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.