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Have PCTs been a failure?

A failure to engage with GPs has left PCTs unable to innovate, says Dr Stewart Findlay, but PCTs have made real improvements and GP commissioners will need to learn how they did it, counters David Stout

I don't think there are many people who would argue that the creation of PCTs was the most successful reorganisation we've ever had in the NHS. Of course that doesn't mean that a lot of good work hasn't been done. And it doesn't mean we don't have

a great number of excellent managers.

Many of those managers have been as frustrated as clinicians at the inability of PCTs to drive change and encourage innovation. Those same managers now face a very uncertain future and we must make sure they can see where they fit in to the new structures as soon as we can or we risk losing them.

But the feeling that PCTs have failed is particularly prevalent in general practice.

I have acted as a gatekeeper to secondary care services all my working life and have been involved in commissioning through fundholding, primary care groups and with the earlier, smaller PCTs.

In those days clinicians worked hand in hand with their managers – we knew the chief executive and the chair. We felt part of our PCT and worked hard to make sure they were successful. There was mutual trust with managers and clinicians working together to make decisions quickly and set up innovative schemes to improve patient care. We actively managed our prescribing and referrals and felt responsible for the financial balance of our organisation.

Some PCTs managed to retain those good relationships with GPs. But in many there was an almost immediate change in that relationship with the big PCT merger in 2006.

The new PCTs were more remote and saw general practice as just another service to commission. They didn't seem to understand that GPs were spending billions on their behalf, or that they needed to make sure we continued to feel responsible for the financial consequences of our referrals and prescribing.

Practice-based commissioning was the easiest way of doing that but most PCTs were too risk-averse to devolve budgets and so the scheme failed, in all but a few areas. Those areas that did embrace PBC and made it work will be at the forefront of GP commissioning and are already seeing the savings GPs can make when they are engaged in the process.

To be fair, PCTs also had their hands tied by the mounting bureaucracy in the NHS. Even the simplest of changes to a service seemed to require endless meetings, the development of specifications, business cases, risk assessments, contracts, procurement and tendering. The result was that many clinicians found it was easier just to stop trying to develop new ways of doing things. And despite their size, PCTs were also unable to control powerful foundation trusts.

The result is that as we try to achieve savings under the Quality, Innovation, Productivity and Prevention (QIPP) initiative, we are seeing a rise in referrals to secondary care, a rise in emergency admissions and an increase in prescribing costs. Those trends will be difficult to reverse quickly but the only way to do it is to re-engage GPs in the commissioning process in a meaningful way.

But if GP commissioning is to work,

our new organisations will have to be smaller and their managers work more closely with groups of federated practices. They will also have to simplify the commissioning process and work in a completely different way to PCTs.

If not, our new leaner organisations will also be buried under a mountain of bureaucracy.

Dr Stewart Findlay is a GP in Bishop Auckland, County Durham, and NHS Alliance regional GP commissioning lead

Some would have you believe PCTs have done a dismal job with taxpayers' money, frittering vast amounts on projects destined to fail and denying patients access to much-needed treatments. Although such criticism has been justified in some cases, much of it has been based on a misunderstanding of commissioning or a denial of the need to prioritise or ration in a cash-limited health system.

Any tax-funded health system requires some form of commissioning – assessing local need, planning and putting in place services to meet that need and holding those services to account. The NHS in England has tried various commissioning approaches over the past 20 years or so, of which PCTs were the latest incarnation.

All forms of NHS commissioning have been subject to criticism – which is perhaps the reason for the frequent restructuring. Often that criticism has been borne out of disappointment at the rates of improvement in the NHS or the power imbalance between commissioners and providers.

But any commissioning organisation is prone to criticism as a decision to prioritise one service will be at the expense of another. And no matter how good the commissioner, some part of the services they commission will be underperforming.

So how have PCTs fared? It is difficult to make historical comparisons as it was only in 2007 that the Department of

Health introduced a system to measure the performance of commissioners. Although much derided, not least for its title, world class commissioning sought to define and measure the effectiveness of commissioners for the first time.

While the baseline year of measurement in 2008/9 showed PCTs had relatively modest performance (not surprisingly, having been reorganised in 2006), the results the year after showed a marked improvement. Objectively measured against a series of competencies, PCTs showed an impressive 39% improvement in one year. Measures of governance – similar to the tests for foundation trusts – showed PCTs across the country performing well.

PCTs have also been shown to improve outcomes for their local populations.

A recent report by the independent organisation Health Mandate showed that where PCTs focused their commissioning priorities, outcomes improved faster than in other areas, demonstrating an ability to commission effectively.

Objective evidence shows PCTs have not failed and are starting to mature and make significant improvements in performance.

This is not an argument for standing still. The challenges ahead are enormous, not least the need to create big savings while maintaining or improving the quality of care. This will require big changes to the way in which we deliver health services and it's right that the health white paper emphasises the engagement of clinical staff and patients in driving these changes. The proposals are still out for consultation, but it is likely that PCTs will be abolished from 2013 and GP consortia will take on many of their commissioning responsibilities.

GPs are starting to understand the full implications of these proposals, and I hope they are ready to learn from both the successes and failures of PCTs .

If we are to make this new system of commissioning work, then clear and consistent communications between those who currently commission and those expected to take it on will be essential at every step.

Learning from past experience will be crucial. We cannot afford to be asking ourselves in five years' time ‘have GP consortia been a failure?' GPs, PCTs and local authorities need to start work now to oversee this hefty structural change and make sure it does not distract from the biggest challenge ahead – the £15-20bn of savings required from the NHS.

David Stout is director of the PCT Network at the NHS Confederation

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