Just over two years ago, in a reorganisation of the NHS in England, 303 primary care trusts were created, each with responsibility for providing primary health care, improving health, and commissioning secondary care services for a population of around 180 000. With about 80% of NHS funding flowing directly to primary care trusts on a capitation based formula, hopes were high that these new organisations would be powerful agents for change in a more devolved, clinically driven, and locally responsive NHS.1

Some in the NHS, however, believe that primary care trusts have failed to fulfil these expectations. There is a growing belief that many trusts are perhaps ineffective organisations—too weak to stand up to providers of acute care in tough negotiations on commissioning and too small to fulfil their public health responsibilities. Some would argue that they have so far been unable to establish strong and credible management teams.2

The unsurprising solution being mooted is a further reorganisation, in which widespread mergers of primary care trusts would reduce their number to …