Memorandum submitted by Colchester PCT
(PCT 10)
BACKGROUND
Essex SHA has submitted a number of options
as a result of informal consultation and stated its preferred
option as a North South two PCT solution. There are currently
13 PCTs. Colchester supports the five PCT option.
1. RATIONALE
BEHIND THE
CHANGES
There are currently 13 PCTs in Essex. Reducing
them from 13 to two is considered to be more severe than anywhere
else in the Country. We accept wholeheartedly the need to strengthen
commissioning capacity and believe that five PCTs for Essex would
bring a sensible balance between size, commissioning capacity
and savings. In the majority of other SHA areas the reduction
in PCT numbers has been far less draconian, reducing on average
from two-three PCTs to one strong commissioning area. If a similar
approach was applied to Essex this would lead to four-five strong
commissioning PCTs.
Drive for Savings
The proportion of management costs that would
be delivered by reducing from 13 PCTs in Essex to two would be
disproportionate to the national average. We are concerned that
this might mean a disproportionate contribution towards national
savings targets from Essex with corresponding devastation to our
staff. Or this might be applied to the new SHAs and PCTs to give
them extra capacity. A more even spread and contribution can be
achieved whilst still creating strong commissioning PCTs and a
fair contribution towards savings and SHA costs. This approach
would also ensure any future divesting of provider functions has
sufficient management resources.
Divestment of Provider Function
Like many PCTs who manage provider functions,
our PCT already separates commissioning and provider functions.
We provide learning disability services for eight PCTs in North
Essex and community services for the 170,000 population of Colchester.
In the latter area we support a merger with Tendring PCT at both
commissioning and provider levels. In both provider functions
in our PCT there are separate management lines to commissioning.
However these two functions, along with commissioning have the
benefit of shared support functions such as finance, communications,
Research and Development, Human Resources etc (within finance
the support for commissioning is separate from the provider functions).
A massive reduction in PCTs in Essex will also
create a significant loss of focus in the primary care agenda
and the success we have had in moving away from traditional hospital
locations for many out patient services. The process of divestment
will distract from this drive and many benefits for patients will
be lost or put in jeopardy—having the exact opposite of
the intended affect of divestment for those PCTs such as ours
where commissioning and provision are already separate. It is
however accepted by merger with our neighboring PCT we will achieve
benefits of economies of scale and be able to strengthen the respective
functions.
Practice Based Commissioning (PBC)
Larger mergers and divestment of provider functions
do not enhance the challenge to ensure 100% Practice Based Commissioning
is achieved. A merger between two or three PCTs will create more
capacity to focus on Practice Based Commissioning but with larger
mergers comes the need to create localities so as to be locally
sensitive to the high risks associated with PBC. It is imperative
to be effective in clinical engagement and enhance PCT to "know
your patch" this is less likely in a very large PCT which
is geographically remote.
If a PCT has, as we have, separate commissioning
and provider functions then there is no reason why this would
be a distraction from PBC, on the contrary we consider this to
be an advantage.
Contestability
We are not opposed to contestability as a means
of achieving change but believe the timing of this should be left
to PCTs to determine. There needs to be a level playing field
so that PCTs can demonstrate that it does not distract from their
commissioning role or indeed on the contrary that there are benefits
(economies of scale etc and support functions).
2. LIKELY IMPACT
ON COMMISSIONING
OF SERVICES
We see the benefits of creating more capacity
in commissioning to be able to match on an equal footing the capacity
in provider services as enjoyed by larger Trusts and in particular
Foundation Trusts. We also believe that the same rigor should
be applied to our own provider services and see this as perfectly
achievable whilst having a separate provide function and from
the capacity created from merging with Tendring PCT and without
the need to merge with seven other PCTs as preferred in the SHAs
submission.
The other benefits of a localised service where
there is engagement of clinicians where relationships have built
up both in Primary and Secondary Care could be seriously jeopardised
with a very large remote PCT even with a locality function.
The best economies of scale and capacity can
be achieved by having a matrix of commissioning where for different
aspects of commissioning there are different population bases
employed. Eg PBC should be small and locally sensitive, DGHs one
coterminous PCT—Specialist and tertiary commissioning from
a PCT on behalf a number of PCTs to have responsibility on behalf
of a larger population and the commensurate capacity to deliver.
3. LIKELY IMPACT
ON PROVISION
OF LOCAL
SERVICES
We have concerns as outlined above that staff
will feel destabilised and seek other employment if they do not
have clarity and protection of pension and superannuation rights.
There is also extreme concern about the prospect of being employed
directly by GP practices and this is very likely to affect turnover,
likewise if being moved back to a secondary Trust provider. There
is real concern at the turnover of staff during a period of critical
delivery, and that the only way to counter this will be by significantly
driving up costs.
4. LIKELY IMPACT
ON OTHER
PCT FUNCTIONS, INCLUDING
PUBLIC HEALTH
There are currently economies of scale being
achieved by sharing backroom functions across commissioning and
provider functions, which will otherwise increase cost wise to
remain effective should they be separated.
Merging with our neighbouring PCT will increase capacity
in some areas where we have separate functions eg HR and Finance
but we already have a shared Public Health Function and fear that
mergers beyond five PCTs into a two PCT Essex model will reduce
effectiveness and dilute capacity.
5. CONSULTATION
ABOUT PROPOSED
CHANGES
Informal consultation in Essex has demonstrated
that there is a significant majority in favor of the five PCT
option and yet after assessment by the SHA against the criteria
they have stated a preference for the two PCT option. They have
said that this the five PCT option would not generate the requisite
capacity, yet other SHAs who have gone for two-three PCT mergers
creating 300,000-350,000 PCT populations seem to consider that
this to be sufficient to create the population base, commissioning
capacity and the financial savings. There is some concern therefore
that the majority view is not being supported for sustainable
reasons.
A particular area of concern is the lack of
localism for the two PCT SHA preferred option. Partnership with
Local Authorities have become vital in many aspects of PCTs work—sharing
resources (shared appointments) commissioning of voluntary sector,
shared priorities (LAAs), working with wider partners (LSPs) are
all dependent on a strong local presence with strong local knowledge.
This is probably the hidden work of PCTs where they have grown
immeasurably in effectiveness in the last few years. Most Local
Authorities (not County) support smaller more coterminous PCTs
or at least ones where there is some synergy now or likely in
the future, a two PCT Essex configuration is going against this
direction.
Partnership working and localism is particularly
important in our work in respect of LIFT (Local Initiative Finance
Trust) and we are already in a LIFT partnership with our neighbouring
PCT and the two associated local authorities. As a result planning
for health in particular is the most effective our population
has ever had.
The former North and South Essex HAs (which
the two PCT model geographically mirrors) did not have the localism
perspective to understand the importance of the relationship between
planning in respect of health provision. As a result many housing
estates were built with inadequate or no health provision. The
relationship is now such that not one house is built without local
planners informing PCTs and working with us on the health impact.
There is also a concern that with a geographically
remote and very large PCT the Non Executive Directors (NEDs) will
be remote—this was the case with the former North South
HAs. We have since the inception of the PCT had the benefit of
NEDs who are local and County Councillors and NEDs who "live
on the patch" and know the issues through living and breathing
them locally. This will be a significant loss in a remote PCT
model, with a locality structure without NEDs who hold the PCT
to account but also have useful other roles or experience.
6. LIKELY COSTS
AND COST
SAVING
The two PCT configurations creates more disruption
and destabilisation than the National average by the draconian
reduction of 13 to two PCTs—the average elsewhere being
in the order of two-three down to one. This is perceived as creating
excessive disruption and significant risks in terms of lost organisational
memory. It will also generate greater surplus than the per head
of population contribution to the savings and therefore be disproportionate.
Or it may create excessive resources either at SHA or PCT level
with the deficit being the loss of localism and risk to delivery
of the National Agenda. The five PCT option in comparison provides
a balance of risk and fair contributions savings and capacity
wise.
Mrs Maggie Shackell, Chair
Brendan Osborne, Chief Executive
Colchester PCT
31 October 2005
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