It’s not just commissioning – who will fill the PCT vacuum?
Margaret Angier had news for the readers of the Sheffield Telegraph. The chair of a local mental health group, Ms Angier wrote to the paper about the government’s health reforms.
The central passage of her letter read: “Browsing through the white paper one cannot help noticing the similarity between it and what we have already. It speaks of supporting GP consortia in their community decisions and creating a lean and expert organisation that draws from best practice. We have one already - our streamlined PCT.
“It states that GP consortia may wish to buy in support for their commissioning activities. No need; NHS Sheffield does that very effectively.”
She concludes: “What we have in Sheffield is fit for purpose.”
Ms Angier’s words tap into the growing feeling that the NHS is in danger of throwing the baby out with the bath water.
It is ironic that just as PCTs begin to contemplate their own mortality, an evidence base is starting to build about how effective some of them are. Last month we commented on the progress demonstrated by the world class commissioning scores.
This week research by consultancy Health Mandate exclusively carried by HSJ shows how successful PCTs have been in targeting and delivering on local health priorities. What is more, the PCTs with the best records did it without spending more money - a criticism levelled by some against those that topped the world class commissioning rankings.
As HSJ (and the British Medical Association) has said before, the NHS will lose the expertise and experience that lies behind these successes at its peril.
The importance of the proficiency - and capacity - of primary care management is underlined by research which sets out the range of PCT responsibilities beyond commissioning.
PCTs have taken on a bewildering range of responsibilities - more than 300 - from medicines management to contract negotiation and child protection. The management costs associated with these duties are the same as those associated with commissioning. Even after a cull of the more esoteric tasks there will still be many duties to allocate. Where will they go?
Loading many of them on to already nervous GPs does not commend itself as an approach. Taking all the responsibilities back into central control does not sit well with the government’s desire to devolve power. Equally, many of these duties will have little appeal to the private or third sectors.
It is hard to escape the conclusion that some kind of local NHS management function - apart from that supporting GP commissioning - will be necessary in the future.
We may, of course, find ourselves with sizeable regional outposts of the Department of Health chock full of freshly transferred PCT and strategic health authority staff.
But might a more acceptable and efficient solution be to ask local authorities to carry out many of the roles undertaken by PCTs? They already cover similar tasks in social care and other areas, meaning they have both the expertise and the infrastructure.
There are problems, of course. Most notably that local government and NHS cultures can often conflict: witness, for example, the concerns afflicting the creation of the new public health service.
However, they are not insurmountable and in places like Sheffield closer integration between health and councils could actually be going with the cultural flow.
As for the public health culture clash, HSJ has a suggestion. GPs are the flavour of the month - so why not appoint one as the new chief medical officer? At a stroke the public health service would be connected to the new power brokers in the NHS. Outgoing Royal College of GPs chair Steve Field would be a good fit.
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Readers' comments (10)
Anonymous | 9-Sep-2010 11:33 am
The problem policy makers are going to have with all of this is making it fit with the utterly absurd management cost reduction target we face. This was a knee-jerk political reaction that was instituted without any attempt to understand the drivers behind the rise in costs. We are now stuck with it, and I am sure the Labour Party will be watching the costs of the Commissioning Board, Consortia and whatever transfers across to local authorities to ensure the management cost ceiling is not breached.
Despite all of the clever minds in DH working on this, it seems inconceivable we are going to arrive arrive at a position of reasonably safe and stable provision in time for a May 2015 election in these circumstances.
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Anonymous | 9-Sep-2010 1:25 pm
Asking local authorities to take on many of these functions is the logical and potentially more cost effective solution. Not without challenges and risks but we cannot and should not be seeking to fund two separate organisational infrastructures for the same local populations. The cultural differences cannot be underestimated but the gains could be substantial in terms of management costs and more integrated working.
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Anonymous | 9-Sep-2010 1:45 pm
Local authorities are going to be wrestling with the managerial challenge and political backlash of the consequences of revenues decreasing by 25-35% over the next three years. So this is a fantastic time to start a discussion about everything from cracking the safeguarding whip over the local acute trust to ensuring a ready supply of prescription pads for all of the dentists in their patch - not!!
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Justin Dix | 9-Sep-2010 3:53 pm
Replicating my posting elsewhere: as soon as you commission a service you have responsibility for things like safety, accountability, use of taxpayers money, dissemination of information, providing a response to the public, compliance with the law ... Working in a corporate role I am staggered at what PCTs do and how hard our staff work to do it. These are things we grapple with every day, and I see colleagues juggling many important issues and generally doing them well, and often working very long hours. There is a genuine risk of losing skills and dedication if we get this wrong.
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Anonymous | 9-Sep-2010 11:57 pm
Nice to see HSJ moving away from lamenting the passing of PCTs. Whilst I agree with removing PCTs the noises about what's coming next are not encouraging. The coalition has made a rod for its own back but directing so many reforms. I would like to see their policy, and whatever DH turn it into, explored and scrutinised rather than guessed at, although the transfer of NHS functions to councils makes sense and many agree (which is why it won't happen perhaps). Lots of challenges with that but more scrutiny and accountability is overdue. So let's start hearing about which companies want to be a consortia, which GPs are leading the way, what the commissioning board has been doing for the past three months, what the governance arrangements will be, how the consortia will be funded, what changes will there be to tariff, who will oversee changes, what ridiculous market rules will there be, who will enforce the contract, how the CQC will start addressing safety, what changes will Monitor make if they ever get a real leader, and what senior managers in SHAs and PCTs are doing just now apart from playing musical chairs. The list is endless. So can we hear more in-depth news? Thanx.
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Anonymous | 10-Sep-2010 7:10 am
On what evidence are commentators justifying the transfer to local authorities. If you are arguing without facts you may as well say local authorities should transfer to PCTs
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Anonymous | 10-Sep-2010 8:45 am
These "reforms" were never about efficiency or streamlining - haw does replacing 152 PCTs with 500 commissioning consortia and 300 public health bodies fit with efficiency?
PCTs, contrary to propaganda, never failed. The problem was that just as they came to grips with one remit they were told to change and do something else. They are also convenient whipping boys when it comes to election time.
GP consortia will have to come to terms that they too will be pulled and pushed around on political whims just as PCTs were and Councils are.
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Anonymous | 13-Sep-2010 10:19 am
Handing these functions to local authorities will be counter productive. Local authorities are not sufficiently able to keep politics out of their decision making - what we have now is accountable without being unduly influenced by political decision making. Councils won't be capable of doing that. (See how some are lining themselves up to take over commissioning already. It won't be pretty).
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Anonymous | 14-Sep-2010 12:52 pm
I predict that GP Consortia will last no longer than 4 years. Which is about the amount of time it takes for the Government to realise that, because of the duplication of services, they are unaffordable.
When will politicians learn that the NHS is not a political football. It desperately needs stability so that it has a chance to improve and develop what it does. Change always leads to chaos and extra expense. Period.
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Gerry Toner | 15-Sep-2010 5:59 pm
It is highly likely that we will see, as some predict, a volte face on the consortia idea; hopefully very soon. It is equally likely that the subsequent 'solution' will be another 'fix' in the DH /NHS 'habit' for change processes.
At core there is an aspect in the mix of this narrative that is avoided and that is that the ultimate leadership of the DH is a politician. Over the past twenty years there have been numerous examples of PM's and Ministers coming up with ideas that are frankly 'insane' but must be obeyed at least 'tried' .
When all is said and done the politician has an objective that she or he sells to the electorate. This should be as far as the politican goes. The DH should, as the Lansley appears to be saying, stay our of operational management. NHS organisations should be held to account for results. All other matters of organisation etc should be left to management.
The legacy from this 'political management system' is a DH that acts a broker for policy and politics and this is in my view has lead to a statist and centrist DH leadership. The result of which is a not at all patient friendly style. The current DH is in denail about the need for change and is pandering to the Secretary of State.
SHA's / PCT's should at least recognise they need to adopt a service orientation and not a control orientation.
Some form of regional structure appears inevitable but the critical thing, as is implicit in the Secretary of States proposals, is to move to a 'service culture' throughout the helathcare sector and stop being a policy driven bureacracy. Up to now SHA/PCT often behave as though they are detached from the service delivery and that, in classic bureacratic style, thay can act outside the dynamics of patient transactions. There are many people in 'SHA / PCT land' who do not feel the immediacy of service delivery. SHA / PCT or whatever future organisation should be there to support service not design and control service as this is not frankly within their competence.
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