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The latest guidance on PCGs has prompted fears of potential stumbling blocks ranging from insufficient pay for key group members to holes in the health inequality strategy, writes Mark Gould

With all the major building blocks for primary care groups now in place, thanks to the publication last week of 'autumn' guidance from the Department of Health, the potential stumbling blocks in the run-up to 1 April are now clear.

For Healthcare Financial Management Association vice-chair Barry Elliott, the big problem is still 'securing a sound financial base for next year, regardless of all that has been said about the comprehensive spending review'.

He says: 'If we don't get that right then a lot of other things will potentially flounder because they will be developed on shifting sands. It's not difficult, but it needs to be tightly managed to strict rules of engagement.'

The 31 January deadline for expressions of interest in primary care trust status is, he warns, 'the most ridiculous thing that I have heard'.

'We have to make sure that PCGs can walk before they can run. There is a huge developmental agenda around PCGs which will have to bed in and evolve before we even think about PCTs. That timetable is silly and dangerous.'

Jaki Meekings, immediate past chair of the HFMA, agrees that it is too early. 'You need to own the business intellectually before you can make decisions like that.' Ms Meekings wants to see guidance on information management and technology, practice-based budgets and standing-order payment instructions. She is also concerned that so much emphasis is being placed on risk management arrangements when most of the big financial burden is taken up by tertiary services.

Karen Bloor, senior policy analyst for the Institute of Health Services Management, believes the guidance is sketchy on reducing health inequalities. 'Addressing health inequalities is encouraged within PCGs but how is it going to be addressed between PCGs?' she asks. 'Sir Donald Acheson has called for a weighted capitation allocation of all non cash-limited budgets.

'To address inequalities, there would need to be a movement of GPs from the south-west to the north-east. I am not sure how that is going to happen.'

She says the guidance displays the 'usual confusion' between clinical and cost-effectiveness. And it is still heavily GP-biased. 'Governing arrangements institutionalise the dominance of doctors, who will be in the majority and chair PCG boards.

'Boards will not be quorate unless there is a GP majority. That doesn't seem to reflect the way that primary care is moving towards a multidisciplinary team approach.'

GPs say PCG chairs will be the first to complain that they are doing more work than they can be paid for. The DoH expects chairs to work between two and four sessions a week on a PCG board.

NHS Primary Care Group Alliance chair Michael Dixon expects lead PCG members to be working a lot harder than budgets allow for (see box).

'You are going to see chairs creating problems because they will realise that they are not getting a fair rate for the amount of work involved,' he predicts. 'They should have paid them by the session, with the emphasis that people will work more sessions so you will get more work out of them.'

GPs and managers are baffled that the government will be allowing former fundholding practices to retain accrued savings of up to£25,000 for four years.

Incentive schemes mean 'good' practices will also be able to control up to£45,000 of future savings each year. Dr Dixon believes allowing GPs to hold budgets, albeit small ones, 'has the potential for problems later'. He says: 'I don't know how, but it seems that health minister Alan Milburn has been got at by a fundamentalist fundholder splinter group.'

Mr Elliott says it is 'interesting to see the language of the market reappearing'. A practice's ability to hold on to cash is 'bound to raise internal tensions'.

NHS Confederation chief executive Stephen Thornton says: 'We would be concerned if practices were able to spend that money even if a primary care group is overspent overall. This could lead to incentives for health authorities to create fat contingency budgets.'

PCGs will also need to finalise arrangements for their name and corporate identity. The NHS Executive is stamping on expensive rebranding exercises by producing a 'primary care group NHS identity kit'. The guidance says: 'As a committee of the health authority, PCGs should not devote resources to developing new logos, but they should utilise the existing NHS logo and adopt a title which describes the community they serve.'

Similar guidance on the use of the NHS logo by HAs is being prepared for the new year by the Executive's communications unit, and PCGs wishing to produce letterheads and other material will get advice and practical support.

HFMA chair Eric Morton says: 'I suspect that most of the general public don't know anything about PCGs - equally I am sure that they don't know what a health authority is. The public identify with their GP and their local hospital.

'It is important that PCGs raise their profile, but I think we have to be careful about not going over the top - we have learned our lesson from some of the excesses when trusts were created.'

Despite the DoH guidance's language of partnership, equity and openness, the British Medical Association GP committee's guidance for GPs on PCG boards hints at potential power struggles.

'Health groups will be strongly encouraged by the NHS Executive to prepare for primary care trust status at the earliest opportunity,' it warns. 'As other players are encouraged to gain control, never before has it been so important for GPs to maintain maximum influence.'See Open Space, page 18.