Developing primary care organisations: Lessons from the English NHS

• Abstract
• Introduction
• Research Design
• The Organisational Development of PCGs and PCTs
• Service Development
• Conclusion
• References

Abstract

The development of primary care organisations, in which general practitioners (GPs) are affiliated to a supra-practice body designed to carry out functions such as primary care development, peer review of practice and service commissioning, is a feature of several health care systems. The English National Health Service (NHS) has in recent years moved towards a more organised model of primary care within a rapidly changing policy context. Drawing upon findings from an English Department of Health Department of Health funded national evaluation study of PCGs and PCTs, this paper examines the implementation of primary care groups (PCGs) and trusts (PCTs) in England, and seeks to identify lessons for the development of primary care organisations in the broader international context. The paper concludes that the successful development of primary care organisations requires adequate time and resourcing, some degree of stability in the policy context, robust methods for securing the commitment of stakeholders and clarity of organisational purpose.

Introduction

A national network of PCGs was announced in the White Paper The New NHS ^[1] and established in England on 1 April 1999. Replacing as they did the previous diversity of arrangements for involving GPs in commissioning including GP fundholding and its variants as well as a range of alternative models such as GP commissioning groups ^[2-3], PCGs represented a new national focus on the development of primary care organisations. Typically covering a population of 100,000, PCGs differed from their predecessors in bringing together local providers of primary and community services under a board representing local GPs, nurses, social services, the health authority and the community.

The introduction of PCGs made membership of a primary care organisation compulsory for all GPs, in contrast with the previous voluntary nature of GP fundholding and GP commissioning ^[1]. The new policy did however acknowledge that it was "going with the grain" of these previous initiatives, emphasising as it did the role of clinicians in shaping primary care organisations and leading service change ^[1].

The government defined three core functions for PCGs ^[4] these being: to improve the health of their local population; to develop primary and community health services; and to commission secondary and tertiary services for their local population.

Primary care groups received a unified budget comprising three elements: hospital and community health services (HCHS), prescribing and general practice infrastructure budgets. As set out in the Department of Health policy guidance in 1997, PCGs were expected to evolve into free-standing PCTs, thus becoming fully independent from their host health authorities as they gained in experience (see Box 1 below).

Box 1: levels of primary care groups as set out in the 1997 NHS White Paper ^[1]

Charged with the same functions as PCGs, PCTs have additional freedom to develop integrated services and a significantly larger range of responsibilities. Having a lay-dominated board and a professionally-dominated executive committee, the governance arrangements for PCTs are somewhat different from PCGs ^[4]. PCGs were initially allowed to decide for themselves whether and when to become PCTs, and there was an assumption by those implementing the policy in the NHS that this would happen gradually over the course of what was billed as a 10-year plan ^[1]. In 2000, it became apparent that the 10-year timescale was to be compressed. The government published The NHS Plan ^[5] proposing that nearly all PCGs should become trusts by April 2004. A year later, the government announced a further stage of organisational reform for the NHS, namely the move of all PCGs to PCT status by April 2002, the abolition of the 95 English health authorities and the development of 28 new strategic health authorities (StHAs). Reflecting a desire on the part of government to devolve power to frontline NHS staff, PCTs will become the lead local NHS organisation in assessing needs, planning and securing all health services and improving health and leading the NHS contribution to partnership agencies with local government and other partners ^[6].

In this paper, we use the findings of a national evaluation study of PCGs and PCTs to consider what lessons can be drawn from this experience for the development of primary care organisations in the international context.

Research Design

The national evaluation study ran over the period April 1999 to October 2000 ^[7-8]. Detailed data were collected at regular intervals from a set of 12 case study PCGs/PGTs in England, all of which had had previous experience of operating as GP commissioning groups ^[9]. Three of the groups made the transition to PCT status during the evaluation, the remaining nine were preparing to make that transition in April 2001 or April 2002. A range of methods was used in carrying out fieldwork for the study, including:

• in-depth face-to-face interviews with PCG/PCT board members in July/August 1999 and July/August 2000
• telephone interviews with PCT/PCT chief executives and chairs at six-monthly intervals
• focus group interviews with PCG members and staff based on core themes such as primary care development, clinical governance, health improvement and commissioning
• postal survey questionnaire of all GPs in the 12 PCG/PCTs in October 1999 and October 2000
• non-participant observation of PCG/PCT board meetings.

Throughout the course of the evaluation the case study PCGs/PCTs demonstrated a significant degree of development. During their first few months of operation, the groups focused on organisational development, relationships and processes. As they matured, PCGs/PCTs began to deliver significant service changes. In order to capture all of these aspects of change, the research team used an evaluation framework that conceptualised and analysed the case study PCGs/PCTs in terms of their structures, processes and outcomes ^[10]. Accordingly, the findings presented below are considered under two main headings: organisational development, which explores the structures and processes characteristic of the evolving PCGs/PCTs; and service development that examines the focus of PCG/PCT activity.

The Organisational Development of PCGs and PCTs

Given the rapid pace of policy change in the NHS over the period of our research, it is not surprising that organisational development was a consistently important issue for the 12 case-study groups. In common with similar studies, all groups reported a primary focus on internal organisational development issues such as the establishment of the PCGs’ organisational structures and modus operandi and the allocation of roles and responsibilities to PCG board members during the first year of PCG implementation ^[11-12]. While our later research revealed a greater emphasis upon service delivery and outcomes, organisational development was a constant priority. The amount of time, energy and effort required to set up new primary care organisations cannot be over-estimated. Some specific themes relating to the organisational development of PCGs/PCTs are discussed below.

Management arrangements and capacity
Our research found that PCGs/PCTs operated within diverse management structures which reflected the level of PCG/PCT staffing and the degree of integration with and support from their host health authorities. Resources for management support and the development of PCG/PCT organisations were a key area of tension and debate across the period of the evaluation. There is an inevitable relationship between the degree of management resource provided to an organisation and its ability to perform the functions required of it. International comparisons in this area are particularly telling, and a recent study pointed to the fact that some English PCGs had just 1% of the management resource available to some of their American cousins ^[13]. It was not, therefore, surprising to find that in some PCGs/PCTs, individuals were operating on the edge of what was sustainable and in some cases well beyond it. Concerns were expressed about the heavy workload carried by PCG managers and support staff as well as the impact this had on PCG board members. While groups were generally satisfied with the quality of their dedicated staff team, many felt that the PCG’s overall management capacity was inadequate, and in several cases this was perceived by respondents in PCGs as a major impediment to progress.

From our examination of the level of management support provided to the PCGs/PCTs, we concluded that the level of resource available to the groups must be increased, both in terms of financial allocation and, in some cases, a more energetic devolution of staff and expertise from health authorities. Areas in need of particular attention included the provision of financial information and advice, information management and technology expertise, public health advice and analysis, and commissioning support. The development of StHAs would now appear to be an important catalyst to this process of devolution.

The PCG board
Although envisioned in policy as multidisciplinary decision-making bodies, our research revealed a consistent tendency on the part of GPs to dominate the agenda and meetings of PCGs boards. This can be seen in figure 1, which charts the interactions and contributions of board members at a public PCG board meeting typical of those observed during research fieldwork.

While nurse board members were perceived as being enthusiastic and hard working, their input to the board was not generally matched by appropriate levels of influence upon PCG decision-making processes. Accordingly, we felt that more must be done to increase the contribution of nurses to PCGs/PCTs at a strategic and policy level. Practice nurses (those directly employed by GPs) were less frequently involved in strategic PCG/PCT work than their community or PCT employed colleagues.

The non-clinician board members (social services representatives, lay representatives, health authority non-executive directors) reported that it had taken a considerable time for their roles to become clear and for them to become "active" board members with their own set of responsibilities. The medically dominated nature of the agenda in the initial stages of PCG development was cited as one of the main reasons for this.

Figure 1: Board member contributions at a PCG public board meeting

With regard to decision-making on strategic and operational matters in PCGs, the chair/chief executive pairing was regarded as the locus of power and main source of policy generation. PCG boards therefore tended to serve a checking and ratification function, rather than acting as a decision-making body. Given that there was concern within some PCGs about the undue influence of those individuals leading the organisation, it appears that a check should be kept on the working of the chief executive/chair pairing (and in PCTs, the chief executive/chair/executive chair trio) in order to ensure that decision-making processes remain as open and inclusive as possible.

Relationships with key stakeholders: health authorities, GPs and nurses
A majority of groups in the study reported difficulties in their relationships with local health authorities throughout the course of the evaluation study. In some cases, however, there had been a clear commitment by both parties, ie, PCGs and their health authorities, to investing in the development of partnership between the health authority and PCGs, and this was reported to have improved communications and mutual understanding. A constructive relationship between PCGs and health authorities appeared to depend greatly on the existence of a trusting relationship between senior clinicians and managers. The readiness of the health authority to "let go" of responsibilities and devolve staff to PCGs continued to be a key facilitator of a good relationship between these organisations.

A perception of continuing control of the PCG by its health authority was the most important factor present in those groups reporting a poor relationship with their health authority. Management resources and support were a key area of tension and debate between PCGs and health authorities and were closely related to perceptions of control and "letting go". The relationship between PCTs and health authorities will of course change to a significant degree when health authorities are abolished in April 2002, a smaller number of StHAs are established, and PCTs assume a much wider range of responsibilities.

In terms of "grassroots" GP involvement in PCGs/PCTs, our two postal surveys of non-board GPs revealed a preference for less active and less direct methods of involvement as summarised in table 1 below. The use of GP representatives and attendance at GP forums and education events were significantly more popular than more active forms of involvement such as attendance at board meetings or PCG/PCT sub-groups. According to the results of the postal surveys, almost 70% of GP respondents spent either "no time" or "up to one hour" on PCG/PCT activities within a typical week. If the government is to succeed in its mission to devolve power to the "frontline" ^[6], there is clear need to improve levels of direct and active GP involvement in PCGs/PCTs. Our research suggests that the provision of properly funded time for GPs and their colleagues to take part in PCG activities, including resources for locum cover for the time spent away from the practice, may encourage higher levels of GP involvement.

While the involvement of nurse constituents appeared to be stronger than that with GPs, with significant levels of involvement reported in nurse forums and sub-groups, most PCGs/PCTs acknowledged the need to engage the allied health professions such as physiotherapists, occupational therapists and dieticians, as well as other contractor professionals (pharmacists, opticians, dentists). As with GPs, building and maintaining wider stakeholder involvement will require protected time and remuneration.

Table 1: Non-board GP involvement in PCG/PCT activities, October 2000

The Transition to Primary Care Trust Status
While there was general support for the transition to PCT status, our research found that there were significant concerns about the pace of change and the impetus for change that was often perceived as being very "top-down". For several groups, there was a real sense of frustration at being "pulled back" to organisational issues at a time when PCGs were beginning to deliver tangible benefits in terms of service developments. Indeed, in common with other studies, we found that preparing for PCT status had had a significant impact on the ability of PCGs to carry out their core functions during the interim period ^[14].

The findings of our research suggest that the process of moving to PCT status requires significant resourcing, management and facilitation. Not surprisingly, the three PCTs within the study reported a renewed emphasis upon internal organisational development as they moved towards PCT status. The establishment of new management structures, the development of relationships between the PCT board and executive committee and the provision of core and support functions had taken an enormous amount of time and energy. As was the case with PCGs, these arrangements were still being put in place in the months following the formal transition to trust status.

A key characteristic of PCT management was the retention of a management structure that included locality divisions relating to specific clusters of GP practices to promote ownership of the PCT by its constituents and to devolve tasks to constituents and to facilitate the delegation of PCT work to practice level. Given that many new PCTs are being formed as the result of merger of smaller PCGs, locality arrangements will continue to be seen as an important mechanism for ensuring that the voice of primary care teams is heard at the strategic and policy making level of the new organisations.

Service Development

Research conducted during the latter stages of our evaluation revealed the initial focus on organisational development had subsequently widened to include a range of achievements and activities to do with the PCG/PCT core functions of health improvement, primary care development and the commissioning of local health services for the PCG/PCT population. Indeed, three-quarters of those interviewed in the final stages of the research reported specific local service developments that they felt could be directly attributed to the work of their PCG/PCT.

Primary care development and clinical governance
As reported in similar studies, developments in primary care provided the main focus for the 12 case-study PCGs/PCTs during the evaluation study ^[14]. The research revealed a strong emphasis on the improvement of practice infrastructure and the development of new practice-based and PCG/PCT-wide specialist services. Much of this activity was being carried out within the framework of local health improvement programme HImPs) which were, at that time, co-ordinated at the health authority level (the responsibility for developing the HImPs will transfer to PCTs from April 2002).

Developments in primary care were underpinned by clinical governance objectives, reflecting a desire to address variations in quality and to improve overall standards. A range of quality improvement initiatives was highlighted, including participation in audit projects, the development of referral guidelines and the establishment of training and development programmes for the full range of practice staff. Not surprisingly, the management of prescribing was a key focus for the case study PCGs/PCTs throughout the course of the evaluation. Our research suggests that the availability of pharmaceutical adviser expertise at a practice level, effective GP leadership and the use of "hands-on" practice based pharmacists were important factors in bringing about change in prescribing behaviour.

In terms of facilitating developments in primary care, prescribing and clinical governance more generally, the research highlighted the importance of incentives for practices and practitioners, the provision of properly funded time and locum cover for primary care and community staff to participate in education/training events, and the sharing of information and peer review between health care professionals, notably GPs. The research found that the focus on primary care development and achievements in this area had been crucial in engaging staff working at the "coal face" of primary care. The retention of this primary care development focus will be an important factor in securing and maintaining the commitment of staff to the move to PCT status.

Health improvement
Health improvement was an area of work that received more attention as PCGs/PCTs moved beyond their early developmental stages. For most of the groups, local HImPs had become an increasingly important driver of developments in primary care, clinical governance prescribing, and commissioning. This was particularly the case for the two National Service Framework (NSF) areas of coronary heart disease and mental health, where meeting the specified national targets were clear priorities for most groups within the study.

Progress was made on health improvement activities despite a number of obstacles, including difficulties with providing accurate information, accessing public health advice and securing the PCG’s full and proper involvement in the development of the HImP. Our research showed that the process of HImP development was often time- and resource-intensive, especially for PCGs/PCTs with small management teams. Nevertheless, it was imperative for groups to be involved in HImP production in order to ensure that these local health plans were meaningful to local GPs, primary care staff and other local stakeholders. Although our research identified examples of service development in terms of health improvement, we also found that there was more to be done to shift the focus of GPs from primary care issues and the delivery of GP services towards the wider health improvement agenda.

Commissioning
Our research identified a distinction between the commissioning of community services and the commissioning of acute services. During the study, more significant progress was reported in relation to the commissioning of community services and services at the primary/secondary care interface. Several groups were involved in commissioning new community hospitals or services "closer to home" often located within community hospitals, for example, leg ulcer clinics, diabetes services, ENT clinics and physiotherapy. In addition, the establishment of intermediate care services was increasingly being seen as a priority for PCGs/PCTs as a mechanism for reducing admissions to secondary care and facilitating early discharge. The commissioning of acute, hospital services was generally less advanced, with relatively few examples of service developments being reported.

Reasons for the limited progress in relation to acute services commissioning included insufficient management support, inadequate information and a perceived "lack of financial clout" of PCGs in the local health economy. Our conclusion was that PCGs chose quite properly to focus their attention on the assessment and improvement of primary and community care services in the early days, leaving the issue of services "further from home" until the second and third year of operation. The further delegation of responsibilities from health authorities to PCTs, brought about by the creation of new StHAs in 2002, will present a particular challenge to PCTs, given their reticence to date in relation to tackling service changes within secondary care.

Conclusion

The findings of our research into the implementation and early operation of PCGs and PCTs in the English NHS point to some important conclusions about the development of primary care organisations more generally.

First, it is clear that the process of creating new primary care organisations takes time, and even where an organisation is being formed from a pre-existing body, as was the case with PCGs developing out of GP commissioning groups, a new and distinct phase of organisational development is required. In the first year of operation of a primary care organisation, issues of internal development will inevitably dominate, including the establishment of management support, the determination of roles and functions of different elements of the organisation and the creation of relationships with partner organisations. A further issue that is always encountered in this phase of development is how to properly reward clinical staff for their involvement in the running and leadership of the primary care organisation.

Secondly, our study points to the importance of the policy context as an enabler or inhibitor of progress. If the policy context is rapidly changing, as was the experience of the PCGs in England, there is an inherent need to keep returning to the drawing board every year or so to reassess organisational design and development. This, in turn, inhibits organisations from moving on to make the changes to services and health status that they aim to achieve. For PCTs in England, the coming few years are bringing a real challenge in terms of bedding down and delivering the NHS Plan objectives for their local areas. The challenge for the government is to allow them the time and the space to do this.

A third lesson from our study is the importance of securing and maintaining the commitment of stakeholders to the primary care organisation. Clearly, it is vital that a primary care organisation can engage with its GPs, community nurses and other staff, if it is to bring about real change to the quality and range of primary and community health services. Crucial to this is the maintenance of a local focus for the organisation, so that GPs and others are able to see direct changes and improvements flowing from the work of the primary care organisation, as well as feeling that they have a real and influential voice in its governance. This local focus could be threatened where organisations cover large populations, and careful thought must be given to the development of robust locality structures in cases such as some of the new English PCTs whose population coverage exceeds 300,000. For practitioners other than GPs, the real challenge for the primary care organisation is to make sure that it operates inclusively and avoids undue medical domination of the agenda and operation of the organisation.

A related lesson is also an important challenge for primary care organisations - being clear about their overall purpose and constituency. Are they membership-based organisations for groups of GPs and their staff (as were many of the primary care organisations in the UK in the 1990s ^[3] or are they mainstream health service bodies with a primary care focus seeking to achieve much wider health care system objectives? In the case of the English PCGs, it is clear that in moving them to PCT status, government policy is identifying them as the main focus for the organisation and commissioning of health and health services in the local context [6]. This presents a different set of challenges to that of predecessor PCGs and the GP organisations of the 1990s. In the international context, it also highlights the need to be clear about what the comparator should be for any single issue. For example, English PCTs could now arguably be more comparable to New Zealand district health boards (DHBs) than to independent practitioner associations, given that DHBs, like PCTs are statutory bodies with a centrally determined set of overall functions.

In conclusion, it is evident from our research that primary care organisations can deliver tangible changes in service provision, but that this takes time, resources and some degree of stability in the wider policy context. Primary care organisations that properly engage their constituent staff will seek to make a range of changes to local primary care provision, "putting their own house in order", before moving on to the greater challenge of addressing and influencing the secondary care agenda. To do these things, they must be clear about their overall scope and specific range of responsibilities and their place in the wider health care system. For the English PCTs, the main challenge now facing them is to deliver on their centrally determined functions whilst maintaining and developing the commitment of their professional staff, in particular GPs. Major cultural change in terms of improved practitioner collaboration can be brought about in primary care, as has been seen in the UK and elsewhere when primary care organisations enjoy the support and leadership of GPs and other primary care staff. Whether English PCTs will continue to enjoy the support of their constituent GPs and nurses remains to be seen, and we can be sure that important lessons will continue to be drawn for application beyond the NHS.

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