The implementation of a national network of primary care groups on 1 April 1999 was considered by many to be an ambitious, if not impossible, objective. PCGs were charged with improving health, developing primary and community health services, and commissioning secondary care services.
At the same time, PCGs have had to establish themselves as new organisations and decide on their particular pace of change in moving to primary care trust status.
One year on, the publication of a national evaluation of PCGs provides a timely opportunity to assess progress and identify key challenges for the future of new primary care organisations.
1The report is based on fieldwork carried out in 12 PCGs across England during July-August 1999:
Basildon Battersea Blackburn with Darwen Carlisle and District Central Croydon Central Southampton Dartford, Gravesham and Swanley Harrow East and Kingsbury Mid Devon North East Lincolnshire Nottingham City North and West Walsall South Although the PCGs were just four to five months old at the time of the research, those studied had all been GP commissioning pilots during1998-99 so had a head start at PCG working.
2Semi-structured face-to-face interviews were held with all PCG board members and health Gary Needle, chief executive Brighton and Hove PCG (the largest in England) Population: 255,000 Practices: 53 Budget:£115m 'Things have moved on a great deal in a positive sense.
We've built up a good relationship with the health authority and we've got over, to a large extent, the debate about who does what.
I'm particularly pleased with the progress we've made in terms of the clinical governance plan for primary care and also the achievements of our prescribing sub-group. We've managed to engage a wide range of GPs over difficult areas such as antibiotic prescribing.
Sharing good practice and sorting out a town-wide policy is quite an achievement given our number of practices.
The other area where we are making great strides is partnership arrangements with the local authority. We have a new board which brings together the two trusts, the PCG and the local authority, and that has responsibility for all the joint planning agendas with the voluntary sector and users and carers.
We've been pursuing the NHS agenda, but we've tried to focus on areas that have not been addressed before. There have been frustrations along the way born of an increasingly heavy agenda and raised expectations of what the organisation could deliver.
Everyone is pressuring us to get involved in a whole range of things but we are not resourced to do it yet. Our management costs are£2. 52 per capita (in some areas it's more like£8). We could do much more if we had more resources, but it was ever thus.
On the issue of trust status, we're aiming for 2002. We're not rushing because we're big and because there is no great track record here of GP practices working collaboratively.
We've had to do a lot of groundwork and also we wanted to pursue other goals, such as the partnership agenda with community services.
So we've put in new working arrangements with the local authority which later on may move us towards a very authority leads.
Focus group discussions were held separately with nurses and trust managers in each of the PCG constituencies, and a postal questionnaire was sent to all GPs in the 12 PCGs (producing a 60 per cent response rate).
Despite having a year's head start at PCG working, the groups in the study highlighted the development of their internal organisation as being a major focus and a key achievement, echoing previous research in this area. 3 The study revealed a diversity of arrangements for PCG management support, reflecting local needs and priorities. The three broad categories of support are summarised in the box above.
Type A infrastructures were typically associated with smaller PCGs (with populations ranging from 70,000125,000) while the extended structures (type B) tended to be found in larger groups (ranging from 110,000230,000).
These extended structures were made possible by a significant degree of devolution of resources and personnel from the local HA.
An example of a type B extended PCG structure is provided by the Basildon PCG (see figure, page 26).
Management support
PCGs highlighted the quality of the chief executive as a key factor in an organisation's progress. A chief executive with a background in senior NHS management was seen as being of particular value, as they 'knew their way around the system'.
Regarded by many as the focal point of the PCG board, the dynamic between PCG chairs and chief executives was also seen as crucial to the successful development of the group, as noted in other research.
4Groups identified a number of key weaknesses in their management support, which they saw as threatening future development. Two-thirds of the PCGs in the study reported that the level or quality of financial and information support provided by HAs was inadequate.
Similarly, progress in relation to the development of information management and technology was reported as 'poor' by most chief executives in the study. The establishment of an effective IT infrastructure, the training of clinical staff, and the collection and management of data for commissioning were identified as needing particular attention.
Over half of the groups felt that the level of their management allowance was insufficient. But by sharing support with neighbouring PCGs, using seconded staff from HAs and trusts, and/or bidding for NHS modernisation fund money, some PCGs had been able to augment resources for their management support functions.
Despite this, concerns were raised about individuals 'burning out', with PCG chairs and chief executives frequently working more than 60 hours a week.
Finally, although management arrangements were largely seen as satisfactory for PCG working, there was a consensus that a greater number of more senior and experienced managers will be required for the leadership and management of PCTs.
Developing the board
Working within a formal board structure was a new experience for most PCG members, but the groups have made significant progress in adapting to public sector corporate governance.
Social services, lay and HA non-executive board members are regarded as a valuable source of expertise in this respect. But there are some tensions on boards, with a tendency for GPs to dominate the agenda and conduct of meetings and a concern that the chair-chief executive combination may be unduly influential in making decisions.
The roles of individual board members are at various stages of development. While naturally concerned with their GP constituents, GP board members tended to see their role largely in terms of representing the interests of particular groups of GPs or individual practices .
This was a view supported by more than 80 per cent of the GPs responding to the postal survey who were not members of the board. Such findings suggest that establishing corporacy in PCGs is likely to be a significant challenge. Although the study found high levels of enthusiasm and commitment to PCG working from nurses who were board members, there were concerns about their actual levels of influence.
Due to the inward-looking focus and medically dominated agenda of PCGs during their first year, there is a strong sense that the roles of the non-clinician board members have yet to fully evolve.
Development work
Given the enormous organisational development agenda, it will be some time before PCGs are able to demonstrate significant tangible outcomes to their core functions.
Some service developments, chiefly related to health improvement and service provision at the primary secondary interface, were identified. The commissioning of secondary care is largely regarded as a future priority, to be addressed once PCGs are sufficiently robust. But seven PCGs were actively involved in the management of their main service agreements.
PCGs are taking their prescribing and clinical governance work very seriously. Strategies formerly employed in managing prescribing, when the groups were GP commissioning pilots, are now being applied to the implementation of other areas of clinical governance in primary care.
These include setting practice service standards, using incentives to achieve PCG primary care development objectives, and gathering and sharing data on a practitioner and practice basis.
Increasingly, PCGs are linking primary care and prescribing incentives to their wider health improvement objectives.
As part of clinical governance, PCGs are developing group-wide clinical and management standards in areas such as prescribing, practice service provision and health screening. These standards are being linked to practice specific action plans. Among issues for the future, it was felt that PCGs will need support when addressing problems with those not meeting standards and poor performance by clinicians.
Groups were concerned about the lack of dedicated resources to support the implementation of clinical governance in primary care.
The research suggests that in many cases there is a significant gap between the PCG board and its practices in relation to understanding and dealing with priorities.
In the wider health service, PCGs are consolidating their relationship with local trusts, with community trusts being particularly well-represented in PCG structures.
Partnership working between PCGs and social services departments is taking time to evolve and relationships with other local authority departments are at an embryonic stage.
PCGs are beginning to develop strategies for service user involvement, often working closely with community health councils. The development of links with existing community and voluntary groups representing service users has been the main approach.
Involving the public more directly is regarded as a significant challenge and an issue for the future. Local authorities' expertise in this area is seen as a considerable resource. Neighbouring PCGs have become influential partners, as management support functions are shared, joint strategies agreed, and collaborative commissioning arrangements put in place.
The PCG-HA relationship continues to be a crucial dynamic. In some cases the relationship is working well, in others there are considerable tensions, most frequently related to the provision of management support and the PCG's perception of the HA's unwillingness to 'let go'.
From PCG to PCT?
Two-thirds of the PCGs in the study had plans to move to PCT status, and most of these were working to a timescale of 2001 and beyond.
In the short term, most PCGs wished to focus on developing themselves and their core functions without the distraction of moving to PCT status.
Although some groups had established planning and review boards to examine the configuration and potential consequences of becoming a PCT, for others initial expressions of interest had been seen as a way of 'testing the water', and caution and uncertainty remained.
It was evident that some PCG constituents, notably nonboard GPs and nurses, had reservations about PCT status.
Only when these groups address the purpose and objectives of being a PCT will this next phase of development be appropriate for many PCGs.
Despite having 18 months operating as GP commissioning pilots and PCGs, the groups in the study felt they needed more time to bed down and deliver tangible changes to constituents before becoming PCTs.
The study has revealed a number of important messages for the future of PCGs and PCTs (see box, right).
The organisational development agenda is huge.
Establishing the PCG's infrastructure and engendering corporacy of the board have been, and will continue to be important and necessary preoccupations. PCGs will need to capitalise on the resource to be found in their lay board membership and ensure that non-medical colleagues are fully involved in all areas of PCG work. This will involve a broadening of the PCG agenda from a largely medical focus to examine health and healthcare in its wider context.
The most striking finding on the impact of PCGs is their willingness to take a holistic approach to service development. Primary care development, clinical governance and health improvement are being addressed within a single programme of PCG work.
But much remains to be done with regard to other core functions. The commissioning of services from trusts must now be a priority.
The consolidation of links with community trusts and the strengthening of strategic links with acute trusts will be crucial to this.
The establishment of strategic relationships with social services departments should now receive attention, with both partners identifying areas for joint working and service provision.
In terms of the transition to trust status, the perceived rapid pace of change within primary care is a central concern.
Most PCGs have just been getting into their stride, and many wish to consolidate the significant progress they have made so far and deliver service improvements before contemplating further organisational change.
Lend me your year: lessons from the pioneers Establishing the infrastructure will continue to be an important preoccupation . Weaknesses in the provision of financial information need to be addressed.
PCGs and health authorities need to work together to ensure that roles and responsibilities are agreed and reviewed on a regular basis.
Management support resources need to match duties.
Corporacy needs to be engendered both at board and locality level. PCGs will need to engage a larger proportion of their GP and nurse constituents in order to develop corporacy and provide legitimacy to PCG decision-making. Domination of PCG boards by GPs and medical issues needs to be kept in check.
If PCGs are to address the commissioning of secondary care services during their next phase of development, they will need to improve and consolidate links with trusts. Partnership working between PCGs and social services-local authority departments should now become a key focus.
PCGs need time to develop and deliver tangible service changes before moving to PCT status. More senior and experienced managers will be required for their leadership and management.
'Caroline Clifton, general manager Leicester Central PCG Population: 102,000 Practices: 18 Budget:£51m 'Because there are 10 PCGs in Leicestershire it makes it a particularly complex scenario. But between us we have a wide range of skills and knowledge so we've been able to work collectively and learn from each other, and we're more effective because of it.
But the number of players means there is greater potential for fragmentation, and the HA has to work hard to ensure coherence across the whole health community.
Perhaps that has led to a more cautious approach here than in other areas. It is a fine balance - on the one hand supporting us all, and on the other letting us go.
The greatest achievement has been pulling together the concept of the PCG as an entity. It's been about identifying core priorities. We've tried to maintain a very clear focus in the face of huge pressures from the centre, the HA and other partners. We've had to keep our eye on what's important for our residents.
Our PCG has a 60 per cent ethnic minority population and we are very focused on providing a culturally sensitive service.
On trust status, there is general agreement that 10 trusts would not be sustainable, so we are working with our partners trying to establish the best configuration for Leicester as a whole. That may or may not involve us becoming a PCT ourselves or part of a larger PCT. There are advantages to trust status, but it is not a prerequisite to success.
Where we feel frustrated is there's so much discussion about trust status that it's creating a perception of 'Why put a lot of effort into the PCG if you're going to change everything?'. We must maintain the momentum as a PCG, and I believe we can do that. We don't have to wait till we have trust status to achieve our goals, though having said that I think the future has to be PCTs.
In the meantime we still have to improve the interface with secondary care and build up a better dialogue rather than trying to achieve everything through commissioning. It's much more strategic and for that we need a new way of thinking 'Dr Chris Price, chief executive Norwich City PCG Population: 127,000 Practices: 18 Budget£80m 'Clinical governance is really taking off here and we have people active in the practices working on areas like risk management, which I thought might take a long time to get going. We've also had some success in commissioning mental health services in Norfolk, so there are already some solid achievements.
We feel we've made a reasonable start in terms of contributing to the health improvement plan. We're also beginning to forge links for public involvement, such as a health forum set up by the city council. We've done some good multi-agency work around the homeless, which is something that we didn't really tackle in Norwich before.
When we look at our primary care investment plan , it's both pleasing and daunting to see the sheer number of things we've been involved with.
But it has not all been rosy. This is proving a difficult financial year and we still haven't worked out all of the responsibilities of the HA and PCG, and how to pass them on.
Our relationship with the HA is pretty good. We're not at the end of the spectrum where the HA says: 'Here's loads of money and so you can do all the things you want. 'But neither are we at the end where we are starved of cash and help.
They are very supportive, though it's a big organisation and within it there are people who are less supportive and who are still coming to terms with the change of role.
We are part of a consortium with other PCGs, which has meant we can communicate and speak with one voice. But the conflict is that different parts of the county have different needs. We have a commissioning team which has a good collaborative feel and it's efficient. But that has to be balanced against the fact that the needs of individual PCGs tend to get subsumed by the needs of all. So I am not sure that model will persist.
On the issue of trust status, people see the benefits in terms of developing a cohesive organisation spanning the various sectors. But we're clear that it probably offers very little in terms of commissioning specialist services. That headache will remain.
We are going for PCT level-four status in April 2001.
Whether you're a PCG or a PCT, the big challenge will remain how much individuality we can we have. The agenda is getting bigger all the time.
Looking ahead five years I would like to see the PCT in Norfolk doing a lot of joint commissioning with social services, maybe with some pooled budgets. I think we will have completely integrated community health staff with practice teams. The board wants to look at the benefits of possibly bringing in things like midwifery and children's services and some currently hospital-based services such as dermatology and medicine for the elderly as well as elements of community psychiatric services. They have quite a far-reaching vision, and if we can pull all that off I think we have the potential to break down a lot of existing barriers.
'Gina Brocklehurst, chief executive West Cornwall PCG Population: 150,000 Practices: 36 Budget:£100m 'The pace is still very hectic, but everything's starting to make sense. At first the amount of work felt like confetti, but now I see it more as a mosaic. It's just putting it all together that's the problem.
One of our early achievements has been completing a review for elderly patients with psychiatric disorders, and there was a great deal of carer involvement, plus other interested groups. By involvement I mean genuine participation in terms of driving the review and shaping the outcome.
What we are trying to do is totally different from the way the health service has worked in the past, and that's not necessarily understood by everybody.
The capability to support this huge change is constrained by the sheer number of people involved - we have 106 GPs.
As for our relationship with the HA, we're managing an organisational transition but also a cultural transition, and that's creating some tensions.
But we're working on it. There are five PCGs and we collaborate very closely. We've all come a very long way in a very short time.
I think our greatest achievement has been building partnerships. I am particularly pleased at the way the primary care investment planning process has moved on.
It has opened up real dialogue with practices. We haven't made a decision on when to go for trust status yet. People's concerns can be exacerbated by changes in organisational boundaries, so we want to understand this before we move ahead.
Still, it's a hugely exciting time. Things are starting to take shape but I anticipate it will take some considerable time for us to create a joint vision.
There is a willingness across the board to work in a different way, which is both exciting and daunting. Getting it wrong is an anxiety, but if we can get it right it will really open up all sorts of opportunities. We've made a significant start, but I'm conscious we are a million miles away from achieving sustainability of process or outcome.
'Ruth Carter, chief executive North Barnet PCG Population: 144,000 Practices: 32 Budget:£45. 5m 'The greatest frustration has been around prescribing issues and expenditure, where much of it has been out of our control.
The major achievement has been getting the general public actively involved in some of our project work.
We are one of five pilot sites for a King's Fund initiative on caring for older people. I think involvement with carers, patients and users has been the part I've really loved.
The relationship with the HA is settling down. We know more about our roles and responsibilities now - it's been a learning curve for us all. We're starting to achieve less duplication and more co-ordination. The HA understands what we're about and we have an identity now.
We plan to apply for trust status probably for April 2001.
It's about integrating primary and community services in a more managed way, because at the moment there is not much of a framework for getting the two to meet and act in a co-ordinated way.
There are health visitors, district nurses and practice nurses with overlapping roles. Being under one organisation could result in a more co-ordinated force across primary care. Then if you bring in social workers we could really start to achieve something.
The public tell us their biggest frustration is being told to see lots of individual professionals who each deal with just one aspect of their care.
We have a close relationship with other PCGs and a good personal relationship at chief executive level, which should help take the sting out of things when we're both striving Ruth Carter: 'Involvement with carers, patients and users has been the part I've really loved. '
Meanwhile, the wider agenda is enormous. When you look at what's coming from the centre the timescales are scary. Things already feel hectic, but if we're going to see the enormous changes we want to within the next 10 years or so, then we actually need to be speeding up.
REFERENCES
1Smith J et al . Getting into Their Stride: interim report of a national evaluation of primary care group s.
Health services management centre, Birmingham University, 2000.
2 Regen E, Smith J, Shapiro J. First Off the Starting Block:
lessons from GP commissioning pilots for PCGs . Health services management centre, Birmingham University, 1999.
3 Audit Commiss ion. PCGs: an early view of primary care groups in England . 1999.
4 Robinson R, Exworthy M. Two at the Top: a study of working relationships between chairs and chief executives at health authorities, boards and trusts in the NHS . NHS Confederation/ NHS leadership programme/ Institute of Health Services Management, 1999.
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