on location Greater Manchester

Published: 01/04/2004, Volume II4, No. 5899 Page 14 15

When John Reid became health secretary, the statistic that most alarmed him was the huge gulf in life expectancy between a boy born in Manchester and one born in Dorset. Mr Reid's determination to tackle the inequalities rooted in 'an accident of birth' is matched in Manchester by an awareness that public health is the biggest single challenge facing the city.

For example, almost one-third of the city's 214 electoral wards are among the 10 per cent of the country's most deprived.

But according to some senior health service managers, the city has one advantage on its side. Its compact layout (2.5 million population within 500 square miles) has allowed it to develop genuinely collaborative working to deliver health improvements.And it seems to be working.

Naturally, Greater Manchester strategic health authority chief executive Neil Goodwin cites high treatment rates as a key issue for the local health economy. But he says progress on waiting times is pleasing to the point where trusts are 'on track' to meet the latest targets (see '5 questions', below).

Director of performance Mandy Wefarne says the SHA did not think it had 'a cat in hell's chance' of achieving such objectives when it was set up two years ago.

For example, there were 6,510 patients awaiting elective admission for more than nine months in March 2002. There were 1,048 in January this year. And it is anticipated that there will be more at the beginning of this month.

The SHA's approach to boosting service provision has put it at the vanguard of the nationwide push to shift the balance of power from secondary to primary and intermediate care.

It has developed a 'tier-two' project, aimed at directing GP referrals to services outside secondary care, as well as the centralisation of booking and choice projects.

Although other parts of the country have attempted to replicate the goals of the tier-two concept, Ms Wearne says: 'We were the first SHA to have a structured programme to actually do something about shifting secondary care into primary care.'

The 54 projects - and rising - stretch across the local health economy, which comprises 14 primary care trusts, nine acute trusts, one trust due to achieve foundation status on 1 April, three mental health trusts and an ambulance trust. Investment in tier-two projects across the SHA planned from 2003-06 is due to total£17m.

It is early days for comprehensive results and analysis, suggests Mr Goodwin. However, the SHA did manage to reach its own 200304 year-end target of shifting more than 17,000 referrals into tier-two services by the beginning of December, says Kieran McGowan, performance manager at the SHA.

At the end of February, the number of referrals in the SHA resulting in secondary care appointments was down by 1.53 per cent on the previous 12 months.

Orthopaedics has been targeted because of exceptional backlogs and most PCTs have seen a fall in hospital activity since benefiting from alternative methods of treatment such as physiotherapy.

Decisions on substitute treatments are made through a referral, booking and management service.

Initially, says Ms Wearne, 'we had lots of people who had been referred wrongly, so we knew we were on to a winner'.

While GPs' referral practices will now be developed through targeted programmes, it was felt the 'maximum' and fastest impact would be made through central referral control. Consultant to consultant and out-of-area referrals are also to be targeted.

At the same time, the SHA is at the forefront of health service redesign, with the creation of the Association of Greater Manchester PCTs. It will build on work already carried out on joint commissioning across PCTs.

Oldham PCT chief executive Gail Richards explains: 'We'll have formally delegated authority to make certain decisions on behalf of the 14 PCTs and that predominantly relates to specialist commissioning.

'But more recently, We have looked at joint responses to things like development of the private finance initiative in central Manchester and the way we take forward the GP general medical services contract. Most of the work is done through the PCT chief executives, who meet monthly.'

A tangible result of the SHA's attempt to shift work away from the acute sector is the scaleddown version of Central Manchester and Manchester Children's University Hospitals trust PFI 'superhospital'.

The proposals are out to consultation with health organisations after what Ms Richards describes as last summer's 'rather difficult process of negotiation to see if we could shift some of the balance back into a community setting'.

But using capital schemes to move services into primary care is key to the new vision in Manchester, supported by SHA managers and pioneered particularly in Salford.

The SHIFT project - Salford Health Investment for Tomorrow - incorporates a PFI project at Hope Hospital, but also a primary care walk-in centre. Elsewhere intermediate care will be stepped up and new health and social care centres will provide anything from immediate GP services and housing and benefits information to schools information and job centres.

NHS local improvement finance trust projects are also being used to improve intermediate and primary care. Oldham PCT is developing an integrated care centre 'slap bang in the town centre' that will include an out-of-hours care centre, round-the-clock drug and alcohol help, and Salford PCT is considering offering 'shares' in its LIFT projects to local people.

Emergency care is also benefiting from the SHA-wide co-ordination by building on expertise developed by Greater Manchester Ambulance Service trust.

Twenty-three new emergency care practitioners, who graduate this year, are expected to support an emergency tier-two project where they will help ambulance crews refer patients to services other than accident and emergency departments.

Pressure is already being eased through a health control centre, which uses electronic information updated every few hours to divert ambulances from hospitals on 'red status'.

Despite this 'hands on' method of improving services and waiting times, Ms Wearne laughs at suggestions that the SHA has acted like a 'government'.

'We definitely knew that we had to add value, otherwise we would have been out on our ears.'