PCT commissioning

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The main problems with current PCT commissioning appear to be regarding the lack of trained managers, the disengagement of clinicians and the relationships between the two ‘tribes’. There is certainly growing concern (some would say alarm!) over PCTs’ ability to commission effectively and the ‘anorexic’ nature of PCT management.

Acute trust chief executives have been scathing about the quality of commissioning of their local PCTs, saying that there was a ‘lack of imagination’ in commissioning. In a HSJ Barometer survey some 87 per cent of people responding to a question as to whether PCTs had the capacity to push through the changes in the NHS said 'no'.

Researchers from the University of Birmingham’s health services management centre (HSMC) have examined how far advanced PCT commissioning is and how much influence they are having on the shape and quality of services. The answer from their research was not very far advanced and not very influential as yet. The HSMC report authors have suggested that PCTs have the potential to be far stronger commissioners than health authorities ever were if only they really are able to shift contracts around.

The new language is about ‘contestable collaboration’ and ‘matrix commissioning’, giving bite to the commissioning role. ‘If PCTs cannot influence or shift contracts with and between providers, there may be very little point to the commissioning function at all’, suggest the authors.

The new patient choice and financial flows regime offers a framework for a greater degree of contestability, as commissioners will be able to move work around on a cost-per-case basis. But if PCTs fail to deliver, the notion of commissioning may ultimately be removed altogether, perhaps by reverting to hospitals within PCTs under a managed care arrangement similar to the structure of some health maintenance organisations in the US. PCTs may have only a limited time period in which to prove themselves. One problem for PCTs is that strategic health authorities are not blessed with a lot of people who understand primary care.

Practice-led commissioning
PCT commissioning continues to remain under the spotlight whilst at the same time plans for practice-led commissioning have been announced. Some commentators have suggested that the scrapping of fundholding when Labour came to power slowed the pace of improvement in NHS services and whilst it had its problems, GP fundholding drove service reform and delivered clinical engagement as few other policies have before or since. So a radically restructured version of fundholding, now reborn as practice-led commissioning, seems a case of better late than never. In the south west, practice-led commissioning is already up and running and seems to have increased clinical engagement, delivered cost containment and allowed innovation in primary care with some structured financial incentives. There is now a move towards a diversity of commissioners as well as providers, although practice-based commissioning would have to be linked to overall PCT strategies.

PCT commissioning consortia
Some PCTs are wrestling with the new challenges being posed by commissioning from foundation trust providers. In Manchester, Cumbria and Newcastle new models of commissioning are developing. The Newcastle, Northumberland and North Tyneside commissioning consortium (with £800m to play with) has put in place
five separate directorates — commissioning, epidemiology, finance, performance and service design. Andrew Gibson, Newcastle PCT chief executive officer, is leading the consortium (with a bit of help from Northumberland, Tyne and Wear SHA).

The consortium are looking for ‘new approaches and new views of old problems and to look beyond existing structures, boundaries and organisations to produce solutions’ and that their vision of the ‘required transformation’ includes moving from ‘increasing demand on hospitals for elective and non-elective care’ to ‘development of integrated patient pathways reducing inappropriate referrals and admissions’.

Yet more ‘must-dos’ have piled up on PCTs through the year 2004/05. The full children’s NSF appeared, PCTs now have a new duty to co-operate with police services more widely in the implementation of crime and disorder reduction strategies for their local communities and in 2005 PCTs will be responsible for local dental services.