Turning round NHS deficits

Editor—Ham believes that the turnaround teams from the private sector will find it difficult to deal with NHS deficits.¹ The solution he describes entails reducing spare capacity, increasing performance, and fully engaging clinicians. These measures, aspects of the failure regime for hospitals,² have some chance of success in provider organisations. The position for primary care trusts (PCTs) in deficit is even more difficult and likely to be even more alien to the expertise of those now being bought in from the private sector as recovery teams.

Primary care trusts are largely commissioning organisations and do not have direct levers to reduce acute capacity, even when it is recognised not to be affordable. Directly provided services form only a small proportion of their spend and are needed to help reduce hospital activity. Were local hospitals to increase their efficiency—say, by reducing length of stay—this would exacerbate the problem for primary care trusts, unless those freed-up beds were closed rather than used to suck in more income underpayment by results. General practitioners are the clinicians who most need to be engaged by primary care trusts, but they cherish their independent status. It takes exceptional leadership to persuade them to act outside their direct interests in demand management, in advance of any of the benefits promised for them from practice based commissioning.

There is little infrastructure in primary care trusts to downsize. Deficits of the size now seen in some trusts would be dealt with by bankruptcy in the private sector or increased long term borrowing, neither of which is available to the trust. Many chief executives believe that the current difficult financial situation is generated by government policies, rather than local incompetence.³ In these circumstances, private sector recovery teams have an exceptional and perhaps impossible task before them,³ especially in primary care trusts.