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Small is beautiful

Fleetwood Community Commissioning Group is one of the smallest pathfinders in England and is being used by the Department of Health to test the viability of small commissioning groups nationally. Chair Dr Mark Spencer gives a progress report.

It may be a cliché, but I like to think that with just three practices and 25,000 patients, we really are ‘small but perfectly formed’.

We started off even smaller. My own Mount View Practice in Fleetwood with seven GPs has had delegated commissioning responsibility since 2004, and the commissioning group we have now basically evolved out of practice-based commissioning. We were joined by a second local practice in 2009 and a year later by a third.

It has been a natural progression to pathfinder status, and in spite of what people say about the NHS reforms being a revolution, for us it really has been more of an evolution to where we are now.

We feel we have done a good job so far and are on course to meet the April 2013 deadline – providing we know what hoops to jump through for authorisation. We think we can become a public body as we stand. The listening pause hasn’t affected our progress at all.

Being this small does have pros and cons. On the positive side, geographically, we are a natural community.

As commissioners, we already have great relationships with both the town and district councils.

There’s a strong community spirit, and community engagement is that much simpler on a small scale.

You really can communicate more effectively across a small community. You have all got a shared identity, which is really important.

The second major benefit has to do with clinical engagement. All of our GPs across the three practices – a total of 12 whole-time equivalents – know one another well and are used to working together.

And because of that, we can achieve real peer support so adherence to clinical pathways is much better. We meet every two months and peer-review our performance.

We feel we are all engaged in trying to drive up quality together.

The major challenge is that we cannot achieve the same economies of scale that larger commissioning groups have. So to tackle that we plan to federate with Blackpool clinical commissioning group, which has a population of about 150,000 and 22 practices.

This has pretty much the same footprint as its PCT – NHS Blackpool – with all its support structures, and we will work with it to pool resources when it comes to commissioning secondary care.


New governance arrangements

We are hoping that the plans for the clinical senate and the health and wellbeing board won’t slow us down.

We already have a local health and wellbeing board and there may be one operating at Lancashire County Council level, but it really would hamper progress if we had to run everything we do past Lancashire.

We’re not looking to do anything on a big scale in Fleetwood, so having to put everything through three levels would be a problem for us.

We are not thinking of the clinical senate as being another professional executive committee, although it will be multidisciplinary. We already have consultant input from outside – a well-respected cardiothoracic consultant.


Balancing the budget

Another big challenge is the same one the NHS is facing nationally – the financial pressures and the need to stay in budget.

It is especially tough because we have all been used to 8% growth year on year.

What compounds the problem for us here is that our area has high deprivation and lower than average life expectancy (see box above).

Part of what we’re doing is working hand in hand with public health initiatives. We’ve got a real long-term strategy to tackle health inequalities – but that requires considerable up-front funding. In terms of the financial situation we’ll inherit from the PCT, we don’t yet know what our budget will be. If it’s £20 a head, its £20 a head. It would just be nice to know.

However, on the plus side, we are low users of secondary care, and if we move to a fair-shares system for our per-capita allowance we will stand to get up to an extra £1m in funding.


External support

To start with, we won’t have to buy any external support in, but where we’ll be in two years’ time, I don’t know. We’ll get our support from the remnants of NHS North Lancashire – but they’ve already had a considerable drop in capacity.

At the moment, it looks like we will be able to stay small. So far, every discussion we’ve had has confirmed that. We’ve been to 10 Downing Street and had an audience with Prime Minister David Cameron and health secretary Andrew Lansley.

The message we are picking up seems to be that there is no real problem with size – as long as you produce the outcomes that your community wants.

Pathfinder: Fleetwood Community Commissioning Group

Wave: First

Practices: Mount View Practice, Broadway Medical Centre and the Belle Vue Surgery

Population: 25,000

PCT: NHS North Lancashire

Hospitals: Blackpool, Fylde and Wyre NHS Foundation Trust

Geography: Fleetwood is a seaside resort and formerly a major deep-sea fishing port in the Wyre district of Lancashire. It is located on the Fylde peninsula on the western side of the mouth of the River Wyre. It forms part of the Greater Blackpool Conurbation. Wyre is rated the 161st most deprived district in England out of 354.

Disease rates: Life expectancy in Wyre is 81 years for women and 76 years for men. The largest causes of mortality are: circulatory disease (coronary heart disease and stroke), 39%; cancers, 26%; respiratory disease, bronchitis and emphysema, 14%; and digestive disease, 5%. In males, a significant cause of premature death is digestive disease – including cirrhosis – of which alcohol is a leading risk factor. In women, digestive disease – including cirrhosis – and stroke are major causes of premature death.

Source: Public Health Profile of North Lancashire PCT. NHS North Lancashire