Primary care groups and primary care trusts have exciting freedom to decide on their preferred organisational model.

This has to be a golden opportunity. Very rarely do we have the opportunity to build something new. But have primary care groups and trusts done anything new in terms of organisational design that takes account of the essential essence of primary care? On the face of it, all but a few seem to have minimal management structures that mirror traditional organisations. How many bumps of collective heads will it take for PCGs and PCTs to find an organisational shape and a way of working that is truly fit for purpose?

Are they really organisations, and what organisational design best supports their development? PCGs and PCTs are in fact outside the traditional NHS structures. At their heart are hundreds of general practices, small businesses that have operated in what's almost a semi-detached relationship with the NHS. PCG boards and future executive committees of PCTs could have a collection of individuals from a wide variety of organisations and networks, and with that come multiple accountabilities.

The important issues for key people within PCGs appear to be:

What are we here to do? The answer is to make a difference to people's wellbeing in the longer term and to their experience of services in the medium term by focusing locally, joining up services and interventions and achieving positive change.

What does this mean for a PCG or PCT? To make a difference requires adaptability. It calls for people who can be flexible, and respond effectively to whatever the issue is, even if this requires breaking through traditional barriers.

We have an emerging policy framework that could enable a more cohesive, joined-up approach to planning interventions with strong local sensitivity - a framework capable of being firmly focused on improving health (and wellbeing) and improving the quality of services with primary care (in its widest sense) centre stage. As we near our 18-month development check, PCGs and PCTs need to make the space to reflect on what kind of 'network' they are aiming to build.

Are PCGs and PCTs organisations? They do not fit in with our cultural norms when we think of an organisation in which there is a line of accountability through a hierarchy.

There are very specific features to the various existing organisations now either represented within PCGs, or by default sitting in PCGs or PCTs, such as community pharmacists, nursing homes and voluntary groups. With these features come particular needs and styles which require PCG/PCTs to think laterally in shaping their form and structure, so that they are fit for purpose. Some of them will have survival needs - for example, direct financial and clinical support.For others it may be developmental or expansionist needs - for example, taking on new business or accessing new networks.

Addressing the particular requirements of constituent organisations will be crucial in building an infrastructure that will deliver the goods. This will require creative thinking and skilled communicators within PCG and PCTs, and support for risk-taking and new approaches within health authorities. If PCGs and PCTs realise these differing needs, they are likely to look and act very differently to traditional public service organisations.

We think that there are a number of organisational concepts particularly relevant to this developmental stage of PCGs and PCTs.

The first is provided by Colin Hastings, who captures the challenges facing PCGs in describing the features of what he has termed the new organisation.

1Central to this concept is staying small while at the same time operating as a larger unit. For PCGs and PCTs this requires the continuation and further enhancement of devolved, autonomous and accountable groupings. This fits well with general practice and extending the capability of the primary care team.Having direct access to social care resources may aid ownership and begin to create a strong basis for developing a new organisation.

Creating the intense independence which is another hallmark of Mr Hastings'new organisation might also help the paradox whereby general practices have no formal line management relationship in the traditional organisational sense to the PCG/PCT board, but this is nevertheless critical for delivering the board's agenda.

We need to think of an approach to organisational design and shape that takes account of the unique characteristics of primary, community and social care and the fact that PCGs and PCTs are still not organisations in a traditional sense.

We suggest that the following ways could be developed so that PCG and PCTs as new entities have a best fit organisationally with the culture and dynamics of the key constituent organisations they are aiming to integrate (see box).

The aim should be the creation of a learning organisation that develops, and transforms through the development of its members.

2The learning company maintains its viability by adapting to its context and, in doing so, maintains meaningful work and development for its members, but also develops that context to achieve a sustainable relationship.

This means that the people in such companies can, through their work, make contributions, not just to their organisations, but through them to the wider society. In return they receive an enhanced sense of personal contribution and meaning.

It would seem sensible to instil these characteristics into PCGs and PCTs from this early developmental stage since this is a golden opportunity to institute these ways of working as PCG and PCT norms.

A PCG and a PCT needs to be a flexible, fun organisation that delivers improved primary and community care and has internal and external recognition for doing so.

Creating effective organisations Decentralise radically By minimising the number of fixed appointments and maximising the number of people on secondments or undertaking projects, PCGs and PCTs would ensure that the balance of power in terms of delivering the agenda was spread out over all the PCG and PCT, optimising the involvement of all stakeholders.

Encourage expectations Practices should be demanding of their PCG and PCT board, the board demanding of practices and other constituents, developing explicit expectations by service users. Involving service users at the beginning of a project such as mapping breast cancer services in primary care gives a commitment to women that we will do something about the issues they raise. Statements of intent between the clinical governance leads and the practices clearly articulate expectations.

Promote interdependency Shared development is required, involving trust and mutual respect.

This should happen through implementation of the clinical governance agenda and initiatives such as shared bank staff, greater cross-training when practices have clerical staff on leave, and a greater acceptance by members of the public for using the most appropriate gatekeeper into the healthcare economy, whether it is their GP, NHS Direct, a nurse or a pharmacist.

Distribute leadership By having strong sub-groups, PCGs and PCTs are able to defuse the focus of leadership, empowering many people to lead on specific areas.

In this way leadership is more about enthusiasm and respect of peers than position power.

Set transparent performance standards While some of these exist in the health improvement programmes and national service frameworks, we think they are probably not sufficiently robust. Standards need to be owned and made more explicit, both from the health authority to the PCG or PCT, and from the PCG or PCT to its constituents.

Bust boundaries The new freedoms around pooling budgets give us a great tool in which to do exactly this. But this is not just about financial resources, it is much more about a cultural change and being much more radical in how we train and develop staff and create new breeds of healthcare worker.

The hallmarks of the new organisation:

Radical decentralisation Intense interdependence

Demanding expectations

Transparent performance standards

Distributed leadership

Boundary busting

Networking and reciprocity

Key points

PCGs and PCTs have to find the sort of structure that best fits their purpose.

Unlike traditional organisations, they do not have a line of accountability through a hierarchy.

While developing, they should concentrate on decentralisation.

Flexibility should be safeguarded.

REFERENCES

1 Hastings C.The New Organisation; growing the culture of organisational networking. 1993.London: McGraw-Hill.

2 Pedlar M, Burgoyne J, Boydel T.The Learning Company, Strategy for Sustainable Development. 2nd edition, 1997.

London: McGraw-Hill.

Jane Beenstock is chief executive of the Southport and Formby primary care group and Sue Jones is director of primary care, Sefton health authority.