Primary care groups have been designed to overcome the fragmentation in the system. At present, practices participate to varying degrees in the commissioning process and co-ordinated development is difficult to realise. PCGs will give a unified momentum to a primary care-led NHS. But considerable management challenges must be faced before they can operate successfully.
Arguably, total purchasing is the closest existing model to PCGs. The insights to be gained from those involved in total purchasing are likely to prove valuable in informing the development of PCGs, and in the summer we held a series of workshops around England designed to capture some of these insights. Each lasted three to four hours.
The 81 workshop participants included 15 GPs, six practice and community nurses, 29 managers from health authorities, 13 practice managers, four managers from provider organisations and at least one community health council representative. Despite the diversity of input , clear messages have emerged , both from the sessions and from answers given to a four-page questionnaire. Participants were asked to list ways in which working in a PCG would be advantageous to them, along with barriers to effective working in PCGs.
There is cautious underlying support for the principle of PCGs. They are seen to overcome the two-tier threat of fundholding and to spread the promise of total purchasing throughout the NHS.
PCGs are seen as providing advantages for patients and for all the professionals involved. Most frequently cited was the potential for improved inter-agency and interprofessional working.
It was felt that PCGs would go further than existing commissioning models because of the greater emphasis on involving nurses, social services and the public.
Other major advantages were seen to be an improved local focus in commissioning, the diffusion of good practice and improved service provision. In addition, budget holding , the ability to commission on a larger scale and the integration of commissioning and referral decisions were cited as important.
But major barriers must be overcome. The biggest will be the requirement for practices to co-operate. People were concerned about managing conflicting opinions among GPs and reaching consensus among practices used to operating independently: distrust and suspicion were recurring themes. As one participant put it: 'Doctors can't agree - they are not that type.'
Other major problems concerned the amount of time required, the size of PCGs, the setting of budgets - especially the need for 'fair' budgets - and the over-hasty timescale set for implementing PCGs.
Different levels of PCG
Those who will be running PCGs want to start with the responsibility clearly in their own hands. More than three quarters of the GPs, nurses and practice staff expect to start at level two, where they will take devolved responsibility for managing their area's healthcare budget.
HA managers also supported devolving responsibility, with over three-quarters expecting local PCGs to start at this level. These ambitions are not surprising, given that most of our participants had been involved in total purchasing. Few wanted to start at level one, where the PCG would merely support the HA in commissioning care for its population.
Ultimately, over 95 per cent of participants expect to achieve level three or level four, with fewer than 5 per cent expecting to remain at level two. The level of responsibility at level four is seen by some to be quite forbidding and about a fifth of participants see level three as the extent of their ambitions. Around 75 per cent expect to end up at level four - as freestanding primary care trusts, commissioning care and providing community health services.
Organisational issues
Mandatory collective working is a new approach to developing primary care in the NHS. Previously, GPs - as independent contractors - have worked together and with other primary care professionals only on a voluntary basis, whether at practice level or in larger commissioning groups.
Crucial to the success of PCGs will be their ability to communicate a common vision throughout the organisation, so that members have a commitment to its objectives and achievements.
Nurses at the workshops felt that they have had to live with decisions made by others for too long, and that too much attention was being paid to GPs. Other voices need to be heard - not just doctors'. PCGs, by drawing on nurses' knowledge of the local population, will provide an opportunity for them to participate in commissioning and to influence decisions.
Nurses felt that their input should be there from the start of a PCG, although others thought that this would be more appropriate after two or three years. PCGs were seen as likely to develop and enhance the role of nurses.
Counting the cost
Whatever happens, it is clear that administrative time will have to be compensated. Under total purchasing many GPs and staff committed time which was not fully reimbursed. More than three-quarters of GPs and practice staff believed that practices would only be willing to give time to their PCG if they were fully compensated. Even if this does happen, there is considerable concern over the loss of professional time and the implications of this for patient care.
Finding locum cover was cited as a problem in a number of our workshops: locums were also considered to be a poor substitute for GP time because of the disruption to patient contact and because paperwork was left untouched. At one workshop it was suggested that the PCG management allowance could be used to employ a pool of salaried GPs to provide regular cover.
Dealing with maverick practices
Free riders - practices that leave all the work to others and then expect to enjoy the benefits - may well cause friction in their PCGs. More than a fifth of GPs and practice managers felt that their practice would reduce its involvement if other practices were not willing to make any contribution to the work involved in setting up and running their PCG. And over 60 per cent believed that there should be financial incentives or penalties to differentiate between practices that do and do not make any contribution to the PCG.
The third exercise at our workshops looked at these mavericks - the free riders who could undermine the efforts of the rest. Each workshop recognised the type - indeed they could identify local individuals - and felt strongly that such people would be brought on board by encouragement rather than by coercion. Naming and shaming was definitely not seen to be a productive approach.
PCGs are perceived to threaten the independent contractor status of GPs. Our workshops established that almost all participants expect that, in the long run, the development of PCGs will lead to an increase in the number of salaried GPs. Not surprisingly, rather fewer - 74 per cent - saw this as a desirable development. Three quarters of GPs expected an increase in the number of salaried GPs, and more than a third thought that this would be a good thing.
For Executive ears
Finally we asked all the participants if they had one message about PCGs that they would like the NHS Executive to hear. Three key messages emerged.
About a quarter of participants were anxious about the timescale adopted for change. It was felt that PCGs would be climbing a steep learning curve and that all professions would need time to develop their new roles, particularly those with limited experience of commissioning responsibilities. Hasty implementation may come at the expense of long-term gains - further guidance and consultation would be welcomed by those involved.
A similar proportion felt that the PCG model would be more costly to manage than the HA and fundholding mix it replaces. It will be important for adequate management funds to be made available - but participants were generally optimistic that the benefits from PCGs would justify the extra expense.
There was also substantial concern that the information technology to support PCGs was currently inadequate.
Significant investment is required to improve the activity and cost data available to primary care, and the development of IT systems and information sets should be undertaken at national rather than local level. Primary care workers want primary care data, and there needs to be a unified national system and central funding.
Our workshops indicate that to succeed a PCG must have:
enough money to manage and develop the PCG as an organisation;
first-class IT capable of providing comprehensive information about the PCG's patients and its performance;
and, above all, PCG members' commitment to work together to achieve its objectives.
PCGs will have a budget for hospital and community health services, prescribing and general practice infrastructure. Practices are likely to have an indicative budget. A key financial objective of each PCG will be 'to manage within the resources available'.2 How can sticking to the budget be reconciled with the 'guarantee that the freedom to refer and prescribe remains unchanged', promised by health minister Alan Milburn in a letter to the British Medical Association in June?
The issue of budgets was explored in another exercise. All the discussions began by talking about the budget setting process and the activity and cost data used to support it.
Participants emphasised that the budget setting process must be perceived as being fair, both for the PCG as a whole and for indicative budgets at practice level. If this was not so they foresaw difficulties in adhering to their budgets. Activity data was of concern in terms of accuracy, availability and interpretation. It was felt that there must be substantial efforts to improve information systems in primary care.
One workshop referred to the concept of the iron triangle of costs, quality and access. If any one angle is anchored then the remaining two have to adjust - an inevitability that is not always understood.
When it came to the crunch, our participants generally failed to face up to the fact that the money might actually run out and that they might have to take action to deal with this - even in our hypothetical vignette. Unless PCGs are prepared to take the budget seriously, HAs may be forced to hold back substantial reserves, penalising all their local PCGs.
Key points
The biggest hurdle in the establishment of primary care groups is practices' reluctance to co-operate.
GPs will want compensation for the time spent on administration.
There is little awareness of the fact that PCG budgets may run out.
The development of PCGs is expected to lead to an increase in salaried GPs.
Current IT systems are seen as inadequate for PCGs.
REFERENCES
1 Marks L, Hunter D. The Development of Primary Care Groups: policy into practice . NHS Confederation, May 1998.
2 Developing Primary Care Groups . HSC1998; 139. NHS Executive, 13 August 1998.
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