Historical circumstances mean some PCTs are in the unusual position of also being mental health providers. Lynn Eaton looks at their options

When looking into why some primary care trusts are mental health service providers, there is a sense not of master planning but of good old-fashioned happenstance.

For most, the scenario is a bit like wanting to build a new house with all mod cons, but ending up with an old one: the plumbing is not quite where you want it and the boiler is past its best, but it just does not make sense to change it.

So it is that, obliged by the circumstances of one reorganisation after another, many primary care trusts are more like historic monuments than purpose-built new buildings. Several primary care organisations that came into existence in October are - for one reason or another - providing mental health services; although, with the government's ultimate goal of making PCTs service purchasers only, having them provide such a major service as mental health does not sit easily within national policy.

Dorset PCT, for example, took over the work of three PCTs: South and East Dorset (which had a separate mental health provider, Dorset Healthcare trust), South West Dorset, and North Dorset. North Dorset PCT had itself previously inherited a community trust with mental health services, so provided mental health services for its own area and for South West Dorset. Now the new PCT is in an unusual situation. In one area, its mental health services are provided by Dorset Healthcare trust, while it continues to provide those services itself in the other part.

No-one would have planned it that way. And it certainly does not look neat on paper.

Dorset PCT director of mental health services Brian Goodrum explains: 'Back in the 1990s, there was a very small local mental health trust. Then it became a community mental health trust, which is now part of Dorset PCT.'

This model of mental health services being in a community health setting, then being taken over by primary care trusts, is not that unusual. Dudley PCT, for instance, inherited mental health provision from its forerunner organisations. However, though there was once some logic to having community-based services under the wing of a primary care organisation, the shift towards the purchaser-provider split and PCTs adopting a purely commissioning role have made that more difficult. Various models are now being adopted.

Should they stay or should they go?

Some PCTs are considering offloading their mental health services to an existing mental health specialist trust. Others are merging services with neighbouring service providers, or even setting up their own specialist trust. Many - like Dorset - are still deciding what the best options will be.

Plymouth has taken the decision that splitting its provider role from its purchasing one is totally inappropriate and is staying as it is.

Plymouth Community Services trust used to provide both mental health and community services for the city. When PCTs were established, local community service functions were merged into the PCT in order to minimise management costs. Chief executive of Plymouth teaching PCT, John Richards, says it will continue as both a commissioner and provider of services.

'We believe this best serves people in Plymouth,' he says. 'Our current arrangement as a single organisation sharing the same boundary and population as [local authority-provided] social care enables us to produce more effective, closer working relationships.'

The PCT is now undergoing the process of separating its commissioning and providing functions. Mr Richards believes this will help redesign services more quickly to meet service users' needs.

He also argues that, because of continuing closer integration of primary care, mental health services and social care services, more services can be delivered in primary care. In addition, PCT commissioners have a strong focus and understanding of the service and the needs of people with mental health problems, he says.

'Our priority is to drive service improvement with vigour and we will keep arrangements under review to ensure we deliver value for money for local people.'

Dorset, meanwhile, is still considering its options. 'At the moment, no decision has been made,' says Mr Goodrum. 'It will be part of our consideration of provider services as a whole. We won't be looking at mental health in isolation.'

He adds that there is a similarity between the approaches of Dorset PCT and Dorset Healthcare trust. 'They provide pretty similar levels of service and were consistently rated as three-star providers. From the patient's point of view, our surveys indicate that we've got good services and that the standard doesn't differ markedly between the two models,' adds Mr Goodrum.

If there is any potential difference, he says, it is that the mental health service provided directly by the PCT tends to provide more services in primary care. 'We are interested in expanding services in primary care and in practice-based commissioning. The issue for the PCT is whether there is an opportunity to keep current providers, as a lot of the services we provide are in community facilities,' he says, suggesting that one option may be to put mental health services into a community trust model.

Dudley PCT, though, is looking into the possibility of developing a separate, specialist mental health trust for its mental health services. It is still early days - it is in talks with service users and, a spokesperson says, a timetable has yet to be agreed. Whatever happens, she adds, the PCT will take into consideration the needs of service users and maintain a local focus.

'We do not want to undertake organisational change for organisational change's sake.'

In the meantime, the PCT is looking into ways of ensuring there is 'clear blue water' between its commissioning and providing roles across all its services, not just mental health.

Getting together

Mark Hemming, manager of mental health services at Hereford PCT, cannot remember how the trust ended up with mental health provision in the first place. 'It was before my time,' he says.

Discussion is continuing about the possibility of it merging service provision with organisations in Shropshire and Worcestershire. As a relatively small provider of mental health services, merging, rather than continuing to go it alone, makes some sense. 'In some ways small can be good, but there are disadvantages,' Mr Hemming admits. Service users may find they need to go outside the PCT boundary for more specialised provision, such as for eating disorders, he explains.

'We seem to have been able to retain staff,' he adds, although he is unsure whether that is due to its being a small PCT rather than a specialist trust. 'Perhaps it is because this is an attractive part of the countryside. The staff have been around for a long time. It makes it a lot easier for people when they know who they are talking to. That is always going to be a benefit.'

Being small, though, means the mental health services are not viable as a foundation trust in their own right. The only possible option might be a social enterprise model, says Mr Hemmings. 'That would give us a lot more creative options to work with partners across health and social care. I don't see it having an impact on service users.'

Each option has its pros and cons, says NHS Confederation policy director Nigel Edwards. Putting all the mental health services across one PCT into a much larger single provider might fly in the face of the latest thinking for the NHS. 'Some people have raised the issue that creating a bigger trust does away with competition,' he says.

Mr Edwards also questions whether, in any case, competition will ever be seen in quite the same way in mental health services as in the acute sector, because the market will always be different.

'Some of these mental health trusts are huge,' he says. 'But many of the people using mental health services are people who have long-term problems. The approach to choice is not so much over the provider as over the care pathway. It raises questions about how competition is going to be a major driver of quality improvements in mental health services.'

Mr Edwards says he can well understand why some organisations are taking a more softly-softly approach than Dudley, which is considering shifting mental health provision from the PCT to a newly established, separate provider.

'Some people have the view that, in terms of all the things that have to be done, putting your provider at arm's length [within the PCT] may make a lot more sense than setting up a whole new organisation,' he says.

They have also learnt, he believes, from the experience of social services, where providers could call the shots unless other options were available to the purchaser. 'By having your own provider, you are less likely to be held to ransom.'

If services are to be provided by the same organisation that is buying them, a Chinese wall is needed between the providing and purchasing arms to avoid a conflict of interest. This can work effectively when times are good but is less effective when things are tough and cuts have to be made.

NHS Alliance chief executive Mike Sobanja agrees that despite the typical model of PCTs having one director for commissioning and another for provider services, 'when push comes to shove, you have only got one director and only one board'.

'It can be done,' he adds, 'but it feels as if you've got to separate the functions very carefully.'

He is cautious, too, of offloading mental health provision just because it does not fit this year's blueprint for the NHS. 'What we should not be doing is fielding them off for ideological reasons, unless they are in a safe pair of hands.'

A safe pair of hands is all that patients on the receiving end of an already hard-pressed service ask for. Mental health charity Mind policy officer Emily Wooster is ambivalent about who provides the services. 'The main concern for service users is not who delivers services, but their quality and availability,' she says. 'What's most important is that they are reliable, responsive and accessible, and that service user involvement contributes to effective and supportive provision.

'Mental health services tend to bear the brunt of budget cuts. However a service is delivered, it must be properly resourced.'

Provider turns purchaser: move to foundation trust partnership relieves financial risks

Shropshire County PCT has been a mental health service provider but is about to transfer responsibility for provision to the neighbouring South Staffordshire Healthcare foundation trust (see below).

Psychiatrist Dr Simon Smith is Shropshire County PCT medical director and in charge of its mental health services. He knows what it is like when things get tough financially for the PCT as a whole: its mental health provision suffers.

'Being a directorate of the PCT meant we were financially at risk,' he says. 'We were being asked to make a contribution to the PCT because it overspent.
We were asked to save£200,000 last year and this year we would be asked to save at least that; it is likely to be even more.'

Despite this, he says relationships with the PCT have always been cordial, and the decision on the merger, due to go through next month, has been completely clinically led.

'There is an advantage in being in an organisation that focuses purely on mental health,' he says. 'In the PCT we have been given a lot of freedom to run ourselves. But within the PCT everything is about commissioning and how we make the books balance. There's very little top-team focus on what happens in mental health. They are just tied up with the commissioning agenda.'

Being allowed simply to get on with it is helpful to an extent, Dr Smith agrees, but he is looking forward to working in an organisation that properly understands mental health issues.

A patient might imagine a single trust covering such an enormous area could fail to reflect local needs, but Dr Smith argues that Shropshire is a large county anyway.

'It is 60 miles from top to bottom, and Staffordshire is nearer to some parts of Shropshire than Shrewsbury [the county town]. There will be no more risk than now if a hospital is full and a patient has to be placed outside the county. But. most of our patients do not go anywhere near hospital.

'I feel confident that we will retain a local focus. What we will gain is a greater critical mass of staff. We may well have the ability to develop specialties.
We also believe both parts of the merged organisation can learn from each other.'

New provider: 'Patients will not see a difference in the services'

Steve Grange is the director of business development with the South Staffordshire Healthcare foundation trust, which is set to merge with the mental health sections of Shropshire PCT and Telford and Wrekin PCT, to form South Staffordshire and Shropshire trust.

'There was a range of options,' he says. 'To wait, to keep provision as part of the PCTs, or to do nothing. Another was to become a partner with other services. These services could have joined with any other neighbouring trust.'

Mr Grange believes moving services from the PCT to a specialist mental health trust will bring standards into line with other mental health trusts, because the clinical negligence scheme has higher standards than in PCTs.

'That has to be better for patients,' he says.

The South Staffordshire trust already offers specialist facilities for mothers and babies and people with eating disorders. The merger will offer more access to such services, argues Mr Grange.

'They have always been available but until now would only have been on a contract basis.'

He describes the move as more an integration of services than a merger. He points to services such as the care of older people and early intervention in psychosis, where Staffordshire can learn from Shropshire's provision.

'Patients will not see a difference in the services. What we intend to do is improve them and build on them in the future.'

The move is not being done as a cost-saving exercise; there have been no redundancies.

'We are not integrating for financial benefit,' adds Mr Grange. 'We did this purely because we felt that, by having a greater clinical mass, we can offer better services.'