PCTs have ambitions to achieve a wholesale shift in resources to primary care. But how will they succeed where health authorities have failed? The obstacles to change should not be underestimated, argues Nigel Edwards

The first primary care trusts, which become operational next week, are out to achieve a fundamental shift in resources from secondary to primary care. Some even hope to accomplish wholesale closure or reorganisation of hospital services. But health authorities have, for years, found it difficult to make such changes. Why should PCTs fare better?

In fact, PCTs will face many of the same barriers that have frustrated others before them. Unlike GP fundholders, they will not be able to use their power at the margins; they will be fully responsible for most of the income of local providers.

The first obstacle to be overcome is persuading hospital staff to adopt new ways of working. But there is evidence that GPs in particular are likely to be effective in doing this. Innovative ideas for changing care system are already starting to appear, as they did in the best total purchasing pilots and GP commissioning groups.

Problems of scale Perhaps the greatest problem is that many of the schemes for transferring resources from secondary to primary care are not large enough to allow the fixed costs of hospitals to be stripped out.

The experience of relatively small hospital-at-home schemes for admission prevention or early discharge is a good illustration of this. Studies show that hospital-at-home is slightly cheaper than the equivalent hospital stay, and considerably cheaper than the total cost of hospital stay.

1But savings from the hospital cannot be realised as at least 80 per cent of the cost per day is associated with overheads and other costs that cannot be saved if the patient is transferred.

It is necessary to stop very large amounts of activity before a radiology room, anaesthetic team, or trust managers can be dispensed with. Savings from the cost of nursing are similarly problematic. Even if there are 10-12 fewer patients it is still necessary to have two to three nurses on a night shift to ensure that patients are safe.

All this reduces the savings available and means that the cost of the alternative needs to be the same, or less, than the marginal direct cost of providing the service, unless the scheme is of a sufficient scale to allow closure of an entire building to release capital charge or other overhead savings. And it is likely that empty beds will allow the admission of additional patients.

This problem is worse where the scheme involves shifting activity between trusts. Take the example of using surgery as an approach to leg ulcers. Using sub-fascial endoscopic perforator surgery rather than compression bandaging for venous ulcers can produce much better healing rates and much lower recurrence and comorbidity.

Promoting the status quo But the savings are made by the community nursing service in reduced need for nursing visits and clinic attendances and, as a result, are not cash-releasing. The costs are incurred by the vascular surgery department and amount to several hundred pounds per patient.

Even though the outcome is better, the average cost is lower and the approach more efficient, incentives in the system tend to promote the status quo.

Schemes that have a payback period of more than a year also present difficulties. Few health economies are sufficiently financially robust and on top of their most immediately pressing priorities to spare resources for investments that may reduce expenditure in the longer term.

Similar problems can inhibit innovations that improve quality but increase the direct costs to the NHS, even if they are more cost-effective in the longer term - for example, new drug therapies.

GPs and strategic change Perhaps the boldest claim made by people who see themselves as being at the cutting edge of the PCT movement is that primary care commissioning will be able to accomplish strategic change in secondary care more easily than HAs. It is argued that GPs are closer to patients and more likely to be trusted. But there are unanswered questions about this.

Will GPs give the PCT sufficient legitimacy if it is attempting a change that is widely opposed? Will the public still trust GPs when they start to be seen as advocates of major change, particularly when they have become, as guidance on PCT corporate governance clearly states, NHS managers?

The answers to these questions are far from clear. PCTs may well have some advantages in arguing for strategic change, but it would be easy to overestimate these. The HA will still retain responsibility for leading these processes, and along with the great advantages of GP and primary care team involvement come some significant problems. The most dangerous could be Balkanisation.

Health economies cover areas with more than one acute hospital, but many PCGs send most of their patients to a single acute trust. Where proposals to rationalise hospital services are made, this means that one or more PCGs stand to bear the brunt of the changes and will have a real incentive to block change unless the process is carefully managed.

Shortage of capital, bridging finance and the restrictions imposed by royal college guidance will also continue to be obstacles to change.

Conclusions There are inherent difficulties in creating change in a highly complex system, with few resources to spare for new ideas. This means that PCTs are likely to experience the same problems as HAs.

Their smaller size may make this worse as they will lack leverage, but they will have other advantages. If PCGs and PCTs do want to shift the balance between primary and secondary care, they will need to act in a way that takes account of problems in the system (see panel, left).

And they will have to make full use of GPHow PCGs and PCT s can shift the balance Rethink the way in which commissioning is approached.

Think big and make large changes.

Develop care management approaches that span primary and secondary care.

Work in federation with other PCGs and involve the HA.

Develop methods for pump-priming innovations with longer pay-backs.

Devise methods for ensuring compliance by GPs and service providers.

Primary care trusts that want to shift resources from hospitals will face many of the barriers that have frustrated others before them.

Part of the difficulty lies in hospitals' fixed overhead costs, which cannot be saved if patients are transferred.

Incentives in the system tend towards preserving the status quo.

PCTs will have to make full use of the relationship between GPs and consultants to effect change.

Resourceful thinking: pointing in the right direction

One of the lessons of total purchasing pilots is that shifting resources seems to be associated with the ability to point management resources at the problem - either a lay manager or a GP with management sessions.

spending on management in even the best-resourced PCT will not allow more than a selective approach to schemes for a major shift of resources.

And it is not just PCGs and PCTs that are under-resourced in terms of management. Most trusts and HAs are tightly constrained and already have a very wide range of government targets to meet before local priorities can be addressed. Some areas of healthcare delivery are hardly managed at all, including some of those where PCGs and PCTs will want to see the greatest change. For example, the public sector productivity panel recently found an absence of management in outpatient services.

The poor quality of the data and the absence of methods to ensure compliance compound these difficulties. It is not just the compliance of the hospital sector with the wishes of the PCG or PCT that is the problem. Many schemes will require the compliance of lots of self-employed contractors, but without the incentives to produce changes that were found in fundholding.

Nigel Edwards is policy director of the NHS Confederation.