Stakeholder Perspectives on the Formation of Primary Care Trusts: Implications for the Merger of Social and Health Care

Although both fundholding and locality commissioning failed to achieve more than small scale changes at practice or hospital level, devolved commissioning remains central to the government's plans for the NHS in the form of primary care trusts (PCTs) in England and Wales, and local health care co-operatives (LHCCs) in Scotland. In this paper we present the results of an analysis of the views of key stakeholders on the likely success of PCTs/LHCCs and assess how previous experience of devolved commissioning might guide future developments. We used data collected at the time of the foundation of the pre-cursors of Primary Care Trusts, the Primary Care Groups and LHCCs. We found very significant disparities in perspectives between stakeholders at health authority, trust and general practice levels. All Health Board and Authority members interviewed were guardedly optimistic about the future, Trust managers were more sceptical about the future and general practitioners (with the exception of some ex-fundholders) were the most negative in their views. The concerns identified were: the absence of mechanisms for promoting change; the continuing fragmentation of services and planning; lack of resources; the complexity of needs assessment; the absence of both collaborative working and strategic thinking from the culture of general practice ; powerlessness; responsibility for rationing; and the enforcement of a salaried service in general practice. Subsequent events have shown that Health Authority respondents, and to a lesser extent those of the hospital Trusts, were too optimistic about the durability of their organisations, and the slow rate of evolution of Primary Care Trusts. The pattern of views and attitudes which we found is consistent with results from other studies, and suggests that a period of considerable upheaval is likely as PCTs form. These findings contradict positive presentations of current developments and raise questions about the concordance of current policy with evidence. We draw conclusions about the implications for social services of integration with PCTs in such an organisational climate, to stimulate discussion with colleagues from social care.