The death knell for PCTs – and the top-down management they have come to represent – was sounded loud and clear last summer in the health white paper. But since then, there have been signs that health secretary Andrew Lansley's headline-grabbing ‘death sentence' may have been commuted.
The PCT clustering process – launched back in January – raised suspicions of retrenchment. And the forced amendments to the health bill in June, with the relaxation of the deadline for CGGs to take over budgets, implied a stay of execution for PCTs beyond 2013 in areas where CCGs weren't yet ready to take up the reins. Now that the drive towards CCG authorisation has begun in earnest, a sense of self-preservation among trusts is being revealed.
Configuration
The draft authorisation requirements for CCGs unveiled by the Department of Health in August in Towards authorisation set a tight timetable. And CCGs and PCTs across the country are now engaged in a race to sort out three key issues: configuration, commissioning support and internal management.
Configuration is the most pressing issue. Risk assessments to check the proposed shape of each CCG have to be completed by December. Even though the guidance is still in draft form, some have already begun the process. But according to Gerry McLean of Consulting Associates UK, which is working with CCGs on management and authorisation, some of his clients were told what their configuration should be back in July: ‘The guidance is still supposed to be a rough cut, but some PCTs are acting as if it's not going to change and are imposing their vision on CCGs. But travel a mile down the road and you'll find another PCT working well with its CCG and asking them what they want.'
Support
Another authorisation hoop for CCGs to jump through involves demonstrating they have external commissioning support arrangements. Lack of clarity on the management support allowance means many CCGs are still unable to work out what they can afford. A survey in September by the NHS Alliance and NAPC suggested nearly half of CCGs responding (46%) feel restricted in the commissioning support available to them. Only 35% say they are not restricted. Of those who feel restricted, 60% say they have only been offered existing PCT cluster support, 40% were given no choice at all, 47% were not made aware of all possible choices and 21% said they would have to bear the financial consequences of not taking the PCT offer.
Damningly, the survey also revealed that more than one in four CCGs (28%) described the emerging relationship with the PCT cluster as ‘mirroring the previous style' with one in three calling it ‘performance-managing and centralist'.
Dr Richard Vautrey, GPC deputy chair, says the process of authorisation will again raise the issue of CCG size: ‘The danger is we're recreating the organisations we're spending millions getting rid of. If CCGs aren't of sufficient size there's a risk they'll become dependent on commissioning support from outside agencies – whether PCTs or the private sector.' And he believes that if CCGs don't want this to happen, they may have to merge. ‘We've said all along that CCGs should consider being the same size as PCTs to have the commissioning clout and to be able to keep commissioning in house but devolve to localities. PCTs have, over the last few years, merged because you need a critical size to be effective. The same goes for emerging CCGs.'
The third revealing component of authorisation involves the internal management of CCGs. According to Mr McLean, the assumption at the release of the health white paper last summer was that the accountable officer for each CCG would be a GP.
‘Now all the documents say may be a GP. The realisation is dawning that the job will take up three days a week as a minimum, which few GPs can spare. So where will the accountable officers come from?' he asks.
Many will be TUPE'd in from PCTs, he believes. And while GPs will, for the most part, want to chair their CCGs, they won't want to be finance officers, leaving another gap for experienced PCT staff to fill.
‘The psychological effect of this will be that we're not a CCG, we're a PCT under another name,' Mr McLean said. ‘And the danger is you'll have a significant number of practices, now slightly apathetic, allowing top-down control to be maintained. In the most extreme cases, they'll simply be taking down two of the letters on the building saying PCT and putting up two others to spell CCG.'
Transition
Georgina Craig, a commissioning consultant and head of the NHS Alliance's pharmacy commissioning network, says: ‘CCGs' focus has been mainly on governance issues and so PCTs have yet to relinquish their commissioning roles. So when a PCT comes to a CCG and says: "This is what we think you should do", the CCGs are not always in a position to argue. The more CCGs roll their sleeves up and focus on the actual commissioning, the more power they'll have.'
Dr Amit Bhargava, co-lead for the NHS Alliance Clinical Commissioning Federation and a GP in Crawley, is aware some PCT clusters are ‘taking a protectionist view,' but stresses this is to be expected in a period of transition. He believes those areas will be brought into line as the national picture develops. ‘There are so many complexities. It's not the same everywhere,' he says. ‘But I'm an optimist. I think the process will weed out people who are wrong for their jobs in PCTs. We'll get the best people involved in the new system, and we'll end up with the best of both worlds.'
Alisdair Stirling is a freelance journalist
