Primary care is changing out of all recognition. The move to independent trust status is snowballing. An announcement on the next batch of 25 or so primary care trusts is imminent and over 100 expressions of interest have been lodged with NHS regions for the third wave in April 2001.
But it isn't all straightforward; opposition to the moves is growing.
There are now several hot spots up and down the country. In Dorset and in Morecambe Bay, GPs have voted against moves to PCT status. In Manchester, a primary care group and the local community health council have lodged formal objections to an application to establish two PCTs in the city from October this year.
Each of these disputes has deepseated local issues at its heart. In Morecambe Bay, 'rich' Lancaster does not want to team up with 'poor' South Lakeside and Barrow PCGs. In Manchester, the HA's proposals involve splitting East Manchester PCG in two - a move bitterly opposed by local health staff. In London, meanwhile, there is a rumble of discontent as PCGs claim that they are being pushed into unwieldy PCT configurations that share boundaries with local authorities.
One chief executive in the capital said: 'It's beginning to look like a stitch-up between regional directors and [health minister John] Denham.
We are told on one level that it's very much up to local determination and get a great deal of support from the primary care team at region, then on another we are getting the message from the bureaucrats that only one PCT per borough will be approved.'
Opinions vary as to whether these local difficulties signal a national trend. Dr Peter Smith, chair of the National Association of Primary Care, says not. 'I haven't really had the impression that there's any sort of a ground swell against PCTs. Generally there's been a feeling that people have been taking a very sensible approach to it.'
Likewise Jane Austin, NHS Confederation primary care policy manager. 'I've not picked up any strong grumblings, ' she says. 'Any organisational change causes anxiety; some of it may be legitimate, some may just be anxiety.'
This is in sharp contrast to the NHS Alliance. Chair Dr Mike Dixon says: 'There is a serious problem here. First of all GPs are suffering from change fatigue; second there is an almost universal suspicion about PCTs. GPs feel very threatened - that they will not be in control, that they will have a lot of their autonomy taken away, that they will lose their independent contractor status.
'There is a lot of dissent among the ranks and it is up to people like myself to make the arguments that the ends justify the means.
'There may be some down side to general practice, but overall there will be an improvement for the patients and the health system that is sufficient to warrant that.'
Dr John Canning, deputy chair elect of the local medical committees conference and secretary of Cleveland LMC, echoes these points. 'We are rushing into PCTs when PCGs have not achieved a great deal. We need some stability and corporate adhesion as PCGs before going forward, ' he says. It is worth remembering that PCGs themselves are just 14 months old.
GPs are also questioning the capacity of up and coming PCT chief executives, says Dr Canning. 'They may be perfectly suitable as managers of departments of 20 people involved in administration. But when it comes to managing a multi-million pound operation, employing a wide variety of health professionals, their ability may be questionable.'
GP support is seen by many as crucial to the success of a PCT. Suzanne Trewavas, chief executive of Brentford Chiswick and Isleworth PCG in west London, sums it up. 'The number one priority is keeping GPs on board, ' she says. 'If you lose them, you have lost it - you have a community trust by another name, not a PCT.'
But it is likely that some will go ahead in the face of opposition from GPs, practice and community staff, both in October this year and April 2001. It has already happened in Southend where subsequent attempts to build bridges now seem to be bearing fruit (see box, page 13).
The NHS Alliance is currently preparing guidance on how better to involve GPs in PCG and PCT work. It will focus partly on the need for good communication.
Dr Dixon says: 'The whole enterprise depends on local people and health professionals commissioning services they need and want and that use resources cost effectively. If you get local health professionals shrugging their shoulders and walking away, you will have an impotent organisation.'
And that, he says, would take us back to the bad old days of district health authorities.
Four play: Mancunians on the march Feelings are running high in Manchester over proposals to create three PCTs from four PCGs. So high, in fact, that health staff took to the streets to demonstrate last week.
The opposition to Manchester health authority's PCT application brings in not just GPs but other health staff, managers and the public too. East Manchester PCG and Central Manchester community health council have each lodged formal objections with the health secretary. Community nurses from the Mancunian Community Health trust - which also opposes the plan - have launched a local media campaign and organised a demonstration outside Manchester HA.
They object to the HA's proposal to break up East Manchester PCG and dissolve the local community trust. The CHC also criticises the local accountability arrangements and the proposals to manage city-wide community health services. The HA defends its proposal on the grounds that it cannot afford four PCTs; merging East and West Manchester PCGs (as campaigners would like) would create a PCT so large it would destabilise the other PCTs.
Many health staff cannot believe that the current application will be approved - and give a dire warning on the consequences of it going ahead as planned. 'They will have unhappy, unco-operative, demoralised staff to contend with, ' says health visitor Jenny Penny.
Pier group: back from the brink in Southend
In November 1999, GPs in Southend voted narrowly against a proposal for their local PCG to become a PCT. Ministers accepted the application and the British Medical Association promptly sought legal advice, arguing that it could not go ahead without doctors' support.
But all to no avail; the PCT was up and running by April 2000.Battle lines seemed drawn.
But within weeks it was all over. At its first public meeting on 17 May, the PCT announced that it had signed a joint charter with the South Essex local medical committee to 'formalise their positive working relationship'. Its stated aim was to reassure GPs that their interests would be respected. Now both the PCT and the LMC describe their working relationship in positive terms.
What went wrong in the first place? And how was the turn around achieved? Katherine Kirk, chair of the PCT, says: 'There was a communication problem. It is a major challenge when you have very busy small practices to find time to talk through all the issues and get a thorough understanding.'
She now visits all 41 practices covered by the PCT regularly to make sure that communication channels are open.
Her advice to new PCTs facing GP opposition is this: 'I'm going to sound awfully Blairite, but it's communication, communication, communication. That does not mean sending reams of paper to GPs who do not have time to read; it means one-to-one meetings where you actually listen to what they have to say.'