It is the responsibility of primary care trusts and strategic health authorities (SHAs) to analyse their local situation and develop plans, in liaison with their local national health service trusts and primary care providers, to deliver high quality NHS services including orthopaedic services while maintaining financial balance. The Department is working with the Specialist Orthopaedic Alliance, specialist orthopaedic hospitals and their host SHA to reach a long-term sustainable solution to rewarding the work of specialist orthopaedic hospitals through payment by results.