While there is near universal revulsion at the idea of merging primary care trusts in another reorganisation, joint working is gathering pace.

PCTs have always collaborated on, for example, commissioning tertiary services. But joint working is increasingly being seen as the solution to two problems: needing bigger boundaries to commission some acute care, such as in London, and overcoming shortages of expertise.

These will be difficult times for managers - being honest about their own organisation's need for help while ensuring the interests of the local community are not lost in some grand regional plan.

PCTs are supposed to be local bodies, in touch with their communities, and usually sharing their boundaries with councils with whom they are increasingly close.

Sharing expertise and pooling resources may well be necessary, but it needs to be pursued in a way which does not undermine what world class commissioning was for.

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