Published: 01/09/2005, Volume II5, No. 5971 Page 13

The dog days of July saw many in primary care trusts dreaming of holidays, imminent or planned.

Some of us were aware of high-level conversations about the relationship between providing and commissioning and the increasing importance of practice-based commissioning, but it took the delivery of Commissioning a Patientled NHS to shake many out of their reverie.

It is not the key issues that have made people gasp, but the timing of the publication of guidance and the order and speed of its implementation.

The key theme is the development of effective commissioning. Many of us who have been in PCTs for a while welcome this sea change.

When PCTs were set up in north west London, each had to support several financial recovery plans for the acute trusts.

The conversations that many of us held, either in contract negotiations or ultimately through arbitration, dealt with the principle that most money flowed to the hospital and the PCT could only negotiate the sum downwards to a limited extent. Any proposals to move money into alternative services were met with scepticism and in some cases derision.

Acute trusts were not averse to briefing the press about decisions that could alter their services.

Several of us were at the receiving end of press headlines as a result of active commissioning decisions to manage waiting lists and control demand.

Frankly the health economy only worked together to a very limited extent: it was a struggle between commissioners and providers, in which the acute providers held all the aces.

Three years later, many of the local acute trusts have bigger debts and now we are finally being permitted, yes permitted, to challenge the money flows to the acute sector. In some areas the introduction of foundation trusts and payment by results has truly altered the relationship between provider and commissioner.

Interestingly, success has not always been predicated on having welldeveloped practice-based commissioners, though most of us see this as a crucial step in developing the responsible handling of the NHS budget by practices.

PbC allows practices and community staff to be rewarded for questioning their use of NHS resources and developing new models of care.

So if the general principle of supporting active commissioning with a focus on the development of PbC is welcome, why does this guidance make me and others feel uneasy?

Most of us recognised the need for PCTs to evolve into bigger organisations with a different emphasis over the next 18 months and had already started some of the changes. It is the rapid prescriptive timetable for implementation, which seems to ignore a number of recognised key issues, that unless addressed properly will drag the system into chaos.

The development of communitybased services as an alternative to hospital care requires different quality measures. How can we offer patients choice if we cannot compare outcomes? In some areas, such as diabetes, some work has been done, but this is not so for all services. GPs acting both as provider and as patient advocates need information to give patients genuine, informed choice.

In a new system where commissioners can increase their own profits by providing services inhouse, the governance of the system needs to be carefully thought through.

In PCTs, the presence of nonexecutive directors and the statutory requirement to work with the community means that service changes are discussed publicly.

Practice-based commissioners believe the power of their structure is the flexibility to respond to patient needs quickly. Emerging needs can be met locally by adapting local services. But how does this flexibility fit with the notion of contestability?

When do new providers have a right to provide a service? Unplanned service changes in-year will increase the risks in the hospital service portfolio.

How will PbC be introduced alongside care trusts? In some areas the integration of community staff and social care staff has occurred.

The issue of practices having their own community staff will arise quickly and needs delicate handling if complex intermediate care services are not to be damaged.

The real noise in the system is the uncertainty about the future of provider services.

I am in the middle of a reorganisation - brilliant timing, eh? - which separates my provider and commissioning functions explicitly. At the beginning of the year, our practices took the decision to work together in groups to maximise the impact PbC could have, and in parallel we have restructured to support their work.

Each group has a clearly defined community services provision - both clinical and management, with practices and community services aligned. Movement of clinical services from the hospital into the community was focused around these groups. The commissioning directorate then supports each group in setting priorities, service development and performance management.

Critical to the development of cohesive commissioning will be the role PCTs play in contributing to commissioning decisions rather than just administering those made by others.

Obviously the changes we are undertaking are not considered sufficient and we now await the healthcare outside hospitals white paper and the rapid planning process in September to see what the final structure of our organisation will be.

The challenge, in this period of threat to many staff, will be to keep focused on the real agenda: to maintain the small but significant progress that has been made in making genuine changes to patient care within the community. .

Lise Llewellyn is chief executive of Brent primary care trust.