Health service weakest link

31st March 2006 at 01:00
NHS reforms threaten to derail the children's agenda by leaving schools out of the picture. Phil Revell reports

Proposed changes in the way the National Health Service works with local communities have massive implications for schools and other children's services. Experts believe that years of progress towards integrated services could be lost unless the Department of Health rethinks its approach.

"There are significant risks in these proposals," said Paul Ennals, chief executive of the National Children's Bureau. "For the past four years we have been working to create joined-up services for children; anything that starts to dissipate that joined-up work is a threat."

Fiona Smith, adviser for Children and Young People at the Royal College of Nursing, said: "There's going to be a considerable period of disruption and a lot depends on how long that period is. The Every Child Matters agenda could be completely derailed."

The NHS reforms focus on primary care trusts; the local organisations that deliver health care in the community. PCTs play a vital role in children's health; employing school nurses, health education professionals, speech and language therapists, child and adolescent mental health workers, and health visitors.

Some of these professionals work in the local multi-agency teams that are at the centre of the ECM approach; others, such as school nurses and speech therapists, work directly with teachers.

The NHS plans involve the re-organisation of PCTs, with most reforming to serve bigger areas. Boundaries will be shared with local authorities where possible, with a consequent saving in management costs. PCTs would no longer deliver all the services in a community. Instead they would develop a commissioning role, with the actual services being delivered by a range of providers; from general practitioners to new health care companies.

Schools could bid to provide some services, either individually or in partnership with others.

"We are looking for all kinds of innovative commissioning of services,"

confirmed a Department of Health spokesperson.

When the reforms were announced last July there was consternation in the NHS, as health professionals saw their jobs being transferred to a plethora of as yet unknown organisations. There had been no consultation prior to the July announcement, and it took a Royal College of Nursing legal challenge before the Government agreed to consult at all.

Consultation has now taken place, but the implications for partnership working seem to have been lost in the process. Ministers have repeatedly said that schools are central to the Every Child Matters agenda, yet headteachers' organisations knew little about the PCT reforms. There is no explicit reference to the reforms on the Department for Education and Skills website.

Outside the NHS there has been anger and dismay about the way the reforms have been handled. In the West Midlands, Telford and the Wrekin is a pathfinder local authority for children's services. Yet, in February, chief executive Michael Frater wrote a scathing letter to his NHS counterparts, in which he complained that the reform proposals "seem designed for the internal convenience of the service rather than to achieve better outcomes for the public".

"The NHS changes appeared to be ... oblivious to the role which local government and other partners play in improving the health of communities,"

he wrote in his formal response to the proposals.

Others saw the go-it-alone nature of the reforms as symptomatic of the NHS approach to partnership working. Blackpool's Claremont primary school is a pioneer of extended services, with a children's centre attached to the school. Yet head Pat Wills had not been included in the local consultation.

"That didn't surprise me, " she said. "The NHS has always been the weak link in the children's agenda."

The Local Government Association shares that belief. "We have been making the case for some time that ... health services have not prioritised children to anything like the degree that we have in local government,"

said Alison King, chair of the LGA Children and Young People's Board.

Within the NHS professionals are worried that the reforms will create a period of disruption and confusion. Carolyn Taylor is a health visitor in Newcastle; she is also the national chair of the Community Practitioners and Health Visitors Association.

"We are just starting to get to grips with integrated working, but we are now going to be worried about who might employ us in the future," she said.

"Many PCTs are merging; in the North-east every single PCT is having to re-organise, which means that partnership working is being thrown into disarray."

Other worries focus on just who might step forward to deliver the new services. The fact that GP surgeries are the most likely candidates does not reassure the critics, who warn that GPs have little current involvement in children's services. One speech and language therapist said that less than 10 per cent of her referrals came via a local GP. Others asked how school-based health education work would be commissioned - when a typical class might have children from half a dozen different GP practices.

The main worries were, as ever, about funding. Some suspect that the change has more to do with saving money than delivering better services. Others are worried that new providers would "cherry pick" the best funded services, or that the Every Child Matters partner organisations, including schools, would be left to pick up the bill.

Some felt that the lack of clear NHS targets for children made children's services vulnerable.

"Children's issues do not feed into our star ratings (the NHS equivalent of an Ofsted grade)," said Fran Beck, director of services for children and young people at Telford's Primary Care Trust. "A PCT ought to be judged on whether it can deliver children's services."

Headteachers' organisations were concerned about the implications for schools.

"Unless they get this one right, properly thought through and with proper costings, it simply won't fly," said Mick Brookes, general secretary of the National Association of Head Teachers. "Heads support the principle of Every Child Matters, but they are very worried about the delivery. If the Government is serious about ECM then everything else needs to be put on hold until that is fully in place."

At the Department of Health Patricia Hewitt defended the reforms. "This is not change for change's sake. We aim to create stronger and more effective primary care trusts which can secure the best possible health and health care, for all patients, in every local area," she said.

But, at the NCB, Paul Ennals advises caution. "These reforms should be very carefully piloted before anything is implemented across the country," he said. "There are many who think that practice-based commissioning makes sense for the rest of the health population, but not for children's services."

More detail about the NHS reform process can be found

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