The Integrator: The LCOs are coming

It’s an exciting time, in theory, for community health services. Ministers, and Lord Darzi, suggest they should have more resources, and they will clearly be pivotal in the promised “neighbourhood health service”.

But it will also be a double-edged sword, intensifying scrutiny and change.

And, rather than community services leading the change, they risk being pulled in different directions by others.

Recent developments are telling.

The age-old tussle over who should run community services seems to be tipping towards acute trusts.

In Cheshire and Merseyside – a system which seems to be succeeding in making stuff happen – two standalone community trusts are effectively folding into the local acutes. It follows similar moves in Coventry and Warwickshire, Lincolnshire, and Kingston.

The motivations are two-fold: Taking out organisational cost and complexity; and – more significant in the longer run – getting community services to better respond to so-called “core business”. Core business means speeding flow out of hospitals, and responding to people quickly at home to avoid emergency ambulance trips, attendances and admissions.

The argument is that some standalone community services/providers don’t prioritise these functions, behave too independently and, in the words of one CEO, “idiosyncratically”.

Says one national source: “There’s a real tension, with some community providers not wanting to see the development of services to support hospital flow, but [arguing instead] that they need to be developed in their own right.”

Supporters of the shift to acutes highlight examples where flow is working reasonably well: South Warwickshire, Walsall, Northumbria and Somerset are favourites.

News of the recent consolidation in Wirral prompted very positive comments from some readers. “Vertical integration can work,” said one. “Should we follow a strategic approach to this or let it evolve if the opportunity presents?”

Another raised the wider issue of “place” leadership – and posited the all-important three-letter acronym – arguing: “This should be seen as a blueprint for others. Local Care Organisations have to be the vehicles to achieve true integration in ‘place’.”

As well as getting a grip on “core business”, the idea of selecting a local NHS trust to lead services in each of the 175-ish “places” around England has several attractions. Namely, simplifying structures with a standard model; and giving powerful local figures (the trust CEO) more skin in the game of shifting resources out of their hospitals. Instead of being a threat to these powerful incumbents and their staff, the strategy becomes an opportunity.

Somewhat unexpectedly, one of the most influential people in the NHS has also chipped in on the topic. NHS England chief finance officer Julian Kelly told its last public board meeting: “Someone is going to have to lead [place]. And one of our hypotheses is, you need a provider who is both going to do the work and lead the work, to pull all the other providers together.”

Who owns the neighbourhood health service?

Some readers will already be screaming at their screen; others won’t be surprised to hear that the above plan is Not Necessarily All Good News.

Many in community services believe those who run themselves or are housed in mental health trusts, are more innovative and help stop resources being swallowed up by acutes. A few of these providers, certainly, are seen as successful and responsive, and their systems won’t want to disrupt them.

Supporting acute flow (and even helping frail/older people at home) isn’t community services’ only purpose. Indeed, the shift to neighbourhood and prevention implies a greater focus much further upstream, and prioritising connections beyond the NHS’s clinical walls, in other services and communities, rather than hospitals. What’s more, hospitals and systems often want more uniformity in community response – not necessarily achieved by carving them up at place.

Then there’s general practice. Many GPs will argue they should call the shots on new neighbourhood services. The government and officials might opt to commission a lot of it as a wrap-around rather than a core part of GP, but they will surely have to be central to it.

GPs could (some would say, must) be brought into statutory NHS employment – or at least be more closely bound – via LCOs and provider trusts. And some locally-focused, general hospital trusts have made headway with this (see Wolverhampton, Northumbria, and Somerset). But that’s a long-term, high-risk strategy, and GP partners are more likely to buy into very local, primary care-run providers.

LCOs in Greater Manchester, which emerged from the Stevens-era “new care models” work, operate as virtual organisations under the umbrella of the system’s two acute trust giants. But they have so far never achieved the tight bond with general practice which was hoped for.

They have also run into some knotty legal and financial problems which – along with politics – have prevented full “place” delegation, or the development of “accountable care organisations”, whether in places like South Warks, Wye Valley; or in the Dudley experiment. (Not to mention procurement rules; and this week’s news from Bath, Swindon and Wiltshire, where a competitive process is moving community services away from acute trusts over to the private sector).

Of course, many community health services (perhaps about a third) are already run by acute trusts. And conversely, LCOs could be led by non-acute trusts – indeed Therese Pattern, the Bradford District Care CEO, who was recently hired by NHSE to develop “place”, is the place lead for that patch.

But they are in the minority. So introducing a uniform approach would mean disempowering a range of current “place” leads who sit in integrated care boards and local authorities. It won’t always go down well with councils, who understandably see themselves as leaders of their place.

If there is a policy of rolling out LCOs – or whatever they come to be called – the question will be how quickly, and with how much compromise. Many wise heads say a bit more uniformity and simplicity are what’s needed right now. But neglecting local relationships and strengths could be just as much of a blunder.