HSJ readers of a certain vintage may remember Stephen King’s 1986 novel It and/or the 1990 TV mini-series. For those unfamiliar with the horror writer’s work, the plot revolves around an ancient evil that wakes regularly over the centuries to spread inexplicable mayhem on an area eventually occupied by the small US town of Derry, defeating whatever attempt is made to prevent its rampage.

IT clown

In King’s story the evil manifests as the horrifying clown Pennywise, who tells the book’s heroes: “I’m your worst dream come true.”

’ A number of PCTs are only being kept in the black by neighbouring commissioners’

As the leaders of clinical commissioning groups begin to put their plans into action, a significant number will be nervously wondering what dormant horror lies waiting in their area’s financial foundations. For would-be CCGs leaders their “worst dream” was inheriting responsibility for financial stewardship just as the service faced the biggest squeeze in a generation.

Andrew Lansley, alive to that deep-seated angst, reassured them no CCG would inherit a deficit from a departing primary care trust.

All now appears calm, with only one PCT predicting a deficit for 2013-14. But HSJ’s analysis of the latest PCT board documents suggest some CCG leaders may soon be woken by creeping doubts. A number of PCTs are only being kept in the black by neighbouring commissioners, some through loans that will need to be repaid. Others are kept afloat by central financing support, the sustainability of which lies outside CCG control.

Financial gloom

What is more, in outer London the NHS has its very own Derry. Throughout the decades, whatever structure the NHS has imposed on the area, a financial gloom has spread to undermine and in some cases kill off the most carefully developed plans. Indeed the unease created by the refusal of the sums to add up has led to decisions in times of plenty which have only made the struggle worse when money grew tight again.

Even detailed research is now unable to determine exactly why the area suffers. It must be something inherent to the area. There are many theories, but no-one fully understands what “it” is.

Elsewhere in the country, financial pressures are less focused − but the demands placed on CCGs by the legacy of unpaid continuing care claims poses a “significant risk”. Many are also starting the year with less money than they expected as the NHS Commissioning Board whisks away the odd billion here or there to finance its growing responsibility for specialised commissioning. More anxiety will be created by the grim macroeconomic picture and the fierce resistance being put up by other areas of public service against becoming the victim of further cuts.

‘There will be little CCGs can do to eradicate the structural issues which mean some health economies are cursed’

There are plenty of health economies which, while lacking the myriad problems of outer London, operate on slim financial safety margins. For the present they can seek aid from the risk pools created by the commissioning board, but that is hardly a promise of future security.

Not being magicians, there will be little CCGs can do in the short to medium term to eradicate the structural issues which mean some health economies are cursed with recurring financial problems. What they can do is prepare their stakeholders, including constituent practices, for the challenges ahead and the decisions and compromises required to meet them.

The model of “clinically led commissioning” may be strangled in its infancy by Labour’s healthcare plans, so CCGs must control expectations and show the appetite for addressing wicked problems if they are to make their case for continued meaningful influence.

It is rumoured a new film of Stephen King’s book is in production. In the NHS, the battle against the spectre of recurring deficits is far from over.