The success and long-term future of personal medical services pilot schemes will depend increasingly on their capacity to cultivate effective relationships with other organisations in their local area.
They will need to demonstrate added value to other organisations, as well as to their patients and staff.
The national PMS evaluation study team at Birmingham University is investigating the nature and style of these relationships. Interviews with key people working in, and with,14 first-wave PMS pilots reveal that, nearly three years on, understanding of the freedoms and flexibilities set out in the NHS (Primary Care) Act is surprisingly poor at all levels in the system - the regional office, the health authority, community trusts, acute trusts and primary care groups. This has hindered several PMS pilots in their attempts to develop relationships with other organisations.
There is limited evidence of closer relationships between PMS provider organisations and other services within the NHS.
In many of the sites acute sector clinicians have been willing to change their style of working and to develop closer links with general practice, only to find their chief executives objecting to change because of fears of loss of income.
Despite these difficulties, one of the pilots is working closely with hospital consultants from a nearby trust to improve co-ordination between services. Hospital consultants attend a meeting at the practice every two months. Together with a GP and other members of the primary healthcare team, they review the care and treatment of between 30-40 patients in a morning.
In another pilot, a specialist rheumatology nurse attends the practice twice each month to conduct an outpatient clinic. In two other pilots continued service development on the boundary of primary and secondary care has reportedly led to a fall in the number of patients requiring outpatient hospital care.
Over the past year, relationships between district nurses and practice nurses have improved in all 14 of the case study sites. In many cases district nurses and practice nurses now meet regularly to plan and review their work together.
Changes in the pattern and delivery of services through greater integration are beginning to happen, though in some cases progress has been impeded by lack of or reluctant support from community trust managers.
Limited capacity In our first-year report we noted that capacity within HAs to support PMS pilots had become limited due to the PCG development agenda.
1 A year later this remains the case:
HAs continue to be focused on the PCG/primary care trust agenda, and in some health authorities, a large number of second-wave PMS pilot sites has meant that attention has been deflected away from first-wave sites.
In the HA, responsibility for PMS pilots tends to be 'locked in' to one individual. Frequently, these people used to work for the family health services authority and are familiar with the rules and regulations governing general practice - the red book.
Over the last 12 months, however, many of these people have 'gone out to the PCGs', and responsibility for PMS pilots has fallen to a senior manager, often in the finance department.
Where there is more than one individual involved, HA staff rarely get together to consider how developments in the pilot could be applied to other developments in the organisation. Generally, ownership within the HA is lacking. Many could not see how PMS pilots fitted in with the new agenda of PCGs and PCTs.
Generally, HAs see PMS pilots as peripheral rather than central to their work. Yet in advance of the establishment of PCTs, HAs could use their PMS provider organisations to explore different mechanisms for commissioning and performance management of primary care providers that would deliver improved services and health status to patients.
Performance management arrangements across the 14 HAs vary greatly. In some cases no year-end reviews have been conducted. In other cases, quite robust arrangements are in place. Pilot sites review their progress together with HA staff about every six months.
Two of the sites in this category are trying hard to move away from routine monitoring of red book activity towards a more meaningful system of performance management.
In two other sites meetings are held every three months and HA staff monitor progress against what is set out in the contract, this tends to be focused on GMS activity targets. Overall, most HAs are not actively managing this new relationship.
Simply co-existing Over the last 18 months, the government has allowed the two policy initiatives, PMS pilots and PCGs/PCTs, to develop as two separate strands.This has meant that at a local level many PMS pilots and PCGs are simply coexisting.
One PCG chief executive commented: 'We do not have a close-knit relationship - there is an acceptance we need to share things, but basically the PMS contract is with the HA and not the PCG'.
Two-thirds of the PMS pilots in our study have a GP on the PCG board. Some GPs keep quiet about their pilot, particularly when they have met opposition from other local GPs. Other PMS GPs actively promote their knowledge and experience of the scheme at PCG board meetings.
A few PMS pilots appear to compete with their PCG, as their aims and means of developing primary care are at odds. Three practice-based schemes with no GP on the PCG board could all be placed within this category. They are not keen to be controlled by the PCG and are using the fact that they hold a contract with the HA to promote a degree of independence.
Over the last six months, staff from many of the PMS pilots have met their PCG chair and chief executive to inform them about their plans for the third year.
A few PCG chairs and chief executives have been involved in the contract negotiations for year two, but most got involved only in relation to prescribing budgets.
Many PMS pilots that had held their prescribing budget in year one handed it over to the PCG in year two. In a few cases, PCG chairs or chief executives attend PMS contract review meetings. But for many, pressures on time have meant that contact with the PMS pilot is no different from contact with other practices in the PCG.
Interviews with PCG chairs and chief executives revealed that in some areas local practices fear loss of business to the PMS pilot practices as pilots develop their in-house services further.
A small number of PCG chairs and chief executives were concerned that pilot schemes might create greater inequity locally as they used their local contract to protect their in-house services built up under the GP fundholding scheme.
One PCG chief executive, however, had plans to use four of the PMS practices in the PCG to improve equity of access by opening up the specialist practice-based services to all GMS practices. He was quite happy to have a mixture of GMS and PMS practices in the PCG, yet recognised that these would possibly require a different style of management in the future.
The announcement of a third wave of PMS pilots to begin in April 2001, and the decision to allow first-wavers to continue for a further two years to 2003 suggests that the government is impressed by the contribution of this particular policy initiative to its modernising agenda in primary care.
At the same time, it continues to promote the progression of PCGs to PCT status.
Our research suggests that while there is real potential for greater synergy between these two central policy initiatives, several developments will be needed at local level.
A deeper understanding of the freedoms and flexibilities in the Primary Care Act on the part of all key players in local health economy is required. Better understanding of the difference between PCGs and PCTs, not least with regard to the role of PCTs in commissioning and performance managing PMS pilots, is also needed.
Without this, the potential of both PMS pilots and the new PCTs to create innovative and locally sensitive patterns of care will not be realised.
1 Walsh N, Allen L, Baines D, Barnes M.Taking Off: a first year report of the Personal Medical Services pilots in England. Health services management centre, Birmingham University, 1999.
Working with services outside the NHS
In year one, we identified a small number of pilot sites with plans to adopt a more community-oriented approach in their work.
They had intentions to work with local government departments and voluntary agencies to improve the health of the local population.
But in year two all of these sites have become 'internally' focused. The turbulent local 'policy environment' of PCG and PCT development, hospital service reconfiguration and local government reorganisation have hindered many of their plans.
Links between PMS pilots and social services are generally disappointing. In pilots where there have been developments, these have been focused around a client group such as older people or children.
Two of the pilots now have social workers located in or close to the practice, which has improved relations between staff.