Comment But will DoH honour commitment to let SHA chief execs 'hold the reins'?

Published: 10/01/2001, Volume 112, No. 5787 Page 19

New year, new structure, new faces. Well, almost. It will be another three months before strategic health authorities begin to function officially and primary care trusts take over responsibility for the bulk of NHS spending, but the countdown has begun.

As for the newly confirmed chief executives who will head the SHAs, staff may be forgiven if they have the words of the Who's classic song ringing in their ears when they return to work: 'Meet the new boss, same as the old boss'.

Which is not to disparage the appointments. Among them are some of the NHS's most outstanding managers, and the fact that most will know large parts of their patches already is a bonus which may bring some much-needed continuity. This was not the time for one of those periodic influxes of managers from outside the service, so in vogue during the Tory years. Ministers may still not be above disparaging the quality of NHS managers when they judge that the moment demands a populist rhetorical flourish, but clearly deep down they realise they need look no further than the service's own ranks for leaders of appropriate calibre. There is too much to be done too quickly - and the cultural changes call for such inside knowledge and sensitivity - that the SHA top posts were only ever going to go to a cohort whose experience would inevitably ensure they all looked a little familiar.

NHS chief executive Nigel Crisp promises that the Department of Health will 'take a back seat' and leave SHAs 'holding the reins'. He is no doubt right to claim massive support for this empowerment and for the 'direction of travel'. But he must be aware of significant scepticism too: no-one doubts Mr Crisp's sincerity, but are ministers really committed to reversing a decades-long trend of ever-greater NHS centralisation? Every government spouts phrases to this effect - it has never stopped them shaping a very different reality. Mr Crisp warns that it may be two years before the new ways are embedded. Most managers will want to feel assured of travel directions, and exercise the reins in their hands, long before that.

The other part of the equation demanding attention is the management capacity of PCTs. This has been severely under-nourished so far; given the scale of the tasks PCTs are about to take up, it has to be urgently replenished. The about-to-be-dissolved HAs should provide a reservoir of managers on which PCTs can draw.

But the arbitrary ceiling which depresses what they can spend on management should be abolished forthwith.

Unless that happens, the task for PCTs will be to carry the NHS on their shoulders with one hand tied behind their backs. l tl