Is Lansley wrong to abolish PCTs?

The Observer today is full of angst about Andrew Lansley's health reforms. In short, everyone inside the NHS - managers, GPs, hospitals - seems to think that abolishing PCT's - the 'bulk-buyers' of health care for local people - and giving the task - and funds - to GPs is a risk too far. GPs, they say, want to just do their core job - not that of commissioning and procurement of services. And what will happen in areas where GPs don't take this on? At the moment, I'm working quite a bit NHS people and I hear similar things from people to whom I speak. To far, too fast, is the over-riding message.

That the NHS needs further reform isn't, in my mind seriously in doubt. To see the way things are done is to see a tangle of groups, sub-groups, mazy reporting lines all of which suck power and energy away from otherwise talented people. Throw in a tetchy operating culture, the clinician/management tension, the primary/acute divide, the special pleading from all professional quarters and the presiding overlord of the Strategic Health Authority and you've got a viscous treacle through which even a boiling hot spoon will struggle to pass.

And all of this costs a fortune to run - so I can see why the Secretary of State, like his zealous Cabinet colleagues want to just get rid of it all - PCTs, SHAs, the lot. As Andrew Rawnsley said today, they have all read their Tony Blair and want to use this term to get radical. But the question to be asked here is whether, in trying to avoid Blair's cautious approach, they risk going in the other direction - and wreaking havoc?

In the case of health, my own view is that the Coalition would have been foolish to leave the NHS to itself entirely. The problems listed above are real and hinder productivity, innovation and change. The NHS was given extra funding without being properly reformed. Yes, we saw some good come of that era - Foundation Hospitals, unprecedented capital spend and an end to some of the worst aspects of the pre-1997 system. But we were slow to diversify supply of healthcare, too worried about the reaction of the NHS establishment to devolve funding to the lowest possible point.

However, while I would be happy to abolish the Strategic Health Authorities tomorrow, I am less convinced that PCTs should go. They play an important function in many healthcare economies. When they go, their function will need to be picked up elsewhere, probably by consortia of GPs which themselves will require an organisational infrastructure. An alternative to abolition would be to reshape the Governance of PCTs to make them more GP-driven organisations.

This wouldn't be a gigantic shift. The PCTs no longer provide many services themselves. This, quite rightly, has been taken off them and given either to social enterprises, an NHS Foundation Trust or the open-market. What remains is relatively small, quite focused on locality with a history and skill-set which is useful in getting the mix of healthcare right in any given area. And unlike GPs Consortia on their own, they include the voice of patients, other professions and sectors. It is easy to forget, especially when we think about our own GP, that this group inevitably have interests which they will, almost certainly use any spending power they have to defend.

The other reason I would defend PCTs at the current time is that they do mitigate the risks incumbent in any system going through change. Payment by outcomes, Any Willing Provider and a much tighter cash environment are all big waves crashing, simultaniously, on the healthcare sector between now and 2013. Individually, each of these will have positive effects. That I do not dispute. But there will also be unintended outcomes, which will need to be managed. The PCTs - were they left in place be in a good position to help to manage the new ecology of healthcare at local level. Now that they too are in the mixer, it feels like there are no fixed institutional points around which to implement change - or manage risk.

Right across Government, similarly bold experiments are taking place in welfare, education and criminal justice. Local government is also having to reinvent itself in the face of unprecedented cuts. In all of these areas, there are huge potential gains to be made - and I applaud the Coalition for being courageous in what they are prepared to do. However, the change, in each case will need parts of the system to remain in place - rather than caught themselves in the vortex - to ensure sound implementation and to deal properly with any intended outcomes.