• Increased demand for health services as recession bites

  • Two-year timetable for service reconfiguration and investment

  • Surpluses vulnerable

The economic downturn means primary care trusts could be asked to make further efficiency savings just as demand for their services increases.

Ernst & Young's healthcare advisory practice director Richard Lewis said: "There are health consequences of a recession which could shade what demands are put on the NHS.

"PCTs will want to re-examine and future-proof their plans."

There could also be a drop in private health insurance, leading people in wealthier areas to turn to the NHS, he said.

The Department of Health held back some£870m from the PCT allocations for this financial year and NHS finance directors will be watching to see if something similar happens next year.

There is additional uncertainty for PCTs as the DH is due to make changes to the formula used to allocate resources.

Minutes from a Treasury financial reporting advisory board meeting indicate it has noted the apparently "irregular" accountancy practices employed by some PCTs in their bid to keep their surpluses to an acceptable level last year.

Any implicit claw-back will be resisted by PCTs. Sheffield PCT chief executive Jan Sobieraj said: "Our strategic health authority knows we need this money to deliver change.

"We have two years to deliver all the changes in the system before the restraint on funds. There's a lot of worry. Beyond 2011 it will be very tough."

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