Primary care trusts (PCTs) are the local statutory organisations in the English NHS responsible for improving public health, providing primary health care, and commissioning secondary and tertiary care services for populations of around 250 000 people. When created in 2002 primary care trusts were intended to become powerful local purchasing agencies, rooted in primary care, and well placed to integrate primary health care, community services, and hospital care.1 In the international context, one of the most notable features of primary care trusts has been the continuing belief by NHS policy makers in England in the value of integrating the purchasing of health care with the delivery of primary care. However, over the past year or more the view that primary care trusts are failing to “punch their weight” in the health system has gained currency, in particular in relation to their supposed inability to achieve strategic change in secondary care.2^–4

This has led to renewed interest in strengthening the commissioning function in the NHS. The assumption is that there will be fewer primary care trusts …