The changes the government is proposing in response to the NHS Future Forum might satisfy most of the people for some of the time but their implementation immediately struck me as posing a number of problems. Where the changes stick to principles, for instance around the NHS constitution, the role of the secretary of state, Monitor’s core duties, then they seem sensible and address many of the concerns raised as a result of the proposed legislation.

The trouble starts when you get specifics – such as that commissioning groups will have to have a nurse and a specialist who “must have no conflict of interest in relation to the clinical commissioning group’s responsibilities, e.g. they must not be employed by a local provider.” Has anyone who wrote this been to Skegness? It goes on to say that each commissioning group must have two lay members. One of them will take a lead on audit, remuneration and managing conflict of interest. In Lincolnshire, right now, we have seven consortia. In effect this means we will have 14 non-executive directors. At present we have one chair of audit, a time consuming job requiring skills and experience that are not in huge supply. We will now need to find 7 people with similar skills. Perhaps we could share individuals between consortia? That does rather beg a bigger question! So now we have four extra people for each commissioning group to recruit and develop in less than two years to get the organisations authorised and fit for purpose. That seems to me to come at a cost. Yet we are cutting running costs not increasing them? We have given each of our consortia £4/head development funding. At least half has already been calculated as being needed just to cover clinical backfill. Does this indicate that the government doesn’t want small consortia?

Putting the affordability issue to one side, having lay input into the governing bodies of clinical commissioning groups, if I was on one, would be welcome as a safeguard against the suspicions some might have about probity and governance. Getting a specialist and a nurse who have no conflict of interest (and why does that not apply to GPs?) is frankly impossible and is it really necessary if we are going to have networks and senates overseeing and advising the commissioning groups?

Sorting out the governance for the groups is one issue. What really got me perplexed was trying to navigate all the layers of people and bodies outside of a clinical commissioning group who now have the right to say ‘no’ to what the commissioning group want to do. There is the NHS commissioning board, Health and Wellbeing Boards, clinical networks (will they have local providers on them?), clinical senates (will they have local providers on them?), local authorities and health scrutiny committees. In addition the public and patients will have to be involved “on any changes that affect patient services, not just those with a ‘significant impact.'” Navigating this sea of potential challenge safely and effectively will require great skill, time and a lot of capacity. It will make driving the sort of changes the system needs even more difficult than at present.

The months and years ahead will tell whether this piece of paper has really brought peace to the NHS in our time.

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire where there are 5,600 miles of road but less than 50 miles of dual carriageway.In April 2011 he was made director of commissioning and QIPP for the newly formed Lincolnshire PCT Cluster. There has, however, been no major change to the road network.