Goodbye (and good riddance?) to PCTsBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2039 (Published 02 April 2013) Cite this as: BMJ 2013;346:f2039
Did primary care trusts improve healthcare? It took just 13 years for them to be created, merged, clustered, and abolished. During that time they were responsible for about 80% of the NHS budget in England.
The original 303 PCTs across England began taking over from district health authorities and primary care groups in 2000. In 2006 they were merged to form 152 organisations and instructed to begin withdrawing from running community services—known in the artless syntax of Whitehall as “separating out their provider arm”—to focus on commissioning. As the local “system leader” they were charged with driving up quality, improving public health, and reducing inequalities.
In 2010 the health select committee delivered a devastating critique of their commissioning performance, condemning them for failing to tackle quality issues such as variations in clinical practice. It attributed their weaknesses to their “lack of skills, notably poor analysis of data, lack of clinical knowledge, and the poor quality of much PCT management.” All this was exacerbated by the Department of Health’s imposition of constant reorganisation, it added.
Lack of power
One of the myths of commissioning is that commissioners wield considerable power. The macho rhetoric of the Department of Health gave the impression that the relationship between commissioners and providers was increasingly one of equals as PCTs ramped up their skills and confidence, fired by the hyperbole strewn world class commissioning development programme.
The reality is that the providers have always been in charge. While in theory PCTs could strip poorly performing services of their contracts and award the work elsewhere, in practice commissioners were generally faced with few palatable options beyond making the existing service work as best they could, and even then there was little they could do to compel improvements or changes.
As the health select committee pointed out: “Commissioners do not have adequate levers to enable them to motivate providers.”
The solution the MPs offered—rigid, enforceable quality and efficiency measures written into all contracts—missed the point that improving services is almost always about time, effort, and relationships.
But PCTs often failed to build the strong, effective relationships with clinicians in both primary and secondary care that were needed to make improvements happen.
In theory, clinicians were well represented on the commissioning side. The professional executive committee provided a voice for GPs and other clinicians in the area while medical, nursing, and public health directors were generally influential figures on the PCT board.
But too often there was a distant, or even antagonistic, relationship between local GPs and PCT management. This failure to bring an authentic clinical voice to PCT strategies made it more difficult for commissioners to engage clinical staff in the trusts. An NHS Confederation study to be published this month exploring the legacy of PCTs and the implications for clinical commissioning groups highlights the problem.
“Did the frontline of clinicians feel ownership of the commissioning agenda? No they didn’t. The opportunity for the CCGs is to get genuine frontline ownership of what they do,” says David Stout, former chief executive of Newham PCT.
The push for safer, higher quality care accelerated the need to “reconfigure” services, often by focusing work on fewer, more specialist sites. The sharp improvements in London in reducing deaths and serious disability from stroke is one of the most celebrated examples.
But major services changes almost invariably drew in the strategic health authority, and national politics began to interfere. As Robert Creighton, chief executive of Ealing PCT, puts it: “Over 10 years we tried three times to address those issues and each time we were unsuccessful. The government’s ambition for us as commissioners was to be bold and change the system, but when push came to shove those attempts got derailed because politically they were not supported.”
Other changes focused on shutting hospital services and opening community ones. Again, there were successes in areas as diverse as Hertfordshire and Manchester, but progress was excruciatingly slow. PCTs learnt harsh lessons about the difficulty of prising the fingers of the public off the gates of their beloved hospitals.
While this was always going to be difficult, commissioners made life tougher for themselves by repeatedly presenting closure plans to the public and asking what they thought, rather than involving them from the beginning in shaping a new service. There is clear evidence that when PCTs talked with the public and developed trusting relationships with key opinion formers such as councillors and MPs, progress could be made. For example, the Delivering Quality Healthcare for Hertfordshire plan unveiled in 2007 to reconfigure hospital services in the county was led by clinicians, with a consultation exercise that included meetings in 32 towns and villages, the distribution of more than 400 000 leaflets, 120 events for NHS staff, and the close involvement of MPs and councillors. The NHS team developed a strong relationship with the county council’s health scrutiny committee, explaining in detail the rationale for the complex proposals and providing evidence for why services needed to change.
PCTs largely failed to rein in the growth in demand for hospital services—although this was a much lower priority during the years of Labour largess. They could never have succeeded. The payment by results system served as a conveyor belt to carry the sharply increasing NHS budget from the Treasury to the acute trusts. The hospitals played their part in slashing waiting times and waiting lists, but the system incentivised them to keep doing more.
There were some modest victories. When funding for emergency admissions was capped PCTs, GPs, hospital consultants, and community care clinicians often managed to cut admissions. But the underlying problem of the funding system remains.
Quality of care
In some areas tension between GPs and PCTs were increased by the fraught, time consuming, and difficult work commissioners undertook to unseat substandard local doctors. In many areas the PCT’s biggest success was making primary care safer. The move was driven both by contractual changes and the murders by GP Harold Shipman. The introduction of personal medical services contracts in 1997 allowed local commissioners to negotiate on service specifications. This was followed in 2003 by the ending of GPs’ monopoly in primary care; PCTs could now commission anyone.1
Meanwhile the conviction of Shipman in 2000 exposed risks and concerns around clinical governance in general practice.
In the NHS Confederation study Stout says: “There are some extraordinary stories about the frankly dangerous and appalling quality of general practice . . . It was incredibly time consuming taking action, to some extent against the will of the GP leadership—they certainly didn’t get behind it even though they knew it needed doing.”
It could take two years to persuade a GP, often working alone, that it was time to go. Buckinghamshire GP Johnny Marshall, who is now also the confederation’s policy director, could see why it was so hard: “It needed a greater partnership between local GP communities and PCTs, and in some areas that simply didn’t exist . . . In many it was quite an adversarial, contractual relationship.”
PCT leaders are adamant that general practice is now much safer. As Sophia Christie, who was chief executive of Birmingham East and North PCT, puts it: “There are a small number of PCT medical directors . . . who have spent 10 years of their lives putting huge personal and emotional commitment into trying to protect patients from dangerous practice.”
One of the great hopes for PCTs was that they would finally begin to reduce the inequalities in health between wealthy and poor people. The idea was that, working with their local authority, PCTs would not only be able to commission services to meet clinical needs but also begin to work with other local services to address wider determinants such as housing, health education, sexual health, and exercise.
There were some successes, such as Liverpool leading the country in smoke-free public places and work in east London to tackle tuberculosis. But taken together, the immense amount of effort thrown at inequalities made virtually no discernible difference to the national picture of a profound deficit in life expectancy and years of healthy life in the most deprived areas.
Overall, it is easy to come to a critical judgment on the record of PCTs, but that is to belie the adversities they faced and the successes.
They played their part in improving the quality and safety of services, including driving through the virtual wiping out of waiting lists. Their share of the credit for these and other improvements, such as the sharp reduction in hospital acquired infections, now has to be balanced against the wider failures that have been exposed in the quality of basic care. CCGs will find that, with the imposition of tight running cost limits, they are likely to be even more dependent than PCTs on hospital trusts supplying reliable data on issues such as dignity and nutrition if they are to avert serious failures.
Local successes in addressing aspects of health inequality add up to a national failure. This highlights the profound difficulties the health service faces in addressing lifestyle and poverty related diseases. And 13 years is simply not long enough to build and sustain improvements that will show in the figures.
Under the new system commissioners have been stripped of responsibility for primary care and most specialist services, which go to the NHS Commissioning Board, while public health has gone to councils. This leaves CCGs with the £60bn part of the NHS budget that is most difficult to control—general acute care.
The PCT legacy to CCGs includes a greater understanding of the health needs of the local area, a firmer grasp of what commissioning involves, and often strong relationships with the local authority. Generous NHS funding settlements allowed them to expand services in deprived areas. The high performing PCTs leave good foundations for further improving care.
But it is inescapable that after 22 years of the purchaser-provider split in the NHS, commissioners have been unable to seize power from the providers on behalf of patients. Will clinical commissioners fare better? If they can use insights from individual patient consultations to drive strategic improvements in services, and build a shared understanding between primary and acute clinicians of what needs to change, then they have a chance.
But the obstacles that PCTs endured, and the imbalance between effort and achievement, expose the extraordinary difficulties commissioners face in making a difference to patients’ outcomes. And that was when there was plenty of money.
Cite this as: BMJ 2013;346:f2039
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare I am the author of the NHS Confederation study.
The NHS Confederation study of lessons for CCGs from 13 years of PCT commissioning is published on 23 April.
Provenance and peer review: Commissioned; not externally peer reviewed.