According to the Kübler-Ross model there are five stages of grief – denial, anger, bargaining, depression and acceptance. Elizabeth Kübler-Ross said her model described the stages people go through when dealing with grief and tragedy, particularly the death of a loved one or the diagnosis of a terminal illness. But it could be applied to a potential loss of employment. At the HFMA primary care trust annual finance conference in Birmingham last week, delegates displayed most of the stages when asked how they were feeling about their future job prospects.

With the government set on paring down PCTs’ responsibilities to little more than public health and some residual commissioning, most had gone through denial and accepted change was going to happen. There was a little anger – but more at the contempt shown to finance staff and administrators in general (as well as a belief in their disposability) – but no bargaining. It was pointless, as no-one believed the government could be swayed from its path.

There was some mild depression, but perhaps more accurately described as anxiety about the future fuelled by uncertainty. All may be revealed in the white paper (more of which later), but then again it’s unlikely to go into details about numbers of finance staff, grade and skill mix, so it is probable a whole new set of questions will be generated once the white paper is published.

The final stage is acceptance, which many at the PCT conference had already reached. Of course, some had got there in double-quick time by looking dispassionately at the government’s plans for commissioning. But the tougher management cost reduction targets – which soar to more than 50% over four years for some PCTs – have clearly made the threat of job losses much more real within finance departments and other support functions.

Of course finance will have to make its contribution to this, although it is not completely clear where the savings will come from. At the transactional level, many efficiencies have already been driven out either by outsourcing to a provider such as NHS Shared Business Services or through local shared services arrangements. There is likely to be more mergers of other financial activities and wider support services (even if PCTs themselves stay separate).

Many of the finance managers at the PCT conference seemed level headed about the changes. PCTs have been here before – okay perhaps without such extreme external pressures. But many will be reasoning that primary care commissioning bodies, whether they are multi-funds, consortia or PCTs, will always need financial facilitators and financial support. One delegate acted as spokesman for those with a positive outlook when he urged PCT finance staff to embrace the change. ‘There will always be work for us,’ he added.

Another delegate even mused that the creation of consortia could support the push on management costs. Commissioning support would come out of PCT management costs, but then (depending on how the management cost issue is defined) the consortia could be exempted from management cost cuts. After all, they would be new organisations that needed business support to get them on their feet. Cynical or naïve? Who’s to say? But it’s certainly not beyond the bounds of possibility.

Some formal body will presumably be needed to receive the acute commissioning budget, which even very rough estimates would put at over £100m (say £50bn across 500 consortia) – the budget of a small foundation trust. Many would be much bigger. They will need robust governance and finance structures to ensure there is proper public reporting and accountability, to ensure financial controls and discipline are in place and to drive better value from resources. Even if some of these roles stay at the PCT – charged with providing the necessary support services - the roles and functions themselves can’t all be eliminated.

Rumours that PCTs may have to wait longer to know their fate could be good news for finance staff. There is speculation that the white paper has been delayed by the Treasury having cold feet over handing billions of taxpayer pounds to consortia with few control mechanisms. Of course, the Treasury may be doing nothing more than applying its regular checks and balances on spending department plans, so there may be nothing to see here. However, if it is insisting on greater local oversight, finance will play a key role and for many finance staff anxiety could turn to relief.

With no major funding announcement, George Osborne’s 22 June Budget could have been very dull for the NHS – in truth levels of personal taxation set in the set-piece affair are usually the only items of interest for the service; the main action normally takes place in autumn’s pre-Budget report. However, two of the chancellor’s proclamations will have led finance managers to check not only their personal finances, but also the impact on their organisation.

Chancellors rarely give with one hand without taking with the other, and so it proved for the NHS. While it gained on the swings of the planned two-year freeze in public sector pay, it will lose on the roundabout of the 2.5% hike in VAT from next January. Of course it’s hard to say how much the freeze will save the service, though we know that each 1% rise for staff on agenda for change (AFC) contracts costs around £300m a year.

The impact of the increase in VAT to 20% is clearer. According to the King’s Fund, it will cost £200 to £300m a year – not dissimilar to the cost of the 1% rise in employers’ national insurance contributions planned by Gordon Brown’s government, which will not now go ahead (though David Cameron plans to press on with his proposal to create a cancer drugs fund using the money that would otherwise have been spent on NI increases).

With potentially similar sums being taken out as being saved, it would be tempting to say the Budget has roughly no overall impact on the NHS, but (as said above) there are other costs to be considered, as well as expenditure avoided (every 1% uplift in salaried doctors’ pay costs £100m a year, for example).

Leaving this aside, one question remains – will the pay freeze apply to the increments for which most staff on AFC contracts are eligible every year? NHS Employers have played a straight bat on this question, saying only that they would be discussing the matter with the government soon. However, we know the potential cost of increments is significant – in its submission to the NHS pay review body for the current year Employers said 70% of AFC staff would be eligible for incremental pay rises in 2010/11 and this would likely add 1% (£300m) to the pay bill.

The chancellor reiterated his commitment to protecting frontline NHS spending and increasing it in real terms, but this has set him at odds with some of his own backbenchers. Some, including Tory grandee Lord Lawson, came out recently to call such protection untenable when other departments were being cut by 25%. It will be interesting to see if such opposition develops as we go through the comprehensive spending review, the results of which will be announced on 20 October.

The Budget wasn’t the only show in town as health secretary Andrew Lansley continues to expand on his vision for the NHS in England. Again, this left more questions than answers – answers that should be supplied in the upcoming white paper, due in the ‘coming weeks’ according to the taciturn Department of Health press office.

The main questions surround the plans for GP commissioning consortia, some of which were raised in a recent report by six national healthcare organisations, including the King’s Fund, the Nuffield Trust and the Royal College of General Practitioners. Estimates on their number vary from 150 to 600, putting the average number of GPs in a consortium at between 240 and 60. Would these numbers be workable – even 50 or 60 GPs offer ample scope for infighting or disagreement. Even so, many GPs will be happy to be led by the enthusiastic few, some of whom will be veterans of GP fundholding, probably organised into a board. Will a chief financial officer sit on each of these boards? Certainly, with each consortium potentially in receipt of hundreds of millions of taxpayer pounds proper governance and financial stewardship will be vital. Where will the Audit Commission stand in all of this – will each consortium have an external auditor? The answer to all these questions should be ‘yes’, but it illustrates the level of detail that must be worked through.

How will funding be allocated to the consortia? We currently have a funding formula that allocates money to 150-odd primary care trusts, but there are questions over whether it will be sufficiently robust to fairly apportion funds to smaller populations? There is an alternative – the ‘fair share’ formula used to allocate indicative budgets to practice-based commissioners, but even the Department of Health has acknowledged this is not without its failings.

What happens if consortia overspend? Or underspend? Will there be a top-sliced pool, perhaps held at a regional level, to cover overspends? Will there be financial incentives, or even clear directions in the operating framework, to underspend? Will there be a failure regime for GP consortia?

Providers will also have many questions for the future. At the recent NHS Confederation conference, the health secretary spent a lot of time addressing the future of payment by results. ‘If the peak of Everest is a payments system that supports precisely what the commissioners are looking for and that patients need on every occasion, then I’m afraid we’re still at base camp’, he said.

The future system would have benchmark pricing, allow contracts to run along care pathways and switch between primary and secondary care (no mention of community care or mental health, but I am sure this was an oversight). It would focus on ‘outcomes not episodes’ and incentivise quality. ‘I want to see a system that rewards performance and is tough on poor quality – a payment system that works for clinicians and patients, rather than the other way round – a system which stimulates innovation,’ he added.

There’s a lot of work to get through to make Mr Lansley’s vision a reality by April 2012, the implementation date he has reportedly given to Department officials. At the confederation conference the message on timing appeared contradictory, with Mr Lansley insisting there be no delay, only for NHS chief executive Sir David Nicholson to later firmly pooh-pooh notions that it could be achieved in less than two years.

Many interpreted this as a gaffe by Sir David; others that he was standing up to his new boss. But perhaps it was a twist in the time-honoured good cop/ bad cop routine, enabling the civil servant to keep managers onside – remember 46% of the 2009/10 management costs are due to be cut by 2011/12. Ouch. But will such swingeing cuts be achieved at a time when so much support will be needed for the new commissioning groups, particularly in the areas of finance and governance? What the government saves on the swings it might have to spend on the roundabouts.