The delivery of public health improvements could be undermined if primary care trusts are swamped by their new commissioning and performance management roles, according to a report by the NHS Alliance.

The government has already set a series of tough targets for public health, including a pledge by health secretary Alan Milburn to cut differences in mortality rates between rich and poor.

Yet while PCTs are seen as the main vehicle in the government's programme, PCTs and Health Improvements - in part, a response to government consultation document Shifting the Balance - suggests some may be developing in the wrong direction by failing to ensure primary care teams adopt public health perspectives.

It also expresses fears that PCTs will not have enough time for 'effective inter-agency working' which is 'essential for health inequalities to be addressed'.

NHS Alliance chair Michael Dixon called for PCTs to devolve their commissioning. 'There has been a tendency for PCGs to merge together to make very large PCTs. The idea is that bigger is better for commissioning.

But there are a number of models up and down the country where they can operate on a much smaller scale.'

'We would like to see that devolve even further where appropriate, even down to sub locality level, to ensure that local people are getting services that fit their own needs.'

As part of this 'devolved' process the NHS Alliance report is calling for public representation on all PCTs to strengthen links with the local community, whose involvement is seen as crucial to delivering public health improvements.

The report says: 'There has been too much recent emphasis on formal needs assessment and consultation, and not enough emphasis on service development. The alliance believes that if frontline staff and local communities are to be empowered, then more attention should be paid to their views. They should be given the opportunity to develop new and innovative services that respond to local needs.'

But along with the need for training and support for lay representation, it says mechanisms will also need to be in place to ensure the emergence of 'professional representatives' who may not be expressing the real wishes of the local community.

PCTs and Health Improvements. www. nhsalliance. org