www.publicinvolvement.org.uk

This is a speculative view of what health and care might look like across London by 2008. This is meant to stimulate thought and discussion, especially amongst lay representatives and organisations, in the wake of "Commissioning a Patient-Led NHS" which appeared at the end of July. (www.dh.gov.uk/assetRoot/04/11/67/17/04116717.pdf)

MAC believes that it is better to grapple now with potential changes that some might term "unthinkable" and at best unpalatable rather than find ourselves surprised by radical reconfiguration when it is too late to influence anything. We are not necessarily advocating the following scenario. It is simply an attempt to draw together what we see as the significant factors influencing change and then describe the possible picture which results. Our overriding concern is to maximise the influence of patients and the public in any new arrangements. We believe these opportunities exist and must be exploited even if PCTs as we have known them disappear.

With the coming "fitness for purpose" debate about PCTs and the consultation later this year on healthcare outside of hospitals in mind, we've looked at the possible future from the wider London perspective, not just from the perspective of whether PCTs might survive. In doing so, we have tried to identify what arrangements could, in our view, give service users and the public the biggest leverage for changing health and care to benefit Londoners and also involving them and their elected representatives in planning and scrutinising the process.

Feedback is always welcome, so let us have your comments, brickbats or carefully considered views on what you think of our picture of where the NHS and social care in London could be heading.

BY 2008, THIS COULD BE THE WAY HEALTH AND CARE SERVICES WORK TOGETHER ACROSS LONDON

1. One Health and Care Authority for Greater London
One Strategic Health and Care Authority (or some other name - titles don't really matter) for the whole of London relating to the Government Office for London and, more importantly, to the Greater London Assembly.

• overall public health, strategic and emergency planning role
• performance managing the London Primary Care Trusts (see below)
• governance arrangements must involve GLA members and mesh with GLA scrutiny functions.
  

2. Five PCTs for Greater London

• 5 in number based on previous SHA areas
• Co-terminus with a number of London Boroughs, but no more than SHAs were
• Board consists of CEO and Exec directors, Chair and NEDs (1 NED from each constituent boroughs who is a Councillor but not an OSC member and 6 "at large". Chair and at large NEDs publicly recruited for their specific expertise.
• Each London PCT is the employer of all managerial, administrative, commissioning and public health personnel, most of whom are based in localities coterminous with local authorities.
• Service providing role has been separated (see below).
• Core role at PCT level:
• • public health intelligence
  • commissioning across the patch on behalf of localities (see below) and Practice Based Commissioning practice clusters to maximise clout with providers and monitor their performance
  • specialist commissioning for the whole patch, including forensic mental health, specialist contractual placements etc
• PCTs no longer have PECs because health professional front-line engagement is through more developed PbC arrangements within the new borough-focused localities and the links these develop with health and care partnerships (see localities below).
  

3. London Boroughs as the new "localities"
Each constituent boroughs of a London PCT will be a locality within the new structure

• reinforces health and care continuum in the wider social/environmental context of heath and well-being. Central core welded from NHS and local authority relationships and jointly commissioned services: children's services, including education; adult social care (elderly, chronic conditions, PLD, mental health, disability etc).
• Localities have no need for Boards or PECs, but instead have much more developed partnership arrangements between health, social care, education and other community (including police) and voluntary sector stakeholders
• PCT field staff work at locality level, in premises preferably shared with local authority personnel.
• Local Strategic Partnership in each former PCT has become a "Health and Care Partnership"
• • based on the local compact (this is essential)
  • membership expanded to include more voluntary/NGO activity, especially where they control public assets
  • partnership structure has secretariat/support provided by relevant PCT to reflect higher profile and complexity of activity.
• Service user and public involvement focus mainly at locality/borough level
• • Patients Forums' relate to the “Health and Care Partnership”
  • user engagement crosses health and social care and is supported and resourced
  • tenders to provide user engagement services open to non-NHS organisations, including private sector.
• Core role at locality level is about the things that make a difference to health and well-being of local people that the NHS and local government should do together.
• • public health intelligence and health needs assessment
  • devising health and care commissioning intentions
  • user involvement and input (including training and support)
  • addressing health inequalities
  • "Choosing Health" health improvement efforts
  • clinical governance
• Health Overview and Scrutiny Committees (OSCs) relate to health and social care partnership areas.
• • Hold relevant PCT accountable for plans, objectives and commissioning appropriate services for their area
  • hold provider organisations accountable for delivering targets and quality issues to their populations.
  • OSCs beefed up by adding Patients Forum members and other lay members as assessors (paid an allowance)
  • public scrutiny takes a much higher profile across health and care.
    

4. Boroughs have neighbourhoods
Localities are encouraged to designate neighbourhoods if there is local demand/need, eg to relate patients/public more closely to practice-based commissioning activities, to encourage clinician engagement/clinical governance.

5. Services are commissioned from and provided by a range of organisations
The most contentious part of the reconfiguration affecting both health and social care is that provision of primary care, community health and social care services is commissioned from a mixed economy of Trusts and Foundation Trusts (which all NHS Trusts will be eventually if they remain in business), private sector providers (both for profit and NFP), voluntary agencies, and new "community interest companies". How Practice-Based Commissioning organisations relate to other providers needs clarifying as they have an ambiguous role.

• All commissioned providers operate under the NHS brand and to common quality standards, including user involvement and complaints/redress processes.
• Healthcare Commission (merged with CSCI and operating as the Health and Care Commission) inspects and licenses all health and care providers and is a key intelligence source for OSCs.