Poor networking and planning by primary care trusts is holding back reform of urgent and emergency care, a major Healthcare Commission review has found.
Just one in three PCTs had "active and well developed" networks for unplanned care, the regulator said.
Commission chief executive Anna Walker also drew attention to failures in reviewing provider outcomes and said PCTs needed to find new "whole system" measures.
"What I think is really important is PCTs having the concept of networks, commissioning something that is holistic, and having information on how these services are improving and where there are problems," she said.
Not Just A Matter Of Time, published last week, is the commission's only report to rate all unplanned care in each PCT area.
The number of different and often new services, such as walk-in centres and out-of-hours GP services, could confuse patients if they were not well co-ordinated, it said.
There have been improvements but services often did not communicate or share information well.
Trusts were weighted on access, integration and effectiveness and nine management criteria. Many trusts monitored GP out of hours care but only 30 per cent looked at patient safety incidents in accident and emergency departments.
Seventy-three per cent of PCTs had run campaigns to raise awareness of services but only 40 per cent had evaluated them afterwards.
Bolton PCT received the lowest overall score of 1.94 as well as a low management score.
Chief executive Tim Evans said the review had not picked up on work in several areas: "It is saying we have not got an urgent care strategy [but] we have a really well-defined strategy. Also, I think we are one of the best at working together."
Wirral PCT was rated 2.58 overall, but was among the lowest on management with 2.00. Director of commissioning and performance Cathy Gritzner said the PCT had recently made significant improvements.
"We are disappointed but we knew this was a potential result because we undertook a review last year," she said.
PCT Network director David Stout said: "By and large the review shows the system is not working badly, though clearly there are elements and processes that are not working as well as we would want them to.
"Part of PCTs' job is to make sure people understand how services operate. But we are encouraging patient choice, so I don't think we should assume that patients using services in different ways is wrong."
The also report highlighted variations in ambulance turnaround times at accident and emergency departments and backed plans to pilot a single urgent care number.
BOTTOM SIX PCTs
Management score (1-5)
South West Essex