Come Together
3 August, 2007

Dr Victoria Barbary, Researcher, NLGN

PCTs need more freedom to collaborate with local councils

Primary Care Trusts were introduced in 2002 to increase local freedom and decision-making power in health provision, reduce health inequalities and improve community health. Many PCTs, however, have struggled to fulfil these roles because they have been in an almost constant state of flux since they were established. They also remain part of the centralised NHS framework established by Aneurin Bevan in 1948, and are thus ultimately financially and organisationally accountable to the Health Secretary.

These circumstances have resulted in poor financial management, exacerbated by pressures exerted by the changes to GPs’ and consultants’ contracts and the Agenda for Change pay initiative. In contrast, local authorities have a considerably better track record: in 2005/06, while PCTs recorded a net deficit of £547m, councils balanced their books and made £1.2bn in efficiency savings.

By integrating commissioning frameworks, PCTs and local authorities could gain more expertise and help orientate services towards the recipients, rather than the suppliers of care and facilitate more responsive, flexible and efficient provision. On one hand, the democratic accountability of councils means that, on the whole, they have more responsive procurement frameworks than PCTs, which frequently appear to commission services on an insufficiently flexible ‘one size fits all’ basis. On the other, collaboration with PCTs would enable councils to improve their care procurement, particularly from the voluntary sector, which the Audit Commission has recently highlighted as being often ‘blighted by poor commissioning practice’.

Integrating PCT and local authority commissioning structures would also reduce Whitehall’s responsibility for primary care, and fit with the Prime Minister’s declared aim of greater devolution of power. To date, the focus on choice of public service providers has overshadowed equally important questions of voice, reliability, equity and accountability. Many decisions balance individual choice in the short term to increase long-term options for all, and there must be greater local accountability where these judgements are madeBut such trade offs can only happen if power is devolved, and local public agencies are empowered to engage in decision-making.

Councils already have overview and scrutiny committees to examine the local health service and refer any changes to the Secretary of State for consideration by the Independent Reconfiguration Panel. Moreover, under the Local Government and Public Involvement in Health Bill, they will also require PCTs and NHS trusts to cooperate in preparing Local Area Agreements for shaping public services.

By further involving local authorities in healthcare delivery, these accountability structures will be extended and thus empower service users and providers by giving more control to citizens and drive up standards. By so doing, people on low incomes who have been alienated by the government’s treatment of individuals as consumers would be re-engaged and empowered as citizens.

NLGN has, therefore, suggested that where a PCT struggles to meet its financial targets and performance objectives, it should be allowed to appoint joint posts on the senior management team with the unitary local authority, or county council. To ensure full democratic accountability, the PCT board could also have a majority of councillors and chaired by the leader of the council or mayor. This would enable democratically-elected representatives to work closely with specialists to help improve commissioner-provider relationships, which can be tense.

Such integration is already happening in some areas: Bristol PCT’s public health management structure is currently ‘changing because of close work with the council’. Herefordshire has recently established a Public Service Trust, which consists of merged teams, accountable to a Board, which is answerable to both the council and the PCT. Nevertheless, these arrangements will only work effectively if PCTs’ bonds to central government are loosened and commissioning frameworks allowed to become more responsive to the local community’s needs through collaboration and shared objectives.