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Currently trying to get my head round tomorrow's board meeting of the Cornwall & Isles of Scilly Primary Care Trust, which (it seems to me) has to make a very important decision.

At stake, eventually, is the future direction of all health services now provided by the £75million/year PCT, which employs 2,400 people. The choices are quite fundamental and highly political. The vision of a health service driven by a local competitive market does not sit comfortably with the post-war vision promoted by Nye Bevan in 1948.

Essentially it's between sticking with the NHS or going down the road of a new "Social Enterprise" organisation called a Community Interest Company. Staff first in line include health visitors, school and community nurses, those working in 14 Cornish community hospitals, the home care service and speech and language therapists.

For children's services the advice is to find a NHS "host" for two years "with a clear exit strategy." The recommendation to tomorrow's meeting is to take adult services into the "Social Enterprise" model. Staff in this group would be leaving NHS employment and are understandably concerned about the long-term prospects for pay and conditions. Inevitably at some point there will be yet more re-branding. I forecast it won't be long before someone introduces words like "creative freedom," "liberation" and "privatisation" into the debate.

The board of the PCT seem a decent bunch - as far as I can tell from their - and no doubt when they agreed to become quangocrats it was with a view to running the NHS to the best of their abilities, not making decisions like this. Not one of them has been elected.

The PCT has tried to engage the public on all this and has held around half a dozen meetings and done its best to brief staff. Yet there has been very little debate in the media - mea culpa, I suppose (too much going on elsewhere.) Tomorrow's PCT board meeting, in Bodmin, is open to press and public. If the recommendation is approved it will lead to the establishment of a business case, and a new Community Interest Company to take over the running of things within six months.

This split between provider and commissioner of health services has been widening, under successive governments, for many years. Next up, as a result of government reforms announced in July, will be GPs, pharmacies and non-emergency dentistry. One thing which everyone is keen to stress is that patients won't be affected. The PCT tells me that as far as patients are concerned, it will be business as usual. But aren't patients what it's all about? So why, exactly, is this happening?