Founded in 2001 as independent statutory organizations, England's "primary care trusts" (PCTs) have emerged in the last 2 years as the new power brokers of the state-funded National Health Service (NHS). Run by general practitioners, nurses, social care workers, and patient representatives, PCTs have been hailed by government Health Secretary John Reid as "the cornerstone of the NHS."
Their broad powers extend far beyond primary care. They are responsible for ensuring that there are enough services for people in their areaseverything from dentists to opticians and from mental health services to cancer care. They have become the main decision makers in the NHS, controlling 75% of the country's health care budget.
However, in a recent report, the All-Party Parliamentary Group on Cancer concluded that "PCTs vary considerably in size and some are simply too small to commission cancer services." The trusts are usually responsible for areas matching local council boundaries, with populations ranging from about 70,000 to 200,000.
The All-Party Group report challenges the political vision that England's 302 PCTs should have greater freedom to decide their own priorities and allocate resources on the basis of local needs. Front-line professionals, so the argument went, have a better understanding than central decision-makers about local wants and needs, and increasing freedom from central regulation would reduce NHS bureaucracy.
However, PCTs are reported to be adding to NHS bureaucracy. The 34 cancer networks responsible for implementing national cancer policy have to seek funding approval from their local PCTs. This results in individual networks having to negotiate with a dozen or more PCTs. Individual PCTs may have different ideas about the best way to allocate funds. In one case in southeast England, 16 different PCTs were involved in a decision to update radiotherapy treatment, complicating a "relatively simple decision making process," said Jane Halpin, M.D., of the Bedfordshire and Hertfordshire Strategic Health Authority. In another case, a plan to construct an additional bunker to house a linear accelerator at the Mount Vernon Cancer Center, just outside of London, ran into problems because of confusion about which PCT was responsible for its funding.
"The budget for cancer services must go directly to the cancer networks," said Parliament member and parliamentary group chairman Ian Gibson.
Mike Richards, M.D., the United Kingdom's first national cancer director, said that one of the reasons patients were not getting access quickly enough to treatments recommended by the National Institute for Clinical Excellence (NICE) was because of failures in commissioning. NICE was established in 1999 to improve the standard of care and reduce inequalities in access to innovative treatments. Since 2000, it has published about 50 technology appraisals to promote evidence-based medicine in routine practice.
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It is mandatory for NHS bodies such as hospital trusts, which include cancer centers, to implement NICE guidelines within 3 months of publication, but the All-Party report noted that, "In reality the extent to which guidance is implemented varies substantially from area to area." In a separate report, published recently in the British Medical Journal, a team from the University of York and the Bradford Royal Infirmary in Yorkshire also concluded that implementation of NICE guidelines has been variable.
It added: "Guidance seems more likely to be adopted when there is strong professional support, a stable and convincing evidence base, and no increased or unfunded costs, in organizations that have established good systems for tracking guidance implementation."
How do the fledgling PCTs measure up to these criteria? Although they have ministerial support, the head of Prime Minister Tony Blair's Delivery Unit Michael Barber warned in 2003 that PCTs "may be unequal to the task" of deciding how to spend the NHS budget.
Giving evidence to the All-Party Group, Richards, author of the U.K.'s National Cancer Plan, acknowledged that "PCTs are young organizations... and they have had to learn a lot about cancer." The Department of Health is hoping that the PCTs will "grow into their roles," but the All-Party group said, "We... remain unconvinced that PCTs are the most appropriate organizations for commissioning cancer services." The group believes that it is "very difficult for PCTs to put a high priority on cancer when in any individual [general practitioner] group it is a relatively low-incidence problem, compared with diabetes and heart disease."
The future may depend on the performance of 28 so-called Strategic Health Authorities (SHAs), described by the Department of Health as the "local headquarters of the NHS." It is the job of the SHAs to ensure that PCTs in their areas strike the right balance between their dual responsibilities to implement national guidance and respond to local needs and circumstancesand that money earmarked for cancer networks actually reaches them.
The Department of Health has carried out two separate investigations in the last 2 years to find out what has happened to money or guidance issued to PCTs to improve cancer services.
A tracking exercise by Richards revealed "a slower start to Cancer Plan investment in 2001/02 than we had hoped, with actual investment of £199 million (US$383 million) in 2001/02, compared with £280 million (US$538 million) allocated in the Cancer Plan."
The All-Party report also wants general practitioners to have more guidance about cancer diagnosis. The report says, "We are concerned at the findings of the National Audit Office that only 50% of [physicians] say that they have read the national referral guidelines and found them useful."
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