Two chief executives for the price of one: Health Service Review


Beyond Section 31


by Paul Gosling


Joint social care commissioning by PCTs and local authorities have blossomed under so-called ‘Section 31 Agreements’. But Section 31 of the 1999 Health Act increasingly seems to be just the start of a longer journey to broader and closer integration of what have historically been very separate and culturally very different organisations.


Chris Bull is the new chief executive of Herefordshire PCT – and of Herefordshire County Council. He becomes the first ever joint chief executive of a PCT and a council – though he has previously been simultaneously chief executive of Southwark PCT and deputy chief executive at the London Borough of Southwark.


But for Herefordshire sharing a chief executive across the PCT and the council is not enough. It is creating a ‘public service trust’ to bring together related services from the two organisations. The public service trust will concentrate particularly on commissioning, so most PCT staff will not operate under the supervision of the trust. By contrast, much of the local authority will. The trust becomes responsible for adult and community services, children and young people, public and environmental health, planning and licensing.


Legal constraints prevent the two bodies formally amalgamating and stipulate that the PCT must remain the accountable body for the provision of some services – community hospitals, community services in the home and mental health services. A formal merger needs a change to Section 75 of the National Health Service Act, 2006 – which is possible, suggests Hertfordshire County Council, if its experiment succeeds.


Only if and when the law is changed will the public service trust become an employer. About 5,000 council staff and 100 PCT employees come under the trust, without formally changing employers. This leaves 1,300 PCT staff, operating in provider roles, not covered by the trust. Arrangements for the operation of the trust are well advanced, with a board sitting from January and the trust being fully functional from September next year.


Joanna Newton, chair of Herefordshire PCT, says both the PCT and the council know what they want and expect from the new structure. “We want to achieve improved services for service users and patients by having more of a seamless service at the front end,” she says. “To do this we have to have teams working together at several levels of the organisation, including the chief executive at the top. This builds on the local government white paper. By working more in partnership we will deliver benefits and efficiencies for the public pound.


It’s a significant step. We have worked with a steering group to get the organisations closer, but you reach a point where it’s hard to have a single vision and leadership without having a single chief executive. Without that, you still have tribalism and different identities.”


While Herefordshire represents the most radical application of joint working between PCTs and councils, it is not isolated in considering how changed structures can aid closer partnership. At Southwark, Chris Bull oversaw the adoption of much closer joint working in local healthcare provision. The borough has one of London’s largest PCTs (with a budget of £400m) and a substantial social services department (which spends £120m annually) and they developed strong structural connections under a common leadership.


Susanna White was appointed earlier this year to a joint post of chief executive of the PCT and director of adult social services at the council. She is very positive about her experience. “Obviously the main [benefit] is whole systems working, looking over the whole health and social care system,” she says. “In doing that to the best of our abilities, to see it as one scenario to make sure the care people get is the right care, delivered in the right way at the right time, without organisational boundaries getting in the way.”


For people who receive care at home, their experience is now much better because of Southwark’s integration, says White. “So, for example, people don’t have multiple assessments. They are assessed by one person, on behalf of the whole system, so that creates efficiencies for the organisation and people don’t like telling their stories to a sequence of people.”


It could be suggested that single assessment systems can be created without integrating the senior leadership of two organisations, but White is unconvinced by this argument. “It’s easier to make it work across both organisations with a single person who leads both,” she says. Typically where adult services and PCTs have agreed to have shared assessments it has tended to be restricted to particular groups of patients – not applying to everyone. Instilling the practice of single assessments for all patients is only likely to be successful where there is a shared leadership, White suggests.


But White admits there are challenges. “It’s a demanding role to do both,” she says. “You need to build in capacity to make it work. The downside is that you are still dealing with a council and an NHS bureaucracy and the role doesn’t take that away.” She points out, though, that in dealing with local area agreements and the local strategic partnership it is much more efficient that she represents both organisations. “I don’t think there are very many disadvantages,” she says.


In the case of Southwark, some systems – HR, finance and IT – remain separate. “That can be tricky,” says White. But, she adds, “I would not say that the cultures [of the two organisations] are in conflict.” Rather, she suggests, “We try to create a local culture which both the NHS and the council can live with. You have to come back to basics and remember you are working for patients: that is what we are here for.”


Efforts have been made in Tower Hamlets, too, to bring social care and health services closer together. Deborah Clarke has been Joint Director of Human Resources for Tower Hamlets PCT and council since March. A council spokeswoman said: “The local authority and the PCT cover the same area geographically. Having a joint director of human resources enables us to take a strategic and effective approach to public sector employment in the borough.”


In Sandwell in the West Midlands, there have been attempts going back over several years to bring health and social care more closely together, including through a secondment of a senior council officer to the PCT. Sandwell Health Partnership is a forum for the two bodies to work together, and it is advised by a joint policy unit, with staff from both the PCT and the council. The unit’s remit is to “weld together” the commissioning arrangements of the two partners into a single structure. Reflecting current government priorities, this goes far beyond the integration and rationalisation of commissioning – it also focuses on the role of social exclusion in poor health outcomes and the need to tackle poverty to improve health and well-being. Tackling drugs and alcohol abuse is another shared priority.


We can now expect to see many more examples of joint local working that seeks to closely integrate service delivery. It is a strong government policy, as spelt out in the Local Government and Public Involvement in Health Bill and in last year’s local government white paper. What is more, according to practitioners, it is a policy that works.





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