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 hadnt 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 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
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
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
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.
There should be one primary care trust covering all Birmingham within which as much
devolution of decision-making as possible goes to neighbourhoods (localities).