Published: 01/12/2005 Volume 115 No. 5984 Page 22 23 24

With the dust at last starting to settle in the debate on primary care-led healthcare, confusion remains over how the reforms will work in practice. William Little reports

When NHS Confederation chief executive Dr Gill Morgan told a confused Commons health select committee hearing last month that 'we are now clear that provision will stay with primary care trusts', MPs breathed a sigh of relief. Someone had at last managed to make sense of the bewildering array of letters and notices coming from the government about the future of PCT commissioning and provision.

According to Dr Morgan, it will also help calm the nerves of the many healthcare professionals who feared they were about to be transferred to a private or independent company.

'If you look at the people who work in PCTs, the vast majority of staff are working on the provision side, not the commissioning side' she told MPs. 'Commissioning is already the smallest component of most PCTs. We are now clear that provision will stay with PCTs. There is some reassurance, therefore, for the vast majority of staff that the provision will remain in the PCT.' The recent slow-down in moves towards a commissioning-only framework for PCTs has become what NHS Confederation policy director Nigel Edwards calls a reality check on the complexity of outsourcing provision. Yet it has still left a state of confusion.

Are PCTs now going to innovate and work with local people and community groups? What alternative providers do they favour? Will they have to go back to the drawing board?

Many strategic health authorities would probably have submitted different PCT reconfiguration plans to the Department of Health in October if they had known there was to be more flexibility over provision, says Mr Edwards.

This view is echoed by Trafford North and South PCTs chief executive Dr Tim Riley, who says there is 'still much to be settled in understanding how the government wants to support local services.

'If there are to be successes for PCTs, there needs to be more discussion.' Yet despite this, says Dr Riley, the 14 Greater Manchester PCTs are still working towards the timetable set out in NHS chief executive Sir Nigel Crisp's letter which said 'there is no requirement to feed or lose provision until 2007', says Dr Riley.

'We are accelerating the development of credible alternatives that are PCT-led. This includes non-for-profit social enterprises and community organisations that are economically successful and will put money back into the service.' In essence, Greater Manchester's PCTs will turn their provision services into social enterprise companies, shifting community nurses as well as other services over to social enterprises.

Dr Morgan may feel the nerves of health professionals have been calmed by government reassurances, but Dr Riley accepts that the Manchester plan could affect staff morale - people like working for the NHS, after all. He says that community nurses, for instance, will still be valued by PCTs and 'we would want to ensure they continue to have access to professional development'.

But Mr Edwards believes the future is not clear cut. He suggests a model for future development might be elective surgery, where private providers have been brought in to improve performance.

'Performance is the basis of contestability, ' he argues. 'There is no point moving provision from PCTs just for the sake of it; there needs to be a rationale.' Mr Edwards believes PCTs will probably need to divest provision in the case of, for example, teenage sexual health, where performance is poor and contestability could help boost services.

This view is echoed by the Terrence Higgins Trust, which points out that a recent report from the Health Protection Agency showed that many PCTs were failing to deliver.

Terrence Higgins Trust deputy chief executive Paul Ward says: 'There is real variation in the quality of PCT service in some areas. The HPA audit showed that the majority of PCTs were failing to meet sexual health access targets and missing their public health targets to reduce the increase in venereal diseases.' Mr Ward believes PCTs will have to change the structure of provision to meet these targets.

He suggests that the Terrence Higgins Trust could be contracted by PCTs to help meet the target for 48-hour access to a genito-urinary medicine clinic. 'We would establish a community-based sexually transmitted infection and HIV testing centre to relieve pressure on the GUM clinics, ' he says.

'It would also act to triage people who can be easily tested and treated, while the GUM clinic focuses on the people in greatest need. We would also provide structured health promotion for those coming to the centre, ' he says.

'We have very strong patient leadership in the organisation, so PCTs have found that commissioning a service from the Terrence Higgins Trust helps them to achieve their overall objective of increasing patient leadership locally.' The vision outlined by Mr Ward is already a reality in many places. The trust works with over 100 PCTs, providing services such as sexual health promotion, community-based testing, HIV self-management and HIV social care and community services.

It is the sort of service provision that Dr Morgan recommended to the health select committee, although she stressed that the solutions would vary for different services.

The starting point would be to identify PCTprovided services that were not delivering 'best in class' quality of care, and other providers that were.

She went on to point out that 'in many parts of the country sexual health services are not up to scratch'.

'In those areas I would be talking to people like the Terrence Higgins Trust, which we know has a fantastic sexual health integrated service that is already running in a number of PCTs.

'I would be finding out whether, one, I could steal their best ideas; two, whether they would want to come and provide the service at the local level; and three, how do I get the services in my patch up to the best in the country?

'That is contestability; it does not necessarily mean that you take the service away from a local provider, but it does mean you really know how you are doing and you aspire to be the best you possibly can.' For the trust, 'contestability should be about choice, not about competition, which suggests the service will be fragmented, ' says Mr Ward.

'Partnership-working is very important if there is too be real success and improvement.' And given the sensitivities around sexual health, patient choice will help to define future service provision, says Mr Ward. 'People will need more than one [type of] service. They will want access to services before or after work, in an area where they will not be seen by a neighbour, or young people might be better treated at a specialist clinic, ' he says.

However, NHS Alliance president Professor Chris Drinkwater believes that the financial problems of many PCTs make them badly placed to plan ahead. 'Many are struggling with deficits. They are only doing the immediate and necessary, and not thinking about the long term, ' he says. If anything, he says, they are maintaining the status quo.

He believes the government should facilitate evolution in primary care reform rather than mandate divestment of PCT-provided services.

Commissioning may be the right route for some PCTs, providing and commissioning for others, he says. In particular, the strong community links of smaller PCTs can often create innovative and imaginative services, such as those provided by Easington PCT to overweight people.

Professor Drinkwater also expects PCTs to be managing community nurses in the long term, a notion supported by Dr Morgan. 'A number of the issues around employment law and TUPE (Transfer of Undertakings [protection of employment] regulations) make it highly unlikely in my working lifetime that you will see large numbers of these staff working for private or other independent organisations, ' she says. 'I just do not believe that is a possibility.' Judith Smith, senior lecturer at Birmingham University's Health Services Management Centre, anticipates specialist organisations providing services for older people or children, for example, rather than them being lumped together.

The models will vary according to the local situation, but 'we will see more community and social enterprises being set up and run by GPs and nurses', she says. Like Mr Edwards, she sees this not as an end in itself but as a way to boost standards.

Unlike Professor Drinkwater, she believes that the biggest group of employees - community nurses - are 'the most likely to be moved into a new form of provision'.

'They will be configured in a way to provide our older people's services around the needs of the client group rather than the discipline of community nursing.' Ms Smith believes nurses will work in smaller units around areas such as tuberculosis control, sexual health or the needs of asylum seekers.

'These services will need smaller numbers of staff than current community nursing teams, ' she says.

'PCTs will begin to provide more specialist services, particularly around vulnerable groups - these are more likely to be kept under PCT management for longer, ' she says.

The model being suggested could be similar to the co-operatives that run GP out-of-hours services, says King's Fund health policy fellow Dr Richard Lewis, but he questions whether nurses and others have the requisite business skills.

'We do not have the means for making this happen, ' he says. 'Will nurses have the entrepreneurial skill to run a small business? Will they have the time? Will they link up with local business leaders? People are going to need support to do this.' In the long run, Ms Smith says PCTs will have to take a 'service by service, staff group by staff group approach, and decide the best place for the staff to be managed'.

'This will vary from one place to another. I would like to think it will be more around assessing the fitness for purpose of services.' .

Key points

Primary care trusts will be able to retain some provision functions in the restructured NHS.

Some PCTs, such as in Greater Manchester, have plans to identify and develop services with community providers.

HSJ readers can access background information at www. uk/primarycarepolicy