05 August 2005
NHS managers will not know what hit them. Despite government assurances that there would be no significant reorganisation following the general election, NHS chief executive Sir Nigel Crisp has announced major changes to the number of health service organisations and their responsibilities as the government steps up its reform of primary and community care.
The reductions in the numbers of primary care trusts and strategic health authorities in England were expected – many PCTs believe their numbers should be reduced to enhance their bargaining power with hospitals. But many also believe Crisp's reforms will not achieve this aim.
His announcement does significantly accelerate the pace of change. In March, the Department of Health heralded an evolutionary approach, saying opportunities to merge the primary care bodies should be taken when they arise.
But last week Crisp announced that PCT reorganisation would be implemented by October 2006, while a cut in SHAs will be completed by April 2007.
PCTs could be cut from 303 to as few as 150 to mirror the number of social services authorities, while SHAs could be slashed to nine from 28, as they take on similar boundaries to the Government Offices for the Regions.
The Local Government Association backed the move to coterminous councils and PCTs, but Crisp will not apply this change rigidly. It is thought SHAs may be halved, while the final number of PCTs will be closer to 175. Organisations wishing to avoid a merger will have to make a good case, as all PCTs are expected to save 15% of their budgets. Some unions feel this will mean redundancies and cuts in services.
The second element of the reforms will strip PCTs of much of their responsibility for commissioning care. While they will still administer contracts, the government wants GP practices to make commissioning decisions, using its practice-based commissioning initiative, launched in April. PCTs must show they can move all their GP practices on to practice-based commissioning by the end of 2006.
'PCTs have got an awful lot of work to do to turn that into a reality. Some of them are well advanced but some have not got very far,' says Mike Sobanja, chief executive of the NHS Alliance, which represents PCTs.
A lot of work must be done on the IT systems and while the transaction costs could be significant, it might not produce an appreciable improvement in the quality of care, he adds.
There is also a question mark over whether practices will want to adopt the commissioning initiative, which remains voluntary. An NHS Alliance survey in March found that 50% of the 600 GPs polled would never take up the initiative, 25% had already joined and 18% would join in the future.
Unison head of health Karen Jennings has reservations. 'These changes will strip PCTs of their commissioning powers, which will undermine their ability to plan local services to meet the health needs of local people.
'It is unlikely that GP practices will have either the clout or the co-ordination to effectively step into this gap,' she says.
It is certain PCTs will lose responsibility for providing care – including out-of-hours and district nursing services. A white paper due this autumn is expected to propose care outside hospitals is moved away from PCTs to voluntary organisations, private firms, foundation trusts and local authorities.
NHS Confederation spokesman John McIvor welcomes the changes, but urges the government not to rule out PCT provision of services.
'Some services may still be best provided by PCTs and there will need to be honest debates locally about the options,' he adds.
The King's Fund believes the government could jeopardise other reforms, such as Patient Choice and payment by results, by introducing such a major structural reform at such a delicate stage.
Chief executive Niall Dickson says: 'We know that unless commissioning is strengthened we're going to have continuing financial problems in the NHS. We need proper demand management incentives and we're not going to get them unless commissioning is significantly boosted. This requires a more coherent vision from the centre,' he says.
The changes will shake up and reinvigorate primary care, the government hopes. But not for the first time, NHS managers will have to implement a range of complex reforms, reduce waiting times and keep spending in check, in the knowledge that they could be working themselves out of a job.
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