'The challenge of the last three years has been demand management. The focus for the next two years must be a considered challenge to activity attribution.'

October welcomes the new primary care trusts - larger than their predecessors (with some notable exceptions), but with a very familiar set of responsibilities.

So what will it take for them to be seen to succeed, where earlier commissioning bodies are viewed as having failed, despite delivery of NHS plan targets, new contracts in primary care, considerable redesign and demand management and, in many cases, progress on tackling long-standing inequalities and variation in performance?

As ever, the NHS focus has been on designing the right structure to deliver effective commissioning - big PCTs coterminous with local authorities. But for the 'new' trusts to deliver, we need not only the right structure, but a set of processes and metrics to support commissioners in making difficult decisions.

As part of the overall NHS redesign, the Department of Health has rejigged processes, a new financial system and a wealth of performance management and scrutiny bodies applying the metrics. Whether these deliver core strategy is more difficult to demonstrate. If the white paper Our Health, Our Care, Our Say is the latest and most comprehensive strategic intervention, we should expect that payment by results, the tariff, central prioritisation decisions and 'shooting offences' would be constructed to deliver it. Instead we had the operating framework 2006-07.

A clear role for those leading commissioner development at the DoH will be to revise financial systems and metrics so they really do encourage strong commissioning.

Strategic imperatives

Going forward, our collective strategic planning must owe more to Sir Derek Wanless than to DoH finance reformer Bob Dredge: Sir Derek highlighted the need to invest in health improvement, primary care capability for managing long-term conditions and patient self-management. Bob gave us numbers.

We need metrics that enable the government to account for this investment (measuring productivity in finished consultant episodes does not help) and we need to communicate the vision for out-of-hospital care coherently to an anxious public that still equates the health of the NHS with bed numbers.

The challenge of the last three years has been demand management, but across the country PCT managers in partnership with GPs have realised huge changes in what can be handled outside acute care. The focus for the next two years must be a considered challenge to activity attribution. Payment by results was always a misnomer, but the historic construction of the tariff and rules of engagement have now got to change to realise potential productivity gains and clinical improvements.

The commissioning framework's commitment to support a 'resource and care utilisation' approach is welcome and needs to be supported by processes, measurement and political will which enable PCTs to interrogate trust activity claims and take action. If a PCT has delivered a 39 per cent reduction in GP referrals, should it have to pay for consultant-to-consultant referrals which run at 39 per cent above the strategic health authority average? If PCTs are to be active commissioners, they must be supported in refusing non-commissioned activity and decommissioning low-priority services.

Effective leverage lies in the fine print, which needs to aligned with the rhetoric. This is most obvious in the attribution of price to different healthcare resource groups, but also applies in more esoteric areas, in particular the rules governing timeliness of reporting activity. Last year, a local acute trust recalled all its activity information in December and 'reviewed' it back to April, then announced an additional£3m of activity it had 'found'. Bizarre, but entirely allowable within current rules, which are designed to support income maximisation to hospitals, not the overall productivity and cost-effectiveness of the service.

Timely reporting

Activity information should be provided within six weeks of treatment, with penalties for late provision and a deadline beyond which there is no requirement to pay. PCTs cannot review use of resources if they are only informed of their bill in the final quarter of the year. Clearly this also requires PCTs to become sharper in tracking referrals, but this is only worth investment if consultant-to-consultant referrals and emergency admissions can also be tracked and challenged quickly.

Beyond limiting inefficient investment, the real benefits of 'care and resource utilisation' don't come from working with hospitals at all. The last three years have seen major efficiencies and clinical improvements from commissioning primary care to manage chronic diseases; collaborations of community services, third sector and social care in new models of intermediate care and care management; and work to tackle social exclusion, deprivation and poor housing.

This work has been largely ignored by NHS performance frameworks and, indeed, came under direct attack from the Commissioning a Patient-led NHS requirement to divest of community provision. The DoH appointment of the two Davids (Nicholson and Behan) for the NHS and social care respectively provides an opportunity to monitor, support and reward collaboration in adult care across organisational boundaries and opportunities for the third sector.

Above all, active commissioning will mean learning how to engage public and patients, in a new and often uncomfortable relationship, in a genuine debate about priorities and investment and affordability. We need to apply the techniques of large group participation, social marketing and surveys much more consistently at local level if the changes required for service improvement and affordability are ever to be accepted by a public informed by Casualty and ER.

This time round we also need to act on the responses. That would mean a very different operating framework for 2007-08 than the current rules of engagement.

Sophia Christie is chief executive of Birmingham East and North PCT.