Published: 11/08/2005, Volume II5, No. 5967 Page 16

Dianne M Jeffrey, chair, High Peak and Dales primary care trust NHS chief executive

Sir Nigel Crisp wrote to primary care trust chairs last week about Commissioning a Patient-led NHS, and this belated acknowledgement is a timely reminder of the role of chairs during this time of change.

Quite apart from restructuring and the commitment to make£250m of savings (news, page 5, 4 August), the broader range of service providers now available to PCTs heralds a new era of procurement.

Skills rooted in understanding the market and corporate governance standards will be as important as strategic financial management.

In terms of legal requirements the new streamlined PCTs, as they enter a real market environment, will need to be mindful of their consultation obligations under the Health and Social Care Act 2001 (section 11) which requires them to have in place arrangements to ensure that patients, or their representatives, are involved in and consulted on planning of provision of services; development and consideration for proposed changes; and decisions affecting these services.

All the more reason then to ensure that chairs - with their specific responsibilities for accountability, probity, and openness - are encouraged to put board performance and effectiveness at the core of NHS business prosperity.

Richard Rackham, associate director, risk management, Waltham Forest PCT

Just think, three months ago it was suggested that the government would be timid about health service reform following a reduced majority at the general election. Far from it: Commissioning A Patient-led NHS talks about reconfiguring PCTs, and looking at the 'fitness for purpose' of strategic health authorities and care trusts.

The NHS has had some difficulty balancing the books this year and yet there are savings of£250m expected from this reform. The source of these savings is clear - management costs. However, the pressure on NHS management is increasing. Combining PCTs may provide some economies of scale, but I have some reservations that they will be sufficient to provide£250m and achieve all the NHS initiatives with which we are inundated on a daily basis.

So this document asks for more management output with lower management costs; it asks for centralisation at a time that the government is adopting a localisation agenda; and it takes us back in time to health authorities (what else is a PCT that has no operational services? ).

Far from bringing clarity to the future of the primary care sector of the NHS, many of us are more confused than ever.

Graham Read, consultant oncologist, Lancashire Teaching hospitals trust

When I read of yet another reorganisation, my heart sank. As an oncologist nearing retirement I still wonder how many more reorganisations I have left to see.

I cannot understand this preoccupation with structure and reorganisation. Surely it is people that matter. If you have the right people they will work around an imperfect structure. Innumerable studies have shown that a major reorganisation will cause an organisation to tread water for 18 months to two years as people first worry whether they will have a job, apply for jobs and then learn new ones.

The present number of PCTs was created by this government. If fewer PCTs were a better option then perhaps a little more thought would have created that number in the first place.

So more anguish for managers.

'Good!' I hear doctors cry. But the NHS is almost the largest organisation in the world (apart from Indian railways, I am told) and it needs good, stable management preferably near to the action and not in some remote ghetto in Elephant and Castle or Quarry House. The government owes the country and the NHS a halt to further reorganisation to allow staff get on with their jobs.