Published: 24/04/2003, Volume II3, No. 5825 Page 10 11
Although primary care trusts were believed to herald a bright new future, their first steps have often been tentative. Alison Moore catches up with four of them as they celebrate their first birthday
A year ago, HSJ visited four embryonic primary care trusts as they struggled into existence and talked to chief executives and staff about their hopes and fears. One year on, have they achieved their goals and what challenges lie ahead?
Leeds North East PCT covers a diverse area, from inner city Chapeltown renowned as a centre for drug dealing, to Wetherby, a genteel suburb which looks towards Harrogate for its healthcare.
Understanding the difference between the localities covered by the PCT has been one achievement of the last year - and will stand the PCT in good stead as it prepares to tackle the area's health needs.
'If you take a very particular locality approach, then you deal with the issues that are there, ' says chief executive Thea Stein. And appearances can deceive: the elderly in Wetherby are often asset rich but cash poor and may have problems of frailty, for example.
'The differential investment you make for children and young people may be skewed towards the inner city area, but the differential investment towards older people may be skewed towards other areas, ' she says. 'We understand that now. That is what the first year was about.'
But she has no illusions about how tough the last 12 months have been - and how major service changes have had to take a backseat as the organisation is set up.
'It has been a very hard year and a challenging one - which I think all PCTs, and all new organisations, face, ' she says.
Much of the first year's work has been about setting up the organisation - even down to finding offices and appointing staff. Leeds did not have a particularly strong primary care group structure and there was an element of starting from scratch.
'In the first year, you have to do everything - sorting out the system for your board meetings, when you test the fire alarms and so on.
'It now feels like there is a really solid base to do the radical things a lot of us signed up to do.'
But there have been some early successes. Community nursing - highlighted as a problem when Ms Stein spoke to HSJ a year ago - has been stabilised for the first time in several years and money has been put into primary care.
'We have big plans. Our core agenda is redesigning secondary care and access, and developing the multidisciplinary primary care team. If we can get those things right, everything will follow.
'The next 18 months will be crucial. But I think we will do it.'
John Mangan, chief executive of Swale PCT in Kent, may head one ofthe country's smaller PCTs - but in relative terms it has been a year of pretty big achievements.
In April 2002, he was still working from offices outside the PCT's area, with key members of staff still to be appointed and with an embryonic professional executive committee.
A year on, the jobs have been filled - the director of public health started on 1 April 2003 - the PCT is in new offices and is working well. Perhaps more importantly, the PCT has managed to carry out some service improvements, including more nurse practitioners, improved primary care premises and extended opening hours for minor injuries clinics.
The PCT is working closely with Medway PCT, its larger neighbour which effectively shares an acute hospital with Swale - Medway Maritime Hospital. Some staff are shared between the PCTs and there is a joint modernisation board.
Ifthere are problems looming, they may be financial as the PCT is well below its capitation target and started life with an inherited deficit of£1.7m. It also has the challenge of providing services for a rapidly growing population.
'But we are confident that we will have a viable financial plan for the coming year and will deliver on key targets, ' says Mr Mangan.
Other priorities include GP recruitment, developing new surgeries and organisational development, including work with the PEC.
'For the PCT to deliver its full worth is going to take a little longer, ' says Mr Mangan. 'I do expect next year to be tough in terms of some of the new targets and service improvements we have to achieve, but I think we are better equipped.'
This time last year, Mr Mangan said the possibility of a merger with Medway seemed remote. A year on, he believes it is even more unlikely: the local health economy is more stable than some others in Kent, there is no external pressure to create bigger PCTs, and the PCT seems to be working well and achieving major targets.
It looks like a case of, if It is not broke why mend it?
South Birmingham PCT is one of the largest in the country - and as well as commissioning services for 374,000 people it provides rehabilitation, learning disability and community paediatric services and runs a dental hospital.
All of that adds up to a considerable management challenge, particularly in the first year of an organisation born out of two PCGs and most of a specialist community trust.
South Birmingham took a positive decision to leave staff working where they were without big internal reorganisations in an attempt to provide as much stability as possible for the first year.
'We expected more service continuity than some other areas and we got that, ' says Viv Tsesmelis, director of performance development. 'But the surprising thing was that we had not appreciated the change that Shifting the Balance of Power would make and the different feeling when you have a PEC.
'It has not been contentious but we underestimated the effect on decision making, for example, that a PEC would make.'
Another area which has proved challenging is performance managing the acute sector. The PCT has been monitoring crucial targets on a weekly basis, working closely with five trusts - all of which also have tertiary responsibilities. On top of this has come the capacity planning and local development plan agenda. 'It was huge for us, compared with a normal service and financial framework commissioning round, ' says Ms Tsesmelis. 'There were lots of positive things from it - we had a whole economy approach and had lots of joint meetings.
'But it has meant months of very long working days for the commissioning team. We were luckier than most in having the majority of posts filled by the time that started.'
As a large PCT, South Birmingham can also afford to provide services inhouse that smaller organisations would have to buy in so, for example, it has a strong risk management team.
However, getting the message across to all the people involved can be a challenge - the PCT operates out of 150 sites and staff question-and-answer sessions with the chief executive have to be repeated at several venues. It also has a far bigger role as a provider of community services than many PCTs, and it is sometimes necessary to separate this from the commissioning role. This happened during the local development plan process when inhouse proposals to develop services had to be as closely scrutinised as external ones.
The creation of the PCT was opposed by a majority of local GPs - though Ms Tsesmelis sees this as more indicative of opposition to yet another structural change than a vote of protest against the PCT itself.
Despite this, the PCT has made progress within primary care, with a strong clinical governance programme taken up by every practice and moving towards primary care access targets.
Setting up localities which did not correspond with old PCG boundaries has proved less successful and may now be revised.
Overall, Ms Tsesmelis sees the first year as a successful one: 'We may not have done all the organisational development that some people have, but the service development was more important to us.'
A year ago, Dr Keith Williams wanted to see public health issues higher up the agenda for PCTs than they were for health authorities.
Today, the public health director for Coventry PCT can feel quietly pleased with the way the last year has gone - and the increasing recognition that good health is about something more than good health services.
'Health improvement is on the agenda of the PEC as well as health services. Our chief executive and chair are as committed to health improvement as they are to health services improvement, ' he says.
'It has been a hectic year, but not in any way unpleasant. We are all quite happy if a little tired.'
His staff now number 50 - clinical governance for the PCT has come under his wing - and he has a public health specialist to head the work on health inequalities.
The PCT and Coventry city council now have a joint plan to reduce health inequalities, and joint working with both the council and the local strategic partnership has advanced. Grassroot services such as smoking cessation have been developed.
Dr Williams points out that his PCT is coterminous with the local authority and matches the area of the old HA - which may have made the last year slightly easier.
But the transition to PCT status was still time consuming - though the PCT has managed to develop services during that time.
'There has not been a hearts and minds job to do, ' he says.
Dr Williams - who is also registrar of the faculty of public health medicine - is well aware that not all PCTs have been able to put the resources and effort into public health that Coventry has.
Many colleagues have far smaller departments - even down to just one public health employee and a secretary - and some PCTs have struggled to recruit directors of public health. A handful of PCTs are still without public health directors, a year on.
Recruitment may remain difficult for some time: not enough potential directors are being trained, even allowing for the way the role is changing to encompass public health specialists without a medical qualification.
'PCTs will need to think about how they make jobs attractive because there are more jobs than people, ' he says.