By Branwen Jeffreys
BBC News, Health correspondent
Hillingdon Primary Care Trust in north west London has the highest deficit of any NHS organisation in England.
Isabelle didn't want to go to hospital
But moves are afoot to address the problem
In the front room of a 98 year-old-patient a rapid response nursing team is dealing with the kind of crisis that usually ends up with someone in hospital.
Isabelle - who asked me not to use her full name - has breathing difficulties and needs to be monitored carefully.
She is adamant that she doesn't want to be admitted to hospital.
"I've got all my things here around me. I don't want to be in a hospital where they don't know me and everybody is strange, everything is strange."
Her GP has called on the new team set up in Hillingdon which offers crisis care for up to 48 hours in a patient's home.
Sue Elvin, the senior nurse, said they are already bringing down hospital admissions.
"I'd say 75% to 80% of the people we see we prevent going into hospital.
"Some people do need to go in. But we have set up a lot of services, we can access a lot to keep people at home safely ."
Once the rapid response team is fully up to speed that could cut the cost of hospital bills by £1.5 million a year.
And that is crucial in Hillingdon, where the primary care trust has a forecast debt this year of £65 million.
Primary care trusts provide community services, and pay for hospital care so weak finances have a big knock on effect.
So a tough debt busting chief executive has been sent in to sort Hillingdon out.
Antony Sumara is a trouble shooter. When he arrived the trust was overspending £2 million a month. He has now got that down to £1.5 million.
Simply rechecking all the bills for hospital care in the first quarter of the financial year revealed £600,000 of accounting errors.
I sat in at the weekly meeting where he holds his top team to account, telling them he won't believe they have saved money until they can show it has been signed off by the financial experts.
As well as running a tight ship there are more radical measures being put in place.
Negotiations are underway with local GPs to run an urgent care centre opening early next year.
That would see many of the patients currently walking into Accident and Emergency at Hillingdon hospital with more minor problems.
Effectively the GPs are being asked to undercut their hospital colleagues.
And Hillingdon PCT may become one of the first in England to contract out some of its management tasks to the private sector.
That could mean contracts with local hospitals to provide care being drawn up by a specialised consultancy firm rather than the trusts own staff.
The number of job losses involved among NHS administrators is not yet clear.
Nationally, it has been a controversial issue with unions strongly opposed to private sector involvement in nhs decision making.
But Mr Sumara told me that weak financial management combined with the upheaval of reorganisation in the NHS has allowed deficits in some areas to spiral.
He said the public have every right to be sceptical about what has happened to record investment in the NHS - and compares his job to a premiership manager.
"If the team is not going well the crowd start shouting: 'You don't know what you're doing.'
"It is a bit like that in the PCT. The public have got every right to say: 'You don't know what you're doing, you're losing money, you can't say how it happened and you haven't dealt with the problem'."
This year, like other NHS managers trying to bring down deficits, he will be under pressure.
Hillingdon PCT can't wipe out its debt in the next few months but Antony Sumara is confident he can stop it overspending and begin to turn the corner.