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The primary care White Paper, 'Our Health, Our Care, Our Say', made much of shifting the emphasis from hospital to a community-based delivery of care.

The government set a target of moving 5 per cent of NHS work from secondary into primary care over the next 10 years.

Two years ago, Birmingham and the Black Country SHA decided to follow a similar route.

It wanted to reduce emergency admissions and buoy primary care. All 12 PCTs aimed to move 2 per cent of funding from secondary care to primary care each year.

While not every PCT met the aim, all tried. It enabled the SHA to put in place new ways of shifting work from the acute sector into general practice. One area was the management of long-term conditions.

Across the SHA, a risk-profiling exercise identified which patients were likely to be high users of services.

The initiative was originally based on PCTs tracking information that has been collected from the acute sector, but it has now expanded into general practice.

Comprehensive data

Paul Maubach, programme director for long-term conditions at the SHA, said this would make risk profiling comprehensive.

'We have a reactive system at the moment,' he said. 'GPs need something like this to manage risk in a systematic process.'

The information from GP is based on the quality framework so the information can be collected without any effort from participating practices.

GP data is amalgamated with details from secondary care and then patterns analysed to predict the likelihood of a patient needing particular care.

It is then returned to GPs in three-monthly tranches.

Professional executive committee chairman for Dudley Beacon and Castle PCT Dr Steve Cartwright said that some GPs were worried about patient confidentiality, especially because United Health Europe was analysing the data. But these fears were unfounded, said the Dudley GP.

'The data is anonymous at the point where risk is worked out. When the risk information is sent back to the practice, they will know which patient it is for, but they will be the only ones,' he said.

Identifying patients at risk will allow GPs to act to prevent the need for more serious interventions. It may be there are issues of non-compliance with patients' treatment or extra input needed from district nurses.

Patients at high risk can be part of a scheme such as the case management programme. Patients are supported and advised by case managers who are employed by the PCT but work across groups of GP surgeries.

The thrust of the long-term conditions programmes is to empower patients.

There is investment in expert patient programmes, as well as an initiative called Birmingham Own Health.

Mr Maubach described the project as 'a halfway house between case management and the expert patient programme'.

Those involved are likely to have lower risk than patients on the case management scheme, but a higher level than those on the expert patient programme. It means 200 patients can be supported compared with 50 for case managers. Mr Maubach said the work had helped SHA planning.

'The pressure in secondary care was as a consequence of insufficient primary care,' he said.

'We put much effort into population analysis and how the public used services. Services were not correctly balanced.'

The SHA's findings were considered alongside public feedback against centralisation of healthcare and the backing of more services closer to home.

Robust evaluation

Another essential element was robust evaluation because so much of the work undertaken had been new. The SHA has embarked on an analysis of this with Health Services Management Centre (HSMC) at the University of Birmingham.

'We would like to disinvest if it is not providing better care. All the information that you can gather can only improve patient care,' said Dr Cartwright.

'Where GPs will make a difference is by keeping people out of hospital and giving them the right care at the right time, so they will have to target appropriately.'