Out in front Just 13 primary care trusts will be launched in the first wave, but guidance only increases speculation over who will control whom.

It was the week when primary care came of age. The list of the 13 organisations that will pioneer the governments health service reforms had been eagerly anticipated.

The first primary care trusts promise to change the largely random mix of general practice and community services, where access to a whole range of healthcare depends largely on where you live and who your family doctor is, where some GPs offer minor operations on-site and others struggle in run-down premises without even a practice nurse.

But more than that, each PCT will control a budget accounting for 80 per cent of NHS spending in its area. The 13 front-runners, due to be launched in April, will replace health authorities - and the government spin is that this means GPs and community nurses will organise not only primary care but most hospital services.

NHS Confederation chief executive Stephen Thornton says: This change in the way the NHS is organised should lead to better quality and uniformity of primary care, which is notoriously patchy .

Nineteen primary care groups - the forerunners of PCTs - had applied to lead the reforms in the first wave from April.

The lucky winners could be joined by four more in time for the launch - ministers are still looking at applicants from London and the South West.

One PCG, Harlow in Essex, has pulled out due to opposition from GPs and is unsure about its future plans. In West Hertfordshire, Hertsmere has delayed its bid and is now planning to join the second tranche in October .

The rest of the first wave had been widely predicted to succeed. A cluster of PCGs in North West Anglia had been working on trust status for more than a year - long before PCGs were even officially up and running.

Fenland, North Peterborough and South Peterborough PCGs plan to set up separate but closely related PCT's.

They will shortly be joined by their neighbour West Norfolk, one of only two PCGs already chosen to lead the second wave.

Audrey Bradford, chief executive of Fenland PCG, is delighted to be given the go-ahead. It has been a terrific amount of work, but now we have got the decision we are going straight from second to fourth gear - from level-two PCGs, which sit as sub-committees of their HA, to fully fledged top level PCT's, running community as well as GP services, in one easy bound.

North West Anglia Healthcare trust will be left as a residual organisation, coping with a£30m budget cut and managing a community hospital on the borders of its district.

Ms Bradford is surprised at the lack of reaction to the changes from colleagues elsewhere. It seems that there isn't much interest from the rest of the country. The response to us has been quiet - if we are pioneers I am not quite clear why people aren't calling.

GP leaders describe the governments agenda for PCTs as a unashamedly populist approach that is highly likely to increase consumerist demand .

The British Medical Associations document, Primary Care Trusts: implications for general practice, warns:

PCTs will become the real source of power within the health service.

Health minister John Denham agrees. Announcing his list of those that will spearhead the revolution, he promised that doctors and nurses would have a whole range of new powers to work with hospital consultants and local authorities.

But managers think the control issue could work the other way round. PCGs are led by GPs. Family doctors have the right to chair their boards and to take a majority on them. Even though PCGs are merely part of HAs, this was a major development in clinician power .

PCTs, however, could be seen as an extension of management control of general practice. GPs highly prized independence - self-employment, choosing which services to offer, making their own decisions about treatments - will be subsumed into the new organisations. PCTs will decide what money is spent where, and insist that doctors comply with national guidance on treatments and standards of care.

As independent institutions controlling multi-million pound budgets, PCTs were always going to need formal arrangements to ensure there was no conflict of interest when professionals took spending decisions that affected their own practices.

Ministers knew, however, that GPs wouldn't stand for boards of directors similar to those in HAs or trusts, full of lay executives and chairs appointed by the government. Instead they proposed a messy compromise, with an executive committee of clinicians handling day-to-day operations, over - seen by a board with a lay chair and a professional chief executive. PCTs will be led by a chair, a chief executive and a chair of the executive committee - which should confuse the post room.

But the latest guidance on how PCTs will be run contained a nasty surprise for managers. The NHS Confederation spotted a subtle change in one paragraph of the weighty group of documents that make up Primary Care Groups: taking the next steps.

Confederation head of primary care Jane Austen says the alteration from the draft guidance is a radical new statement that fundamentally changes the power balance of the triumvirate of chair, chief executive and chair of the executive committee .

The latter - likely to be a GP - will now be responsible for the operation and performance of the PCT. Ms Austen says: It could end up with effectively the chief executive being a servant of the executive committee.

The guidance says the executive committee chair is directly accountable to the overall PCT chair - leaving the chief executive out on a limb.

Why did the NHS Executive think this up? asks Ms Austen. The confederation has written to NHS chief executive Sir Alan Langlands, demanding an answer. The rest of us will have to wait to see how this first batch of PCTs - and the power struggle between GPs and managers - turns out.