PRIMARY CARE

Published: 14/07/2005, Volume II5, No. 115 Page 26 27 28

Professional executive committees were supposed to be about fostering clinical innovation and engagement. But many feel they have lost their way and are now focused on the wrong things. Mark Gould reports that reform is on its way

Professional executive committees were conceived as the clinical voice for GPs, nurses, pharmacists, dentists and everyone else involved in primary and community services. They were intended to drive forward primary care trusts and provide professional clinical advice and leadership.

Their job is to ensure that services are commissioned and developed with the patient in mind rather than PCT boards or their higher political masters.

But expectations, it seems, are being disappointed. When staff at Hillingdon PCT in north London discussed PEC reform at meetings last year, these were among the comments: 'What was most striking is that staff feel that the PEC will not be missed as they had little understanding of what we did and there is little communication between the PEC and frontline staff.' It continues: 'Staff felt that the PEC had not communicated effectively and has been focused on the PEC meetings rather than reaching out to the front line. The reformed PEC must take a very different approach.' So rather than flying the flag for clinical leadership, it seems that some PECs may have 'gone corporate'. In many cases there has been little sign of members providing managers with the necessary clinical perspective on issues facing PCTs.

Hillingdon PCT chief executive Graeme Betts had to act. He set out the need for reform in a proposal he wrote in May last year after an awayday involving the PCT board, the PEC and the management team.

'The away-day focused on the engagement of clinicians, ' says Mr Betts. 'There is a growing view that too much stress is placed on the PEC and its structure and processes and too little on the contribution clinicians need to make to the development of the PCT and its role in providing and commissioning services. Also, it is essential that the PEC moves away from duplicating the work done by the management board.' And PECs do not come cheap. PEC chairs are paid£37,694 a year, including allowances and locum costs, and board members receive£13,055.

So it is hard for PCTs to justify the expense if all members do is take time out from their own specialisms to play at replicating managerial functions.

And with the growth of practice and localitybased commissioning, and increased government pressure on PCTs to work with secondary care to provide effective patient pathways, PECs cannot afford to be perceived as what one Hillingdon away-dayer described as 'clinicians in name alone'.

Although there are questions about their effectiveness and value for money, it is the development of these ground-up locality initiatives that could provide the salvation of PECs. But if they are to find a role, PECs will need to adapt to these new ways of working.

To ensure that PECs are in the right shape to respond to the challenge, the NHS Confederation and the Department of Health last month published guidelines to help redesign and refocus their activities.

Former NHS Confederation director of primary care Edna Robinson, who worked on the guidelines, says: 'There is a natural transition in organisations after about three or four years - a sort of shelf-life. PECs in their current structure are seen as last week's ring-tone.

'There have been a lot of changes in primary care. The latest intake of GPs is 80 per cent female. GPs and nurses are opting for more parttime work and more are working in other areas of the system. We have a new intake of nurse practitioners and are working with the NHS Alliance on developments there. All these need to be taken into account when commissioning services, ' says Ms Robinson.

North East Lincolnshire PCT PEC chair Dr Peter Melton feels there was a lot of enthusiasm for the original PEC concept - clinically led agents of transformational change for both the professionals and patients. 'But they have become increasingly more corporate and more bureaucratic, focusing on targets, risk assessment and risk management - both clinical and corporate - and financial risk management.' He refers to a presentation he gave at a PCT recently at which the GPs said they had little confidence in their own PEC and PCT and felt they were not responsive to local issues. Ironically, however, it brought the practices closer together.

'Those GPs are using practice-based commissioning to bring power and influence back to them. And it means practices are working together in a way they hadn't been doing for two or three years.' Dr Melton feels that worries about corporate sell-out are making clinicians keen to rekindle that original enthusiasm. 'We are going through a period of systemic change - practice-based commissioning will empower practices and clusters of practices to be able to bring about that innovative transformational change.' He says practice-based commissioning creates an opportunity to shift the balance back. He sees in his PCT almost a split in the role of the PEC - one part in the practice-based commissioning forum as part of the practice representation and the other as a corporate, overseeing executive function.

And he says the growing use of the independent sector by the NHS and greater liaison with secondary care may mean that new faces need to come on board - or at least be represented on the PEC.

Some PCTs have already grasped the nettle. Dr Vicky Pleydell, PEC chair at Hambleton and Richmondshire PCT and chair of North Yorkshire primary care network, says the PEC restructured about a year ago.

'All PCTs have struggled with what the role of the PEC is. We have to show that we are good value for money as PECs are very expensive.

'We wanted to move the focus away from more general work that PECs were doing - lots of PECs were pre-reading board papers. We wanted to focus on modernisation and decided that a much smaller PEC was needed - a huge one creates lots of problems.' A recurring problem has been getting the right balance of clinical specialisms in a world where, for better or worse, the voice of the GP seems to be the loudest. To get around this problem, Hambleton and Richmondshire decided that the PEC was not going to be representative. 'We deliberately decided against it. Instead we went for a selection process looking for people interested in change management and leadership.' She admits the process was 'not without some tensions', but eventually the PEC board consisted of two GPs (including Dr Pleydell), a psychologist, a physiotherapist, a nurse member of the intermediate care team, a school doctor, a social services representative and the statutory PCT board members.

'Although we are not representative, that doesn't mean we do not spend a lot of time talking to nurses, physios and everyone else, ' insists Dr Pleydell.

The PEC has taken charge of the modernisation agenda and plays a part in locality implementation-planning, ensuring cross-cutting strategies are in step with current thinking.

'Members of the PEC are leading on particular areas of the modernisation process such as redesigning chronic obstructive pulmonary disease pathways.

All PEC members have a locality for which they are responsible - It is deliberately not their own so there is no chance of being partisan.' The PEC is also helping practices develop practice-based commissioning. Dr Pleydell says one of the problems for the area is that there are not many GPs with experience of past budgetholding schemes, such as fundholding. 'The GPs need quite a lot of encouragement to see positives. We want to be able to develop more direct access to scans. But rather than allowing that to develop in a piecemeal way, which could lead to a postcode lottery, we want to ensure that it becomes PCT-wide.' Dr Pleydell hopes patients will see more joinedup care. 'The patient pathway is the focus of what we are doing. As a GP I get so frustrated that patients fall through gaps in the service and I spend hours on the phone trying to make sure that doesn't happen.

'We also help with the local delivery plan every year. The requests for new money come through the PEC because we are championing modernisation - it has been a tough process and you do not always win friends. But in a lot of PCTs this process is not very transparent - at least with us It is as fair and transparent as it can be.' One sure-fire way of making PECs keep their eye on the goal of clinical innovation and engagement is to give them more power by handing over budgets - even if it means the Audit Commission comes gunning for you.

Zenna Atkins is chair of Portsmouth City PCT, one of the first wave set up in 2001. 'At some point with an organisation of this age, you need to have a poke about to check It is not getting tired and bored and is still doing what It is supposed to do, ' she says.

But Ms Atkins does not think Portsmouth City PEC needs any more change. 'We have got a dynamic and engaged PEC board because our PCT delegated more power to them.

That got us in trouble as the Audit Commission challenged us that we were delegating our powers away. In the end they conceded we had not exceeded our powers. If you are going to have clinicians driving clinical business they have to have control over budgets - ours is something over£200m.' Despite there being just four GPs on the 14strong Portsmouth City PEC board, there have not been any problems with quotas or lack of representation.

'More and more we are seeing things as a clinical pathway from the patient's eye not from the perspective of one professional specialism, so there is less of a feel that people are fighting their own corner, ' says Ms Atkins. 'We have a waiting list to join our PEC board - a lot of other places have trouble recruiting a whole board.' She feels that large-scale changes would simply be change for its own sake. 'There is no such thing as the perfect NHS organisation; it doesn't exist. You have to accept that It is imperfect and make it work.' But there are still some areas of activity that feel under-supported - especially practice nursing, which is taking on new prescribing responsibilities and minor treatment work from GPs.

Shirley Butler, community nurse representative on the PEC of Chiltern and South Bucks PCT, says she struggled with her PEC role because of the different employment structure of general practice, where very little emphasis is put on personal development.

'Some practices are very good and others are not, so there has to be some consistency, and perhaps funding from the strategic health authority to ensure that there is training to sit on a PEC and contribute effectively.

'The first wave of PECs had good training but the second wave was left to fend for itself. I had been in management but a lot of people were starting from the ground up. Practice nurses can feel isolated and they need this extra support as their practice managers can vary as well.' .

SIZE MATTERS

CRAVEN, HARROGATE AND RURAL DISTRICT PCT

Craven, Harrogate and Rural District PCT has already carried out a major professional executive committee overhaul that started in September 2003. But it seems more reorganisation will be needed.

PEC chair Clive Story explains: 'Previously we had a large PEC with a preponderance of GPs.

The feeling was that they were dominating the meetings too much and there wasn't a plurality of representation among the professions.

'The whole group was too big and there was a problem with decisionmaking and reaching a consensus. People became very parochial and more self-interested rather than being strategic, ' he adds.

The PCT took advice from a professional organisational development expert and decided to create a PEC that had eight members as well as the statutory obligation to include the PCT chief executive, director of finance and director of public health.

The idea was that representation should be spread across all professions. Now the PEC consists of one GP (Dr Story), a pharmacist, a dentist, an optometrist, a health visitor representing nurses, a physio representing allied health professionals, a social care representative and a consultant psychiatrist, because the PCT is also a mental health trust.

Dr Story concedes that local GPs were not entirely happy with the new arrangements; they felt under-represented given the sheer weight of work they do. And there were other problems.

'When we started talking about redesigning and reconfiguring services, strategy and implementation, we found that people like the dentist and optometrist had very little knowledge or experience of issues such as the links between primary and secondary care. The pharmacist was better, more forward-thinking and keen to use pharmacy much more inventively, ' he adds.

He says the small size of the group has been helpful in speeding up decision-making, but has suffered in terms of representation. As a result redesign work will continue over the summer.

'We are going to reorganise again. We feel that the new model will have to be totally different. It will require representation from all local groups, but the GP presence will have to be much stronger, ' says Dr Story.

He hopes arguments over board configuration can be avoided. 'We expect to have three locality groups. At present we have 24 practices out of a total of 26 signed up and one of the two not signed up is vacillating, so That is not bad.

'The new PEC will support practice-based commissioning, governance issues, making sure that it is in agreement with national and local policy strategies and making sure that any big developments are affordable. And it will also be responsible for ensuring we are in tune with the modernisation agenda.

'It will not look anything like a PEC, but we will be calling it a PEC because we are statutorily obliged to have one.'

Key points

Professional executive committees were devised to be the clinicians' voice in primary care trusts, but staff have complained of corporate sell-out.

Policies like practice-based commissioning are seen as a catalyst to reform the committees.

New-style PECs are abandoning some more general work to focus on modernisation.