19 September 2008
With Lord Darzi's review pushing for greater integration of health and social care, the appointment of a joint finance director for Kingston's council and primary care trust is being closely watched
Tracie Evans stands out from her peers. Not only is she strategic director of finance at the Royal Borough of Kingston upon Thames, but she is now also director of finance at Kingston NHS Primary Care Trust.
The joint appointment, initially only for six months, is thought to be unique. Other local authorities and PCTs have appointed joint directors of public health, and directors of adult social services have become chief executives of PCTs (often as a prelude to the merger of the PCT and social services into a care trust). However, this is believed to be the first time a council finance director has been given the same role in a PCT.
Across Britain, local authorities and the health service are being encouraged to work more closely than ever before. In England, this has taken the form of greater collaboration between PCTs and social services departments, formal partnership agreements and, in some cases, care trusts.
However, Kingston's move is being interpreted as a new departure, following the push towards integration given by Lord Darzi's Next Stage Review. Darzi envisages a range of collaborations across health and social care, as well as the wider determinants of health, such as housing and employment. He proposes new integrated care organisations to act as local umbrella bodies for these new partnerships, and pilots are due to begin towards the end of the current financial year.
In many parts of England, local authorities and PCTs will be considering whether to stick or twist on partnership working. It is clear the Department of Health wants the ICO pilots to test different combinations of partners and funding models. This will include vertical and horizontal integration.
In vertical integration, PCT services, such as district nurses, might link up with the local foundation trust for a range or services, or for particular groups of patients such as the elderly, or for particular disease types, such as stroke. Horizontal integration would involve partnerships between PCTs and social care, and possibly other public and voluntary sector bodies. ICOs could emerge from groups of GP practice-based commissioners and from the NHS social enterprises.
David Stout, NHS Confederation PCT network director, says ICOs could be like traditional NHS organisations, directly employing those who deliver care, or could subcontract the work to different organisations.
He says it is likely new funding systems outside the pooling arrangements will be needed for funds under the Health Act, which are generally used to finance joint health and social care projects. 'If you are going to commission an ICO you will want to ensure you are not setting up a monopoly provider. That might need a contract that is something more like the standard NHS contract.'
To many minds, Evans' joint appointment, together with the appointment of a joint director of public health and the close ties between the local authority and PCT generally, makes Kingston a frontrunner for an ICO pilot. However, Evans insists that 'all options' are being discussed and the structure Kingston chooses will determine how funding will flow. 'We will do whatever needs to be done to ensure good outcomes are delivered. The key thing is that the PCT and the borough are small and we have to take that into consideration when looking at the changes on the health side,' she says.
The funding mechanism will depend on the model chosen. More importantly, she believes both organisations must ensure the model they choose gives them sufficient capacity, or 'resilience', for the future.
'In order to deliver the outcomes the NHS and the Department for Communities and Local Government want, we need a corps of people. We don't necessarily have the capacity to be as flexible as some others, and one way of providing resilience is by collaborating,' she says.
The PCT faces several challenges, with the advent of the Department of Health's World Class Commissioning initiative and the move to divorce PCT provider arms from their commissioning function. 'All this restructuring of how health care is delivered will have an impact on how organisations can manage outcomes. Together with colleagues, I am looking at how we in Kingston are going to find solutions to that.'
Evans' appointment in July came about not only because of the close ties between the organisations, but also because the PCT needed some stability after five directors of finance in two years. The trust had recently been turned around financially after recording a £21m deficit in 2006/07. Evans acknowledges that the improved financial outlook has made her job easier. 'There's now money for investment. My main job is about bringing back trust that may have been lost of the last couple of years,' she says.
She adds: 'I prefer to think of it as a strategic approach rather than a purely financial one. When two sides are working in partnership they each have a view of how much priority to give to things. The joint post allows me to keep reminding people on both sides of the fence what partnership is. I wouldn't be able to do that if I didn't have a foot in both camps.'
Being director of finance and second in line to the chief executive in both organisations gives her the clout to ensure both bodies share the data they collect. 'I am hoping to gain a better understanding of the needs of our population by joining up the public health data and the local authority's demographic data. This has not been done before here.'
There are financial benefits, too. 'I can say what is the best way to fund a particular project, rather than having a long, drawn-out negotiating process between the council and the PCT. Is that working in partnership or not? It is certainly the most efficient way of delivering on the outcomes we require.'
For all its benefits, the joint appointment has its downside, mainly because of the complexity of running two diaries and carrying two BlackBerrys (public sector IT has yet to get to grips with partnership working).
However, Evans insists this can be overcome: 'My PAs at the council and at the PCT are doing a great job and are doing as much collaborating as anyone else,' she says.
Evans, who has been the council's strategic director of finance for the past two years, has not worked directly in the NHS before, though she gained NHS experience during her six years as a consultant for Arthur Andersen. She is well aware of the cultural and governance differences between the NHS and local government, though she points out that this should not be a problem as everyone wants the same thing – to deliver high quality, efficient care.
There are two quite different masters at government level and local government is a different environment to the NHS, she says. 'In local government we are used to quite a lot of flexibility to use our money to deliver outcomes and we can plan our finances over a number of years. The NHS has a much more controlled spending regime and there is little flexibility. That's a real difference for me to get my head around.'
Evans says other local authority treasurers are keeping a close eye on the progress of the Kingston experiment. The appointment is due to end in January. The organisations will monitor and review its success before deciding whether to make it permanent. However, Evans says that without structural change a joint appointment might not be the ideal solution.
'Finance directors are quite hard to find and you can't scrabble around looking for one when you are trying to achieve something. However, I think what I am doing is completely unsustainable. There are two full-time posts and two organisations, and while that structure remains I think it will be difficult in the long term.'
Darzi has opened the door to a new era of collaboration between the NHS and other parts of the public sector, and local authorities in particular. It is likely that many new models will appear, but Kingston could provide some pointers as to how these models could develop.
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