Professional executive committees have been weighed down by corporate affairs and unable to influence strategy and clinical design, so the DoH's decision to review them has been widely welcomed. But what will the new PECs look like? Daloni Carlisle finds out

Last month's announcement that professional executive committees were to be retained was greeted with a sigh of relief across the NHS.

But Department of Health director general for commissioning Duncan Selbie made it clear that primary care trusts' committees of GPs, nurses and other health and social care professionals could not carry on as they are.

'The need to retain PECs in future is a given,' he wrote in a letter to strategic health authority chief executives. 'However, their form and function is not, and it is something we want to discuss with stakeholders.'

That discussion is now under way. The NHS Alliance is busy taking evidence in a rapid review of the future role, membership and support needs of PECs in the future health system. It expects to report at the end of this month. In the last two weeks, the DoH held the first meetings with professional groups representing clinicians.

This is all welcome news to anyone with an interest in clinical engagement in primary care trusts. That the subject of PECs should have been ignored for so long was something of a scandal.

As Donal Hynes, NHS Alliance deputy chair and a GP in Somerset puts it - with just a touch of hyperbole: 'This is something that should have been sorted out in 1947.'

He explains why. 'The challenges facing this government are immense. Care must move out of costly hospitals. It's going to be very hard to win the hearts and minds of the population. This kind of difficult decision-making must be local.

'To achieve this we will desperately need a set of corporate clinicians to say: &Quot;I work and live here and I think we should shut that service or move it elsewhere.&Quot; At the moment, politicians stand up and say &Quot;close something&Quot; and the clinicians line up to say &Quot;no&Quot;.'

It's going to take a whole new level of clinical engagement to generate these 'corporate clinicians', he says.

Mr Selbie did not characterise the argument in quite such a blunt way. Rather his letter touched on the vague role that the PEC has had up to now, bound as they were by proscriptive legislation that laid down their size and who should be represented.

'Many PECs found it difficult to have a clear identity. On the one hand they wanted to be key in the corporate decision-making of the organisation, but often found that they got so bogged down in complex corporate papers that they then did not have time to do what they were really good at, which is clinical redesign,' says NHS East Midlands chief executive Barbara Hakin, a former GP and PCT chief executive.

'I also think in some areas individual members were not able to leave their representative role behind,' she adds. 'It's obvious that they must be able to do this.'

On the PCT side, very few were brave enough to put in place the tripartite governance arrangements envisaged when PECs were first introduced in 2002.

'The concept was right,' says Dr Hynes. 'The chair represented the people, managers were represented by the chief executive and clinicians by the PEC chair. But very few PCTs had the courage to appoint a medical director or PEC chair as an integral part of their top team.'

The recipes for reinvigorating the PEC structure have been pouring into the inbox of Peter Reader, facilitator of the NHS Alliance PEC chair network who is now leading the review commissioned by the DoH. He has been given a very tight timescale, with just one month to pull together a report that will form the basis of a consultation. Fortunately, this review is being launched straight into an ongoing debate. 'We have 15 months' worth of dialogue and meetings that we can build on,' he says.

The response to the call for input has been heartening, he adds. 'I am up into the small hours reading the submissions.'

There are some general themes emerging even at this early stage. First, PECs need to be appointed and not elected or partly elected, as at present. Second, they need a clear skills set and job descriptions for everybody.

Two years down the road

Dr Hakin agrees. 'My view is that PEC members should be selected by individuals and senior clinical representatives,' she says. So, for example, the local medical committee and Royal College of Nursing should both be involved. 'People should be selected because of their personal ability and according to a skill-mix.'

Current thinking, outlined in an NHS Alliance policy document, points towards PECs becoming clinical executive committees with a much more strategic role than they have had, but with a broad responsibility for service redesign.

'We are very clearly seeing from the majority of the feedback that PECs need to be involved at a strategic level,' says Dr Reader. 'They do need to be involved in finance and strategic direction. They may also be involved in some of the pathway work, but again at a strategic level.'

Dr Hynes adds: 'We have to bring clinicians into what are non-clinical issues such as finance and strategy. If we put clinicians right at the centre and say &Quot;this is our resource challenge; what do you want for your department?&Quot; we get a very different response from the general whingeing about service cuts. All decisions should be put through a body that has clinicians represented at least 50:50 with managers.'

This is happening already. Ashton, Leigh and Wigan PCT is a non-reconfigured trust and therefore keeping its old PEC membership. It is emphatically not keeping the old structure but replacing it with a clinical executive committee.

'We won't have a separate senior management group,' says chief executive Peter Rowe. 'All the clinical strategy and all the major decisions will be made in the clinical executive committee (CEC) within a framework agreed with the board. We are determined to devolve real power.' The board's role will be to challenge and scrutinise the CEC proposals.

On the CEC, clinicians will be in the majority, with the director of public health counting among their number. They will have clear job descriptions and will lead on discrete areas, whether that's a portfolio such as choice or a service area such as mental health. The CEC will be small - around 15-17 people - but have sub-committees to ensure the relevant competencies are brought to bear, and also to widen the clinical involvement.

Ashton, Leigh and Wigan's CEC chair is Dr Marwan Ghalayini. 'We want to put into practice what the DoH preached in 2002 when it set up the PECs,' he says. 'We want a twinship between clinicians and managers that produces proposals that will be priced and financed. We are absolutely convinced that the transformation of services will come from a total and wholesome partnership between the managerial and clinical leadership.'

Mr Rowe admits that the new arrangements - to be put before the PCT board next month - feel quite scary, but adds: 'If we are going to achieve the scale of transformation we need, we are going to have to do something a bit frightening.'

East Lancashire PCT is moving in a similar, if less radical, direction. Here two PCTs have merged so a new PEC can be appointed; the PCT board considered a consultation document on the way forward at its first meeting on 2 October.

Chief executive David Peat says: 'We have about 40-50 clinicians involved in leadership here. We believe the advent of so much locality commissioning means the conflict of interest and time pressures on PEC members will become much more apparent.'

He is proposing a clinical advisory group. 'I think it needs to be smaller and more tightly focused. It needs to be appointed against a person spec and to support three main functions: strategic thinking, developing provider functions and professional advocacy - in other words, testing the clinical integrity of PCT plans.'

So far, so good. What is not clear is how the new structures will fit in with practice-based commissioning. This is currently being delegated to sub-groups of proposed new structures - in other words, kicked into the long grass. At a policy level, there is an argument that PBC will in the end obviate the need for a PEC; it is an argument with which the NHS Alliance disagrees.

Dr Hynes says: 'Let's look two years down the road with PBC in place. There have been huge shifts because clinicians are getting together and commissioning for patient needs. That would be a huge achievement and what, then, would be the role of the PEC?'

Quite simply, the PEC will be the line of engagement between PBC and the PCT, he says. 'Who will provide governance for PBC commissioning plans? Who will make sure they are of a high standard? Who will deal with issues of equity and access and whether it hits national targets?'

Try to do this as a management function and you're lost, suggests Dr Hynes. 'Within a very short time you would have a destructive interface between the PCT and PBC. It can only work by putting clinicians at the centre.'

For those involved in the clinical engagement debate these are interesting times. Will clinicians be enticed into the lion's den? And once there, will they be given the power to tame the beast, or find themselves served up for dinner?