Possible new models for service delivery

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The coalition government has continued to drive the organisational change in PCTs through the Transforming Community Services agenda.

By 2011

• Any transfers to NHS organisations must be completed.
• Any transfers to local authorities must be completed.
• All aspirant first and second wave CFTs to have achieved NHS status.
• First wave social enterprises to be fully operational.

All subsequent Right to Request Social Enterprises must have made significant progress through the R2R assurance guidance and have agreement of their business plan by their PCT by Feburary 2011.

Any proposed changes must pass the eight tests in the Transforming Community Services assurance document. These are:

• improving outcomes
• improving quality
• service integration
• stakeholder engagement
• efficiency improvements
• infrastructure ulilisation
• sustainability
• whole system fit.

Further details can be found in Transforming Community Services, the assurance and approvals process for PCT provided community services (PDF 483KB).

Guidance for RCN members working in PCT provider services

The Joint Trade Unions have produced guidance to support members and activists with the TCS agenda. These can be found on Tools for activist members.

The options are listed below with information which RCN members may find useful in formulating their views on and responding to their employing PCT's proposals.

Integration with another NHS organisation

What is it?

Your employing PCT could opt to merge with an NHS acute trust (known as vertical integration) or another PCT provider arm (known as horizontal integration). It could also merge with a mental health trust. Some PCTs may choose to integrate different services with different organisations, ie specialist services such as diabetis or COPD services could integrate with an acute trust and intermediate care services from the same PCT could integrate with a mental health trust.

What would it mean for you?

You would transfer to the NHS organisation under TUPE with your existing terms and conditions.

• You would continue to be employed by an NHS organisation
• You would continue to be covered by NHS employment terms and conditions and negotiating machinery. Some foundation trusts are now exploring making alterations to some NHS terms and conditions
• You would continue to be eligible for the NHS pension scheme
• New starters would be appointed on NHS employment terms and conditions and entitled to join the NHS pension scheme.

If you work in middle or senior management, your role is more likely to be affected by any management restructuring arising from vertical or horizontal integration. Any changes would be subject to consultation and the provisions of organisational change policies.

Community Foundation Trust

What is it?

Your employing PCT may have applied to the Department of Health to become a Community Foundation Trust (CFT), it may join other PCT providers in order to do this.  If approved they will have to apply to become an NHS Trust. If this is approved they can then undertake the rigorous process potential foundation trusts have to go through before they get approval from Monitor, which is the organisation which approves and regulates foundation trusts. The CFTs will be NHS organisations with similar freedoms and flexibilities to foundation trusts in secondary health care.

The following organisations have been given approval to seek NHS Trust status in order to apply to become a CFT:

• Norfolk Community Healthcare
• Hertfordshire Community Health Services
• Cambridgeshire Community Services
• South Birmingham Community Health
• East and Coastal Kent
• Central London Community Healthcare
• Liverpool
• Ashton, Leigh and Wigan and Warrington's Community Services

A second wave of aspiring CFTs has been announced:

• Leeds
• Richmond, Twickenham and Hounslow
• Telford, Wrekin and Shropshire
• Derby
• Southampton and Portsmouth
• Lincolnshire

What will it mean for you?

• You would continue to be employed by an NHS organisation
• You would continue to be covered by NHS employment terms and conditions and negotiating machinery (subject to the additional provisions that apply to foundation trusts)
• You would continue to be eligible for the NHS pension scheme
• New starters would be appointed on NHS employment terms and conditions and entitled to join the NHS pension scheme.

A CFT would be able to develop its own terms and conditions of employment and human resources policies in consultation with staff and trade unions. The amount of change involved would depend on how the CFT was formed.

As a stand-alone CFT, the changes would be minimal. Even if the CFT were formed with another PCT provider organisation, most staff would see little change in their terms and conditions. 

The exception in this case would be middle and senior managers. This is because the new organisation would need to implement a new management structure. Any changes would be subject to consultation and the provisions of organisational change policies.

Social Enterprise Organisation

What is it?

As a PCT employee you have a right to request to set up a Social Enterprise Organisation to deliver primary health care services. This would be an independent employer and would not be part of the NHS.

The RCN has produced more specific guidance about social enterprise and the right to request. The final deadline for Right to Request Social Enterprises has now passed it was 30 September 2010. The RCN believes social enterprise should be considered on a case by case basis and upon its merits in the local context. The RCN recommends that any proposals to set up social enterprises are assessed against the RCN principles (PDF 282KB) and are supported by staff and patient and user groups.

What would it mean for you?

PCTs would be obliged to consider requests from staff to establish a Social Enterprise and, if approved by the Strategic Health Authority, a contract for an initial three years would be given. The contract will pass onto the relevant GP Commissioning Consortia if PCTs are abolished in 2013.

• You would transfer to the Social Enterprise under TUPE, retaining your existing employment terms and conditions.
• You would not be covered by the NHS negotiating machinery and, as such, all future changes or improvements to NHS employment terms and conditions and pay would not automatically be granted.
• You would be able to stay in the NHS pension scheme if the Social Enterprise obtained a direction from the Department of Health to include employees in the NHS pension scheme. If the Social Enterprise undertook non-NHS work your NHS pension scheme membership would be affected.
• If you returned to NHS employment after being TUPE'd into a Social Enterprise, that period will be counted as reckonable for sick pay, annual leave and incremental credit. It is not continuous service, therefore would not be counted for redundancy purposes. 
• New starters, even if they were from an NHS employer, would not be eligible for the NHS pension scheme. The Social Enterprise would need to provide separate pension scheme arrangements for new staff.
• New starters would be employed on organisation specific terms and conditions, which should be overall no less favourable than the terms and conditions of transferred employees.

Arm's length PCT provider unit (DPO)

The Coalition Government has made it clear that an Arm's Length Provider Unit is no longer an option.

Polyclinic/GP-led health centre

What is it?

This model would bring together family doctors, nurses, allied health professionals,  specialists and other services more usually associated with hospitals, such as diagnostic testing, minor surgery, blood tests and X-rays. These could be run by large private companies or consortia of GPs.

What would it mean for you?

• If you were transferred to a GP practice as a member of practice staff you would continue to be eligible for the NHS pension scheme
• If the polyclinic or health centre were run by a private company it is likely you would not be eligible for the NHS pension scheme
• TUPE transfer would protect your existing NHS terms and conditions
• You would not be covered by the NHS negotiating machinery and, as such, all future changes or improvements to NHS employment terms and conditions and pay would not automatically be granted
• You may not necessarily have access to the NHS Injury Benefit Scheme or to early retirement on the grounds of redundancy.

Integrated health and social care services

What is it?

In this model health and social care services are managed and delivered jointly. This may be through joint management arrangements between health and social care organisations or formally through integrated care organisations or by the creation of a 'care trust' model.

What would it mean for you?

• You would retain NHS employment terms and conditions
• You would continue to be eligible for the NHS pension scheme
• New starters would be offered either NHS or local authority terms and conditions
• New starters may be eligible to join either the NHS or Local Government pension scheme depending on individual circumstances.

Private sector or non-NHS/independent sector

What is it?

This arrangement would arise from your employing PCT deciding to transfer individual services or bundles of services to a private company (or to a community or voluntary sector provider) through the process of tendering and contracting.

What would it mean for you?

• You would no longer be working in the NHS
• If TUPE applied, you would have some guarantee that your existing terms on transfer would apply, though future nationally negotiated terms may not
• Otherwise, you would not be covered by NHS employment terms and conditions
• You would not be eligible for the NHS pension scheme.

Health unions are concerned about the privatisation model as experience to date shows that staff job security, guaranteed pay, improvements to terms and conditions, trade union recognition and access to the NHS pension can all be lost as a result of transferring out of the NHS. It also means that services can become fragmented, particularly if a series of different organisations run individual services.

Staff Passport

For more information on transfer of employment between different organisational models the national Social Partnership Forum has developed a toolkit. This can be found on the Social Partnership Forum website.

Commissioning

The coalition government in it's NHS White Paper, 'Equity and Excellence: Liberating the NHS', is proposing that the responsibility for commissioning the majority of health care services is handed over to GP Consortia. This is based on a belief that primary care professionals are best placed to co-ordinate the commissioning of care.

An autonomous NHS commissioning board will be set up to provide leadership and to allocate and account for NHS resources. Further information will follow.