A year ago, I wrote to the Secretary of State for Health expressing my concern about proposals for the amalgamation of the Selly Oak Primary Care Group covering most of my constituency with the neighbouring Hall Green organisation to form the South East Birmingham PCG. This was part of a move to create seven larger groups (to include two that had opted for Primary Care Trust status) and for the ultimate designation of all of them as Primary Care Trusts. I felt that the reorganisation would damage the close relationships that were being developed between the Selly Oak PCG, elected representatives and the local community and that the Trusts would be too large to enable the boards to have meaningful relationships with GPs and other health professionals. I provided evidence that this view was shared by many GPs in the area I represent. I urged caution about, in effect, reverting back to the unsatisfactory system that existed in the Eighties when there were five health authorities in Birmingham responsible for the main hospitals. These bodies were too large to develop close grass roots relationships but were fragmented in terms of an overview of City-wide needs and good working arrangements with Birmingham City Council. After years of financial problems, the eventual creation of one Birmingham Health Authority resulted in the Health Service being run much more efficiently (though with the usual problems coming from inadequate funding). Around the same time, GPs unhappy with the bureaucracy and inequity arising from GP Fundholding were working together in commissioning groups to develop best practice and to place greater emphasis on the prevention of ill-health rather than just treating it.

In his reply, the Secretary of State informed me that Birmingham Health Authority and the 12 PCGs have agreed that 5 PCTs are likely to be established in Birmingham provided that a strong locality focus could be ensured within each one. He added that larger PCTs elsewhere have incorporated a locality substructure to ensure local focus is preserved whilst retaining expertise within the organization (indeed, the Chair of Birmingham Health Authority informed me that savings from the merger of PCGs would be used to enhance locality focus within new organizations). It was suggested that I contact the Regional Office of the NHS Executive West Midlands with the information I had obtained from local GPs. This I did and, in April of this year, I received a response from the primary care lead for the West Midlands, Vanessa Barrett, informing me that the recent reduction from 12 PCGs to 5 PCGs and two PCTs will make further boundary changes less likely.

Reluctantly, I accepted the proposals would go ahead and hoped they would work. I was therefore surprised to be alerted by a GP member of the SE Birmingham PCG to yet more change involving the establishment of only four primary care trusts in Birmingham, which ended up as the subject of the current consultation. Already concerned that the size of the amalgamated Selly Oak and and Hall Green organisation, would make it too remote, my anxiety grew at the prospect of my constituency being covered by an organisation double in size again. My initial reaction was to argue for the retention of at least seven primary care organizations, after all hadn’t Ms Barrett herself advised me that further change was unlikely and that it would be important to learn from the experiences of the first two PCTs in Birmingham! However, after studying the consultation document with its proposal for a Birmingham-wide Primary Care Agency to co-ordinate PCTs and provide central services as well as engaging in discussions at a number of meetings during which emphasis was given to the potential for locality structures to involve GPs, other health workers and local communities, logic draws me to the conclusion that there should now be one Primary Care Trust serving all Birmingham.

The Proposals

The consultation puts forward options for one, two, three, four or five PCTs covering Birmingham. A larger number is rejected on the grounds of the costs associated with numerous management structures. Indeed, this is the reasoning behind the changes that have occurred so far. On the other hand, the creation of one primary care trust for the whole of Birmingham is rejected because more local configurations allow for a greater awareness of local circumstances and the ability to take these into account in decision-making. This might have some merit if it were not for the fact that the favoured option can hardly be considered to create local organisations, particularly for South Birmingham.

It is proposed to set up four PCTs as listed below, covering the populations indicated:

North Birmingham 165,000

Eastern Birmingham 261,000
Heart of Birmingham 310,000
South Birmingham 376,000

This structure is favoured on the basis that it would enable the continuation of existing quadrant-based services, ie those centred around the four acute hospital trusts.

This option also proposes the dissolution of the Birmingham Specialist Community Trust.

Community nursing and health visiting services will transfer to PCTs but the location of specialist services seems problematical.

These services were brought together for the first time in April 2000, when the two Community Trusts covering North and South Birmingham were amalgamated. Now it is to be all change again, much to the concern of many staff.

Only recently, in its Corporate Strategy for 2001-6, Birmingham Specialist Community Trust set out its "vision" making the point that:

"There are strong arguments for (other) services to continue to be managed on a City-wide basis within the Trust".

This is clearly not possible if the Trust is to be abolished. Instead, the proposal is to share out the functions between the four PCTs, with the lions share going to South to operate on a City-wide basis.

For the time being Mental Health Services would remain with the two Mental Health Trusts but with the intention of transferring the services to a City-wide Care Trust next year.

Commentary

The proposed PCT structure creates bodies that are not small enough to enable genuine grassroots participation, particularly in South Birmingham where the proposals have been overwhelmingly rejected in the GP ballot (60.31% against on a 55.75% turnout). GPs who started out enthusiastic for the new structures are telling me that they feel that they have no influence on the larger organizations now developing. It is not surprising that most enthusiasm comes from GPs in the North where a PCT of much more manageable size is proposed and 85.48% of GPs are in support. Overall, however only 47% of GPs on a 55% turnout support the favoured structure. This is hardly a ringing endorsement given that there was no opportunity to vote for alternative structures, nor any common knowledge that, already, consideration is being given to the amalgamation of Good Hope Hospital (in the North sector) and Heartlands Hospital (in East) no doubt creating pressure, in the not too distant future, for a structure involving three Birmingham PCTs. If this goes ahead, I would submit that the support of even the most enthusiastic might wane.

The proposed structure does not work well for services that are to remain or develop at a City level. It will be difficult to work out who is responsible for what, as PCTs take on both sector and City-wide functions. South Birmingham, already the largest and more remote organization, is set to take on most of the City-wide services only recently amalgamated under the Community Trust thereby confirming it as the big brother of the PCTs. On the other hand mental health services currently provided by two trusts and Birmingham City Council Social Services are to be brought together in one City-wide Care Trust.

There seems to be no coherence in these proposals. The large size of three, if not all four of the PCTs in the favoured option will still require the development of the "significant substructure of locality arrangements" that is seen to be a major disadvantage to the option of one Birmingham PCT. For example, it has been suggested that up to 10 locality organizations would be needed for South Birmingham PCT. At the same time, the favoured option will not have the advantages that a Birmingham-wide PCT would have in supporting cross-City partnerships with mental health services, Birmingham City Council (especially social services) and voluntary organizations. Such an arrangement would also do away with the need for the Birmingham-wide Primary Care Agency.

Furthermore, the consultation document fails to take account of proposals by Birmingham City Council to develop neighbourhood-centred service delivery through the building of sub-City partnerships to which budgets and management of key local services would be devolved (Birmingham Constitutional Convention, Framework Document). I very much support this approach which is similar in concept to that of the health service ‘locality focus’.

Finally, the question has to be asked, will the proposed structure last? Heath service workers yearn for stability. I predict that if the proposal for four primary care trusts goes ahead, cost pressures in the future will eventually lead to their amalgamation into one body (possibly through the transition into three mentioned above). This unnecessary disruption could be avoided by accepting the inevitability of one organization now. I know there will be reluctance on the part of ministers to accept that any new body should take on the same boundaries as those left behind by the abolished health authority but they should not let political dogma overcome common sense. People in Birmingham identify with their City and with their local neighbourhood. To achieve the aims laid down in the consultation document, it would be best to set up structures that mirror this reality.

Conclusion