primary care trusts: Many primary care organisations still rely heavily on their health authorities to commission care.So what will happen in 2004 when they are in control of three-quarters of the NHS budget? Kate Baxter and colleagues report

Published: 14/03/2002, Volume II2, No. 5796 Page 28 29

How ready are primary care trusts to become the lead NHS organisations for 'planning and securing all health services', as envisaged in Shifting the Balance?

1To what extent is devolution occurring already, and how empowered are primary care organisations? Previous research has shown that the level of a primary care group is not always reflected in the delegation of budgets and commissioning responsibility.

2Last year, we sent questionnaires to the chief officers or chief executives of all 49 primary care groups and trusts in South West region; 28 replied.

Of these, 24 were level-2 PCGs, taking devolved responsibility for managing a budget for commissioning services for their local population;

one was a level-3 PCT, a free-standing body responsible for commissioning; and three were level-4, free-standing bodies responsible not only for commissioning care but also for providing community services. None was level-1.

The questionnaire asked about the level of the PCG, details of the budget and perceptions of how the PCG/T worked. In some cases, usually where PCGs were working together in preparation for merging to become a PCT, questionnaires were completed jointly. So the returned questionnaires represented 63 per cent of the PCG/Ts in the region.

Respondents were similar to non-respondents in terms of size (numbers of GPs and numbers of practices per PCG/T) and the gap between their actual and target unified budgets. About 40 per cent of responding PCG/Ts had some form of previous purchasing or commissioning experience.

We asked PCG/Ts what percentage of the unified budget was devolved to them from their health authority after deducting 'top-sliced'money such as funds for HA management and specialised services.

The minimum requirement in 2000-01 was that 60 per cent of the unified budget for general medical services, hospital and community health services and prescribing should be devolved to PCG/Ts, other than for those at the advisory level (level-1).All but one PCG/T had 60 per cent, or more, of the unified budget devolved to it.

Not all the funds devolved to PCG/Ts were kept by them to commission care.We asked about the amount of the hospital and healthcare services allocation that PCG/Ts handed back to their host HAs to commission services on their behalf.Of the 26 PCG/Ts responding, three gave the whole budget back to their HA, four gave back more than half, 11 gave less than half and eight kept it all themselves.

Those PCG/Ts still relying heavily on their HAs to commission care may find the going tough as they progress to become the lead NHS organisations for planning and securing all health services. The target, specified in Shifting the Balance, of 75 per cent of total NHS funds to be allocated direct to PCTs by 2004 may seem a pipe-dream for some.

We asked respondents about the level of autonomy they felt they had for managing their allocated resources. They were asked to put a cross on a line 100mm long; one end labelled 'very little autonomy', the other 'a lot'. Twenty-six PCG/Ts responded with an average perceived degree of autonomy of 39.5 (range 0-91 for individual PCG/Ts). Fifteen felt they had not been given much autonomy at all.

Shifting the Balance recognises that PCTs secure the provision of only 'a limited range of services' but expects them to secure the provision of 'the full range of services... as strategic health authorities step back from a hands-on commissioning role'.

This step back by SHAs will be a big step forward for some primary care organisations.

PCTs are encouraged to collaborate, both to commission tertiary and secondary care services.

1,3 Athird of PCG/Ts that responded were delegating some commissioning responsibility to neighbouring PCG/Ts. These may find they have gained valuable experience in preparation for the demise of HAs.

With the responsibility for securing the delivery of services moving to PCTs, one might expect PCG/Ts to begin to develop indicative budgets at practice level. This could give them a baseline for managing activity within agreed service levels.Of the 25 PCG/Ts that retained at least some of their hospital and community services budget, only one had any indicative practice-level budgets. This was a PCG that had indicative practice-level budgets for both emergency and elective admissions. This finding begs the question of how the government's suggested incentive scheme for commissioning, based on practice-level savings, can be implemented.

3Looking at this issue in a little more detail, we asked respondents to indicate the level at which various budgets were managed.We defined 'managed' as 'ensuring that agreed activity and expenditure levels are met'. The choices offered were that budgets were managed at HA, PCG/T or practice level.Most budgets were managed at PCG/T level.Hospital and community services budgets were managed at practice-level in only one PCG.

We also asked about the level at which these same budgets were monitored.We defined 'monitored' as 'examining actual against planned spend'.Most budgets were monitored at PCG/T level.

Emergency and elective admissions were monitored at practice level in three PCG/Ts, and community services in two.None of these PCG/Ts had practice-level budgets, so it is likely that activity rather than expenditure was being monitored.

Notably, general medical services, prescribing and former fundholding savings were most often managed and monitored at practice level.

We asked about the ease with which PCG/T managers were able to get GPs and practices involved in PCG/T activities. Shifting the Balance states that 'PCTs are the most local NHS organisation and are led by clinicians and local people' and they 'will need to fully engage their front-line staff '.

Most respondents (68 per cent) said it was easy to get some or most GPs engaged in discussions about the resource implications of referrals and other decisions. But that left a few who thought it was not easy to get many GPs engaged in such discussions; and one PCG had found difficulty in engaging any GPs.More than half the respondents (60 per cent) said some or most practices did work together.

So what do these results mean for PCTs from April? It is encouraging that many primary care organisations are taking on more devolved responsibilities. In most PCG/Ts, the management and monitoring of many budgets occurs at PCG/T level. Some responsibilities are delegated down from PCG/T to practice level.Others are delegated to neighbouring PCG/Ts. But some functions are still delegated from PCG/T to HA level, and these include commissioning. It is those PCG/Ts still relying heavily on their HAs that will have to take the biggest steps to be equipped for April's changes.

But despite what appear to be positive moves by PCG/Ts towards their increased responsibilities, why do many still feel that they have a limited degree of autonomy? Perhaps this is because, even where PCG/Ts negotiate their own agreements with providers, they are accountable to their HAs and must show that they comply with the many government targets and priorities.This leaves little room for manoeuvre on more local issues. It is unlikely that this situation will change; SHAs will performance-manage PCTs and acute trusts.

The follow-up document, Shifting the Balance of Power: the next steps, stressed the importance of changes in behaviour as well as structure.

4It also emphasised the supporting role the Department of Health would play by adopting a 'less hands-on approach, with clear priorities, fewer targets and less guidance and instruction from the centre'.To date, the message to primary care organisations has been equivocal, giving devolved responsibility to achieve what the DoH dictates.Our findings show that while some PCG/Ts are making progress with their devolved responsibilities for commissioning and management of related budgets, they still feel controlled from above. Perhaps this year the DoH really will empower the front line. l Kate Baxter is research fellow, division of primary healthcare, Bristol University.

Jill Shepherd is locality manager, Bristol North primary care group.

Dr Marjorie Weiss is lecturer in the primary care, division of primary healthcare, Bristol University.

Julian Le Grand is professor of social policy, London School of Economics and Political Science.

Key points

A survey of primary care groups and trusts in South West region found most felt they had little autonomy.

Most were level-2 PCGs, taking responsibility for managing a budget for commissioning services.

About a third were still relying heavily on their health authority for commissioning.

The results suggest that the proposal to allocate 75 per cent of NHS funds to PCTs by 2004 will be unrealistic in some areas.


1 Department of Health.

Shifting the Balance of Power in the NHS: securing delivery.

Department of Health, 2001.

2Smith J, Regen E. Getting in on the act. HSJ 2001; 111(5771): 28-9.

3NHS Executive. The New NHS: Modern, dependable.

Primary care groups: delivering the agenda (HSC 1998/228). Department of Health, 1998.

4Department of Health.

Shifting the Balance of Power: the next steps. Department of Health, 2002.