primary care trusts

Published: 12/09/2002, Volume II2, No. 5822 Page 22 23 24 25

How are primary care trusts, and their chief executives, facing up to their huge agenda? Jeremy Davies investigates

Writing in HSJ three years ago Richard Banyard, then chief executive of West Hull primary care group, said the traditional notion of the chief executive was almost 'a misnomer' in the context of PCGs.

1PCGs were 'an almost unique experiment in UK social policy', he said, and their chief executives needed to be strategists, diplomats, organisational developers, protectors, resourcers, facilitators and priority-setters.The customary chief executive functions - planning, controlling, budget management and human resources - were 'a necessary part'of the PCG chief executive's armoury, but 'at first, perhaps, of a lesser order', he said.

Three years on, Mr Banyard is a project director at what is now West Hull primary care trust, having failed to get the job of chief executive at the new organisation, something he does not regret now.'The move from PCG to PCT chief executive looks like just a name change, but in a multitude of ways It is a much more challenging task, 'he says.'The new chief executives have a huge job to do, and they're in an increasingly exposed position.'

Kieran Walshe, director of research at the Manchester centre for healthcare management, part of Manchester University, says the problem PCT chief executives currently face is meeting the simultaneous, and often conflicting, demands of national targets and local priorities - while at the same time establishing and consolidating their new organisational structures.

'People are still daunted by the size of the agenda.As new organisations they have such a huge list of things to do. It is hard to imagine they could deliver on even a substantial proportion of them, 'he says.

And all this must be done under threat of removal by the secretary of state, points out NHS Alliance chair Dr Michael Dixon.'PCTs are supposed to be all about the triumvirate of the chief executive, the chair and the chair of the professional executive committee (PEC) - but the only person who can really get sacked is the chief executive.'

In some cases, chief executives already seem to be wilting under the pressure.One chief executive of a PCT that went live in April 2001, who wished to remain anonymous, says he and many other PCT chief executives feel 'weighed down by the maelstrom of targets issued by the Department of Health'.

'The GPs here feel as if the PCT has now become a mini-health authority.We are supposed to have freedom, but It is really just freedom to do what We are told.We are doing lots of great things, but in truth we have an impossible set of tasks to deliver, especially given our inherited deficits.

'Sometimes I wonder if It is me being weak and incompetent, or whether It is similar for everyone.'

The next phase of the national tracker survey of 72 PCGs and PCTs, being carried out by the national primary care research and development centre at Manchester University - which is set to report in October on progress up to March 2002 - should help answer that question.The previous report, which focused on the period up to December 2000, suggests that this anonymous chief executive is probably not alone. It concluded that in their first two years, PCGs and PCTs had made substantial advances in developing and extending primary care provision, and in setting up processes to support quality improvement.But progress on commissioning, building partnerships and health improvement had been slower.'Maintaining continued progress on all fronts with limited managerial capacity will be extremely challenging in the year ahead, ' the study warned.'A growing list of priorities and targets is highlighting an increasing gap between expectations and capacity.'

This has undoubtedly been the case for the three chief executives we interviewed in depth for this article (see panels) - all of whom,16 months into their new posts, feel they have a long way to go to meet the expectations of the government, professionals and public.

Some of the more advanced PCTs feel more confident about the progress they are making towards improving health services for their local populations.

North Bradford PCT, for example, is one of 80 PCTs that have already participated in the NHS Executive's Primary Care Collaborative, led by National Primary Care Development Team head Dr John Oldham.Chief executive Dr Ian Rutter stresses that the experience has empowered clinicians across the district 'to innovate and believe they can really make a difference'.

The aim of the collaborative is to give PCT managers and clinicians alike transferable 'quality improvement skills', focused initially on three aspects of service delivery - access to primary care, management of patients with coronary heart disease and secondary-care demand management.

PCTs learn to commission services through analysis of patient care pathways, rather than seeing the commissioning process as 'a fiscal and bureaucratic procedure', says Dr Oldham.

The PCT sends large numbers of patients to GP specialists instead of hospital consultants for minor surgery and some ear, nose and throat, ophthalmology, cardiology and orthopaedic treatments.The PCT commissioned some 3,800 first outpatient and 1,400 follow-up outpatient appointments, as well as more than 400 inpatient procedures, from GP specialists in 2001-02.

'Our approach is to focus on improving the quality of patient outcome, and in so doing to use the money more effectively, ' says Dr Oldham.The plan is for all PCTs to have the chance to take part in the collaborative by the end of this year.

Dr Rutter says having an effective PEC focusing on care pathways in Bradford has enabled primary and secondary care professionals to work together.'If we look at non-acute chest pain, for example, rather than invest in GPs doing tests that take ten days to come back - during which time the condition could have worsened into an emergency - why not set up a rapidaccess clinic, whereby the specialists can deal with the serious cases without delay? Or in ophthalmology, why should an optometrist who's diagnosed a cataract have to refer the patient to a GP, who then refers on to a consultant? Why not send them direct?'

But it is not just through government-led initiatives that progress can be made - sometimes it arises from individual PCTs finding enough space to sit back and develop ad hoc solutions to their own particular problems.

North Dorset PCT found itself struggling to get to grips with 'at last count,478 targets', says Bill Boa, director of finance and performance.

The answer? A bespoke, intranet-based monitoring system to allow PCT staff and GPs to keep tabs on performance against targets as the weeks and months progress.A traffic-light prioritisation system allows the trust to focus on problem areas as they arise, and the database helps prevent duplication of effort when submitting information to the strategic health authority.

'By organising all our performance data in this way, I can tell you that currently we have red lights against just four targets.

That means everyone knows what they need to focus on right now, rather than feeling like We are always running round chasing our tails, 'Mr Boa explains.The targets not quite being met concern 13-week waits for outpatient appointments, reduction of under-18s pregnancy, immunisation rates, and proportion of new mothers breastfeeding.

'It is given us a bit of headroom, which then enables us to get on more quickly with tackling some of the difficulties we face here, 'says Mr Boa.

Reaching a position where it is possible to make innovations in IT and other areas feels like a particularly steep uphill struggle for the chief executives of PCTs which only moved to trust status in April 2002, says Birmingham health services management centre senior lecturer Dr Judith Smith.

She conducted a three-year evaluation of early PCGs as they made the transition to PCT status, and says evidence shows that the new organisations have little scope to create change in their first year: 'The first year is likely to be dominated by internal organisational and management development issues, 'she says.

'These, together with the wider range of responsibilities PCTs now have, are likely to reduce their ability to deliver in the short and medium term.'

But the way the government is going about performancemanaging PCTs takes little account of such pressures.For 200102, PCTs received national indicative performance ratings against a set of data designed to measure health improvement, access to quality services and GP service provision.The government balked at publishing these as 'star-ratings'as for acute trusts, but has made clear they will be introduced next year - using the 2001-02 figures as a baseline.

More detailed guidance on how the Commission for Health Improvement, which is to take over responsibility for next year's star-ratings, intends to rate PCTs, is expected later this autumn.

Unless it introduces significant refinements to the system, CHI will have a big job to do to convince clinicians, at least, of the ratings' robustness.

'The indicators could be far more inventive, and much more closely linked to the PCTs'daily business. It is important that the PCTs themselves are allowed to be fully involved in deciding how they're assessed, 'says Dr Dixon.

'One of the indicators is gonorrhoea, for example - a pretty rare infection.All it takes is a few extra cases in a year to make your rate of increase look enormous.How can a PCT be held responsible for that? And what's it supposed to tell us?'

The danger of the star-ratings, says King's Fund visiting fellow in primary care Richard Lewis, is that chief executives 'will inevitably start to focus on that particular set of indicators as being central to the PCT's goals'.

Zero-star acute trust chief executives have already been sacked for failing to turn their organisations around.Whether PCT chief executives could suffer the same fate remains to be seen.The DoH has denied rumours of a Modernisation Agency 'hit squad' to parachute into failing PCTs, but chief executives' pay - which DoH guidance says should be in a range from£78,625 to£107,500 - suggests a similar level of 'ownership'by the centre.

Dr Dixon understands the pressures chief executives are under: 'When it feels like your head's on the block, There is a big temptation to act as a clearing house for national edicts, rather than find that delicate balance between ministerial and local priorities.'But he warns that such an approach risks disengaging from the frontline professionals whose very involvement is central to PCTs'potential success.

'In the days of the internal market we had a commissioning group in mid-Devon.Of the 60-70 local GPs, around half would turn up to meetings.Now the PCT would be lucky to get 11 or 12 people coming along to meetings - and unlike in the old days, we have no-one directly sitting in on meetings with the acute trust. I am sure the connection can be built up again, but only if the doctors feel they're genuinely involved in something meaningful.'

And maintaining grass-roots links might prove particularly challenging if PCTs are tempted down the merger route, as Kieran Walshe suggests they might be.'There is a widespread sense that PCTs lack experience in commissioning, and There is a real concern that they might not be very good at it. In many places they're now buying care from huge acute trusts, so whereas in the past they might have exerted power by threatening to move away, now they're dealing with natural monopolies.More PCTs could start to think they need to be larger to be effective.'

But Judith Smith warns against such moves: 'Mergers rarely achieve what they were set up to do.The trick will be to work with neighbouring PCTs on issues where risk-sharing makes sense.Services should be commissioned at the appropriate level, whether That is very local or across a group of trusts.'

More importantly, says Dr Dixon, PCT chief executives need to avoid a 'safety in numbers'philosophy, and learn to take risks.'Of course, the government needs to know how PCTs are spending our money.But the whole point of the new arrangements is greater local control.PCTs will sometimes need to stand their ground and say 'stop telling us what to do and how to do it, and instead come and ask us what we need to do our job!'

'The strategic health authority might not like the way things are going, because they're not government policy.Being strong enough to ride that out is about the triumvirate working cohesively, and the chief executives being brave enough to put their jobs on the line.'

PCG chief executives might never have had to go there... but those at the head of PCTs are well on their way. l Carolyn Clifton, chief executive, Eastern Leicester primary care trust Three years ago I was chief executive of Leicester City Central primary care group, which merged with Leicester City East PCG to form Eastern Leicester primary care trust in April 2001. I became chief executive of the PCT a few weeks before we went live.

We look after a population of 182,000, covering an incredibly diverse inner-city catchment area.We are coterminous with the city's unitary authority.We have a large number of minority ethnic communities, including 30 different native languages, along with a range of asylum seekers and refugees from parts of the EU, and below-average numbers of GPs and community staff.

We are hard pressed.We finished recruiting to our director team in April 2002, so appointing the board took a year in total, partly because of delays caused by Shifting the Balance of Power coming out mid-way through the year.We also had the task of creating a new organisation out of what were two fairly disparate PCGs.We haven't been able to do as much as we would have liked in the past year, but have started a personal medical services pilot to allow us to employ clinical staff in an under-doctored area, focusing particularly on refugee patients.This has brought in GPs from outside the area, which feels like quite a coup.

In partnership with neighbouring PCTs We are also going forward as a second-wave local improvement finance trust (LIFT) site [scheme for improving primary care facilities], which should help us bring some of our buildings into the 21st century at last.

Working with the other five PCTs in what used to be Leicestershire health authority, We are trying to develop commissioning That is responsive to patients'needs, but at the same time not make it impossible for the big acute provider, Leicester University Hospital, to do its job.

In the past I've worked in acute trusts, so this has been my first involvement in primary care and I love it.There is so much potential to really make a difference for a population that so badly deserves it. It'll take a while for PCTs to establish our credibility, but There is no doubt in my mind that my job is as challenging as that of an acute trust chief executive. It may not be as high-profile now, but wait till PCTs start getting star-ratings.

Dr Chris Price, chief executive, Norwich primary care trust We have been going since April 2001, and as well our own 140,000 population we provide community services to other primary care trusts across Norfolk.

Commissioning, especially of acute services, is top of our agenda now. I think We have been slower than some other places in getting to grips with that, and That is partly about the kind of momentum you have in place when you start.We had 60 per cent fundholding here, and some GPs felt the move to primary care groups and PCTs was a step back in terms of influencing providers.

Shifting the Balance of Power has been an awful upheaval, but the fact is, It is only really been in the last five months that our acute trust has started to understand that We are the commissioners now.

Money is our biggest pressure - a number of health authority-initiated strategies are now coming to fruition, and We are having to deal with the costs of those, so it gives us very little room for manoeuvre.

Sometimes it feels like I am chief executive of an HA, a community trust and a PCG all at the same time.There is an awful lot of business just to keep it all running, whereas as a PCG one could devote a lot more energy to innovating.You can eke out bits of money and carve out some space for yourself, but It is a huge effort.

In terms of my career, I feel There is an awful lot still to be achieved here, and I guess I've given up trying to look ahead too far.Up to now I've always been lucky and found new opportunities to expand my role - but I suppose as a manager you only have so many reorganisations in you.

Gina Brocklehurst, chief executive, West of Cornwall primary care trust We became a trust in April 2001, but the biggest change came with Shifting the Balance of Power.That had a huge effect because we had already got staff in place, and the change brought significant additional responsibilities.

We did an intensive management review in October to December 2001, looking at the new as well as the existing responsibilities.But It is only in the past few weeks that I've been able to sit down and reflect on having moved through the chaos.We are starting to feel like a corporate body with its own identity at last.

The range of responsibilities the PCT has makes it feel like you're contemplating the universe sometimes, and It is a big challenge to make sure the incredible energy people have is not going to get sapped.There is a real sense here that We are in the throes of a revolution - for once, the NHS is not just going through slow, incremental change.That is great, but there are a lot of 'must dos'and my optimism doesn't stop me sometimes sitting at my desk with my head in my hands.

In terms of commissioning We are organising it through clinical modernisation groups, mainly working on individual disease areas.We are looking at redesigning services and setting up diagnostic and treatment centres.

I joined the NHS in 1973, and have worked in acute and specialist services as well as in a unit administrator role back in the 1980s.For me what's special about PCTs is their understanding of the partnership agenda - we straddle the NHS and social-inclusion agendas and That is pretty unique. I think as far as the rest of the service is concerned, the jury's still out on PCTs, but if we meet the expectations I am sure our value will start to look enormous.

REFERENCE

1Banyard R.King-pin wizards.HSJ 1999; 109 (5655):26-29.