Published: 31/01/2002, Volume II2, No. 5790 Page 13 14
This weekend a group of 20 doctors, nurses, managers and academics from the NHS Alliance will meet in Oxford.
It should be a celebration - in less than two months' time, primary care trusts will take over the bulk of NHS commissioning and will run many community-based services and non-acute hospitals.
Frontline primary care staff - GPs and nurses - should have unprecedented influence in how services are delivered and developed.
But if the NHS Alliance's dream has been realised in principle, there are growing doubts about how it is being implemented on the ground. Rather than cracking open the champagne, NHS Alliance leaders will be writing a document - Vision in Practice - which will be launched in the House of Commons just days after the shift to PCTs takes place on 1 April.
'I am warning it could go wrong, ' says NHS Alliance chair Dr Michael Dixon, a Devon GP. 'I am absolutely sure that we can fix it, but there are some things that we need to get right that we have not got right.'
Top of the list is commissioning - not surprisingly, given the alliance's roots in the commissioning groups which emerged in the final years of fundholding.
National priorities, little spare cash and acute trusts that are reluctant to change are all obstructing PCTs as they try to change service delivery.
'We must make local commissioning effective, ' says Dr Dixon, who has decided to stand down as commissioning chair in his own PCT. 'This is the big win for the professionals.'
He argues that the thrust of the government's white paper and the alliance's own document, Restoring the Vision, toward primary care involvement in commissioning has been lost.
While there are few voices calling for a return to fundholding, one thing the internal market had which PCTs seem to be struggling to find is leverage - the ability to make things happen on the ground.
'In our own commissioning group we did once use a private provider in Bristol and once threatened to go to another NHS provider. When we did these things the local provider changed, ' he says.
So why is commissioning now such a problem? In part it is the proliferation of national targets which, however worthy, push other local priorities down the agenda: 'Trusts are only really interested in what are national priorities. . . That is totally undermined our role as commissioners.'
In part the issue is the need to find money to make changes, while still funding existing services. Introducing changes to how patients with potential heart problems are monitored took 18 months to bring to fruition in Dr Dixon's Mid-Devon PCT.
A delaying factor was finding the£11,000 needed to buy new equipment out of the£80m PCT budget - even though it had the potential to reduce substantially outpatient appointments and would offer patients reassurance and a quicker diagnosis.
Although more money has been pumped into the health service, it has been largely eaten up by things PCTs are powerless to alter - staff pay increases, spending on national priorities and prescribing increases. There is little left to pump-prime change.
And finally, there is the attitude of the trusts and their staff to change. Trusts can outflank PCTs by 'playing games' with the financial figures and use their greater access to financial information to gain the upper hand in negotiations. Arguments such as increased risk can be used to oppose changes, especially when they take services outside an acute hospital. And many changes are only happening if they have the local consultants' say-so, adds Dr Dixon. 'People have got their crash helmets on and can't look sideways, ' he says. 'Every time we look at how a service might be developed, the consultants come back and say we need another consultant.'
One solution would be a little bit more 'grit in the system' - a hint of competition which would make local commissioners feel empowered once more.
He also has serious concerns about the way in which the structure of PCTs is working out in practice - and in particular how the professionally led executive committees (PEC) relate to the main board of PCTs.
'We do have a problem as to whether professionals are in the driving seat of PCTs, ' he said, pointing to a survey carried out at the alliance's October conference, which showed that very few frontline staff felt they were in control.
Some PEC chairs do not feel they are given equal weight with the main board chair or the chief executive; the PCT chair and chief executive get all the departmental guidance, for example. Many PEC chairs were primary care group chairs and found their new role a downgrading - 'It is a bit like the ministerial car being withdrawn.'
The alliance believes that almost half the PEC chairs around the country are also having to act as medical director, which is symptomatic of the difficulties of getting GPs involved at lower levels. But he sees the contribution of GPs and nurses as vital to PCTs: 'If the professionals do not feel on board, we have lost our way.'
One of Dr Dixon's concerns is that PCT managers will be so heavily performance-managed by strategic health authorities that they will resort to 'playing safe' in terms of structure and operation.
'The safest way to play in terms of risk management is the acute trust mode - hierarchical.
'There is a great danger they will be run as sinecures responsible to the SHA, responsible to the DoH.
That would mean they are HAs all over again. We are in danger of reinventing bureaucratic, hierarchical organisations.'
PCTs have turned out to be too large - often serving 300,000 or 400,000 people - leaving the management distant, not only from local communities, but from local professionals. Breaking down PCTs into localities can help to overcome this. But many newly formed PCTs will come to a grinding halt in April, he predicts.
'The great problem has been the speed of structural change - when you go into PCT mode things come to a halt for six months.
'We have bulldozed this through. . we have to make sure that PCTs do deliver. The DoH says that we have to go to PCTs because they have clout. That is true, but if we lose the people who are meant to deliver. . ' The Department of Health has, he believes, survived almost unscathed the permanent revolution which has engulfed the rest of the NHS. Dr Dixon believes it is now the DoH's turn to change its shape and challenges NHS chief executive Nigel Crisp and health secretary Alan Milburn to commission an independent report from the alliance on how the DoH could be reconfigured in order to be better co-ordinated and more supportive of frontline staff. 'The individuals who work at the DoH are excellent; it is the system that is rotten, ' he maintains. In particular, he would like there to be a direct 'passageway' to allow PCTs access to the heart of the department, rather than dealing with numerous different areas of the department and its agencies.
Dr Dixon insists he still very much supports the principles behind the government's policy - and he speaks warmly of the health secretary. 'I have great personal admiration for Alan Milburn, ' he says. 'I think he is one of the first health secretaries to understand the system inside out.He has a lot of balls.
These are all issues of implementation, not of policy.'
He argues that his critique is 'creative friction' which may help the government to understand what is happening on the ground and points out that it is taking place against a backdrop of years of underfunding.
But coming from someone who has been one of the main supporters of the government's plans for the NHS, his warning that things could go wrong must carry even more weight.