primary care trusts

The first wave of primary care trusts have enjoyed some obvious successes. In many places positive relationships have been established with key local organisations, particularly schools and local authorities.

Local connections and networks have been used to good effect to inform people about the role of PCTs and the opportunities they present. PCTs have been able to put their weight behind health messages in schools where others have been less successful in the past.

There has also been success in attracting more funding for high profile initiatives such as walk-in centres and imaginative public/private partnerships.

PCTs have shown an ability to think creatively and act quickly on long-standing problems.

Many of the first PCTs have been enormously dynamic and energetic. They are not necessarily typical of future cohorts but some problems they face may become more common in the future.

The first challenge for most of the existing PCTs has been to put together their senior management teams and boards. There has been a considerable delay in appointing executive committee chairs, chief executives, board chairs and non-executive directors in most areas of the country. This has meant that team building has been delayed and corporate decisions on strategy and vision have been difficult to take. The piecemeal approach to appointments has been frustrating for all involved.

It is important to ensure that the sequence of events is clearly defined and managed. First, prospective PCTs need ministerial approval.

Nothing further can happen until the chair of the board and two non-executives are in place. It should be a priority for the new NHS appointments commission to ensure that this is achieved as rapidly as possible, once approval has been given.

If the speed of the appointments process is one problem, the ability to recruit enough people with the right skills is another. Many PCTs find the agenda overwhelming, and do not have enough staff to carry out basic administrative functions, let alone some of the commissioning, planning, primary care development and public health tasks. The failure to transfer resources, people and skills quickly enough has become the biggest challenge of all.

The two areas of greatest need are in human resources and information. Some PCTs are getting their advice and support from health authorities, trusts or 'NHS agencies', which have been set up to service a number of PCTs. But there are others where there is very little external support for key responsibilities. Most PCTs feel they are very small organisations facing a huge range of responsibilities and targets which have to be delivered immediately.

PCTs have established very different relationships with their health authorities. The early waves of PCTs have, unsurprisingly, emerged in areas where HAs are essentially willing to 'let go'. But 'letting go' takes many forms. Some HAs have devolved budgets and responsibilities remarkably quickly.

Other HAs have encouraged PCT development but have maintained strong control over budgets and the commissioning process themselves. Some of these HAs would argue that there are diseconomies of scale in PCT purchasing and commissioning and that the interests of the local health economy are best served by retaining this function at a higher level. A third group of PCTs find themselves in situations where their creation came 'bottom up'.

HAs have played a passive role and displayed little leadership or sense of direction. It is too early to say whether any of these models works more effectively than the others.

Some PCTs have clearly developed despite their HA while others have had full support and encouragement. The PCT/HA relationship is clearly crucial in the early months, and would repay further examination.

The 'three at the top' programme was initiated by the Department of Health to enable leaders in PCTs to work effectively together. Research had shown that the 'two at the top' relationship between the chair and chief executive in trusts and HAs had often proved challenging. The added dimension of having an executive committee chair who also had a professional role was a new feature. Most of the early PCTS are making this relationship work well.

The Manchester Centre for Healthcare Management has been running development workshops, known as 'three at the top', on behalf of the NHS leadership programme. Some of the emerging themes of these workshops appear in this article. But beyond the most obvious tasks, there is no blueprint for who should do what in PCTs. So each PCT is working differently on how to establish roles.

Executive committee chairs face perhaps the most difficult demands of all. Apart from the day-to-day work in their practices (all but one of the chairs is a GP), they have to gain the support of their partners (both professional and domestic) to carve out time for the PCT role. The pressures on a chair can create additional burdens on those around them, especially in small practices. Developing relationships in the GP community and the wider professional community in primary care can be difficult when there are mixed views about the transition to PCTs and the pace and direction of change. Some GPs still mourn the loss of primary care groups, not to mention the loss of fund holding.

Chairs themselves may regret the rapid change from PCG to PCT and the changed nature of their leadership role. While those chairs who have stayed with the organisation through the PCG/PCT transition are invariably positive, the demands upon them have changed considerably.

The principle of professional leadership in PCTs may be very important to their success but there are fundamental structural problems that need to be addressed in relation to chairs and other executive committee members. Finding time and resources to take on the role is a problem for many. At present, most GPs are simply adding it to an already exhausting schedule.

The role of chair requires skills that many GPs have never had the opportunity to acquire. The nature of general practice means that GPs do not always have a feel for the broader context of health policy and a sense of how to influence it. Very few have ever had any training to enable them to develop basic management skills.

Worse still, the multiple pressures on chairs mean that they do not have the time to acquire these skills through training and development programmes, or they do not see this as a priority. The strains on existing PEC chairs have already raised questions about succession planning. There is no queue of GPs waiting to become PEC chairs, if the current incumbents burn out or lose interest.

The problem of having independent contractors in prominent management and leadership roles in PCTs throws up some really important issues which must be addressed. Aside from the questions of corporate governance which are beginning to emerge, there are the structural problems of ensuring that chairs are properly rewarded, supported and trained. Unless these issues are addressed directly the current leadership arrangements in PCTs could begin to crumble.

The other scenario is that if GPs begin to lose interest in chairing PECs, there may be other primary care staff very ready to take their place.

Community nurses, in particular, may see this as an opportunity to hone their management skills in new leadership roles. In many senses, as employees (not independent contractors) and as professionals who have been trained to understand the 'bigger picture' and to work across boundaries, they may be ideally placed. The present situation cannot be left to drift.

Nurturing effective professional leaders is a critical task.

The role of nurses on committees also needs further thought. In some areas there are tensions about the process for election/selection, the 'representative' role and the contribution made at the board table. There is enormous potential in having NHS professionals at the heart of the decision-making process but there is also a need to ensure that professional staff have the skills and support they need to do an effective job.

Many of the early PCTs would nominate 'managing expectations' as one of their biggest stresses. Although there is now less talk of a 'primary care-led' NHS, there is still an expectation that PCTs will be at the forefront of modernisation. While PCTs remain positive about their role, they worry about their ability to deliver change fast enough, where budgets, skills and the primary care workforce are severely constrained.

A major disappointment for PCTs, in recent months, has been the demands placed upon them by the Service and Financial Framework (SaFF) round. What had motivated many PCT boards was the opportunity to address the health agenda in imaginative new ways. The all-absorbing SaFF process was a distraction which they had not anticipated. The recognition that, in the short term at least, the vast majority of NHS resources remained locked up in traditional services, which would be difficult to modernise, has been a disappointment to some. Shifting the focus to the public's health seems a very long-term goal for PCTs wanting to make a difference tomorrow.

The other distraction for some PCTs is the prospect of merger with adjoining PCG/Ts and the development of care trusts. Some PCTs would urge a slower pace to allow them to build their teams and to consolidate early achievements.

None of these problems should be taken as evidence that the PCT movement is ill advised. But there are some major challenges about organisational development, pace of change, roles and relationships, management of expectations and access to resources which require attention.

PCTs need support quickly if they are to fulfil their true potential.

Key points Primary care trusts, which went live last year, have had some success in attracting additional funding for new initiatives and tackling long-standing problems.

There have been considerable delays in appointing executive committees.

Management capacity is a huge problem. Many feel they do not have the staff to carry out basic administration.

GPs find chairing PCTs very stressful.

Major issues of development, roles and resources need to be addressed.