Primary Care Trusts

Primary care trusts evolved from primary care groups, which replaced health authorities. They were introduced precisely because it was hoped that that would strengthen the local focus of the NHS and improve clinician and patient engagement in the planning and commissioning of health care. In my constituency, however, the latest decision is to replace Dartford, Gravesham and Swanley PCT with a PCT covering the whole of west Kent, which looks remarkably like the health authority area that was originally replaced. The decision could threaten the successful working relationships that managers and the professional executive committee of the PCT have been able to build up with individual clinicians throughout the PCT area. The close working relationship between the PCT and Dartford and Gravesham’s 120 GPs has been helpful in ensuring that the introduction of some of the challenging and potentially contentious changes, such as choose and book and practice-based commissioning, happens as smoothly as possible. The relationship has enabled individual clinicians to become involved at an early stage in the implementation of the reforms and to take ownership of them in a way that would be much more difficult with a larger PCT that was less rooted in the various communities that it served. The only way to ensure that that consensual approach is maintained is to ensure that all the professional executive committees—PECs—that are about to become redundant are replaced by strong practice-based commissioning groups that have the necessary resources and management support to function effectively. Without bodies of that nature, which are capable of championing the interests of local practitioners at PCT level and maintaining clinical engagement in the reform process, we will jeopardise much of the progress made in the past few years since the PCTs were set up. The presence of effective locality practice-based commissioning groups will also help to provide a mechanism whereby examples of best practice can be fed through the system and shared among local practitioners. My worry, which many local practitioners to whom I have spoken share, is that very little has been done to prepare for the launch of the new PCT, which is to take place in October. With only three months to go, no one has any idea what management structures and what arrangements for liaising with front-line professionals will be put in place. All that is known for certain is that some PCT jobs will go. Not unnaturally, that has created a great deal of uncertainty and pessimism at local level about what the future might hold. That needs to be addressed, and quickly. Aside from the possible loss of local clinical engagement, my major concern is how the new PCTs will manage to reconcile the competing clinical priorities of each former PCT area. Dartford, Gravesham and Swanley PCT has a clear sense of the particular health care needs of the local population and has been able to put in place a wide range of strategies tailored to the needs of that population. Life expectancy in the area, which is 76.5 years for men and 80.5 for women, is among the lowest in the county. The area has a significantly higher percentage of people with a limiting long-term illness than any other area in Kent except Swale and Ashford. Levels of cancer, coronary heart disease, mental illness and teenage pregnancy are also higher in my area than in other districts in the county. Dartford and Gravesham, situated in a major part of Kent Thameside, not only have similar health care needs, but face considerable development pressures. There are plans to build 20,000 new homes over the next 20 years. That is unlike what is happening in any other area coming into the new PCT. As a local organisation with strong links to each of the major development partners operating in the area, the present PCT is well placed to influence the design of those new communities and to ensure that the health care needs of new residents are given appropriate consideration. In amalgamating Dartford, Gravesham and Swanley PCT with PCTs serving Sevenoaks, Tonbridge and Malling, Tunbridge Wells and Maidstone, all of which have very different health care needs from those of Dartford and Gravesham, there is a risk that the local focus will be lost. That could mean that some of the key strategic issues affecting Kent Thameside will not get the priority that they deserve at PCT level. There is also a risk of planning blight in the run-up to the introduction of the new PCTs later this year, as PCT boards, in their twilight period, shy away from making some of the more difficult decisions about service development, which have become necessary as a result of the ““Agenda for Change”” programme and the introduction of payment by results and practice-based commissioning. Reconfiguration will also prove a significant distraction for PCTs in the next 12 to 18 months, absorbing a great deal of management time and resources at a time when many are grappling with major financial and strategic challenges. The uncertainty caused by reconfiguration is also likely to unsettle medical and managerial staff, leading some to seek posts elsewhere. It is vital that we try to prevent the loss of key personnel with experience of the local health care market and the health needs of the local population. Although PCTs are now responsible for spending 80 per cent. of the NHS budget and have considerable freedom to decide which services should be commissioned and how they should be delivered, that increase in resources and power has not been matched by an equivalent increase in the level of accountability to the communities that they serve. Unlike local education authorities, which are at least politically accountable, PCTs are in no way accountable to the communities for whose health care they are responsible. Anyone who approached the Department of Health, for example, with concerns about the way in which a local service was being provided would simply be told that it was a local matter and that Ministers and civil servants could not possibly intervene. They would probably be referred back to the patient and public involvement forum for the PCT, which has some input into the decision-making process, as well as a scrutiny role, but that is an appointed body and is not directly accountable to the public. At present, the local focus of PCTs and the fact that most key executive and non-executive board members and members of the PEC live or work in the area have helped to ensure that they are at least receptive to the views of local community bodies and patients. Once the newly configured PCTs have been created, however, that local connection is likely to be lost. Although the board of each newly configured PCT will contain non-executive directors who, between them, will have some experience of the health care system in each locality, it is inevitable that the voice of each locality will become less prominent at board level, whatever the NHS Appointments Commission tries to do to balance the situation. The only way to overcome the problem, and at the same time to address the accountability gap that has always affected PCTs, is to include some directly elected members on PCT boards. At the very least, we should introduce a system along the lines of that used by foundation trusts, whereby trust members, who are patients and other members of the public in the area, are given the opportunity to elect the majority of representatives who serve on the trust’s board of governors. The board of governors helps to set the trust’s strategic direction and ensure that it operates in a way that is consistent with its terms of authorisation. In addition, its elected members must put themselves up for re-election every three years if they wish to continue to serve on the board. Foundation trusts therefore have an element of accountability that PCTs continue to lack. The presence of a group of directly elected individuals on the board of governors, which would operate in parallel to the board of directors, as in the case of new foundation trusts, would certainly help to assuage my constituents’ understandable concerns about the remoteness and lack of accountability of the new PCTs. I also want to talk about the involvement of pharmacists in PCTs. As part of the reconfiguration process, I should like community pharmacists to be given a much greater strategic role in the management of local PCTs. At the moment, it is quite rare to find pharmacists involved in the decision-making process at PCT level. As a result, they lack any real say in defining local health care and clinical priorities. The mandatory appointment of community pharmacists to PCT executive committees, for example, would be a great way of ensuring that the voice of pharmacy is heard at executive level. Increased PCT liaison with local pharmaceutical committees would also ensure that PCTs made the best use of the skills of community pharmacists. Finally, new PCTs should be encouraged to commission and properly fund new primary care services from pharmacists. The Government have made it clear that they want community pharmacy to play a key role in the delivery of primary care services in the future, and such commissioning and funding would be an important way of achieving that. The new White Paper ““Our health, our care, our say”” emphasises the need to make greater use of community pharmacy services and refers to the strong support for them among the public. According to the consultation that was carried out prior to publication of the White Paper, the public want pharmacists to have an increased role in providing support, information and health care in future. In addition, the Government strategy for reducing health inequalities highlighted the important contribution that pharmacists can make to reducing obesity, improving sexual health and helping people to quit smoking. Although some PCTs have used their commissioning powers to great effect and have committed themselves to expanding the range of primary care services available to patients, others have been very slow to grasp the new strategic responsibilities. I want to make sure that that is addressed as a matter of urgency in future. I have pointed out that there are some benefits in the PCT reform. However, I do not believe that the reform has been properly thought through, and I share some of the concerns that the Chairman of the Health Committee voiced in his opening remarks that some of the process seems to have been rushed. I do not believe that there has been enough consultation or involvement, nor do I believe that there has been sufficiently careful examination of the long-term implications.