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On the verge of a merge

Newham Commissioning Group is about to merge with another CCG to become borough-wide. Dr Hardip Nandra explains how.

http://www.pulsetoday.co.uk/practical-commissioningl

Newham Commissioning Group (NCG) is small, with 11 practices covering a population of 70,000. We only cover part of the borough of Newham – the rest is covered by the much larger Newham Health Partnership (NHP).

We were hoping the two groups could exist in their present form and work in a federation across Newham. But recent discussions have shown that because of issues around governance and financial risk, the decision-making process would need to be carried out as a Newham-wide body. The two groups are about to merge to cover 66 practices – a population of around 250,000 – and we're still working out the structure. We are seeking authorisation to have shadow status from April and full responsibility from 2013.

NCG's strength as a clinical commissioning group is that, because we're small, we can work together easily and agree pathways more readily. The driving force for us is the question: at the end of the year, can we point to improved patient care due to structural change in its delivery? We feel it is important to keep sight of our original aims. We don't get up in the morning to spend more time on governance – we do it to make a difference to our patients.

Our vision

As a smaller group our focus is on clinical pathways. Because we are more focused we can support our practices not just in the areas of primary care indicators, prescribing and so on, but also with clinical pathway development. A cardiology pathway has been agreed and we're working with the providers to implement it.

We're also looking at COPD and diabetes and will be working closely with the community health services, who have a virtual ward pilot in the community as a step-up or step-down facility. Once we've merged, clinical pathways will still be our focus – we are keen to maintain ourselves as a group with that vision within the larger CCG.

NHP, which is much larger, has broken itself down into about seven clusters of five or six practices who will each elect one GP to the board. NCG will make up another of the clusters, but will elect two GPs to the board.

Commissioning support

In terms of commissioning support, we are using Commissioning Support Services (CSS). We would like to be able to use some of the money this costs to get support from outside CSS for things such as prescribing and data, but it's not clear at the moment whether we are allowed to do that – we'd like the data we get from CSS to be turned into useful information about activity at practice level, and they can't do that. As well as CSS, both groups have directly employed some ex-PCT staff.

Newham is a deprived borough, with some pockets of affluence around the Docklands, a high rate of unemployment and a range of ethnic groups. One of our biggest issues is that Newham is used as a staging post – people arrive and then move on. We see a lot of illness, late presentation for maternity and high levels of TB and HIV as well as the usual health issues.

As people don't stay long, it creates a large workload for the GP practices – by the time patients have been assessed and care agreed, they've moved away. It's an administrative challenge as well as a medical one, and means we have low achievement on indicators such as immunisations and cervical screening.

Acute provision

In terms of acute provision, we have Newham General Hospital. We have about £127m worth of activity with the Newham Hospital Trust, and we provide about 97% of their total turnover. They are in financial difficulties at the moment and a merger with two other hospitals is being discussed, which would create the largest trust in the country. GPs locally are not very happy with the idea of the merger. There would not be any competition and patients would not have any choice of provider.

For the whole of Newham, the budget is some £550m and we have to make savings of about £13m. We have been told we can't take any more money out of Newham General Hospital because of the risk of it going bankrupt. It's going to be a difficult balancing act.

Health and wellbeing boards

We have a very good working relationship with the borough of Newham and the mayor.

Historically, the PCT and borough have worked very closely together and we've carried on with that. We have a shadow health and wellbeing board and that's being firmed up. We are still trying to get guidance about clinical senates.

Once we have merged we are determined to keep the focus on clinical pathways and firm evidence of improvement in the delivery of care to patients, but the amount of paperwork and form filling involved in commissioning is increasing so rapidly I am worried that in a year's time the CCG will just be a PCT by another name.

Dr Hardip Nandra is chair of Newham Commissioning Group, London.

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