Primary Care Trusts (PCT): an impact evaluation

In the last decade the United Kingdom National Health Service (NHS) has undergone the biggest revolution since its inception in 1948 (Trimmins, 2006). In response to growing political and public discomfort with the quality of NHS services, the Government announced a raft of changes at the turn of the century to modernise the NHS and improve patient care (Secretary of State for Health, 2000). The new NHS was born, accompanied by new sets of expectations concerning the expedience, cost and quality of patient care. New expectations would amount to little without mechanisms to drive the changes. The waiting times that so frustrated politicians, practitioners and patients especially, would not cut themselves. To meet the challenges posed by new performance expectations structural reform was desirable. Central to the on going reform of the NHS is a movement away from a state-provided, centrally-controlled system, towards a devolved model with the introduction of more voluntary and private providers. This transition is consistent with the trend in the industrialised world away from centralised regulation and towards free market approaches to the provision of public services (Lewis et al, 2006). By opening up the health care sector to a wider variety of providers, including voluntary and private interests, it was theorised that increased competition would lead to more efficient and cost-effective provision, wider choice for patients and those charged with commissioning health care, and the highest possible standard of care.

More importantly however, the devolved health care model was designed to shift the balance of power from central government to the communities in which health care is actually being provided and utilised (NHS Executive, 1999a). By placing more responsibility for managing local health care provision in the hands of local health practitioners and patients, the new model was expected to promote more efficient and better-integrated provision that closely reflects the unique needs of local communities. Under such a model it was hoped, for example, that waiting times could be reduced by better targeting funding, that people would not so readily fall through the cracks because health and social care would be better integrated at a local level, and that special interest groups unique to a particular region would receive appropriate care that they might miss out on under a centralised model.

Primary CareTrusts (PCTs) were established under the Health Act (1999) to give life to the reform and by 2002 had become the leading NHS body responsible for managing local NHS services. PCTs grew out of the Primary Care Groups (PCGs) of the former Health Authorities and have the same overall functions, including “improving (and addressing inequalities in) the health of their community; developing primary and community health services through investing to improve the quality of care; and, the integration of services, and commissioning secondary care services” (NHS Executive, 1999b). Unlike the PCGs however, some PCTs also directly provide community health services, and all were set up to have their own budgets and the ability to set their own priorities within the overriding budgets and priorities set by the relevant Strategic Health Authority, and the Department of Health. Practising primary and community care professionals comprise the majority of a PCT’s executive committee and they are statutorily obligated to involve the public, patients and other carers in service development, and to work in conjunction with social services.

The predicted benefits of managing services at a local level are several fold (NHS Executive, 1999a). In addition to bringing decision-making closer to local communities, PCTs are expected to provide closer and better-targeted support to their constituent practices (e.g. investment in premises development, development of practice-based information systems, ongoing education for practice staff and recruitment through local channels), as well as better support to individual clinicians (e.g. enhanced/diversified career opportunities, alternative employment models, continuing professional development). Over time PCTs are expected to promote better integration of local community health, general practice, social services and local authorities and facilitate the development of ‘intermediate care’. So for example, a patient suffering a traumatic accident should experience a seamless transition between initial medical treatment, rehabilitation and counseling. PCTs are also expected to identify cosTt effective strategies to provide more services locally, and in doing so increase access to care in their communities. Overall, it is expected that managing and delivering services through PCTs will develop a more efficient and effective health service that better reflects the needs of the local community and improves health outcomes for all.

Impact of the Policy

While solid progress has been made in achieving national performance targets relating to primary care, by and large the reforms are yet to live up to expectations. The Commission for Health Improvement’s (2004) sector report did not find consistent evidence of meaningful consultation by PCTs across practitioners and with the public, suggesting that truly integrated, devolved decision-making was not occurring across the sector (albeit in pockets). Many practitioners attached to PCTs expressed that they weren’t being appropriately consulted, and still others were unsure how they should be working with the local PCT. In most cases PCTs were yet to develop robust monitoring systems to assess the quality of care, and the lessons being learned throughout the reform process were not being effectively disseminated amongst PCT stakeholders. In fact, the Commission found little evidence to suggest that PCTs were actively attempting to identify or shape provision to meet local needs. Ironically, and on the positive side, PCTs were consistently meeting national NHS access targets under the devolved model.

Evidence gathered from patients in the new NHS suggested they did not receive better information, let alone become directly involved in the reshaping of health services. While clients were happy with the manner in which they were treated by health practitioners, they expressed confusion about their eligibility for NHS funded services and felt poorly informed in relation to medication decisions. In relation to the unique needs of minority groups in local communities, the Commission expressed concern about a lack of information available in alternative formats. Neglecting to provide alternative information sources threatens to preclude for example, non-English speakers, the visually or hearing impaired and other minority groups from health services (Commission for Health Improvement, 2004).

The expectation that staff would be better supported by the PCT model had also not been lived up to (Commission for Health Improvement, 2004). Health professionals and practice staff that were aware of the training and career development opportunities available to them were frustrated by the lack of available cover to engage in training and development. In relation to the maintenance of quality standards, the Commission expressed concern over the lack of staff appraisal processes to ensure the competence of practitioners.

Evaluating the Policy

Devolution from centralised to localised management of the health sector was rapid. From 2000 to 2002, PCTs increased in number from 17 to 303 and 80% of total NHS funding in 2002 (Commission for Health Improvement, 2004). Critics have argued that such a sudden structural adjustment threatened to undermine the success of the entire policy by not allowing managerial capability, stakeholder relationships and effective organisational processes to develop in PCTs prior to their inception (Wilkin and Coleman, 2001). In response (at least in part) to a large NHS budget deficit, the government announced in 2005 that the 303 PCTs would be merged cutting their number in half. The PCTs were also seen as too weak (or lacking the clout) to drive the reforms envisioned by the policy architects. Ostensibly, reorganisation into a structure that more closely resembles the former centralised system suggests that the devolved model experiment failed, but on closer inspection, is it possible that the rapid implementation of the reforms rather than the policy itself doomed the experiment to fail?

Underlying the PCT’s lack of progress in supporting clinicians and health practices, in informing and involving sector and public stakeholders in devolved decision-making, and in increasing access to health services for all, there appears to be a deficiency in organisational capability. Members of PCT executive committees have consistently reported being overburdened and unable to give effect to the diverse expectations of the policies associated with NHS reform and being unable to recruit additional management capability. Could it be that the devolution of decision-making to local authorities created a gap in management capability that ‘hamstrung’ PCTs? Furthermore, staff shortages across several disciplines have impacted on the ability of PCTs to implement the reforms and engage in activities beyond business as usual. If managerial capability, governance and management practices and stakeholder networks had been seeded early and given a chance to mature prior to inception, with adequate staffing resources the PCTs would likely have been better able to fulfill the expectations associated with the NHS reforms. Eroding the demarcations that have developed over centuries between disciplines, between institutions and between the patient and practitioner will take more than a couple of years. Culture change takes time and the benefits of devolved decision-making are worthwhile. It seems a shame to end the experiment prematurely.

Bibliography

Commission for Health Improvement. What CHI has found in primary care trusts: sector report. London: CHI, 2004.

Lewis, R., Alvarez-Rosete, A., Mays, N. (2006) How to regulate health care services: an international perspective. King’s Fund: 2006.

NHS Executive (1999a). Primary Care Trusts—Establishing Better Services.

NHS Executive (1999b). Primary Care Trusts—Establishment, the preparatory period and their Functions.

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Trimmins, N. (2006) Designing the new NHS: Ideas to make a supplier market in health care work. Report of an independent working group. Kings Fund: 2006.

Wilkin, D., and Coleman, A. (2001). From primary care groups to primary care trusts in the new NHS in England. Primary Health Care Research and Development; 2; 215–222