Restoring confidence requires an end to financial fudges

Last week, in the first of three issues examining Tony Blair's legacy to the NHS, primary care trust leaders took a bit of a battering.

And not for the first time. Acute trust colleagues accused them of incompetent commissioning and said they simply did not face the same level of blame as peers running provider trusts when things went wrong. This week, primary care trust colleagues have responded with equanimity, at least on the latter point, accepting that leaders of provider organisations are always likely to be more publicly associated with the highs - and lows - of running frontline services.

The risks running PCTs may be more subtle, they argue, but equally important. And they, more than anyone, are aware that the levers and controls they operate have not always been strong enough. But just whose fault is that?

This week, the new generation of primary care leaders come out fighting.

At the heart of it is analysis by the NHS Confederation's primary care network showing the extent to which the achievement of financial balance by year-end will rest on the top-slicing of PCT funds. Well over half of the PCTs recording a deficit at the end of quarter three were shown to have fallen into the red purely because of funds removed by their strategic health authority. Meanwhile, primary care leaders are furious about the damage and waste caused by repeated restructuring of their organisations.

As demonstrations around the country last weekend show, this has been a difficult year for the service. For public confidence in the NHS to be restored, financial balance is important: sometimes this requires sacrifices from different parts of the system for the greater good.

But at a time when the NHS is supposed to be moving towards a more transparent market, with brokerage a thing of the past, top-down decisions on the distribution of funds must not become the norm.

If ministers want to win increased confidence from managers, an end to financial fudges such as top-slicing and resource accounting and budgeting will be key to securing it.