Primary care trusts

During 2001 and 2002 a significant milestone in the Government's reorganisation of national health services in this country took place. During this time primary care trusts (PCTs) were established, and they took on the roles and functions previously carried out by health authorities, but serving populations of around 100,000 people. PCTs are a development of primary care groups, but rather than effectively operating as a committee of the health authority, they now act as free-standing NHS statutory bodies charged with commissioning health services for their local population.
The Government's intention was to maintain the local input and knowledge derived from primary care groups and their members but within an organisation that had the power and budget to meet the needs of the local population directly rather than through an overarching body. In simple terms, PCTs have four core functions:

To improve the health and well-being of their local population, involving local people in decisions about the development of services and working in partnership with other agencies, particularly social care, addressing health inequalities and providing more accessible, higher quality services
Commissioning hospital and other health services on behalf of the local population
Providing a focus for the development and involvement of primary care and community care, ensuring better integration of primary and community services and social care services
Providing community-based and specialist health services for children and adults from community hospitals, health centres and clinics, GP surgeries and within people's homes.

Each PCT therefore has responsibility for planning and delivering high quality healthcare to its local population and to develop and organise these services to ensure improving standards of health and equality of access for patients. In order to meet these goals a PCT can act in its own right as a provider of health services, or commission them from other providers such as hospital trusts or primary care practitioners.
The use of optometrists to provide diabetic eye screening services is a good example. They are responsible for providing, or managing, all local community and primary care services, including the national services with non-cash limited budgets such as the General Ophthalmic Services, as well as commissioning acute hospital services from other NHS trusts or the private sector.

Each PCT is likely to:

Serve a population of around 100,000-150,000 people (some are bigger, few are smaller)
Have a budget of around 250m
Employ around 1,000 staff, both administrative and clinical.

Structure
As I have said the intention with the introduction of PCTs was to ensure that decisions were made based on a clear knowledge and understanding of the needs of local people. To this end, PCTs are autonomous bodies that can set their own agenda and priorities based on the perceived needs of the local population. The work is guided by input from local frontline healthcare providers and the public who use the services.
All PCTs are structured in similar ways and comprise three important elements (Figure 1). The first and most important of these is the trust board. As Figure 2 demonstrates, this is made up primarily of lay people and has a lay chair. The board is responsible for the strategic direction of the PCT. The second element is the professional executive committee (PEC). PECs, as they are commonly known, are made up mainly of local healthcare practitioners and are responsible for the development of policy. The PEC makes recommendations for the development and delivery of local health services for consideration by the PCT board. The final element of the organisation is the executive, the management team led by a chief executive.
Let us look at these three functional parts of a PCT in more detail.

PCT board
The PCT board is responsible for overseeing the work of the trust, developing strategy and ensuring probity. This means that proper use is made of public funds and that, where possible, value for money is obtained in the provision of services.
As described above, a PCT board is typically made up of 11 people (Figure 2), primarily lay people who do not work for the PCT and who are not healthcare professionals. They are the so-called non-executive directors.
The remainder of the board comprises executive directors, members of the senior management team (see below) such as the chief executive and finance director, representatives from the professional executive committee, and the lay chair. Commonly the director of public health is a co-opted member who sits on the board but has no voting rights.
Meetings of PCT boards are conducted in public and therefore open to all and normally take place every other month

Professional executive committee
The PEC is made up of GPs, nurses and other health and social care professionals (Figure 3). Its role is to work closely with the PCT board and executive in developing and planning the future direction of the PCT.
PEC functions include developing policy, monitoring service delivery, providing a forum in which professional issues can be debated and ensuring that acceptable clinical standards are maintained across all areas of activity. The committee is primarily made up of GPs and nurses and there is no automatic place for optometrists, dentists or pharmacists. In addition to the GP and nurse members, however, there a three other places that are available for 'other' or 'allied' health professionals. This might be an optometrist but might also be a chiropodist or physiotherapist.
It must be recognised that professional members of the PEC are not there to represent their profession as such, rather they are selected to support the work of the PCT in a generic capacity based on their knowledge of the healthcare needs of patients in the area.

PEC functions include:

Formulating service development and investment plans and monitoring service delivery
Providing a forum for debate about professional issues and allowing clinicians to offer expert advice and to influence the development of strategy
Providing advice and guidance to the PCT and board in order to ensure that acceptable clinical standards are reached and maintained.
The executive
All PCTs will have a chief executive. This is a formal position defined by regulations. Under the chief executive the work of the trust will be managed in a number of sub-division each headed by a director (Figure 4).
As PCTs are autonomous bodies, exactly how the management structure under the chief executive is organised will vary, and no two PCTs will be exactly the same. This can give rise to some confusion as staff roles and responsibilities may well be organised, or grouped, differently and job titles are likely to differ from PCT to PCT.
While this may not matter to a GP or district nurse who only work in one area, it can cause difficulties, or confusion, for professions like optometry where many practitioners work in a number of practices, some of which are likely to be in different PCT areas.

Function
There are, however, a number of key areas where a PCT has responsibility and the directors in the senior management team, or SMT as it is often referred to, will reflect these (Figure 4). Although the exact names and job titles may vary, PCTs will all function in the following general areas:

Finance - PCTs are responsible for, among other things, primary care contractor payments
Public health - The responsibility for public health surveillance, communicable disease control and screening programmes now rests with PCTs
Complaints - PCTs are responsible for handling patient complaints about the service that they have received and they also operate the patient advice and liaison service (PALS)
Performance management - All PCTs are expected to achieve certain standards and work towards targets as part of the Government's drive to improve and modernise health service provision. These standards and targets may be national, local, statutory, or voluntary and cover all aspects of a PCT's activity
Primary care contracts - PCTs are responsible for the management primary care contracts such as the General Ophthalmic Services contract and maintaining local lists of suitably qualified practitioners
Community services - A number of community health services are provided directly by PCTs. These include child health services, district and school nursing, health visitors, chiropody/podiatry services, support for those with drug and alcohol dependence and mental health services.

Local delivery plan (LDP)
In addition to its day-to-day functions of managing, funding and delivering services, the PCT is responsible for developing and maintaining a strategy to meet, and improve, the particular healthcare needs of its local population. Initially this strategic view was articulated in the publication of an annual document entitled the Health Improvement Plan.
More recently this has been superseded by the Local Delivery Plan (LDP). This is again an ongoing process of dialogue and consultation, which identifies local health needs and inequalities, outlines agreed priorities and ensures that funding is available to deliver those priorities. Once agreed, each LDP is published, again on an annual basis.

Localities, neighbourhoods and local health groups
Many PCTs have decided to sub-divide their area into a number of smaller units based around a natural grouping of their population in a specific location or neighbourhood - hence the names. This arrangement allows an even greater understanding of the needs of the local population and a greater interaction with community staff.
Some PCTs use different names to describe their sub-units, but essentially the concept is the same. Typically there might be three or sometimes four areas, which might be named geographically, ie North, West and Central as in the case of Northumberland PCT, or after prominent conurbations , for example Peckham and Camberwell, Dulwich and Bermondsey and Rotherhithe in my own area of Southwark in South London.
The development of the locality concept is likely to become a greater feature of the development of PCT activities in the future.

Getting Involved
At first sight it may not look as though there are many, if indeed any, opportunities for optometrists to become involved in the work of a PCT. For instance there is no automatic entitlement for an optometrist to be a member of the PEC. However, there are ways in which the views and advice of optometrists, both collective and individual, can be fed into the work of their local PCT.
Firstly, a great deal of the responsibility for successful interaction with a PCT rests with local optometric or optical committees (LOCs). LOCs must be enthusiastic, proactive and well supported by the practitioners they represent in order for this relationship to be effective. This is particularly important as it is usual now for LOCs to have to work with several PCTs rather than a single health authority. In many areas this has stretched LOCs almost to breaking point. Optometrists must be active and involved in the work of their LOC if it is to be successful.
Many PCTs are beginning to realise that input from a wider representation of primary care practitioners is an important and necessary requirement for the satisfactory functioning of their PEC rather than relying on the membership defined by statute. And they cannot expect the three statutory 'other' health professionals to provide the necessary input on their own and in isolation. For this reason many PCTs have been actively recruiting co-opted optometrist members for their committee. If your PCT does not have an optometrist member of the PEC then individual practitioners and the LOC should be actively lobbying and encouraging the trust to recognise this deficiency and act to enlarge it.
Some PCT areas are now looking at the notion of developing groups of local practitioners to act as sub-groups of the PEC and to provide it with a wider input.
Obviously, any optometrist or dispensing optician can, as a member of the public, attend the regular meetings of their PCT board and although it may not provide an opportunity to input views and opinions it would enabled an understanding of the PCT's current activity and future direction.
Finally, PCT localities or neighbourhoods normally organise a regular forum in each area to involve local healthcare professionals in the planning and development of services. Unfortunately up until now many of these groups have been GP focused and take place in the middle of the day to fit in with GP working practices. Despite this it is important that as many local optometrists as possible become involved.
These forums provide an ideal opportunity to build relationships with colleagues from other professions, many of whom you will be referring patients to. It will also keep you informed about what is happening in your immediate catchment area.

Geoff Roberson is an optometrist and a member of the Lewisham, Lambeth and Southwark Primary Care Trust