Comment / All we are saying: give PCTs a chance

Ahead of the HFMA PCT conference – to be held on 30 June in Birmingham – Cathy Kennedy argues that commissioners are showing signs of coming of age.

In the past, a change in government has been swiftly followed by changes in NHS structure. The end of the internal market and creation of primary care trusts after the 1997 election is an obvious example.

The NHS does need to change. We need to radically redesign pathways and optimise services around patients to create sustainable services. That may mean re-providing some traditionally hospital-based services in the community and, yes, that may lead to the downsizing or even decommissioning of some local hospital services. While this may mean structural change would be an advantage, it should stop short of wholesale dismantling of the commissioner/provider split.

We face unprecedented financial challenges. But a knee-jerk response that equates commissioning with unnecessary bureaucracy and radically alters PCT structures across the service would distract us from the job in hand. We must focus all our energy on delivering sustainable services with fewer resources.

I doubt the perfect health system exists. But I believe with time and the right tools, most systems could be made to work. We simply can’t afford to spend time on reorganisation. Research suggests this leads to stagnation, instability and delays.

I’m not pretending commissioning is where it needs to be. The results from the first year of world class commissioning were not great. But it was always going to take time to develop such a new concept, and this was a real test of competence, not a rubber-stamping of PCTs’ existence. Results will improve in year two and must continue to improve.

But to dismantle the ‘experiment’ now because it hasn’t delivered fast enough against expectations, would be a mistake. There is plenty of anecdotal evidence that PCTs are coming of age. They have become more challenging in their contracts, building in high-level expectations of managing out demand and downsizing in the acute sector. This wouldn’t have happened a few years ago and providers wouldn’t have signed such challenging contracts. PCTs have become tougher.

Some things clearly need to improve. Practice-based commissioning isn’t working properly. We need to address the underlying approach, incentives and competencies. If practice-based budgets are the way forward, we must find ways to make that work.

Demand management will be key and that means finding ways to engage and incentivise GPs to play a greater role in understanding and controlling activity and demand. Perhaps we need a quality and outcomes framework financial incentive linked to an assessment of total PCT resource spent on each practice list, compared with their share of resource.

It’s not just about GPs. Patients enter the secondary care system from various routes, including care homes and accident and emergency. What we need is clinical engagement across the system.

In North East Lincolnshire, we believe our approach, with responsibility for commissioning both health and adult social care, has advantages – not least removing any danger of cost shunting between budgets and the ability to marshal resources from both health and social care when redesigning services. This integrated approach has real potential.

We also need to get to grips with what services are provided in the NHS. There will always be a mix of services that should be available everywhere, without a postcode lottery, but we must also respond to real differences in local need and local priorities. PCTs – divorced from delivery of services – remain best placed to make these decisions in an unbiased way.

Commissioning has come a long way, but now has to go much further and much faster. The NHS needs to hold its nerve and give PCTs the time and the opportunity to show what they can deliver.