The first 17 PCTs - due to start in a fortnight - are putting together their plans, while ministers firm up accountability arrangements.But doesn't it all taste a little of fudge, wonders Lynn Eaton

Four years ago, Queensway surgery in the centre of Southend, Essex, had its own budget of£3m a year, hired 22 hospital consultants to perform day surgery and other clinics and was one of the first GP practices to offer the latest Lichenstein mesh method for hernia repair.

The patients loved it. 'Wonderful, ' said one 76-year-old woman after her hernia operation. 'I went home and within a couple of days I was back to normal.'

But it was tough on anyone not registered with that particular surgery.

For them, there was no access to such high-tech services.

Since Labour came to power the word 'fundholding' has been airbrushed from the language. In its place came collectives - primary care groups and primary care trusts.

No sooner had the 481 groups that started last year found their feet than the next generation was launched. The first 17 PCTs take off in just two weeks, with responsibility for providing primary and community healthcare and commissioning hospital services. They will control£1.25bn of NHS money between them.

Incoming PCT officers warn against high expectations. Chris Town, newly appointed chief executive of North Peterborough PCT, says: 'By and large patients won't notice any difference, although I hope maybe in 12 months they will.'

But there are serious concerns about how the reforms will work. North London GP Dr Ron Singer, an executive member of the NHS Alliance, says:

'Resources are obviously an issue. The other thing is how you get an organisation like this together from the different cultures.

'Accountability is another big problem. It is not quite clear how responsibilities will stack up between the chief executive of the trust, the trust chair and the chair of the executive committee. This is a bit of a fudge they have got themselves into.'

Guidance on PCTs suggests that the overall chief executive could be left out in the cold.

The day-to-day running is down to the professionally led executive committee, beneath the board. The doctor or nurse chairing the committee will be responsible to the overall trust chair, not the chief executive.

The health minister in charge of PCTs, John Denham, says it is clear:

neither the chair of the executive committee - which represents professional interests - nor the trust chief executive is directly accountable to the other. But both are responsible to the overall chair of the board.

Doesn't this smack of the old hospital boards, where the real power lay with consultants, not managers?

Mr Denham sidesteps: 'It is an arrangement which allows us to have a strong professional leadership and to have a clear sense of accountability. The system is clear and workable.'

He denies any suggestion that many PCTs will be coming on stream with a limited budget, the result of inheriting last year's PCG overspend on prescribing.

But Audrey Bradford, acting chief executive of Fenland PCT, near Peterborough, admits that it will have to make savings next year. 'We've been through some very difficult decisions in the PCGs and come to an understanding with the health authority about how we are going to handle it.

'Our biggest fear is that the level of growth and inflation on the prescribing side is set to increase to 11 per cent, which is far higher than most of us have budgeted for.

'We've got£53m to spend and£8.5m of that is on drugs. It is important that we understand how that money is effectively and efficiently prescribed.'

The community trusts that remain, with smaller staffs and fewer responsibilities, face their own problems.

Barbara Kennedy, chief executive of North West Anglia Health Care trust, is now responsible only for mental health and learning disabilities.

'Increasingly, it will be difficult. Some of the top team here moved into PCTs. New people have come in. But maybe within the next few years this trust will cease to exist.'

Possibly the most revolutionary idea of all is GPs working together.The local medical committees in Poole and Southend voted against moving to trust status.

David Pelta, one of the GPs from the Queensway practice, says 48 GPs voted against the PCT and only 31 in favour.

He admits to being ideologically opposed to the principle of trusts, but is particularly concerned at the current situation.

'I am totally disenchanted with what is going on' he says. 'We haven't got a single thing in place.'

He says his surgery counselling services - which cost less than£10,000 a year - have been dropped because the PCG has deemed this service not clinically effective.

Mr Denham argues that the PCT would not have been approved had the Department of Health thought GPs in the area would not get involved. But it is not for one single professional group to veto the initiative. 'You couldn't give one group that right, 'he says.

The proof of that pudding - or fudge - will be in the eating.

Proposed budgets for new PCTs, subject to final adjustments

PCT Budget Population size

Central Derby£61m 107,000

Daventry and South

Northants£45m 93,000

Epping Forest£60m 100,000

Fenland£53m 88,000

Hillingdon£170m 245,000

Mansfield District£60m 93,000

Nelson£90m 155,000

Newark & Sherwood£68m 118,000

North Peterborough£64m 110,000

North East Lincolnshire£89m 170,000

Poole Bay£56m 79,000 Poole

Central & North£54m 91,000

Southampton East£79m 128,000

Southend£90m 171,000

South Manchester£103m 146,000

South Peterborough£49m 90,000

Tendring£65m 133,000

Total budget£1,256m