They were supposed to be the organisations which would bridge the gaps between primary and secondary care, and also between health and social care. Set up via the NHS Reform Act in 2004, Community Health Partnerships (CHPs) were seen as the solution to providing joined-up services, truly shaped around the needs of the communities they were set up to serve. Hopes – among the optimistic at least – were high.
Now, not even ten years on, the future of CHPs – at least in their current form – looks uncertain at best. A highly critical report, published today by Audit Scotland, paints a picture of hapless organisations, some of which are so dysfunctional that they cannot say how many people they employ, or even what their budget is.
This might not matter so much were it not that CHPs actually account for (or don’t, as the case may be) around £3.2 billion of NHS Scotland (and some social services) expenditure annually. To put it in context, that’s a pretty substantial slice of the total £13 billion health and social work services budgets.
So what are CHPs? It’s a question I’ve always found hard to answer, largely because the term means different things depending on where you are in Scotland. You can’t even be sure that there will be consistency within health board boundaries: NHS Lothian, for example, has three “traditional” CHPs, covering Edinburgh, East Lothian and Midlothian, while West Lothian has a Community Health and Care Partnership (CHCP) which manages a substantial range of council services as well as health services.
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They even vary enormously in size, as well as function, with Orkney’s serving 19,960 people while Edinburgh's covers 477,660. And it’s an ever-changing landscape: there were 30 when Audit Scotland started its research, now there are (probably) 36 – and that’s not even getting into the specific problems which have blighted local structures, such as the well-documented issues in Glasgow. Fundamentally, however, CHPs (and CHCPs) are expected to co-ordinate the planning and provision of a range of community health services for their area. This can include GP services, community dental services, community health services and other things such as hospital at home. CHCPs and Community Health and Social Care Partnerships (CHaSCPs) are integrated health and social care structures accountable both to the health board and relevant local council. Audit Scotland’s main criticism of the bodies as they stand appears to be around leadership – and that’s probably not entirely the fault of the managers who work within the structures. According to the report, CHPs were set up with a challenging agenda – but without the necessary authority to implement the significant changes required. This is a particular shame, because CHPs were actually made statutory bodies, in part, presumably, to give them some clout (unlike their predecessor bodies, local healthcare co-operatives – LHCCs). But this clearly hasn’t happened, or at least not everywhere. As well as weak leadership, the report castigates CHPs for their attempts to implement joint working within and between organisations. “Approaches to partnership working have been incremental and there is now a cluttered partnership landscape,” the report says. “A more systematic, joined-up approach to planning and resourcing is required to ensure that health and social care resources are used efficiently.” The report describes a depressing muddle, where health and social services are trying to run services without having much of an idea of what the other does – or of how much joint resource they have available. The report speaks of organisational barriers, differences in cultures, complex governance and accountability measures – in short, it’s a mess. Why should this matter? Well, apart from the large amount of public money at stake, there are political issues, too. The Scottish government has made it clear that it wants to see better joint working between health and social services; indeed, it wants to integrate them (we don’t yet have the detail of how that will work, although NHS Highland is some way down the path). CHPs should be the key bodies to make that happen, yet they’re not working. Ministers cannot say they haven’t been warned. The British Medical Association (BMA) has been banging on about CHPs for years, and not in a complimentary way. It’s a standing subject for debate at the annual conference of local medical committees (LMCs) and every year GPs criticise them (although the GPs who are clinical directors just as stoutly defend them – but are very much in the minority). I’ve just had a flick through my notes from the various LMC conferences and found that, in 2009, GPs called for CHPs to be scrapped because they were an unworkable concept with no sustainable future and had wasted an extraordinary amount of NHS money. Two years before, GPs “questioned the value” of CHPs and said there should be a more “meaningful” system for the provision of local healthcare. It’s hardly surprising then that the BMA was quick to say I told you so – and in quite strong language, too. “This is a highly critical report which confirms our experience of the management and performance of these organisations,” said Dean Marshall, chairman of the BMA’s Scottish GP Committee. “It is deeply disturbing that, with responsibility for such a significant sum of NHS funding and despite the many bureaucrats that work for these organisations, their financial management, strategy and governance is so poor. That a CHP cannot say how many staff it has working within its structure, or how much it has spent on administration costs, is beyond belief.” Of course part of the problem, as the Audit Scotland report points out, is that GPs are not engaged with CHPs – but Dr Marshall, for one, doesn’t blame his colleagues. He said GPs had turned their back on CHPs because they [the CHPs] were “bureaucratic monoliths caught up in their own internal processes” rather than influencing the planning, funding and development of local services to meet patient needs. And the nurses aren’t happy, either. The Royal College of Nursing Scotland’s director Theresa Fyffe endorses the report’s call for a fundamental review of CHPs at a national level, adding: “The confusing and cluttered landscape of health and social care provision raises questions about how patients can understand where or how services are delivered.” Specifically, she called for integration processes in Highland to slow down at the very least. “The concerns that nurses in Highland have raised with us are reflected in this report which says that plans there to integrate health and social care have serious risks in relation to the scale, complexity and timescale of the planned changes.” So where does that leave us? Very likely with the end of CHPs, at least in their current form. The probable death knell came late on Wednesday afternoon when the Scottish government issued its response to the report and Nicola Sturgeon said that CHPs would “have to change”. "Planning care for increasing numbers of older people is one of our biggest national challenges," the health minister said, "and health boards and councils need to work together far more closely. We want to see health and social care for adults delivered in an integrated way by NHS and council social work staff and CHPs will have to change to adapt to this." She said that proposals for integration of social care, which are still to be finalised, would determine how CHPs were developed. Importantly, however, CHPs were set up under the previous Labour-led administration. Although the SNP has been just as keen to promote partnership and joint working and all the other things that CHPs are supposed to embody, presumably they are less wedded to them as a concept than they would if they had been their own baby. Audit Scotland has mapped out a way forward in its report – although it reads as though they were scratching their heads at the apparent intractability of the problems. But there is some urgency about the issue. Elderly care is one of the biggest problems we face now and it’s only going to become more pressing. CHPs had the potential to be the answer, but for now it seems as though they’ve had their chips.Donate to us: support independent, intelligent, in-depth Scottish journalism from just 3p a day
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