Dr John Havard: What happens next to community healthcare in Suffolk?
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In six months’ time a new provider will have to be chosen to take over the community services contract, responsible for all the services in the community from district nurses to cottage hospitals.
Is this important?
You need to cast your mind back a few years to when Serco started and recall the disruption and unhappiness amongst many staff and patients. The District Nursing model was fundamentally changed to take nurses out of practices to start working in teams with a senior nurse managing larger numbers of more junior nurses and controlling work patterns. Many nurses resigned and a lot of valuable experience was lost. Patients found they were seeing different nurses depending on the complexity of their problems and there was some inevitable loss of continuity.
Was it all bad?
The contract was very tightly negotiated so Serco had to make ‘efficiencies’ to manage it. After a false start they did introduce better IT to reduce the endless paperwork that the old organisation relied on.
This should have resulted in more face to face patient time but the demands have increased in the meantime. They did recognise that as an organisation they were light in clinical strength and experience so teamed up with Bromley Healthcare, who have provided useful insights and made a practical difference. So Serco put up a good fight against the dinosaur – but lost a leg in the battle!
Could they lick their wounds and carry on?
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Serco have made a judgement that they do not want to continue so will not be bidding for the new contract. You have to wonder that if such a strong and managerially capable company decide to get out that something must be seriously unattractive about the future. The over-riding paradox here is that at a time when we should be beefing up community services to deliver more care out of hospitals, it is the hospitals who are still eating all the pie.
What about the future control of all our community services?
It seems likely that east and west Suffolk will each see one of two options which will either mean greater hospital control of community services or less. We all want better patient-centred integrated care but how should it be delivered? It may be judged successful if it contributes to better care experiences, improved care outcomes and is more cost effective.
What are the options?
Vertical integration. This is the hospital model involving integrated care across the local hospital and wider community.
Horizontal integration. This is the integrated care model between primary health services, social services and other care providers providing multi-disciplinary teamwork.
We need to acknowledge that effective care co-ordination can be achieved without the need for the formal integration of organisations. Within single providers, integrated care can often be weak unless internal silos have been addressed. Clinical and service integration are the key elements that matter most.
Are there any examples round the world that might be relevant?
In the USA, hospitals controlling community services have largely been abandoned in favour of large controlling organisations that own the hospitals and so can objectively decide how to manage where patients are best treated. One example is the Veterans Health Administration which employs all the medical staff and owns and runs hospitals to manage the full range of care to veterans within a budget allocated by the federal government. It operates through 21 regionally based integrated service networks that receive capitated funding.
There is rigorous performance management centred on key markers of clinical quality and outcomes that incentivise home-based care and care co-ordination for people with chronic illness.
What is to happen in Suffolk?
Our two CCGs will decide but I feel they need to be mindful about giving control to hospitals whose first priority is their own futures – at a time when they definitely have to change. There must be a not-for-profit model that is really sensitive to the needs of our local Suffolk communities which will put district nurses back into practices while embracing some more modern techniques.
Although there are some inefficiencies in familiar face to face support there are also immense immeasurable benefits.