Local Commissioning in Primary Care

This guidance has been issued to enable community mental health nurses to both gain greater understanding of the impact of local commissioning, as well as to offer advice on the potential role that they might play.

Author: George Coxon

From April 1999 the long awaited changes to how primary care services are to be run take effect. There is some variation to how the primary care reforms are being configured across England, Scotland and Wales; however there are many common themes.

It is important to stress that changes to primary are affecting the whole of the UK, but the precise configuration does vary. England has PCGs/PCTs, whereas Scotland are setting up Local Health Care Co-operatives (LHCCs) responsible to PCTs with joint investment funds to co-ordinate primary and secondary services1. In Wales, Local health Groups perform a similar role to both PCGs and LHCCs and are to be based on their 22 unitary authorities.

Common themes for all services include:
Developing partnerships and co-operation for appropriate care;
Abolishing the ‘internal market’;
Tackling inequalities;
Having primary care at the centre of health service reforms.

In England Primary care groups (PCGs) form one of the main parts of the Government White Paper “The New NHS - Modern and Dependable’ (1997)3, which details the reforms to health care provision. The replacement of GP fundholding which many have argued has seen a divided and inequitable primary care service has been greeted with delight by a large number of health professionals, however the new arrangements still need time to show discernible improvements to primary care services.

There are 481 PCGs in England serving populations of between 50,000 - 250,000 in so-called ‘natural communities’: collectives of GP practices which will work together to address local health needs and inequalitieis and, it is hoped, will be more accountable and responsive to local people.

Membership of the new boards will be made up of:

GPs 4-7
Nurses 1-2
Social Services nominee 1
Lay person 1
Health Authority
Representative 1
Chief Executive 1

Co-opting provisions exist for any individual with special expertise to help the PCG or equivalent to develop particular services, eg mental health. Voting rights at the board will, however, not be extended to co-opted members.

What will they do?

PCG boards will take responsibility for commissioning services for local communities and develop stronger, more integrated links with their respective populations.

There will be four levels at which they can operate:

Level 1 advising the health authority in commissioning care for the population (minimum entry level)

Level 2 Devolved responsibility for managing the local health care budget, acting as part of the health authority.

Level 3 Acting as a free-standing primary care trust, able to run community health services and community hospitals, accountable to the health authority for commissioning care.

Level 4 Becoming primary care trusts with added responsibility for providing community services, accountable to the health authority for commissioning care.

The vast majority are entering at Level 2 and will be able to progress through the four levels at their own pace. The government would hope that all will work towards becoming free-standing primary care trusts (PCTs) overtime.

Key Principles of Primary Care Reforms
Better local ownership and representation;
More co-operation and equity between practices in a given area sharing services and agreeing priorities;
New board multi agency membership with clearer accountability and open meetings for the public to attend;
Four different levels of operation, each with more independence for decision making regarding services.

Health Improvement Programme (HImP)

Each new board will be developing its own accountability framework and investment plan to address local target setting in it HImP. This will set out priorities for action assisted by both local and national guidance. All of this will enable each board to develop its work programme to be both open to all and therefore more accountable.

There will be a board member, probably a GP in the first instance, responsible for the clinical governance arrangements for its practice. This person will act on behalf of the board to help set quality standards and monitor plans for how they will deliver health improvements to patients. Details are set out in ‘A First Class Service’4.

The expected national service framework for mental health in Spring 1999 and the public health green paper, soon to become white paper, ‘Our healthier nation’5 is likely to retain a mental health target addressing suicide reduction. Both of these documents should ensure the health authorities’ and the new board’s HImp feature mental health as a target area. This is likely to herald more opportunity and challenge to community mental health nurses (CMHNs) in how they work with primary care.

Implications for mental health nurses

The process of selection/election of nurses to each of the PCg boards involved a period of ballots, applications, manifestos, voting, meetings and even hustings culminating now with approaching 1,000 nurses taking up places on respective boards. Each of those successful will have up to three years’ term office, but can then seek re-election for a further period. The main groups of nurses involved and represented are:
District nurses
Health visitors
Midwives
CMHNs/CPNs
Practice Nurses/Nurse practitioners

Many appointments to the boards have been clinical managers of local nursing services; however some mental health nurses have achieved membership in their areas.

Guidance has indicated a need for Local nurse forums (LNFs) where views can be taken up from the constituent group to be offered to the board in decision-making.

CMHNs should:

Get involved with LNFs;
Be aware of the developments and priorities ie. Relevant HImP details in their respective areas;
Take the initiative in approaching both the nurse representatives at board level and the lead GP or Chief Executive regarding mental health services and the role of the CMHN/CPN;
Be conscious of the implications that changes to primary care services will have on commissioning local mental health services in the future.

Despite some disappointment that most of the new boards will retain a majority of GPs forming its membership, there has never been a better time for nurses to contribute to decision-making affecting patients’ care. Opportunity for CMHNs to develop political skills in negotiating for positive change to primary care mental health services will become more evident as the new arrangements evolve.

Summary

The radical reforms to primary care across England, Scotland and Wales bring opportunity and challenge. The need to develop co-operative, integrated services to address health inequalities and local need in primary care with a clearer and more accountability framework can be seen as very exciting.

CMHNs, many of whom quite understandably see primary care as being of less priority in terms of work focus than the traditional serious mental illness focused secondary care services, may not anticipate much involvement with the new primary care boards.

It is highly probable, however, that as the new boards progress, for example in England where PCGs will move toward independence at PCT level, that commissioning services from provider specialist trusts may well have an impact on mainstream mental health work.

This paper indicates some of the key points contained in the white papers relating to primary care NHS reforms. We should all, at the very least, be aware of these which have implications on the work of the CMHN, if not affecting us already.

References

1 The Scottish Office (1998) ‘Designed to Care: Renewing the NHS in Scotland’

2 Marks, L & Hunter, D (1998) ‘The Development of PCGs: Policy into Practice’ Nuttfield Institute of Health, Leeds University

3 DoH (1997) ‘The New NHS - Modern and Dependable’ London: Stationery office

4 DoH (1998) ‘A First Class Service’ London: Stationery Office

5 DoH (1997) ‘Our Healthier Nation’ London: Stationery Office

6 Gould, M (1998) ‘Courting Danger’ Nursing Times 94, 23:pp38-39