GPs would be handed direct responsibility to manage demand under a Conservative government because the party does not believe primary care trusts are up to the task.
Shadow health secretary Andrew Lansley told a fringe session at the party's conference in Bournemouth that too many PCT managers were weak on 'leadership and innovation'.
He said he would like to see practice-based commissioning extended to give GPs real budgets and the ability to draw up their own contracts ? a return to some of the major elements of GP fundholding.
Mr Lansley said: 'We have PCTs and managers who have not taken on commissioning responsibility. There are good managers but they are in a system where the DoH tells you what to do and you do it - there is no innovation.'
He added: 'There have been extreme financial difficulties for PCTs because they do not know how to manage demand.'
Mr Lansley said practice-based commissioning as introduced by Labour did not go far enough because it did not give doctors real budgets or allow them to draw up their own contracts.
He also indicated he would go further than Labour in giving the private sector the right to supply and give foundation trusts freedoms he said had been denied by chancellor Gordon Brown.
Mr Lansley said he wanted to see the creation of an incentive structure for hospitals, similar to the quality and outcomes framework, to ensure that providers spent their money more effectively.
And under a Conservative government, managers would be held to account through local contracts. 'They need to stop looking up the chain to the Department of Health rather than looking to patients,' he said. 'NHS staff need to work within a proper commercial framework.'
But Mr Lansley promised there would be no organisational upheaval if his party came to power.
'I don't want people to feel everything will have to be thrown up in the air again.'