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Published: 02/06/2005, Volume II5, No. 5958 Page 22 23

Since their creation, doubts have lingered over PCTs' ability to manage acute trusts and other providers in an increasingly competitive market. But together, they are stronger. Tim Riley and Will Blandamer report on a Manchester project that is proving the power of collaboration

Doubts about the robustness of primary care trusts have haunted their development for much of their short lives. These have focused on whether they have the capacity and the capability to negotiate effectively with acute hospitals to achieve both sustained improvements in waiting times for elective surgery and emergency care, and transfer of significant tranches of secondary care services into primary care.

This has been the impetus for the increased collaboration among PCTs promoted in Creating a Patient-led NHS: delivering the NHS improvement plan, in which the government encouraged PCTs to work together to manage the complexities of an increasingly pluralistic healthcare market.

Of course, agreeing service-level agreements - and now contracts - with hospitals remains only one of the four broad responsibilities of PCTs. But it is the most challenging one because of the preference for localness over critical mass in the design of PCTs almost five years ago.

The other responsibilities - improving public health in collaboration with local authorities, overseeing the relationship with independent contractors and managing the delivery of local community-based health services - all pointed towards the importance of localness. But some original PCT configurations seem to be more the product of local NHS politics than of ambitions for improved local delivery.

One of the emerging solutions to this lack of critical mass has been the creation of integrated management structures in which one set of directors serve on the boards and professional executive committees of two or more PCTs.

In the two Trafford PCTs, one chief executive has managed both Trafford North PCT and Trafford South PCT since 2003. The PCTs 'zipped up' both management teams and both sets of PCT provider services into one organisation serving two statutory bodies.

This has undoubtedly enhanced the PCTs' partnership with the local borough council in the management of their provider services and achieving broader negotiating power with acute providers. However, it was clear that this approach alone was not enough to enable the PCTs to become proactive in shaping services and getting the best value for local people.

This was increasingly the experience for other PCTs in Greater Manchester when it came to negotiation with local acute hospitals on issues such as acute sector investments and service changes to improve access.

Aims and ambitions

From early 2004 the city has had an Association of Greater Manchester PCTs, a voluntary body set up by the 14 PCTs themselves. It has three key aims closely linked to the aspirations of the act that established them: to put in place collective capacity and capability in procurement and contracting for health services; to invest in PCT provider functions to enable them to compete on an equal footing in the local healthcare market; and to establish a coherent framework for the improvement of public health in collaboration with the Association of Greater Manchester Local Authorities.

The association appointed an associate director, who has worked with members to develop a shared vision for the future of primary care services.

Its statement of strategic intent included an outline framework for the completion of capacity planning and local delivery plans for 2005-06 and beyond.

This was followed by a financial formula that had a major influence on the strategic health authorities' financial guidance for 2005-06. The public health directors are working on a document that aims to make public health central to the activities of the association. And the PCT chairs' forum played a major part in raising the profile of the association, with its official launch in London in March.

Getting leaders on board

The presence of senior PCT leaders in the association is starting to bear fruit. The model of enhanced individual PCT capacity and capability to carry out work on behalf of the association has resulted in the recruitment of directors of managed care and, in partnership with Greater Manchester SHA, directors of mental health.

Further development of a genuinely powerful procurement and contracting unit for Greater Manchester - building on lessons learned from US health insurers on the need for more, and higherquality, information to inform decision-making - will call for considerable courage on behalf of member organisations in terms of sharing both sovereignty and resources.

This is not a new challenge - an effective collaborative commissioning function is already in place. But PCTs will find it a challenge to retain ownership of 'their' service.

And although not a priority for the association itself, some of the constituent PCTs may become entangled in potentially distracting conversations about shared management or merger. The message from the association - and borne out in a report from the NHS Alliance (see box, below) - is that PCTs are now sufficiently mature to ensure independence for those functions that require localness by pursuing interdependence for those that require critical mass.

This success of the association also shows that the necessary collectivisation that interdependence entails does not need to be driven by SHAs - in fact, it is undoubtedly better if it is not. And legislation is not required to make it happen faster.

Beyond tackling the immediate issues facing Greater Manchester, one of the real benefits of the association to local PCTs is the creation of an independent and authoritative voice for them on the national policy stage, arguably for too long the preserve of the 'hospital lobby'.

A network of PCT collaboratives is already being formed. Perhaps we can look forward to a national alliance of PCT associations, which will shape policy as much as responding to it .

Dr Tim Riley is chief executive of Trafford North PCT and Trafford South PCT and chair of the Association of Greater Manchester PCTs. Will Blandamer is associate director of the Association of Greater Manchester PCTs.

THE NHS ALLIANCE VIEW

The NHS Alliance published a report in April highlighting the 'enterprise and innovation' of primary care trusts in designing organisations to be prepared for the future. The report, conducted in conjunction with Birmingham University's Health Services Management Centre, aims to inform PCT boards and professional executive committees on the influence of policy on PCT reconfiguration and options for interdependence. You can read more about the report in the primary care round-up in next week's HSJ.

Key points

PCTs are being urged to work together to increase their capacity to negotiate effectively with acute trusts.

In Manchester a collaboration of 14 PCTs has enjoyed considerable success, with member trusts sharing a statement of strategic intent.

The experience the Manchester PCTs suggests col laborat ions of th is type are more effective when not driven by SHAs or central legislation.