PCT — chief executive

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The role of the chief executive

The PCT chief executive is likely to be a key customer for NHS influencers, although new customer relationship strategies probably need to be devised. Chief executives will only exceptionally be interested in individual products, and the relationship may need to be based at a much higher strategic level. The turnover of PCT chief executives appears to be very high at the moment with posts advertised almost every week in the Health Service Journal.

Commercial sponsorship: ethical standards for the NHS
It could well be that in many of the dealings with PCTs, NHS influencers will relate at a more operational level, such as with the pharmaceutical adviser. One area where direct contact with the chief executive is likely to be made will be that of partnership working. PCT account managers may need to assess whether the chief executive is central to progressing any partnership arrangements. Guidance in Commercial sponsorship: ethical standards for the NHS suggests that such arrangements may need board approval and that any sponsorship should be at a corporate level.

Although there is a recognition that collaborative partnerships with the industry may have benefits, it is suggested in this document that a ledger of all gifts needs to be kept and any partnership arrangements should be based on best clinical practice, value for money and be ethical and transparent. Linkage to purchase of particular products is forbidden. A code of conduct is given in the document as well as useful examples of potential conflict — a ‘must-read’ for NHS influencers.

PCT — mergers

Discussions continue around how big a PCT should really be — primary care groups started with a population base of around 100,000 but with PCTs this has now drifted up significantly and PCTs are torn between the need for critical mass versus the danger of losing local vision and ownership. The NHS has a fixation around ‘structural solutions’ to handle change and what we have seen over the last half of 2004 is a significant number of ‘quasi-mergers’ of PCTs where adjacent PCTs have merged their senior management teams (and appointed one chief executive) but retained the PECs in place. This has largely been as a result of the need to increase the effectiveness of PCT commissioning and has either been driven by the PCTs themselves or imposed by the SHA. NHS influencers no doubt will be aware of many examples of where this has occurred, including Oxfordshire, Northamptonshire, Trafford, Cumbria, Wiltshire, Mansfield, Derby and Liverpool.

Hampshire and Isle of Wight SHA has formed three ‘clusters’ of PCTs across their patch from an existing seven but with Portsmouth and Southampton City PCTs remaining unchanged because of their fit with local authority boundaries. This is also happening elsewhere, for instance Surrey and Sussex PCTs may also come down from 15 to five. And on the Isle of Wight, with its population of 130,000, there appear to be plans for one healthcare organisation for the whole island by 2006. Such ‘vertical integration’ is now being openly discussed more and more in the NHS.

Many commentators are suggesting that too many PCTs are rather ineffective organisations — too weak to stand up to providers of acute care in tough negotiations on commissioning, too small to fulfil their public health responsibilities and have failed to live up to the expectations placed on them — and should ‘formally’ merge. It should be noted though that the average PCT population size has now grown to and average of 200,000 since this particular piece of ‘furniture’ was rolled out — twice the average at the inception of PCTs.

In an impassioned editorial in the BMJ, a whole battery of ‘big names’ including many professors of health policy, argued strongly against the expected epidemic of mergers and wholesale reorganisation of the NHS after next year’s expected general election. Any such moving of the NHS furniture could reduce the number of PCTs in England down from around 300 to around 100-150. Interestingly, the authors note that this is quite close to how many health authorities existed prior to the last major reorganisation in 2002! Such enlarged bodies could threaten the very existence of SHAs, which then might be reduced down in number to about eight regional offices of the Department... The authors conclude:

'Reorganisations are a clumsy reform tool, and research shows that they seldom deliver the promised benefits. Every reorganisation produces a transient drop in performance, and it takes a new organisation at least two to three years to become established and start to perform as well as its predecessor.'

They add:

'The Department of Health and NHS managers should resist the temptation to reach for the old panacea of reorganisation'

Please see BMJ 2004; 329:871-872 (16 October).

John Hutton, when asked about this at the 2004 NHS Alliance annual conference said, 'I can confirm that we currently have no plans for PCTs mergers after the election.'

The other new factor to add to the mix here is of course the arrival of practice-led commissioning, again leading to PCTs being written off in some quarters.

For local NHS teams the current wholesale merger of PCT senior management teams (SMTs) is hugely significant and needs to be added as a new factor in any ‘sophistication grid’ being used. Any possible future large-scale PCT mergers will of course also be important to local NHS teams in terms of present targeting and the relationships developed over the last couple of years.

The publication Meeting the challenge from the NHS Confederation should be worth NHS influencers having a look at as it talks about the range of PCT models being developed from using shared services as in Lincolnshire where 10 PCTs share various back room functions such as payroll; partial integration as in the Trafford PCTs, to a more fully integrated model as in the Derby PCTs. The document also picks up on commissioning developments and PCT consortia.

So are we now looking at a default reversion to structures akin to the old health authorities?

Retaining local focus will be a key issue and was seen as the major strength of the original primary care groups. Also it should be pointed out that such is the pace of change that patient choice, foundation trusts and payment by results were not around at the time of the original restructure.

The other important thing that has been happening is the growth of PCT commissioning consortia as in Newcastle, South Yorkshire and North Derbyshire. In Manchester the ‘Greater Manchester Association of PCTs’ and North Manchester Primary Care Trust have appointed an associate director of partnerships to work across the 14 PCTs and with NatPaCT. In East London, PCTs have formed a primary care transformation unit with the help of North East London SHA.