comment: Does primary care deserve the same powers as foundation hospitals?

Published: 16/01/2003, Volume II3, No. 5838 Page 17

As the row about foundation hospitals continues to build (news, page 6; politics, page 21), the emotive accusation that foundation status will create a two-tier health service continues to get plenty of airtime.

But the more telling criticism is that the logical argument for giving greater freedom to the best-managed hospitals is undermined if something comparable is not considered for the best primary care trusts. The current proposal runs the risk of strengthening secondary care dominance over the NHS.

The prime minister told HSJ (pages 11-13, 7 November 2002) that he was 'very sympathetic' to PCT managers and clinicians who wanted more freedom. He added:

'We have got to be careful that there is not a gap between the rhetoric of 75 per cent devolved to the front line and reality of the freedom [PCTs] have.'

But there is little doubt that the current direction of the foundation debate is helping create an impression that the government does not quite trust PCTs to deliver.

National Association of Primary Care chair Dr Peter Smith believes he knows how primary care can assert the necessary influence over the NHS - by using commissioning to improve patient care and choice, and re-engaging primary care clinicians in the process of reform (HSJ interview, pages 22-23). Practices must become more influential - and, no, he is not talking about a return to that other NHS F-word, fundholding - through commissioning arrangements which link those who generate healthcare activity to its provision. There is much to debate over how this should be achieved, but the rationale is undeniable.

But, for argument's sake, let us assume that Dr Smith's wishes come true. Are practices justified in claiming that they should wield significant spending power on behalf of their patients? Our feature on patient involvement (pages 26-28) should give pause for thought. East Lincolnshire PCT found clear discrepancies between how well practices were serving patients and how well patients actually thought they were being served.

For hospitals to win foundation status, they must prove they have the support of a wide range of constituents, including PCTs. Might it not be reasonable to argue that practices must involve patients - and demonstrate their support - if they are to get their hands on the commissioning reigns.