Some decisions will always be unpopular, so PCTs must improve their reputation by ensuring that all decisions are seen to be transparent, efficient and fair

“Pensioner denied funding for ‘sight-saving’ drugs” and “The baby the NHS would not let us have” are two examples of the kind of headlines we often see accompanying stories of primary care trusts “turning their back”, “leaving people to die”, and “forcing people in their care to pay for treatment or go blind”.

With public finances set to shrink dramatically over the next few years, reconciling the expectations of the public with the reality of NHS budgets will become more important than ever

Most PCT chief executives will have dealt with this type of story at some point. We accept that part of our role is to carry the can for the difficult decisions the NHS has to make but which the public may not fully understand.

For the people involved and the readers, these are stories of tragedy, fear and despair - and explanations of why a patient’s treatment or care falls outside guidelines or is not considered cost effective are never going to be popular.

Attempts to place such cases in a wider context and to promote examples of a PCT’s investment in other local health services are likely to be unwelcome at such times.

As a former PCT chief executive I know this comes with the territory, but increasingly I see a more fundamental issue at stake.

Set against the backdrop of debate over the strength and quality of NHS commissioning, the drip effect of negative headlines about PCTs’ decision making has a significant impact on their collective reputation among media commentators, politicians and the public.

Is this inevitable - or is there more that PCTs could and should do to defend their reputation?

The first thing we need to acknowledge is that there remains a fundamental lack of understanding among the general public - and arguably among some in the health service - about the role PCTs play.

Some may argue that this is not in itself a problem; on a day to day basis, most people do not need to know what or where their local PCT is.

Yet a low profile leaves PCTs exposed to challenge regarding the transparency of their policies and the legitimacy of their decisions when contentious issues enter the public domain.

Where PCT commissioning has been subject to public scrutiny, it has often not fared well. Commissioners have attracted criticism from a range of commentators, and notably in the health select committee’s progress report on the next stage review this year, which argued that poor commissioning was threatening Lord Darzi’s vision.

Those of us in or close to PCTs know that such reports reflect an outdated and partial view of PCTs’ role and progress as commissioners.

The world class commissioning framework, which is still in its infancy, highlights the huge scope for improvement in the way in which PCTs operate as commissioners.

The initial assessment of PCTs’ performance against world class standards has been highly encouraging. Last year’s assurance process showed that, in the short time since PCTs were last reconfigured, most have built strong foundations for effective leadership, partnership and governance.

This year’s self assessments against the Care Quality Commission’s core standards provide evidence of stabilisation and improvement, indicating that PCTs as commissioners are now the best performing sector of the NHS, having previously lagged behind.

From my own interaction with PCT leaders across the country, I get a tangible sense of the increasing maturity and confidence of their organisations as the local leaders of the NHS.

I am less confident they are recognised by everyone within the NHS or the Department of Health, let alone by the man or woman on the street.

Many PCTs have made huge strides in improving communications with local people, particularly in terms of consultation with specific groups, or on particular issues.

However, research carried out by Ipsos MORI on behalf of the PCT Network indicates that many have a long way to go in fostering understanding of their role and their constraints.

Knowledge of PCTs remains low, and messages about value for money and the opportunity costs of decision making and the rationing of treatment are not well received.

While some aspects of a commissioner’s role will never be palatable to or popular with the public, PCTs can influence their reputation locally by ensuring that all their decisions appear transparent, efficient and fair.

With public finances set to shrink dramatically over the next few years, reconciling the expectations of the public with the reality of NHS budgets will become more important than ever. Paradoxically, these financial challenges may provide an opportunity for public dialogue about difficult decisions.

Now is the time for PCT leaders to be stepping up with confidence to lead this debate and engage with the public about the challenges of managing care for local people.