Painted out of the picture?

Executives in community trusts must feel, as the Talking Heads' song says, they are on the road to nowhere.

The second wave of their highprofile successors, primary care trusts, is rolling up this October, and perhaps half of primary care groups will move to that status next April. All community trusts are facing major change.Most won't exist in a few years' time.

Take North West Anglia Health Care trust. 'We are on the pathway to nonexistence, ' says chief executive Barbara Kennedy. 'Or rather, in the process of reinventing ourselves as a new and different organisation. The end result is that we will not exist beyond 2002.'

At Hounslow and Spelthorne Community and Mental Health trust, chief executive Ros Lowe is no less blunt: 'I do not see a future for community trusts as they are at the moment. I certainly won't have a job by 2002.'

Many community trusts are metamorphosing into mental health and learning disabilities providers, with their remaining services transferred to PCTs.Others face complete disestablishment. A few hope to retain a role by providing corporate functions such as IT, human resources and estates management to a group of PCTs.

Significant grey areas remain, though, especially over specialist services - the ones that don't fit neatly with acute or primary care and where local authorities and/or the voluntary sector would like to get involved.

These include services such as learning disabilities, specialist children's care, rehabilitation, dental services, palliative care and services for older people.

Little national guidance has been forthcoming, although health secretary Alan Milburn did tell the NHS Confederation conference two weeks ago that he envisaged creating a new level of PCT. Level 5 would be capable of commissioning both health and social care services, such as those for the elderly. He warned that it would not be 'one-way traffic' local authorities may well take over some of what is currently health territory, particularly child protection activities'.

In north-west London, health authorities and trusts have been looking collectively at this issue for over a year. Ms Lowe says: 'We wanted to see where specialist services would best fit in the new world. Our view is where PCTs share boundaries with boroughs, they should be managed in PCTs. Where PCTs cross borough boundaries, one PCT should manage the service for both.'

A similar model is proposed for Manchester, where ministers have just approved a controversial proposal to set up three PCTs from October and shut Mancunian Community Health trust.

Although she supports PCT development in principle, trust chief executive Elizabeth Law is unhappy about Manchester HA's proposal to split specialist services between the PCTs, with each managing discrete services on behalf of the others.

She says: 'Unfortunately this was not discussed with us. I think it's a very complicated way of arranging what are interdependent services. There are real questions about the sophistication of that model and whether we can do it with PCTs which are not as yet mature.'

Birmingham Specialist Community Health trust has handled the issue by proposing to provide city-wide specialist services. It is one trust that does see a long-term future for itself.

Cynthia Bower, who was appointed chief executive in April this year when Birmingham's two community trusts merged, says: 'We believe that there is a market for us running more specialist community services. People want to see those developed in community-based settings, and we want to retain the skills we have built up working with ethnically diverse and disadvantaged communities.'

Not one trust chief executive approached opposes the move to PCTs in principle. Ms Lowe says: 'I do not want to get hung up on organisations.

'What matters is the services being delivered, the people we are delivering them to and the staff delivering them.'

But all had the same questions about the managerial capacity of the new organisations. Just where will all the chief executives come from?

How will the skills base of the community trusts be retained? Will staff feel destabilised by yet another change of employer? Ms Lowe says: 'There's lots of expertise in community trusts at the moment at director and sub-director level.

'It is very important that this is not lost. PCGs are embryo organisations with lots of clinicians with good ideas but no-one to manage them.

'We need managers to harness that energy and lead.'

Barbara Walsh of Community Health Sheffield trust agrees: 'They are big and difficult jobs and they must be done by the right people. The most difficult scenario might be where the GPs are on board and the PCT does not deliver. The new chief execs are going to have to hit the ground running.'

Many trusts are preparing the next generation of executive directors through secondments to region, joint appointments with PCGs and mentoring schemes.

Among chief executives themselves, morale is high - even though they are the only staff with no jobs to go to.

Many plan to take up a post in a new PCT or in a newly configured mental health service.

But not all plan to stay, Ms Walsh among them. She says: 'A lot of trust chief execs feel like we have been doing this work for a long time and we should let other people pick up that challenge. A lot of chief execs will be leaving altogether. I will not be going for a PCT job.'

To boldly go: what community trusts could turn into:

a stand-alone specialist mental health and learning disabilities organisation;

a corporate services provider, offering functions from IT to estates management, human resources and finance to a group of PCTs;

part of a single PCT, providing a range of services such as community rehabilitation and rapid-response teams for a whole HA area, including other PCTs;

divide services between local PCTs and disappear completely.