What now for our Health Service?

WHEN it became clear that plans to streamline the NHS included the abolition of Darlington Primary Care Trust, the town's MP saw red.

Alan Milburn has described proposals to allow Darlington to become part of a large, County Durham-wide PCT as "ludicrous, bungled and ill-thought out".

This outspoken attack - revealed by The Northern Echo - from the man who dreamt up PCTs and ran the Health Service for years, set the phones in his constituency office ringing as national newspapers followed up what looked like a good story.

Mr Milburn still thinks the proposals are wrong-headed, as does Darlington Borough Council, but his constituency office has stressed that his objections are purely from a local MP's point of view and not an attempt to challenge the authority of his successor, Patricia Hewitt, the present incumbent in the Health Secretary's spacious Whitehall office.

The NHS is in the throes of one of its periodic upheavals by a Government anxious to be seen to be making greater progress in improving health care and smoothing out inequalities.

Despite overseeing a massive increase in NHS funding, Government ministers are worried that they are not seeing the improvements they expected. They have also been stung by Opposition accusations that too little of the extra money has made it to front-line services.

Blairite reforming Health Secretary, Mrs Hewitt has ordered a new shake-up of NHS structures - although this week she hinted that more PCTs may survive the cull.

The twin aims are to streamline the Health Service in the run-up to greater patient choice and to save an estimated £250m in overhead costs.

As part of those moves, many PCTS would be merged and asked to give up the role of providing services such as district nurses, moving to a more strategic function.

But MPs and local authorities up and down the country have voiced concerns that the rush to scrap many PCTS in favour of larger organisations could damage highly effective partnerships working at a grassroots level.

This is particularly true in towns with unitary councils like Darlington where the PCT and local authority boundaries match, allowing joint planning of children's and older people's services.

Mr Milburn says having decisions about social services taken in Darlington but decisions about health services taken in County Durham is "a recipe for total confusion". PCTs in historically under-funded places like Easington and east Durham have also helped to obtain big funding increases.

There is also some scepticism about the wisdom of handing health commissioning to groups of already over-worked family doctors.

It was Mr Milburn who championed the setting up of self-contained primary care organisations to commission health for local populations of around 100,000 around 2000. This followed the experiments of the previous Conservative government which involved giving NHS funds to groups of GPs, known as fund-holding practices, to buy health services for their patients.

The Milburn reforms, which swept away divisive fund-holding practices and set up the new network of PCTs were intended to ensure similar levels of care. Now, five years on, the current Health Secretary is seeking to put her own stamp on the NHS by ordering a new round of reforms.

To some observers the changes look suspiciously like a return to the situation which existed before today's PCTs were set up.

If the changes go ahead, groups of GPs will again be asked to take on the role of commissioning local health services. Even the old, pre-2002 sub-regional health authorities will be revived under another name. With their new role of planning care, the new, enlarged PCTs will carry out a similar function.

But is it such bad news?

Apart from producing significant savings in overheads - said to be up to £15m across the North-East - it should also simplify the way the NHS works.

In a briefing document produced for the leaders of Durham County Council it is pointed out that the changes should lead to greater efficiency and consistency of approach across the PCTs.

Hospital trusts will no longer have to negotiate with up to five or six PCTs to try to get agreement over an investment which can only be made if all agree. There will be just one chief executive, one set of directors, one headquarters at each PCT, rather than five or six of everything.

According to the county council, the worries about particularly deprived places such as Easington losing out in such reforms have resulted in "firm assurances" from the NHS that this will not be allowed to happen.

In North Yorkshire, where four large PCTs look likely to be replaced with a very large county-wide organisation, other concerns have surfaced, with fears that the interests of people living in borderline areas such as Richmond and Northallerton - which have traditionally had links to hospitals further north - might not be well served by a much larger body.

If the expected changes do take place - barring some rebellion by backbench Labour MPs - all sides seem agreed that a great deal will depend on the sensitivity of "locality" working.

David Flory, chief executive of both the County Durham and Tees Valley and the Northumberland, Tyne and Wear Strategic Health Authorities, says that locality working does not necessarily mean retaining offices in particular areas but having individuals within larger organisations who have specific responsibilities for looking after local areas.

Mr Flory is aware that the reforms are unpopular in some quarters, but he and his two soon-to-be-merged boards are convinced that the four big PCTs proposal is the best way to meet the demands laid down by central Government.

"They would all prefer to keep their own PCTs, I respect that view," says Mr Flory. But he insists that within the NHS there is "a lot of support" for the moves to streamline structures.

What of the medical, nursing and allied professionals who will have to work within this new system?

Dr John Canning, a Middlesbrough GP who is a member of the British Medical Association's national GP committee, says it is inevitable that small PCTs would be swallowed up by larger bodies after the provider role had been taken away.

"To be frank, a lot of PCTs have not worked, Many are very small and are top heavy with administrators," says Dr Canning.

But he agrees that any new system needs to be strongly represented at a local level.

He forecasts that there could be a mismatch between a system which sees groups of GPs purchasing hospital services for patients who might vote with their feet and choose different hospitals as part of the upcoming patient choice regime.

Dr Canning worries about the possible unintended consequences of wider reforms and wonders whether it might further undermine the stability of smaller district general hospitals. "If GP commissioning and patient choice moves certain services away from a local hospital, this will have an effect on its viability. I think the future is going to be quite difficult," he says.

He warns that the Government must guard against possible fragmentation of health services.

The proposed changes to PCT boundaries are not the only NHS reforms in the pipeline. The two North-East SHAs are set to merge along with mental health trusts.

But before any of these changes can take place the NHS proposals will have to undergo a 90-day period of public consultation. That is when Health Service users can have their say... if they can understand the NHS jargon.