We're probably unique in England in that we're composed of practices from two PCTs – Sandwell and Heart of Birmingham – but the boundary is quite arbitrary in a way and there's a lot of common ground between the GPs.
Most of the practices have traditionally worked together and have been of one mind about GP commissioning since the days of PBC. We're also all focused around the same acute trust – Sandwell and West Birmingham Hospitals. The majority of our patients go there. But as things stand, we're across council boundaries too, which makes things more complicated and interesting.
Another element of uncertainty is added by the fact that we're expecting a new hospital development. It was due in 2011, but now looks more likely for 2015 – and will have fewer beds than the present one.
To add to the challenges, we're in quite a deprived area with a high incidence of diabetes and a high multi-ethnic population. The PCTs have similar Joint Strategic Needs Assessments. To illustrate the complexity of the area, a piece of work we did recently showed that a total of 33 languages are spoken in Smethwick, just one of the towns in our patch.
Beginnings
HealthWorks emerged about a year ago when two PBC clusters came together. We are now one of five clinical commissioning groups (CCGs) in the Heart of Birmingham and there are two further CCGs in Sandwell. Rather than incur the expense of a new legal framework while the final shape of the health reforms are being decided, we set up as a ‘joint venture' as a pragmatic interim solution.
One of our priorities is to ensure all practices have an equal voice in the development of local service provision, so we set up a voting system based on proportional representation for the board, which was elected in July. Our chair is Dr Nick Harding, a GP who practises in Handsworth Wood, and vice-chair is Dr Niti Pall, a GP in Smethwick.
We've kept our working structure as lean as possible and have eight work streams:
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finance and performance
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audit
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quality in general practice
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medicines management
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community services
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planned care
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unplanned care
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population health management.
One of the great advantages of spanning two PCTs is that we've got a great group of clinicians who really can work together. But it can be a nightmare from my point of view making things work across the administrative divide.
However, this is overcome by having
two managerial leads from the two PCTs and meeting regularly with the chair and vice-chair.
Authorisation
NHS West Midlands have asked us to do a risk assessment, so we've already embarked upon that. We're looking towards federation in order to achieve authorisation.
We will definitely federate with the 30-practice Intelligent Commissioning Federation based in the Aston, Ladywood and Sparkbrook areas of Birmingham, and with the 10-practice Pioneers 4 Health, and go for authorisation together with them.
Two further CCGs may join with us from Sandwell – Sandwell Health Alliance and Black Country GP Commissioning. We're already looking at the economies of scale we'll be able to achieve through federation.
The five-CCG federation could involve around 100 practices and up to 500,000 patients. The three-CCG federation would involve 40 to 50 practices and around 270,000 patients. So we're having to think through working at several different levels.
Our commissioning support will be through PCT clusters. We haven't got as far as an accountable officer. That, and other organisational questions, will probably be answered at federation stage and be in abeyance until then.
Priorities
In terms of finances, with the health economy shrinking we're already looking at ways to save at practice level. We've just set up a referral management scheme, and with practices we're looking at using the shadow period to get things on an even keel for 2013.
A big piece of Department of Health-funded work we've just completed was around end-of-life care. We've taken a person-centred approach, and with the help of the consultancy Experience Led Commissioning we've redesigned the service through patient, public and front-line clinician involvement. We're now ready to work with providers to look at ways we will contract for and measure the quality of end-of-life care.
At the last meeting, we had 60 people including patients. We're going to move on to use a similar approach to tackle long-term conditions and urgent care.
Challenges
Obviously the key challenge for us is how to pull all this together. I think we'll feel a success in three years' time if the practices feel engaged, we've redesigned our care pathways to make them more patient-friendly and we're in budget – general elections permitting.
Lloyd Brackstone is lead manager of HealthWorks CCG assigned from NHS Sandwell
Pathfinder: HealthWorks CCG
Wave Third
Practices 23
Population 142,000
PCTs NHS Sandwell and NHS Heart of Birmingham
Hospital Sandwell and West Birmingham Hospitals
Demographics HealthWorks includes practices from NHS Sandwell (Smethwick, Oldbury, Wednesbury, West Bromwich, Rowley and Great Barr) and NHS Heart of Birmingham Teaching (Aston, Handsworth Wood, Handsworth, Soho and Lozells).
The health of people and rates of deprivation in Sandwell are generally worse than the England average. In Heart of Birmingham, around two-thirds of residents live in neighbourhoods classified as among the most deprived (worst 20%) in the country. There has been little improvement since 2004.
Disease rates In Sandwell, death rates for cancers, all circulatory diseases, diabetes and respiratory disease are higher than the national average. It's a similar picture in the Heart of Birmingham.
While life expectancy has improved in the last decade, it remains short compared with the rest of England. Infant deaths and premature deaths from heart disease, diabetes, stroke and cancer, are the main causes of life years lost and low life expectancy.
