Statutory control on decisions is not enough to allay fears

All over the country, primary care trust chief executives are sitting hot and sweaty in their best suits, fighting for their future careers.

They will have prepared as best they can for the interviews taking place. Presumably that would have included the 15 documents on PCT fitness for purpose issued last week, with over 100 pages of spreadsheets and diagnostics. The 40-page commissioning framework that emerged last Thursday will have seemed like light relief: though perhaps not to those who spotted that the meat was in its 78-page annex.

Most will have had to rely on a quick skim. This will have told them that there will be no let-up in the expansion of the role of the private sector in the NHS. The government last week reissued its OJEU advertisement to clarify that PCTs could outsource the running of their management services, not the whole of their commissioning function. What this really means remains to be seen.

Meanwhile, the document set out a host of incentives which could be used to attract new providers into the primary care market. Options include giving the private sector facilities, lending companies money and paying them at above tariff rates.

Finally, interviews close this week for the job of running the NHS. Just one candidate from the service has made it onto the shortlist.

Each of these developments requires separate analysis. But who has the time? While the private sector works up its bids, NHS managers feel under attack from all sides. A lack of faith in previous government commitments (remember promises of an 'organic' restructuring?) mean it is hardly surprising if people are reading the worst into the overtures being made to the private sector, and are looking for a clear ideological line to be drawn.

The pragmatic answer, as the Institute for Public Policy Research argues is to draw a line - and not cross it - at the point at which commissioning decisions are actually made. But statutory control of decisions is not enough. Any board which outsources its supporting functions needs to be at least as sharp and twice as strategic as those running them if it is to retain genuine control of its levers.