Following the publication of Commissioning a patient-led NHS, a circular from NHS Chief Executive Sir Nigel Crisp which outlined plans for a review of the configuration of commissioning organisations, the House of Commons Health Committee launched an inquiry to assess the proposed restructuring of primary care trusts.
The committee was concerned about the lack of clarity around whether PCTs would be required to divest their provider functions following the steer that the PCTs’ role in the provision of services would be minimal by the end of 2008. There was a concern that if PCTs were required to do so, community services would be fragmented. Additionally, there was a fear that alternative providers might not be available to pick up the provision of services.
Aims of reform
The committee felt that PCTs had not had enough time to fully develop and the reduction in their functions during a time of increased investment in the NHS was inappropriate. The functions of PCTs were still considered ‘highly relevant’ and the committee feared that the government’s actions were motivated by financial rather than quality considerations.
Reconfiguration to create larger PCTs
The committee noted that the reform programme promised that reconfigured, larger PCTs would yield greater bargaining power against large, powerful provider organisations. However, the committee pointed out that the reconfigured PCTs would be similar in size to the former health authorities, whose sole function was commissioning. Health authorities had been deemed ineffective and isolated from patients.
The committee noted that the creation of PCTs was aimed at devolving decision making to a level close to the population. By reverting back to a model of larger and fewer organisations, the committee felt that localism would be lost. The committee made clear its opposition to the government’s assertion that practice-based commissioning (PBC) would improve patient and public involvement and engagement.
The committee was concerned that the introduction of practice-based commissioning could make PCTs, as commissioners, redundant. The government envisaged that the majority of commissioning would happen locally, at practice level, meaning that if PCTs were left in their current form, there would be too many commissioners securing services for the same area.
The committee suggested that while the government had suggested that there should be a division between the purchasing and providing functions of PCTs, it had not appreciated that the same should also apply to practices. PBC could result in perverse incentives where GPs directed patients to their own in-house services instead of directing them to external providers. The committee suggested that PCTs could have a role in ensuring practices were offering patients a range of provider options.
‘It is striking that, despite the considerable attention these proposals have attracted in
Parliament and elsewhere, debate has focused almost exclusively on the shape of future organisations, the morale of staff, and the consultation process, largely ignoring the critical issue of how commissioning can actually be improved in the NHS. In order to improve commissioning, PCTs need better skills and better information systems.’