Nearly all primary care trust commissioning strategy plans describe a rationale for their intentions over the next five years. Tailored to the health and healthcare needs of their population, they describe future actions which intend to move activity out of secondary care, and cut emergency admissions and attendance at A&E.

In 2007 I began talking to providers about how they anticipated dealing with this dramatic shift. They seemed not to take these intentions seriously, basing their own provider strategies on their understanding of their future. I warned them that, surely, not paying attention to commissioning intention was a bit short sighted.

They looked at me as if I did not understand what really happened in the NHS. I felt they were missing a market signal and said so. Mainly they were right and I was wrong. They knew there was a considerable gap between intention and action and felt that such a gap was normal.

I have been exploring this gap to find out more about the culture that expects it. At the NHS Confederation conference I chaired a session on commissioning. PCTs in the audience were asked: who is buying more acute care than last year? Nearly all. Who had intended to buy less this year? Nearly everyone. Most had good “reasons”, but if this gap between intention and realisation continues, then the NHS faces a big deficit.

The PCTs are the only organisations that can create much better allocation efficiency for the NHS. They can plan to commission care in the most appropriate setting and can move much more long term condition care from urgent admission into patient self-management.

But to provide better health and healthcare outcomes from the same resource, they have to not only plan this but to make it happen. And to make it happen in the next 18 months, as well.