Published: 03/06/2004, Volume II4, No. 5908 Page 18 19

Just two years after taking on an enormous range of responsibilities, primary care trusts have done what was asked of them - and sometimes more.

So why do they receive so little credit for their success?

It is only two years since the majority of primary care trusts came into existence, yet in that time we have seen a remarkable transformation in the NHS.

Waiting times have fallen in all sectors, quality has improved enormously, and patients are at last beginning to say that they are properly involved, consulted, listened to and valued.

Of course, such improvements have come about for a broad range of reasons. But two years on from taking on new responsibilities PCTs have largely delivered all that was asked of them and often more.

So it is disappointing to hear, instead of recognition and acknowledgement, another round of the familiar chorus of concern about PCTs' capacity and capability.

There is now a growing sense that longer-term delivery of the NHS plan will depend on highperforming primary care supported by competent, mature PCTs capable of fully assessing their patients' needs and securing the appropriate services to meet them. The long-term solution to sustainable, affordable and accessible care rests with primary care; system reform will largely be delivered by PCTs.

Every PCT has a huge remit:

co-ordinating and developing primary care and giving it its strongest ever voice;

securing appropriate secondary care services for their population; working with their communities to improve health and tackle inequalities.

Much of the change we still need to see is predicated on the movement of resource downstream and the delivery of more and more services in the community setting. PCTs are uniquely placed to achieve this and there is already a wealth of examples of their progress.

Despite suggestions to the contrary, we are seeing unprecedented clinical involvement and leadership. In most places professional executive committees and their broad range of clinical substructures have an enormous impact. The introduction of payment by results and the new focus on chronic care should reenergise everyone, as it gives us a mechanism for swift links between service redesign and funding which means that the money really does follow the patient. This will also mean a radical change to the way commissioning is done.

There are realistic and reasonable concerns about PCTs' technical expertise. There is no doubt they will need to be better at information analysis, predictive modelling and procurement. Increasingly, most commissioning will be done on a cost-per-case basis.

Sophisticated local information and the right incentives and levers to manage demand properly and deliver timely and informed choice will be key.

Payment by results presents PCTs with an enormous opportunity to expand community services and prevent admissions and referrals.While an overview of planning will be needed, the whole methodology will be very different from the sort of block commissioning to which so many are accustomed.

I suspect this is part of the reason why acute colleagues are critical of PCTs' commissioning (HSJ Barometer, page 27, 20 May), since many do not understand the direction of travel.Or perhaps they just do not like the fact that we are not prepared to hand over vast sums of money for simply more of the same.

Clearly, PCTs must work closely with one another and many have already created sophisticated arrangements for sharing work across the district and the strategic health authority - or even wider. This is important not only to commissioning but in many other arenas. Absence of robust networks, particularly at SHA level, not only compromises patient care but leaves PCTs open to criticism about competence to manage the bigger picture. It also opens the door for others to usurp our role. But we must make this model work since it is much easier for small organisations to build up networks of common purpose than for large ones to create meaningful, local substructures.

What we really must not underestimate is either the critical importance or the scale of the task PCTs have in developing primary care.Variability is still a cause for concern. For the first time in most areas, PCTs have brought together primary care clinicians to consider quality issues - and the results are stunning.Many have tackled poor GP performance where it was once ignored. Some are lucky and have inherited innovative, dynamic practices and practitioners, capable of actively driving the new agenda. Others have an uphill struggle to create that capacity.

Unless we give these PCTs time and value their improvement, we will end up with an even greater inequalities gap. This is where we need our best leaders, yet the performance system often leaves them unable to demonstrate success, as deprivation and long standing under investment affect current measurements.

Of course PCTs' capacity to manage this huge agenda is stretched and they would be the first to say that they need more investment in clinical and managerial leadership.

Unfortunately, in some areas they still struggle to overcome the legacy of the early days, when the complexity of such new organisations was poorly understood and remuneration was pitched too low. As a result, PCTs failed to attract the right calibre of leader.However, most are now beginning to cement their infrastructure and find new and imaginative ways of making the resource stretch.

So what support can PCTs expect for the future?

Commitment from the centre is clear, with consistent messages that this is the right model and that PCTs are about the right size.

Some PCTs still complain, however, that they need more support from their SHA to uphold their right to challenge secondary care's funding demands. Development opportunities are important but currently appear plentiful - indeed most say they are overwhelmed by them and actually need more capacity back at the ranch to allow them to do what they know needs doing. I believe that devolution of all resource, including the resource for modernisation, is the right way forward.

The Modernisation Agency's National Primary and CareTrust development programme has created a comprehensive infrastructure to allow PCTs to grow and work together and spread good ideas quickly. The 7,000 weekly visitors to the NatPaCT website, the 11,000 who have attended events over the last nine months and all the local and national network activity are testimony to that. But frontline organisations now want to take more control.

Good access to information will always be important, but frontline staff want to do things for themselves. They - not the centre - need to have ownership of this infrastructure.However, maintaining the appropriate links, which connect policy and modernisation through to PCTs at local level will be vital.

SHAs have a crucial role to play.

Their remit is both performance management and development, and providing both of these well is a difficult balancing act. They need to ensure the right support is there for those who can do well while not shirking from tackling those who are really not up to the task; otherwise they tarnish the reputation of all PCTs.

But I would encourage them to value the softer skills so critical to delivery in an organisation within which most of the workforce is not directly employed.

Many with these skills have successfully brought together diverse clinical teams - not just medical and nursing, but in pharmacy, dentistry and optometry. This is producing true partnerships with acute providers, social services, communities and the voluntary sector to create holistic care and a focus on health improvement as well as health services.

So come on everybody, give PCTs a chance. Let's celebrate the successes as well as working on the faults.We have a massive task to complete this quiet but profound revolution. PCTs have demonstrated their potential to play a decisive part in bringing about the radical change we all want to see. They need the time and space to get on with it.

Dr Barbara Hakin is National Primary and Care Trust development programme lead and chief executive of Bradford South and West PCT.