News analysis - PCG revolution starts in slow motion

17 Jun 99
They were trumpeted as the end of an iniquitous internal market in health.

18 June 1999

But what may prove to be the most momentous reform of the NHS in its 51 years has caused little more than a ripple on the surface. GP-led commissioning potentially gives every doctor in Britain a vote on how and where NHS money is spent and local health services are delivered, but in most areas these new powers have yet to be exercised.

So why the lack of visible action? One thing is simply time. Primary Care Groups in England, Local Healthcare Co-operatives in Scotland and Local Health Groups in Wales have been up and running for only 11 weeks. Prospective commissioners in Northern Ireland will have to wait until at least next April before they join the fray.

Though they were formed late last year, many PCGs in England are still advertising for staff. Those with a full complement are still coming to terms with the task that faces them. Commissioning groups in Scotland and Wales, which have more limited powers than those in England at the moment, report similar situations.

No-one seriously believes that commissioning groups will make a huge impact in their first year. This appears to be borne out by a recent NHS Confederation survey, which revealed that commissioners were most concerned with recruiting staff and 'getting everyone working together'.

Many commentators believed that ex-fundholders would become commissioning's vanguard, particularly those who participated in 'total purchasing' pilot studies set up by the previous government. In these pilots, groups of fundholders bought all care for their patients.

The National Association of Primary Care, formerly the National Association of Fundholding Practices, says some doctors are using their powers to the full. 'It's very much a curate's egg,' says Clive Parr, its chief executive. 'I think PCGs with GPs from a total purchasing background have probably had a head start. Many of them have expressed an interest in becoming Primary Care Trusts. But some PCGs are still advertising for chief executives. These obviously haven't made much progress. For the vast majority, it is early days.

He adds: 'I get the feeling that the whole of PCGs' work at the moment is to do with process – setting up the boards, their procedures and the arrangements for communication with the GP practices and other bodies.'

Like many of its peers, Somerset Coast PCG believes the first year is a learning period. 'We have some minor improvement plans but this year will see a bedding-down process, with the emphasis on the non-commissioning parts of our role – health improvement and primary care development,' says chief executive Alan Carpenter.

'The Service Level Agreements for this year are done and dusted. The challenge is to learn about commissioning, but we don't want to leave this for too long.'

The PCG will begin work soon on commissioning care for 2000/01. 'In a few weeks, we will begin to have regular speciality commissioning meetings. Primarily, they will be about monitoring this year's agreements but, increasingly, they will take us into issues for next year,' Carpenter adds.

The selling point of commissioning was that it keeps the acknowledged advances of fundholding, particularly in practice-based services where, for example, hospital outpatients' clinics are held in local GP surgeries. But Chaand Nagpaul, chair of Harrow East and Kingsbury PCG, believes practice-based services must also be effective and value for money. 'I would be disappointed to feel I was supporting a service that was inappropriate or not based on a health needs assessment,' he says.

As ever, cost-effectiveness is the watchword but concern is growing that good services are being axed. 'In some parts of the country, services developed by fundholders have not been carried on because of funding issues or opposition from PCG boards,' Parr says. 'Where good services were being provided, PCGs should bring about a levelling-up of services so all patients benefit from it.'

Many groups will be just finding their feet when the next big question arises – whether to become a Primary Care Trust.

The first of these more powerful bodies is due to be created next April and the English health department has announced it has already had 170 expressions of interest.

However, Nagpaul believes the department should wait another year. Somerset Coast is interested in forming a PCT but not next April. 'It's just too quick. We would like to have a year's preparation and planning, be a shadow PCT from April then go on to full PCT status in 2001,' Carpenter says.

Commissioning groups are getting their acts together. But it will be next year before they begin to make waves.


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