Published: 01/09/2005, Volume II5, No. 5971 Page 10 11

In the final part of HSJ 's series examining major themes in the forthcoming primary and social care white paper, Mary-Louise Harding asks what happens next for the quarter of a million displaced staff

Two years ago, a paper by a leading think tank called on policy-makers to move on from structural tinkering and get to grips with revolutionising working practices. Only then could services really become patient-led, said author Liz Kendall.

Speaking to HSJ shortly after her thesis The Future Health Worker was published, Ms Kendall said it was too easy for politicians and policy-makers to become 'obsessed with structure'.

It was time, she added, for them to grasp the 'difficult and controversial' workforce nettle to achieve 'highquality, patient-centred care'.

Ms Kendall is now on the other side of the fence - since May she has been the health secretary's policy adviser - and some primary care managers might ask whether she has gone native. She is now part of a team responsible for last month's controversial Commissioning a Patient-led NHS, which called for widespread structural change. Is she is in danger of deferring workforce reform - and falling into the very same trap she warned against?

It is clear primary care trust reform will force change, but it seems to those in the sector that the entire workforce issue had been thrown into the air with no obvious thought as to where it might land.

According to sources at the 'topteam' meeting at which NHS chief executive Sir Nigel Crisp revealed his commissioning masterplan to SHA chief executives and senior civil servants, there was considerable debate about the commissioning of primary care provision.

They had been so focused on getting the structures right that when asked who would provide the services PCTs were expected to ditch - which range from school nurses to prison health - it was clear the authors could not provide an answer.

This uncertainty was underlined on Friday, when Department of Health director of health and social care John Bacon wrote to strategic health authority chief executives, urging them not to 'form a firm view' on future provision until the white paper is published.

With an estimated quarter of a million staff facing an uncertain future, it is hardly surprising that the creation of the new workforce strategy (to replace 2002's HR in the NHS Plan and expected within the next two months following the white paper consultation) 'feels like trying to pick up the pieces of shattered glass after an explosion', according to a senior government official.

'Commissioning a Patient-led NHS is very weak on the future of primary and community services staff, ' the well-placed government source told HSJ. 'With the whole direction of moving services into the community it is not at all clear who is going to manage them. It is clear from the fact that we have to make£250m management savings that we have to dismantle PCTs, so where are these services going to go?' The source insists there is no-one who can employ the bulk of staff such as district nurses, school nurses and health visitors on PCT payrolls at the moment.

'You could argue these services could be run by GPs but they do not have the capacity at the moment, and you could say they'd go to private and voluntary sector providers, but where are the organisations that are ready to run this? And if you give them to acute trusts, That is completely contradictory to the whole policy direction of shifting everything out into the community.' The union whose members are most affected by impending homelessness following this new policy direction slammed the forthcoming white paper consultation last week as 'little more than a facade'.

The Royal College of Nursing scorned the reforms outlined in Sir Nigel's July policy paper as 'rushed through with little evidence it will improve the NHS', and argued it meant the public consultation would be presented with a 'fait accompli'.

However, some are hopeful that Commissioning a Patient-led NHS, together with the healthcare outside hospitals white paper, will present the health service with a golden opportunity for the white paper to grapple with 'difficult and controversial' ways of transforming service delivery.

DoH director of workforce Andrew Foster says that function will follow form and workforce policy will follow any macro-organisational changes that may be required by the white paper, rather than being a major theme in itself within the document.

He argues it would be 'wrong to suggest what the issues will be ahead of the consultation', but that there are themes they will be likely to address such as the 'big problems of social care recruitment and retention' and 'how best to integrate health and social care workforces'.

'There are good examples of integration at the moment, such as in mental health where there is true collaboration [between health and social care], but the principle behind all of those is one of voluntarism, ' he says. 'It is perfectly possible that the consultation may say That is not good enough and we must find more deliberate ways to promote integration.' There has been some speculation that the white paper will lead to local government becoming responsible for some health commissioning. There is also talk that perhaps town halls could also provide a solution to the looming homelessness crisis for primary and community staff.

However, such a move would not chime well with the government's chosen direction of services currently provided by local authorities, where the preferred model is to move assets off council balance sheets to contracted separate organisations.

It is more likely that policymakers expect a menu of new private providers, the voluntary sector, new types of public interest companies, expanded GP practices and perhaps foundation trusts to take on the staff. They hope this revolution could provide the opportunity for commissioners and policy-makers to fundamentally reform the primary and community workforce.

National director for primary care Dr David Colin-Thomé says the challenge is to attract providers who in turn can offer attractive packages for doctors and nurses.

'A lot of GPs haven't settled down yet to their vocation. Many do not want to run a practice, and the salaried options some PCTs have offered are not delivering good conditions of service, so if new providers can offer better salaries and off-duty rates then we should be able to tempt these people, ' he says.

He adds that the same holds for the 'legions' of qualified nurses that are not practising because they can't find hours and terms that suit, such as fitting in with childcare commitments.

His comments are echoed by Professor Paul Corrigan, a former chief policy adviser to health secretaries Alan Milburn and then John Reid. 'There are loads of GPs out there not doing GP work because the form at the moment doesn't enable them. There are lots of locums that stay as locums because the organisations do not let them work the way they want to.

'We have got the capacity now. We just need to work out how to utilise it, ' he told a recent Social Market Foundation seminar on delivering choice in primary care.

The consensus is that the new breeds of non-medical workers, such as health trainers, will be strongly pushed in the white paper. Dr ColinThomé says the 'current [primary care] skill-mix is unlikely to be the skill-mix of the future', not least as practices with control over commissioning budgets move to offer more cost-effective services than their acute rivals.

Indeed, back in 2003 Ms Kendall called for a non-medical generic health and social care practitioner role to be created, supported by a strong NHS patient information service empowering patients and carers to take more of an active role.

Professor Chris Ham, former DoH strategy unit head and director of Birmingham University's Health Services Management Centre, says: 'The first thing I would say is It is fundamental that we have a consistently high standard of primary care teams, which do not need to be prescriptive in the way they're made up, but have excellent GPs working alongside nurses and pharmacists and in collaboration with social care.

'And this needs to happen in real terms, not just on paper.' However, he warns that policymakers should avoid the tendency to create new and narrow specialist posts in primary care to meet the growing needs of people living with long-term conditions, for example.

'We need to avoid problems, which I see developing in the US, of increasing specialisation, ie GPs and practitioners with special interests.

If you look at US healthcare, you can see the dangers. People with chronic conditions need teams with mixed general skills, ' he explains.

'We have got a lot of things right in the NHS because we have welldeveloped primary care. But it is not consistently good, particularly in poorer areas where people are most at risk. We need to get that right rather than creating a new workforce.' So it appears the onus will be on the primary and community organisations of the future to offer attractive choices to the workforce, as well as to patients.

But any potential transfer of staff raises the thorny issue of pensions.

Potential independent providers argue that they will have to come to some sort of deal with the government in order to match NHS schemes, which they would be legally required to do if staff are transferred.

'There is not a private pension scheme in existence that can come anywhere near what the NHS offers.

If the government wants a range of providers to compete on a level playing field for contracts, then they are going to have to come up with a central solution to this, ' said one independent sector source who did not want to be named.

And if social care and health staff are brought onto the same payrolls, issues of equal pay and conditions are sure to rear their head. HSJ understands that the DoH may look for Treasury funding in the 2007 spending review to introduce Agenda for Change for jointly run services.

The question is: will the savings from reducing the role of PCT-run providers in primary and community care, outlined in last month's document, justify the extra funding needed to smooth the transition of staff to different providers?

Ultimately, a quarter of a million staff will be hoping the white paper will soften the blow of Commissioning a Patient-led NHS.