As work gathers pace to develop primary care groups, tribalism is rife, says health minister Alan Milburn, who talks to Peter Davies

Will history repeat itself in this 50th anniversary year? In 1948, as the appointed day for launching the NHS drew closer, health minister Aneurin Bevan faced last-minute resistance and threats of non-co-operation from GPs.

Today, as work gathers pace to implement The New NHS , health minister Alan Milburn faces threats from a band of dissident GPs that they will not co-operate in setting up primary care groups - which have to be identified by the end of July.

Despite an initially warm welcome from the British Medical Association's general medical services committee, it is dawning on the grass roots that the reforms represent a more significant change in the GP's relationship to the NHS than had first been apparent.

Some want PCGs stopped, or postponed until their concerns are answered. Murmurs can be heard about the local medical committees' conference in June considering industrial action.

All this just as the Department of Health issues guidance stating that LMCs 'have an important role to play' in setting up PCGs and that health authorities will need to ensure LMCs are 'fully involved'.

Is the minister worried?

'There are bound to be concerns. This is a big change going on. I'd be more worried if there was silence out there. . . PCG development is happening across the country. I know because I go out and about and see what's happening. . . The picture out there is pretty good.

'Not surprisingly, turf wars are going on, and arguments about boundaries in particular. That's inevitable at this stage in the game.'

If GPs' perennial anxieties about their income is at the heart of the matter, Mr Milburn is quick to assure them they will be rewarded for the time and effort they invest in PCGs.

'It's important the people playing a leading role in developing these organisations are recompensed, and we will recompense them. We'll be making an announcement in due course about that.

'We'll provide fundholders who want to move beyond fundholding with an exit route to the new arrangements and the ability to take some of their management allowances on the way. We'd expect to see those incentives taken up and, as a consequence, PCGs developing pretty rapidly.'

But he is not dangling in front of GPs the prospect of their exercising the dominant role in PCGs - yet. 'We haven't made any final decisions on board structure. That will have to wait.'

He adds: 'It's not about one set of health professionals emerging as the kingpins in the new NHS at the expense of everybody else.'

Guidance will appear in due course on the complexion of PCG board membership - and how members are to be appointed. It is possible some may be chosen by vote. 'We're looking at a number of models. There's no final decision on that. We're talking to representative organisations.'

No stipulation either on GP members having commissioning or purchasing experience. 'Local leaders will emerge.

Very often they will have commissioning experience, but that won't necessarily be so, and it will be a matter for them and their colleagues to determine.'

The accent is on consultation with 'stakeholders', though one group is conspicuous by its absence - hospital consultants will not be offered places on PCG boards. They can exercise their influence via health improvement programmes, Mr Milburn says.

Much current effort is directed at ensuring community nurses are involved.

HAs have been told to identify a lead community nurse in every provider unit as a liaison point. But progress is limited.

'As I go around the country, it's patchy. And I don't want it to be patchy.'

Tribalism is still rife, Mr Milburn acknowledges. 'What we have to get away from is the idea that the only way to solve the problem of tribalism is for one group to emerge triumphant. That isn't what the government wants to see.

We want to see partnership working.'

And to press home the point: 'We're moving beyond the 'me, me, me' emphasis within the NHS. We're moving into an era where it's the broad community that counts. I expect those factors to be properly taken into account.'

It is, he admits, 'an enormous break with the past. I don't pretend for a moment it's going to be easy. Partnership is an easy word to use, but it's very hard work to achieve on the ground. I know that from local partnerships I've established in my own constituency. But the prize is an immense one'.

Partnerships stand a better chance of thriving if based on 'natural communities', and the minister is determined that PCGs will reflect this.

'It's quite important people understand the top priority for me is to ensure PCGs are formed around natural communities. We're prepared to be flexible about the size of the population. We're not prepared to be flexible about the principle of natural communities.'

Defining natural communities is far from straightforward, but Mr Milburn is clear about what they are not: 'Forming PCGs from like-minded individuals across scattered communities is not something we're prepared to sanction.

If we see those proposals they will be rejected.'

While populations of 100,000 are the ideal, if the HA and prospective PCG can show a natural community exists on a different scale - and agree on its boundaries - 'we'll be prepared to look at that'.

What of the manager's lot in the brave new NHS of PCGs? Will they be the natural choice for PCG chief executive posts, or will they have to bow to GPs?

Mr Milburn says it is 'possible' managers may become chief executives, but sensing a definitive answer may land him in the middle of a tribal war, he adds: 'That's part of the tension we have to get right between what we prescribe from the centre and what we facilitate.'

His instincts are to restrict the centre to setting and policing standards, and holding to account, 'saying, these are the parameters and principles - it's for local determination and agreement how they are worked out.

'As far as possible, we want these organisations to be flexible and to work for the people who are delivering services on the ground. They have to command confidence locally.'

Once PCGs become 'free-standing organisations' employing their own staff, 'there will be a role for managers there, and happily lots of people who have built up experience within existing primary care structures, or elsewhere with HAs, will find a new role.

'We want to try to ensure we can slot experienced people in. We don't want to lose people who are doing a good job for the NHS.'

To HA staff despondent that PCGs look like the beginning of the end for them, Mr Milburn says: 'This is a big challenge for HAs. They are going to be extremely important organisations in the new NHS.

'They are going to become the accountable organisations, the focus for much of the partnership and liaison work, which means they will have to develop those skills as well'.

Capability Milburn

The day before he spoke to the Journal, health minister Alan Milburn could be seen in his role as the scourge of NHS bureaucracy on the floor of the Commons boasting at Question Time of the£1bn the white paper would save in that very area.

He owes his status as one of Labour's fastest-rising stars in part to the campaign he waged soon after becoming an MP in 1992 to highlighting - and condemning - the growth in the number of NHS managers.

His agitation from the backbenches led to the 'grey suits bad, white coats good' sloganeering, eventually taken up by the Tories, which so damaged managers' morale. Now he declares: 'I want to see a new sense of self-confidence among managers in the NHS.' And he confides that his hope is 'that we start to see managers in the NHS as a national force'.

They have, he says, an opportunity to shape the structure of the new NHS. How they go about forming PCGs will demonstrate to the centre whether they are capable.

'I believe they are, but it's a different set of skills than under the old market arrangements. That's going to require some handling, and it will raise issues about managerial capacity. We need to make sure we've got the right managers in the right places doing the right sort of jobs.'

He wants to see much more innovation in trusts and HAs, too. 'If you ask me if I think the capability is there, well I think it needs some development.'

That does not mean recruiting managers with the requisite skills from outside the service. 'We want to make the existing set of managers in the NHS have the appropriate skills to do the new jobs.'

The development programmes for chief executives and finance directors are a start, but none exists for human resources directors, 'which strikes me as pretty odd'.