Table Of ContentTrust in Experience
Transferable learning for
primary care trusts
Edited by
Geoff Meads and Tricia Meads
Foreword by
Professor Mike Pringle
Boca Raton London New York
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First published 2001 by Radcliffe Publishing
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© 2001 Geoff Meads and Tricia Meads
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Contents
Foreword V
Preface vii
List of contributors xii
List of abbreviations xiv
Part 1 Policy into practice
Geoff Meads and Tricia Meads
1 Transferable learning 3
2 Traumas and turning points 17
3 Rhetoric, resources and realities 35
Part 2 Practice into policy
Health Management Group and Associates
4 Releasing the dividend of 'new' partnerships 49
John Ashcroft
5 Owning up to the public health agenda 69
Yvonne Cornish
6 Getting to grips with social services 89
Rosie Benaim
7 Turning community hospitals into assets 103
Helen Tucker
8 Balancing bigger budgets 121
Robert Moore
9 Developing new organisations: a case study 133
Elaine Cohen
10 Making friends with clinical governance 149
Michael Berridge
iv Contents
11 Taking evidence-based medicine on trust 165
Jacqui Barker and Leroy White
12 Prescribing: remedy needed for chronic inflation 187
David Coleman
13 Practising both care management and managed care 199
Marie Hill and Roger Hudson
14 Realising research can be relevant 207
Roland Petchey
Part 3 Looking ahead
Derek Cramp, Geoff Meads and Fedelma Winkler
15 Regaining public confidence 219
16 Taken on trust: an essay on reflective decision thinking 111
Appendix 1 Central guidance 239
Appendix 2 Sources 245
Index 247
Foreword
Many, myself included, saw the election of a new Labour administration in
1997 as a watershed for general practice and primary care. I expected
the demolition of fundholding to presage a swing of the pendulum from the
rhetoric of a primary care led-NHS' towards either a management-led
NHS' or a 'hospital-led NHS'. There were genuine fears that we had had
our chance in the sunshine and that we were about to enter the umbra of
diminished importance.
Some have not yet realised still the error in this analysis. The focus of
influence has changed but primary care's position has been strengthened.
The practice is no longer pre-eminent, but it has not been replaced by a
reformed 'FHSA'. We now have community level organisations — primary
care groups and trusts — that have reinvented the primary care centre of
the NHS in England.
While fundholding practices developed influence and skills that they
applied for their own patients, their commitment to a wider local health
community was often weak. Under PCTs, the strength of individual prac
tices and their primary care teams has been diluted. Indeed, it can be argued
that the power of individual general practitioners and of the general
practitioner community has been reduced. For some this is a source of
regret; for others it is the empowering of all primary care disciplines.
In a world in which variations in care — especially under-performance —
are no longer acceptable and in which standards must be locally delivered,
the practice increasingly looks like the right unit to deliver care, but not
to commission or manage it. In the smaller PCTs the population size is at
the lower limits of efficiency for commissioning for populations and yet the
largest are still able to reflect the characteristics of their population.
If standards of care in primary care and service configurations through
out the NHS lie in the hands of these new bodies, we must consider their
competency for this task. Some of their skills have come from health
authorities, some from fundholding and some from community trusts.
Considering the scope for cultural conflict between these backgrounds,
PCTs have made a remarkable start in establishing themselves.
However, these skills alone will not be sufficient. Fundholding staff can
provide 'general practice' and 'commissioning' perspectives; health authority
staff can offer 'organisation' and 'management' skills; those from community
vi Foreword
trust backgrounds can offer multidisciplinary and human resource skills —
but PCTs will need more.
They will need political, systems engineering and strategic skills. They
must deliver on quality assurance, service development and benchmarking.
Their leadership will extend into consultations and clinical decisions
throughout their area in order to get quality care — National Service
Frameworks, NICE guidelines, best practice - available to every patient. And
they must monitor the care of their populations, matching health need to
service development in order to reduce inequalities and improve outcomes.
This is not a trivial agenda! Indeed, it is arguably the most demanding
list of expectations ever placed on health service organisations in England.
And these are nascent PCTs, starved of management cash and with an
uncertain pedigree. Under these circumstances PCTs need to learn all they
can from each others experience. They need to avoid reinventing successes
and replicating errors.
This readable and informative book sets out and succeeds in offering a
paradigm for the transfer of experience. It is an essential read for every
person involved in PCTs in England, and in similar organisations throughout
the UK. Those coming to terms with the new NHS need to understand the
networking and sharing potential that lies within the experience of all PCTs
today - a potential that is explored between these covers.
Professor Mike Pringle
Chairman of Council
Royal College of General Practitioners
January 2001
Preface
We can bridge the gulf between the reality of the NHS today and the
vision of what it should be like tomorrow.1
This book represents another kind of third way. In seeking to strengthen
those involved with the development of NHS primary care trusts, it offers
an alternative source of assistance to either national policy guidance on the
one hand (see Appendix 1) or individual management consultants' expertise
on the other (e.g. Lilley 2000). Arguably, the New NHS, partly as a result
of possessing this very title, has already witnessed enough of both. The
wheel can only be reinvented so many times. Our third way tries to recog
nise this. The chapters that follow are, therefore, not about 'new' learning but
about the application of existing knowledge. The aim is to help generate a
real commitment to the new organisations by enabling their participants to
make practical use of: relevant past and parallel NHS experience; comparable
developments in other public services and sometimes other countries; the
appropriate research literature; and the almost inexhaustible range of work
ing models and concepts these can supply.
This sense of commitment has often been lacking, in our experience, over
the past two years. Feelings of actual ownership have not yet embraced
many of the new primary care organisations at the end of 2000. They remain
essentially a central creature and the freelance facilitator's paradise. There are
many well rehearsed reasons for this general ennui. The practical burden of
shifting from the pre-1997 internal market into a social system modus oper-
andi has been heavy. It has been hard to see the wood for the trees.
Organisational instability and uncertainty has been pervasive throughout
the New NHS. Unlike in previous times there have been no fixed points in
the healthcare environment serving as the pivotal change agents for others.
Even in primary care, many have felt the basic practice unit threatened by
the advent of such potential alternatives as walk-in centres and telephone
helplines; and the future prospects of partner health authorities and NHS
community trusts, in particular, seem precarious. Over 3000 GP fundhold
ing units have been abolished. People, and professionals especially, have had
to adjust to the reassertion of political leadership and administration with a
plethora of revised arrangements for their probity and public accountability.
1 NHS Plan 2000: 1.29
viii Preface
Clinical governance, the NHS Plan, National Service Frameworks and the
new czars are simply the most publicised examples of this new, apparently
all-pervasive context.
In circumstances such as these it is hard to believe decentralisation really
is taking place. NHS primary care trusts can all too easily be regarded as an
imposition rather than an opportunity and, curiously, the harder central
civil servants try to clarify the scope of the new organisations through
more circulars and conferences, the worse it often actually seems to feel.
The space for experimentation, for trial and error, for getting things down
right wrong, becomes ever more limited. And all of these are the essential
ingredients of making something your own. So far, too few care too little
about primary care trusts. Significantly, over three years into the post-fund-
holding period it remains difficult in primary care to name local champions
of the cause. The popular platform speakers are still few and far between.
The heroic tradition of individual GP-based primary care in the UK appears
to be coming to an end.
In part, this is because thinking, and speaking, independently in respect
of the contemporary NHS has become seen as, at best, unfashionable and at
worst unacceptable. You are either onside with NHS primary care trusts
and their associated reforms, or you are not. And if you are not then you
have to find another game. This perception is a pity. Questioning, at all
levels, helps to gain the kind of commitment Drucker refers to below as
becoming the critical component of future citizenship and contemporary
public services:
Every developed country needs an autonomous, self-governing
social sector of community organisations. It needs it to provide
the needed community services. It needs it above all to provide the
bonds of community and to restore active citizenship. Historically
community was fate. In the post-capitalist society and polity com
munity has to become commitment. (Drucker 1994: p. 161)
It is through the answers we find to our questions that we move into real
relationships with the New NHS. Primary care trusts can turn in this
process from organisational hosts to organisational homes. And if the
answers have the robust quality of independent appraisal then the strength
of the commitment can reflect this rigour. The writers in this book have
been charged with delivering defensible independent appraisals in their
specific subject area. Each of the latter has been selected for its utilitarian
purpose. Together they constitute the critical interfaces where primary care
trusts will stand or fall as organisations: with social services; with public
health and the new NHS mental health trusts; with regulators and agents of
financial control; with managed care and hospitals of all types; and with a
Preface ix
patient public itself. In each case the writer of the designated chapter has
not sought to critique government policy. Embarrassing the Secretary of
State is not part of the brief. On the contrary, indeed, all of the contributors
support the overall central policy direction. Their contribution is to enhance
this by making available as applied academics the kinds of evidence and
experience that, in the form of independent appraisals, may be most akin to
the needs of those in primary care where the culture of independence itself
has conventionally been at its most deep-rooted. Historically, GPs, dentists,
optometrists and other family health services professionals have reacted
rather than responded to central policy direction. Many of their most
enduring developments owe their origins to the independent status of
primary care practitioners. This book is true to this tradition.
Its contributors are mostly drawn from the staff and their associates in the
Health Management Group of City University. From its central London
base, they have worked, over the past three years, with almost half of the
original 481 primary care groups. It is a unique, nationwide pool of experi
ence, based, unlike that of other universities, on a wide variety of sponsors,
with little direct government support through, for example, mainstream NHS
research and development contracts. This multi-funding, ranging from life
sciences companies to the Bible Society, facilitates an independent perspec
tive. We are not beholden to anybody. The writers can state freely what works
and what does not and, as a result, what could be either usable or useless.
The Health Management Group currently offers four postgraduate
degree-level teaching programmes and some of the material in the book has
been taken into these, sometimes through teaching in seminars and simu
lations, and sometimes as subject matter for project-based enquiry and dis
sertations. The chapters by Benaim, Berridge and Cohen, for example, each
have their origins in the MSc in Contemporary Health and Social Policy,
while both Barker and Tucker have been registered for MPhil degrees. These
students are in the guise of either associate researchers or lecturer-practi
tioners and several of the HMG staff also have this 'boundroiduality' that the
King's Fund and other applied research institutes seem to find so valuable in
the NHS development work (Poxton 1999: pp. 1—3). The chapters on the
benefits of new partnerships' and 'transferable learning' by Ashcroft and
Geoff Meads respectively, for example, owe a great deal to the writers' com
bined roles in a series of recent collaborative ventures between the Health
Management Group and the Cambridge-based Relationships Foundation.
Individual health districts have served as the principal data sources for the
material on managed care, managing change and financial management
contained in the chapters prepared by Hill and Hudson, Tricia Meads and
Moore, while both regional surveys and national pilot sites have fed into the
research of Coleman, Cornish and Petchey. All of these look to learning
beyond local boundaries, and the application of concepts and ideas from
