With only a few months to go before primary care trusts have to submit their strategic plans, the scale of the world class commissioning challenge is becoming clear.

Among the welter of formidable difficulties, many PCTs are struggling to assemble data defining where they are. Without knowing from where they are starting, they will be unable to plot a route to their destination.

Even some PCTs that have the numbers are not yet adept at using them to drive commissioning decisions.

Others are allowing themselves to be overwhelmed by the process, at the expense of focusing on the health goals they want to achieve for their communities. The Department of Health believes PCT boards are key to providing local leadership of the NHS, but some are not even discussing outcomes. As Department of Health commissioning director Gary Belfield observed at HSJ's conference on world class commissioning last week, would the board of Tesco manage to get through a meeting without discussing food?

The first year of the new world order in primary care is going to be a rough ride. The NHS Confederation predicts that only a handful of PCTs will be scoring more than half marks on most of the world class commissioning competencies. The DH appears prepared to take that in its stride, but the performance screw will be turned sharply in the second year. Boards coming from a low base that fail to demonstrate strong improvement could be sacked.

The strategies will have to spell out in detail not just what the PCT intends to do, but how. Platitudes expressing the desire to get obese teenagers to have sex less and exercise more will not suffice. The irony that strategic health authorities, who will be among those judging a strategy's efficacy, slipped a good crop of unsupported platitudes into their regional Darzi plans will not be lost on PCT managers, but no-one said life in the NHS was fair.

But primary care trusts should not allow the number and scale of problems to shake their confidence in long term success. PCTs are young and small organisations, wielding billions of pounds of means in the search of profound ends about life and death. It was never going to be easy.

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