After an exceptional week spent in each other's roles, the chief executives of a primary care trust and its main acute provider agree the idea works. Daloni Carlisle reports

If you had dropped in at the chief executive's office at St Mary's Hospital in Paddington one week during June you would have been in for a bit of a surprise.

Instead of the tall and rangy Julian Nettel you would have found the blonde figure of Lynda Hamlyn, chief executive of Westminster primary care trust.

Mr Nettel, meanwhile, was to be found out and about in Westminster, chairing a practice-based commissioning board meeting or accompanying the community matron on her rounds.

The two were doing a week-long job swap - possibly the first between the chief executives of a PCT and its main acute provider.

'I've never come across it before,' says Ms Hamlyn. 'Me neither,' agrees Mr Nettel.

Sitting together in Mr Nettel's London office as the week drew to a close, they did part of their debriefing for HSJ. It had been a tremendous week; they had each enjoyed it immensely and learned a lot as well as been able to challenge some assumptions.

'I think we might be in danger of sounding smug,' admits Ms Hamlyn. 'But that's actually the truth.'

The swap was not an experiment in whether either of them fancied jumping the fence into the other's territory. It was an exercise in getting closer for mutual benefit.

Westminster PCT and St Mary's trust have been cosying up to each other for some years. Where other PCTs and acute trusts retreated into their respective bunkers as the challenges of service redesign and payment by results began to bite, these two have worked together to find ways round the constraints (see case studies below).

Hence their reason for talking to HSJ. Both feel this sort of job swap is something everyone at their level should think about trying. 'You need to have the level of trust there,' says Mr Nettel, 'But it really does open your eyes.'

'It's really about credibility and legitimacy, having a conversation and really understanding each other's role,' adds Ms Hamlyn. 'We need to really understand each other's business rather than thinking we do.'

Ms Hamlyn has been in post in Westminster (PCT name changes notwithstanding) for five years, and Mr Nettel at St Mary's for eight years. They are both in high-performing organisations in good financial shape and feel this may add to the level of trust they have.

They do big business together. Westminster PCT contracts for around£50m of services a year with St Mary's. Following the PCT reorganisation of 2006 and the creation of NHS London, it has taken on the lead role for all London PCTs commissioning from St Mary's - around another£100m of activity.

Impressions and suspicions

During the job swap, each took on the full responsibility of the role they stepped into. They even had access to each other's e-mail. They chaired senior management meetings. They also spent time getting to know the frontline staff.

Some of what they say is to be expected: they were each enormously impressed with the clinical staff they met. And it was fascinating to get an understanding of the role of support staff that they do not normally see - imaging staff or hospital pharmacy in Ms Hamlyn's case and community nurses in Mr Nettel's. Well, they could hardly say otherwise.

Ms Hamlyn was horrified by the state of the estate. St Mary's is 150 years old in parts and it shows. Mr Nettel, meanwhile, was pleasantly surprised by the high quality of some of the newly built facilities in the community.

It gets more interesting as they dig a bit deeper. 'The impressions and suspicions I have were very strongly reinforced, particularly the degree of expertise and capability that exists outside hospital,' says Mr Nettel. 'I think this is something a lot of people in the acute sector do not understand and it is a fundamental issue in taking forward the agenda for getting hospital services properly tailored for the needs of people and moving them outside hospital.'

Community matrons as witnessed by Mr Nettel are a good example. 'It's an experimental service where highly trained nurses have a caseload of patients with complex needs,' he says.

'They are the first point of contact and co-ordinators of care. It has not been the subject of any longitudinal study yet but the evidence is building that they really are able to stop the deterioration of particular problems that lead to admission. That can only be a good thing.'

Acute perspective

What was interesting and different from Mr Nettel's acute perspective was the depth of relationship matrons have with patients - something that is rare in the fast throughput of most acute sector work.

Ms Hamlyn nods in agreement. 'I wanted Julian to see this first hand. Unless you see it and meet the people you will always be anxious about whether the right services are being developed.'

Under current financial rules it is difficult to provide advice or support from the acute side to these matrons, who might be dealing with patients who have not just diabetes but underlying chronic obstructive pulmonary disease as well. Can the two find a way for matrons to access consultants' expertise - for example by telephone or e-mail - and the trust to be paid for it? They hope so.

'I admire Julian for the lead he gives,' adds Ms Hamlyn. 'His view is: "Do not let the tariff be a barrier to the right patient care." We are now even more committed to finding the best financial solution to underpin care.'

The swap also brought home to both parties the absolute necessity of decent IT systems and the need for the electronic care record.

Mr Nettel cites urgent care. The PCT and acute trust recently co-sponsored a meeting of 22 people leading urgent care services across the patch to see how it can be better organised. The electronic record came up in these discussions.

During the job swap Mr Nettel was able to see the patchwork of services in the community. 'Patients are moving across organisations and between teams and people are having to make quite difficult clinical decisions without any information or limited information about what's gone on beforehand,' he says.

For example, an elderly person arrives in accident and emergency in a state of confusion. 'Staff have no information about what's considered normal for this patient and therefore the only sensible and responsible decision is to admit him.

But if there was a profile and we knew more about them the reaction might be different. We are working on that right now.'

It is a similar passion for Ms Hamlyn, looking at the other end of the patient episode and the need for electronic discharge summaries.

Neither will admit to feeling out of their depth in each other's roles. 'At this level the competencies are around leadership and that's more similar than different,' says Ms Hamlyn.

'We both have stable top teams who were happy to do the job swap,' says Mr Nettel. 'If we had tried to become each other's director of operations, we would have struggled.'

St Mary's director of operations Matthew Hopkins is far too diplomatic to endorse this statement, saying he depends on having a good team. He enjoyed the job swap, which both raised awareness and helped communication between the two organisations.

He says: 'What Lynda brought was that certainty of where the PCT is in its thinking and how it looks at value for money. That's helpful to us in terms of scrutiny of our initiatives.'

For example, she was able to cast a new eye over the trust plans to spend£10m on modernising pathology services. 'Her critique of the value for money for the NHS and PCT was quite helpful,' he says.

Close working

Mr Hopkins does think working closely with the PCT and with GPs is key to meeting future challenges in the NHS - and agrees with both chief executives on the tariff issue. A payment system that rewards trusts for appointments attended is no use in designing packages of care.

He gives an example: 'We are now developing a package for a cluster of GPs around their patients with COPD. The proposition is that we will provide the technology to support people in their own homes from a hub at the acute centre while the provider arm of the PCT makes sure patients are supported.

'We will ensure that admissions are kept to a minimum but for that package of care we will need to be paid an appropriate amount.'

He feels that the strong relationship between the trust and PCT will help them unshackle from the tariff in a way that is mutually beneficial.

Westminster PCT director of human resources and corporate affairs Karen Broughton also enjoyed the challenge of the job swap: 'Julian brought a very different perspective to some of our discussions and that was incredibly useful.'

During a discussion on sexual health services, for example, he brought the team up short with questions about the strength of their local engagement and whether they had tested ideas with the acute clinicians.

'I think we had but he prompted us to do some more work,' she says.

For the two chief executives, life is about to change. Mr Nettel is moving to Barts and the London trust in September; Mark Davies is taking over at St Mary's and Hammersmith Hospitals during the merger with Imperial College to form London's academic health sciences centre.

The two job swappers would gladly repeat the move with new counterparts but, more fundamentally, agree that the exercise needs to be repeated lower down the ranks.

'It shouldn't stop here,' says Mr Nettel. 'It should go right the way down. What about a job swap between the professional executive committee and the medical director?'

Freeing beds: IV antibiotic delivery to patients at home

Pity the patient who had a hip replacement seven years ago and now develops an infection deep inside the wound site. The usual treatment is six weeks of antibiotic therapy - as an inpatient.

St Mary's trust and Westminster PCT have developed a service where the patient can be treated at home, freeing up an expensive bed.

Jan Hitchcock, clinical nurse specialist for the outpatient parenteral antibiotic therapy service, says: 'There's quite a range of patients who need long-term intravenous antibiotics but who, medically, do not need to be in hospital. We felt there must be a better way of treating them.'

The OPAT service was modelled on a similar innovation in Oxford. It is based at the trust and patients remain under hospital supervision but the IV antibiotics are delivered daily at home by district nurses.

'It's very much a joint service,' says Ms Hitchcock. 'We have joint care plans with Westminster PCT and agreements about who pays for what.

'We have very close relationships with the district nurses. They know they can phone for advice. They used to say they needed 48 hours' notice to take on a patient but now there is the trust there that if we have an exceptional patient they can move much more quickly.'

It's not only better for patients and nurses but for the bottom line, too.

It has been running since September 2004 and in the first 18 months saved nearly 2,500 bed days.

Older people: transforming intermediate care services

Intermediate care is a tricky area that spreads across boundaries. In Westminster, the PCT, acute trust and city council have agreed a strategy to jointly transform the service.

'We had a history of good clinical engagement,' says PCT's director of service development Paul Jenkins. 'So before we put pen to paper we took time to find out what was working well and what was not working from clinicians and service users.'

In May 2006 they set up a transforming intermediate care board with representatives from all partners plus programme groups to help undertake analysis.

A strategy is now in place that will shift resources to where they are needed and create new services to fill identified gaps. For example, the PCT will now commission more beds for older people with mental health problems. Mechanisms are in place for clinicians to identify patients who might be supported at home.

'Doing it this way has broken down the divides between the acute side and the community,' says Mr Jenkins. 'We have got a good model that will improve patient care and could also be used in other areas.'

Fast facts: Westminster PCT

  • Inner London PCT with very mixed community, including some of the country's wealthiest and poorest people as well as a wide range of ethnic groups.

  • Population is 244,000 although a million people a day visit the area.

  • Healthcare Commission ratings: fair for quality and services and fair for use of resources.

  • Financially sound, in surplus at March 2007. Green lights across the board in 2006 fitness-for-purpose review.

Fast facts: St Mary's trust

  • The district general hospital for west London.

  • Teaching hospital for academic research and medical education.

  • National and international specialisms in paediatrics, obstetrics, infection and immunity, ophthalmology, robotic surgery and cardiology.

  • Healthcare Commission ratings: good for quality and services and fair for use of resources.

  • Financially sound, in surplus at March 2007.