It’s not just commissioning – who will fill the PCT vacuum?

The central passage of her letter read: “Browsing through the white paper one cannot help noticing the similarity between it and what we have already. It speaks of supporting GP consortia in their community decisions and creating a lean and expert organisation that draws from best practice. We have one already - our streamlined PCT.

“It states that GP consortia may wish to buy in support for their commissioning activities. No need; NHS Sheffield does that very effectively.”

She concludes: “What we have in Sheffield is fit for purpose.”

Ms Angier’s words tap into the growing feeling that the NHS is in danger of throwing the baby out with the bath water.

It is ironic that just as PCTs begin to contemplate their own mortality, an evidence base is starting to build about how effective some of them are. Last month we commented on the progress demonstrated by the world class commissioning scores.

This week research by consultancy Health Mandate exclusively carried by HSJ shows how successful PCTs have been in targeting and delivering on local health priorities. What is more, the PCTs with the best records did it without spending more money - a criticism levelled by some against those that topped the world class commissioning rankings.

As HSJ (and the British Medical Association) has said before, the NHS will lose the expertise and experience that lies behind these successes at its peril.

The importance of the proficiency - and capacity - of primary care management is underlined by research which sets out the range of PCT responsibilities beyond commissioning.

PCTs have taken on a bewildering range of responsibilities - more than 300 - from medicines management to contract negotiation and child protection. The management costs associated with these duties are the same as those associated with commissioning. Even after a cull of the more esoteric tasks there will still be many duties to allocate. Where will they go?

Loading many of them on to already nervous GPs does not commend itself as an approach. Taking all the responsibilities back into central control does not sit well with the government’s desire to devolve power. Equally, many of these duties will have little appeal to the private or third sectors.

It is hard to escape the conclusion that some kind of local NHS management function - apart from that supporting GP commissioning - will be necessary in the future.

We may, of course, find ourselves with sizeable regional outposts of the Department of Health chock full of freshly transferred PCT and strategic health authority staff.

But might a more acceptable and efficient solution be to ask local authorities to carry out many of the roles undertaken by PCTs? They already cover similar tasks in social care and other areas, meaning they have both the expertise and the infrastructure.

There are problems, of course. Most notably that local government and NHS cultures can often conflict: witness, for example, the concerns afflicting the creation of the new public health service.

However, they are not insurmountable and in places like Sheffield closer integration between health and councils could actually be going with the cultural flow.

As for the public health culture clash, HSJ has a suggestion. GPs are the flavour of the month - so why not appoint one as the new chief medical officer? At a stroke the public health service would be connected to the new power brokers in the NHS. Outgoing Royal College of GPs chair Steve Field would be a good fit.