Reform changes may threaten what little progress is being made

The short answer is that, 11 months after the white paper, very little of real substance has been delivered – apart from emptying the offices of primary care trusts and strategic health authorities. However, it would be wrong to think that nothing else has changed.

Beyond the much hyped but largely paper exercises, such as the designation of pathfinder consortia, some new models of commissioning are emerging which have a chance of surviving the transition and fathering a sustainable system in a couple of years.

The Cambridge commissioning senate, for example, proves two things. The first is that while managers came up with the grandiose “world class commissioning”, GPs are every bit their equal in coming up with pompous titles (Cumbria has a commissioning senate too). The second is that the senate’s responsibilities both demonstrate a clear shift of responsibility and provide a mechanism for enabling that transfer.

HSJ’s Local service is reporting that across the country – in Northamptonshire, Nottinghamshire, Somerset, Devon, Birmingham, Essex, Leeds, Manchester, London and elsewhere – new commissioning arrangements are being put in place, typically as PCT sub-committees. This week comes the news that private GP service provider Intrahealth wishes to form a consortium – linking up “like-minded” practices across the North East.

These new models are emerging from amid the chaos of PCT degradation and policy confusion – but they are beginning to make decisions on provider contracts, service planning, disinvestment and even primary care performance management.

In Western Cheshire for example, the PCT cluster has formally delegated 60 per cent of its £400m budget to a single consortium. In Sandwell, GPs have been given responsibility for 75 per cent of the area’s cost improvement programme.

Where these new models work well, their clinical leadership – with the appropriate managerial support and advice – stand a better chance of shifting some of the previously intractable problems afflicting health economies and delivering improvements and savings.

Of course, these gains could have been achieved without the radical surgery of the government’s reforms: many of the best models are reminiscent of the most effective PCT professional executive committees. But the damage to PCTs has been done and the NHS must work with what it has.

The government is terrified of letting a two tier commissioning system develop. It remembers how divisive fundholding was, with its evangelists and refuseniks, and how it gave Labour a weapon with which to attack the then Conservative administration (the opposition has already been presented with quite an arsenal). Consortium commissioning was also always likely to increase local variation, but the coalition will do almost anything to avoid the “postcode lottery” charge.

The government clearly intends to slow down the reform timetable – encouraged by the nervousness of some GPs and other clinicians to sign up – and tweak its content to take the heat out of these debates.

We know now that consortia will not automatically be taking over commissioning from April 2013. This is a sensible move.

The expansion of clinical senates to include non-GP expertise is also largely welcome and effectively builds on the experience of specialist commissioning networks, which seem set to be retained.

However, the decision to mandate hospital doctors and nurses as members of commissioning consortia boards is pure tokenism - as Future Form chair Professor Steve Field has pointed out.

What is more, consortia now face their actions being scrutinised by clinical senates, the NHS Commissioning Board, Monitor and local authority Health and Wellbeing boards – who are very likely to see their role strengthened. It is not a recipe for encouraging bold and rapid action.

Both David Cameron and Andrew Lansley have declared their intention of learning from New Labour and not wasting their first few years in office. Through the cack-handed way the NHS reforms have been handled they are in danger of doing just that. However, they can salvage some progress by ensuring the changes to the reforms do not undermine those few who – at the least – have a chance to make a difference.