One of the UK's smallest community trusts and its local GPs have set in motion a proposal to merge and create the UK's first primary care trust. Patrick Butler reports
Oddly enough, it comes as little surprise that the first formal bid to be one of New Labour's flagship primary care trusts should emanate from Andover, a sleepy Hampshire market town so out of tune with the zeitgeist that it returned a Tory MP at the last election.
The shiny new primary care trust concept was unveiled in The New NHS as part of Labour's bid to drive forward the community care agenda. As a 'free-standing body' of GPs and other community providers, it would both commission care for its local population and provide community services.
That was nothing new in Andover. Two years ago the town's fundholding GPs and community trust managers held a review of local service provision, after which they concluded that the best way forward would be to merge and become a primary care trust - or as they called it, a 'primary and community care agency'.
Back then, when the internal market was the orthodoxy, such an agency was merely an idea in search of a management structure. It took an anti- fundholding government to legitimise the ambitions of Andover's enthusiastic fundholders.
The town's five fundholding practices were not slow off the mark. Last December, just eight days after the white paper was published, they and Andover District Community Health Care trust met and agreed unanimously that they wished to establish a primary care trust in April 1999.
'One of the things that has helped us is the feeling that there's now a legitimate model that is being encouraged by the centre... and it is almost identical to the primary care agency we were developing three years ago,' says trust chief executive Robert Sloane.
He says fundholders and the trust have worked together to develop services over the past five years in a way that closely shadows the list of functions and requirements of primary care trusts set out in the white paper.
The New NHS calls for health improvement programmes outlining local health needs. The trust began developing an epidemiological mapping project, led by a district nurse, in 1995. It says this exercise has been 'influential in setting local priorities and local services'.
The white paper calls for better integration of primary and community services and closer working with social services. The trust points to its shared budget with social services for adult mental health services, and its decision last April to appoint both social services and local authority representatives to its board.
Joint working with GPs has led to a new day surgery unit carrying out procedures 'from endoscopy to cataract surgery'. There is a local, osteopath- led back-pain team. Locally provided services include ultrasound, mammography and podiatry.
'There are services now available to the town that would never have been available under the old scheme of things,' says Mike Marval, senior partner at St Mary's surgery, a second-wave fundholding practice in Andover.
But the development of an adult mental health team, which Mr Sloane counts as one of the trust's biggest successes, does not fit the white paper model, which holds that primary care trusts 'will not be expected to take responsibility for specialised mental health or learning disability services'.
The white paper says primary care trusts should be able to commission services, monitor service agreements with other trusts and develop quality assurance and clinical governance approaches. Mr Sloane lists several instances where this is in place.
The Andover trust also claims well-developed arrangements for public involvement. Marion Kerley from Winchester and Central Hampshire community health council has been a co-opted board member since 1993.
Local support for both the community trust and fundholding reflects public identification of the local NHS with Andover War Memorial Hospital, which, as a poor relation of more powerful NHS interests in nearby Winchester, is regarded as almost permanently under threat.
But the white paper gives primary care trusts the power to 'run community hospitals'. GPs have made it clear that they are committed to the survival of the War Memorial Hospital as an essential resource for developing services.
There are obstacles to overcome. North and Mid Hampshire health authority, which was meeting the trust and fundholders this week, has questions that the nascent primary care trust project board will have to answer.
Is the proposed trust, with its 50,000 population catchment area, big enough to fit into the white paper model of 100,000-strong localities? If not, can neighbouring GPs be attached to the project, and will they share the ambitions of their Andover colleagues?
'We need clarification at this stage. There's no doubt the trust and GPs are committed to working together, and a primary care trust would fit the bill exactly. But we need to know what is in it for patients and how it will work in practice,' says Dave Willett, HA head of contracting.
Clive Parr, general manager of the National Association of Fundholding Practices, suggests Andover might be a special case. 'It's fine if you have got a group of like-minded people who think like fundholders... in other parts of the country they will find it more difficult for practices to work together.'
Dr Marval accepts that there will be difficulties, despite the close working relationships of Andover's GPs. 'How do you get a large number of doctors to agree priorities when you are used to acting independently? Only time will tell.'
Andover, however, might say it is used to being ahead of its time, and Mr Sloane is already thinking about the future.
'I think the primary care trust is a stepping stone to a health maintenance organisation. I know that frightens people into thinking these things are an American implant, but that is the way it is driving.'