The pace of change and reform in the NHS has been relentless as government and those who work in the NHS seek ways to improve the service. The King’s Fund set up an expert working group to examine how effective the current incentives were in achieving this aim. The group focused on the role of PCTs as commissioners and on practice-based commissioning but discussed other issues, including patient choice. This paper includes specific proposals for government, the Department of Health, strategic health authorities and primary care trusts. These conclusions should feed into Lord Darzi’s review and help to clarify the next steps for the NHS.