A frequent refrain is “we mustn’t recreate PCTs.” Increasingly, when I hear or see it said I want to ask five why’s. 
Let me give you an example. 
“We don’t want to recreate PCTs.”
Why? 
“Because they were bureaucratic.”
Why?
“Because they made people jump through loads of hoops to get anything done.”
Why?
“Because of the regulations and law they had to abide by.”
Why?
“To ensure there was openness and transparency in the way they did business and to avoid conflicts of interest.”
Why?
“Because otherwise you have the potential for the misuse of public funds and suspicion that people are doing things for their own personal interest rather than for the public good.”

The problem is that when people talk about “recreating PCTs” it seems to me they are talking about problems of governance and decision making which create a particular culture and behaviour. PCTs might be abolished but the problems remain. If we are to really reform the nature of commissioning in the NHS then perhaps we need to think harder about these issues and how to address them?

The governance of PCTs has, in the main, disempowered and disenfranchised clinicians from real engagement and leadership in commissioning. The culture of the NHS has been centripetal – the central pull has been strong and constant for a decade. Management accountability has been upwards and, nominally, to boards but in reality “the centre.”

How can that be changed? Perhaps what we need to do is understand that dealing with conflicts of interest by excluding clinicians from real engagement and leadership in commissioning also absolves them from any responsibility for the effective management of resources and that is no longer tenable. Instead of using a form of governance by exclusion we need to embrace conflict of interest as a necessity in a system as complex and difficult to manage as healthcare. That doesn’t mean abandoning governance but learning how to deal with it by inclusion and not exclusion.

I also believe we need to change the incentives and accountability within the management system to create a centrifugal pull so that the focus is as much towards supporting frontline clinicians, patients, and local communities, as it is the centre. Imagine if the very senior management performance assessment was based on a 360 degree assessment of impact across the system rather than, as it is now, hierarchical and based mostly on financial performance?

As ever, I remain optimistic that the reforms have the potential to permit the emergence of inclusive governance and management structures that support widespread professional engagement and leadership of commissioning. It will be for the CCGs to actively ensure that they understand what were the rules, regulations, and incentives that excluded clinicians from commissioning and create a new, enabling framework – and the centre needs to help.

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.