Primary care trusts: do they have a future?
Authors: Judith Smith, Nicholas Mays
Journal: BMJ (2005)

Primary care trusts (PCTs) are the local statutory organisations in the English NHS responsible for improving public health, providing primary health care, and commissioning secondary and tertiary care services for populations of around 250 000 people. When created in 2002 primary care trusts were intended to become powerful local purchasing agencies, rooted in primary care, and well placed to integrate primary health care, community services, and hospital care.1 In the international context, one of the most notable features of primary care trusts has been the continuing belief by NHS policy makers in England in the value of integrating the purchasing of health care with the delivery of primary care. However, over the past year or more the view that primary care trusts are failing to “punch their weight” in the health system has gained currency, in particular in relation to their supposed inability to achieve strategic change in secondary care.2-4

This has led to renewed interest in strengthening the commissioning function in the NHS. The assumption is that there will be fewer primary care trusts and that these will concentrate on funding and contracting for primary care, supporting the purchasing of other services led by practice based commissioners, and divesting themselves of their provider responsibilities such as community nursing and health visiting.5 This is driven partly by the perception of the trusts' “failure” as commissioners. But it is arguably driven more so by policy makers' encouragement of a greater range of providers of primary care beyond traditional NHS general practice6 and the planned roll out of practice based commissioning (a scheme whereby practices are delegated a purchasing budget for their enrolled population) to all general practices in England by the end of 2006.5

The recent encouragement of a more plural primary care market, where patients can choose to enrol with or use a greater range of providers as well as conventional general practices, arguably represents the strongest reason for a change to primary care trusts. Practice based commissioning challenges their commissioning role, and the development of a market in primary care threatens their constitutional integrity. As long as primary care was almost entirely provided by practices owned by general practitioners operating to a national NHS contract, the conflict of interest inherent in having the commissioning function run by bodies dominated by NHS general practitioners was manageable, justifiable, and arguably a strength. The development of a market in primary care provision requires that ultimate responsibility for local commissioning should be undertaken by a body entirely separate from all providers. Despite an apparent backtracking by policy makers about the need to remove provider functions from primary care trusts, it is hard to justify them having a continuing provider role in what is clearly a primary care market.

However, the reintroduction of general practitioner budget holding (in the guise of practice based commissioning) appears to contradict this since it is intended to increase general practitioners' engagement in the purchasing of services, facilitate a further shift of care from acute to community settings, and provide a demand management counterweight to the power of the new, more autonomous foundation hospitals.7 Primary care trusts have to determine which practices can take devolved purchasing responsibility—and ensure that all practices are engaged in some commissioning by the end of 2006.5 Primary care trusts also have to find resources for new forms of management, information, and analytical support for local practice based commissioning.

A more pluralist yet still publicly financed health system calls for stronger market development, management, and regulation. While some elements of these functions will fall to national bodies regulating healthcare standards, patient safety, and levels of access to and choice of care, a local body (with a more appropriate name) is still needed to act as both the local “brain” in the system and its “conscience.” As brain it needs to determine public health priorities, overall resource allocation, and service design across primary and secondary care; as its conscience it needs to assure service quality, manage and oversee contracting on behalf of practice based commissioners, govern conflicts of interest, secure public involvement, and assure probity in the use of public funds.

Recently, it has been argued that non-NHS bodies should be eligible to become commissioners of NHS care.8 In a publicly funded system, however, it seems reasonable to assert that the brain and conscience should be a public body, particularly in a mixed economy of providers. That is not to say that elements of commissioning cannot be contracted out to actuaries, contracting specialists, and disease management plans, and that some commissioning could be delegated to private providers of primary care, but rather that ultimate accountability for use of public funds should remain with a public body.

So do PCTs have a future role? The answer is unequivocally yes in relation to the need for stronger strategic purchasers and governors of local health systems as detailed commissioning decisions pass to practices and perhaps in time to their private sector competitors as well. But, as the primary care system becomes increasingly diverse, they should no longer be service providers. This leaves unresolved the question of where current community health services such as community nursing and public health will be relocated, a conundrum that would seem to be yet another unintended consequence of a policy shift towards a more plural primary care market.