Amid the excitement over the start of primary care groups, it is widely assumed that Primary Care Act pilots will be assimilated into the new system. But some pilots are determined to continue to build on their successes. Thelma Agnew reports

Primary Care Act pilots rarely grab the headlines or excite passions. The creation of a dying Conservative government, their thunder has been stolen by the invention of primary care groups. And no wonder. PCGs will be bigger, more radical and 100 per cent New Labour. But there are signs that PCA pilots are not prepared to be simply absorbed into PCGs.

In Tipton, West Midlands, the pilot is big, well-established and staying put. The fledgling local PCG would be advised to approach with respect. Eight GP practices formed the pilot, called it the Tipton Care Organisation, and now commission and provide services for 40,000 patients, including managing hospital admissions and discharges.

'We are taking on a lot of the work that the health authority did,' says project manager Dawn Wickham. 'The advantage we have, that the HA never had, is that we are here right on people's doorstep. We get a got more co-operation and trust.'

Like every other PCA pilot, TCO was formed by committed and innovative people who didn't know that the PCG option was just around the corner. They tried to convert the PCAP (as the jargon calls them) into a PCG, but fell 10,000 patients short of the minimum threshold.

'Our PCG was only announced last week. We did a small presentation to them about our primary medical services pilot. At the moment it's difficult to speculate about what the PCG will do,' says Ms Wickham.

'But we hope to keep some identity within Tipton. We have worked incredibly hard over the past months and it's been a huge success. There is no way we want to see that compromised. We will be pressing hard for recognition,' says Ms Wickham.

Tom Butler, senior fellow at Birmingham University's National Primary Care Research and Development Centre, suggests that the significance of PCA pilots has been overlooked and their role misunderstood.

'PCAPs were the first really tangible product of the shift in policy emphasis, the move to a primary care-led NHS,' he says.

The act was the first to give healthcare professionals permission to operate outside existing regulatory boundaries, he points out.

'What we have with PCAPs is an opportunity to experiment with different ways of working. Potentially we have prototype organisations that other people can draw on in the future. Yet there is still this naive assumption that a PCAP is a PCAP, that they are all the same.'

The latest PCG guidance calls for action in areas such as health outcomes and patient involvement which many of the 88 pilots are already addressing. But this doesn't mean that there will be a duplication of effort.

'There's more of a public health focus in PCGs, and a strategic view of populations and their needs,' Mr Butler says. 'PCAPs are much more about the delivery of high-quality services, and have a specific function to ensure that people have access to primary care in areas where that has been difficult.'

The centre and the King's Fund have been evaluating the pilots since they began in April. Mr Butler is impressed, especially by the work of the nine demonstration sites selected for close examination and support.

Nurse-led primary care teams and salaried GPs have already taken root, plugging service gaps in areas that have been beyond the best efforts of HAs. The Pennywell estate in Sunderland, where there were no GP practices at all, now has a full primary care team including a GP.

Sunderland HA primary care development director Colin Waine is delighted at how quickly the new service has established itself. 'Pennywell has been grievously under-doctored for decades. But since the salaried GP was put in, the patient list has gone from zero in April to 1,000 patients - that was beyond our wildest imagination.'

Local residents now have a GP, a practice nurse, a community psychiatric nurse and a social worker on their doorsteps. The GP has the satisfaction of breaking new ground, supported - in sharp contrast to the traditional single-handed practitioner - by a community trust.

The Pennywell pilot has a two-year life but Dr Waine hopes it will become permanent. And he expects the salaried GP option - favoured by 'a lot of GP registrars' - to spread across the country.

The concept of a nurse-led primary care team, where nurses directly employ a GP, is also showing early signs of promise, according to Southern Derbyshire HA's director of primary care and commissioning, Bob Ballantyne. Nurse Catherine Baranaik, who is leading a new pilot in Chellaston, Derby, says she had no difficulty in recruiting a GP.

'In the fullness of time I just expect this to be another option for providing services,' says Mr Ballantyne.

PCA pilots have turned the rhetoric about providing care across boundaries into reality. In Warrington, the pilot developed by the local community trust and North Cheshire HA to serve a growing new town area is collaborating with the local authority to build a primary school and a healthy living centre on a shared site.

It may not work everywhere. The South West London Primary Care Organisation, a PCA pilot that started life as a total purchasing project, includes seven GP practices spread across three boroughs. Its work, which includes a hospital discharge project, may be complicated by the likely configuration of local PCGs. To avoid being split up and slotted into whatever PCGs emerge, the pilot is proposing to become a single practice.

Wandsworth Community Health Council chief officer Lesley Stuart has 'mixed feelings' about this defensive tactic. 'Some of the things the PCAP has done are brilliant. But I don't see any reason why they can't be spread to PCGs,' she says.

But she is worried that local services will become hopelessly complicated and opaque, especially for patients who are supposed to be the object of the changes. 'It's incredibly difficult for patients to have the vaguest idea of what's going on. Trying to explain all this is just a nightmare.'

But Michael Sobanja, chief officer of the NHS Primary Care Group Alliance, cannot imagine PCA pilots causing any hiccups for PCGs, which he thinks will simply absorb them. He says some commissioning pilots have already folded in anticipation of PCGs.

'I know of one that has been stopped before it's even been evaluated. People are obviously looking to the future of PCGs. From 1 April there will be about 500 of them. And that will be an end of it.'