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Understanding the PCT … and getting them to understand you!

19 June 2009

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Independent Healthcare Consultant

Director of Primary Care
National Services for Health Improvement

Steve is a former Royal Navy Officer, and joined the health service as a chief management accountant in 1984. He has worked at all levels of the NHS. He was an associate tutor at the Institute for Health Policy Studies at the University of Southampton and has worked for the professional development committee of the Institute of Healthcare Management

It’s like the saying goes: “Can’t live with them, can’t live without them!”

Very often the primary care trust (PCT) is seen as being the adversarial party in respect of many relationships with general practice. This is due to the fact that both sides have conflicting objectives. However you perceive your relationship with the PCT, this is one relationship that you must manage effectively.

First, the PCT is meant to create dialogue and discussion with its resident population to plan and deliver appropriate healthcare. In truth, this is established through the network of general practices that are the very first point of contact. This includes ensuring better healthcare provision and intervention.

Second, it achieves this by commissioning a full range of health services, which is equitable and of high quality. Again, this is done largely via practice-based commissioning.

Lastly, the PCT provides direct services where this is deemed to represent best value for money. This is all achieved by working with its registered contractors in general practice.

The PCT is accountable for its actions to the responsible strategic health authority (SHA). The SHA will provide strategic leadership, organisational and general workplace development, and monitor local PCT systems to ensure that they actually work.

Each PCT will be governed by a set of standing orders and standing financial instructions. They have a statutory duty to deliver services in accordance with their interpretation of this guidance.

What do the standing orders include?
Most importantly, they summarise the framework under which the PCT operates. This includes the statutory framework and their legal duty, combined with their responsibilities under the NHS framework. Lastly, it stipulates where and when it may consider delegation of powers.

Membership of the PCT
Notwithstanding the staff employed by the trust, the decision-making process is carried out by ultimate reference to a board, which is compiled from a number of different areas. The board is composed of a chairman and other members. The terms of office and other members must be defined by the PCT.

The board is responsible for the appointment of the vice chairman and other members. Joint members may be appointed and officer members can be appointed to the board following nomination by the executive committee. The structure of the board should be democratic and its working practices transparent. Each board should have a patients’ forum and representation at board level. New local networks are to be introduced in the future.

It is almost a necessary evil, but one of the key purposes of the PCT is to hold meetings. The board must call meetings and give notice of the business to be discussed. It must provide supporting documentation and agenda papers. It must be able to deal with petitions and notice of a motion to be put forward. This may include an emergency motion and a need to call an extraordinary meeting. The board must clearly stipulate how and when a motion may be tabled. It must stress who is allowed to propose, and the process for amending or withdrawing a motion.

PCT structure
To alleviate some of the burden and remove the beaurocratic nature of such formal meetings, the board is able to delegate powers and some decisions by forming committees and subcommittees that become accountable for their actions to the board. The PCT will ensure that there are clearly laid guidelines about the appointment to committees and the delegation of powers to subcommittees and officers of the PCT.

Examples of committees might include:

  • Executive committee.
  • Joint working committee.
  • Audit committee.
  • Remuneration and terms of
  • service committee.
  • Charitable funds committee.

The list is not exhaustive, but gives a flavour of how the structure of the PCT will be made up. Somewhere between the board, the committees and subcommittees is the authority for the officer (member of staff) to carry out his or her daily duties.
It is these staff that the practice manager will have normal dealings with and sometimes invite to our own weekly meetings with the doctors. We will, of course, minute such meetings and
any outcomes.

However, it is important not to feel intimidated by the structure of the PCT. If you feel that you are not getting anywhere with the person you are dealing with, do not feel afraid to escalate matters higher and even request matters be discussed at a board meeting. Talk to your colleagues in other practices. You may find that they are experiencing the same frustrations as you, and together you will be able to influence change.

Aim for a frank relationship
You should not try and create personal crusades. It is all to easy to get swept away by the politics and personalities of certain situations, but if you feel that you have the support of your doctors and you have a valid concern, then do something about it!

As a practice manager, you will need timely and accurate financial information from the PCT. This is one of those times where they must understand your requirements and the consequences of failing to provide accurate or valid information. I have experienced too many occasions where the manager has to pursue financial payments or reimbursements.

You know what you have to manage in general practice, and below are PCTs’ key functions:

  • Service agreements for the provision of NHS services.
  • Commissioning.
  • Terms of service and payments for members and staff.
  • Accountable for all other nonpay expenditure.
  • The local financial framework.
  • Capital investment projects.
  • Private finance projects.
  • Fixed assets registers.
  • Security of assets.
  • Stores and receipt of goods.
  • Disposals and losses, and special payments.
  • IT.
  • Patients’ property.
  • Funds held on trust.
  • Gifts to staff and general business conduct.
  • Payments to independent contractors.
  • Retention of records.
  • Risk management and general insurances.

You only have to look at the above list and then consider the core competency framework for practice management to see how you, as a manager, are expected to be skilled in a variety of business areas, whereas PCT staff will belong to a department that deals with one particular aspect of their work. I believe this will always give you the edge to understanding how change affects you on a daily basis.

In comparison to the average general practice, the PCT is an organisation that is bound by certain statutory requirements. While general practice is also bound by certain guidance and legislation, the simpler structure of a standard practice means that decisions can often be made more quickly and efficiently than at the PCT.

This is why, at times, general practice and the PCT can seem to be pulling in different directions. It is important that you understand that you are well within your rights to ask them to understand your point of view.