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PCTs are dead. Long live the PCT cluster?

Here’s a quiz for you. What do the following numbers - 581, 331, 162, 62 - represent?

The answer is the number of accountable chief executives with statutory responsibility for the planning and commissioning of NHS services in 1999, 2002, 2006 and 2011 respectively. With further clustering of primary care trusts likely and the NHS commissioning board taking over from strategic health authorities in July next year, that number could dip to just below 50.

True, in some areas, nascent commissioning consortia are getting their hands dirty, but they will not be legally responsible for their decisions until, at least, April 2013.

Some of the clustered PCTs are gigantic organisations. Has any NHS commissioner ever had more spending power than the Greater Manchester cluster’s £4.7bn? Mike Burrows, that cluster’s chief executive, will be personally responsible for approximately 6 per cent of the NHS commissioning budget. A further 12 clusters have commissioning budgets of over £2bn.

The clustering of PCTs was a sensible response to the haemorrhaging of management capacity and the need to maintain a grip on the system as the demand for efficiency savings ramped up.

But there is a strong possibility that the clusters will be asked to take on a wider range of responsibilities for a longer period.

The listening exercise being undertaken into the government’s reforms is beginning to throw into contrast what is likely to change and what is not. In short, the basic architecture of the reforms – barring acts of Liberal Democrat self-immolation – will not alter. However, it is likely this new world will come into being slower than health secretary Andrew Lansley would wish and in more a graduated way.

NHS Future Forum chair Professor Steve Field places the emphasis on secondary legislation and, along with NHS chief executive Sir David Nicholson, the authorisation process for commissioning consortia. This is a recognition of (likely) reality, as Professor Field says it is changes “outside the bill” which will have the most influence on “how you would make things work”.

A very good example is the influence of hospital doctors and other clinicians over commissioning decisions. The prime minister has indicated this is an area in which he expects to see change. However, it is unlikely – and undesirable – that a legislative change would be made to insist that X number of clinicians, members of the public and so on should be represented on consortium boards. Professor Field is right to say that “tokenism hasn’t worked in the past [and] it won’t work in the future.”

It is also clear that GPs do not think it is a solution. HSJ’s unique analysis of consortium boards shows very few believe that this is the right way forward, with none of the 51 analysed offering a seat to a hospital doctor. They have, on the other hand, almost all recognised that management was an essential element of any board.

A more likely (and desirable) solution to involving other clinicians in commissioning is to make it a part of the authorisation regime that consortia involve the appropriate expertise when making decisions about services. Just as it would be sensible to require Monitor to make sure that the developing healthcare market made the best use of cooperation rather than writing into the bill, for example, that competition should never undermine providers.

But this, yes, evolutionary, approach takes time – and also requires careful oversight as well as someone to mind the knitting.

Which takes us back to the PCT clusters. Set up and staffed with one purpose and timeframe in mind – a rethink may be necessary to recognise both the length of time they (or something like them) will need to exist and, also, the power they will wield over that period.

Readers' comments (8)

  • The clustering of PCTs was a sensible response to the haemorrhaging of management capacity...

    Are you sure about this? I thought the clustering of the PCTs happened in anticipation of the haemorrhaging, not as a clever ruse to cope with reduced management capacity. It also implies something natural occurred - it was about as natural a haemorrhaging as that experienced by Trotsky with an icepick.

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  • Clustering was specifically designed to deal with reduced management capacity. Not sure I suggest that reduction in PCT management was 'natural', but it was certainly on the cards for a long time (ie before the election). Not that I agree with the scale or the pace of those reductions - I don't.

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  • It is not worthy of Alistair McLellan to talk of the possible "self-immolation" of Lib-Dem MPs. It is these very Lib-Dem MPs who hold the parliamentary trump card -- they can break the coalition; and with careful spinning can win the public's admiration for "saving" the NHS from the grubby hands of the privatising Tory iconoclasts. This would go a long way towards redeeming themselves in the public eye after their student fees self-immolation. It would be very sad for the NHS if they do not take this new opportunity that the third reading will eventually present.

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  • I knew I was being facetious about the "icepick" effect of the move from coterminous PCTs to clusters but that was how it felt at the time - something brutal was being inflicted and there didn't appear to be a great deal of thought going into the reversion to what are, effectively, nineties-style health authorities. Rationally, post-election something had to happen to PCTs due to the financial position of the country and of the NHS, with PCTs and managers as an easy target for savings. Given the time limits placed on clusters (subject to change post-"pause"), I wouldn't be so sure that the upheaval and impact on morale of those left in post will pay off.

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  • I do hope Alistair is not proposing a continuing future for PCT clusters and the expected sub regional infrastructure of the Commissioning Board ......for clarity, focus and efficiency, we need to get from the first to the second as quickly but as effectively as we can.

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  • Not proposing, but perhaps predicting. The real question is - how would they be different in role and effect? On one hand I hear that the Board will not have a sub-regional structure, but a series of fluid 'case by case' mgmt arrangements, on the other hand there is the continuing desire (some would say need) to keep 'control' of the system.

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  • Clustering PCTs makes whole heap of sense especially when the community provider has clustered and the PCTs buy from the same Acute and Mental health. What I don't understand is why it is so big when when there are less providers to purchase from?

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  • PCT clusters seem to be concentrating power at a level above the statutory board, ever more remote from patients.

    It seems strange to be setting up such a power base for the 'old guard' yet tasking it to create a new order within which the test of cluster's success will be their irrelevance, and the loss of jobs of their leaders.

    As for the 'secondary legislation' it is a good idea intellectually, but politically wont wash. Nobody (including many within the coalition) will trust that primary legislation problems will be voted in based on a commitment to fix them in secondary legislation later.

    Secondary care clinicians involvement? We could always try Networks and Clinical advisory groups, with commissioners required to consider their, and the public's views in making decisions. That way we'd get influence without a conflict of interest (turkey's voting for Christmas) on the commissioning body boards.

    Hang on, wait - that's the CURRENT system.

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