So here’s the thing – all major NHS re-configuration strategies have Out of Hospital plans and enhanced primary and community health care at their core yet it is clear that the public remain, at best, sceptical and, at worst, downright opposed to shifting services out of hospitals into primary care settings. We are continually reassured that moving services closer to home will be better for patients, more accessible, more acceptable and more likely to secure patients’ compliance with their treatment programmes.  Furthermore everyone seems convinced that better and more comprehensive management of long term conditions can be achieved by serviced delivered at patients’ GP surgeries and in primary care centres rather than in hospitals.

Of course the main reason for this scepticism and opposition is that improvements in primary and community health care services are always inextricably linked to hospital closures. Yet even if we could separate one from the other, I’m sure that there is still a significant credibility gap which Commissioners and NHS Strategists need to bridge before they can convince the public that they are better off receiving more of their services in primary care and community settings care rather than in their local hospital.

Why might this be the case? Well I think the main reason is that very few of us have actually seen the primary care nirvana.  Whilst many have experienced good GP primary care, it is sadly rare to see this as an integrated part of extended and enhanced out of hospital services – primary care linked to advanced diagnostics and outpatient-style services that were previously offered in hospital settings.  How many of us have entered the health service for care that they previously received in hospitals and then experienced a complete, high quality package of care without having to cross the hospital threshold?

I’m sure that the majority of you ready to quote good examples of joined up services built around the primary care setting are not sitting in densely populated urban or suburban areas – the main areas likely to be affected by sector-wide acute reconfiguration plans. These are the areas with the biggest variations in the quality of primary care and where plenty of people choose A & E Departments, Walk-in Centres and Urgent Care Centres to receive primary care rather than their GP Practices.

So – what can be done about it? In many respects this is a marketing or re-branding exercise, not least because more people than we realise must actually look upon the going to hospital experience favourably (if not actually like going to hospital!). We need to do a number of different things to change perceptions and really communicate the benefits – to disassociate the enhancement of primary and community care from the hospital closure agenda, promote better examples of what extended primary care actually is and, probably, find a way of giving this new model of care a new brand.

Easier said than done perhaps but it is time that we bring some fresh thinking to this issue or else we run the risk of losing a lot of excellent thinking and vision to what is essentially a PR failure – just ask Professor Ara Darzi about his Polyclinic model.

How services are shaped and where they are located geographically is one of the issues that is, to put it kindly, less well thought through in the new arrangements for the NHS. System-wide reconfigurations like North West London’s Shaping a Healthier Future are being led by the soon to be abolished Clusters. This is because the scale of the challenge is so large and because only the Clusters have the clout to tackle these issues.

In fact there are many commissioning challenges of differing scales that have estates configuration consequences but there is a real concern that the new Clinical Commissioning Groups will have too many other things to focus on without also having to address issues relating to the location of services.  More worryingly, some providers may adopt a “this is what you are getting” approach because the challenge of reconfiguring their own estate to meet commissioniners’ requirements is equally difficult. It is unlikely that market mecahnisms alone will ensure that services are provided in the optimum geographical configuration for each area.

These issues remain outstanding at a time when NHS community and primary care estates resources are seriously depleted and when the plans for the new PropCo (Property Company) are not yet fully developed.

So, who in the system has a great interest in where services are located and has the opportunity to influence these issues? Local Authorities have always had a much greater focus on how their services are located across their territories and their elected representatives genuinely know every street in their patch. The only other agencies with a similar geographical interest and focus are Public Health Departments, now to be located inside local authorities.

I therefore think that Health and Wellbeing Boards can bring a real geographical focus to the configuration of service provision and the reduction of health inequalities by their leadership on developing the Joint Strategic Needs Assessments and their co-ordinating responsibilities to the actions of the CCGs and the local authorities.

Hopefully CCGs will see the benefits of HWB engagement and leadership on this issue as they are likely to share similar objectives of increasing access to health care and reducing health inequalities.

I’m a great one for taking a metaphor and running with it, sometimes to the point where it loses any useful meaning, so please bear with me on this one.  Thanks to Andy Cowper of Health Policy Insight for his excellent post “The re-plumbing of Power” in which he is inspired by his domestic refurbishments to explore how the Nicholson Commissioning Board (copyright A Cowper) will aim to control the NHS finances over the coming challenging period, not least through the NCB’s oversight of the Commissioning Support Services (CSSs).

It was during the Watergate scandal that Richard Nixon, a control-freak to warm the cockles of Sir David’s heart, sent in a Special Investigations Unit to bug the Democratic Party HQ in the Watergate Building.  The were known as the White House Plumbers. The NCB won’t need to resort to anything so secretive – a simple command and control mechanism involving a very tight grip on the work of the CSSs should ensure that they keep a similarly close control on the work of the Clinical Commissioning Groups (CCGs). Andy rightly notes “concerns are developing that CSS may become ‘eyes and ears’ of the Nicholson Commissioning Board”

This is hardly a surprise but what Andy correctly goes on to do is make the connection between the NCB controlling the CSSs and the NCB also controlling the contracts for all of primary care. I can’t think of a suitable plumbing analogy at this point but these are the rock and the hard place between which the CCGs may be existing for the next 3 or 4 years.

CCGs will need to ensure that the performance of their member practices as prescribers and referrers does not give cause for concern and also that they treat the major variations in the quality of primary care provision as robustedly as they wish to address the variations in secondary care. Otherwise they may well have the tap turned off.

How do commissioners plan services for non-standard geographic entities?  it’s not as easy as it should be/could be because if you do not know enough about the total community served you cannot identify their needs precisely. “But is this a problem?” I hear you cry. Well yes it is because the most important building block in our health system, the GP practice, does not serve standard (ie measured and recorded) communities.  A legacy of GPs’ independent contractor status is that they can define their own practice areas.  In reality this is done with a black marker pen and a copy of an A-Z street map.  ”We don’t take any patients to the east of the High Street or south of the railway line” is how practices tend to define their practice areas and then they draw up a map and pin it on their notice board, print it in their leaflet and post it on their web site.  There is nothing wrong with this except that the geography they define through this process is not one that they can have any accurate statistical data about.  They cannot know the number of people that live in the territory they serve, the age-sex population profile, the extent of deprivation and the areas and communities of greatest need. Of course GPs know lots about their practice areas – their hands on experience on the ground is second to none but they have no numerical baseline for their “territory” against which to compare their actual practice population and t measure how well they are meeting local need.

Of perhaps even greater importance is the fact that some Clinical Commissioning Groups have currently defined non-standard ie non coterminous) territories. This poses a major risk to the wider public health and health and well-being agenda and is something that we believe the analytic mapping technologies used by Public Health Departments will struggle to deal with. It is possible that the DH will iron out these wrinkles in the system but, if they do not, this remains a significant public health risk.

Damson Health have been working with our friends and colleagues at Gavurin (they may be our relations – it’s complicated – how long have you got?) to use their innovative data and analytic mapping technology G-View to create bespoke geographies that can then be used to establish denominator data for non-standard geographies such as practice populations.

In the UK we have a hierarchy of official geographies – below counties and boroughs we have Super Output Areas – Middle Super Output Areas (MSOAs – approx population 7,200 people), Lower Super Output Areas (LSOAs – approx 1,500 people) and Census Output Areas (COAs – approx 250 people).  These geographies never change and most official data is collected and recorded using these geographical categories. Most health managers talk about electoral wards within PCT boundaries but these are not used for official statistics because they often change.  The Super Output Areas hardly ever change which means that data can be collected and analysed over longer periods of time.

An example of what we have done can be seen below – in Liverpool the PCT Community Services run the Pricess Park GP Practice and have prepared the map below to illustrate their practice boundary

Using G-View we have matched the practice boundary as closely as possible by selecting those Lower Super Output Areas which correspond with the practice area.  Although it is not possible to match it exactly it is clear from the image below that one can largely create the unique geographical area served by the Princess Park GP Practice.  In the map below we show the Index of Multiple Deprivation scores for each of the LSOAs in the practice area.  They highly which LSOAs are in the 5% of most deprived LSOAs in England (darkest blue) and the single LSOA which is in the 50% least deprived LSOAs in England (yellow).

Having created the practice geography we can then compare the practice area’s population with that of the whole city of Liverpool – the chart below shows the population served has a far greater proportion of people between the ages of 20 and 34 than the whole city but has fewer people aged 40 years or older than the rest of Liverpool.

The government’s masochistic tendency came to the fore again today with the Prime Minister launching his plan to share health records with Big Pharma.

As everyone knows, medical and pharmaceutical innovation is one of UK PLC’s few remain stellar sectors and clearly worth supporting for the benefits that it brings to the economy and to UK healthcare. My concern is not with the policy per se but with the politics.

As sure as John Terry’s slip gave a free run on goal to Robin van Persie last month (the less said about that the better) surely this is an open goal to Labour that even the not very missed John Healey could have taken.  Andy Burnham, a more in-form shadow Health Secretary, should have no trouble scoring with this one.

Public fears about the NHS changes, the predominance of the privatisation and profit-making narratives and general suspicion of the government’s intentions should make it easy for Labour (and the few Lib Dems following Evan Harris on health matters) to paint these changes as another feature of the Government’s obsession with opening up the NHS to their mates in the private sector.

I can hear it now: “would you trust your private medical records to those US multi-nationals coming over here to skim millions of pounds out of our NHS?”

That’s a tough one to deal with on the doorstep or, for that matter, in the GP surgery talking to local Clinical Commissioning Group Chairs.

Now I don’t often quote Churchill, Winston that is, not the talking insurance dog, but his famous quote “Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning” may be apposite for the Private Finance Initiative – somewhat of a bugbear for this author.  Two more bricks tumbled out of the wall this week.

1) “PFI deals should be used “sparingly”, Treasury warns” reports Crispin Dowler in the HSJ yesterday.  Although Dowler is referring to the Treasury Select Committee’s views rather than those of the Treasury itself, weight is now gathering against the Private Finance Initiative as a model for development of the NHS’s estate.  Dowler notes that the Committee commented “If we assume that the outturn costs of construction, maintenance and services will be the same between the PFI and conventional procurement options, the government could have spent £175m less, [in net present value] terms, by borrowing directly from the capital markets, rather than through a [special purpose vehicle] intermediary,” .  Interestingly this assumption is precisely what the Treasury has NOT been doing for the past 15 or more years.  They have been stacking the deck against conventional procurement options in a blatant fashion and academics like Allyson Pollock have been describing this jiggery-pokery in great detail for years

2) Also from the HSJ, essesntial reading for all in the NHS, and also from Crispin Dowler, we read that “Trust wins backing to vacate £3.6m PFI unit“.  This is most definitely a loose thread that should only be tugged at with extreme caution.  Quite rightly the SHA has accepted the service reconfiguration and economic rationale for allowing Manchester Mental Health and Social Care Trust to vacate a PFI-built unit on the Manchester Royal Infirmary site.  However this leaves a huge hole in the finances of the Central Manchester University Hospitals Foundation Trust and, obviously, a vacant building that is contractually bound to be serviced and maintained for the remaining years of its (usually) 25 year lease.

I worry that local decisions like this have not been fully thought through for the national precedent that they set. Back in February we learnt that an NHS Trust buys back it’s PFI debt when a MH Trust in the North East successfully made the case that it was cost effective for them to buy out their PFI contract for £18m allowing them to save £2m per annum over what was remaining of a 30 year contract.

As a taxpayer I hope that Financial Directors up and down the country are reviewing cases such as those quoted above  to see how they can make their NHS funds go further by ditching existing PFI projects let alone not starting new ones.  If FDs find the work of Allyson Pollock a little too radical for them they could do a lot worse than visiting the web site of Tory MP for Hereford and South Herefordshire, Jesse Norman  http://www.jessenorman.com/ who is leading the charge against the inequities of the Private Finance Initiative in articles such as Clawing Back the PFI Cash from the Guardian in June 2011 and It’s time to derail the PFI Gravy Train in the Telegraph in January 2011

Sally Gainsbury’s article “Wistful thinking on PFI” in the Health Service Journal dated 9th June (reproduced below) does a great job of linking two huge waves hitting the NHS and points out there may be a tsunami behind – the problems with the Private Finance Initiative and the threat to community health services through vertical integration with acute trusts.

I’ve posted before about how PFI legacy debt is “The elephant in the room” – Sally has joined the dots and pointed out why fears about the unaffordability of hospital PFI schemes may lead to finance directors of vertically integrated acute and community trusts looking at their community health service divisions and deciding that they could offset some of their PFI costs by moving them into under-utilised PFI hospital accommodation.

Just like in the 1980s and early 90s, when combined acute and community units used to raid community services to make cost savings, our decade’s version of this threat to the viability of community services is driven by the need to support hugely expensive PFI schemes that have effectively frozen configurations of health care, at least in building terms.

Hopefully the Co-operation and Competition Panel can take this into account when considering applications to merge acute and community service providers and demand guarantees that the integrity of community services remain protected – specifically that they are not artificially concentrated on hospital sites.

Sally Gainsbury: wistful thinking on PFI – Health Service Journal 9th June 2011

Ask an NHS finance director what they hope will come out of the McKinsey review of 22 trusts with tricky private finance initiatives and they talk wistfully about a revised market forces factor – the calculation that determines any top-up paid for delivering services in a particular area.

In theory, a market forces factor would recognise the added costs of new, privately funded capital by supplementing the tariff prices paid to certain trusts.

More likely, a new centrally funded facility, effectively offering a subsidy to trusts with expensive PFIs, would need to be established to avoid minsters being embarrassed by an ensuing competition on price driven by differing tariffs.

But the real bickering would come over where the line should be drawn. The 22 currently listed are self-defined; what about the other 100 or so trusts with PFIs?

Others are looking to more pragmatic solutions. Most PFI contracts contain a clause which allows the costs for “soft facilities management” services – cleaning, portering – to be benchmarked against alternative providers. The irony is that the staff doing those jobs are often retained employees: if “efficiencies” were required their redundancy cheque would need to be signed by the NHS.

The hopeful point to Cabinet Office minister Francis Maude’s withdrawal in December of the two tier workforce code as a sign the government could take its industrial battering ram to regulations preserving the terms and conditions of outsourced workers.

The fallback option remains the South London scenario: shutting other facilities – be they acute wards, community clinics or GP centres – and stuffing them into the PFI building until it sweats.

While hospital closures attract most attention, the area to watch could be community services. The larger portion have already been swallowed up by acutes, so how long before we start hearing of the integrated benefits of hauling community service patients into PFI buildings?

Like everyone I was horrified to watch Panorama’s undercover exposure of Castlebeck’s Winterbourne View care home. Jim Mansell [Care: a failure on every level - Guardian 2nd June 2011] points out how NHS-run facilities have consistently performed better than larger, fuller, poorer staffed privately-run facilities.

Fortunately both this Government and their predecessors support a solution that can help address these problems – patient choice and market mechanisms.  Patients (and in this case their carers) should be able to exercise choice by asking their PCTs to be referred to the best units.  If these are NHS-run units then the market mechanisms can work their magic and the poorer homes will wither and die.

Only now is the wisdom of successive Secretaries of State for Health becoming clear to me.  Who would have thought that quietly, in the background, the Department of Health was implementing a 30 year mastermind strategy to build stability into the NHS.  Repeated re-organisations of the NHS have all been part of  an incredible masterplan to embed organisational and personal resilience skills amongst the NHS management cadre.

As the pause  becomes a hiatus becomes a temporary cessation becomes a 15 week summer recess, managers within the NHS are doing what they do so well, and as now becomes clear, what they have been cunningly prepared for – they are just getting on with running the whole system in the face of superficial intentions to change things.

Some people make the mistake of painting this as an in-bedded, institutional resistance to change but they are wrong.  Without NHS management’s amazing, Darwinian adaptive qualities,  endless political messing about would have done for the NHS long ago.  Fortunately the powers that be recognised that we needed an undercover programme of skills development so that managers could cope with the endless machinations of the politicians and keep the whole thing running.  Like London cabbies who can keep going safely while a party or a full scale fight is breaking out behind them, NHS managers are able to keep the whole shabang on the road.  Just don’t ask them to go south of the river after dark.