DESIGNED TO CARE

Renewing the National Health Service in Scotland

65. A Trust's prime responsibility is the provision of patient care of the highest quality. To do this it must skilfully design, as well as deliver, the patient services agreed between it and the Health Board. The Trust should seek to provide integrated services which have clear health gain objectives, are clinically effective, have minimal waiting times, and have integral quality standards. In order to achieve this, Trust management must focus on improving the delivery of health care, and not let administrative processes become ends in themselves, rather than the supporting means. Among other things, this requires that clinical staff are central to the management of hospital, community and primary care services and are able to lead the development of clinical services.

66. Trusts will be responsible for all operational matters and managed by teams concentrating on the delivery of clinical services. Trusts' management teams will be able to take decisions relating to the local management of health services without undue interference from others, and will be responsible for the effective and efficient discharge of day-to-day operational activity. They will work within current national and strategic frameworks and in particular in line with the Health Improvement Programme developed with their Health Board. Trusts will continue as separate legal bodies, with power of employment, and will be required to work with each other to ensure that support services are organised cost-effectively and provide value for money.

67. This approach requires reform of existing arrangements for Trust Boards. Trusts will in future be managed by a Trust Team led by a part-time non-executive Chairman appointed by the Secretary of State. The Chairman will also act ex officio as a non-executive of the host Health Board. Supporting the Chairman will be a Team of up to 5 executives, including the Trust's Chief Executive. In addition, up to 5 non-executive trustees will be appointed to work as integral members of the management team. The existing Health Appointments Advisory Committee (HAAC) will continue to provide advice to Ministers on possible candidates who will be sought from areas including the NHS in Scotland, the voluntary sector, local government, and, in the case of Trusts with medical schools, from the universities.

68. The Government's new emphasis on the quality of services to patients must be reflected in the responsibilities and management of Trusts. The Government will amend Trusts' statutory duties to make explicit their responsibility for quality of care. This will need to be taken every bit as seriously as the existing financial responsibilities. Trust Chief Executives will carry ultimate accountability for the quality of care provided by their Trust, in the same way as they are already accountable for their Trust's proper use of resources. Trust Chief Executives will be expected to ensure there are suitable local arrangements to give them, and the Trust board, the assurance they need that this duty is being met. The intention is to build on existing patterns of professional self-regulation and corporate governance principles, but offer a framework for extending this more systematically into the local clinical community, and ensure the internal 'clinical governance' of the Trust.

69. Control of the estate, comprising land and property, will be retained by Trusts, but Health Boards will be responsible for monitoring its utilisation to ensure consistency with Health Improvement Programmes and locally agreed estates strategies. The Government will have power to ensure that the estate is managed in ways which are consistent with strategic plans.

Types of Trust

70. Two principal types of Trust are envisaged. First, Primary Care Trusts (PCT) will be responsible for primary, community and mental health services within the geographical boundary of individual Health Boards. Second, Acute Hospital Trusts (AHT) will be responsible for a defined set of acute hospital services within the geographical boundary of individual Health Boards. Whilst these are the preferred forms for Trusts, the Government recognise that there will be particular circumstances where this will have to be varied to best serve the needs of the local population.

Primary Care Trusts

71. Developing primary care is at the heart of the Government's commitment to the NHS in Scotland and is essential to the development of an effective and efficient system of care. Our family doctor system is the envy of the world, but if the primary care sector is to realise its potential, it must be supported by the development of a robust organisational structure.

72. Primary care depends on the contribution of a wide range of professionals working together. GPs and the general practice team need to work closely with community nurses, midwives and therapists to offer comprehensive and appropriate support to their patients. Community pharmacists, dentists and ophthalmic opticians provide essential services, and access to their skills and professional expertise can greatly enhance the effectiveness of the team.

73. The NHS has been well served since its inception by the independent contractor status of general medical and dental practitioners, community pharmacists and opticians. The Government have no plans to change that status. It is however important in the interests of good patient care that the Family Health Service practitioners are involved in the design of that care and that the contribution they make is advanced and supported within a cohesive framework.

74. General Medical Practitioners and their teams are increasingly aware of the advantages of working together to plan and deliver new services in different ways. Out-of-hours schemes, primary care purchasing groups and locality arrangements are all examples of such collaborative working. In particular, practices are forming alliances, creating the foundations for new primary care organisations, which will overcome the artificial boundaries which have existed between community trusts and primary care.

75. Recognising the emergence of these new collaborative working methods and the benefits they bring to patients and practitioners alike, primary and community health services will be brought together under a single unifying structure in the form of Primary Care Trusts. The establishment of these Primary Care Trusts will build on the strengths of general practice and give a voice to community nursing and other primary care professionals managing and delivering care to their local communities. In this way primary care will be able to pool resources, work across organisational boundaries, and develop shared aims and objectives which will underpin the drive towards better quality of care for patients.

76. In placing the emphasis on the primary care development role of Primary Care Trusts, the Government also recognise that these Trusts will have substantial responsibilities for the management of some hospital services, and in particular a range of local services for people with learning disabilities, people with a mental illness, and frail elderly people. Primary Care Trusts will need to ensure that they are able to structure themselves so that the needs of patients using these services are met appropriately.

77. Government policy envisages continued progress in the transition from institutional care to a comprehensive range of services provided either in patients' own homes or in homely settings in the community. The successful implementation of this transition depends in part on the creation of effective primary and community health services, and more effective working between health and other agencies, notably housing and social work. The Government have already announced a Local Care Partnership initiative to help find new ways of breaking down boundaries between health and social care, and plan to publish a discussion paper on the relationship between these services. Primary Care Trusts will have a key role in leading the implementation of these policies and can do so through their other responsibilities to develop extended teams of primary care professionals working in partnership.

78. The configuration of services within Primary Care Trusts must take into account natural groups which reflect local circumstances, in line with the Government's commitment to devolved decision-making. PCTs serving urban areas will be responsible for large patient populations requiring an extensive range of community and primary care services. Those covering rural areas scattered across several small centres of population may include elements of acute care provided within community hospital settings in addition to the primary and community services provided through general practice.

79. The new roles of the PCTs will be:

• to provide support to general practice in delivering integrated primary care services;
• to formulate primary care policy and to direct the future development of services within an agreed framework of organisational and financial accountability;
• to work in partnership with Health Boards, Acute Hospital Trusts and others to develop Health Improvement Programmes, to implement local health strategies, through Local Health Care Co-operatives, and to deliver their Trust Implementation Plan;
• to engage primary and secondary care clinicians in forming agreements on the design and delivery of clinical services reinforced through the allocation of Joint Investment Funds (paragraph 91);
• to stimulate improvements in quality and standards of clinical care;
• to address inequalities in health provision and support the development of local initiatives, which address local health needs; and
• to develop the role of community pharmacists, dentists and ophthalmic opticians in providing high quality care to patients as part of the primary care team.

80. PCTs will reduce the bureaucracy associated with fundholding and allow individual practices to concentrate on providing high quality primary care, freeing them from the distractions of managing an individual fund. It is envisaged that primary care clinicians will play a key role in directing and managing these new organisations, creating a strong sense of ownership within the general practice community. The internal organisation of the Trust will reflect the formation of Local Health Care Co-operatives. These will be voluntary organisation of GPs which will strengthen and support practices in delivering care to their local communities.

81. The objectives of Local Health Care Co-operatives will be to:

• provide services to their patients within an identified level of resources, including expenditure on prescribing;
• work with the support of public health medicine to develop plans which reflect the clinical priorities for the area, whilst taking into account specific health needs of the registered patient population covered by the Co-operative;
• support the development of population-wide approaches to health improvement and disease prevention which require lifestyle and behavioural change;
• improve the quality and standards of clinical care within practices and to support clinical and professional development through education, training, research and audit; and
• support the development of extended primary care teams which are formed around the practice structure, and promote the development of clinical expertise and the emergence of specialisms within primary care.

82. The funding of primary care under PCTs reflects the move away from the individual practice model towards a collective arrangement managed through the Local Health Care Co-operatives. Co-operatives will have the right to hold a budget for primary and community health services, if they wish. The extent of these budget-holding powers will be reviewed by the Government in the light of experience. The fundholding management allowance will be re-directed to support the work of the new Co-operatives, which will require access to specialist expertise providing a range of skills and support across the practices. These arrangements are designed to empower all GPs, working collectively, to ensure that they have flexibility to invest in services which optimise the health gain to their local communities.

Acute Hospital Trusts

83. Acute hospital services in Scotland face a number of pressures from rising demand, both for emergency and elective admissions. Acute hospitals in Scotland have managed to keep pace with these pressures by developing innovative approaches to care and by seeking and securing increases in productivity and efficiency. As a result the acute sector now treats record numbers of patients; those admitted from waiting lists are admitted sooner than in the past; and the overall efficiency of acute services has increased. This is a significant record of achievement by the NHS in Scotland.

84. At the same time the acute hospital sector faces a number of issues which are affecting the way in which care is organised and delivered. Medicine is becoming increasingly specialised. As technological developments create an ever expanding range of therapies, difficult issues emerge about the extent to which the specialist skills needed to utilise these therapies can be provided throughout Scotland. The development of care networks" is one of the ways in which these difficulties can be overcome, and has been the central feature of plans for cancer services which the NHS in Scotland has been developing and implementing. The objective in these plans is to make expertise available where it can provide the greatest benefit to those patients with specialised needs, and at the same time link cancer centres to services provided more locally, which meet the needs of the majority of patients. In this way the aim is to try and balance considerations of local access with the need to make the best use of scarce specialist skills. These trends to establish effective networks of clinical care in the acute sector are likely to intensify.

85. In addition to their main role in delivering patient care, acute hospitals in Scotland play a vital role in the education and training of health service staff, and in the pursuit of clinical and related research. Scotland has a long and internationally recognised reputation in these fields. The Government are committed to ensuring that this continues to be the case and wish to work closely with the universities and other interests to make certain that Scotland's proud tradition in education and research is maintained.

86. With these considerations in mind the Government have concluded that there are currently too many Acute Hospital Trusts in Scotland, which the internal market expected to compete amongst themselves. By reducing the number of separate organisations the Government believe the opportunity will be created for clinical networks to be strengthened, for more effective strategic planning to take place, and for greater efficiency to be secured through elimination of duplication and wasteful competition.

87. The Government intend that in most Health Board areas there should be one Acute Hospital Trust. For practical purposes, notably in Glasgow and Lothian, this may not be feasible. In consequence, the Government do not have a fixed view of the number of Acute Hospital Trusts which should emerge, but expect there to be significantly fewer than is currently the case. In developing proposals for the new configuration of Acute Hospital Trusts the following criteria should be applied:

• the ability to respond positively to change in clinical practice and technological development;
• improved opportunities for patient choice and access to the benefits of specialised services at a local level;
• adequate management competence and structures to ensure effective organisational development and high quality service delivery;
• increased ability to recruit and retain clinical and other staff, to offer enhanced education and training provision and to address the workforce challenges facing the NHS in Scotland;
• improved arrangements to ensure that patients receive the best possible co-ordinated care throughout any acute illness;
• improved ability to maximise the utilisation of scarce resources including capital assets and human resources; and
• reduced management cost overheads.

88. The longer-term future structure of acute hospital services in Scotland will also be influenced significantly by the outcome of the Acute Services Review which is expected to report in May 1998. In developing its proposals for Acute Hospital Trusts, the Government have been primarily concerned to create arrangements which will assist implementation of the conclusions of the Review, bearing in mind that the Review has been asked to identify planning principles to guide the development of acute services over the next 5 to 10 years.

89. It is the Government's intention that the new configuration of Acute Hospital Trusts should be identified and put in place as quickly as possible, consistent with the need for careful planning and appropriate consultation.

Collaboration between Trusts

90. The development of an integrated delivery system requires GPs and their extended primary care teams to work with secondary care clinicians to design clinical services around the needs of their patients. The main purpose of this dialogue is to evaluate and test, within a clinical framework, those elements of care which are best provided in hospital and which elements can be delivered through the primary care team.

91. In order to support these improvements, each Health Board will establish a Joint Investment Fund. The objective is to increase responsiveness without attendant bureaucracy. These Joint Investment Funds will allow changes in the clinical settings in which care is to be delivered and priorities for quality improvement to be agreed. The size of Joint Investment Funds will be for local determination by Health Boards and Trusts in the light of the Health Improvement Programme (see also paragraph 107).