1 INTRODUCTION
1. On 28 July 2005, the Government published Commissioning
a Patient-Led NHS.[1]
The central tenet of these proposals was that Primary Care Trusts
(PCTs) would be reduced significantly in number in order to achieve
15% efficiency savings, whilst simultaneously strengthening their
commissioning function by devolving more commissioning to GP practices,
and contracting out the provision of NHS services.
2. In a damning report of initial reactions to the
proposals, the Health Service Journal, the generally even-handed
NHS trade magazine, described them as 'intellectually incoherent':
The government's blueprint for primary care trust
reform was this week slammed as 'incoherent', 'ill thought out'
and 'an incredible way to treat important organisations' by senior
NHS managers and policy analysts.[2]
3. In addition to their strong reservations about
the content of the Government's proposals, commentators were appalled
at the Government's specified timescale which allowed the NHS
only 11 weeks, largely over the summer break, in which to consult
local stakeholders and put together plans for reconfiguring local
PCTs. It was initially thought that these plans would also have
to cover the divestment of PCT provider services. The divestment
of provider services, including community nursing services, to
providers outside the NHS, was also greeted with astonishment,
as this appeared to anticipate the outcome of a much-vaunted Government
consultation on 'out-of-hospital' care announced only a month
previously.
4. The background to PCT reforms is complex. PCTs
were established three years ago, replacing larger commissioning
structures called Health Authorities. The intervening three years
have seen far reaching change in the NHS, including the establishment
of Foundation Trusts, the introduction of the new financial system
of Payment by Results, the expanding use of the private sector,
the advent of patient choice, the introduction of new pay and
contracting arrangements for NHS staff through Agenda for Change
and new contracts for consultants and GPs, and the implementation
of the European Working Time Directive. PCTs currently have a
complex and crucial role in implementing all these policies, and
currently control 80% of the NHS budget, which currently stands
at £76 billion.[3]
5. While sometimes organisations are abolished or
downscaled because their functions are no longer needed and they
have effectively become redundant, it is clear that the functions
PCTs perform are still highly relevant. In fact, at a time of
unprecedented investment in the NHS, PCTs have never been more
critical to the success of the NHS in ensuring the provision of
high quality, value for money health-care. Reducing their number
so drastically while their functions remain strongly implies that
PCTs have not proved themselves equal to their significant task.
However, at only three years old, PCTs are a new addition to the
complex jigsaw of structures that make up the NHS, and arguably
have not been given enough time to demonstrate their effectiveness.
6. It is perhaps inevitable that structural changes
in the public sector attract a degree of resistance from those
working in the organisations which are under threat, who obviously
are concerned about their own futures. However, the strength of
response to these announcements across the NHS suggested to us
something more than a knee-jerk reaction prompted exclusively
by thoughts of self-preservation and we, in common with many others,
were concerned that the tight timescales might allow insufficient
time for debate on these far-reaching reforms. Equally, all organisational
change brings significant distraction from core tasks, and the
prospect of a further reorganisation only three years after the
last significant reform of NHS structures raises inevitable questions
about the potential impact on PCTs' day to day functions, which
include providing vital patient care. We were thus persuaded to
conduct an inquiry, within a necessarily condensed timescale,
into this complex subject.
7. We announced this inquiry on 21October 2005 with
the following terms of reference:
The Health Committee has decided to undertake
an inquiry into potential changes to primary care trusts' functions
and numbers arising from Commissioning a Patient-Led NHS,
including:
Rationale behind the changes
Likely impact on commissioning of services
Likely impact on provision of local services
Likely impact on other PCT functions, including
public health
Consultation about proposed changes
Likely costs and cost savings.
8. During the course of two sessions, we took evidence
from the Minister of State for NHS Delivery, Lord Warner of Brockley;
John Bacon, Group Director of Health and Social Care Services
Delivery at the Department of Health; bodies representing the
interests of those working in and with the NHS, including the
NHS Alliance, the NHS Confederation, the Royal College of Nursing,
the Faculty of Public Health Medicine, London Local Medical Committees,
the Local Government Association, and the Association of Directors
of Social Services; and from Chairs, Chief Executives and officials
working in NHS Strategic Health Authorities and Primary Care Trusts.
We also received over 50 written memoranda. We are extremely grateful
to all those who gave evidence to our inquiry, many of whom prepared
written material and accepted our invitations to give oral evidence
at extremely short notice. We are particularly indebted to those
witnesses working in the NHS who gave us frank and compelling
accounts of the impact of these changes on their own organisations,
against a backdrop of extreme political sensitivity and ongoing
uncertainty about their own future roles. Their evidence was extremely
valuable in shaping our assessment.
9. We would also like to thank our specialist adviser,
Dr Richard Lewis, an independent consultant and senior health
policy fellow at the King's Fund, for his detailed and insightful
support throughout this inquiry.
10. This report begins by providing some brief background
to the proposals set out in Commissioning a Patient-Led NHS.
It then discusses the implications of these proposals in three
separate sections:
- The initial consultation process,
including announcements about divestment of provider services
- The likely impact of PCT restructurings, including
immediate impacts on PCTs' day to day functions and clinical services,
and longer term impacts on commissioning, on public health and
financial impacts
- The impact of divestment of PCTs' provider services
We have also included a chapter on issues surrounding
the potential contracting out of commissioning in Oxfordshire,
which is a separate, but related issue.
1 Department of Health, Commissioning a Patient-Led
NHS, 28 July 2005. Back
2
Health Service Journal, PCT reform strategy slammed as 'intellectually
incoherent', 4 August 2005 Back
3
Department of Health, Departmental Report 2005, Cm 6524,
June 2005 Back
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