primary care trusts: The influx of lay members gives primary care trusts a breadth of experience, expertise and influence.But could this opportunity be lost, ask Dr Rodger Thornham and Richard Nicholson

Published: 07/06/2002, Volume II2, No. 5808 Page 26 27

On 1 April, there were 1,200 new recruits to the NHS. These were the chairs and nonexecutive members of primary care trusts who will form PCT boards with frontline workers - GPs, nurses and allied health professionals - and PCT chief executives and finance directors.

Has the NHS the wit to use this influx with imagination and enthusiasm, or will it stifle their potential in a morass of regulation and performance management?

The bringing together of frontline staff and the new lay board members could create the chemistry for rapid and successful change. Frontline staff are well aware of the realities of the NHS, warts and all.

The new lay members bring experience and expertise from all walks of life, along with a desire to improve the service. They have been through a rigorous selection procedure and have been given a clear guide as to their role and responsibility. They are tasked with ensuring public probity in PCTs, ensuring they provide and commission healthcare effectively, involve and listen to their local population, and that they do this within the budget.

Our non-executive directors are asking the same questions that frontline staff have asked for years without effective answers. The difference is that they are in a position of power and responsibility and expect the NHS to answer their questions.

These questions have included: just why is the NHS like this? Why can't this or that be done? Why is there so much contrast between the political spin and reality? Where does the money go? How can we be responsible for balancing the budget when the funding is inadequate? What stops patients getting better care? Why do partnerships work or not work?

It has taken a year for our lay members to become proficient with NHS jargon and structures. It has taken our PCT considerable time to develop as an integrated organisation, aware of its role, strengths, weaknesses and internal and external drivers. There is a need to work out how the individuals in the new organisation function, what everyone's role is and what role the new people should have.

The new model of shared leadership in PCTs has real potential if all parties feel their contributions are valued. An NHS Alliance survey of PCT clinical chairs found fewer than one in five believed their role was not understood by the Department of Health.

1They found they were not always included on circulation lists and had to wait for the chief executive or PCT chair to pass on important information. It is to be hoped strategic health authorities recognise the important role of executive chairs and maximise opportunities for clinical leads to be involved in discussions across local health economies about strategy and delivery. There is some anecdotal evidence from different parts of the country that suggests executive chairs are not being invited to meetings along with lay chairs and chief executives, so the potential for strong clinical leadership is being squandered.

In our PCT, we try to make it 'four at the top' - that is, the chief executive, chair, executive chair plus the director of finance - and 'four throughout', with non-executive directors involved in our subcommittees and working groups. The nonexecutive directors are benefiting from working alongside clinicians and managers. The executive committee encourages non-executive directors to attend their meetings, which enables them to gain in-depth understanding of issues before they come to the board.We are all aware of the official lines of accountability, and understand about corporate responsibility, but these considerations should not inhibit constructive working relationships - especially between people who pool their ideas and experience as equals.

Non-executive directors learn to respect the clinicians and managers because they observe their skills and competencies being brought to bear in collective decision-making in this collegiate approach. It is to be hoped managers, who carry huge burdens in our relatively small organisation and have impressed the new non-executive members with their skills, appreciate influencing executive committee and board members at first hand, rather than waiting for their ideas to be evaluated at a later date without the opportunity for real dialogue. Another key player is the director of social services, who chairs our improving health and wellbeing sub-committee. This mixture makes room for lively debate and eventually consensus on the way forward.

If it is agreed that there is something potent in mixing clinical, lay and management input, it seems logical to create as many opportunities as possible for these elements to come together.

It should be even more powerful and creative when we add users, carers and volunteers into the melting pot. There is already a strong model locally in the way that users and carers are involved in decision making in mental health.We have accepted the principle that users, carers and volunteers should be invited to join our subcommittees and working groups.We are trying to integrate this with the ideas from the centre about patient and public involvement and expert patients.

The PCT development agenda must not be underestimated.While it is commendable that the NHS has now recognised this with organisations such as the National Primary and Care Trust Development group, we have had to do our own development work and have learnt some valuable lessons. It is crucial the PCT board, executive and managers share understanding and vision. They need to build this, along with understanding, trust and respect.None of these can be assumed as a right - all have to be earned. External developers can point the way, but the people in the organisation have to 'do' the development. This is especially important for the PCT chair, chief executive, executive committee chair and director of finance.

Those of us who were in the primary care group needed to move from our PCG roles into the new PCT world, and we needed to develop our own understanding of roles, develop trust and sort out responsibilities.We are very aware that we still have some way to go. It is clear we have conflicts between the 'must dos' of the PCT, the exponential agenda, our other non-PCT work and the lack of time. It feels as though we are becoming very good at justin-time management. The pace of change and development means we worry that things might be skimped or missed.We may have developed clear visions about long-term aims to improve patient care and the health of our local community, but the pressure to change quickly makes it feel as though the short-term, quick wins are seen by our masters as more important.

Clinical involvement in PCTs is crucial: without it there would be no possibility of accelerating change.

Clinical input into the board and executive committee means there is an involvement in decision-making processes that makes it more likely decisions are accepted by and workable for frontline staff.

It is crucial strategic health authorities recognise and foster the new relationships. SHAs need to foster innovation and change and not be stuck in the performance-management culture. The SHA has a potentially very exciting role in orchestrating and stimulating innovation and change. It does not need to be involved in the local minutiae of each structure, and will stifle innovation if it tries to be involved in detail. It seems to be a problem that the centre is insisting on the SHA being controlling. So PCTs must send a clear message to the centre that we need to have the space, time and resources to deliver. The involvement of frontline clinicians and lay people in PCTs is fragile and could easily be damaged by top-down performance management. It will also be damaged by cynicism, a lack of commitment to new ways of working and a lack of resources.

There is a growing feeling that the idea of 'earned autonomy' is potentially damaging, in that it restricts development and innovation to the areas defined from above, and has the perverse incentive of bringing extra resources and management to those organisations in the red-light area.What PCTs need is support and trust so the new relationships will monitor and control themselves. PCTs will struggle to avoid being bureaucratic mini health authorities and need a degree of freedom to be able to give their staff real morale-boosting power to make changes.

Only if we are serious about devolving decisionmaking to frontline staff will we be able to deliver what the government says it wants - a workforce-led local health service, responsive to patients' needs.

Years of underfunding means there is not enough money yet to provide PCTs with the freedom to make real changes. It appears the extra funding promised in the Budget will take some time to arrive.

Meanwhile, the NHS needs to nurture the potent mix of management, clinicians and lay people.Will the chance to use PCTs as agents for effective change be grasped, or will the NHS fudge it?

Dr Rodger Thornham is executive committee chair and Richard Nicholson is chair, North Tees primary care trust.


1NHS Alliance. National Survey of PCT Clinical Chairs.March 2002.

Key points

Involving clinicians, lay members and managers on the boards of primary care trusts has great potential for producing innovative services.

The involvement of clinicians means decisions are more likely to be acceptable to staff on the frontline.

It is important that strategic health authorities foster innovation and do not seek to become controlling of PCTs.

It is vital that a culture of performance management does not hamper PCTs' development.