The number of primary care trusts in England could be significantly reduced under Conservative health plans, HSJ has learnt.

If they win the next election, HSJ understands the Conservatives are likely to require all GP practices to become practice based commissioners. Most of their commissioning functions would be performed through federations of GP practices operating as consortiums. This would result in a reduction in the commissioning role of PCTs in some areas, potentially leading to a raft of mergers.

Under the tories…

The merger of PCTs would be welcomed but not be forced by central government

All GP practices would be expected to become practice based commissioners

Trusts would be expected to negotiate prices for acute care at a rate under the PbR price

The Conservatives would welcome such mergers as part of an organic process but stress they would be voluntary. They hope to encourage more GPs to take up commissioning by turning the currently indicative budgets into real cash budgets.

Shadow health secretary Andrew Lansley told HSJ this would give practices “real opportunities to save and reinvest, and real control over contracts”. However, he was clear that any underspends would remain ringfenced for patient care, not practice profits.

Mr Lansley said this would combine “the decision-taking responsibility for where and how patients are treated with the finances which are necessary to support it”.

David Furness, health project leader at the Social Market Foundation think tank, said the implications of an enhanced role for practice based commissioning were “much more significant than has been [previously] discussed”.

If consortiums took on more responsibility for commissioning health services there could be less rationale - and management funds - for all 152 PCTs.

In some areas, such as north London and the East Midlands, PCTs have already merged some of their commissioning responsibilities to reduce costs and potentially increase their relative strength over acute providers.

Asked if the Conservatives would want to see more such mergers, a spokesman said: “It would be perfectly reasonable to aggregate, but it will be up to them [PCTs] to decide. It would be done on an organic bottom-up way if [they] choose to do so.”

Sources within the NHS, who have been asked to advise the Conservatives on the development of their health policy, said they thought the party would ideally like to see strategic health authorities and PCTs merged to create maybe 40 strategic commissioning bodies, organised around city regions.

That would resolve the perceived problem of PCTs being “too small” to negotiate good value from large acute hospitals.

However, a spokesman for the Conservatives denied they were planning to merge SHAs and PCTs. He said it was “very clear that’s not what we are planning”. However they do foresee SHAs moving their focus away from providers as more become foundation trusts.

Both Tory leader David Cameron and Mr Lansley have pledged they will not subject the NHS to another round of structural reorganisation.

Mr Lansley said PCTs would play an important role organising contracts between commissioning consortiums and acute providers.

The Conservatives will also expect PCTs to negotiate prices for acute care at a rate under the payment by results price - a plan that will only work if PCTs can get acute trusts to compete for their custom.

Management consultants advising the party have said it should allow private contractors to take over SHA functions on a “franchised” basis.

Organisations smaller than SHAs, charged with a mixture of current SHA and PCT roles, would be attractive to private sector commissioning organisations that have been disappointed by the opportunities and size of contracts available to them under the framework for procuring external support for commissioners (FESC). These could resemble US-style health management organisations if GPs were allowed to choose which they contracted with.

Nick Bosanquet, consultant director of the think tank Reform, said work at the Nuffield Trust to develop an NHS funding formula more sensitive to individual health needs would make it possible for patients to choose their commissioner.