This week's HSJ survey of the extent to which primary care trusts have been decommissioning services represents the calm before the storm of world class commissioning.

It reflects the fact that many PCTs did not decommission any services last year, and those that did tended to focus on primary services such as alcohol dependency.

At first glance it might appear that PCTs are failing to flex their commissioning muscles, but to date there are good reasons for taking a cautious approach. Many have been increasing capacity in acute services to hit the 18-week treatment target, while every single PCT is still gearing up to cope with the challenges ahead. None are yet gold standard. They need to get to grips with acute services, but that does not mean turning the exercise into a decommissioning virility test.

Route to improvement

Decommissioning is an important - but by no means exclusive - route to service improvement. Simply steaming in and dumping services would be reminiscent of the worst days of tendering for public services in the mid-1980s. The more sophisticated and productive approach is for commissioners to work alongside providers to agree standards and goals that will jointly drive up quality and efficiency. Cancelling a contract should rarely be the first move.

However, commissioners must not flinch from the tough decisions needed to meet their goals of stimulating the market, managing the local health system and making sound investments.

The tightening financial outlook means that from 2011 at the latest, funding growth is likely to slow to barely perceptible levels, and real terms cuts cannot be ruled out. Getting the right services in place before the financial turbulence hits the health service will allow calmer decision-making and more effective long-term planning. For some hospitals, that will be a painful experience.