As HSJ's exclusive world class commissioning league table reveals this week, most primary care trusts have emerged from the first round of world class commissioning with good foundations in place.

The three PCTs that led the field are Birmingham East and North, led by Sophia Christie, Tower Hamlets, led by Alwen Williams, and Somerset, led by Ian Tipney. Close behind were another 24 with green ratings for strategy, finance and board governance.

These high fliers will have to wait to discover what freedoms emerge from the Department of Health’s negotiations with the Treasury. But the fate awaiting failing PCTs is already becoming clear. The two with triple red ratings, and around another eight or so, should steel themselves for “directed development” by their strategic health authorities. Some will almost certainly endure the further humiliation of the private sector taking a central role in their improvement.

Out of patience

The DH has run out of patience with a handful. It is angered they have repeatedly been exposed by regulators as failing their communities. Action could be swift and bloody.

At last week’s HSJ conference on world class commissioning, PCTs’ relative success in the softer skills such as collaboration and local leadership was contrasted with weaker performance on the harder edged skills such as procurement and stimulating the market. But there was sympathy for the argument that it is better to invest in relationship building before putting the commissioning boot in than to unleash the full fury of world class commissioning before local partners are on board.

But, even for the top performers, year two of the programme will be tough. This year no PCT achieved a top-rated score of four on any of the 10 competencies, and managers are realising that getting up there will require a great deal more than simply incremental improvement.

Fundamental change to existing practices will be needed, requiring leadership of the highest calibre.

See PCTs exceed expectations in year one