October 2009

    Non-NHS providers of services will only be contracted as a last resort, the health secretary has assured the general secretary of the TUC.

    Following his announcement in September that the NHS would be the “preferred provider” of services, Andy Burnham has written to Brendan Barber promising that where NHS service providers underperform, the primary care trust will work with the provider, giving them “at least two formal chances” to improve.

    Even after this point, the health secretary has assured Mr Barber, the PCT will give the NHS provider every opportunity to continue to provide the service if it can demonstrate improvement.

    The letter says: “Only if there was insufficient improvement within a reasonable timescale, and the scale of underperformance was significant, would the PCT consider engaging with other potential providers or other solutions (eg franchising).

    “If market testing was subsequently pursued, the PCT would be expected to continue to engage the provider and its staff, and give them the opportunity to compete on a fair and equal basis.”

    Andy Burnham assures Mr Barber an almost identical scenario would occur if NHS providers needed to improve services or their capacity; where there was a risk of clinical or financial uncertainty; or where patient choice needed to be increased. Tendering for alternative providers would be a last resort and the original NHS provider “would be able to bid on a full and fair basis”.

    In contrast, it says where an independent or third sector contract expires, the PCT would tender openly from the outset, giving NHS providers a chance to bid.

    Mr Burnham’s letter was included as an appendix to one sent by NHS chief executive David Nicholson to all PCT and strategic health authority chief executives last week.

    Mr Nicholson said the letter was to clarify how the commissioning process will change in light of the shift in policy.

    There will be new guidance to replace Necessity – Not Nicety, which was published just five months ago, and the Department of Health will issue a revised procurement guide and “refined” rules for cooperation and competition.

    Mr Nicholson wrote: “In addition to the revised guidance, there will be implications for assurance processes, including for world class commissioning and transforming community services.”

    But he said: “It is too early to tell what these are likely to be”.

    He added the DH “remained committed” to the establishment of regional commercial support units and the national strategic market development unit and to the participation of independent and third sector providers “where this is the right model for patients”.

    Primary Care Trust Network director David Stout warned against “inventing new barriers” to commissioning high quality services in the current financial climate.

    NHS Partners Network director David Worskett described the policy shift as a “great pity”, which risked slowing procurement. He said Mr Nicholson’s letter still failed to address whether the “any willing provider” policy had been dropped.

    “It doesn’t clarify anything at all – it’s a thoroughly incoherent bit of policy. I find it hard to see how it helps anyone,” he said.

    HSJ’s Intelligent Information for World Class Commissioning conference is on 8 December, for details

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    Tory plan could give GPs interest bonanza

    Posted on October 22, 2009. Filed under: Journals | Tags: |

    Health Service Journal | BY SALLY GAINSBURYSTEVE FORD | 22 October 2009

    GP practices could earn thousands of pounds a year in interest payments under Conservative plans to turn practice based commissioning budgets into “hard cash”.

    At present, primary care trusts spend on average £1,600 per head of population. Under Conservative plans to extend the scope of practice based commissioning, the average GP practice with 6,000 patients could be handed a cash budget of around £7m if practices were given responsibility for 70 per cent of the budget.

    HSJ has calculated that if just half of that budget was stored for six months of the year in a deposit bank account paying 3 per cent interest, a typical practice could earn an extra £105,000 a year – a sum equivalent to an entire year’s pay for an average GP.

    Most practices are expected to group together into consortia, covering populations of around 100,000, or 17 average size practices. That could translate into annual interest earnings of around £840,000.

    A Conservative spokesman confirmed the party planned to transfer hard cash budgets into consortia bank accounts, but said interest earned could not be taken as profit. He said: “Any interest earned would have to be used to invest in patient care, not for their own profit.”

    He said the party had yet to decide precisely how and when in the financial year cash budgets would be transferred toGPs.

    Public finance experts have questioned how workable the plans are. For example they could involve the Treasury laying out up to 70 per cent of the NHS budget on “day one” of the financial year, as opposed to the current system where PCTs “draw down” funds when they are needed.

    That would have implications for Treasury borrowing needs and, after the collapse of the Icelandic banks, there will be concerns about GPs’ ability to make wise choices about where to store money.

    Jeff Finney, chair of the Institute of Chartered Accountants in England and Wales and director of a GP accountancy service, told HSJ practice consortia would need to set themselves up as not-for-profit entities in order to ensure interest earnings were not taken as profit.

    The questions over GPs holding their own budgets follow national primary care director David Colin-Thomé’s admission last week, revealed by HSJ, that efforts to reinvigorate practice based commissioning have so far failed. He described the policy as a “corpse not for resuscitation”.

    Social Market Foundation head of strategic development David Furness said it was time to stop ploughing money into expanding GP commissioning.

    Mr Furness said at least £100m had been spent on trying to reinvigorate practice based commissioning through entitlements, and it was time to “turn off this tap”.

    “Let it work where it is working,” he said. “But let’s stop trying to drive it from the centre.”

    He said it was wrong in the current financial climate to place the “onus” for commissioning on those whose primary role was clinical practice, and the role of PCT commissioners should be strengthened instead.

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    Walk-in doctors’ surgery launched in Nuneaton

    Posted on October 20, 2009. Filed under: GP-led health centres, Integrated care, Journals, Press/News Releases, Providers | Tags: , |

    Coventry Telegraph | 20 October 2009

    AN INNOVATIVE walk-in doctor’s surgery has been launched at a health centre in Nuneaton.

    It will allow patients to have an appointment even if they are registered with another surgery and is part of a government programme to increase access to family GP services.

    George Eliot Hospital has become the first Acute NHS Trust in the country to run a GP-led facility, which is based at Camp Hill Health Centre, and is supported by NHS Warwickshire.

    Health Minister and North Warwickshire MP Mike O’Brien, who performed the opening, said: “This will make a huge difference in improving access to health care for local people.

    “Centres like this one are opening up and down the country, complementing services provided by existing practices.

    “The centres are proving popular with patients who have told us that they want to be able to see a GP at times convenient to them.

    “This centre will offer patients the greater choice and flexibility they want, being able to see a doctor or nurse between 8am and 8pm seven days a week, while still remaining registered with their family GP if they so wish.”

    As well as increasing access to GP services, the Ramsden Avenue centre will also have a strong focus on promoting better health and ensuring everyone has access to the services and care they need, particularly for hard-to-reach groups.

    Some of the health checks and treatments on offer will include physiotherapy, minor surgery and family planning.

    Paul Jennings, chief executive of NHS Warwickshire, said: “We know that those living in the north of the county are statistically more likely to suffer ill-health and we are focused on tackling these health inequalities.

    “Camp Hill Health Centre is the result of effective partnership working between NHS Warwickshire, the local community and George Eliot Hospital. Its opening is sure to have a positive effect on health services in the area.”

    Sharon Beamish, chief executive of George Eliot Hospital, said: “As a well known local NHS health care provider we are delighted to have been given the opportunity to provide primary care to the community.

    “We are looking forward to working with local people to develop services that they want and need in the area and we are fully committed to providing the best care possible to all who choose to use the services in Camp Hill.”

    Opening of new GP-led health centre with Warwick Medical School

    Warwick Medical School | News Release | accessed 1 October 2009

    A new GP-led health centre in Warwickshire developed in conjunction with Warwick Medical School has officially opened its doors for the first time. 

    The Camp Hill Centre, based in Nuneaton, has been opened by the Minister of State for Health Services Mike O’Brien MP.  

    The Camp Hill area was chosen to benefit from a new health centre as part of the Department of Health’s alternative providers medical services (APMS) contracts. These contracts enable PCTs to deliver health services tailored to local needs. 

    Warwick Medical School has contributed towards the development of the health centre and created a learning environment for both its undergraduate and postgraduate students. The health centre will become a teaching hub, providing local leadership to teaching practices.    

    Hospital trust opens GP centre

    Health Services Journal | 20 April, 2009 | Updated: 23 April, 2009 0:00 am | By Sally Gainsbury

    A hospital trust in Warwickshire has become the first to take over the running of a GP-led health centre.

    George Eliot Hospital trust plans to open the new 8am to 8pm health centre this October.

    The development will be watched carefully as there have been concerns that hospitals should not be allowed to “vertically integrate” with GP services lest they be tempted to use them to create additional demand for acute care.

    DH approval

    The Department of Health’s guidance on the issue states that any such proposals must be agreed with the department.

    But George Eliot trust chief executive Sharon Beamish said the trust “fully supports the drive to provide care closer to home”.

    She added: “As an organisation that provides local hospital services we are well placed to extend these services within the community to offer a complete range of healthcare and have a more direct impact on improving the health and wellbeing of [the area].”

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    Two thirds of PCTs still to agree provider model

    Posted on October 8, 2009. Filed under: Arm's length providers, Journals, Social enterprise | Tags: |

    Health Service Journal | By Steve Ford | 8 October 2009

    Two thirds of primary care trust provider arms have not yet had their future form agreed by their board and strategic health authority, a survey suggests.

    According to a survey of 83 PCT provider arms, one third said their service model had been agreed by their PCT board and the SHA before 1 October.

    This was the original deadline – now dropped – set out in the NHS operating framework for 2008-09 and the government’s Transforming Community Servicesguidance.

    Around 40 per cent of providers said they had changed their plans as a result of the removal of the timetable, while the rest indicated that they were significantly advanced in their planning and were not changing pace.

    The survey, carried out by the PCT Network, found that most PCT providers welcomed the relaxation of the original deadline for developing their plans.

    A minority of respondents were concerned that the move could slow progress.

    For example, one respondent said: “We need separation closure – not as an end in its own right – but mainly in order to allow us to move on.

    “There is a danger as far as we are concerned in the perpetuation of uncertainty.”

    The results of the survey, carried out in September, were announced on Tuesday at the network’s community services conference in London.

    Overall most providers said they intended to “stay in house”, (29 per cent), or seek community foundation trust status (28 per cent). Only 4 per cent intended to become a social enterprise scheme.

    Where decisions on provider models have been agreed, the preferred option was slightly more in favour of becoming a community foundation trust than remaining as providers within the PCT.

    This trend was reversed for provider arms where no formal decision has been made.

    The majority of providers, 58 per cent, said their planning had not been affected by the creation of the co-operation and competition panel in January.

    Most were also positive about the panel’s impact, saying that it had improved dialogue with commissioners.

    However, while the removal of the deadline was intended to allow increased focus on transformational change rather than form, the survey revealed that there was some way to go on commissioning and contestability plans for community services.

    More than half, 56 per cent, said their commissioning arm did not have such a plan in place, although many commented that plans were in progress and would be presented to PCT boards before the end of the year.

    PCT Network director David Stout said: “The removal of a deadline to agree upon organisational form has allowed providers to focus on transforming the quality and efficiency of services without being fixated on a timetable in which to change their model.

    “However, it is important that the momentum for this transformation is not lost,” he added.

    Providers were also asked to highlight their top priorities.

    Top six priorities:

    • Quality and patient experience
    • Improving productivity and value for money
    • Clinical care pathways
    • Workforce transformation
    • Integration and partnership working with local authorities and primary care
    • Metrics/data and IT
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    CQC calls for review of out of hours GP services

    Posted on October 2, 2009. Filed under: Journals, Providers | Tags: |

    Health Service Journal | 2 October 2009

    A Care Quality Commission report has urged healthcare managers to review the quality of their out of hours services over fears that some private GP companies do not meet basic standards.

    The CQC recommendation follows the death of 70-year-old David Gray last February, who was accidentally killed by a German doctor on his first out of hours shift in the UK.

    Mr Gray died after being injected with a 10-fold strength dose of morphine. The doctor, Daniel Urbani, later told a court he was exhausted at the time and had only slept for a few hours before starting private work for a Cambridgeshire health trust.

    The report into Take Care Now, the company that employed Dr Urbani and has additional contracts at trusts in Essex, Worcestershire, Suffolk, Great Yarmouth and Waveney and Cambridgeshire, concluded that all PCTs should scrutinise out of hours services more closely.

    The report said: “They should look in detail at the services that they commission, including the efficiency of call handling and triage, the number of unfilled shifts, the proportion of shifts covered by non-local doctors, the induction and training those doctors receive, and the quality of the decisions made by clinical staff.”

    CQC chief executive Cynthia Bower added current trust monitoring of Take Care Now’s services was “only scratching the surface”.

    The CQC’s advice was backed up by health minister Mike O’Brien, who said patient safety was paramount.

    Mr O’Brien said: “Primary care trusts have a clear legal responsibility to provide safe, high quality out of hours care and are required to have in place robust performance management arrangements to ensure their out of hours services are delivering against contractual requirements.”

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    Andy Burnham’s preferred bidder pledge questioned

    Posted on September 24, 2009. Filed under: Journals, Providers | Tags: , , |

    Health Service Journal | BY REBECCA EVANS | 24 September 2009

    Questions have been raised over the implications for competition and world class commissioning of health secretary Andy Burnham’s statement that the NHS is the “preferred provider” of services.

    Previous Department of Health policy had been that “any willing provider” should be considered when commissioningservices.

    But in a speech last week at the King’s Fund, in whichMr Burnham stressed the importance of raising quality, he said: “The NHS is our preferred provider. But it is the important job of the commissioner to test whether these services provide best value and real quality.

    “Where a provider is not delivering quality – and the new accountability information will more readily demonstrate that – we will set out a clearer process that will provide an opportunity for existing providers to improve before opening up to new potential providers.”

    Answering questions after his speech, he said NHS providers should be given at least one opportunity to improve before commissioners went out to tender for an alternative provider.

    Unison senior national officer for health Mike Jackson told HSJ the speech was significant: “I think now there’s clarity that the NHS is the preferred provider and there ought to be co-operation before competition.”

    But Primary Care Trust Network director David Stout said the speech “would potentially cross over quite a number of the co-operation and competition panel principles”.

    DH spokeswoman said: “The health secretary signalled the need to clarify policy and guidance to ensure that whilst putting quality of the heart of everything we do in the NHS, staff were treated fairly by being given an opportunity to improve performance and services before commissioners considered engaging with alternative providers.”

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    World class commissioning: efficiency made a core competency

    Posted on September 23, 2009. Filed under: Journals | Tags: |

    Health Service Journal | By Steve Ford | 23 September 2009

    Assessing how effectively NHS commissioners spend their funding receives greater importance in the latest government guidance on world class commissioning.

    The revised version of the world class commissioning assurance handbook says competency number 11 – ensuring efficiency and effectiveness of spending – will be assessed as a core competency.

    Competency six – to prioritise investment of all spending – is revised and now also requires primary care trusts to prioritise investment in different financial scenarios.

    Reflecting the current financial situation, they are the most significant of the competency changes in the programme’s assurance handbook for year two, published by the Department of Health last week.

    DH acting director general of commissioning and system management Gary Belfield said: “Commissioning has never been more important given the need for greater efficiency the NHS faces.”

    The changes follow a comprehensive evaluation of world class commissioning assurance by the DH plus interviews and an online survey of more than 300 PCT and strategic health authority stakeholders. The handbook says overall world class commissioning assurance had been “judged a success” and was seen to be “rigorous and stretching”, with only “fine tuning” of the framework required.

    Changes to the assurances include making the description of competencies, particularly sub-competencies, clearer about how the levels equate to different standards of performance.

    Governance assessments are strengthened to differentiate more clearly between red, amber and green ratings; and better metrics have been introduced for some of the national outcomes, such as mental health and health inequalities.

    NHS Birmingham East and North chief operating officer Andrew Donald welcomed the changes, which he described as “very subtle”.

    He said: “They have listened to everyone and tweaked year two accordingly.”

    He said the addition of competency 11 to the core list was “always going to be the case”.

    “We are going to have to raise our competency in that area,” said Mr Donald.

    At the end of world class commissioning assurance year two, July 2010, nationally calibrated results will be published by the DH to enable comparison across PCTs and improve the sharing of good practice.

    Mr Donald said: “We need to link and share the learning,” and commissioners should “steal with pride” ideas from other trusts.

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    NHS ‘must decentralise’

    Posted on September 22, 2009. Filed under: Journals |

    Health Service Journal | 22 September 2009

    The NHS must be decentralised and freed from government control if it is to thrive, according to think tank Demos.

    Its report says top graduates are spurning public service because of a “vicious circle” of falling status and low morale compounded by a “crippling” lack of trust.

    And it says that if staff were given more autonomy – “because they know their job better than anyone” – significant improvements to the NHS, teaching and social services would follow.

    To achieve that, it says, bureaucracy must be cut, tiers of management removed and quangos such as the Audit Commission abolished.

    Report author Max Wind-Cowie said: “Failure in public service stems from a failure to trust that experienced teams and individuals know best. We will get better services if we put trust back in the professionals.

    “All the talk at the moment is about protecting frontline staff from cuts, but that alone won’t make the difference if we continue to treat them like untrustworthy teenagers.

    “Every government has the tendency to centralise. Whoever wins the next election must do everything they can to resist that urge and let go.”

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    Chris Ham on increasing NHS co-operation

    Posted on September 17, 2009. Filed under: Journals | Tags: |

    Health Service Journal | By Chris Ham | 17 September 2009

    Tighter budgets and more integrated care mean the co-operation and competition panel must change tack away from its old policy of relying on competitive markets.

    Policy makers, like generals, are always at risk of fighting the last war. So it is with the health reform programme in England.

    Just as the NHS co-operation and competition panel starts to flex its muscles in support of a bigger role for markets, so the policy emphasis is shifting to encourage increased co-operation between NHS organisations to deal with the financial challenges ahead. With NHS chief executive David Nicholson reportedly arguing that competition needs to be seen as a tactic rather than a guiding principle of health reform, the dangers of inconsistency are plain to see.

    How did policy makers get into this fine mess? Part of the answer can be found in the time it has taken to establish the co-operation and competition panel. The genesis of the government’s market oriented reforms can be traced to publication of Delivering the NHS Plan in 2002 and yet it was six years before the panel was established.

    Given this delay, there was always a risk it would be steering through the rear view mirror. So it has proved with the panel’s early work focused on promoting competition rather than encouraging co-operation.

    Policy makers’ one eyed approach to health reform supplies another part of the answer. After the release of Delivering the NHS Plan, attention focused almost entirely on extending patient choice, stimulating greater plurality of provision and developing incentives to support a bigger role for markets.

    To be sure, there was recognition that in some areas of service provision – urgent care is a good example – there needed to be increased co-operation between providers, but the levers and incentives to make this happen were not put in place.

    Recent indications from ministers and senior officials suggest the importance of co-operation is now recognised. While the proximate reason for the change of heart is the prospect of much tighter budgets, especially from 2011 onwards, there are many other reasons why increased co-operation is desirable.

    One of the most important is the need to develop integrated models of care for people with long term conditions. Integration is required to enable primary careteams to work much more closely with hospital based specialists and in the process to overcome the professional and organisational silos that risk patients experiencing a fragmented service.

    Another reason is to reduce inefficient duplication of services. This is most apparent in relation to acute services in parts of London where hospitals working in close proximity are providing many of the same services in a context where this is simply not sustainable.

    Rationalising services

    Encouraging competition in these areas will not only make the rationalisation of services for the benefit of patients more difficult, it may also lead to further duplication as organisations seek to protect their own self interest without regard to the wider system.

    Co-operation is also needed to improve the quality of care. Recent inquiries into failures at Birmingham Children’s Hospital and in the Baby P case have provided compelling evidence of the difficulties facing NHS organisations in working together to provide high standards of care.

    It is, however, the need for NHS organisations to work together to rise to the financial challenges ahead that calls for an urgent review of the work of the co-operation and competition panel. This can be illustrated by reference to the Better Care, Better Value indicators produced by the NHS Institute, showing the scope for savings of around £3bn by reducing variations in length of stay, day case rates and similar measures of performance.

    Many savings depend critically on co-operation. For example, cutting lengths of stay requires NHS trusts to work with primary care trusts to develop intermediate care.

    Similarly, reducing delayed transfers hinges on the NHS working with local authorities to improve discharge processes and to enable people leaving hospital to move easily back to their homes or a residential facility of their choice. There is a long way to go in many areas to achieve the co-operation needed to release resources locked up in inappropriate service provision.

    If the panel is to perform a useful function, then those steering it should fix their gaze on the road ahead rather than the rear view mirror. The work of the panel should reflect its title, with a much stronger focus on facilitating co-operation than has been the case so far. For their part, policy makers should provide a clear steer to the panel on the direction of travel, and move quickly to ensure the levers and incentives are in place to make co-operation a reality.

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    Integrated care: pride of the community

    Posted on August 28, 2009. Filed under: Integrated care, Journals |

    Health Service Journal | BY DALONI CARLISLE | 28 August 2009

    District nurses embody the high quality workforce envisioned by Darzi, but the sector lacks the commitment to attract new nurses to this 150 year old service, says Daloni Carlisle.

    • District nursing is changing to reflect a modern service.
    • The workforce is ageing and training has been slashed.
    • Renewed commitment to the sector is necessary to deliver the vision laid out in the next stage review.

    When Anna Gibbins started as a district enrolled nurse in the early 1980s in Cheltenham, Gloucestershire, she never took her hat off while on duty.

    “I was issued with five dresses for summer, five for winter, a cardigan, a blazer, a wool coat and a pillbox hat that I wore at all times,” she recalls. “The Queen’s Nurse in charge told me ‘a district nurse never takes her hat off’, so I didn’t.”

    This was just 25 years ago, in the days before the central sterile supply department took away soiled dressings – so they went into the grate. “Every house had an open fire,” says Ms Gibbins.

    And district nurses were thrifty, re-using everything and fashioning items from what was to hand – turning eiderdowns into pressure relieving cushions, for example.

    That world is hardly recognisable now and seems to have more in common with 150 years ago, when district nursing was founded (see box), than with 2009. In their anniversary year, district nurses are reminded of their past, but also looking to the future to find their place in the post-Darzi health policy landscape.

    The home front

    District nurses are defined by their place of work: people’s homes. With health policy aiming to provide care closer to home – whether managing long term conditions, preventing unnecessary emergency admissions or delivering end of life care – who better to help develop such services than a corps of district nurses?

    That, at least, is the argument put forward by the Royal College of Nursing and Queen’s Nursing Institute, the charity that supports community, or district, nurses. The institute’s report 2020 Vision: focusing on the future of district nursing, published in January, stated: “The principles… that have lasted 150 years still fit the bill today. In today’s terminology, they are known as ‘better care, closer to home’, ‘patient choice’, ‘integrated care’ and ‘co-production’.”

    “We know there are a number of people in hospital who do not wish to be there, in addition to the people who are admitted but did not need to be,” says RCN primary healthcare adviser Lynn Young. “The public say they want to die at home and that is pure district nursing. We can provide such care to fabulously high standards.”

    Institute director Rosemary Cook says district nurses have the skills to deliver on the new agenda.

    “There is a bigger difference between nursing in the home and in clinical settings than between primary and secondary care nursing. Nurses are unsupervised, which has implications for quality of care and their own safety. They have learnt to apply principles such as asepsis [techniques to reduce infection] in an environment where every single case is different,” she says.

    Clinically, they have come a long way too.

    “District nurses’ work has changed significantly because of the push to discharge patients earlier,” says Sally Bonynge, executive director for long term conditions at Central Surrey Health, a social enterprise led by nurses and associated health professionals.

    “We are now taking some complex cases that would historically never have been able to come out of hospital,” says Ms Bonynge. “Yet with different ways of working, partnerships and extended roles there is always a way to do it.”

    But do commissioners recognise this?

    “It is somewhat taken for granted,” says Ms Cook. “[Primary care organisations] have had district nursing services for a long time and let them get on with it. They know what they do in the home is different but there has been no real scrutiny of the different elements that make up the kind of care they deliver.”

    However, there are examples of organisations that have used district nurses’ skills to their full. Examples are in telehealth or in virtual wards, both of which are initiatives designed to help people stay at home and prevent emergency admissions.

    Central Surrey Health is a learning centre for the NHS Institute’s productive community initiative.

    “We are focusing on the district nursing team and changing current working practices,” says Ms Bonynge. “This could be even more exciting than the productive ward [the model on which the initiative is based], as it is so complex. There is only so much you can do to control the patient’s home environment.”

    But all is not well in the sector. Both the QNI and RCN have charted rising case loads and falling numbers of qualified district nurses over recent years.

    “There is a whole range of issues facing our members. The national trend has been to employ more healthcare assistants to do the work of district nurses. We are not against healthcare assistants, but you have to get the balance right and we are concerned that there has been a dilution of workforce that will get worse as the elderly population grows and more people need these services,” says RCN director Peter Carter.

    The RCN says bald workforce figures showing a rise in the number of community nurses from 50,481 in 2000 to almost 62,000 in 2007 disguise a drop in district nurses, whose roles have been replaced with staff nurses and healthcare assistants. There are now around 10,800 district nurses employed in the NHS.

    “If you align the workforce with the government’s push towards care closer to home we estimate that we have actually got about half the number of district nurses needed to do it properly,” says Mr Carter.

    The workforce is ageing too. In 2007, 58 per cent of district nurses were over the age of 45 and 17 per cent over 55. Training has also been slashed, says Ms Young, so closing this gap will require long term commitment and investment in creating new training opportunities and attracting young nurses to them.

    The QNI is also concerned. The 2020 report says: “District nursing services are currently being diluted by loose use of the title, wide variations in pay banding and career structure, reduction in leadership opportunities and lack of recognition of the value of their specialist education.”

    Friends in high places

    The role has some friends in high places, however. Health minister Anne Keen is a former district nurse and general secretary of the Community and District Nursing Association. Like any district nurse she is ready to regale you with tales of her time in the community.

    “There was the time I got bitten on the leg by a goose,” she recalls with evident glee. “I was nursing a pig farmer but he refused to come out of the pig pen so I had to go to him, get him to drop his trousers, give an injection and then run across the fields chased by geese. I don’t think there are many health ministers who could say they have had that kind of experience.”

    In 25 years of nursing, her time as a district nursing sister was her favourite, says Ms Keen.

    “Your community is proud of you. You go through the front door and you are in a patient’s home. You have to be a confident practitioner and very knowledgeable.”

    She is well aware of concerns about the role’s erosion – and of the potential for the role to develop in the near future.

    “The high quality workforce of Lord Darzi’s next stage review is made for the role. We cannot afford to lose district nurses and we need to look after them.”

    But skill mix will have to change, with district nurses delegating their skills and knowledge to others, she adds.

    Ms Keen also agrees with Ms Cook about commissioners’ views of district nursing.

    “We must spell out the value of district nursing to them more clearly. Nurses have not been very good at that in the past and it has been easy for people to dismiss them.”

    Welsh chief nursing officer Rosemary Kennedy started as a district nurse in rural North Wales in 1973, caring for a village community and outlying farmsteads.

    “We were very much part of the community, seen as ‘theirs’ and almost on a level with the school master or minister. It was a really wonderful feeling of belonging and knowing the people you cared for.”

    The NHS in Wales also wants to move care closer to home and Ms Kennedy says she has brought a “huge amount” from her days in the district to her current role. She knows from experience the intensity of nursing that is possible at home, having cared for patients with acute coronary conditions.

    “It was a question then of the balance between moving them 52 miles or caring for them at home.”

    Ms Kennedy identifies capacity as the main challenge. Some of this will be addressed through skill mix changes, but getting the right levels of specialists will take time. A consultation on the future of community nursing in Wales is due to close in May. It will also consult on a new career ladder that would offer modular education, allowing nurses who want to test out the specialism the chance to do it step by step without having to make the jump in to a full time role or education.

    “The crucial thing is that one size does not fit all,” says Ms Kennedy. “Our starting point is this: what is the community? What are their needs and how do we

    meet them? In some cases they will be heavily weighted towards specialist nurses delivering intensive and holistic care. In others it will be different.”

    Overall, there is a good deal of optimism about the future of district nursing. There are some dinosaurs around but there are many more innovators, says Ms Cook. There are areas where district nursing skills are being diluted and lost but some primary care trusts are investing in them, adds Mr Carter.

    In England, there is the prime minister’s commission on the future of nursing and midwifery to look forward to, as well as the primary and community care strategy now being developed, which is chaired by Department of Health director general for commissioning and system management Mark Britnell.

    “It is a time for optimism,” says Mr Carter. “We have a great deal of faith in Mark Britnell. If his ideas are properly supported it could transform community services.”

    The history of district nursing

    District nursing as an organised movement began when the Victorian Liverpool merchant and philanthropist William Rathbone employed Mary Robinson to nurse his wife at home during her final illness. Following his wife’s death in May 1859, he wrote: “It occurred to me to engage Mrs Robinson to go into one of the poorest districts of Liverpool and try, in nursing the poor, to relieve suffering and to teach them the rules of health and comfort.”

    Three months later “she came back saying the amount of misery she could relieve was so satisfactory that nothing would induce her to go back to private nursing, if I were willing to continue the work”.

    Florence Nightingale advised Mr Rathbone to start a training school attached to the Royal Infirmary in Liverpool. Built by May 1863, district nursing associations soon spread to other cities, including Manchester, Leicester and London.

    The Queen’s Nursing Institute was founded in 1887 with a grant from Queen Victoria’s Women’s Jubilee Fund. Queen’s Nurses later joined the war efforts of both world wars before joining the NHS in 1948. Although training ceased in 1968, the title Queen’s Nurse was again awarded in 2007 to those who passed a rigorous assessment.

    For more information

    A changing role

    Candy Pellett qualified as a district nurse in 1999 and is now a district nurse case manager for Lincolnshire primary care trust.

    “My role is with people with long term conditions and palliative care needs. That means I spend longer with patients with more complex needs and delivering a complex package of care. We now do work that was previously only done in hospitals, for example managing Hickman lines [intravenous catheters to deliver medication] or delivering intravenous antibiotics. I have just started undertaking paracentesis [draining fluid from the abdomen] and that is radical.

    “This is all very much in line with the Darzi review. I sit on the Department of Health transforming community care review board and think we will see patients being offered more and more complex care in a primary care setting. It is a good time to join the specialism. There are so many different pathways you can follow.”

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