Trust us?

These are still early days but primary care trusts need to act
fast if they are to dispel concerns over the future of children’s
services, reports Carol Lewis.

Reform is taking place at breakneck speed. In recent months
primary care groups have grown into primary care trusts (PCTs) and
health authorities have been dissolved and replaced by their
strategic counterparts.

Meanwhile, some social services departments have devolved into
care trusts and a variety of new partnerships with new agencies
including Sure Start and Connexions have been launched.

There are fears that some services will be cast aside in the
inevitable struggles for power, not least those for children.

A survey of community paediatricians in West Midlands published
last autumn¹ showed that the majority believed the
formation of PCTs would lead to the fragmentation of children’s
services.

The paediatricians feared that well-established teams would be
split between different PCTs. They cited as particular causes for
concern: plans for school nurses and nurses working in specialist
care to be employed by different agencies; and employment of
paediatricians by PCTs while child and adolescent mental health
services remained within adult mental health services.

Commenting on the survey results, Dr Angela Moore, convenor of
the West Midlands Regional Community Paediatrics Group, says: “The
importance of multi-disciplinary teams working in community
paediatrics must be preserved. The multi-disciplinary team must not
be divided into very small professional groups in each PCT.”

She adds: “Decisions regarding children’s services should be
based on the needs of children rather than on politics.”

These concerns are echoed by social workers. Jane Held,
co-chairperson of the Association for Directors of Social Services
children and families committee, says: “PCTs have several roles in
providing, contracting and performance managing. This is an
extremely tall order with everything that is going on at the moment
and everyone jostling for position. Major structural change is a
time of high risk and we know that it is at these times that child
protection can lose its rigour.”

It might have been this concern about child protection which led
health minister Jacqui Smith to write to all PCTs outlining their
responsibilities on child protection in January this year (see
panel).²

Loretta Light, community paediatrician and author of the West
Midlands survey, says: “PCTs have not got around to looking at
child health and well-being, whereas with child protection, the
letter from Jacqui Smith has been very reassuring and most trusts
are now getting their heads around the requirements.”

Although positive about the future under PCTs, she says there
are concerns that public health commissioning expertise has yet to
transfer from health authorities to PCTs.

But progress is being made. Dr Light, who is designated
paediatrician for South Staffordshire, says that in her area
fragmentation of services has been prevented by employment of
expert teams at community trust level to serve local PCTs.

She adds that colleagues in other areas report that a lead PCT
has been nominated to commission child services for up to seven or
eight other PCTs under the strategic health authority. Each PCT is
taking on a commissioning speciality rather than trying to be
masters of all.

In Nottingham, geographical boundaries have ensured
co-ordination between teams on child protection. Paul Snell,
director of the city’s social services department, says: “In
Nottingham, the PCT, the city council and the area child protection
committee share the same boundaries, enabling us to have a shared
interest in child protection issues.

“A senior manager from the PCT sits on the ACPC as do the
designated nurse and doctor, ensuring that there is an overview on
all aspects of the health service contribution to safeguarding
children. The PCT also ensures that health services and
professionals within the city PCT area contribute to inter-agency
working via joint staff training and clinical governance and audit
arrangements.”

Yet Snell sees room for improvement: “In future it may be
possible to strengthen this further through the co-location of
health and social services teams and linked IT systems.”

Potential partnerships between PCTs and a wide variety of
agencies are among the key benefits of the new arrangements. While
David Vickers, consultant paediatrician at South Cambridgeshire
PCT, says it is too early to judge PCTs on delivery of child
services, he adds: “They do encourage a holistic approach across
health, social services and education. PCTs are certainly better at
this than acute trusts.”

That view is backed up by Jane Held, director of social services
in Camden, with the proviso that social services retain the lead on
child protection issues. “PCTs structurally provide a very good
basis for child well-being and should be responsible for child
protection. But I don’t see them as a successful lead agency. This
should remain with social services. We need to create a more
closely linked network between social services, health, police,
probation services, voluntary sector, housing, hospitals and
PCTs.”

She continues: “PCTs give us a much better chance in the long
term to improve links between well-being, health, welfare and
protection. I am very positive about what can be achieved, so long
as there is not a major structural reorganisation of the service.
Social services have a strong record of getting it right. We need
to work smarter but not structurally differently.”

A survey of 72 PCTs and primary care groups (the forerunners to
PCTs) by the National Primary Care and Research Development Centre
last year showed that the majority were already working with local
authority departments on community development (87 per cent),
leisure (73 per cent), education (68 per cent) and housing (65 per
cent). Two-thirds reported joint training initiatives for NHS and
local authority staff.³

The relationship between health and social services is being
tested with the launch of the first four care trusts – amalgamated
health and social service organisations. Three out of the four care
trusts launched this April are concentrated on mental health
services. The government wants to see the concept introduced across
the country – so why not child services?

Penny Banks, author of a recent King’s Fund report⁴
on the subject, warns: “While there may be merit in care trusts,
there are dangers that these new structures threaten ‘shotgun
marriages’ or incentive-led national models rather than supporting
sustainable joint-working. Any quick fixes to address problems with
a high political profile can divert local agencies from working
together on local priorities.”

She cites constant change in both health and social care,
competing local and central priorities, and a “perverse range” of
incentives in both sectors, as other reasons why true partnerships
continue to elude us.

The flow of targets and advice from the government to PCTs in
the form of national targets on waiting and admission times,
national service frameworks, Commission for Health Improvement
inspections and National Institute for Clinical Excellence
recommendations is leaving little time or resources for local
priorities.

This prompted the charity Young Minds to issue its own guidance
for PCTs on commissioning child and adolescent mental health
services.⁵ However, the guidance lacks the teeth of
government-issued directives.

This concern is highlighted by Dr Light: “Children’s services
are not a top priority for PCTs burdened down with the NSFs on
cancer, heart disease and mental health. And as the NSF for
Children hasn’t happened yet, there is a danger that children’s
services will be put on the back burner. I would like to see
forward-thinking partnerships between health and social services
getting up and starting to commission children’s services now.”

With the community section of the NSF for Children delayed, PCTs
are going to have to get their act together – and fast – for the
sake of the children.

¹ L Light, Location of Employment of
Consultant Community Paediatricians, British Association of
Community Child Health, 2001

² J Smith, Child Protection
Responsibilities of Primary Care Trusts, DoH, 28 January
2002.

³ D Wilkin et al, National Tracker Survey
of Primary Care Groups and Trusts 2000/2001, National Primary
Care Research and Development Centre, 2001

⁴ P Banks, Partnerships under
Pressure, King’s Fund, 2002

⁵ D Morley, P Wilson, Child and
Adolescent Mental Health, Young Minds, 2001

PCT child protection
responsibilities

– There should be a named public health professional who will
input into children in need issues including child protection.

– Designated professionals are to be performance managed by the
PCT director of public health.

– Service specifications drawn up by PCG/Ts as commissioners
should include clear service standards for safeguarding children
and promoting their welfare, consistent with local ACPC
procedures.

– Child protection forms one of the key competency tasks for
PCTs.

– PCTs are expected to ensure that clinical governance and audit
arrangements are in place to assure the quality of child protection
services.

– PCTs should ensure that all health agencies with whom they
have entered into commissioning arrangements are linked to a
specific ACPC.

– Each PCT will be accountable for their own child protection
processes, and those undertaken by agencies with whom they have
commissioning arrangements.

– Each PCT, acute trust, and mental health trust is expected to
have a named doctor and a named nurse for child protection.