Published: 28/07/2005, Volume II5, No. 5966 Page 3

The Department of Health's announcement that the much-trailed rationalisation of primary care trusts is to begin will produce a variety of reactions.

There will be relief that the process is underway and that there is a clear steer on what the future will bring. The 15 per cent target for management cost cuts will engender fear, and there will be weariness at the prospect of another re-organisation.

Which feeling predominates probably depends on your job and your employer - even within PCTs some will see the reconfiguration as an opportunity, others as a death knell.

At least a third of all PCTs are set to disappear within 15 months (news, page 5).

During that time, PCTs will also be expected to develop plans to divest themselves of the bulk of their provider role and to have enthused most of their GPs to adopt practice-based commissioning. Given their already lengthy to-do list, this is a fiercely demanding schedule.

As with every NHS reorganisation, there will be a significant impact on service delivery and improvement.

However, on balance the strategy is the right one - and not simply because the logic of fewer, larger PCTs is persuasive.

The message from the DoH inscribed between the lines of the 10-page policy document is that 'in the future we expect to manage NHS performance through effective commissioning'. This is the inevitable result of the creation of foundation trusts, the shedding of PCT provider functions and the greater involvement of private sector provision in both secondary and primary care. It will eventually produce a significant change in the relationship between the NHS and government.

The DoH is in transition from HQ of a nationwide healthcare provider to healthcare insurer. Both kinds of operation are interested in effectiveness and value for money, but the levers they can pull to try to achieve it are very different.

As the provision of healthcare becomes less and less the 'business' of central government, commissioning will be pulled ever closer. How this can be achieved while maintaining local flexibility and sensitivity is perhaps the sternest challenge for the reconfiguration.