Balancing local flexibility against a single national framework for service delivery is a challenge for the NHS, but it can be overcome, say Paul Batchelor and Catherine Needham
For medical care, responsibility for decision making at a local level has been transferred to clinical commissioning groups and local area teams. For the remaining “independent contractor” groups, namely dentistry, optical and pharmacy services, local professional networks (LPNs) are seen as providing the link to NHS England, albeit working through the local area teams.
‘For any LPN to function it needs to form at least four relationships: NHS England, the local area team, local government and care providers’
In 2010, the three Thames Valley primary care trusts, which then had considerable experience of managing dental matters through a collaborative network, decided to invest in both developing a shadow LPN but also an evaluation of its progress. This, it was argued, would help ensure that when the actual LPN came into existence it was fit for purpose.
For NHS dental care, the relationship between contract holders and the Department of Health has hardly flourished in recent years. A contract in 2006 that simply was not fit for purpose and a subsequent series of imposed targets of questionable value have led to a level of cynicism, which any new arrangements must overcome if they are to succeed.
Four key relationships
For any LPN to function it needs to form at least four relationships. It will need to work with NHS England, the local area team, local government and, perhaps most importantly, all care providers. The dental sector consists of both NHS and non-NHS components, with best estimates suggesting that by cost volume they are equal in size. Issues in either sector can affect the other. If an LPN is to be sustainable, changes in state funding and its implications need consideration.
‘In the organisational complexity of an NHS transition, LPNs offer space for something distinctively local’
The sensible starting point for the LPN − indeed for any organisation − must be to clarify what it is supposed to do. What then logically follows is an understanding of the skills necessary to achieve this, enabling the relevant appointments to be made to the group.
Due to the limitations of the guidance, the then commissioning and public health team in Thames Valley decided to create three clinical leadership posts that would work with the commissioning arm of the PCTs to form a shadow executive.
The term “shadow” was crucial as the executive had no statutory power and would not do so until 1 April 2013 at the earliest. A guiding principle behind the work was to try and ensure a smooth and effective transfer from shadow to formal body.
The posts were advertised and an appointments panel was put together that included professional representation from outside Thames Valley. Applicants from all aspects of the dental care delivery system applied. The three appointees were joined on the shadow executive by dental commissioners and a consultant in dental public health.
Dialogue and understanding
A decision to appoint the incoming medical director as chair of the shadow team was also taken to help ensure strong dialogue and understanding of the issues between the local area teams and the LPN. While the DH had stressed the importance of the patient’s voice within its initial guidance, when approached, the Local Involvement Networks team was happy to be kept informed as opposed to being in attendance at meetings.
The first meeting of the shadow LPN was a facilitated discussion dealing with how the attendees saw it evolving, not least setting its priorities and recognising its limitations. As LPNs would only come into existence on 1 April and with no statutory powers, the shadow group could only hope to achieve engagement and communication about possible roles, not least as stronger guidance from the DH could change the course of what it set out to achieve.
‘Perhaps not surprisingly, success has been varied. Not all parties were happy’
As priorities, the shadow LPN set goals for agreeing its terms of reference, governance, membership, funding and accountability channels, including its relationship with local area teams; there was a high level of awareness of and support for LPN among local dental community and projects with measurable benefits for oral health.
So how successful has it been and what are the key lessons to learn? Perhaps not surprisingly, success has been varied. While the terms of reference and membership of the shadow executive were agreed by the PCT cluster, not all parties − especially those not included in the executive − were happy. A number expressed a feeling of a lack of transparency in the processes. Formal engagement events, a website, a Twitter feed and attendance at local dental committee and British Dental Association events took place and while the events were well attended, some of the other activities were sporadic.
Uncertainty around LPN role
Feedback from the events indicated that some people found them useful; others, uncertain about the role of an LPN, queried the mandate of existing clinical members and expressed doubts that commissioners would take any notice of an LPN.
The final engagement event took place in January. After that engagement activities lapsed as part of a broader “pause” in LPN activities, reflecting shifts in organisational and personal priorities in the run-up to the 1 April transition. Some interviewees expressed concern that this lack of communication was failing to deliver on promises made to the dental community about the LPN being open and informative about its work.
Perhaps least successful has been the role of the shadow LPN in developing projects to achieve benefits for oral health − perhaps the major reason for its existence. However, the context must be remembered. The shadow group has no formal powers. Any decisions on projects had to go back to the respective PCT boards for approval. As previously, organisational and personal priorities set the agenda.
‘The executive must continue to be honest about the gaps in knowledge about the future of LPNs’
So what comes next? Clarification of the role of an LPN, especially with regard to performance, remains paramount. This will be achieved by working on the terms of reference and accountability with the area team. The LPN will need to establish appropriate recruitment procedures for the chair and other clinical member, ensuring they are well advertised and transparent.
The process must also ensure there is a clearly communicated rationale for selecting non-clinical members of the LPN executive. Finally, there is a continual need for engagement activities to promote awareness of what LPNs are for and to increase the legitimacy of the executive by demonstrating that it listens to local dental stakeholders and practitioners.
The LPN executive must continue to be honest about the gaps in knowledge about the future of LPNs, so that there is no sense that the executive is withholding information. Building and retaining trust is a key lesson for all LPNs and central to achieving this is engagement in an open and transparent manner. Only by working with the relevant parties using a whole system approach can an LPN hope to succeed.
If the current reforms are to work and LPNs add value to the delivery system, then the lessons from history must be learnt. Openness and transparency in decision making are essential, as is developing a good communication network in which all people are aware.
All common sense, but to date not commonly practised. The extent to which local diversity in LPNs will be allowed to flourish or will be constrained within a national framework is uncertain, but in the organisational complexity of an NHS transition, LPNs currently offer space for something distinctively local.
Paul Batchelor is consultant in dental public health at the Thames Valley Dental Public Health Network and Catherine Needham is senior lecturer at the health services management centre, Birmingham University