How well prepared are the boards of
primary care trusts to fulfil the aspirations
of world-class commissioning?
Like PCT boards around the country, most
of our nine were focused on splitting their
commissioning and providing functions,
creating arm’s-length arrangements between
the two and searching for an appropriate
governance model. They were asking
themselves what impact this would have on
their forward plans, what new issues they
would need to consider and at what point.
They were also concerned about their
capacity and capability as commissioning
organisations. While they might command
a major slice of the NHS’s resources as
commissioners, often they did so with a
disproportionately slender number of staff.
A particular shortage exists among financial
professionals who can create sophisticated
models to predict the financial impact of
demand for health services. There is a similar
scarcity of contract managers able to set up
and monitor agreements with providers.
PCTs are striving to genuinely understand the
needs of their local populations and anxious
to examine what services are available to
address those needs. Where they discover
gaps, they are asking what they must do to
stimulate the market in order to encourage
new entrants into it.
Clinical engagement is another preoccupation.
PCTs are asking how they can secure real
clinical engagement – through practicebased
commissioning or other means – in an
environment where GPs tend to dominate
clinical representation. How representative
are GPs of the rest of the clinical community?
Halfway through the financial year, many
PCTs are finding that pressure is building
on their budgets and they are beginning
to worry about sliding into deficit. In most
cases this is being driven by their main acute
providers over-performing against budget.
The suspicion is that this may be the case
especially where an acute trust is seeking
foundation status. PCTs want to know how
they can better control demand for secondary
care services – for example, by working with
GPs on referrals – as well as putting in place
much sharper and more robust contractual
arrangements with their major providers.
What can PCTs do to address these
issues and ensure they are fit for the
purpose of implementing world-class
commissioning?
Most PCTs currently have too much on their
agenda and do not have the management
capacity to deliver everything that is expected
of them. This results in ‘headless chicken’
syndrome: overwhelmed with busyness,
they fail to prioritise and do not always have
the time (or energy) to drive delivery of their
plans, and so the benefits they are trying to
achieve are not always realised.
As an initial step, boards and their
executive teams need to hold the difficult
conversations about what they are no longer
prepared to devote scarce management
resources to tackling. That is, of course, a
hundred times more easily said than done,
and the NHS is notoriously bad at doing
precisely this. But PCTs are so overworked
they must face up to it. Only then can
they be confident of getting real closure
on the key aspects of their strategic and
organisation development plans.
Once that is accomplished, they should carry
out some sophisticated root-cause analysis
of their supply chain to ask why demand for
secondary care is increasing and what they
can do about it. Many PCTs are investing
significantly in market analysis, but that is
an expensive luxury when your acute trust is
over-performing by 10 per cent – an urgent
problem that must be sorted out first.
If PCTs fail to do that, they will find their
funds for investment in new services rapidly
disappear in acute sector overspends.