Most Primary Care Trusts (PCTs) are currently incapable of implementing the reforms set out in Professor Lord Ara Darzi’s Next-Stage Review (NSR) of the National Health Service (NHS), even though it will be their responsibility to do so, Members of Parliament (MPs) have warned.
Too often now, commissioning by PCTs is poor, they lack analytical and planning skills and the quality of their management is “very variable,” and this reflects on the whole of the NHS, says the report of the House of Commons Health Select Committee’s inquiry into Lord Darzi’s Review. One witness had told the Committee’s enquiry that the NHS “does not afford PCT commissioning sufficient status,” a comment which the MPs say they consider to be both “striking and depressing.”
The Committee credits the Department of Health for accepting that serious weaknesses remain in PCT commissioning and for launching the World Class Commissioning programme to improve the situation, but says that it is not convinced that this will make the necessary changes. Therefore, implementation of the NSR may be slower and more uneven than the government hopes, it says, and stresses that the government must not only publish milestones for implementation of the NSR but also monitor them rigorously.
The MPs also express doubts about the ability of Strategic Health Authorities (SHAs) to manage the performance of PCTs. The Authorities’ performance in this area has been inadequate, the inquiry heard, and the Committee report says that their work in this area must be evaluated independently and rigorously. “If SHAs are to manage performance effectively, they must improve their ability to gather and analyse data and to assess the strategic needs of their region,” say the MPs.
Announcing the report’s publication, Committee chairman Kevin Barron MP said that the members remain “very concerned that PCTs are not yet up to the task of putting these reforms into practice.” During the inquiry, “we heard a lot of evidence about weaknesses in PCT commissioning, which our Committee has highlighted in previous reports, and the ability of PCTs and SHAs to manage effectively these changes is a genuine worry,” he added.
It is also unfortunate that the NSR does not place more emphasis on the importance of recruiting and developing better managers, the report adds. The quality of management in the NHS has long been an issue, and the inquiry was told that some managers lack the analytical skills or motivation to handle and interpret the wide range of performance and routine administrative data that they have to deal with. With the introduction of Patient-Reported Outcomes Measures (PROMs) and other quality-related measures, this issue is becoming ever more important, and the Department must address the issue of weak management skills in this area “with urgency,” says the report. One way of doing this would be through more effective use of the NHS Graduate Management Scheme, which has attracted graduates of great ability but too often failed to make the best use of them, it suggests.
Also, the government is placing considerable stress on turning doctors into managers, but many doctors are currently put off taking on such responsibilities, and the MPs say that more training and support must be given to those who wish to do so.
Nor is the Committee convinced by government plans, reiterated in the NSR, to create 150 GP-led health centres, one for each PCT in England. The MPs say they are “disappointed” that witnesses representing both the government and the doctors had not been able to tell the inquiry what criteria should be used to decide whether a PCT needs a GP-led health centre, and also by the fact that the Department is introducing such centres and polyclinics without proper pilots and evaluation. “PCTs should not make their decisions on a whim – national criteria should be set out for them to follow to ensure that benefits and costs of their decisions are known,” they say, and go on to point out that investment in primary care might well increase demand for hospital care, as deprived people get better access to care and referrals increase with more diagnostic tests.
The Committee notes that the NSR’s main focus is on improving the quality of care provided by the NHS; Ministers believe that the policy emphasis in the last decade has rightly been on access and that it is now possible to look at improving quality, say the MPs. However, they add: “we do not accept that it was necessary or sensible to improve access before improving quality.”
They also criticise the NSR for providing too little detail about how much it will cost to implement Lord Darzi’s proposals, and call on the Department to publish, as soon as possible, figures for each SHA region and for each PCT, identifying these costs. The Department should also quantify the savings that it expects to make from improving quality and indicate when the money will be saved, they say.
Documents from the Department have “too often provided a long list of priorities without ranking them; it is unfortunate that the NSR repeats this bad habit,” the Committee report comments. Many of its key recommendations have been made before, although the involvement of the SHAs is new, as is the extent of consultation with clinicians and patients, and the MPs say this is welcome. Added Mr Barron: “Lord Darzi’s reforms must not just be the latest in a series of failures to make real change; the blueprint for effective reform is there, but the Department must listen and respond to the concerns and challenges highlighted in our report.”
