Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Here we go again
- Sergio A Battistessa (15 October 2004)
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A bigger picture
- Keith J Edgar (16 October 2004)
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The Primary Care Trust - an inappropriate body to fund secondary care
- Nicholas M Wilson (17 October 2004)
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Its the complexity, stupid!
- Steven Ford (18 October 2004)
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Primary care trusts are a flawed model for service integration
- Laurence A Malcolm (18 October 2004)
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Whatever happened to evidence-based policy?
- Marcus J Longley (18 October 2004)
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We need to be prepared to expect and accept the inevitable
- Padmanabhan Badrinath (18 October 2004)
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Victims or benificiaries?
- Andrew J Wall (19 October 2004)
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Zen Buddhism in the NHS
- Stephen f Hayes (19 October 2004)
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After wars and fox hunting - it must be healthcare
- David A R de Berker (20 October 2004)
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Re: Zen Buddhism in the NHS
- Peter Morrell (21 October 2004)
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Mergers should not be delayed
- Richard M Vautrey (22 October 2004)
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Vaguely right is better than precisely wrong
- David P Kernick (29 October 2004)
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Sergio A Battistessa, GP in New Zealand - recently emigrated Waiuku Medical Centre. Waiuku, NZ
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Dear Editor, As a former Executive Board member of a Primary Care Tust (PCT), I don't share the author's optimism about their future. Their commnent about them being "too weak to stand up to providers of acute care in tough negotiations on commissioning and too small to fulfil their public health responsibilities" is is not only apposite; but also the sad experience of many naive GPs who, like myself, believed a difference could be made in a system already heavily weighed towards mantaining secondary and tertiary care in the style they are accustomed. The creation of Foundation Trusts should be the final nail in the coffin of Primary Care priorities. However, I wholeheartedly agree with the author's view on the deleterious effects of even more change as the lastest change has barely had time to take effect. Even getting past the absurdity of demolishing Health Authorities to recreate them all back again under a different name, this reaches levels of as yet unsurpassed waste of energy and limited resources (as we are repetedly told). Having spent millions to deconstruct the former organisations and create new ones, now millions will be spent constructing them back again. Millions that could be spent on Primary Care development. Yes, that rara avis that always gets postponed in the PCT budget in order to satisfy the latest hospital demands. The effect on GP morale of constant change has been well documented in the last several years. From the macroeconomics of PCTs to the microeconomics of individual practices, it seems that as soon targets are achieved: new ones are set asking GPs to go further, and so on and so on. An elegant experimental design to augment stress and decrease morale, that has been replicated many times in rats. Neverthless, it continues with a now monotonous repetition. It is with certain bemusement that, now in New Zealand, I see the recent creation of PCTs (as Primary Healthcare Organisations) being advertised as the panacea to all ills. Many illustrious authors sign this article. Their most important message is: Reorganisations are a clumsy reform tool. Is anybody listenting? Sincerely Dr Sergio A Battistessa Competing interests: None declared |
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Keith J Edgar, G.P. and Clinical Governance Lead Revel Surgery, Brinklow, CV23 0LU
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The authors' have rightly raised concerns about future NHS policy regarding Primary care trusts. I would like to add a further important driving factor, and raise some further key questions. Driving Factor. The establishment of practice based commissioning will degrade local PCT function further, but might secure better clinical engagement. However this "protects" foundation trusts and large secondary care providers from cohesive commissioning for several more years. This is probably an intended consequence. Merged PCTs will become ring masters for complex and often chaotic practice based commissioning. Questions. How do we secure healthcare governance in such a potentially chaotic future? How do we build our public health functions to ensure that commissioning arrrangements are meeting local health need and actively dealing with inequalities? Conclusion. This is a very important topic. It should be widely debated. Competing interests: I am a Clinical Governance lead and have caried out varied educational activities to promote it |
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Nicholas M Wilson, Consultant Surgeon Winchester Vascular Unit, Royal Hampshire County Hospital, Romsey Road, Winchester, Hampshire SO22 4
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Editor - Smith et al (Primary care trusts BMJ 2004; 329: 871-2) highlight some of the weaknesses of primary care trusts (PCT's). Whilst focusing on primary care, they fail to acknowledge the detrimental effect these bodies have had upon secondary care. Primary care trusts control the bulk of funding for secondary care but have neither the expertese nor interest to engage adequately in the provision of their local acute units. As a result, secondary care is increasingly starved of resources and personel that do not precisely fit the models of care delivery embraced by PCT's. Issues determined by on-call rotas, the European work time directive, cancer targets, clinical governance and training committments are so far removed from the PCT's area of expertese that seconday care funding should surely now be transferred to an alternative body which is appropriately focused, skilled and resourced. Competing interests: None declared |
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Steven Ford, GP Haydon & Allen Valleys Medical Practice. NE47 6LA
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Editor Excellent introductory article to an important topic and already interestingly disparate responses have appeared. Reorganisations on the sort of scale under discussion should not be subject to major revision within about a decade - for all the reasons given. This is not to say that refinements cannot be made. Locally, I am struck by the inchoate nature of the management structures. Nobody seems able to give convincing account of who does what, with whom, when, where etc. There are countless hours of meetings, usually attended by the similar groups of people but under different headings, legions of bureaucrats, mountains of paper that nobody reads or understands, financial confusion, exasperation all round and the merest suggestion of progress anywhere. The dramatis personae, further up the tree, seem to flit in and out of post after the briefest of perchings. The things that urgently need to be done are never mentioned and fatuous box ticking exercises rule our days. The role of PCTs should be, chiefly, to promote the efficient operation of primary care. Key actions to be taken include; funnelling funds in dramatically increased quantities to the coal face, bypassing the slough of management entirely, acting as a firewall (marking most departmental post 'Return to Sender') between the paroxysmal idiocy of the department of health and primary care, rapidly deleting all the box ticking activity, not implementing any new activity without the express consent of all of primary care locally and, generally, getting out of our hair. Simple things, like not expecting any clinician to devote more than, say, three hours per month to meetings (including travel), limiting total written communications to practices to five thousand words per month, limiting requests for information to activity that can be completed in three hours per month, putting a stop to all funding of junketing by managers and committees, ensuring that total management costs do not exceed one per cent of local funding and making things happen by return of post, or sooner, would all help massively and actually make savings. 'Well, bugger me sideways with a fish fork, Carruthers - there goes a whole flock of flying pigs!' Yours sincerely Steven Ford Competing interests: None declared |
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Laurence A Malcolm, Professor Emeritus and Consultant Aotearoa Health
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The concerns raised by so prestigious a group of academics must raise serious concerns about the future of primary care trusts. I agree with their important statement that securing clinical involvement and leadership is crucial to the success of PCTs. But this clinical leadership needs to be at arm's length from bureaucracy and be free to challenge it where appropriate. PCT mergers may only lead to further bureaucratic capture of primary care leadership. That trusts might effectively commission secondary care services seems to be based upon the enduring faith of bureaucracies in their power to control outcomes through money. But when it comes to the crunch powerful hospital interests will always override purchasers. Relationships between primary and secondary care need to be based upon common goals, trust and collaboration, not on financial leverage. With due respect to the authors I do not share their opposition to reorganisation. Fine tuning a fundamentally flawed organisation, such as currently exists in the NHS, will never be successful. Is there a better way? The New Zealand model of fully integrated district health boards (DHBs), bringing primary and secondary care together into one virtual organisation appears to be working very successfully1,2. Organised primary care, now rapidly evolving through primary health organisations (PHOs) remains at arm's length from funders. These new organisations are based upon a decade of organised general practice3,4 and have rapidly expanded to include over 90% of GPs and their enrolled populations3. PHOs are flexible, locally based and have enrolled populations ranging from 5000 over 330,000. They do not and will not commission secondary care. However they provide an important power base, within the DHB framework, for primary care clinical leaders to constructively engage with their secondary care counterparts in new and trusting relationships3. I agree that reorganisation as such is not a solution. It will fail if it merely shuffles the cards of the current dysfunctional and fragmented arrangements. Organisational integration of secondary and primary care must be considered, including disbanding of the powerful hospital trusts. Integration needs to be based upon collaboration, rather than conflict, with mutual respect and trust between primary and secondary care. Clinical leadership must be given a key role, supported rather than controlled by bureaucrats2,4. References 1. Malcolm L, Wright L, Barnett P, Hendry C. Building a successful partnership between management and clinical leadership: experience from New Zealand. BMJ 2003; 326: 653-654. 2. Barnett P, Malcolm L, Wright, L and Henry C. (2004) Professional leadership and organisational change: progress towards a quality culture in New Zealand’s health system. NZ Med J, 2004 http://www.nzma.org.nz/journal/117-1198/978/ 3. Ministry of Health (2004) www.moh.govt.nz/primaryhealthcare. 4. Malcolm L, Mays N. New Zealand’s independent practitioner associations: a working model of clinical governance? BMJ 1999; 319: 1340 -1342. Competing interests: None declared |
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Marcus J Longley, Senior Fellow and Associate Director Welsh Institute for Health and Social Care, University of Glamorgan, Pontypridd, Wales, CF37 1DL
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Walshe et al's argument is surely convincing, yet no-one expects the Department of Health to heed it! Wales' experience provides an interesting - and perhaps useful - comparison. The nearest equivalent of PCTs in Wales are the 22 Local Health Boards, serving an average population of 140k, but with a range from about 60k to 300k. They are coterminous with local government, and commission primary and secondary care - but (with one exception) do not provide direct-patient services themselves. Their alleged weaknesses are also size (too small), age (immature) and lack of expert resources (minnows to the Trust whales - forgive the pun). But the current indications are that the Welsh Assembly Government has eschewed yet another reorganisation, aiming instead for more effective management of their performance over the next 2-3 years. Bravo Wales! Work we carried out two years ago suggests that major structural reorganisation in NHS Wales typically delays substantial service modernisation by up to 18 months in many localities - the last thing we need now. The opportunity which this offers is the chance to gather some evidence on the relative merits of the English and Welsh structures. As Walshe et al suggest, there really is no satisfactory evidence-based way of determining whether PCTs are fit for purpose, and the same applies to Welsh LHBs. Why not gather some evidence over the next year or two so that, for once, policy may ultimately be (somewhat) evidence-based? Competing interests: Research and consultancy funded by the National Assembly for Wales and the Department of Health |
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Padmanabhan Badrinath, Specialist Registrar in Public Health & Recognised Clinical Teacher Southend on Sea PCT & University of Cambridge, Harcourt Avenue, Southend on Sea, SS2 4HE,
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Dear Editor, The editorial on Primary Care Trusts (BMJ, 16th October) by illustrious academics and health policy gurus heralds of the things to come in 2005. There is widespread expectation among some frontline staff that there will be mergers of PCTs in the life of the next parliament. Mergers and reorganisations are not new to the NHS. From 1982 to 2003 there have been 18 reorganisations of the NHS (1). However, reorganisations create uncertainty and take away the valuable time of professionals from their main duties. A survey (2) of chief executives found that three-quarters of the respondents felt that the “Shifting the Balance” reorganisation would delay the delivery of the NHS plan. On average, chief executives were spending a quarter of their time implementing the reform. Although there is some literature (3) on the process and impact of merger of acute trusts, little published data can be found on the merger of primary care organisations in the UK. Wilkin et al (4) analysed the relationship between size and performance of PCOs in England and concluded that there is little evidence that the performance or efficiency of a primary care organisation is associated with its size. They warn of the danger of larger primary care organisations recreating hierarchies and losing local ownership and participation. The other danger the proponents of mergers and reorganisations need to bear in mind is the deeply cynical and dismissive attitude constant reforms create among NHS staff. The NHS should stem and turn around the cynical view – “We have seen it all before, nothing works, just ignore it and keep your head down because it won’t last very long” (1) if any reforms are to succeed. The possible reasons for the potential merger of PCTS include: many PCTs are too small to survive on their own in the long run, mismatch between PCT boundaries and elected civil bodies (5), capacity issues in areas such as public health, economies of scale and the potential savings on management costs. Although evidence is hard to find on the benefit of another reorganisation, in anticipation of the merger many managerial changes are already happening on the ground. NHS regions have established single management structure across PCTs and directors of Public Health continue to be appointed across PCTs. These changes are happening as a response to local needs and imperatives and it is hard to turn the clock back. We shouldn’t be surprised if there is a press release in the next 12 to 24 months titled “United to excel” and a statement like “many PCTs in England have united to form larger and effective trusts to improve the quality of patient care after extensive consultations with key stakeholders including service-users and patient groups”! Keeping our cynicisms to one side, we could look in to the potential positive aspects of a merger of PCTs. This could create primary care organisations coterminous with local governments benefiting the local communities. If mergers are not dictated from the top and allowed to proceed according to local aspirations and needs, this could boost morale and further strengthen the PCTs in their dealings with other key players in the local health economy. The editorial states that older health authorities that were larger than current PCTs were not better at commissioning. However, one wonders whether PCTs, which are part of the modern and dependable NHS, created as locally-based organisations could equate to the old Health Authorities. PCTs have the role of running the NHS and improving health in their areas and operate in the new atmosphere of practice led commissioning, Choice, DTCs, Foundation trusts, Health Care Commission and Patient and Public Involvement in the NHS. Although the authors suggest public health networks as one of the solutions for maintaining status quo, a recent study (6) found that “public health professionals have a similar but broader understanding of the term "public health network" than that of the government, with greater emphasis on sharing of information”. Informal discussions with colleagues across the country reveal that there is wide variation in the development of networks with well resourced regions with a perfect network structure, while other areas have networks in their infancy leading to the phenomenon of postcode lottery (networks), which has been one of the criticisms of the NHS in the past. Reorganisations are a part and parcel of any major dynamic organisation. Hence the academic and service community should be prepared to provide their valuable input in to the planning, implementation and evaluation of the next reorganisation if and when it comes, so that its impact on clinical care, commissioning and implementing other key programmes listed in the editorial are kept to a minimum. It may be worth recalling and re-emphasising the statement by Sheldon & Maynard published in the BMJ (7) five years ago today, when we face the prospect of yet another reorganisation due to possible ground realities and political imperatives; “What is needed with mergers is surely a clear statement of goals and predicted outcomes with performance monitored openly by the Audit Commission. Only then can we augment the evidence base and distinguish between political wheezes and the wise use of scarce NHS resources”. References 1. Walshe K. Foundation hospitals. A new direction for NHS reform. J R soc Med 2003;96:106-110. 2. Walshe K, Smith J. NHS reorganisation. Cause and effect. Health Serv J. 2001 ;111:20-3. 3. Fulop N, Protopsaltis G, Hutchings A, King A, Allen P et al. Process and impact of mergers of NHS trusts: multicentre case study and management cost analysis. BMJ. 2002;325:246. 4. Wilkin D, Bojke C, Coleman A, Gravelle H. The relationship between size and performance of primary care organisations in England. Health Serv Res Policy. 2003 ;8:11-7. 5. Griffiths S. The "redisorganisation" of the NHS. Doctors working in public health have extra worries in latest reorganisation. BMJ. 2002;324:672. 6 Fahey DK, Carson ER, Cramp DG, Muir Gray JA. User requirements and understanding of public health networks in England. J Epidemiol Community Health. 2003;57:938-44 7. Sheldon T, Maynard A. Politicians may not have same goals as clinicians with regard to mergers. BMJ. 1999;318:1762-3. The views expressed above are that of the author only and not of his employer or of any other associated organisations. Dr.P.Badrinath MD,PhD,MFPH. SPR in Public Health & Recognised Clinical Teacher, Southend on Sea PCT & University of Cambridge, Southend on Sea, Essex, SS2 4HE. Competing interests: The author is currently training in Public Health in the National Health Service. |
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Andrew J Wall, Visiting Senior Fellow HSMC University of Birmingham B15 2RT
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One of the characteristics of the seemingly countless reorganisations of the NHS has been the apparent enthusiasm with which NHS managers have faced these recurrent challenges. Yet a significant number of them will become victims losing their jobs in the process. Cynics might argue that after the age of fifty most senior managers have had enough and hope for a substantial redundancy package which will allow them to retire early. Indeed the money spent on such packages has never to my knowledge been calculated by the DoH presumably because it would be politically hazardous to do so. A less world-weary reason for managers' enthusiasm is that they are by instinct people of action and reorganisations offer plenty of that. The pity is that such energy cannot be used more directly in the patients' interest. Competing interests: None declared |
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Stephen f Hayes, freelance GP Southampton
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I remember discussing PCTs et cetera with a fellow GP 5 years ago. He opined that PCTs would never give GPs any real power, would end up being amalgamated, thus re-inventing the old Health Authorities, completing (for the time being) the circle of re-organisation. I opined in return that I suspected that there was a secret circle of Zen fundamentalists behind it all, for Zen Buddhism as I understand it teaches that life is fundamentally meaningless and goes round and round in circles for ever. Is there any other logical explanation? Competing interests: None declared |
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David A R de Berker, Consultant Dermatologist Bristol Royal Infirmary
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It is interesting to hear that there may be the creation of commissioning bodies comparable to old health authorities. Why don’t they go the whole way and commission from Whitehall? Cut local management drastically, let clinicians see patients rather than stale coffee and wrinkly sandwiches and just fund us to deliver a consistent and centrally agreed level of service. Why should it be so important that every practice gets to have their say? We are used to despising the government for their mistakes – it would save a lot of time, money and local anguish if they took on healthcare as well as wars and fox hunting. Competing interests: None declared |
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Peter Morrell, Hon Research Associate, History of Medicine Staffordshire University, UK
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Stephen f Hayes refers to a, "secret circle of Zen fundamentalists behind it all, for Zen Buddhism as I understand it teaches that life is fundamentally meaningless and goes round and round in circles for ever." Having accrued a smattering of understanding through studying Buddhism for several decades, I would have to say that Stephen Hayes' comment is misleading. The Zen school of Japanese Buddhism, which is the transplanted Chinese Ch'an sect, which is the transplanted Dhyana or meditation school of Indian Buddhism [6th century] is a practice lineage and not a wisdom lineage. What this means in essence is that it comprises a religious tradition that stands outside of, completely ignores, and is largely contemptuous of the vast corpus of Buddhist scripture and instead concentrates itself entirely upon the practical methods of achieving mental stillness and equanimity through meditation, and NOT upon such abstruse matters as philosophical debate about the nature of existence. Because scripture and debate is deliberately and vociferously avoided by Zen Buddhists, therefore, there can be no such thing as a "fundamentalist Zen Buddhist;" there is no such clearly defined *philosophical position* for a Zen Buddhist, their focus being entirely upon the practice of meditation to achieve mental stillness. However, it is true that most Buddhists do tend to believe that self [ego] is an illusion, that nirvana is bliss and that the world is permeated by myriad forms of suffering contingent upon the pervasive and ineradicable impermanence of all things. I don't think that really approximates to the phrase "that life is fundamentally meaningless and goes round and round in circles for ever." The likes of the latter sentiment might, however, be construed as flowing from scientific materialism and synonymous with the apparent meaninglessness of modern secularism. The justification the Zen school usually makes for its approach is that the *method* of achieving enlightenment must always be superior to debate about the nature of existence...for afterall, that is how Buddha [6th century BC] himself obtained enlightenment...not through engaging in tortuous philosophical argument, but through the practice of equanimity, and detachment leading to unfading bliss. More detail about Buddhist philosophy can be found in A Raft to Cross the Ocean of Indian Buddhist Thought, by Gendun Gyatso, the second Dalai Lama, in Glenn Mullin, Selected Works of the Dalai Lamas II, Snow Lion or in Jeffrey Hopkins, Geshe Lhundup Sopa, et al, Cutting Through Appearances, Theory and Practice of Tibetan Buddhism, Snow Lion, USA. some useful websites: http://en.wikipedia.org/wiki/Buddhist_philosophy http://www.ciolek.com/WWWVL-Zen.html http://www.hinduwebsite.com/buddhism/history_of_buddhism.htm http://www.ship.edu/~cgboeree/buddhahist.html Competing interests: None declared |
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Richard M Vautrey, GP Meanwood Group Practice, 548 Meanwood Road, Leeds, LS6 4JN
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Walshe et al (1) argue that the Department of Health should resist the temptation to encourage PCT mergers, suggesting that further structural reorganisation would not bring benefit to patients. This is despite their own observation that there is a growing belief that many trusts are ineffective organisations. From their creation it has been clear that many PCTs were too large to be able to secure meaningful engagement with both clinicians and public, and too small to have the capacity and capability to deliver the agenda that was set for them. Despite the best efforts of many working within them, PCTs have been hampered by significant budget deficits, and PCT boundaries have been a barrier to co-ordinated and cost-effective working, resulting in increased inequalities within health care economies (2). In addition the cost of maintaining large numbers of Boards, Professional Executive Committees, and senior executives is a scandalous use of scarce NHS resource. With the advent of Practice Based Commissioning (3) , which will allow front line clinicians to get involved in commissioning care for the communities they serve, the need for PCTs becomes increasingly questionable. A move to larger PCTs that unite a health care community rather than divide it, and can bring a level of competence and efficiency not current seen should be encouraged. Not only will this bring benefits for patients, but it will also restore GP’s confidence in primary care management. Richard Vautrey 1 Walsh K, Smith J, Dixon J, Edwards N, Hunter DJ, Mays N, Normand C, Robinson R. Primary Care Trusts. BMJ 2004; 329:871-2. 2 Vautrey R. Larger trusts may reduce inequalities. BMJ 2001.323:49 3 Department of Health. Practice Based Commissioning. Engaging Practice in Commissioning. London: DoH, 2004 Competing interests: None declared |
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David P Kernick, General Practitioner St Thomas Health Centre
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Dear Sir It’s the nature of academia that confident statements are made about the nature of reality by those who sit outside the system. In their collective admonition on the perils of Primary Care reorganisation, the high priests of health service policy analysis and research are in danger of exposing their own vulnerabilities. They state that “we have no good evidence to show that a structural re-organisation of Primary Care Trusts will bring benefits to patients”. Unfortunately, they fail to acknowledge that they have yet to provide evidence to suggest that any type of healthcare delivery system is preferable or acknowledge the fact that there may be no correct organisational solution or indeed that any search for one is futile. Yes, we need space to work on implementing policy initiatives and building relations in local healthcare communities and it is generous of the policy analytical elite to try and get policy makers off our backs. Nevertheless, they need to think carefully about their own contribution to the developing service and whether its impact has commensurate with the resources that are invested into their academic effort. (1) Thanks for the offer of help but we can manage without it. Yours faithfully David Kernick 1. Kernick D. Life on the exponential curve - time to rattle the academic cage? Journal of Evaluation in Clinical Practice (in press) Competing interests: None declared |
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