Unknown quantities

Published: 04/04/2002, Volume II2, No. 5799 Page 11 12

The NHS's serial reorganisation takes a new twist this month with the disappearance of health authorities and primary care groups and the emergence of primary care trusts as the cornerstones of the health service.

PCTs will take on many of the responsibilities of HAs - including commissioning, public health and primary care - and hold threequarters of the NHS budget for England. Many will also be running community services. But will PCTs - some of which only came into existence three days ago - be ready for the job? And how much difference will they make?

NHS Alliance chief officer Mike Sobanja has no doubts about the size of the task facing PCTs: 'The concern is that this is just too much at one time.'

Money is, as ever, top of the list of concerns for many PCTs - both for running their own organisation and for commissioning and developing services. PCTs are not starting from ground zero. They are frequently working within a health economy with an underlying deficit and this will constrain their freedom of action.

They are further constrained by much of their expenditure being eaten up by services over which they have little influence - those demanded by national priorities and the ever-expanding cost of prescribing, for example.

'We have had to look seriously at what we cut, but the realistic control we have so far over the budget is minimal, ' says Jan Hawes, Basildon PCT chair and an NHS Alliance executive committee member. 'We took a decision that we would not cut the primary care development fund. Most of our money is going straight to the acute side.We are probably going to end up having to borrow money.'

With many health professionals still ambivalent about PCTs, they need some 'early wins' to convince GP and nursing colleagues on professional executive committees that they can bring about change: yet some PCTs have already had to sacrifice their development budget for the next year.

They are also battling with management costs. Senior staff transferring from health authorities may be on substantial packages: PCTs need both the funds to employ them and to deal with the delicate position of their own chief executives, who may find newly appointed staff earning nearly as much as them. Morale among other staff may be affected: 'There are people who made the leap of faith a year ago to go into PCTs, but at the moment they may feel their career path looks blocked because there are people coming across who PCTs have to take, ' says one PCT chair.

In many cases, staffing has not yet been finalised, with both strategic health authorities and PCTs hunting for appropriate people. And this is not just lower-grade staff: in late February a number of PCTs were still advertising for chief executives, with interviews to be held after 1 April. In Surrey and Sussex alone, there were 27 'top team' finance jobs still unfilled.

PCTs are also still negotiating the resources to employ the staff they need. 'The ability to move monies to create new or appropriate structures is being hampered, ' says Kathy Balcombe, chair of Bexley PCT. 'I do not think that anyone is being difficult, it is just that it is not feasible to release resources at the drop of a hat.'

Nevertheless, she says the biggest risk is that PCTs do not have the managers and structure they need to take on the task ahead. She says Bexley PCT did not have everyone in post on 1 April due to a 'mixture of the financial position and people working out where they want to be in the future'.

Ms Hawes agrees: 'There have been delays about where people would go from HAs. That has hindered our ability to structure in the way we would like (see box).'

King's Fund primary care director Dr Steve Gillam suggests that newly created PCTs may lose out in the battle for scarce staff.

For many PCTs moving from PCG status this will be the first time they have directly employed staff and, unlike previous waves of PCTs, their ability to do so is not a deciding factor in the shift to PCT status. 'Suddenly on 1 April you become an organisation which is responsible for hundreds, if not thousands, of staff - I worry a bit about how geared up people are, ' says Mr Sobanja.

There is also a cultural shift for those former HA staff who move to PCTs. PCTs would like to be smaller, less hierarchical organisations, but they have grown out of several other organisations and this inevitably affects them.

West Cumbria PCT chair Patrick Everingham says: 'We have inherited a lot of policies, protocols and procedures from previously redundant trusts. PCTs are actually a jigsaw, made up of bits of other jigsaws.'

Many of these problems may be particularly acute for PCTs born of a merger of PCGs. Mr Sobanja points out that the average PCT will cover 160,000 people, and some will serve populations of more than 300,000. The local responsiveness and flexibility which was one of the drivers for early PCTs may be hard to maintain.

There is work being done to address many of these issues, and also to look at the tripartite leadership structure of PCTs - chief executive, chair and chair of the PEC - and how to make these complex relationships work.

Health secretary Alan Milburn has admitted that the structural upheavals are a 'huge risk'. Dr Gillam goes further: 'Some of these fledgling organisations may fall over. They have to be given a chance and time - the direction of travel is right but the speed and weight of expectations are overwhelming.You could say that they are being set up to fail.'

In the end, 1 April was just one date - albeit an important one - in the evolution of PCTs.They have a breathing space until October before they take on all of their legal duties - and many will need it.

'The thought that we were going to see PCTs hit the ground running on 1 April is laughable, ' says Mr Sobanja. 'It is inevitable there will be a degree of dislocation as new relationships settle down.

People will have to turn all their attention to working internally. . If you are busy setting up an organisation, you can't give 100 per cent to the local population.'

But PCTs are meant to be about doing things differently; and if they do not start making a difference to patients soon, this year's round of NHS musical chairs will have been in vain.

Post modern: the battle for public health talent Just six weeks before the 1 April deadline, primary care trusts had to rethink their plans and start competing for some of the 100 directors of public health previously employed by health authorities.'We may not be able to fill this post.There are going to be huge numbers of PCTs chasing these people, ' says Basildon PCT chair Jan Hawes.PCTs in Trent and Northamptonshire alone were still advertising for 34 directors of public health as late as a fortnight ago.