Newly reconfigured and streamlined, primary care trusts (PCTs) are now facing up to tough new challenges and targets that are set to impact on general practice.
Practice-based commissioning (PbC), a greater emphasis on community and primary care-based services, the 18-week waiting target and changing patterns of service provision are just some of the reforms that practice managers are going to have to keep pace with over the next few years.
The new ministerial team for health appointed by prime minister Gordon Brown in the summer has signalled that PCTs will be expected to perform to higher standards, improve health outcomes, tackle health inequalities and improve the quality of healthcare in the community.
This was the message of a conference on the future direction of PCTs. "The new emphasis on 'local' is extremely important for PCTs," said Mike Farrar, chief executive of NHS North West.
He warned that life was set to become more challenging for PCT commissioners, and they would have to ask themselves tough questions to ensure they achieved a return on the resources they invested in healthcare.
They would also have to become more involved with their local communities, listen to the views of patients and would need to work collaboratively with practice-based commissioners.
The status quo was no longer going to be good enough. "PCTs must want to do better," he said. In particular, they would have to become more discerning about PbC, about what it could deliver and how it operated. He said he too often heard managers describe PbC as a power struggle between practices and their PCTs.
"If we get into a power struggle about who is calling the shots then we are going to be in real difficulty," he warned.
He said the role of the practice-based commissioner was very clear – it was to be innovative and challenging, and to use resources differently while operating within the strategic framework set by the PCT. He stressed that PCTs must work collaboratively with general practices.
Redesigning patient pathways
Joe Rafferty, director of commissioning and performance for NHS North West, said PbC is a way of redesigning patient pathways. "PbC is a real priority in the sense that it is part of the journey towards greater legitimisation of commissioning decisions, although it is not the only important element. It is very important that PbC is seen to put health and healthcare spend close to population need."
Mr Rafferty added that it is essential that PbC focuses on the quality of healthcare and the services that links in to the health and wellbeing of the community. It is the job of PCTs to empower practice-based commissioners and local communities to assess need and to performance manage providers to ensure they obtain value for money.
He said PbC would also be important in helping PCTs to achieve the new 18-week waiting target from GP referral to treatment. "Eighteen weeks is coming at us like a steam train. It is going to be an enormous challenge, and one of the litmus tests of the new PCTs," he said.
Scrutiny of risk
Anna Walker, chief executive of the Healthcare Commission, said that over the next few years there would be a greater scrutiny of risk in primary care. Primary care is growing – GPs are already dealing with 300 million patient contacts a year – and is set to expand further as more care is delivered closer to home.
There are an estimated 16 errors per 100,000 patient contacts, or 120 mistakes per day, that could potentially harm patients, and 11% of prescriptions contain errors.
PCTs are regulated as providers and assessed against a set of standards, but currently GP practices are not regulated in any way. "There is quite a muddle around what is and isn't regulated in primary care as a whole," said Mrs Walker. "Increasingly, we are trying to move our regulatory system to one based on risk. There is a lot of info on risk in the hospital sector, but very much less in primary care."
But, she said, they plan to adopt a "light touch" approach, which would involve the collection and publication of key information and greater professional accreditation.
PCTs, which spend £75bn a year, are also set to face greater scrutiny and regulation from the new healthcare regulator, Ofcare, due to replace the Healthcare Commission and other regulatory bodies next year. They would be assessed on local outcomes, whether they are providing joined-up health and social care, and on patient feedback.
John Pope, a Department of Health (DH) policy adviser, said the challenge ahead for general practice and community services is to improve care, provide a better patient experience and greater value for money.
"The reforms will centre around these issues. Everything so far has focused on the acute sector. Until now, we have believed the NHS was all about hospitals, but we now know it happens in GP surgeries and community services, and that side of the business hasn't yet had that focus."
John Pope said community services are now a growth business, and new models are being suggested for providing directly managed services. A current pet project of the DH is Community Foundation Trusts.
Mr Pope explained that these organisations would provide community services currently run by PCTs, and that the foundation trust business model would allow them to compete with other entrants to the market. They could commission more diverse providers, and would have greater freedom to innovate and improve services, and to organise care around patients. They would benefit from greater financial freedom, but would have stronger governance and would be accountable to the local community.
The DH is currently working with seven PCTs interested in this model of care, and the new trusts could be up and running by 2009.
Mr Pope said the DH is also keen for more social enterprise organisations to provide healthcare. A fund of £73m has been set up, and 26 "pathfinders" have been appointed. Social enterprises have primarily social objectives, with any surpluses they make reinvested into the business, he explained.
Meeting the 18-week waiting target
Tim Evans, chief executive of Bolton PCT, outlined their work to meet the 18-week waiting target. He said they are using PbC and payment by results as tools, and are refocusing services into primary care and increasing one-stop clinics.
GPs are encouraged to propose ways
of increasing the supply of services through PbC, and to use the Quality and Outcomes Framework (QOF) to reduce demand by addressing health problems before they become acute.
The PCT is employing 25 active case managers to prevent admissions to hospital, and has established a community unit alongside their accident and emergency department to reduce demand for urgent care. Other health prevention measures include health promotion and the use of health trainers based in 15 GP practices to encourage people to change their lifestyles. They are also actively tackling childhood obesity, smoking and
Bolton PCT is set to become an early achiever on the 18-week target, having established a referral management scheme – an Integrated Clinical Assessment and Treatment Service (ICATS). Patients who need surgery, but do not require urgent treatment, are no longer referred by their GPs directly to secondary care, but to a one-stop-shop team of health service professionals for assessment and diagnostic tests. They may be referred on to secondary care or to alternative treatment provided in the community.
Orthopaedic surgeon and ICATS lead Andy Maskell said the new service is a radical change. Patients arrive in secondary care "all worked up" and ready for their operation within 18 weeks. The service is popular with patients because it cuts down the number of visits they make to hospital, and they can be seen at an accessible building in Bolton town centre.
They are now able to offer more diagnostic facilities and intermediate treatments, such as rheumatology in primary care, preventing some admissions to hospital, and those who needed hospital treatment are much better prepared for their treatment.
"The Clinical Assessment and Treatment Service is one of the most radical tools in our armoury. We are trying to deliver a patient-focused service of excellence, and we are already achieving 18-week waits for more than half (52%) of our patients," he said.
To the future
The conference provided only a taster of the reforms that practice managers will be involved in over the next few years. But one thing that was made clear is that they can expect to be dealing with a tough new breed of PCT managers in the future.
Conference chair Mike Farrar said the future of PCTs was absolutely critical, and there are many ways in which PCTs would now be expected to step up and work differently.
He warned: "The future of PCTs will be determined by the extent to which people in them are ambitious for their futures."
The conference, The Future of Primary Care Trusts, was held in Manchester in July.