Published: 21/02/2002, Volume II2, No. 5792 Page 30 31
What should primary care groups and primary care trusts be doing and what have they been doing? The government has given an answer to the first part of the question. It has charged PCG/Ts with three core functions: primary care development, commissioning and health improvement.
The second question is more difficult to answer.
PCG/Ts have been involved in a flurry of activity but it is difficult to discern exactly what their priorities are.
Perhaps their greatest achievement is their continued existence. The establishment of PCGs in 1999 effectively created hundreds of organisations that had little precedence in prior institutional arrangements, and that were given responsibility for billions of pounds of public money. It sounds like a recipe for a political nightmare, but it passed off quietly with only a few murmurs from organisations representing GPs.Why were PCG/Ts accepted so calmly, while the Conservatives faced battles with opposition politicians and health professionals when they introduced the internal market?
The reason for this calm has something to do with the hard work of PCG/T managers, primary care professionals and other stakeholders. Probably as important was the political context. The greater trust voters place in Labour when it comes to the NHS, the decision to give GPs such a large role to play in PCG/Ts, the political unpopularity of the opposition, and a preference for co-operation in health matters, as opposed to market competition, all contributed their share to the quiescent political environment in which PCG/Ts were born.
Beyond the feat of radically reorganising primary care without crisis, it becomes more difficult to list achievements of PCG/Ts. Looking to the major evaluations of PCG/Ts carried out by Birmingham and Manchester universities, it appears that the two areas in which they have really made progress are in clinical governance and prescribing.
1,2 Though it is difficult to determine the precise effect of their measures, most PCG/Ts have established subcommittees to determine local policies on the two topics. They have set targets and in many cases they have incentive schemes attached.What is notable is that they both involve improvements to primary care.
What about the other two core functions: health improvement and commissioning?
Health improvement is a major weakness of PCG/Ts. They lack strong public health infrastructures allowing them to collect information necessary to engage in public health initiatives that would make a real difference to the health of their populations.At best, they are embedding some notions of public health in primary care that were lacking previously, but the strong influence of GPs whose experience is so removed from the concerns of public health is not a propitious base from which to build a new public health infrastructure.
The primary source of public health thinking appears to be coming only from the centre in the form of, for example, national service frameworks.
PCG/Ts' record on commissioning seems no better.
Progress has been minor. Research at Manchester University found that 60-70 per cent of a random sample had taken on responsibility for a range of different commissioning budgets.
2Sixty-two per cent had developed commissioning subgroups, between a third and a fifth reported making changes to service-level agreements with providers of secondary care, and three-quarters reported they had achieved some or none of their commissioning objectives. But a substantial minority reported obstacles to sufficient commissioning and over two-thirds reported that their infrastructure could not meet the demands of commissioning.
Perhaps the most noteworthy aspect of PCG/Ts is just how little innovation or change there appears to be. This is remarkable following immediately after the internal market. For the better part of the 1990s, the NHS was the site of a natural experiment with the establishment of different variants of primary care commissioning, ranging from fundholding practices to health authority commissioning to total purchasing pilots.
It is fairly clear that there is room for a diversity of primary care commissioning. A decentralised and efficient NHS could have a variety of commissioning mechanisms, depending on factors including, for example, the range of local secondary providers, the characteristics of GPs' patient lists and individual GPs'willingness to take risks.
This was recognised by the government in the white paper that heralded the creation of PCG/Ts. The New NHS: modern dependable, despite criticising allegedly inefficient characteristics of the internal market, praised many innovations in primary care commissioning.
3It even envisaged a situation in which practices would be given indicative hospital and community health service budgets attached to incentives - a step short of fundholding but a move in the direction of decentralisation.
Despite their immediate history and the intentions expressed in the white paper, PCG/Ts appear to have developed models of primary care commissioning that vary little from a single model - and an ineffective one at that. In this model, commissioning budgets are held at a level that is PCG/T-wide without any devolution of control.Manchester University's survey found that less than 10 per cent of GPs had devolved any budgetary control to locality groups (unfortunately they do not report if any of the commissioning budget was devolved).Only 6 per cent of PCG/Ts had introduced indicative budgets at the level of practice, and only two had linked incentives to these budgets. In addition to a lack of control, it is not clear at all that the model used by most PCGs gives GPs any real voice in commissioning decisions.
More than a third of PCG/Ts do not even have commissioning subgroups. Even in those that do, it is not clear how representative they will be - committee decision-making is open to influence politics and less likely to reveal GPs' preferences than control of their own commissioning budget would.
By removing GPs' budget control, they remove incentives they have to get involved in designing commissioning arrangements, and the information GPs receive about the wishes of their patients has less influence on the commissioning process.
In their defence, one could argue that PCG/Ts are new organisations that have had to prioritise across a wide range of actions. It could be claimed they have focused on organisational development, prescribing and clinical governance instead of commissioning.While the importance of those priorities is clear, it could be argued that the issues facing the NHS, such as waiting lists and efficient use of the budget, will only be tackled through commissioning. To spend too much time on (admittedly important) issues like prescribing and clinical governance distracts attention away from achieving real improvement in the NHS.
In many ways, the most important lesson that the internal market taught us appears to be lost. Rather than simply using reform of primary care to alter its own practices, it can be used to alter practices in secondary care and the entire health service.Other changes to primary care appear somewhat parochial from this perspective.
The internal market treated all parts of the NHS as a system of interconnected parts, where reform in one area affected other parts.When that perception is kept in mind, the vital importance of commissioning immediately becomes apparent.
Why have things gone so wrong? Perhaps the answer lies in the organisational structures of PCG/Ts and the way control of commissioning was assigned between PCG (and HA) managers and GPs. All initial control was assigned to the PCG/T and/or HA managers, and it was up to them to decide how much control should be delegated.
Keeping control at the top of the organisation and spreading the consequences of commissioning choices equally across all GPs is a recipe for creating apathy among GPs and increased organisation costs if the centre is to gather enough information to make commissioning decisions responsive to the needs of the population it serves.
Imagine how different things would have been if a wide range of commissioning powers and budgets had initially been given to GPs while responsibility for commissioning services that affect public health, for instance, were kept at a PCG/T-wide level. GPs would have had the incentive to take part in commissioning decisions, and the information they have about local conditions would have been used in a way that does not involve the extensive organisation and compromise involved in commissioning subgroups.
This is not to say that all GPs would have had to take on the responsibility of controlling their own budgets. By making the control alienable, they could give their control to more enterprising practices or they could cede control to the PCG if, for example, they felt their bargaining power was increased by being part of a cartel.
If this sounds like fundholding, perhaps it should.
While PCG/Ts may be suitable organisational forms for the reform of primary care, they do not appear suitable vehicles for improving commissioning and ultimately for increasing competitive pressures on secondary care. In the light of evidence about PCG commissioning, the virtues of the internal market are becoming clearer and its defects less important.
It is time the discussion of PCG/Ts broke out of the parochial framework used until now. The reform of primary care is important - everybody wants GPs to practise cost-effective, high-quality medicine. But the really large challenges facing the NHS will only be effectively tackled when the reform of primary care is linked to changes in all other parts of the NHS.
Key points
Primary care groups had few precedents in the NHS, but their introduction was met with little political hostility.
It is difficult to discern PCG/Ts' achievements.
The record on commissioning and health improvement is poor.
They have not exploited their potential to change the whole NHS.
REFERENCES
1Smith J, Regen E, Goodwin N, McLeod H, Shapiro J.
Passing on the Baton: final report of a national evaluation of primary care groups and trusts.
Birmingham University, 2001.
2Wilkin D, Gillam S, Crawford A. The National Tracker Survey of PCG/Ts 2000/2001: modernising the NHS? National Primary Care Research and Development Centre, Manchester University.
3Secretary of State for Health (white paper). The New NHS: modern dependable.London: Stationery Office CM3807.
Matthew Bond is a lecturer in health services research, Royal Free and University College Medical School, London
No comments yet