From paper to practice

and a failure to learn from the past?

The New NHS white paper has had an easy ride so far, no doubt helped by its easy if dubious rhetoric. Of particular interest are the government's proposals for primary care groups (PCGs).

The politics

The government faces a problem: how can it capitalise on the perceived success of fundholding and yet make it look different, and get away from the lack of fairness which has been the most damaging criticism of the scheme? And how can it pull together the other experiments - locality commissioning, multifunds and total purchasing projects - into one coherent proposal?

Keeping GPs sweet is clearly part of the aim, but the government has also had to acknowledge that community nurses do a great deal of primary care, even at times undertaking what GPs are contracted to do.

The continued promotion of the virtues of primary care - and the implied criticism of secondary care - is still part of the political culture, presumably because it endorses the government view that some of the pressures on the NHS have been overstated, especially by hospitals and their clinicians.

Producing something which looks new and 'modern' is the challenge. How far has the white paper succeeded? Primary care groups will be established across the country, usually covering populations of about 100,000. GPs and community nurses will be at the forefront of commissioning services for these given populations. They will enter into service agreements renegotiated about every three years. These agreements will be in line with guidelines and standards set by health authorities.

The internal structure of PCGs will vary. Ambitious PCGs can be reborn as primary care trusts, but the less committed will be content to act as advisers to the HA.

A significant change is proposed which will integrate primary care budgets, removing the present separate allocations to hospital and community health services, general medical services and prescribing. PCGs will start up in April 1999, replacing fundholding and other arrangements.

Practice issues

Cutting up the country into manageable populations has always raised problems. 'Natural communities' are not self-evident. Geographic characteristics do not necessarily match cultural patterns or transport arrangements.

Involving GPs and community nurses in commissioning is necessary to the success of the new arrangements. Fundholding has shown that there are many GPs who are interested, but equally there are many who are not and wish instead to spend their time in clinical work. This is fine if they are happy to accept the decisions of their managerial colleagues.

PCGs are a new level of management and this has bureaucratic consequences. Managers will be needed to help make PCGs effective. Considerable expertise and experience will be needed and the work will be much more than a small addition to the job of an existing practice manager. GPs and community nurses may be natural partners in the presence of the patient but elsewhere their relationship may be much less united. Other professions - physiotherapists, occupational therapists, speech therapists, dieticians, chiropodists - will also want to influence events, particularly given the reference to rehabilitation and recovery services (5.32). Their involvement is given short change in the proposals.

Involving the public in health issues is difficult. Mobilising pressure groups around a particular proposal is one thing, but getting informed public opinion on matters such as priorities is much more difficult. GPs have little experience beyond surgery-user patient groups.

PCG budgets are to be capped. Given their size, how will contingencies such as expensive or litigious patients be dealt with?

The critique

The first obvious point is that the purchaser-provider split remains fudged and in some ways worse than before. Originally, the concept that HAs purchased care and clinicians provided it was an easy one to understand. Then with fundholding and the other experiments - total purchasing, multifunds - purchasing passed down the line, with HAs remaining the commissioners.

Such a split seemed at times to be more in the use of the word than in practice. The new PCGs are to be commissioners and purchasers, but their constituents, the GPs and the community nurses, are also providers.

If it is assumed that some GPs can be commissioners one minute and providers the next, does this not just prove that the split is fundamentally unsound?1 Indeed, the HAs of the future, fewer and larger, are going to have even more difficulty keeping in touch, not only with their communities, but also with their providers on whom they may rely for expert knowledge.

The government's desire to reduce bureaucracy sits very uneasily with the white paper's proposals. PCGs are an extra level of management interposed between HAs and GPs whether or not they are fundholders. GPs and nurses will have to be nominated to serve and will have to forgo some clinical time to give justice to the PCG. But it will remain a part-time commitment which will need the support of full-time managers.

Such managers can presumably be found from redundant HA staff. But it is important that their managerial expertise is not downgraded, otherwise their ability to enter into balanced negotiations with their counterparts in trusts or at the HA will be compromised. They need proper training, and they need the ability to understand not only the skills of purchasing but also the bigger picture to ensure that PCGs do not just attempt to satisfy the immediate needs of their patients. They will also be required to guide HAs in their work towards improvement of their population's health.

The white paper fails to acknowledge the difficulties of organising health promotion staff, who it assumes will be part of the PCG. In fact, the most effective health promotion departments are still attached to HAs.

Effective organisations are those which can streamline the number of relationships they have. While this may lead to snide comments about command and control organisations - which in today's managerial culture are assumed automatically to be a bad thing, the complicated networks which are now part of the system are likely to become unmanageable.

The white paper attempts to have its cake and eat it regarding local autonomy. For all the assurances of bottom-up developmental approaches, the emphasis on performance management is even more focused than under the last government. No one can be in any doubt as to what happens to backsliders. Just look at section 6.20, which describes several ways of punishing the recalcitrant.

If trusts fail, HAs can bring in the regional office, which can then set up an investigation. The Commission for Health Improvement might be involved in this. PCGs can remove agreements and starve trust boards. What if PCGs themselves fail? Will the same pressure be brought to bear? Presumably so.

Here is an uneasy mix between encouragement and sanction, with the latter tending to dominate. This tension is never far from government. Local discretion is fine while it is compliant, but when it isn't, top-down pressure quickly emerges.

Accountability is compromised when an organisation is expected to be accountable to several other organisations. There is a danger of having to serve too many masters at the same time. HAs expect PCGs to commission services in line with policy. In turn, PCGs negotiate agreements with trusts and hold them accountable. But trusts are also apparently accountable to the regional office and HAs. This puts them in the invidious position of having to satisfy three organisations whose objectives cannot always be totally integrated.

Indeed, accountability remains a fundamental problem with all those public services which have been granted some autonomy. If services are not managed directly - the so-called monolithic model - they have to be regulated. The processes of regulation are bureaucratic and inflexible. Despite this, those being regulated do not necessarily improve standards, unless sanctions are used, and they in turn may reduce accessibility to essential services. Few HAs can be satisfied that standards are being maintained in the large number of independent nursing homes providing the bulk of nursing care of the elderly, but if they interfere too much they become oppressive. The provider apologising for shortcomings in no way ensures improvement (look at the railways).

More public involvement might be thought to ensure higher standards and the dependability of the white paper's title, but the lack of organisational clarity is a problem. Very few people outside the NHS could give a coherent account of the relative responsibilities of HAs, trusts, fundholders and community health councils. The white paper suggests that almost any NHS body should consult local people. This is naive and impractical. Consulting the public is a sophisticated and complicated exercise.

Any old survey is worse than useless

Lurking behind the white paper's proposal is the suspicion that this is the second step to a more fundamental alteration in the relationship of GPs to the NHS. It is emphasised a suspicious number of times that GPs' independent contractor status will remain. Existing legislation allows for salaried GPs, and there is much in these proposals which would make that a more likely, and maybe a more satisfactory, arrangement. If PCGs evolve into fully-fledged trusts it would be odd that one of the most significant clinical groups should not be employed by the trust. Consultant hospital doctors have not suffered unduly from being employees.

The proposals for PCGs, although apparently an innovative development, in fact compound some of the intrinsic problems facing the NHS since the 1990 changes: increasing organisational complexity, confusing lines of accountability, conflicting ideas of local discretion and central control, romantic allegiance to concepts such as primary care - all are likely to make the health service more difficult to manage than ever. Is there an alternative?

The development of a healthy nation must be a government priority, but the task is largely beyond the capacity of the NHS, which has scant control of the economy, of employment, housing or the environment. The NHS therefore remains largely concerned with its patients.

So how best can patients' interests be served? Patients are at the centre of the NHS, and the clinical staff surround them. It is the duty of managers to provide these staff with the wherewithal. But it's also the duty of managers to take advice to ensure what is being provided is appropriate. This advice comes from the experts and from two types of public, the informed and the uninformed. Organisations therefore need to build on this model which gives clear roles to the doers, the enablers and the commentators.

Such a simple concept is utterly obscured by the white paper's mixture of organisational naivety and political rhetoric, and government inability to learn from past experience.