The government's response to the Health Bill listening exercise, that was led by former RCGP chairman Professor Steve Field, made welcome noises about blocking price competition in the NHS and rethinking plans for the regulator Monitor to promote competition. It made clear that the health secretary would remain ultimately responsible for making the NHS work.
But for GPs worried that consortia would have too little freedom, the government response offered little comfort.
Consortia, which will now be called 'clinical commissioning groups', with 'GP' struck from the title, will now be overseen by more than just the NHS Commissioning Board.
Health and well-being boards, structures that will sit between local authorities and consortia, will now have a 'formal role in authorising' consortia to become statutory organisations.
'Clinical senates' - regional groups of health professionals that will be set up to advise consortia - will also have a role in their organisation.
Consortia that win these groups' initial approval will then have to win their backing for any commissioning plans.
GPC deputy chairman Dr Richard Vautrey says health and well-being boards will be the single biggest issue for consortia in the coming years. 'If you don't nurture and get involved with them now as they develop, it's going to be a real problem,' he warns.
Although consortia will be represented on health and wellbeing boards, local authorities will control their make-up, and 'will be free to insist upon having a majority of elected councillors'.
The DoH also announced other requirements consortia must fulfil. They will be expected to have a governing board including a nurse and a hospital doctor who do not work in their area.
They will have a duty to promote integrated health and social care. Consortia will also not be allowed to cross local authority boundaries unless they can show a 'clear rationale' that the NHS Commissioning Board accepts.
Dr Stewart Findlay, County Durham and Darlington pathfinder consortium chairman, says the system is 'all starting to look more top-down and bureaucratic'.
'If we are going to cope with the financial challenge the NHS faces, we need to make changes quickly. But this is a recipe for bureaucracy, delays and disengagement of clinicians - all the things that went wrong with PBC.'
Dr Findlay says health and well-being boards or senates could force consortia to merge against lead GPs' wishes.
Forcing consortia to appoint a nurse and a hospital doctor from outside the local area is 'the most bonkers idea I have heard in my life', he adds. Consortia will struggle to find people willing to work on commissioning care outside the area they work in, he warns.
National Association of Primary Care (NAPC) chairman Dr Johnny Marshall says he has warned ministers that consortia must not be 'hamstrung in getting on with improving services by layers of bureaucracy'.
Dr Marshall says it is vital the NHS does not recreate PCTs - although plans for consortia to have a name that 'uses the NHS brand and has a clear link to their locality' means they will sound a lot like PCTs.
The NAPC is working to 'iron out' these concerns, he says. He adds: 'I think there's going to be continuing flexibility in trying to map out what these arrangements are going to be.'
Essex GP Dr Shane Gordon, national co-chair of the NHS Alliance GP commissioning federation, agrees there is 'a lot of detail still to come'.
He says plans to involve a nurse and a hospital doctor from outside the local area 'do not preclude' consortia from talking to local specialists.
Some consortia may have to make structural changes to adapt to the revised DoH blueprint, he says. But he adds: 'I don't feel we've been derailed by these amendments.'
Dr Vautrey, however, says that nearly a year on from the White Paper Liberating the NHS, 'there is still no clear vision of what the final structure is going to look like'.
He says new organisations, such as the clinical senates, will be expensive to run, and warned the NHS could 'slash and burn' services to hit its £20 billion savings target.
Health secretary Andrew Lansley says the Health Bill pause is now over, and is urging consortia to forge ahead with their development.
But Dr Vautrey said expecting consortia to develop before other organisations that could heavily influence them even exist was 'topsy turvy'.
The uncertainty could put off GPs who initially embraced commissioning. Dr Findlay warns: 'I'm not throwing the towel in yet, but I'm looking very hard at my pension plan.'
|How NHS reform changes affect consortia|