The early days of a PCT may be marked by feelings of loss and ambiguity.It is important to clearly define roles and responsibilities, explains Barbara Kennedy

What are the important issues to address in the early days of a primary care trust? And what can it expect? A new PCT can be accused at various times of behaving like a health authority, a community trust or having 'gone native'with the GPs.

Milton Keynes was one of the larger PCTs when it was established in October 2000.With funding of£121m, the PCT has a registered population of 226,000, 31 GP practices, and 1,000 staff in mental health, learning disability, rehabilitation, children's services, intermediate care and community nursing.

One difficulty has been maintaining balance of effort between the main functions of a PCT:

improving the health of the community;

developing primary and community services and commissioning secondary care.

Early priorities had to focus on finalising organisational structures, recruiting, formal schemes of delegation and financial limits - plus, of course, melding the primary care group and community trust into a single cohesive body.

Community staff and GPs had mixed feelings about the establishment of the PCT. There was a sense of bereavement for the old community trust.

The new PCT had a wider scope and new ideas - this led to feelings (sometimes at the most senior level) that the achievements of the past were not valued. GPs felt much closer to the heart of decision-making in a PCG, where the organisation was much smaller and GPs were in a majority on the board.

There are many layers of decision-making in a PCT, with its board and executive committee, its responsibility for large numbers of staff and a crucial role in developing partnerships with the local council, acute trust, voluntary sector and wider economy. All of this leads to executive committee members feeling a loss of control over the agenda. For example, the role of the executive committee chair had changed substantially from leading the PCG to a more ambiguous one of heading the executive committee.

A developmental programme for the organisation is vital. This started with coaching for the board chair, chief executive and executive committee chair.

Early work clarified which issues should be decided at board level and which by the executive committee. The board takes responsibility for performance, strategy and risk management, while the executive committee's responsibilities include setting priorities for clinical developments and monitoring the work of sub-committees.

The executive committee has concentrated on patient pathways (for example the development of a new care pathway for ophthalmology), integration of systems to improve access, and work to unify mental health and learning disability services into integrated health and social care models.

Key sub-committees of the executive committee, such as the audit committee, are chaired by nonexecutive directors. Non-executive directors also take a special interest in service areas overseeing the implementation of national service frameworks and service improvements.Meanwhile, the executive committee chair's role was defined more explicitly, and a role description for executive committee members clarified.

But the difficulty remained of defining within the PCT how best to fulfil the role that would have previously been held by a medical director. Some PCTs have appointed medical directors (generally GPs by background) within their structure, but the PCT was concerned to ensure that the doctors supported the process. Two associate director (medical) posts were created. They had dual roles managerially, as a public health doctor and a clinical director for adult psychiatry. They support doctors to ensure appraisal processes are set up, and carry a range of other responsibilities.

The PCT has tried to innovate and spread good practice. It has paid for emergency cover for surgeries while GPs attend educational events. It is also a pilot site for the national evaluation of the public health role of health visitors.We hope to be able to re-define the health-visiting role as a result, and boost the public health capacity of the PCT.

The PCT needs to operate confidently in a pluralistic environment, in partnerships with the local authority, acute trust and voluntary sector. A joint commissioning team was set up with Milton Keynes council last year.

Work is under way to establish a partnership board ahead of unifying mental health and learning disability services into health and social care models (and thereby pool resources).

There is tension in the difference in distribution of resources across the PCT. Practices which were previously fundholders have generally invested savings in their practices or in services such as practice-based physiotherapy or outreach hospital clinics. Non-fundholding practices and those operating in the more deprived populations often appear to have lower levels of investment and staff.

The PCT needs to equalise resources, target needs and ensure that there is a risk assessment which incorporates primary care (whether it is buildings or access to care). This process is quite challenging.

Existing policies within community trusts are not robust enough for PCTs.We need to find new ways of working with practices to spread good practice and minimise risk.

The style of working in a PCT is crucial.Managers' key competencies are often poorly tested by the usual batteries of psychometric tests. Commandand-control models do not work with practices that operate as independent businesses within the NHS.

Rather, a networked leadership model is needed.

Without the ability to persuade, influence, facilitate and negotiate, numerous islands will remain in the archipelago of PCTs.

The key is for clinical and managerial leaders to adopt an enabling role to improve healthcare and performance, rather than directing, controlling and monitoring results. They need to be visible and accessible, and create an environment in which openness, creativity and experiment flourish.

They need to make time to bring staff together.We have held two conferences for staff to share information. This has been followed up by workshops. The developmental agenda fits with key goals for the organisation which include:

improving access (meeting the targets in the NHS plan and older people's national service framework);

integrating mental health and learning disabilities into a health and social care model (for mental health, integration with primary care is also crucial);

supporting the development of clinical governance across the PCT (and minimising risks);

supporting the development of primary care.

With this huge agenda the PCT cannot behave merely reactively. For example, for acute services commissioning it is easy merely to grasp funding opportunities as they arise such as 'action on'money to improve trauma and orthopaedics, ear, nose and throat, and ophthalmology. Such approaches lead to 'add-on-itis'without a fundamental rethink about how access can also be improved.

The PCT worked with the local authority and the hospital to identify the key constraints in the system.We found that these were lack of homebased care and access to nursing home and residential care, causing delayed discharges and medical outliers in surgical beds; blockage in access via accident and emergency services because of lack of diagnostic facilities, and the availability of medical and surgical skills to provide rapid assessment, treatment and throughput.

The analysis led to the PCT supporting a case for investment in a diagnostic and treatment centre to provide an intensive assessment of surgical and medical cases backed with an improved range of diagnostic services and with investment in intermediate care beds and home-based care.A whole-systems approach was required to deal with the problem effectively.Having a strategy helps to ground new initiatives within a coherent plan.

Early experience within the PCT suggests that there is much to gain in the future from working in this model. Despite early reservations, GPs have found the PCT to be close to their concerns - many of which were about access to care for their patients. It is possible to spot problems early.We have identified poorly performing doctors, for example, and provided appropriate support.

Until there is full devolution of resources from health authorities (as they move to a more distant strategic role), capacity is constrained within the new organisations, although by joint working with partners skill availability can be maximised.

Finally, by being locally based, and with good clinical leadership, they have at their heart a need to ensure that local care for patients is the best that can be delivered within the resources available.

Barbara Kennedy is chief executive, Milton Keynes primary care trust.