Supplementary written evidence from the
Primary Care Trust Network (COM 141)
PCT PAST AND CURRENT PERFORMANCE ADDITIONAL
INFORMATION FROM THE PRIMARY CARE TRUST NETWORK, JANUARY 2011
1. INTRODUCTION
1.1 As you will be aware, the NHS Confederation
has submitted written and oral evidence to the Committee on its
inquiry into commissioning. During the course of the inquiry Primary
Care Trusts' (PCTs) past and current performance was discussed
by a number of witnesses. In particular, some members and witnesses
have suggested that PCTs are currently in "meltdown".
1.2 In light of this we felt it would be
helpful for the NHS Confederation's PCT Network to set out below
some of the evidence on past PCT performance, our analysis of
how PCTs are currently performing, and what changes to Government
policy may be necessary to help PCTs manage the combined efficiency
savings and organisational transition challenges they are currently
faced with. This is intended to supplement the NHS Confederation's
original evidence which focused on the Government's proposed reforms
to commissioning in the NHS in England.
1.3 The PCT Network was established as part
of the NHS Confederation to provide a distinct voice for PCTs.
91% of existing PCTs are members of the Network.
2. PAST PCT PERFORMANCE
2.1 During oral evidence sessions of the
Committee's commissioning inquiry, a number of witnesses noted
the progress PCTs had made and highlighted the need to ensure
good PCT managers transfer over to the new system.
2.2 However, some commentators inside and
outside of Committee sessions have criticised the performance
of PCTs and suggested that they have failed as commissioning organisations.
Often these comments do not match the weight of evidence that
demonstrates PCTs made good progress as commissioning organisations.
2.3 There has of course been variation in
performance between individual PCTs, and all PCTs would acknowledge
that there is scope for further improvement of their commissioning
activities as evidence of effectiveness improves and best practice
evolves. However, we believe that some generic comments about
PCTs' collective failure may be based on outdated evidence that
ignores the significant progress in recent years. Criticism of
PCTs is also sometimes based on dissatisfaction with particular
decisions and actions that they have taken as commissioners. Commissioning
decisions are not always popular with all parties affected or
involved, but this is inevitable given the difficult trade-offs
that all health service commissioners are required to take, and
is not in itself an indication of failure or poor performance.
2.4 Objective analysis of the overall performance
of PCTs across the country demonstrates real achievements in delivering
improved health outcomes, as well as improvements in commissioning
capability and financial performance.
2.5 These positive achievements have been
enabled, in part, by a period of relative stability in structure
and remit since October 2006 (following numerous changes to the
role and configuration of commissioning bodies) and for the first
time a serious attempt to prioritise and support commissioning
through introduction of the World Class Commissioning programme
and related changes to NHS policy and system management.
OUTCOMES
2.6 The Department of Health's recent paper
on the NHS Outcomes Framework for 2011-12 shows the significant
improvements achieved over the last few years on the key targets
PCTs have been asked to prioritise, including:
— Healthcare associated infections.
PCTs have also overseen significant reductions in
waiting times and public satisfaction with the NHS has risen in
recent years.
2.7 While it is difficult to distinguish
PCT contributions to these achievements as opposed to provider,
SHA and regulator contributions, these were the priorities PCTs
were asked to deliver and they have been almost uniformly achieved.
COMMISSIONING CAPABILITY
2.8 There is also objective evidence demonstrating
improvement in the commissioning capability of PCTs. This is in
spite of a number of reorganisations that took place to the commissioning
side of the NHS under the previous Government. This evidence includes:
— World Class Commissioning Results:
The 2010 World Class Commissioning[58]
results showed that PCTs improved on all 30 of the individual
tests of commissioning competency that they were assessed on this
year and last year, with an average 42% increase in scores compared
with 2009.
— PCT priority setting benefits local
outcomes: A key characteristic of effective commissioning
is the ability to identify health improvement priorities amenable
to local intervention, take appropriate action to address them,
and as a result deliver more rapid improvement in the prioritised
outcomes than would have been achieved without intervention. A
recent report by Health Mandate[59]
provides evidence that PCTs have been effective in prioritising,
focussing on and then delivering improvements in rates of smoking
cessation, breast screening, Clostridium difficile infections
and childhood obesity, and in improving end of life care. It finds
early signs that where commissioners have prioritised these issues
they have achieved a faster improvement in outcomes and are more
successful in controlling expenditure.
FINANCIAL MANAGEMENT
2.9 PCTs have achieved significant financial
improvement in recent years. In 2005-06, 35% of PCTs were in deficit
with a gross deficit of £616 million and a net deficit of
£492 million. By 2009-10 only 3% of PCTs were in deficit
with a gross deficit of £39 million and a net surplus of
£1,274 million.
2.10 The Audit Commission's Use of Resources
scores for 2009-10 also show a significant improvement in PCT
performance with 96% of PCTs at or above minimum requirements
for managing finances. The proportion of PCTs performing above
minimum requirements rose to 75% in 2009-10 from 53% in 2008-09.
The report also concluded that in each SHA the majority of PCTs
are "performing well".
3. CURRENT PCT PERFORMANCE
AND RISKS
DURING TRANSITION
3.1 During the course of the Committee's
inquiry on commissioning, some witnesses questioned PCTs' present
performance as they deal with the transition and efficiency savings
at the same time as reducing their management costs. It was suggested
that PCTs are in "meltdown".
3.2 PCTs have continued to perform well
despite the challenges arising from the announcement in the White
Paper of their abolition from April 2013. While the PCT Network
has warned, along with other commentators, of the risks during
the period of transition to the new commissioning arrangements
set out in the White Paper, it is wrong to suggest the system
is currently in meltdown.
3.3 The most recent financial data reported
that the returns for the second quarter of the financial year
2010-11 show that SHAs and PCTs are forecasting an overall surplus
of £1,286 million (£1,345 million surplus at Q1), which
is 1.3% of total revenue resources. Four PCTs (out of 151) are
forecasting deficits, but these are the exceptions.[60]
3.4 The fact that PCTs have succeeded in
maintaining their core commissioning activities, and have also
been able to progress complex plans to transfer their community
services to other organisations whilst ensuring the provision
of these services[61]
is maintained during this period of change, is testament to the
efforts of PCT staff and managers to ensure the stability of the
NHS. This has been achieved despite the significant reductions
in PCT capacity currently being implemented.
3.5 We support the action recently proposed
by the Government in the Operating Framework to help manage the
transition risks. It is very important that PCTs retain a grip
on performance over the next two years.
3.6 The proposals to "cluster"
PCTs to retain critical mass are sensible, as long as these decisions
are based on a proper analysis of local issues rather than being
imposed from above.
3.7 Similarly we entirely support the recognition
in December's command paper of "the many excellent staff
currently working in PCTs"[62]
and the expectation that significant numbers of them will find
roles within the new commissioning organisations. Retaining skilled
staff is absolutely essential to the successful implementation
of the reform to commissioning set out by the Government.
4. CONCLUSION
4.1 It is important to take a realistic
and balanced view of the achievements of PCTs if we are to learn
lessons for the future. While we certainly would not claim that
all PCTs have been successful or that PCTs have achieved everything
that was hoped from them, we believe the concrete evidence of
the progress made by PCTs should be acknowledged so that future
commissioning organisations and policy-makers learn from good
past practices and retain skilled staff.
David Stout
Director, PCT Network
January 2011
58 The World Class Commissioning results were not published
nationally by the Department of Health. However, the Health Service
Journal collated local results and published them online here:http://www.hsj.co.uk/topics/world-class-commissioning-scores-2010/ Back
59
Health Mandate (2010) Commissioning in the new world: An analysis
of the impact of prioritisation on quality, expenditure and outcomes
in the health service. Back
60
Department of Health (2010) The Quarter, 2010-11 quarter 2. Back
61
PCTs directly provide the vast majority of out of hospital/community-based
NHS services but are required to fully separate their commissioning
and provider functions by April 2011. Back
62
Department of Health (2010) Liberating the NHS: legislative framework
and next steps, p 56 (4.26). Back
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