Primary care trusts are struggling to cope with the financial fallout of increased referrals, with some now expecting the extra costs to drive them into deficit.
PCTs' finance reports show they are facing severe pressures in their commissioning budgets from the dramatic increase in GP referrals that started earlier this year, together with increases in continuing care costs.
In NHS South Central alone PCTs are facing£40m overperformance on acute contracts.
PCTs are also being affected by a rapid increase in the costs of providing continuing healthcare, where a national framework has been introduced. Some are facing bills of£5m more than budgeted.
Many PCTs are still expecting to break even, but this is often reliant on massive savings being achieved in the next few months, or using rapidly diminishing contingency funds. Those under most pressure seem to be concentrated in shire counties, often dealing with a number of local authorities and with dispersed populations.
Devon PCT, for example, has seen a 15 per cent rise in referrals to acute hospitals and has overspent against plan by£9.9m. It had originally planned to make a surplus, then expected a£14m deficit but is now predicting to break even, although this is dependent on realising£33m through a recovery and redesign programme by the end of the financial year.
Chief executive Kevin Snee said this involved delaying projects that did not contribute to the savings and accelerating ones that did. For example, an urgent care centre in Tiverton would be delayed until next year but a GP-led service to take the pressure off accident and emergency at the Royal Devon and Exeter Hospital would go ahead.
Some PCTs have gone back to major providers to get them to share the risk of these increased referrals. Buckinghamshire PCT has negotiated a capped upper spending limit with Buckinghamshire Hospitals trust. The PCT is now forecasting a£13.1m deficit at year end, with major savings being achieved in the last three months of the financial year.
NHS Alliance chief officer Mike Sobanja said there was a need for clarity around how PCTs were expected to prioritise. "What is needed is a clear cut message from the centre about what is the top priority. If it is balancing the books at all costs, what degree of political flak are politicians and the Department of Health prepared to take?"
Hampshire PCT predicts a£5m deficit this year, even if it achieves more than£17m in turnaround savings which would require it to break even for the rest of the year. It is currently£18.6m overspent with trusts but underspends elsewhere and contingencies reduce this to£6.8m.
Warwickshire PCT was£2.6m in deficit by mid-year and forecasts from break even to£10.4m in deficit by year end. Acute healthcare was overspent by£5.8m.
Manchester PCT has overspent by£9m so far and expects this to increase to£15m by year end. Continuing care is also overspending by£3.1m so far. The PCT is now forecasting breaking even rather than a surplus.
Oxfordshire PCT has reduced its forecast to a£2m surplus from£3m as it copes with£9.3m overspend so far on commissioned services.
Cambridgeshire PCT forecasts breaking even but has an overspend of£3.3m on its main service level agreements which is forecast to rise to£8.6m by year end.
Torbay Care trust expects to overspend on acute services by£4.3m by the end of the year but this is offset elsewhere.
Source: PCT board reports