PRIMARY CARE : An analysis of primary care groups' investment plans revealed important gaps, write Brenda Leese and Stephen Gillam

How advanced are primary care groups in allocating resources - and do their plans reflect local priorities?

From September 1999, PCGs were required to produce primary care investment plans for 19992000 covering various elements of general medical services infrastructure including premises, staff and computers, as well as in-house services and developments in community nursing services.

The plans form part of the annual accountability agreement between the health authority and the PCG/primary care trust.

1They are required to assist PCG/Ts to ensure equity of service provision for all patients and protect current general medical services expenditure and primary care provision as well as acting as a planning tool to assist in the development of equitable services.

The requirements for the plans as specified in central guidance are set out in the box opposite.

They are also expected to reflect the priorities of the local health improvement programme and are essentially a stock-take of existing infrastructure and services, together with realistic plans for the future.

As part of the national tracker survey of PCG/Ts which is being undertaken jointly by the National Primary Care Research and Development Centre and the King's Fund, 33 plans were collected in order to analyse their contents and discover how well they followed the requirements set out in the guidance.

1,2 The plans varied greatly in size, averaged 23 pages, including sometimes extensive appendices, and ranged in length from eight to 87 pages. Twentyseven (82 per cent) covered the year 1999-2000. The table opposite shows which issues were covered.

As required by the guidance, all plans covered premises and most also covered the workforce and information technology - the basic infrastructure.

There were, however, some notable gaps. Details about out-of-hours investment plans were provided in only 76 per cent despite their central importance.

Out-of-hours initiatives revolved around developing joint plans between PCGs and local medical committees and attempting to achieve a unified system in all practices, as well as identifying how the budget should be distributed across the PCG. Just 73 per cent had anything to say about community nursing. The reviews of community nursing services were concerned first with identifying the workforce and, second, with specifying initiatives which were in place already or planned to begin very soon.

These latter could be divided into four distinct groups. First, there were PCGs which were planning the management of service shifts from secondary to primary care with initiatives involving the employment of discharge co-ordinators and the general support of early discharge and reduced length of stay.

These initiatives were linked to a second group designed to keep patients at home by providing rapid-response nursing teams to prevent admission.

Then there were initiatives around skill-mix and workload involving workload assessments, integrated nursing schemes, and multidisciplinary working.

The final group was concerned with the provision of specialist nurses to serve specific groups in the population such as homeless and elderly people, schoolchildren, those requiring flu vaccinations, and the introduction of nurse triage.

Only 52 per cent mentioned personal medical services pilots, and then just to note existing pilots and plans for any additions in the future. Fewer still mentioned section 36 schemes, which are GMS local development schemes aimed at generating incentives for the development of higher quality care and increased patient satisfaction. Though reference was made to modernisation funding, no PCGs were yet clear what was likely to be available to them or how they would spend it. Financial detail, particularly any evidence of disinvestment, was notable for its absence.

Fundholder savings were considered by just 14 plans (42 per cent); decisions about the equitable distribution of fundholder savings were at a relatively early stage. Most plans which included this issue were, however, committed to finding a solution that would benefit all PCG patients by 'levelling up' rather than down.

Various ways of reaching agreement were proposed, together with contingency plans when agreement on redistribution could not be reached.

This included allowing practices to retain their savings provided they were used to benefit patients.

Details of practice incentive schemes other than in relation to prescribing were notably sparse.

Several plans included additional details beyond the basic requirements. For example, 61 per cent mentioned partnership working.

Many were using their joint investment plan to improve the co-ordination of services for elderly people and had plans to integrate with social services to a much greater extent. Two primary care investment plans pointed to initiatives under Partnerships in Action.

3Just four plans made any mention of public involvement in primary care development. The initiatives were essentially agreements to move forward on this issue, with one PCG having already set up a public engagement advisory group.

There was some indication of intent to organise plans for primary care around local and national HImP priorities, but little progress so far. Altogether there was surprisingly little detail as to the processes guiding resource allocation. What criteria do guide PCG/Ts in primary care investment?

Accepting that secondary analysis of dry documents tells only part of the story, what can be inferred? The great variability in the structure and content of the individual primary care investment plans is telling.

More robust guidance in terms of specific headings might have helped PCGs and would have produced a more uniform structure and consistent content - possibly at the expense of local flexibility.

As it was, very few plans contained indicators of eye-catching innovation. The variation is likely also to reflect different levels of achievement.

Despite the difficulties which PCGs must have encountered in preparing their plans, most now have information about their basic practice infrastructure which should provide a good basis for future development. It will help them address service variations or inequalities in access which all have identified as an important priority.

More specific detail with greater evidence of strategic thinking on how levers such as PMS or new funding are to address local priorities should emerge in the next generation of plans.