Irwin Brown of the Socialist Health Association reads a requiem for primary care trusts

It appears unlikely that we will see marches and protests to “Save our PCT”. They have few friends, and the few they had are now as passionate about their demise!

They were widely blamed for the failure of the policy around commissioning. In many places, PCTs have effectively ceased to exist; their provider functions are at arms length and soon to be detached; pre-formed GP Consortia are already weighing into the commissioning functions. Key staff are already leaving or disengaged.

Discussion has begun about what happens to the hundred-odd functions carried out by PCTs that have yet to be found a home, as an afterthought. Which may not be the ideal way to go about it, but there we are.

From PCT believers to PCT bereavers
A year ago, the same NHS leadership was claiming PCTs had made great progress and that World-Class Commissioning would be the answer to all the questions. Many of the key figures who were expressing that confidence are now leading the lemmings over the cliff, albeit from the safety of posts outside PCTs.

Those leaders were wrong then, in ignoring the reality that clinicians were disengaged and distanced from decision-making. They were wrong then, too, in papering over the emerging evidence that the many initiatives to use commissioning to influence demand were failing.

’If a split between commissioning and provision is the right approach, then surely a home should have been found for the commissioning parts of PCTs not the other way round?’

The mixture of providing some elements of primary care, some public health functions and a lot of bits and pieces with no other home all combined with commissioning was always toxic. PCTs should have been what it says on the tin; trusts to provide primary care.

Forms of integrated trust, where primary care is provided alongside mental health and services closely connected to local authorities, would have been an experiment worth trying. If a split between commissioning and provision is the right approach, then surely a home should have been found for the commissioning parts of PCTs not the other way round?

Never given enough of a chance?
Many of the top managers in PCTs were promoted into the job, rather than being appointed from the same level. There were almost no examples of key figures within the NHS, with a proven track record, taking up senior posts in PCTs. They often had to fish in a depleted pool for both executive and non-executive talent, with little to offer as they were not free to offer their own salary levels.

They were also generally dominated by the SHAs, with little real autonomy to progress local initiatives and huge pressure to deliver on national targets. Despite that, there were some who did a good job - and hopefully some of the positive experience will be carried forward into the redisorganisation.

Much of the thinking behind the Nicholson Challenge (the QIPP programme to reduce projected NHS expenditure by £20 billion) is dependent on shifting care from acute settings into primary care. Such models of care are known to be possible, and could save money and allow patients to be treated closer to home.

However, those models assume that access and provision of services in primary care are at a much higher level than they are now. Moreover, funding the expansion of primary care out of savings made as hospital facilities shut down is, unfortunately, not deliverable.

Partnership and integration
The shift from acute to primary care and onwards down the pyramid to self-care and prevention, can only take place through extensive and long-term collaboration across organisational boundaries. Competition and markets have little or no role in this; and partnership working and integration founded on engagement with patients and the public are the only possibility.

Shutting down hospitals is necessary, but will not be popular
To make this shift requires very strong advocates for primary care, able to overcome the long -standing inbuilt culture of the National Hospital Service in favour of acute care – shutting down hospitals is necessary, but will not be popular.

And here, the sadness around PCTs continues. The break-up of provider arms - or worse, their transfer into the private sector (or as John Lewis Mark 2) will not produce strong and influential organisations able to articulate the case for a greater role for primary care.

If PCTs were weak in relation to the large acute trusts in the past, things can only get worse. And for those who chose integration into a nearby foundation trust, we have to hope their influence is not even further eroded – time will tell.

It is wholly unclear how the shift to using GP consortia as commissioners will change the landscape or how the local authorities will be able to exert the strategic role in integration of services. As it now stands, the commissioning of much of primary care will actually be done by the National Commissioning Board and local commissioners will still have little or no direct control over GPs – one of the most important providers. It is hoped this will become clearer as the Bill is progressed.

And just off stage, there are rumours and whispers that some kind of residual PCT will live on. But not in response to public protest.