Practice-based commissioning is the 'Cinderella' policy reform of the NHS.
Payment by results, foundation trusts and increasing use of the private sector have tended to hog the headlines, but the package of reforms won't click unless PBC is used robustly and effectively.
Yet it has been introduced so cautiously and with so few incentives that it has barely got off the ground, as this week's report from the King's Fund and the NHS Alliance has shown.
More than half the GPs and practice managers polled believe PBC has made no difference to patient care, a sign of failure for a supposedly key reform. Just 1 per cent say it has delivered major benefits for patients.
And chances for progress have been hampered by confusion between primary care trusts and GPs over the size and control of budgets.
The odds are stacked against GPs being able to commission their way to a better NHS when they are swimming in the same pool as giant foundation trusts and independent providers.
GPs and practices don't have the commissioning expertise or muscle to make such a difference that providers will sit up and take notice - although commissioning clusters could begin to alter the balance of power.
PCTs are not providing sufficient support for practices wanting to hold the purse strings, and even where practices make significant savings they cannot be confident they will be able to keep half the money as promised. The British Medical Association has warned GPs not to sign up to PBC unless they get such a guarantee in writing.
This week's report at least shows that doctors and practice managers want PBC to succeed and believe it can. But if better and more cost-effective services are to be commissioned by practices, they are going to need more support.
Read the full story, Poll reveals dissatisfaction with PBC