| Review of: | Towards managed primary care: The role and experience of primary care organizations by Judith Smith, Nick Goodwin |
|---|---|
| Reviewed By: | Andrew Gray |
| Reviewed in: | Public Administration |
| Date accepted online: | 14/01/2008 |
| Published in print: | Volume 85, Issue 03, Pages 857-883 |
Reviews
With primary care trusts (PCTs) in the throes of further reorganization in the UK, Smith and Goodwin draw on their research to provide a history, organizational analysis and evaluation of primary care organizations to date. The style is methodical and comprehensive; particularly useful are the end of chapter elaborations of the implications and lessons for research, practice and policy. This device in itself commends the book to a wider than usual readership.
The starting point is the increasing emphasis in the UK's health services on primary care services and commissioning. After an international comparison of this shift, the authors provide chapters on the development of English primary care organizations (PCOs), the evaluative methodology, the governance of PCOs, the role of general practitioners and nurses within them, performance management, partnership with other local organizations, the development of primary care services, the potential of PCTs as commissioners and the challenge of sustaining clinical engagement. They conclude with observations about PCOs of the future. No doubt a later edition will assess the impact of the current reorganization of PCTs designed to serve greater populations in boundaries co-terminous with local authorities, and provide more effective commissioning and arm's length, if not out-sourced, services.
Smith and Goodwin's evaluation finds PCTs wanting in significant respects: they have problems as learning organizations, attracting and retaining the engagement of the clinical professions and building partnerships for health improvement. It is also not clear whether they have improved health outcomes and whether the improvements they have made to primary care services can be sustained. If all this sounds negative, Smith and Goodwin are both careful with their evidence and to offer explanations, many of which point to factors outside PCT control. Nevertheless, as this reviewer, himself a former Vice Chair of a Primary Care Trust noted, the authors might have made more of the considerable service developments for communities in general and particular sections (there is nothing about the development of prison health, for example). Such developments have been secured often against considerable obstacles such as destabilizing reorganizations, changing performance targets and contract regimes (including the woefully misnamed 'Agenda for Change' a service wide job evaluation and grading restructuring that has diverted resources from service development). To the extent that PCTs have endured all this and managed to contribute to the enhancement of clinical standards, they have established their credentials and justified further investment.
Smith and Goodwin are perhaps most severe on the failure of PCTs to embrace their commissioning role. This is a valid observation. PCTs have not been effectively established to play this role and the health economy investment of political, intellectual and organizational capacity has been significantly greater in the provider function (in the creation of foundation trusts, for example) than the commissioning. As a consequence, PCTs have remained payers of bills (usually at the bidding of acute sector providers) rather than buyers, let alone commissioners, of services. The current reorganization has been designed to remedy this. Whether it has been sufficient, given the political fudge that has resulted in many areas, and whether it can be sustained while protecting and further developing the primary care services so desperately required particularly in the care of long term conditions, remains to be seen.
Pointing out omissions probably reveals as much about the reviewer as about the authors so, in addition to prison health, I mention only the inattention to non-executive directors in the governance of PCTs and the role of PCTs in local strategic partnerships and local area agreements. In general the evidence comes rather more from the life of primary care