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Published: 26/09/2002, Volume II2, No. 5824 Page 12

While chief executives across the NHS face huge workloads, those leading primary care trusts are also coping with a lack of management capacity.

Here, three of them discuss the implications Southern Norfolk: 'It is an incremental loading of straws on the camel's back' Chief executive Mark Millar describes life at the helm of a new Southern Norfolk primary care trust as 'hectic'.

At the moment, the PCT has been trying to stay within the management cost envelope it inherited.'My big question is I do not think we can survive much longer given what's being asked of us, without investing much more in management in the wider sense.

'Everybody is very stretched trying to keep lots of balls in the air at once.Every week, There is a new initiative or We are asked to nominate a new lead for this or that.

'It is an incremental loading of straws on the camel's back.'

On the other hand, the trust has its management staff in place.'We have been very successful in filling all our posts, except public health where we know there is a national shortage.'

He adds: 'I've been trying to meet partners and practices - That is taken a significant amount of my time, as We are setting up a new organisation.'

Nor has he gone far enough through the 'set-up stage' to say whether he is able to fill the chief executive role in the way in which he would like.'It is the early days.This hasn't been done before.'

Huntingdonshire: 'There is always so much paper in the NHS' It would be fair to say Huntingdonshire primary care trust is not exactly over-burdened with managers.

'We are quite unique as a PCT, ' says chief executive Karen Bell.'We didn't have a community trust.

We didn't inherit the managers other PCTs have.

'What we have been doing is increasing our management capacity.We are still significantly below what was the ceiling.'

But she says shared services for human resources, IT, risk management and finance running across six local PCTs have given Huntingdonshire access to a much broader range of services than it could sustain alone.

'In some areas, We have had to recognise that shared services need investment as well.'

Filling the gaps herself is something Ms Bell does not do much.'I've got a very stable, very competent team and a deputy.'

She adds: 'I like to think I am strategic. I do not get involved in the nitty gritty. I delegate a lot. I do think the chief executive's job is about leadership - supporting, developing and being there for the team. . . to bounce their ideas off.'

She is also spending a lot of time 'talking and influencing'board members, the professional executive committee and partners such as the top team from social services.'I spend a lot of time talking to provider chief execs, ' she says.

Like many NHS managers, Ms Bell notes, 'There is always so much paper in the NHS; keeping up with that is difficult'.

But long hours 'go with the territory'.

Nottingham City: 'It looks a bit top-heavy but it reflects the scope of responsibilities' Nottingham City primary care trust chief executive Sam Milbank says her PCT spends just 0.86 per cent of its budget on management costs.And though it is a big organisation that should allow economies of scale, sufficient management capacity is needed to keep up its locality focus.'One of our localities is bigger than the neighbouring PCT, ' she points out.

She adds: 'In terms of our structure, it looks as though we have a lot of directors.'

But many of these are managing services that the PCT hosts, such as NHS Direct for the whole east Midlands area.'It looks a bit top-heavy but it reflects the scope of responsibilities.'

But hosting other bodies and shared services is something Ms Milbank has now had to call a halt to.

It has taken time to recruit the top tier of managers, with the finance director starting 10 months into the PCT's existence.Stressing the importance of finding the right people, she says:

'We are still getting the next tiers sorted out, particularly around finance and performance management.'

Areas like public health and the new patient engagement agenda are putting the PCT 'to the test', while an ageing workforce and GP vacancies make staff recruitment and retention a key concern.

The time taken to get staffed up has affected Ms Milbank's own workload 'tremendously', she says.'The first set of board papers were all mine, everything from high-level policy to laying on the whole service and financial framework process.'I am probably dealing with things that in an ideal world I wouldn't. I have a work plan of what I want to do, to get a balance between the internal focus and the external focus - and being visible, which is important.

'That is severely compromised.'