SPEAK OUT

Published: 25/08/2005, Volume II5, No. 5967 Page 17

An anonymous PCT manager says it is politics, not patients, driving the latest reforms

As Star Trek fans might put it, It is the NHS - but not as we know it.

Commissioning a Patient-led NHS will make a substantial proportion of the NHS workforce wish that they too could be 'beamed up'.

When these changes are implemented the user will not be able to think 'what a great service the NHS has provided me with', but instead 'what a great service the NHS has bought for me'. The health service will have become like a US health insurance organisation: a body that buys packages of care from the local provider.

There are many who argue that this is the best use of public funds, and they may be right. The problem might not be the destination of travel, but rather the route and the methodology.

Commissioning a Patient led NHS wants us to consolidate the role of the primary care trust as an informed commissioner of services, and to roll out practice-based commissioning. This will require PCTs to shed the mantle of a service provider in a manner which is undefined, but which creates 'contestability'.

The paper is vague about what happens to the host of communitybased services currently provided by PCTs, but it makes clear that independent and voluntary sector involvement should be increased. It is also understood that contestability implies many small, competing providers. To satisfy the red tape bashers, there will also be a 15 per cent reduction in management costs.

Proposals are to be with strategic health authorities by mid-October. For local boards to have time to consider their options, proposals need to be completed by mid-September, apparently including staff consultation.

Never mind 'putting patients first'; this is putting politics first.

While we await further guidance, let's consider some of the issues:

PCTs will be small organisations that handle large amounts of money

Current PCT staff will form the vast bulk of the organisations' workforce and account for most of its infrastructure - human resources, payroll, facilities, administration etc. The future configuration of PCTs and providers is apparently to be determined by 'the PCT', which in future will have a limited provider interest. The new PCTs will be at the front of the queue to cherry-pick resources and satisfy future capacity before it dumps the bulk of its former provider services.

There is a theory that those who supply provider services can go and work for GPs. But doesn't this simply re-create the conflict between service commissioner and provider?

Staff have employee rights that cannot be compromised if reorganisation is to take place without major disruption to services. Core rights such as pensions will need to be protected and transferable to the myriad organisations which could inherit these staff.

The NHS only gets one chance to rig the market. It can create as many artificial providers as it likes to develop contestability, but after that there is nothing to stop liquidations, mergers and the development of large provider monopolisation. Here come the Americans!

The demand for reduction in management costs is open to interpretation. If it means the residual costs of managing the new PCTs, this will be easy to achieve - especially as the actual cost detail gets lost across competing providers. The real costs will inevitably rise. As we move towards a process of care pathways, an administrative industry will be created as commissioners strive to ensure value for money and providers ensure they receive their dues. Each new provider will require its own organisational structure. The NHS still does not appear to have learned that a new organisation also creates a new bureaucracy.