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Making a differencehow primary care trusts are transforming the NHS

PCTs and the new system

The voice of NHS managementThe NHS Confederation brings together theorganisations that make up the modern NHSacross the UK. Working with our members, we are an independent driving force to transformhealth services and health by:

• influencing policy and the wider public debate

• connecting health leaders through networkingand information sharing.

What are our values?

• championing health and health services

• engaging our members

• speaking out independently and with responsibility

• leading the debate

• working in partnership and embracing diversity

• providing value for money.

NHS Confederation1 Warwick Row, London SW1E 5ER

Tel 020 7959 7272 Fax 020 7959 7273E-mail [email protected]

Registered Charity no. 1090329Published by the NHS Confederation© NHS Confederation 2004ISBN 1 85947 115 3

Making a difference

Contents

2 PCTs and the new system

3 Introduction

4 Going for growth in South Cambridgeshire

6 Medicine and management in North Bradford

8 Northumberland united

10 Scaling up in Selby and York

12 The Waltham Forest renaissance

14 Conclusions

Making a difference 1

Making a difference2

PCTs and the new system

A priority for the NHS Confederation is to promote the role of PCTs, who face a particularlychallenging agenda as new contracts, patientchoice, payment by results and a greaterdiversity of providers all transform the system.

The NHS Confederation is publishing a series ofreports looking at how these pieces of the healthpolicy jigsaw fit together and their impact on PCTsin particular.

The reports will focus on:

• how PCTs are making a difference

• learning from existing examples of integratedmanagement across PCTs

• the relationships between PCTs and acute trustsand how they can be strengthened

• exploring new models of commissioning

• where next for PCTs.


Introduction

The last two years have witnessedunprecedented change and unprecedentedscrutiny in the NHS. At the centre of themaelstrom have been primary care trusts (PCTs),charged with turning policy aspirations into areality on the front line.

The onus has been a heavy one: PCTs are nowresponsible for three-quarters of the NHS budget inEngland. They must commission services as well asprovide some themselves. They must formulatestrategic plans for the future as well as ensureadequate care for their populations today. They haveto forge complex and fruitful relationships – withGPs, local authority, voluntary and commercial sectorpartners – often where none has existed before, orworse, where the history of such relationships hasbeen a poor one. All this would be a demandingagenda for long-established bodies; fororganisations still in their infancy it is testing indeed.

It is perhaps small wonder then that much of thespotlight has focused on what PCTs have so farfailed to achieve, with reports from the AuditCommission and Commission for HealthImprovement (CHI) this year both focusing on PCTperformance. Yet, while independent challenge andscrutiny is clearly important, we are in danger ofoverlooking the remarkable improvements in thestate of the health service that PCTs have broughtabout in a short and difficult time – and for whichthey have so far had scant credit. While the systemaround them was changing fundamentally in somany ways, they have set in motion initiatives thathave made a real difference to patients, and inplaces have begun to solve perennial problems thathave dogged the NHS since its inception. Often PCTmanagement ingenuity has been brought to bearto extract surprising results in the teeth ofunpromising circumstances – all this while theorganisations themselves have had to mature at anunnatural pace.

Not every PCT can boast of outstandingachievements yet, but many can and the five in thisreport are certainly leading the way.

What is the role of PCTs?

Primary Care Trusts, set up over the last four years, arenow responsible for health and healthcare services intheir locality. PCTs have three key roles:

• to purchase care for local communities from hospitalsand other local providers

• to directly provide services such as community nurses

• to work with local agencies to tackle healthinequalities and improve public health.

Each PCT covers a catchment population of around170,000 people and is responsible for budgets of up to£330 million. Some of the larger PCTs cover over 70 GPpractices in their area.

GPs are at the heart of PCT decision-making. A GP is a keymember of the board and often chairs the ProfessionalExecutive Committee (PEC) made up of a range ofclinicians who oversee the day-to-day running of theorganisation.

A challenging agenda

Just some of the current challenges facing PCTs include:

• managing 75 percent of the NHS budget to buy andprovide services on behalf of their local population

• implementing a new contract for over 32,000 GPs thatwill improve the quality of patient care

• preparing for a new contract for nearly 10,000community pharmacists

• managing over 300 million procedures by GPs andpractice nurses every year

• managing the public health agenda to prevent illness,promote health and reduce health inequalities acrossthe country in accordance with National ServiceFrameworks

• working with local government to provide joined uphealth and social care

• managing the largest ever investment in IT to improveaccess to healthcare and patient outcomes.


Going for growth in South CambridgeshireSally Hind, Chief ExecutiveSouth Cambridgeshire PCT

Ensuring that new houses have gardens is acampaigning issue for South CambridgeshirePCT. “We’re lobbying for things that you mightask,‘why is the health service doing that?’”admits Chief Executive Sally Hind.

“We’ve effectively designed out most physicalactivity from our lives, so need to encourage, as partof our Physical Activity Strategy, exercise whichpeople will do and enjoy, like gardening.”

With population growth of 37,000 people in itspatch by 2016, 20,000 of which will be in a singlenew town development, the PCT is keen toanticipate the demands that so many newcomerswill make on its services. Encouraging healthylifestyles to begin with is the first step towardsresponding. It also wants houses designed so that,as people grow old or become frail, they cancontinue living in them.

The policy is typical of how the PCT systematicallyanalyses problems. Its plan for improving theexisting 140,000 population’s health displays thesame approach. “We analysed mortality andmorbidity on all of the significant key areas and said,where do we sit in comparison to others, and whereis there scope for improvement? That gave us arobust set of pointers as to where we should put ourefforts and energies,” says Ms Hind. “We weren’t thenrushing off on the first good idea somebody had.We’re systematic in asking: what needs to be done?How are we going to do it? Who else do we need toengage?”

The technique perhaps owes something to MsHind’s geography and statistics degree. “Youwouldn’t believe how often both of those subjectshave turned out to be useful.”She joined the NHS asa management trainee after university, and hasspent all of her career in it except for a year as ahead-hunter. “I earned a lot of money and reallydidn’t enjoy myself at all.”She picked up valuablebusiness acumen, but quickly realised that profit-making was insufficient motivation. “I felt that myvalues were better suited to working in a publicservice.”

Ms Hind became South Cambridgeshire’s chiefexecutive in April 1999 when it was a primary caregroup (PCG). It was fortunate to be part of aforward-thinking health authority that encouragedPCG autonomy by devolving commissioning tolocalities. “That was a wise move because it meantyou built the competency from an early stage –particularly important here as we didn’t have asingle GP fundholder.”

As a result, the PCT was set up to succeed, Ms Hindfeels. That has culminated this year in services forolder people being integrated across health andsocial care, with 140 social services staff and a£15 million budget transferring to the PCT. It meansfurther responsibility and challenges for the PCT.“Whereas in an acute or mental health trust they’refocusing on delivery, in a PCT you plan and try toprevent, you deliver and you commission. Wearingall those hats can sometimes be a real challenge,but there’s value in keeping the functions withinone organisation because you’re seeing things allthe way through,” says Ms Hind.

++ The number of people who quit smoking in England using local


South Cambridgeshire ispiloting patient choicein orthopaedic servicesfor the strategic healthauthority, grappling withpredictions of patientflows, the best way toprovide help for patientsto make informedchoices and how toinitially move to offeringwhat Ms Hind calls aseries of ‘set menu’ –choices hopefullyleading eventually to anà la carte menu, withchoice at every stage ofthe pathway.

In its two years ofexistence it has notchedup notable successes: exceeding its smoking-cessation target by 187 per cent; a substantialnumber of GPs with a special interest, including anaccreditation scheme that has attracted the royalcolleges’ attention; and developing health advice forteenagers via ‘Teen-Texting’ – a service that hasaroused interest from around the country andoverseas.

On the horizon are plans for further improvingchildren’s services through integration, respondingto population growth, managing demand andachieving significant shifts in activity fromsecondary care to primary care settings. And as thePCT is over its capitation funding target, this meanscreative investment, as it will receive less growthmoney than many others.

‘Whereas in an acute or mentalhealth trust they’re focusing ondelivery, in a PCT you plan and tryto prevent, you deliver and youcommission.’Sally Hind

South Cambridgeshire PCT

smoking cessation services doubled last year compared to 2001/02 ++

“It’s part of our NHS nature to look at all the thingsthat might go wrong,” says Ms Hind. “The challengeis to make sure we don’t get so angst-ridden thatwe fail to put all our energies into delivering andachieving the benefits that are there for us.”

Encouraging gardening as exercise: Sally Hind


Medicine and management in North BradfordDr Ian RutterChief Executive, North Bradford PCT

Few jobs can be more demanding than those ofa GP and an NHS chief executive. Yet Ian Ruttercombines both. For three days a week he headsNorth Bradford PCT, and for two he practisesmedicine.

Dr Rutter joined the organisation when it was still aprimary care group and has noticed how the chiefexecutive’s role has become dramatically morecomplex and increasingly demanding since then.“It feels quite different, and a much bigger job thanwhen I started.”Ruthless segmentation is the key tofulfilling dual roles, he says. “I have a good team, andit works well.”

Not surprisingly, North Bradford has a strong recordof engaging with its clinicians. “There’s no sense ofthem and us,” says Dr Rutter. It has 35 GPs with aspecial interest serving its population of 94,000,as well as GP and nurse leads in every clinical area.Power and responsibility have been devolved topractices through personal medical servicescontracts. A policy of openness and transparencymeans any clinician can compare their ownperformance with another’s. “Peer review is apowerful driver for quality improvement,” saysDr Rutter.

The PCT has also developed a culture of innovationand change. It has adopted the National PrimaryCare Collaborative’s approach of instigating small,local changes which precipitate larger ones thathave a major impact.

North Bradford is soon to host one of the firstindependent sector treatment centres, providing aone-stop shop for diagnostic procedures and day-case surgery, reducing waiting times. Radicallyimproving cancer survival rates is another aim.

The PCT is proud of its achievements but is aware itcan do much more. “My guess is we’re doing quitewell compared to the rest of the country,” says DrRutter,“but not as well as Kaiser Permanente orsome of our worldwide colleagues.”

Listening carefully to the views of people who useits services is crucial to the PCT. A newly establishedconsumer council has begun to expand the role ofpatients in developing policies and services.Members are recruited through a formalappointments process involving an interview andare paid an honorarium. Some practices have criticalfriend or patient participation groups. “They’restarting to be able to get their message directly tothe practice that’s delivering their care,” says DrRutter.

He recently met local primary schoolchildren to findout how the PCT could improve services for them.“They hate dentists because they don’t like the tasteof rubber gloves in their mouths,”he says. “Waitingrooms have nothing for them to do or to interactwith to better understand their health.”

“Things that matter to consumers are not the thingsthat overtly stand out to professionals. Some of thatinformation will automatically start to feed into themainstream of what we do,”Dr Rutter promises.

Relations with acute trusts are a key concern forPCTs. Dr Rutter is concerned that the payment-by-results system is not yet sophisticated enough tosupport the type of contracts that the PCT wants.Unless a number of key technical issues are dealtwith, this may undermine previous work to developa positive relationship. He warns: “A lot needs to bedone urgently, otherwise there will be quitesignificant problems generated around thecountry.”


‘Things that matter to consumersare not the things that overtly standout to professionals. Some of thatinformation will automatically startto feed into the mainstream of whatwe do.’Ian Rutter

North Bradford PCT

Combining two roles: Ian Rutter

++ Nearly 9 out of 10 people are seen by a GP within 48 hours ++


Northumberland united

Linda Ions, Chief Executive Northumberland Care Trust

Imagine an organisation with no delayeddischarges, which has helped every teenagemother in its area back into education, whereGPs and social workers sit in equal numbers onthe professional executive committee and towhich the local authority has delegated aquarter of its budget. Shangri-la? Not quite:Northumberland Care Trust.

Chief Executive Linda Ions is frank that integratinghealth and social care one stage further than most– Northumberland is one of only eight care trusts –brings advantages and disadvantages. She has torun the organisation through two different systems:the NHS and local government. Different rules applyin each to performance management and activitymeasures, for example. Timescales may not besynchronised, and local government is morepolitically dominated than the NHS. “But it’s do-able.I don’t regard it as two different jobs,” she says. “Youcan’t expect the whole world to change. You haveto make the best of it.”And she is adamant that theadvantages outweigh the drawbacks.

“Staff operate as one team. They don’t seethemselves as being part of different organisations.That makes a huge difference to the way they work.There are things you take for granted which yourealise you shouldn’t when you speak to others: staffbeing in the same building, shared records, thesame computer system, social workers based ingeneral practices. They may seem small, but they’revery significant.”

Services are better organised and easier tounderstand, says Ms Ions, a career NHS managerwho has spent her working life at the interface ofhealth and social care. Every user has a single caremanager – whose profession may vary – as their‘entry gate’ to the system. A MORI poll found thatabout 60 per cent of local people recognised thecare trust or had had some contact with it.

Its patch is vast, covering 314,000 people andstretching 70 miles. The care trust’s 3,000 staff aredivided into four localities, which encompass areasof both urban and rural deprivation. “The challengeis about how to take services to people in theircommunities and reducing inequalities,” says

At the interface of health and social care: Linda Ions

++ PCTs piloting more active management of patients with long-term


Ms Ions. Rates for coronary heart disease, smokingand teenage pregnancy are high, but falling.

Working with young people is a priority, particularlywhere youth unemployment is high. “We have aresponsibility as the largest employer in the countyto help raise aspirations to look for learning andemployment opportunities,” she says, so the caretrust runs schemes involving apprenticeships andcadetships.

“We employ a lot of staff who you and I might thinkwere quirky but the kids think are wonderful”, saysMs Ions. Falls in teenage pregnancy rates thatexceed targets and the return of young mothers toeducation are among the results.

Looking to the future for care trusts, she says: “Wewould hate to see it undone. We’d lose an awful lot.You can achieve a similar outcome by different

means: for example, seconding staff. But you misssomething.”

The emergence of children’s trusts is likely to havean impact on care trusts, Ms Ions believes, as thelatter deal mainly with older people’s services.Though she thinks ministers are keen to see morecare trusts, they will not instruct organisations to setthem up. “Children’s trusts might just force theissue.”

The voices of care trusts are heard, Ms Ions says, buttheir influence is limited because they are few innumber. Nevertheless, they will face many of thesame issues as their more numerous colleagues inPCTs. “As always, secondary care access remains thebiggest challenge, and the rise in emergencyadmissions that many are seeing. The challenge ishow we work with primary care and others to tacklethe emergency care workload.”

‘Staff operate as one team.Theydon’t see themselves as being partof different organisations.Thatmakes a huge difference to the waythey work.’Linda Ions

Northumberland Care Trust

conditions are reducing hospital admissions by as much as 15 per cent ++


Scaling up in Selby and York

Jeremy CloughChief Executive, Selby and York PCT

At first glance, Selby and York PCT looks an oddanimal. York’s 210,000 population might wellhave expected a PCT of its own, and probablywould have had one, except that when theboundaries were drawn Selby’s 60,000 peoplehad no natural place to go. The resultingorganisation is bigger than its main localgovernment partner, the city of York unitaryauthority, while North Yorkshire county counciland two district councils are partners too.

It could have been a bureaucratic nightmare.But what might appear a hotchpotch in localgovernment terms makes perfect sense as a health-planning entity: people in both York and Selby turnnaturally to York District Hospital for their acute care.“We have a one-to-one relationship with the localacute trust,”explains PCT Chief Executive JeremyClough. “Therefore there is no balance of powerissue.”

Hard work has cemented good relations with all thelocal authorities, he says. Together they have formeda health and social care partnership board,prompted by the need to solve operationalproblems such as delayed discharges. These havenow fallen from 80 to 20. “Policy changes likereimbursement have had an effect, but a lot of it isabout better understanding.”

Mr Clough joined the PCT as its finance director in2001, when it was very much in its fledgling stage,and became chief executive in February this year.Having worked previously in Doncaster – which hasthree PCTs – he soon recognised that Selby and

York’s singular presence in its area meant it wouldattract the limelight. “I suddenly realised I wasentering a world where problems were going to beplayed out on the front page of the localnewspaper,”Mr Clough says.

But the organisation’s scale brought benefits too,which meant it was undaunted by the overnightrevolution in PCT responsibilities heralded by thegovernment’s move to shift the balance to the frontline. It can support a large management structurethat makes it ‘big with capability’, says Mr Clough.Where some PCTs may have doubled up roles, Selbyand York has specialist functions and departments.For example, it has separate heads of governance,patient experience and learning disabilities. Inaddition, more than half its executive directors areclinically qualified. “That’s a big change at the top ofthe organisation.”

Mr Clough sees the performance of the wholehealth system as the most notable achievement.“We have been a central part of the NHS at a time ofunprecedented change, performance managementand improvement. PCTs need to take more of thecredit for this delivery.”

‘We have been a central part of theNHS at a time of unprecedentedchange, performance managementand improvement. PCTs need totake more of the credit for thisdelivery.’Jeremy Clough

Selby and York PCT

++ PCTs are implementing a new contract for over 30,000 GPs


Learning disability services have been one of thePCT’s biggest individual successes. “We’ve taken aservice that was neglected and turned it into one tobe proud of,” says Mr Clough. “It’s integrated withthe local authority and has been given an emphasisit’s never had before.”

Mental health services have undergone a similartransformation. The trust employs 20 consultantsand runs a full range of community, inpatient andsecure forensic mental health services. “The servicesare flourishing in this organisation. We’ve created adifferent feel. There’s a sense of optimism amongthe staff. They’re a differently motivated workforce,”says Mr Clough.

But inevitably, a few clouds have appeared on thehorizon. Like many others, the PCT faces achallenging financial situation and rising demand

for its services, which makes investing for the futuredifficult. Mr Clough wonders whether theproliferation of national initiatives has beenreconciled with the total resources of the NHS. “It isa concern that not enough work has been donecentrally to plot the cost of the totality of systemreform and show it is affordable. It is difficult tomake sense of all of that locally,”he says.

And he is clear that the precious one-to-onerelationship with the local acute hospital if, as seemslikely, it soon becomes a foundation trust must bemaintained. It may have an incentive to admitpatients rather than co-operate in treating them inthe community. “That alters the dynamic. We have avery strong partnership at the moment. We need toensure we share a vision and objectives so theydon’t exploit growth in a particular area that doesn’tfit with our goals.”

In the limelight: Jeremy Clough

to reward family doctors for the quality of patient care ++


The Waltham Forest renaissance

Sally GorhamChief Executive, Waltham Forest PCT

Fate dealt Waltham Forest a tough hand:healthcare services in this North Londonborough were perceived for years asunderperforming and suffering from chronicfinancial problems, with poor-quality primarycare, emaciated community services, astruggling acute hospital, little managementinfrastructure and shabby buildings.

“I was given a list of a dozen practices that werenever going to be redeemed – the worst caricaturesof single-handed practices,” says Chief ExecutiveSally Gorham, who has now been in post for threeyears.

The health authority had misjudged the significanceof PCTs and stifled their development, she says. Sothe area ended up served by Walthamstow andLeytonstone PCT, one of the few in London notcoterminous with its local authority. Its GPs – whohad never really been ‘loved’, says Ms Gorham –continued to feel that they were not part ofanything.

Yet recently the PCT hosted an event for 200 people,mostly GPs. Such occasions, with all 68 localpractices represented, are no longer unusual. ThePCT is one of the few to have been reconfigured –as Waltham Forest – and now matches boroughboundaries. It has achieved levels of participation byits clinicians that most other PCTs would envy, whilerelations with its local authority – which itself hasnot enjoyed the best of reputations – are excellent.

“We see ourselves as a group trying to take forwardthe renaissance of Waltham Forest,” says Ms Gorham.The local authority recently offered the PCT acarpark site on which to relocate three or fourgeneral practices and house a child assessmentcentre. “Once you know each other really well, it’sthe informal network that delivers,” says Ms Gorham.

Closely involving GPs has been central to the PCT’sapproach, born not least from Ms Gorham’s ownexperience. She joined the NHS at 21 as anoccupational therapist, and moved intomanagement when the Griffiths reforms of the mid-1980s encouraged clinicians to do so, becomingone of the NHS’s youngest unit general managers.But it was while heading another PCT and trying toset up a walk-in centre without GP support that sherealised how crucial they were to any attempt atinnovation. “You’ve got to have them with you. Ifyou haven’t, you’re absolutely lost,” she says.

So when Waltham Forest’s financial situation made itimpossible to establish locality management, shedevised a structure based on grouping the PCT’s

‘The whole organisation is aboutbeing positive, about WalthamForest being one of the best PCTsin London, about improvingperformance and believing inpeople and their ability to achievethat.’Sally Gorham

Waltham Forest PCT

++ More than 1.5 million people


general practices into six clusters, with the GPs onthe professional executive committee each takingresponsibility for one – ‘not as managers, but as thecommunication link with the PCT’. After initialreluctance, they embraced the idea.

“We put a lot of performance management datainto the cluster areas and we held events on clusterbases. Now everyone talks ‘cluster’ all the time. Weorganise virtually everything in the PCT aroundthem,”says Ms Gorham. Each is configured to reflectthe community councils or area committees thatthe local authority uses for consultation.

The PCT has made major strides in helping improveservices at Whipps Cross Hospital, in developing

high-quality care for coronary heart disease aheadof the requirements in the General Medical Services(GMS) contract, in encouraging the roles of specialistnurses and community pharmacists and inredeveloping practice premises. It is even retrainingrefugee health workers as cardiac technicians. Anddespite its history of poor financial management, ithas broken even.

For the future it is working on practice-basedcommissioning, readmission avoidance and chronicdisease management. “The whole organisation isabout being positive, about Waltham Forest beingone of the best PCTs in London, about improvingperformance and believing in people and theirability to achieve that,” says Ms Gorham.

are now using walk-in centres ++

Retraining refugee health workers: Sally Gorham


Conclusions

The striking feature of these case studies is thedemanding role that PCTs have been given:

• the scope of their work is very large, rangingfrom health improvement in schools to tertiaryneonatal intensive care

• they have to be innovative and prepared tochallenge accepted ways of doing things,including clinical work

• to do this effectively they have to build high-quality relationships with clinical staff in GPpractices and in hospitals as well as with localgovernment and other organisations

• PCTs have to integrate care, balance priorities,actively engage with local people, meetgovernment priorities and a wide range of otherobjectives simultaneously.

PCTs have to do all this with limited managerialcapacity, with both the Audit Commission andCommission for Health Improvement recognisingthat PCT management resource is thinly spread.

A number of emerging policies provide newopportunities for PCTs to make a positive impact onhow healthcare is delivered by using choice,payment by results, new contractual arrangementsfor staff and new approaches to commissioning.However, one of the most significant issues thatPCTs face is how to deal with this large number ofdifferent policies – many of which do notimmediately appear to interrelate – and to turnthese into a coherent whole in such a way that theysuccessfully engage with the interests andaspirations of local people and, crucially, with thoseof their clinicians. Without this coherent story it is

very difficult to get any enthusiasm for the role ofthe PCTs or their objectives from stakeholders, thepublic or even policy makers.

The PCT chief executives also highlight how theseindividual policies bring their own challenges. Thereis concern that payment by results and theemergence of foundation trusts contain powerfulincentives to undermine some of the collaborativeworking that the most effective PCTs have managedto develop. PCTs and the trusts they work with areambitious for change but many are worried by tightfinancial situations, which they fear could make amockery of their best laid plans for care in thefuture. And all are keen to tackle the challenges ofcoping with rising emergency admissions andfinding better ways of managing chronic disease.

Some are thinking hard about the advent offoundation status for neighbouring acute trusts. Willit upset formerly symbiotic relationships? Could itundermine the PCTs’ mission? Whatever happens, itwill clearly require PCTs to find new ways to engagetheir local community to ensure genuineinvolvement in key investment decisions.

These case studies demonstrate some of the PCTs’aspirations for the future and their thinking abouthow their role can develop. In the next reports inthis series we will focus on how PCTs need tochange and adapt to meet the many significantchallenges and opportunities ahead.

PCTs have been in existence for less than four yearsand they have been subject to significant changeduring this period. However, as usual, there are somewho are already talking about the need for further

15

reorganisation, with PCTs in their sights. This reportshould give the sceptics pause for thought. In theface of an enormously challenging agenda andmany competing claims on their time and resource,the case studies are a snapshot of the progressalready being made. Of course, there can be noroom for complacency, and there is much more tobe done. But PCTs are now demonstrating thedifference they can make and can claim credit forsome outstanding achievements in their shorthistory.

For more information about the NHSConfederation’s work in this area, please contactNigel Edwards, Policy Director [email protected]

Making a difference

Further copies can be obtained from:

NHS Confederation Distribution

Tel 0870 444 5841 Fax 0870 444 5842E-mail [email protected] visit www.nhsconfed.org/publications

Price £15

Making a difference

A priority for the NHS Confederation is to promote therole of PCTs, who face a particularly challenging agendaas new contracts, patient choice, payment by resultsand a greater diversity of providers all transform thesystem.

Making a difference is the first of a series of reportslooking at how these pieces of the health policy jigsawfit together and their impact on PCTs in particular.

Making a difference reflects on the scale of the taskfacing PCTs, who have been charged with turning policyaspirations into a reality on the front line. Drawing oncase studies from across the country, it shows how PCTsare making a real difference and argues that PCTsshould be given credit for the improvements achievedin their short history.

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The NHS Confederation1 Warwick Row, London SW1E 5ER

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