Managers, GPs and politicians are the best of friends. Even rival national PCG organisations love each other really. Yet, somehow, the NAPC's conference wasn't entirely tension-free, writes Kaye McIntosh

Former fundholding guru Dr Rhidian Morris really, really likes managers, he told the annual conference of the National Association of Primary Care in Harrogate. He has no idea why anyone would think otherwise.

Managers who remember his reign as leader of the National Association of Fundholding Practices may be able to supply a few reasons.

He told HSJ that he 'has always been a supporter of managers'. And he told his audience of GPs, nurses and primary care group managers: 'It is hopeless for managers to tell clinicians what to do or for clinicians to think we don't need managers.'

And if the transformed chief cheerleader for PCGs is not fond of his rivals in the NHS PCG Alliance, he is not going to attack them. If the alliance wants to be the voice of PCGs, that's fine. They may claim that between 300 and 400 groups are signed up, but Dr Morris isn't going to argue. He isn't going to reveal how many PCGs are members of NAPC, either.

'We now represent more practices than we did when we were the National Association of Fundholding Practices.

I don't want to get into that battle. My job is to represent the people who are members of my organisation, ' he says.

But he can't resist a knock. 'There are 725 people here at this conference.

How many were at the alliance? We try to represent people in primary care, but I am not arrogant enough to say I am the voice of PCGs.'

Cosiness became something of a theme at the conference in Harrogate last week. Health minister John Denham told delegates that Dr Morris and the NAPC were his new best friends.

'I want to acknowledge all the help and support we have received from Rhidian Morris and his colleagues, ' he said.

Dr Morris reciprocated: 'We have an excellent relationship with this government. We accept their right to shape policy.'

Even the hostility of grassroots doctors towards the new commissioning process couldn't threaten his optimism. NAPC's surveys of practices and PCGs show that practices see PCGs as threatening, bureaucratic and unsupportive.

A worrying 55 per cent said the PCG system would not work. Nearly 60 per cent of practices had lost services in the first year of PCGs and 39 per cent hadn't even seen the health improvement programme which is supposed to drive PCGs' efforts.

Dr Morris saw this scepticism as understandable. 'There is a new relationship between PCGs and practices.

There is a difference of perception and PCGs have only been in existence for six months. They have started making changes, but it has not yet fed through to the grassroots.'

But if the survey results were the same next year 'that would be very worrying', he added.

PCGs were only slightly more upbeat. Almost half were struggling with less than the£3-a-head management funding originally promised by ministers. Nearly two-thirds said they were short of the money they needed to be effective, and nearly as many said their health authority was 'reluctant' to fund the PCG.

While 70 per cent had enough faith to plan to become pr imary care trusts within the next few years, almost 30 per cent said board members had resigned.

NAPC executive board member Dr Howard Freeman said he was 'surprised' that resignations were so high, although some of the movement could be explained by nurse members changing jobs. But he said many of the concerns that emerged from the survey were 'issues which Whitehall officials will have to take seriously'.

He added: 'It is about HAs letting go, it is about the variation in management costs.'

Mr Denham promised delegates he was 'addressing' the issue by collecting data on management costs. 'The emerging results show wide variations, and on the face of it, it is difficult to justify, ' he said.

Ministers would be asking HAs - 'particularly the outliers' - to account for the discrepancies and would ask PCGs for their views.

Mr Denham tried to escape without taking questions and was booed for his efforts. Changing his mind, he agreed to answer three - but insisted on taking them together. Delegates disapproved.

In response to calls for more money and moves to tackle the crisis caused by increases in generic drug prices, Mr Denham mentioned the fabled£21bn from the comprehensive spending review. He told his audience it was up to them to put the right systems in place, including prescribing protocols.

Dr Andrew Taylor, information technology board lead at Oldham East PCG, said: 'Cynicism is there, definitely. We have a spectrum of GPs and the interested ones are already on the board.

'We should be sharing more information about what we are doing, but it is difficult to share ignorance rather than knowledge.'

His chief executive, Derek Hathaway, said: 'We shouldn't expect within six months to be able to give a long list of what we have achieved.

'We have been creating the infrastructure so far, so we shouldn't be too despondent about the results.'

GPs may be cynical about PCGs. But not half as cynical as senior managers are about their chances of surviving the transition to PCT status. The enthusiasts for PCTs are out there, urging everyone to make the jump. Dr Morris and the NAPC believe PCGs should move fast to grab the increased power of PCT status. 'We said we should go as quickly as we are able to. We thought it would take about two years to create an identity as an organisation. If you were in a total purchasing pilot you might be ready next year. But two years is about the right time to go from scratch.'

Mr Denham cajoled his audience: 'I believe these fledgling organisations are now ready to fly. They will gather momentum as PCTs are established.'

From level one PCGs, advising HAs, to level two and beyond, it was 'essential' for HAs to 'foster this process' and fund the management costs of allowing PCGs to develop into trusts, the minister added.

Dr Alison Smith from Adur PCG challenged the speakers: 'What is it we can't do as PCGs that we can as PCTs?'

Lucy Hadfield, chief executive of South West London Community Health trust, had no doubts: 'The division between hospital and community health services and general medical services is a barrier to the delivery of an effective domiciliary service, especially for those with chronic illnesses.

Working alongside is not enough, we have to work together.'

But Linda Hughes, chief executive of Newham PCG, thought the future could prove uncomfortable. A regional office source had told her 'the lifespan of PCG chief executives would be as limited as that of community trust chief executives'. And Ms Hughes was steaming.

She challenged London region director of primary care Dr David ColinThome, himself a GP.

He replied: 'The fitness for purpose is inherent in the PCG chief executive.

Where it gets complicated is with the mergers of PCGs, but if you are fit for the purpose we are saying your chief executive is also fit for the job.'

Ian Ayres, chief executive of a PCG bidding for trust status in the first wave next April, pointed out that PCG staff, including chief executives, 'need personal development as much as other individuals'.

But few chief executives are confident of hanging on to their status. One, who asked not to be named, said:

'There are 481 chief executives out there and we don't know what our future will be.

'Why were we appointed as chief executives if we are not PCT chief executive material?'

Mr Ayres' chair at Nelson PCG, Dr Freeman, said: 'It depends on the individual. I don't know if Ian Ayres will be our chief executive, because we will have an open appointments process.

But we recruited him to a PCG that would be a PCT within a year so that was always in mind. Some PCGs recruited people to do a PCG job and that may not be the same.'

Dr Morris said: 'The right people must get the jobs - it would be a disaster if we get the wrong people.' A level four PCT would have big management needs, he added.

Anne Willis, development manager at Greater Yardley PCG in Birmingham, said PCG chief executives' skills were 'not in the ordinary style of chief executives'.

'The way that chief executives manage PCGs is around facilitating GPs - otherwise they will revolt and they have the majority on the board.'

When it comes to PCTs, it would be different. With a formal lay-majority board 'it will be more diverse in terms of management skills'. But PCG senior officers would have the advantage of having 'learned how to manage GPs'.

A skill that should be prized for its rarity.