Published: 03/11/2005 Volume 115 No. 5980 Page 18

Name and address withheld

I am chief executive of a primary care trust which has never been less than two stars, and is now three. I should feel proud. But I feel I have been dubbed a 'failure' in terms of implementing Commissioning a Patient-led NHS (news, page 6, 27 October).

My confidence for the forthcoming local development plan negotiation is dented by the ferocity of the debate on the poor quality of commissioning. I worry we will struggle to convince providers that they have a role in achieving financial balance, and that any problems are not purely down to our own competence.

The speed at which PCT leadership has come under attack is startling since it does not recognise the extent of central influence. Implementation of Agenda for Change, the consultant contract and the new general medical services contract have all been concreted in our cost base.

I suspect they will all deliver long-term liberation, but it is hard to realise this potential at present. The implementation of payment by results, foundation trusts and independent treatment centre procurement also determine our destiny. Given the degree of centralised policy implementation, we must not allow the creation of a myth that a wholesale clear-out of current PCT leadership will solve our ills.

I am a total believer in the reforms, but I implore senior leaders to embrace the full complexity of the commissioning challenge in the NHS.

I have sought to learn from the many good examples of strong commissioning demonstrated by health maintenance organisations in the US. I was in awe of the clarity demonstrated by their chief executives - in particular the way they styled services around the patient while minimising expenditure. I saw how the house medical officer booking GP appointments and patient taxis redirected a determined emergency room attender to the appropriate and most cost-effective care. But since my return from these eye-opening visits, I have struggled to implement this approach at home.

I will watch with interest how policy-makers and SHAs deal with commercial commissioning professionals who will never agree to rapidly changing standards, demanding new targets and unready technology on budgets that are already 'in the baseline'.

I have seen some extremely impressive models - but all on a pre-negotiated price-per-person deal encompassing clinicians who have no option but to work to predetermined protocols and deliver preventative outcome measures such as smear rates and immunisation figures well below those we are proud to deliver.

I will be interested to see how commissioning bodies will take to the Houdini-like contortions required to achieve change amid overview and scrutiny committees and patient forums.

And this is before we take into account the fact that it is the many hundreds of GPs who are really supposed to be doing the commissioning!

But perhaps the most depressing part is that I do not feel secure enough to put my name on this letter.