Tom Coffey On primary care

Published: 05/08/2004, Volume II4, No. 5917 Page 17

Fledgling primary care trusts are again under the microscope.

The 'who to blame' culture in the NHS always seems to search out an easy victim when goals are not being fulfilled. The PCT, as yet, does not have a group of clinical foot soldiers defending it when it comes under attack. The recent concern over PCTs has focused on size, clinical engagement and commissioning effectiveness.

We all know that size does matter (no matter what any wellmeaning GP tells you). An analysis of primary care groups and commissioning organisations at the turn of the decade sat carefully on the fence on this. It was suggested that smaller organisations - those with populations of about 100,000 - are much better at clinical engagement, local service development and quick responses to local clinical need.

However, larger organisations with populations of about 300,000 were much better at commissioning, strategic work and partnerships with other statutory organisations. It seems the second argument is now winning and there is a creeping move towards merging smaller PCTs.

The increase in size of PCTs may undermine clinical engagement even further unless it is accompanied by cultural changes in the organisation.

Clinicians hate change and they would scream from the rooftops if people suggested another one in primary care. They would prefer a cultural change, and the answer may lie in practice-based commissioning.

Richard Lewis's work for the King's Fund on practice-led commissioning ('In the balance', pages 16-17, 10 June) describes the mechanics of practice-based commissioning and its relationship to a burgeoning and strengthened PCT.He lays out a system that will increase clinical engagement, deliver cost containment and allow innovation in primary care with structured financial incentives.

The system would cover high-volume, low-risk areas including prescribing and would be a model most GPs would favour.Mr Lewis rightly argues that with the introduction of payment by results, a primary care demand management system will need to be developed, and practice-based commissioning seems to be the ideal solution.

PCTs' new role will be to oversee and facilitate practice-based commissioning, ensuring the enormous transaction costs of fundholding are not replicated. Larger PCTs would commission specialised and emergency services and be the key vehicle for delivering innovative, integrated models for chronic-disease management between primary and secondary care. The legitimacy of PCTs depends on the wider NHS perceiving them to be vital to its activities, clinician support, and politicians believing they are making a difference. The adoption of successful practice-based commissioning could provide these for PCTs in one fell swoop.

Dr Tom Coffey is a south London GP and chair of the New Health Network.