When Scottish health minister Malcolm Chisholm is asked why there are no foundation hospitals north of the border, he has a swift response. "I tell them we have CHPs," he says. "We have our own reform agenda, of which CHPs are one of the most exciting parts."
Not perhaps, the type of "chips" for which Scotland is best known, CHP stands for community health partnership. Provided the NHS Reform (Scotland) Bill - which is currently before the Scottish parliament - is passed, these new statutory bodies will become one of the most important parts of the health service.
Despite the minister's choice of comparison, which he quoted last month when giving evidence to the parliament's health and community care committee, CHPs bear precious little similarity to foundation hospitals. In fact, the only thing they really have in common is that they are the respective "big ideas" in the NHS England and Scotland.
Indeed, they are practically polar opposites. While foundation hospitals will recreate a market rewarding the elite, CHPs aim to get everyone working together, from GPs and pharmacists to local authorities.
The partnerships will build on, or evolve from, existing bodies known as local healthcare cooperatives (LHCC). Made up of voluntary groups of GP practices with input from others working in primary care, LHCCs make decisions on how to best meet the needs of their local communities. But while the cooperatives are non- statutory, relying on the largesse of their local health board, CHPs will have the right to funding.
Even their supporters accept that LHCCs have grown up patchily, with the best making huge strides for their local communities, while the worst have struggled to do anything at all. In contrast, CHPs will have devolved budgets and will be expected to run a greater proportion of services. In return, they will have to work more closely with local authorities and demonstrate real patient involvement.
There is no doubting ministerial enthusiasm for CHPs, but not everyone is convinced they will cure the ills of NHS Scotland. Robin Balfour, a GP in Edinburgh, sat on the Scottish Executive working group charged with looking at possible successors to LHCCs. He is also deputy chairman of the British Medical Association's (BMA) Scottish general practitioners" committee and is involved in his local LHCC, North West Edinburgh.
"I think CHPs have potential, but I don't think a bad LHCC will transform into a good CHP," Balfour says, citing various challenges ahead. "There's mutual suspicion between health and social work - both fear their budgets will disappear.
"And there's also the question of how to keep clinicians on board. The good thing about LHCCs was that it was voluntary groups of GPs from different practices getting together. The priorities were worked out by clinicians. If CHPs are seen more as management structures, then the GPs won't go along. They'll send their practice managers."
That's not to say there is no enthusiasm for CHPs, even among GPs. Mustafa Kapasi is lead clinician in Inverclyde LHCC in the west of Scotland - and he is very excited.
"We are already communicating," Kapasi says. "The LHCC, local authority, acute hospital and primary care are sitting down and talking to each other. This is the one opportunity we've got to get it right. I feel the CHP is about people working together and I think in Inverclyde we've already started doing that. We're already multi-disciplinary and we're coterminous with the local authority. There's a risk that people work in their own silos, but CHPs have the potential to change that."
Kapasi's delight in CHPs, with their statutory status and the promise of devolved budgets, is particularly understandable given Inverclyde's history. Two years ago, GPs in the former Argyll and Clyde health board area, where Inverclyde falls, felt aggrieved at not receiving money pledged by the Scottish Executive - because managers wanted it for other things. Since then, the three trusts and health board in Argyll and Clyde have merged, following the departure of all four chief executives.
The new body, NHS Argyll and Clyde, still has Þnancial difÞculties, however, and Kapasi knows getting money will not be plain sailing. But he is optimistic - and why not? After all, even with limited resources, Inverclyde LHCC can already point to improvements.
"We've achieved a lot of things," says Kapasi, listing an LHCC-wide service for drug addicts, a programme for young offenders, a one-stop diabetic clinic and the clearing of a two-year waiting list for incontinence services. Inverclyde's LHCC, covering 99,000 patients and 17 practices, Þts the Scottish Executive's ideal criteria for a CHP. At the moment, there are about 80 LHCCs of varying sizes serving different parts of Scotland. That number is likely to fall to between 40 and 50 when CHPs get under way properly.
Discussions are continuing across the country over the form the new organisations will take and how to sort out boundaries, which are expected to match up more closely to local authority areas than at present.
Last month, for example, NHS Greater Glasgow announced the start of a consultation that will probably see 16 LHCCs evolve into eight or possibly nine CHPs, each serving populations of 90,000-plus. The health board hopes CHPs will start in April next year.
When he spoke to the health and community care committee, health minister Chisholm says detailed guidance would be issued on all aspects of CHPs as soon as possible. This is likely to be next month. In contrast with LHCCs, which grew up in an ad hoc way, CHPs will be deÞned structures and will have to have proper arrangements for clinical and Þnancial governance.
Warwick Shaw, chairman of the Association of LHCCs, is enthusiastic about the proposed arrangements, which he hopes will build on the best of what has already been achieved. He is also optimistic about keeping clinicians engaged in what will essentially become NHS management structures. "More governance will come into it, but clinicians like action," he says. "As long as they see that CHPs are still doing things, then they'll be involved."
Shaw, who is also general manager of Borders LHCC, can list achievements around the country - not least public health initiatives such as walking routes and innovative hypertension services.
While Balfour believes the key to getting GPs excited about CHPs would be to give them commissioning power - which they will not have - the Glasgow proposals show that they will have big responsibilities. LHCCs in the greater Glasgow area already run a huge number of services, from health visiting to speech and language and foot-care services.
CHPs will be expected to take on these services and add responsibility for others, including community-based health promotion and school nursing. The consultation will also look at how CHPs should work with other services on, for example, child health, mental health and learning disability.
Shaw, however, would like to see all CHPs reach the level of the highest-achieving LHCCs, then go further. For that, he believes it will be important to take the "cooperative" element and apply it across different services and sectors. "The most successful LHCCs have been multi-disciplinary focused, not GP organisations," he says.
Technically, of course, it's all up for grabs, as the enabling legislation is still going through parliament. But ministers, smitten with their big idea, will brook no turning back. Speaking to the health and community care committee, Chisholm laid it on the line.
"In contrast with England, our attempt to develop singe-system integrated working is the most distinctive feature of our health reform agenda," he says. "We want single systems in a decentralised context, which is where CHPs are key."
What does the bill mean?
If the NHS Reform (Scotland) Bill is passed, it will ensure further divergences between the health services north and south of the border.
Under the terms of the bill, all NHS trusts will be abolished. They will be replaced by 15 unified NHS boards running operating divisions. These may be similar to the trust organisations, but they will not be statutory bodies. Currently, most health board areas have a health board, and at least one acute trust and primary care trust.
Some NHS board areas, including Borders, Dumfries and Galloway and Argyll and Clyde, have already made the move ahead of legislation.
Community health partnerships are intended to be at the heart of the new agenda, which aims to foster cooperation and integration among primary and secondary care and other agencies, such as local authorities.
Devolution of powers to the Scottish parliament has brought other divergences between England and Scotland. In Scotland, for example, the state picks up costs of personal care as well as nursing for people needing long-term care.
For more on healthcare in Scotland: www.show.scot.nhs.uk
For more about devolved government in Scotland: www.scotland.gov.uk
