By Ray Dunne BBC News Online health staff

PCTs pay for most NHS treatments

Dr Graham Rich manages a team of 500 people and an annual budget of �180m.

He plays a key role in efforts to improve the health of the 163,000 inhabitants of West Hull.

He decides what services patients need and how much money the NHS should spend on them.

Yet few people in Hull or beyond will have heard of him.

The former GP is one of England's 298 primary care trust chief executives.

Together, they are spearheading a quiet revolution in the way healthcare is delivered across the country.

The first primary care trusts were established in April 2000. Within two years, every village, town and city in England was covered by a PCT.

They have a wide range of responsibilities. These include delivering primary care services in their area, buying services from hospitals on behalf of local patients and improving public health.

But crucially they also control 75% of the NHS budget - some �49bn this year.

Where West Hull's money goes Staff salaries: 65% Hospital/ mental health: 16% Prescriptions: 14% GP Services: 2% Nurses: 3%

In theory, this should make them the most powerful bodies the NHS has ever seen. In practice, their hands are, for the moment at least, largely tied.

"Although we control around 80% of the NHS budget, the amount we have true discretion over from year to year is relatively small," says Dr Rich.

Like most PCTs, West Hull's biggest expense is salaries. "Roughly 65% of our total budget goes on staff salaries," says Dr Rich.

Prescription medicines account for another large chunk - �25m or 14%. Another �5m goes on GP services and �6m on community nurses. The remaining �27m is divided between mental health and hospital services.

After all these expenses are met, West Hull PCT like many others around the country has very little change left.

It is one of the reasons why many PCTs are trying to come up with new ways to save money.

Most are focusing on the amount they spend on hospital services, since it is one of the few areas where savings can be achieved.

Controversial scheme

This has led to some innovative and controversial schemes.

For instance, nine PCTs have risked the wrath of trade unions and some sections of the Labour Party by teaming up with United Healthcare, an American healthcare provider, to try to reduce the number of elderly people admitted to hospital.

The trusts involved are Airedale, Bexley, Bristol North, Bristol South and West, Halton, South Gloucestershire, Walsall and Wandsworth.

PCTs in numbers There are 298 PCTs in England They manage a combined budget of �49bn this year They have an average budget of �164m They range in size from 500 employees to 3,000 Average salary of PCT chief executives is �92,500

They have appointed nurses to visit elderly people in their homes and to identify and treat any potential problems before the need to go to hospital arises.

Another eight PCTs have teamed up with Kaiser Permanente, another American healthcare provider, to try to reduce the length of time patients spend in hospital.

The scheme, which has come in for some criticism, involves providing a wider range of specialist care in the community so patients can go home earlier.

It is being piloted by PCTs in Blackpool, Eastern Birmingham, East Sussex, Lincolnshire South West, Northampton, St Albans, Taunton Deane and Torbay. If successful, it could be adopted by other PCTs.

Torbay PCT sparked controversy recently when news of its latest money saving scheme hit the headlines.

It is paying GPs �100 for keeping high-risk patients out of hospital. The PCT believes the scheme will deliver savings. However, some doctors have accused it of trying to bribe GPs into keeping patients out of hospital.

Another 40 trusts are reported to be considering something similar.

In London, Haringey PCT has teamed up with Pfizer Health Solutions, a subsidiary of the pharmaceutical giant, to set up a new call centre.

It is staffed by nurses who call patients with serious conditions, like heart disease and diabetes, and try to encourage them to live more healthily and take their medication.

New powers

The new NHS contract for GPs, which came into effect in April, also gives PCTs some new powers and new responsibilities.

For instance, many are expected to take over responsibility for providing care to patients in the evenings and weekends from GPs by the end of this year.

The contract paves the way for a major increase in the amount of money spent on primary care services.

But it also gives PCTs a big say in how that money is spent.

"They now have the power to make sure practices are delivering the care patients need," says Dr Michael Dixon, chairman of the NHS Alliance which represents most PCTs.

That means they can now set up specialist clinics to treat patients that are perhaps missing out on healthcare - refugees, for instance.

"They are able to look at the needs of local population for the first time," says Professor Martin Roland, director of the National Primary Care Research and Development Centre at Manchester University.

Big changes

Many PCTs are also using the new contract to change the way healthcare is delivered.

With extra money in their pockets, they are encouraging more GPs to take on some of the work traditionally done in hospitals.

This has already led to an increase in specialist clinics, for minor surgery or skin disorders for instance.

"It means many patients can now being treated in their local GP practice instead of having to go to hospital," says Professor Roland.

All of these schemes and changes are geared towards one thing - increasing the amount of money PCTs can spend on other things.

"I think one of the areas that PCTs still have to fully engage in is improving public health," says Dr Dixon.

"This could involve tackling issues such as local traffic and diet."

According to Dr Dixon, PCTs will really start to make their presence felt when they move into these areas.

"They are pretty powerful already," he says. "But they will become more powerful and they will have a much bigger impact."