Siobhan Melia
Chief Executive
Sussex Community NHS Foundation Trust
Siobhan has held several clinical leadership roles in the NHS. Before becoming chief executive at Sussex Community NHS Foundation Trust in September 2016, Siobhan held senior management and board positions in another community health provider was the head of the telehealth division in Telefonica UK.
The long term plan is a call to action to deliver more joined up and integrated services, predominantly in conjunction with primary care. That’s absolutely the right thing to be doing – in Sussex we’ve been organising ourselves with a focus on integrated networks of community and primary care services focusing on populations of 30-50,000 for the last three or four years.
It feels as though we are at a really exciting juncture for community services and it feels quite motivating to know that services that make a real impact across the systems that they work in are receiving national focus and having some policy and investment decisions specifically targeted at them.
A need for realism and investment
The aspiration in the plan is around dissolving historic divides in order to join up care. The divides are not there because people have built them, they are from custom and practice. Although the plan represents a call for us to do things differently, to join up care and to be more responsive will require a degree of realism and a degree of investment.
The aspiration in the plan is around dissolving historic divides in order to join up care.
Chief executive, Sussex Community NHS Foundation Trust
Realism is needed around the timeframe to change some of the service models and investment is necessary to expand capacity and capability in out-of-hospital care models. We’ve faced growing demand with an ageing population. There will come a point where the capacity is saturated in a workforce that is already pushed to do more for less every year.
The targets in the long term plan don’t feel particularly realistic at the moment because of the absence of any clarity about investment. While the sector is focusing on 2019/20 as a transition and rebalancing year around the money, I would welcome some firmer commitments beyond this next year.
The plan talks about several big priority areas. There needs to be either a minimum investment standard in some of these community services, or at least, as alluded to in the plan, a clarified ringfence or an amount of money that is available for the next three years, targeted specifically at two to three headline areas of community service delivery. What needs to happen is first and foremost a commitment to investment in particular areas of community services, clarity over the timeframes and realism that some of this will take a good two-to-three years to sustain and embed because of the workforce challenges.
The targets in the long term plan don’t feel particularly realistic at the moment because of the absence of any clarity about investment.
Chief executive, Sussex Community NHS Foundation Trust
Tackling unwarranted variation
We’ve been left with huge degrees of variation based on historical commissioning patterns and, across the sector, service delivery models are very different. The poor standard of data systems and standardisation of data at national level is without doubt a risk. The lack of a national tariff has created gaps in the quality and the accessibility of data and business intelligence in the community sector.
There needs to be a better national narrative about data in the community sector. There’s a minimum dataset, and NHS Digital has done some work, but it still doesn’t seem clear to me that at national level we can articulate either the value of the community sector or the variance within it.
It would be good to have a small handful of national metrics that are counted in the same way and mean the same thing. We all know an A&E target is an A&E target, an 18-week pathway is an 18-week pathway. Similarly, there need to be a handful of high-profile standardised metrics that give us the ability to discuss, compare and improve facets of community services.
There needs to be a better national narrative about data in the community sector.
Chief executive, Sussex Community NHS Foundation Trust
Dealing with workforce challenges
The other headline risk is around workforce availability. There is a challenge around the supply of clinical staff into the NHS full stop, but the demographic profile in district nursing and community nursing errs much more towards retirement age, which is a well-documented challenge for us.
I don’t think that risk is insurmountable as long as we get sufficient headroom and a timeline to plan and put actions in train now. If we can promote the breadth and complexity of our services, that should start to attract new graduates into the community as their first or second place of work rather than what was traditionally seen as something you went into later in your career.
We’ve been able to create some rotational posts for new graduates so they get that breadth of experience quickly. As we’re a large organisation, it’s not that difficult for us to support someone with some early career rotations so they can get a feel for the breadth and complexity. Within our community-based services, we’ve been able to support nurses in experiencing older people’s care on a ward, urgent care at a minor injuries unit, home-based care through the community nursing team, and responsive services.
There is a challenge around the supply of clinical staff into the NHS full stop, but the demographic profile in district nursing and community nursing errs much more towards retirement age, which is a well-documented challenge for us.
Chief executive, Sussex Community NHS Foundation Trust
While the development of primary care networks is a massive opportunity for the community sector, it’s also a risk in that if implementation of the networks is focused on money going directly to GP practices to choose how to expand the workforce, that could cause further fragmentation and some movement of staff from the community sector towards primary care. I would hope we will be able to ensure that we build new integrated workforce models that are resilient and don’t encourage a drift of clinical staff one way or another.
Challenges and benefits of being a standalone community trust
Being a standalone community provider gives you an absolute focus on the types of governance and quality assurance that you need when a significant percentage of your day-to-day care model is delivered in patients’ own homes. That enables us to expand and care for patients with increased levels of complexity and acuity and deliver more care outside hospital. There’s a huge degree of clinical, psychological and emotional complexity involved in the care delivery that our teams are undertaking.
Increasingly, the vast majority of the partnership working is interfacing with primary care and the local authority, either with children’s social services or adult social care. We work quite extensively in partnership with the local authority at both ends of the age spectrum. We have absolute focus on that partnership agenda, whether it’s children’s safeguarding or joining-up care packages for older people through adult social care teams, staff in a standalone community trust have to work much more in partnership across organisational boundaries every day.
There are very few teams I can think of where who can undertake their clinical day job in isolation – that does bring something very unique around the culture, the understanding of the way of working and the focus on partnerships. As a standalone, all of the standard key performance metrics that we are delivering and that we are monitored on are focused on that community-based service model.
Increasingly, the vast majority of the partnership working is interfacing with primary care and the local authority, either with children’s social services or adult social care.
Chief executive Sussex Community NHS Foundation Trust
The reality on the ground for us is that primary care partnerships and health and social care partnerships coming together are what matters to join care up for the patients on our caseloads. We’ve got some good models of community and voluntary sector partnerships and a big volunteer workforce – joining-up care across organisational boundaries is absolutely what’s right for patients, but I don’t see any evidence that trusts that are integrated are more able to do that. Things like 'super-stranded' patients, delayed transfers of care and ambulance handovers, so many metrics would be vastly improved in those organisations if the reality on the ground was one that supported that theory and I just don’t see it.
A sector with diverse models of provision
Variation in the models of community provider is simply a fact of life – I’m not sure there is any value in trying to rectify something that happened a number of years ago in terms of standardisation of the delivery footprint. I would encourage the arm’s-length bodies to focus on what makes a difference to patients and not organisational structures. It does feel as though conversations over the last couple of years, and certainly the long term plan, are focused much more towards joining up care for patients in a variety of ways rather than organisational change. I’m not sure that moving the deckchairs around again in terms of organisational form is going to help us help patients or build more resilience in out-of-hospital services.
There’s quite a lot that could be done at national level that would improve all aspects of community services, irrespective of whether it’s provided by a social enterprise, a standalone or an integrated trust. I don’t necessarily think that the organisational infrastructure needs to get in the way of progress. If the national ambition in the plan can be translated into a blueprint for success and commissioned using a system approach, then the organisational type shouldn’t really get in the way.