Primary care trusts will only be able to outsource all of their commissioning expertise in 'exceptional circumstances', with plans to be signed off by the Department of Health.

A policy statement published last week introduced stringent conditions under which PCTs could fully outsource commissioning support.

Last September, PCTs were told they could outsource micro, macro or 'end-to-end' packages of commissioning support, variously representing one service, more than one related services or 'a complete package of services' which would leave the PCT with only its statutory functions.

The framework for procuring external support for commissioners, published last week, sets out significant limits to this. PCTs would only be able to outsource the 'end-to-end' package of all functions in 'exceptional circumstances'.

Such proposals would require sign-off from DoH director general of commissioning Duncan Selbie, as well as the local strategic health authority.

The document says a number of payment models should be used when procuring services, to provide an incentive to the supplier to deliver value. It adds: 'This requires the supplier, in some circumstances, to accept similar financial risk that the PCT faces as a commissioner.'

But PCTs that do outsource the full 'end-to-end package' of all support functions, will not transfer high levels of risk to the private sector for two years.

The document suggests current PCT commissioning is not of a very high standard, requiring 'a major improvement in the capacity and capability of PCT commissioners'.

It says SHAs have indicated that the results emerging from the PCT fitness for purpose exercise and discussions on development plans show 'gaps in both PCT competency and capability levels'.

'The level and complexity of these gaps vary but there are distinct common themes that match the four main groupings of commissioning activities offered in the framework,' says the document.

A list of approved commissioning support suppliers is expected to be published by the DoH shortly.