It feels pretty remarkable – as well as quite scary – to have been delegated budgets totalling £720m. The decision to delegate some 72% of the PCT's budget was taken in October last year following a assessment.
We now have a single CCG covering the whole city. Within that, we have kept four localities – north, west, central and Hallam and south central – as these were more or less how the previous PBC consortia were arranged. We also used to have four PCTs in Sheffield, which in 2006 merged into one.
We have kept the four localities within the CCG because we want to keep the local sensitivity and build on local clinical innovation and engagement. At the same time, covering the whole of the city brings economic and other advantages. Our 93 practices cover a population of 566,900 – but because we have two universities, that can increase by 100,000 during term time.
Another local consideration influencing size is our large acute provider. Sheffield Teaching Hospitals NHS Foundation Trust is one of the biggest in the country, and we wanted to make sure we as commissioners could have one, strong, contractual discussion with them.
Challenges
Our main challenge, as for everyone, is engaging practices. Sheffield practices are well engaged and there's been quite a lot of activity in that area. We want to take as many GPs with us as we can. We're probably ahead of the game on that compared with elsewhere, and have concentrated particularly on the relationship between the CCG and the localities. One thing that has helped in terms of engagement was a election for GPs on the CCG overseen by the LMC. So we have got that mandate.
Another big challenge is the financial one, and we need to keep on top of that. Handling the £720m budget is new territory for us – especially for GPs. It's a big responsibility that we're slowly coming to terms with. We're getting more used to regular financial reports, for one thing. But it does feel as if we're at the bottom of a very steep learning curve. We've had a £5m recovery plan built in for 2011/12 and are on track to deliver that on top of our QIPP plan. We achieved it partly by making improvements in how we handle unscheduled care – we set up a GP assessment centre for acute admissions, which has had some impact, and we've moved more treatments for diabetes and musculoskeletal conditions, for example, into our community services.
In Sheffield, we had a recurrent deficit of £36m in the four PCTs at the start of the single PCT merger and it's been a struggle getting on top of that. To some extent we have been diverted by the financial agenda, but now we can see our way to getting onto the transformational work we want to do.
Long-term conditions
We've already launched a series of projects called ‘right first time' for patients in the community with long-term – or sometimes several long-term – conditions. The first project deals with how we manage those patients; the second, what to do when their needs escalate; thirdly, trying to improve the patient's journey through hospital; and fourthly, how people get discharged home again with an appropriate care package. This involves not just GPs, but secondary care and social care providers too.
This has been launched across the city and we've got project managers in place. We envisage it will run for at least two years, and we hope to see the unscheduled care services in Sheffield transformed. It will improve the patient experience and would make the landscape quite different.
‘Right first time' signifies that we want to get the right level of care to the patient at the right time, in the right place. In some ways, it could be seen as the beginning of an integrated care model. It could morph into that and get away from the silo mentality. In the past, tensions have arisen from the gaps between services or the interfaces between organisational responsibilities.
Transition
The transition from PCT to CCG continues. We ran a voluntary redundancy scheme this year as part of delivering our running cost target and lost some staff – around 26 – across a range of services.
In terms of authorisation, the SHA risk assessment has rated us green. There's a great sense of optimism around the authorisation process, although we're not yet entirely sure of the logistics around it. In the next phase we'll need a robust constitution, among other things.
On commissioning support, we attended a meeting with the CCG cluster and decided we wanted a commissioning support organisation within the footprint of the cluster, which equates to around 1.4 million population. We wanted appropriate services for each CCG – Sheffield CCG has around 550,000 population, the smallest locality covers around 100,000 and the two others are around the 230,000-240,000 mark, so we don't want a one-size-fits-all approach. It will be a combination of old and new – some of the staff will be from the PCT, but we're not going for a private-sector solution. We need the support to be economically viable, but locally adaptable and built on the strong commissioning support we had as a PCT.
It's hard to say where we want to be in three years' time. Our vision clearly sets out our ambitions to improve primary care services and further reduce health inequalities in the city. In three years, if we're running services supported by the public and we're making a financial dividend to put into more preventative services, that will be a success. We need to get away from crisis management and concentrate more on preventative care.
We'll also see an increase in the significance of the relationships between individual CCGs. That's something we have to get to grips with quickly. There's also the relationship with the emerging clinical senates to consider.
And CCGs have got other relationships to build. We've got our first shadow health and wellbeing board meeting this week.
The relationship looks very promising, but we haven't started discussing policies yet. CCGs are also going to have to meet MPs and a whole variety of other people, and we're going to have to develop a relationship with patient representative bodies.
Pathfinder: Sheffield Clinical Commissioning Group
Wave: First
Practices: 93
Population 550,000
PCT: NHS Sheffield
Hospitals: Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield Children's NHS Foundation Trust and Sheffield Health and Social Care NHS Foundation Trust
Demographics: The CCG covers the city of Sheffield, which has a higher than average score for the index of deprivation (2010). It has a higher proportion of patients in the 20-24 age group than the rest of the region, because of its large student population.
Disease rates: The proportion of people considering themselves to be in good health is higher than the average for the region. Prevalence of obesity, CHD and cancer are significantly lower. Prevalence of diabetes and stroke is higher.
