VOL: 97, ISSUE: 45, PAGE NO: 30
Jennifer Banks-Smith, BA, is project officer
Steve Gillam, MD, FRCP, is director, primary care programme;Cathy Shipman, MSc, BA, is research fellow, all at the King's Fund, London.Therese Dowswell, PhD, BSc, was senior research fellow, National Primary Care Research and Development Centre, University of Manchester, at the time of writingThe NHS has been undergoing a major reorganisation. The implementation of the white paper The New NHS: Modern, Dependable (Department of Health, 1997) resulted in the creation of primary care groups (PCGs) in April 1999.
The NHS has been undergoing a major reorganisation. The implementation of the white paper The New NHS: Modern, Dependable (Department of Health, 1997) resulted in the creation of primary care groups (PCGs) in April 1999.
The purpose of these organisations was to:
- Improve the health of the local populations they covered and address health inequalities;
- Develop primary and community health services;
- Commission hospital and specialist services.
Primary and community health care professionals, including nurses, were to be at the forefront of these developments as PCG board members, together with representatives from local communities. PCGs were also expected to adopt mechanisms to enable the participation of groups not represented on their governing boards.
Practice and community nurses are at the heart of these changes, either in influencing local policy decision-making or experiencing developments at first hand. These developments put a new emphasis on partnership and integration, and cut across the work of many different professional groups in primary and community care.
From January last year, PCGs were encouraged to apply to become primary care trusts (PCTs). These are independent bodies, although they are accountable to their local health authority. All PCTs have the same responsibilities as PCGs but can also commission hospital and community health services. Higher-level PCTs can also provide community services, run hospitals and employ the staff they need.
This article offers a broad overview of the progress of PCGs and PCTs, using data from the national tracker survey (Wilkin et al, 2000; 2001). Published by the National Primary Care Research and Development Centre and the King's Fund, these two documents contain the most comprehensive research carried out on PCGs and PCTs.
The tracker survey and methods used
The tracker survey aims to:
- Describe how PCGs and PCTs have tackled their core functions;
- Evaluate their achievements against national and local policy goals;
- Identify features associated with these achievements.
So far, surveys have been carried out at six months and 18 months after the official launch of PCGs. The six-month survey involved a national sample of 72 PCGs (organised by region), while the 18-month survey included 71 PCG/Ts (two of the original PCGs having merged). The 18-month sample consisted of 65 PCGs and 6 PCTs.
The data was collected using structured questionnaires and interviews. In addition, key stakeholders completed postal questionnaires. Details of the methods used can be found in the full reports of the surveys (Wilkin et al, 2000; 2001).
Organisation and development of PCG/Ts
During their first year, PCGs spent a considerable amount of time, energy and resources on coordinating a disparate group of professionals and transforming them into a corporate working body. Lack of management capacity restricted their successful development. Many continued to have these difficulties in their second year.
Most PCG/Ts have improved work in areas such as commissioning, prescribing, clinical governance, primary care development, health improvement and public consultation by forming sub-groups with particular responsibilities. Nurse representation on these sub-groups has increased, with many nurses take leading roles, and most nurse board members serve on at least one sub-group with specialist responsibilities. However, most of these groups have yet to be allocated any real budgets.
By April 2001, 164 PCGs had gained trust status (Table 1). These are now established as organisations independent from the health authority. This transition has given them greater financial control and freedom to pursue innovation and service development. The integration of primary and community health services, particularly community nursing services, is a key feature of trust status and a motivating factor for many PCGs to apply for it.
When applying for trust status, it is important to ensure that everyone involved is fully committed to making the transition. The trusts surveyed stated that there was no opposition from nurses and only a few GPs were against the idea.
Relationships with stakeholders
The development of PCGs and PCTs was intended to enable primary and community services to become more integrated. It is, therefore, important that all stakeholders are represented on the boards and support such collaborative developments. In the first survey, PCGs reported that it had been a struggle to engage some stakeholders and some said that developing a cohesive working body was a major achievement. While there is evidence that real progress has been made in gaining the confidence of GPs, concerns about some GPs' apathy and resistance to change remain. Also, some have not been happy about losing their fundholding status.
Stakeholder representation in board discussions improved between the first and second surveys, although the views and interests of GPs continued to dominate. Nurse representation had improved, however, as had representation of the views of the public and local community, although this remained a challenge.
In the second survey we found that most PCGs and PCTs had made considerable progress in forging links with non-NHS agencies and groups. For example, 55% were working to develop joint initiatives with local authority leisure services departments and 45% with housing departments.
Relationships with health authorities improved during the second year for many groups and trusts. Fewer felt that their health authority was authoritarian and more thought of it as 'hands-off' or 'laissez faire'. However, tensions between health authorities and PCG/Ts remained, and the second survey revealed concern about a lack of support from health authorities in areas such as finance, organisational development, training and health improvement.
The development of primary care
One of the main objectives in setting up PCGs and PCTs was to facilitate the development of primary care, and considerable headway has been made in this area. This is not surprising, given the preponderance of primary care professionals on executive boards.
PCGs also had to tackle problems resulting from the abolition of GP fundholding and the levelling services between different practices.
After 18 months many initiatives were planned or under way. For example, most groups and trusts (88%) had initiated schemes to enable practices to share resources to improve access to services and promote equity in service provision. These initiatives included shared facilities for specialist nurses, minor surgery facilities, out-of-hours centres and specialist outreach clinics (Table 2). There is also evidence of the sharing of services previously established for fundholding patients, such as counselling.
Initiatives that affected community and practice nurses more generally included educational opportunities with protected time, the integration of practice and community nursing, joint meetings and shared records. There was also an increase in nurse-led personal medical services pilots, minor injury clinics and the recruitment of specialist nurses. Deficiencies in premises, equipment and information systems were also being tackled by many groups and trusts.
Implementing clinical governance
Developing a framework to deliver quality improvement is a key task for PCGs and PCTs. After a baseline capacity and infrastructure was developed in 2000, considerable progress has been made in implementing clinical governance. It was encouraging to see that most clinicians and managers support this initiative.
Progress has also been made in educational approaches to improving the quality of care in practices, practice accreditation, patient surveys and the use of benchmarking data. Developing a culture of information sharing has also been an achievement.
Many nurses are involved in clinical governance activities and share joint leadership with GPs. However, lack of time and resources continues to be a problem for those leading in this area.
Commissioning community and hospital services
Primary care groups and trusts are now expected to commission most hospital and community services. Over the first six months, commissioning was not a priority. There was little activity and most PCGs were using existing contracts drawn up by their health authority, over which they felt they had little influence. Since then there has been progress and they feel that they exert far greater influence over contracts with hospital and community services.
Many PCGs and PCTs commission collaboratively with neighbouring groups and trusts, particularly for acute and community hospital services. Most have now taken full responsibility for commissioning community health services and acute hospital services. After 18 months many were developing proposals for intermediate care and there is evidence that the national service frameworks (NSFs) are exerting considerable influence, particularly on services for coronary heart disease.
Consultation is important to enable services to be commissioned collaboratively, and this is heavily concentrated among primary and community care professionals. About two-thirds of groups and trusts had consulted nurses and most had consulted GPs about the commissioning of these services.
The development of unified budgets potentially enables greater flexibility in the commissioning of services. After 18 months there are indications that PCGs and PCTs are planning to shift expenditure away from hospital and community health services and towards prescribing and practice infrastructures.
Improving the health of local people
The health improvement function of PCGs and PCTs incorporates a definition of health that goes beyond the medical model of health and illness and most were planning health promotion initiatives. For example, 91% planned smoking cessation programmes, 80% planned programmes to increase physical activity and 47% planned campaigns to promote healthy eating, all of which demanded increased nursing input.
Progress has been made through sharing knowledge about local health and service needs. Groups and trusts have developed relationships with organisations outside the NHS. These include local authorities, social services and voluntary organisations that were instrumental in developing and implementing health promotion programmes. Their involvement also encompassed the implementation of NSFs such as that for coronary heart disease.
The number of health needs assessments carried out increased considerably between the two surveys, particularly with regard to NSFs. Although primary care groups and trusts reported increased support in respect of health needs assessments and public health, they felt they still needed more help from their health authorities. Almost three-quarters now have their own health improvement plans.
Information management and technology
Developing good systems of information is vital to support integrated primary and community care and the commissioning of hospital services. While many PCGs and PCTs had access to staff with appropriate information management and technology skills, they felt this was insufficient to meet national targets on the use and transfer of electronic patient records and the monitoring of referral rates.
Nurses in particular would benefit from further training as there is evidence that they have little contact and opportunity to acquire and improve these skills (Alpay et al, 2000). Our survey showed that many groups and trusts thought they had inadequate information to fulfil their core functions, but there was little planned investment to make good these deficiencies.
Our survey shows that primary care groups and trusts have made considerable progress in developing an infrastructure to enable them to fulfil their core functions and develop primary care. At 18 months they had made progress in developing the modernisation agenda outlined in The NHS Plan (Department of Health, 2000).
They are improving access to and extending the range of services available, and levelling services previously restricted to fundholding practices. There is also evidence to suggest improvement in the collaboration of practice and community nurses, with initiatives such as joint training and the sharing of information.
Progress has also been made in implementing clinical governance, where they have effectively engaged practice and community nurses, GPs and other primary care professionals. This has been achieved mainly through educational interventions, which to some extent has brought about a cultural shift regarding quality and governance.
However, progress in other areas, such as commissioning, health improvement and partnership working, has been slower. Not surprisingly, resources (or the lack of them) were seen as the main obstacle to achievement.
The effectiveness of PCGs and PCTs in fulfilling their objectives to improve the health of their communities and to develop primary and secondary care services will depend on them having a committed workforce and being guaranteed a consistent flow of funding.
Primary care groups have faced constant organisational change, particularly with the transition to trust status (which all are to complete by 2004). This will again demand much time and energy and may delay the development of strategic priorities. Groups combining clinical and corporate working will find this process increasingly difficult, and maintaining their engagement will be vital to strategic development.
Government targets, in terms of NSFs and national guidance, compete with local priorities for scarce resources. Primary care groups and trusts will continue to find it difficult to address the apparent disparity between these expectations and their capacity to achieve them.
For practice and community nurses working in PCGs and PCTs, there is evidence to suggest that nursing issues are being taken forward within primary and community care, and that nurses are making a greater impact on local policies.
It is particularly encouraging that primary care groups and trusts believe they face no opposition from nurses in the transition to trust status. This is essential to ensure the effective integration of primary and community nursing services.
Next week's article examines the views expressed by nurse board members and the level of attention given to staffing, integration and other issues experienced by community and practice nurses in the context of the development of PCGs and PCTs