pct spotlight: What is it like trying to set up one of the biggest PCTs in the country? In the last of our four-part series on those spearheading the shift to a primary care-led NHS, Ann McGauran finds out how Birmingham is faring

Published: 09/05/2002, Volume II2, No. 5804 Page 14

Born just six weeks ago, South Birmingham primary care trust is reckoned to be the biggest of its kind in England. But what is it like setting up such a large new organisation in the absence of most of the key directors, and with a staff who have every right to be rearrangement-weary?

The trust's newly appointed director of performance development, Viv Tsesmelis, is not a fan of modern NHS mantras. 'I have promised myself I am not going to use the expression 'We are up for the job', ' she says. Yet she remains a confident and cheery soul. In many ways, the bringing together of three separate organisations, including a specialist community trust, has been seamless due to some good project team work.

She says many staff are reluctant to go through change, but 'if you give people some examples of how we are starting to see improvements by belonging to the same trust, they begin to see real benefits'.

NHS staff in Birmingham, with a scepticism borne of endless rounds of structural musical chairs, will need those advantages spelled out explicitly. The city's original 12 primary care groups were reduced to five trusts, along with a number of community trust mergers. South Birmingham PCT is formed from three organisations - Birmingham South East and Birmingham South West PCGs - plus most of the former Birmingham Specialist Community trust's functions.

As a big commissioner and provider, opportunities for developing care pathways are excellent, says Ms Tsesmelis. The trust is responsible for rehabilitation services for all of the West Midlands, a dental hospital and city-wide learning disability and community paediatric services.That adds up to a staff of almost 4,000, serving a diverse population of 376,000.

South Birmingham grew out of a stack of villages where fairly deprived terraces now back onto large detached homes.

What headaches have characterised the start-up? In terms of the financial cost of the change and trying not to confuse the public or relocate staff, it seems to have been successful so far: 'We have not changed our phone numbers and we changed some of the functions. But we have not had a mass move around of people, because we operate out of 150 sites.'

She adds: 'We have a headquarters in the old community trust building right in the middle of the patch, where the chair, chief executive and the directors will be based. The chief executive, Cynthia Bower, has been in post a few months and the chair has been in place a month.'

Easter was spent changing signs outside the many health centres telling people which organisation is now responsible for the premises. The project board set up last summer to include representatives from the three organisations made the process easier. In addition, 'all of the boards and nonexecutives came together for two away days and talked about the sort of organisation we wanted to develop'. The result, she says, is that getting off the ground is 'genuinely less troublesome for us'.

Ms Tsesmelis's involvement in Birmingham goes back to fundholding days. For the past year she had been performance director at the specialist community trust, preceded by two years as primary care group manager at Birmingham health authority.Her new job is 'helping the clinicians to find more effective ways of providing services' and involves liaison with the Modernisation Agency.

What is bothering staff in these early days? There is still the little matter of the missing directors of commissioning, primary care and public health. 'Though We have slotted people into posts, they do not know who they will be working for. It doesn't stop them doing their jobs, but it does make them feel less comfortable. The worst thing is fear of the unknown. We need now to properly unite the cultures of the old organisations, and we will not start to see the vision developing until the directors are in place.' She adds diplomatically: 'Morale is not at an all-time low compared to last summer... but even if staff have been transferred under TUPE [employment regulations] they do not feel secure.' Noone can tell them that until everyone is in post. 'People are saying it ought to be sorted by now.'

Some staff seem to be assuming wrongly that existing systems are changing. 'For the first month, staff were concerned about whether they would get paid.'

Otherwise It is minor details. 'A couple of nurses did not know where they could get prescribing pads from. Their answer is they get them from exactly the same place they did before.'

There may be clouds on the horizon.One clinician says that in the local acute provider, University Hospital Birmingham trust, 'we have an enormous private finance initiative threatening to swallow all our development funds over the next 15 years and many challenges lie ahead'.

But Ms Tsesmelis is a natural optimist and says the acute trust's chief executive, Mark Britnell, has promised a properly shared planning approach. She is convinced that the new PCT's commissioning people are experienced enough to go it alone, and her organisation's size will prove a great strength.'You can't have a huge acute provider and a small community provider.

You need a voice That is heard.'