A breach of trust

The thing about joining up services is that everyone else’s reorganisations become your problem too. And children’s services are no exception.

No sooner had local authorities been told to merge their education and children’s social services departments, than their health partners were told in July’s policy paper Commissioning a Patient-led NHS to brace themselves for three fundamental changes.

Firstly, the paper demands the number of PCTs be drastically reduced – possibly by more than half – ostensibly to make a better match with local authority boundaries, but also to achieve 15% efficiency savings.

Secondly, PCTs are to be largely stripped of their role as employers of community nurses – a prospect that has angered the Royal College of Nursing so much that it is challenging the government over the move in the High Court.

And finally, GP practices will be able to commission health services individually or in clusters in a scheme which bears similarities to the old GP fund-holding idea.

This potential upheaval in primary healthcare has led Professor Al Aynsley-Green, the children’s commissioner for England, to warn that budding partnerships built up around children’s services may be a casualty of PCT reconfiguration.

“A lot of PCTs have made tremendous efforts to develop collaborative links with local authorities,” he says. “There are fears – which may or may not be unfounded – that these proposed changes may set back this incredible enthusiasm.”

Added to this is the fact that no one on the panel considering PCT reorganisation has a social services background. “Where do children fit into these proposals?” asks Aynsley-Green. “Who is thinking about the impact on children’s services?”

Others see both threats and opportunities in the proposals. “We would like to see a move towards coterminous [boundary] arrangements,” says John Coughlan, co-chair of the Association of Directors of Social Services children and families committee. “Where they already exist, they should be protected. But where they don’t, we should consider this an opportunity to establish them.

“We would also expect our NHS partners to look at how the reconfiguring arrangements will support children’s services. If PCTs can no longer line-manage the delivery of services, is there an option for children’s trusts to host certain community-based services for children, like health visiting, school nursing and child and adolescent mental health services?”

Rosalind Turner, director for children and young people at Suffolk Council, agrees that such opportunities for children’s trusts are a potential outcome. “Is the government going to say that PCTs will be commissioning bodies only? In that case, we will be looking to children’s trusts to deliver community-based children’s health services.”

In integrated teams, it will already be the case that some community children’s nurses are line-managed by their local authority but receive clinical governance from their NHS employer, she points out.

But even in areas where staff secondments are already established, there may be some downsides to the changes.

Patrick Power, managing director of Redbridge Children’s Trust, which has 130 children’s health staff on secondment under a section 31 agreement, warns: “It’s the backup, the support services and organisational infrastructure, where there’s a potential for muddle.”

Power explains that NHS staff would still expect to receive their clinical governance from the NHS and would not want to be moved to local authority employment.

GP-led commissioning is also an unknown quantity, he says. “We will work much more closely with GPs because of the way we are establishing children’s resource centres in localities. But can GPs organise and construct delivery arrangements in services that they are not themselves providing?”

Moreover, GPs in Redbridge have banded themselves into three groups for commissioning services which share no boundaries with the local authority, a situation which Power predicts might be “slightly confusing”.

Perhaps, above all else, there is a fear that the agenda set out in Every Child Matters may become last year’s crusade as the NHS once again fixates on its own anatomy.

“We have to constantly fight to maintain children and young people as a priority,” says Turner. “They still don’t feature in the seven priorities for the NHS, despite the excellent children’s National Service Framework.”