Column

Learning from PCT-land

Dear Reader

I became chair of a large urban primary care trust a year ago, so this seems a good time to offer a personal reflection on the potential of PCTs to ‘make a difference’. For me, there are three clear lessons from PCT-land:

• Local accountability remains very weak
• Secondary care providers remain the dominant force in the local NHS
• National top-down priority setting (almost entirely focused on secondary care) overwhelms the NHS policy agenda

None of this will surprise you, dear reader of healthmatters, but it does run counter to the intended purposes of PCTs and so presents a discouraging picture.

Not all is gloom, however. In my area, the relationship between the NHS and the city council has improved dramatically, strenghtening local democratic influence. Inherited financial problems are acting as a lever for change in secondary care, and the PCT is busy developing more efficient models of care. The national agenda on access is cutting waiting times, which will be welcomed by the public, who see this as a priority.

But the important question for us is whether, in time, we will be able to move from being little more than local administrators of a highly centralised policy agenda, to becoming effective change agents who really can ‘shift the balance’. For this to happen:

• Power must shift from those representing provider interests to those representing patients interests
• Service development must shift from an secondary care to primary care
• Health promotion has to be backed with sufficient resources as a prerequisite for reducing health inequalities
• Service planning has to allow local priorities to sit alongside national targets

For my PCT to make progress we need to achieve financial balance, so we have the elbow room to develop our own agenda.

The scale of our deficit means that recovery will be a long haul – at least five years.

Local NHS accountability could be boosted if local authorities were given responsibility for commissioning health services. But given the government’s lack of enthusiasm for this, foundation PCTs with directly elected board members may be worth a second look.

Together, foundation hospitals, tariff pricing and patient choice could force hospitals to be more customer focused, and also allow us to move services into primary care where appropriate. ‘Every hospital a foundation hospital’ does reduce my opposition to them.

Do I end the year a pessimist or an optimist? We have substantial growth in resources and can plan for the medium term. We have the prospect of proper planning and service integration between the NHS and local councils. A philosophy of devolution is emerging from Whitehall. In my area, clinicians and others appear prepared to work in new ways. The scale of our deficit means we must be patient but I do believe we have an opportunity. So I start my second year as an optimist.

Yours sincerely