HA chief executives will be given tough powers to ensure PCGs keep in line

The guidance, to be issued next month, makes it clear that PCGs will have to draw up annual 'accountability agreements', which will be monitored by their HA.

PCG chairs will be personally accountable to the HA chief executive and the HA will have to 'approve' their appointment.

The move is likely to anger GPs but reassure health service managers concerned about concessions extracted from health minister Alan Milburn by the British Medical Association's GP negotiators last month.

A letter from Mr Milburn gave GPs the option to be in a majority on PCG boards and to hold the chair. But further checks on PCG board members set out in the guidance include a three-year limit on terms of office and new rules for electing GP representatives that should stop a small cabal taking charge.

'They cannot and should not be dominated by a small circle of individuals appointed to the governance arrangements or by one professional grouping,' says the guidance.

It also says that groups excluded from core PCG membership in Mr Milburn's letter may be co-opted onto boards, but without voting rights.

Nurses' organisations, the professions allied to medicine and other groups have been lobbying hard for greater representation since the letter was issued.

The health service circular, due to be issued in the week beginning 10 August, says HA chief executives will be held financially accountable for PCGs.

They may delegate many financial responsibilities to them but will remain the accountable officers 'responsible for ensuring the robustness of the financial management of PCGs and that the HA stays within its cash limit'.

Where schemes to delegate are developed, they must be explicit about responsibilities for financial stewardship and preserving financial control. Model standing financial instructions and standing orders will be issued in the autumn.

The guidance sets out eight key financial objectives, including ensuring fairness between PCGs, practices and patients, establishing risk management strategies, and guaranteeing 'at least the existing level of investment in primary care'.

Each PCG is expected to appoint a senior doctor or nurse at board level to take responsibility for clinical governance and for publishing an annual accountability report.

HAs will be able to extend the present brokerage system to bail out PCGs where 'exceptional pressures' cause an 'unavoidable' overspend.

Underspends will be retained by PCGs for use in the following financial year.

Intriguingly, the guidance also allows scope for 'incentives at practice level' to 'promote better use of resources or improved clinical performance'.

The guidance recognises the difficulties some HAs are facing in drawing up the configuration of local PCGs by giving them until the end of August - instead of July - to reach agreement.

But shadow boards must be in place by 31 October.

The guidance calls for shadow PCGs to identify and initiate a programme of action and report back to HAs by December.

The third tranche of guidance, covering advice and examples of good practice in developing PCGs, routes to primary care trusts, and steps to be taken by PCGs up to 1 April 1999, is promised in the autumn.

See Comment, page 15.