On 1 April 1999 the National Health Service lurched into a brave new world with the introduction of primary care groups (PCGs). At a stroke the landscape was transformed from a patchwork of fund-holders, multi-funds, non-fundholding consortia, and area commissioning groups to an over-arching system of PCGs.
These groups now hold a monopoly of purchasing power and – more significantly – are compulsory. Like it or not, a GP is in his/her local PCG for good or ill.
The greatest challenge facing PCGs today is not the millions of pounds of debt they have inherited, but how to involve all their fiefdoms in the governing process. It is upon this hidden reef that most PCGs will flounder, through rift and internal dissent.
The speed with which the new NHS has gestated is staggering. When we see the summer guidance coming out after Halloween, and the autumn guidance delivered by Santa Claus, one may be forgiven for thinking the whole process to be reckless.
The danger of this approach is that it leaves jobbing GPs, district nurses, health visitors and the like feeling thoroughly disenfranchised. PCGs must engender a culture of ownership if they are to be effective.
The route to this ownership is through dialogue. And here lies the crux of the problem. How can a PCG with its paltry management budget effectively engage all the outposts of the empire?
Word of mouth is a grossly underrated form of communication, but when attempting to garner opinions from anything between 50 and 100 GPs, scores of nurses, dozens of health visitors, and tens of practice managers, it is clearly not appropriate.
Most PCGs will inevitably resort to that old NHS favourite: paper. As a PCG board member I have received a mountain of paper over the last year. A pile of it sits festering in my once spacious study. But in the final analysis paper does not achieve the aim. Swathes of woodland are decimated in order that a PCG drone can tick a box to confirm that all concerned parties have been 'informed'.
The result of this scriptorial incontinence then gathers dust in practices groaning under the new malady of paper fatigue. The box is ticked, but the aim is missed.
The third method is, of course, electronic. This mode of communication offers many advantages, and has the potential to avoid most of the pitfalls. Anybody, anywhere, can contribute and distribute their opinions widely. The PCG can disseminate appropriate information. There can even be separate areas for 'hot' and 'cold' business.
Communication by electronic means does, however, raise a whole new set of questions:
- Are bulletin boards better than e-mail?
- Who should be connected?
- Can the system be policed, and if so by whom?
Bulletin boards are rather like cornershop windows: full of little cards advertising second-hand guitars and bunk beds. Comments appear piecemeal, and following a conversation is impossible.
E-mail is much better for extending a train of ideas that may be generated, but there is a fundamental problem: they are private. To include everybody in the conversation requires everyone-else to be 'copied in' each time a contribution is made. Inevitably, there are times when this process fails, making replies such as 'That's rubbish. Option two is clearly better' utterly nonsensical.
In North Devon we considered these problems carefully. We assessed the various options and found that our educational colleagues were beginning to network through a medium called CIX. This stands for Compulink Information eXchange, which is a commercial electronic conferencing service.
It works in a similar way to a bulletin board, but with a very real difference: within each topic in a conference there may be a number of conversations being conducted. Each contribution is tagged by means of a line showing to which message it is a reply. Each conversation therefore develops a number of 'threads' which can easily be followed (Figure 1, below). Suddenly, the corner-shop window is organised and easy to read.
|Figure 1: Screen shot from the Compulink Information eXchange (CIS) electronic conferencing service|
The advantages of CIX are enormous. Virtual conversations can be seen developing over days or weeks, with each contribution being depicted graphically in its appropriate place. This is an ideal medium for garnering opinion and distributing information.
The CIX software package is extremely easy to install. It is an off-line reader, so that the machine dials up the main server, extracts any additional contributions since it last logged on (or 'blinked'), and then drops the connection.
The operator is then free to compose replies or start new conversation strands at her/his leisure without the worry of excessive call charges. Once everything has been prepared off-line, another blink is launched before closing the system down. It is simplicity itself.
There are thousands of private users of CIX, and a bewildering array of conferences that one may join. The important point, however, is ownership. Each conference is run by a moderator. To become a moderator one simply installs a small add-on program that comes with the original disks.
This allows the creation of conferences from scratch. Thus I can create a new conference called 'North Devon PCG' and include all my family and friends. The point is that I decide who has access to the conference, I can throw people out, and I can delete inappropriate material.
The main drawback to the system is its slightly cumbersome file-handling capacity. Whole files can be posted onto a conference, although the downloading process is not the simple drag 'n' drop exercise one might hope for. Users must also actively seek out these files. In order to deliver them automatically they must by e-mailed to each user separately.
Despite the huge potential of the system, it was still necessary to convince the health authority of its merit. In North and East Devon we are fortunate in having an authority with the vision to appreciate the importance of communication.
As a result, money was set aside to pay for a pilot project to assess the use of CIX. We went for a 'nodular' approach in which each general practice was reimbursed for opening a CIX account (£7.25 per month for conferencing and unlimited e-mail boxes – note no internet access).
This was done on condition that all attached staff would have access to the dedicated machine upon which the software runs. In the first 6 months before April, this was paid for out of PCG set-up costs. For the year from April, the cost will be met by the PCG management budget as sanctioned by our PCG board and supportive chief officer.
The benefits of the system are obvious. The PCG can canvass opinion in a general way, or target specific individuals via e-mail. As the conference has evolved, separate discussion areas have been instituted for practice nurse, health visitor and practice manager matters, in addition to acting as a medium for our GP forum.
Many individuals have taken out their own CIX accounts, and have been included in the PCG conference, while the hospital's postgraduate department has made CIX accounts available on a pilot basis to many of our local consultants, who can also keep abreast of developments and contribute when appropriate.
At present, all practices are connected, in addition to more than 30 named individual GPs (including all LMC members) and 15 consultants. All PCG board members have individual accounts.
As a tangential benefit, clinical conferences are being set up – a sort of 'Dear Marge' column asked of our consultant colleagues with respect to tricky clinical problems.
After an initial flurry of activity, we have found that traffic has slowed. This is of benefit in itself, as people at the sharp end are now able to see that things are quiet because there is little happening, rather than because they are being frozen out by those who prowl the corridors of power.
As with any new idea, there have been grumbles from both ends of the distribution curve. E-luddites have complained that as information is disseminated on CIX, those who are less techno-aware are at a disadvantage. At the other end of the curve, certain digital zealots have complained that connecting CIX to a network is like pulling teeth. It has been achieved, but is a challenge.
The real drawback here is that true desktop access is difficult, though most practices are happy to continue with a dedicated machine that people can deliberately access if they want to see what is new with the PCG.
The main threat to this fertile process of intellectual cross-pollination could ironically be the NHSnet. It is not difficult to see the Government pulling the funding on any non-NHSnet pilots, and the NHSnet replacement offering is unlikely to be anywhere near as user-friendly. The vulnerability of recurring funding remains the principal cloud on the horizon.
The other potential menace to the pilot is domination of the discussion by a handful of verbose contributors with axes to grind. So far this has not happened, and the system's feature of self-moderated conferencing allows a clearly defined individual or individuals to act as chairperson and withdraw such traffic.
The CIX project has yet to be formally evaluated, but does offer PCGs an exciting method of communication at a fraction of the cost of less promising alternatives. Neighbouring PCGs have already voted with their feet, and launched pilots of their own.
With clinical governance, GMS shortfalls and chronic underfunding to address, the early years of PCGs could prove turbulent. Internal communication might just be the key to survival.
- Useful information
- Compulink Information eXchange (CIX) website: http://www.compulink.co.uk
- CIX administration: e-mail: email@example.com; telephone: 020 8255 5000.