Colin Scales, chief executive of the Bridgewater Community Healthcare NHS Foundation Trust, talks about the changing role he sees for community trusts that operate over large geographies, and why his organisation will not exist in its current form in two to three years’ time.
Bridgewater was licensed as a foundation trust on the week that the Five Year Forward View was published in 2014, which for the first time in policy terms set high expectations for the role of community healthcare in a national reform programme, focusing strongly on neighbourhood delivery and place-based integration. Serving 14 commissioners with different ideas across a large geography, our challenge was clear! The Long Term Plan and the advent of PCNs pushes the expectation of community health services further still.
For several years my board has been committed to the delivery of new models of care, and the overall move towards place-based population health described in the Long Term Plan. We welcome the strong focus on community services, on primary care, and the integration of a range of NHS and council services at neighbourhood level to better serve our citizens.
Alongside this, it’s encouraging that the NHSE/I regional team in the north west is not yet pushing organisational change as a necessary component of delivering the Long Term Plan. We strongly believe that the solutions lie at neighbourhood level, in getting frontline teams working collaboratively, in sharing local knowledge and skills and in building services around citizens. Given that in the past, the pace of reform has often been impeded by a focus on organisational sovereignty, we musn’t let that prevail, and with partners we are now working collectively and with maturity to deliver intregration and to find local solutions for local neighbourhoods.
Community services and partnerships
Community services are pivotal to the system working differently. Generally this should be delivered in a way that is co-terminus with place, and in our patch with several unitary local authorities. Personal relationships are key to progress being made. Covering a patch from Crewe to Oldham and to Preston with pretty much everywhere in between, our ability to sustain those relationships in each place is challenging.
In this kind of world, an organisation like ours with a very distributed workforce over arguably too large a geography, has needed to rethink both what we are and where we should operate. Our board is clear we should consolidate our geography (we are choosing to exit several contracts), safeguarding the services we provide ahead of the organisation, in order that we focus on realising the significant opportunities described in the Long Term Plan.
Our evolving relationships with PCNs are exciting. Again I’m strongly of the view that we and our partners must be organisationally blind in support of the discussions that are going on between GPs, community services clinicians and social care colleagues. This is where the effort needs to be. We initially built resilience into neighbourhood working by letting these new teams develop of their own accord and at their own speed, and now the Long Term Plan’s requirement for a framework and for pace can be confidently applied.
Like most, my trust has some long-standing relationships with GP colleagues and has always made it really clear from the outset that we are not interested in delivering GP services - and I think that this has helped. We’ve been clear that we’re interested in building links between professionals, in co-locating, sharing space, sharing the milk - just helping relationships grow. And as a trusted and established partner we’ve been able to share our expertise on organisational development and growth to help them develop the capacity to one day hold large contracts, and PCN leaders have been receptive to this approach.
Place-based health and care
My board has always been clear that in place-based health and care, organisations standing alone will not deliver the best outcomes. While integrated delivery isn’t synonymous with organisational change, we mustn’t be resistant to that if we can see that better outcomes would be brought. As we become smaller, we are building a strong partnership with a local acute trust that shares our core geography – Warrington and Halton Hospitals Trust – with local authorities and of course the local PCNs. Over time we hope this may develop into something more formal with one or more of these partners.
“I don’t expect Bridgewater to exist in its current guise in two to three years’ time,” sounds a really challenging message for our board, stakeholders and staff. But we have been engaging with our staff on these matters for several years now, and building up a future vision with them. We anticipate that by 2021, along with others we will have helped, the PCNs that we work with will have built some organisational capacity and that we’ll be able to help them step forward.
One concern I do have, and I’m not sure we’ve covered it yet as a system, is how we not only retain but develop the leadership and clinical expertise that exists in community trusts like ours. We are one of the largest employers of school nurses, district nurses and health visitors, and resilience in these professions is much stronger than in other more specialist services where each place may only employ four, five or six staff. Our size and geographical spread has helped us network such services, building resilience across multiple teams. With the necessary focus on neighbourhood and place we need to make sure we’re not undoing this and recreating small fragile teams of highly specialist staff who through losing these networks, also lose the resilience, the clinical governance or the opportunity to simply share thinking with peers.
As we consolidate our geography and where we choose to exit places, I obviously want our legacy to be that we have developed staff and services of a very high calibre. Community services’ clinical leadership requirements are different. We need to find ways of networking isolated community specialists from different organisations, maybe over large geographies to provide resilience and to enable them to build governance and peer support. We may need to find a way of creating an organisational shell (or an ‘underarching structure’ as Thea Stein, chief executive at Leeds Community Trust, would call it) to ensure that community specialists benefit both from what it is in particular they need from scale - clinical leadership infrastructure, corporate governance expertise, recruitment and retention, rotation, clinical guidance and governance, research and peer support - and from neighbourhood.
What we are doing here as a foundation trust cuts completely across the focus of the last few years on growth, competition and tendering – but is the right thing to do. We recognise that if you focus on clinicians, their services and the people who use them, then a service strategy naturally follows that - ours has. Once we got to that point with our staff, many of the difficult decisions melted away and our staff can see the benefits to their practice and the opportunities for focused quality improvement as community-based practitioners become stitched into the fabric of their local communities.
Colin Scales, chief executive of the Bridgewater Community Healthcare NHS Foundation Trust. Follow him on Twitter @ColinScales1