It has been an up-anddown ride for one wouldbe PCT, with planning interrupted by a simulation exercise - and awkward questions in the school playground. Julia Squire reports

We were on target - awaydays completed, consultation document drawn up, local GP practices on board, all ready for our move to primary care trust status.

The summary consultation document was in final draft stage, relationships with all main stakeholders were positive.We had spent the summer working in the local area talking to our partners in other agencies, key opinionformers, GPs and health partners.We had come to agreement with the health authority about consulting on a proposed service configuration and timing of the application for April 2000.And we had a project team established and cohesive, complete with a reasonable first draft project plan.

It had been frenetic hitting deadlines but we were feeling comfortable that we'd make the consultation start date, at the end of September when the guidance was in.

Our naivety was savagely punished by two events: late guidance giving timings which made our preferred consultation period of eight weeks - negotiated with the community health council - impossible, and an HAorganised simulation exercise.

We'd already realised that a 12-week consultation from the end of September would not give us time to get a consultation report in, convince the regional office to back us and hit the three-month preparatory period in January.

Now we had to curtail it to six weeks but still make it participative and comprehensive.

The simulation of six months before and six months after the establishment of PCTs with the usual NHS agenda to tackle at the same time - waiting lists, financial problems, developing a meaningful health improvement programme and acting on it, proposed reconfigurations, a mental health incident and a cottage hospital fire - was a revelation.

The exercise involved trusts, the HA, primary care groups, local authorities, the press and members of the public.We had a year concentrated into two days and key objectives to deliver in the time.The exercise brought a few th ings home to us :

Some of the relationships we were most confident in needed the most work.

People don't necessarily react logically in the face of major change.

Something will always throw you off course at a crucial time.

The most functional teams can be frightening to key partners.

Not everyone prepares, and it takes time to bring people to the same understanding.

These seem obvious, but the implications weren't until we saw them in action.We ran 40 consultation meetings and numerous press interviews across a broad, largely rural geographical patch.These were with local people, staff in primary care and the services proposed for inclusion, and key partners - unions, local authorities, trusts, other PCGs and voluntary sector agencies.

We also asked the CHC to administer a ballot of all nurses, GPs and therapists in the PCG patch.

During the consultation process we received 240 written responses, many needing a reply, and numerous requests for further meetings, most of which we managed to fit in.

And the work of the PCG continued - we felt strongly that letting our PCG agenda slip would diminish confidence in our ability to achieve as a PCT.

The overwhelming majority of responses were positive but some were not, the main concerns being:

timing - short consultation and implementation timeframes;

financial viability and equity in the context of a countywide deficit;

inclusion of some small services to increase the number of nurses on the PCT board.

The PCT project team, backed by our board, amended the proposals in the light of consultation.

Northamptonshire, where we are based, is a small world, and tension built up around the inclusion of some small services in the PCT application.The rumour machine worked overtime and we spent a disproportionate amount of time allaying concerns that had been unnecessarily generated.

Running consultation meetings is a very personal thing in a small organisation.People decided whether they supported our proposals for reasons of content and sense, but also responded to whether they trusted us to deliver the promise.

If we had a year without major change in the NHS, most of us would think the world had stopped turning, and Nor thamptonshire is no except ion. People aren't inclined to major change in this generally conservative county.

This change really interested people though - mostly because it makes sense and because, in our patch, there is relief that, finally, someone has realised that rural life is different.

The concentration of services in the major towns has neglected a significant proportion of the county's residents who live in villages.And they are not, by any means, Aga-running, two-BMW families.We don't have the deprivation found in metropolitan inner cities, but we have isolated young families and elderly people trapped in villages with negligible services and little public transport.

We have primary care teams that manage complex cases locally to give a quality of life to patients and their families which would not be there in distant hospital wards reached only by two buses.

The consultation process was intense - and very close to home.Occasionally my integrity, or that of the chair, was questioned - were we trying to fragment services, were we lying, was this about cuts, were we empire building?

This was very uncomfortable.Had our proposal not felt so fundamentally right for the patch, and had it not been so heavily supported by the staff directly involved, our GP practices and local people, it would have been very difficult to pursue.

Getting stopped in the school playground while dropping offmy son, halfway through the consultation, brought home the major benefit and, in my view, the biggest managerial challenge for PCTs.

I had appeared in a district council newsletter and the other mums had seen it. I suppose I am a bit of an oddity when I take Ben to school - all suited up, in a tearing hurry, generally last, with him reading his book on the way in if I've been working late the night before. I try to avoid having to describe my job.

It's not that I'm not proud of it, it's just that I've kept home and work separate for years as a sanity saver.Not possible any more.

PCTs are developing local services and health programmes for local people.They are not big HAs or trusts.They are out there, in schools and the supermarket, and if we ever needed an incentive to get it right it's in the playground.Many GPs and community staff are used to that; managers are not.

The outcome of the consultation was extremely positive, and it had challenged our thinking, our aims and reasons for making the proposal. Some changes came out of the process, and it also helped to develop both our agenda for year one and partnerships in the patch.

Getting a consultation report completed, including the amended application, in two weeks and approved by the PCG and HA boards stretched our resources.Then the work really began.The regional office wanted, rightly, to be absolutely sure we could deliver before recommending us as one of the first level-four PCTs, and asked for more evidence and clarity.

Silence was punctuated by Christmas, the new year and a minor, but timely, wobble about the role of the board, lay members and clinicians.The pre-Christmas rush in GP practices, millennium planning and no news on the application left many of the project team feeling flat over the holiday period, although not the GPs and others on duty in the out-of-hours centre.

We continued implementing the project plan, set up the formal staff consultation and completed debates about shared support services and transfer of overheads.

The announcement, when it finally came, was greeted w ith re l ief more than any th ing e lse . It took us a couple of days to be pleased and a weekend to get over the sheer terror at all that still needs to be done.Although it was tough enough getting this far, this is where the work really begins if we are going to make a difference.

Julia Squire is chief executive, Daventry and South Northants PCG.