Andrew Lansley claims primary care trusts had to be abolished because they failed to commission effectively - an arguable accusation.

The health secretary would have been on firmer ground if he had axed them because they had not improved the quality of general practice. The reason he did not choose that line of argument will be obvious to most. It is interesting to ponder how the reforms would have played if the public were aware of the variability in GP performance.

General practice is one of the NHS’s strongest attributes. But there is a significant minority of GPs who deliver poor quality care. There are also those who spend public money ineffectively - a failing of growing importance. Meeting the £20bn efficiency goal will require a step change in GP efficiency from 2012-13 onwards.

We do not know exactly how big the problem is within general practice - the profession, government and some PCTs have indulged in a conspiracy of silence on the issue - but we are not talking about the odd “bad” doctor. Exclusive research by HSJ indicates failings are widespread in nature and prevalence.

These problems will often be historical and embedded in accepted ways of working. In some cases GPs will be at fault, in others they will be victims of poor local and national decisions. The problems are likely to be unevenly spread across the country and the failings of poor inner city GPs will be different from those providing a bad service to rural communities.

Mr Lansley hopes commissioning consortia will use their professional knowledge and credibility to grasp the nettle. If they fail to, the NHS Commissioning Board will be incentivised and culturally attuned to do so. Ask any senior health service manager about board chief executive-elect Sir David Nicholson’s enthusiasm for robust performance management.