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Structures for the future – north and south of the border

6 June 2008

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Anne Crandles

Practice Manager
Morningside Medical Practice

Practice Development Facilitator
South Central Edinburgh Local Healthcare Partnership

Anne has worked in general practice since 1985, and in practice management since the last “New Contract”. Over this time she has picked up an AMSPAR Diploma, an MBA and the Prince 2 foundation course in project management. She is currently “enjoying” studying the European Computer Driving Licence (ECDL) syllabus in computing skills. Outside of work, Anne goes to the gym and attends a weekly French class. She has two grown-up daughters, who act as her own personal Trinny and Susannah

The challenges of future population numbers – increased elderly and a diminished pool of people of working age – are well documented. For example, it is predicted that by 2031, 26.6% of Scotland’s population will be over 65 years old (see Table 1).(1)


The impact of this will be felt by all public sectors – pensions, benefits and social services, to name but a few. How will the NHS respond to the challenges of a reduced staff and a top-heavy elderly population with its inherent health needs?
Add to this the increasing prevalence of long-term conditions (LTCs) and the number of patients living with more than one LTC, the public’s expectation of what the NHS can deliver and continuous innovations in health technology, and it is very easy to understand the temptation to just stick your head in the sand!

The NHS Health Plan (2000) and Delivering the Health Plan (2002) aimed to address these issues by changing the way primary care services are delivered, making them “closer, safer, better and quicker” for patients.(2,3)

The approaches used to realise these plans differ throughout the UK. With apologies to colleagues in Wales and Northern Ireland, this article looks at how these plans are being implemented in England and Scotland, the strategies used and organisational structures that have been adopted.

England has foundation and trust hospitals, Payment by Results, practice-based commissioning (PBC), Choose and Book, community matrons and pilot Kaiser Permanente sites.(4)

Scotland, on the other hand, has resisted PBC, and has taken onboard the vision set out in the Kerr Report (Building a Health Service Fit for the Future, 2005) and Delivering for Health (2005) – ie, integrated community partnerships, including health, social work, housing and education.(5,6)

Both models require changes to working practices – in particular, nursing practices – and focus on delivering care to patients with LTCs in the community and reducing hospital admissions.

Yet the structures used by each country require further explanation.

Healthcare structures in England

  • The Department of Health (DH) is the government’s health department, which sets policy.
  • There are 10 strategic health authorities (SHAs) in England, including North East, Yorkshire and the Humber, West Midlands and London.
  • Each SHA manages a number of primary care trusts (PCTs), of which there are 152 in England. The purpose of PCTs is to:
    – Improve the health of the community.
    – Secure the provision of high-quality service.
    – Integrate health and social care locally.
    PCTs employ staff (eg, district nurses/health visitors, etc), have their own budgets, and develop new integrated patient services. In time, these services are likely to extend to include social care and support services (as part of the DH’s Commissioning framework for health and wellbeing). PCTs hold the “cash” for PBC, with practices holding indicative budgets for services they commission.
  • Generally speaking, practices have formed local groups (PBC consortia) to purchase and develop services. It is envisaged that practices/consortia will focus on delivering care in the most appropriate setting, for example reducing the number of patients attending hospitals by managing their treatment in primary care, service redesign and driving up quality of service through competition.
  • Any efficiency gains/savings must be ploughed back into patient services. Commissioned services should reflect the needs of the local population, the PCT Local Delivery Plan and NHS priorities.
  • In the meantime, individual practices will grapple with the day-to-day ramifications of PBC, Choose and
  • Book, Agenda for Change and the new General Medical Services (GMS) contract.

Healthcare structures in Scotland

  • The Scottish Executive Health Department (SEHD) is Scotland’s government, which has the power to set its own national health policy.
  • There are 14 health boards (HBs) covering Scotland’s regional areas, eg, Lothian, Highlands, Ayrshire and Arran. Responsibility for implementing the SEHD’s policy rests here.
  • Community Health Partnerships (CHPs) cover sectors within regional areas. For example, there are four CHPS in Lothian, Edinburgh, East Lothian, Midlothian and West Lothian (although technically West Lothian is a CHCP – the extra “C” standing for “Care”). Health services now work in partnership with social services and housing to create CHPs. This has meant the realigning of services, creating coterminous boundaries, making cultural and organisational changes and forming new working relationships.
    The Kerr Report recommends that the four main priorities for CHPs are:(5)
    – Supporting patients at home.
    – Preventing avoidable admissions.
    – Identifying opportunities for more local diagnosis and treatment.
    – Enabling appropriate discharge and rehabilitation.
  • Local Health Partnerships (LHPs) are smaller units set up within large CHPs to maintain contact with localities, keeping local needs to the fore. CHPs, via the LHPs, provide primary care services to practices, including community nursing and health promotion.
  • Practice participation in CHPs/LHPs is mandatory, unlike the old Local Health Care Cooperative set-up, which was optional. This is over and above the day-to-day practice work of the new GMS, which includes the Quality and Outcomes Framework (QOF) and directed/local enhanced services.

Figure 1 summarises the different approaches and structures used by each country.


Evolving strategies and relationships
English practices have embraced PBC with varying degrees of enthusiasm. The problems with Choose and Book are well known, although a recent DH report claims 81% of English practices used Choose and Book in June 2007 and 89% during May and June 2007.(7) Change has been sporadic and a complete picture has yet to emerge.

In Scotland, the new organisations have appeared at varying stages over the past two years, and each one looks slightly different to the rest. The development of partnership groupings and innovative working practices has meant that, in parts of Scotland, the focus has shifted from working with practices to establishing new organisational structures.

While this is an important first step, it has left many practices feeling disenfranchised, missing the previous levels of involvement experienced in the old structure. However, as these new partnerships begin to embed, attention is returning to practices and the relationships that need to be in place to make new strategies work.

Two structures – one outcome
In both England and Scotland, practices are the last link in the value chain, but without practice participation these strategies will fail – LTCs and care in the community need primary healthcare teams in order to succeed. I am in no doubt that this means more work for practice managers – such as involvement in new organisations, PBC consortia, working with/in PCTs, CHPs and LHPs, and encouraging practice buy-in.

These are interesting times, full of opportunities not only for improving patient care but also professional development for practice managers. If you are not already involved, I urge you to do so. You, and your experience, will be welcomed (and needed!).

As to which model is best … I would not dare comment! Only time will tell.

1. Scottish Executive Health Department. Predicted population in Scotland, 2031. Edinburgh: SEHD; 2005.
2. Department of Health. The NHS Health Plan. London: DH; 2000.
3. Department of Health. Delivering the Health Plan. London: DH; 2002.
4. Ham C. Lost in Translation? Health Systems in the US and the UK. Oxford: Blackwell; 2005.
5. Scottish Executive Health Department.  Building a Health Service Fit for the Future. Edinburgh: SEHD; 2005. Available from:
6. Scottish Executive Health Department.  Delivering for Health.  Edinburgh: SEHD; 2005. Available from:
7. Department of Health. Choose and Book statistics. London: DH; 2007.