Alisdair Stirling takes a look at what PCTs actually do and which responsibilities will be transferred to GP consortia
Fledgling GP consortia are getting to grips with the functions of their local PCTs with the aim of taking over from them in 2013. So what do trusts really do – and which responsibilities are GPs likely to have to shoulder when the reforms take effect?
PCTs will be abolished. That much is clear from the Government’s sometimes sketchy white paper, Equity and Excellence: Liberating the NHS. We also know that their public health functions will be given to local authorities.
The new NHS Commissioning Board will take over commissioning GP, dentistry, community pharmacy and primary ophthalmic services (as well as overseeing new GP consortia) and GP consortia will take over the commissioning role from their local PCTs. So far, so good.
But the other certainty is that NHS management costs are to be slashed by at least 45% over the next four years.
Estimates for how much management allowance GP consortia will receive range from £9 to £14 per head of population – which is a fraction of the funding PCTs currently enjoy.
So does that mean there is a massive amount of waste in PCTs that can be easily dispensed with in transition, that services they currently provide can be axed when the consortia take over? Or will it mean GPs will have to take them over on a massively reduced budget?
Will consortia be able to concentrate wholly on commissioning, or will there be a raft of other functions to assimilate into the new organisations?
These are the questions fledgling consortia all over the country are scratching their heads over. Part of the problem is that even practice-based commissioning groups that have been working closely with their PCTs for the past few years are unsure what the full range of their trusts’ activities are.
Listing the functions
The Department of Health is at least aware of the problem GPs on the ground are facing. They recently collaborated with the NHS Confederation to map PCT functions at a national level.
Their findings are not reassuring reading for consortia. For a start, the resulting document runs to 14 pages.
It lists hundreds of responsibilities, many of them statutory (see box, below left). Many apply to the roles we know will be taken on by the NHS Commissioning Board, perhaps at regional level and by local authorities, but many could equally apply to a greater or lesser extent to consortia’s core function of commissioning care.
Another Department of Health exercise is also under way to ‘map the money’. Government accountants are working with two unnamed PCTs and scrutinising the trusts’ books to see how much of the management budget they spend on each function. That will provide the first clear picture of how much commissioning actually costs to run – and how much management allowance GPs will need to take it over effectively.
David Stout, director of the NHS Confederation’s PCT Network, says PCTs’ responsibilities have burgeoned since they were formed.
‘Much of this has grown up from 2005 when huge responsibilities were transferred down from Strategic Health Authorities. They also took on the new GP and dental contracts in 2004 and 2005 respectively. The management costs have just rocketed since about 2002,’ he says (see box on PCT history, below).
Part of the rationale of the NHS Confederation exercise – for the DH at least – is making sure that nothing important slips through the net when PCTs are abolished. Mr Stout believes that is likely to mean GPs taking on more – even if they have to do so with less funds.
‘This list of functions goes well beyond the duties that GP consortia as statutory bodies will have. And if GP consortia have to operate on a smaller management allowance than PCTs did, we’d be anxious that there’s a risk of taking more management capacity out than would make the system viable.
‘We would start from the assumption that PCT functions will sit with GP consortia unless they are otherwise accounted for.’
A blank sheet
Not everyone, however, is making the same assumption that these PCT functions will shift to consortia. Management consultants Tribal have carried out their own analysis with a view to identifying the essential responsibilities that GP consortia should take on for the new system to work properly.
• knowing what outcomes and value current spending is delivering for patients
• understanding how providers work so they can influence services
• improving the patient experience by delivering individualised patient care
• developing themselves as robust and effective organisations.
PCTs have been doing, or trying to do all these things – among many others. But in Tribal’s view, starting with a blank piece of paper makes it possible to crystallise the following core duties for commissioning consortia:
• information and knowledge management – consortia will have to be able to manage and analyse large volumes of data
• financial management – this should be professionally-led and could involve large-scale health economics
• service improvement and leadership – blending public health and epidemiological knowledge with patients’ views
• provider influence and management – this could extend to ‘encouraging’ the local provider market to ensure the success of the ‘any willing provider’ model. It will also involve monitoring providers’ performance
• pro-active health management – targeting patients at risk of hospitalisation and leading this systematically and routinely for every member of the consortium population
• care navigation – potentially including referral management and GP performance review
• consortia development – ensuring sustained investment and working in a complex multi-agency environment
• statutory governance – ensuring continued viability by managing financial and clinical risk through strong and robust procedures.
‘There’s a lot of noise around structures,’ says Jeff Anderson, Tribal’s director of primary care services. ‘But it’s more important to talk about the key functions for consortia.’
‘The white paper offers a great opportunity and we don’t want to risk falling into the trap of reinventing the wheel – just recreating what’s been before. GP consortia can escape the bureaucracy of PCTs. If they are really going to do what they’ve been made for, they’ll need a fresh set of priorities.’
If red tape is to go, he believes some of PCTs’ current activities will have to fall by the wayside: ‘I’m pretty sure consortia won’t be able to do everything. If you speak to people at different levels, they’ll agree that some of the things PCTs do have sometimes been more internal than for the benefit of patients. Those activities will drop off.
‘I would advise consortia to turn that around and focus on what they really need, which will be fantastic information and financial management.’
Julie Wood, director of the NHS Alliance’s commissioning federation, says more detail of consortias’ roles will be supplied by the Government’s response to the white paper consultation due in December.
But she predicts that GP consortia will only have to take on a fraction of what PCTs currently do. She refers to the NHS Confederation’s 14-page list as ‘scary’ and says that GPs should not be phased by the complexity of PCTs’ current roles.
‘You’ve got to remember that consortia won’t be managing primary care. They won’t be doing public health or any number of other things PCTs currently do. People worry about the management allowance and say it will be far lower than the estimated £23 per head that PCTs now spend.’
‘But that’s comparing apples with pears. GP consortia will have their statutory duties surrounding the commissioning of care and that’s it.’
Alisdair Stirling is a freelance journalist
PCTs – a history
Primary Care Trusts emerged with the new millennium, growing out of the 481 Primary Care Groups (PCGs) set up in 1999 by the new Labour government and accompanying Labour’s flagship abolition of GP fundholding. PCGs evolved quickly, often merging with others, and in 2000 the first 17 PCGs formally became PCTs. By 2002 there were 302 PCTs and PCGs entirely abolished.
According to Geoffrey Rivett, a former NHS administrator and author of Cradle to Grave. 50 Years of the NHS, the original functions of PCTs were:
• engaging with the local population to improve health and wellbeing
• commissioning a comprehensive and equitable range of high-quality and efficient services within allocated resources
• directly providing high-quality and efficient services where this gives best value.
But when 80 per cent of NHS funding began to flow through them in 2003, their role rapidly became more important and the number of health authorities fell, driven by progressive reduction in their responsibility for commissioning services.
Mr Rivett says: ‘PCTs had to develop commercial commissioning skills because their decisions were open to challenge, particularly when independent contractors tendered.’
PCTs were expensive to run and in a 2005 streamlining exercise, their number was slimmed down to 152 with an average population of around 330,000 per trust. In the process, they inherited many more functions from health authorities. The changes meant that around 70% of trusts were coterminous with local authorities. This is the landscape that GPs are now about to inherit.NHS Confederation list of PCT functions
In addition to running primary care, the list covers PCTs’ general statutory duties, including providing a comprehensive range of services and the duty to break even – as well as a series of other statutory duties delivered on behalf of the health secretary, including compliance with the European Court of Human Rights and discrimination legislation.
Other responsibilities include:
• strategic leadership and planning – covering duties such as reducing health inequalities
• partnership, engagement and advocacy – including statutory duties to co-operate with other NHS bodies and local authorities
• engaging local partnerships – including such responsibilities as effective winter planning
• providing and securing services – a large range of statutory duties in relation to commissioning and providing care
• monitoring and evaluating – both of quality and of money
• accountability and ensuring – making sure the money is well spent
• workplace responsibilities – including employment regulations and health and safety
• estates and IT – both the PCT’s own and GPs’
• service-specific duties in relation to legislation such as the Mental Health Act and the Children and Young Persons Act.
The list also covers a whole range of other duties from the requirement to publish an annual report to handling litigation and clinical negligence cases.What do PCTs do?