Published: 02/12/2004, Volume II4, No. 5934 Page 33

As a medical student I was in a group labelled as not incapable, but frequently incapacitated. Twenty-five years later, working as a part-time primary care trust medical director, it is somewhat disconcerting to hear similar value judgements being made about my new organisation.

There is no doubt that many PCTs have problems with the magnitude and the range of tasks confronting them. But PCT staff lamenting a lack of capacity while on a series of management 'time outs' does little to engender sympathy among their clinical colleagues.

First, expenditure on management priorities such as 'time outs' or consultancy does not appear to warrant the same financial scrutiny as spending on clinical services.

Second, as a GP I cannot say to a patient, 'Sorry I probably have the capability to manage your chest pain but I haven't got the capacity'.

Partly through failing to understand the importance of strategy, some PCTs appear unable to get a firm grip on priorities. This is exacerbated by a tendency to become introverted and parochial.

Management processes ought to support and encourage clinical service developments. But recent research has illustrated a lack of integration between clinical service delivery and quality initiatives such as clinical governance.

In view of doctors' rigorous selection and training it seems selfevident that they ought to be central to both the delivery and planning of healthcare. This is being recognised by government in a number of recent policy initiatives, such as practicebased commissioning.

Strong clinical leadership has also been recognised as key to the success of the Kaiser Permanente approach to chronic-disease management - currently being enthusiastically promoted by the Department of Health.

However, the recent furore over the management of out-of-hours services - whereby the Department of Health, supported by GPs and patients, intervened to stop one Lincolnshire PCT from setting up an out-of-hours service without any doctors at all - has highlighted the fact that the thinking of some PCTs seems to be moving in the opposite direction.

Some PCT managers see practicebased commissioning as a threat, while others have expressed reservations about procuring clinical services from the independent sector.

However, many GPs would argue that it makes sense to devolve the mechanics of purchasing and contracting to those clinicians who are directly in contact with the patients receiving that care.

Moreover, some of us in general practice see enormous opportunities in allowing our NHS patients the choice to access a wider range of treatment and diagnostic services.

PCTs are at a crossroads. To enhance their capabilities they need to consolidate their management teams. However, they also need to adopt a much more favourable view towards involving GPs and the private sector.

Involving independent contractors and organisations is challenging and potentially disruptive for tightly managed public organisations. Have PCTs got the capacity and capability to do it?

Dr Nick Summerton is a GP and medical director of Yorkshire Wolds and Coast primary care trust.