Sophia Christie on why tenders need loving care

The pilot wave of community foundation trusts has been announced, with persistent references to social enterprises as a model for future organisational arrangements. Yet what is expected from future models of community provision is unclear.

This may be a good thing. It should be for primary care trusts, as local commissioners, to review arrangements for the future. Structural change should support the delivery of core strategy and make best use of the workforce.

The health secretary has said that it will be for local organisations to consider their future arrangements. But the working assumption seems to be that all PCTs will divest themselves of any element of provision within a couple of years. This would be a significant and high-risk step for the individual organisation.

Current NHS strategy is to prevent ill health, with a focus on secondary prevention. More recently, there has been an interest in care closer to home and patients as partners.

Given that Gordon Brown commissioned the Wanless report, we can hope for some continuity if he becomes prime minister. What we need is a skill-mixed, multi-disciplinary workforce outside hospital settings. At the core of that workforce are the 250,000 people employed in PCTs and undertaking, with GPs, 90 per cent of NHS contacts.

In Birmingham East and North PCT, we have been reviewing our experience of service provision over the past five years. PCTs have brought commissioning, primary care leadership and community services together in one organisation. We have found a number of strategic benefits from this model.

We can pilot, test and develop new services until they are fit for purpose. Our alignment of district nursing, case managers and advanced nurse practitioners to support those most at risk of unplanned admission has undergone 18 changes in 18 months.

If we had tried to specify and tender this service from the start, we would have got it badly wrong. We would have been tied into contracts, which limited our ability to make adjustments without cost and delay.

We learned from the contracting out processes of the 1980s that you need a comprehensive understanding of a service before you put it out to tender, and you need ongoing intelligent contract management. It is very difficult to write a good specification for a service innovation. However, our PCT has succeeded in developing a new service as a strategic partnership with external suppliers (Pfizer Health Solutions and NHS Direct).

Managing our own services has. allowed us to establish new interventions or offer alternatives to failing services in short timescales; we could ensure patients received flu jabs, offer same-day urgent care and recruit salaried GPs. We could also offer alternatives to traditional models of care, where the historic supplier refused to develop more appropriate models of practice.

Most of this could have been done through tendering and market development, but not at speed. The development of specifications, tendering processes, scrutiny committees and notice and lead-in times tend to mean at least six months between identifying a need and service delivery by an alternative supplier.

In-house, we have been able to make a difference in quality and availability of service delivery in days or weeks. This has changed the nature of our relationship with acute hospitals. Historically, the option to switch provider was theoretical. Having commissioners who also have a provider role in the local market has given us leverage with our major suppliers.

A comparison can be drawn with those local authorities that divested themselves of public provision of care in the early 1990s. Many are now trying to re-establish a market share to give leverage and challenge.

Having a workforce of over 600 clinical staff has changed the culture of the organisation. Providing services gives us real-time intelligence and organisational insight into best practice. It has helped us to do the right thing and not just the cheapest.

Most difficult to quantify, but potentially most significant, is that, as service providers, we have a very different relationship with the public from a commissioning-only organisation. Commissioning bodies tend to come into the public eye when they launch a formal consultation on changing local infrastructure or when refusing to fund an individual's access to specific high-cost, low-value treatments.

Hospitals have always won the PR war because they have clinicians and patients and local people have benefited from their services. PCTs have their own cohort of grateful patients, and can talk about opportunity costs more credibly when we are directly responsible for safeguarding children as well as commissioning cancer drugs.

If the strategy is to invest more in health improvement and care close to home, at the best possible price, it seems illogical to prioritise off-shoring the capacity to deliver such a strategy, especially since the goodwill, enthusiasm and skills are sufficiently rare to be at a premium. This may not be the case if we had other proven and readily available organisational models.

However, I am not aware of many£40m social enterprises operating in the UK and delivering core public services. Community FTs reproduce the organisations we disbanded five years ago, and the associated board and management overheads. We have an increasingly rich market in specific services and. this can be grown so that the majority of care is undertaken in non-NHS settings, although this has both transactional and price costs.

We all need to keep under constant review the contestability and quality of our provision, but the experience of the past 12 months should have caused us all to reflect again on the true costs and risks of wholesale structural change.

Sophia Christie is chief executive of Birmingham East and North PCT.