It is no coincidence this is happening now. With the NHS under huge pressure to make efficiencies and the boom years of funding about to end, this is all about saving money.

The NHS Alliance's Dr Michael Dixon has said that vertical integration would be a 'huge step backwards'. The move certainly seems at odds with the push to make the NHS more accountable to, and better involve, local patients.

Of immediate concern is what will happen to community services if they are run by organisations with little understanding of primary care. The NHS Alliance has warned of redundancies and scaled-back provision.

What would this mean for practices' relationships with services such as district nursing and health visiting, which in some areas have already suffered greatly due to PCT reorganisation and cost saving?

In addition, health commentators have been warning for years that foundation trusts hoover up money and resources from health economies. PCTs, often with less experienced and less well-paid managers, have frequently struggled to negotiate change, especially moving services into the community.

Commissioners will have an even tougher time if they come up against 'super providers' that can 'do it all'. It is debatable how much commissioning there would be left to do and whether commissioners would have influence over such powerful organisations.

All this could happen at a time when both Labour and the Conservatives expect GP practices to take greater responsibility for commissioning, with the Tories saying that GPs who fail consistently to balance their books will lose their contracts.

If these changes come to pass it will do little to persuade those GPs who do not want to commission that now is the time to get involved - and this factor could scupper many of the politicians' plans.