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Published: 21/11/2002, Volume II2, No. 5832 Page 12

Setting up clinical networks without the full involvement of primary care is surely a recipe for failure. Paul Stephenson reports

If tomorrow's NHS is supposed to be primary care-led, one might assume that clinical networks, providing joinedup services to health communities, would be rooted in primary care trusts.

However, the record so far has been that those in primary care have had to push to make sure they are involved.

Though PCTs say the situation is beginning to improve, tensions remain about the way in which the networks work.

Mid Devon PCT professional executive committee chair David Jenner says a cardiac network had initially been set up by South West Peninsula strategic health authority without full consultation with primary care.

But following representations to the SHA, the process to bring primary care into the fold has begun.

He says: 'The issue was that the cardiac-managed network had been set up with good intentions, to get going fast, but without consulting with PEC chairs as to appropriate representation of PCTs.

The SHA-wide steering group, which would drive resources into specialist commissioning-type areas, had not had any representation from primary care at all, whereas there was representation from secondary care and managerial care.'

He continued: 'There is a real danger that clinical networks will focus on secondary care and tertiary care at the expense of simple, cost-effective, evidence-based primary care interventions.

'The problem is that 99 per cent of the targets are in secondary care, but often modernisation can best be effected by looking at primary care and community solutions to some of the issues.'

NHS Alliance chair Dr Michael Dixon says the situation has improved: 'I think things have changed and SHAs understand the problems. Before, almost by default, primary care clinicians were being left out of the equation.

'There is a general realisation by a lot of [SHA] chief executives that they got it wrong. It is not that they wilfully left the primary care practitioners out; they just didn't notice they were not there.'

Dr Dixon says there is still an issue about who takes the decisions on funding and resources for a network, with PCTs having to agree recommendations made by networks: 'It seems to me we are creating rather a bureaucratic twostage process. You could make it a one-stage process in theory if you embed clinical networks in PCTs, if you had a lead PCT.'

South Directorate of Health and Social Care head of performance Maggie MacIsaac says there are problems of resources, which have been significant when networks have spent a lot of time identifying priorities and then find the money is not available.

However, she cautions against giving networks formal powers over spending decisions: 'I think it is particularly difficult to say to a PCT, 'You are responsible for the health of your population, but not for coronary heart disease, cancer etc'.'

Walthamstow, Leyton and Leytonstone PCT PEC chair Dr Ken Aswani agrees that specialist services have tended to dominate networks and says there are other ways of working: 'What the cardiac network is doing is concentrating on specialist areas.

'There is no doubt that in terms of better health for the patient and better value for money, we need to concentrate on primary and secondary care issues.

'Sector-wide networks are unhelpful in a number of ways.

Their role is only in specialist areas. They should devolve some areas to local PCTs.

'You have a sector-wide network and then a local network around one or two PCTs and a district general hospital.

'We have had a multi-agency group for diabetes that covers primary care and secondary care, but that is around a DGH. That is the sort of thing that should assist for a number of areas.'

North East London SHA director ofpublic health Dr Sheila Adam also shows some reluctance: 'Not everything needs to be a network.

We have quite a lot of services working together, but a much smaller number of networks.'

She says the initial lack of focus on primary care was not just about the new structures bedding down, but also a result of the priorities for the networks, such as the need for the cardiac networks to improve revascularisation services.

She believes these are now being refocused and primary care has become more involved.

However, she says networks are not a panacea and require a lot of managerial and specialist time:

'What I think we can't do is have too many networks.This requires really well-informed people who can spend time on a defined set of issues.'

And NHS Confederation policy director Nigel Edwards says: 'The real hazard of networks is they are organic, and the worst thing you could do is stick hierarchies on them.

'The way around [arguments about funding] is discussing the issues and getting the rules of engagement. The tempting solution is to turn them into NHS organisations. I think it could kill the networks.'