Just seven months ago, GP commissioners were poised to lead a clinically driven revolution in the NHS. Their deep understanding of the needs of patients and ability to eyeball hospital clinicians on service quality were billed as the levers for radical improvements.

But there is a grave danger that much of the early ambition around the reform of commissioning is being thwarted by two major obstructions—competition rules and financial instability.

Commissioners are struggling through a thicket of competition and procurement law, exacerbated by contradictory advice and uncertainty. Regulator Monitor has done its best to reassure clinical commissioning groups that they have considerable freedom to determine when and how they go out to tender, but many feel that is not enough to allow them to wriggle free of the legislative straitjacket provided by the Health and Social Care Act 2012.

Commissioners are also struggling over how much they are prepared to risk destabilising providers. Reconfiguring services always entails some degree of destabilisation, but with dozens of trusts facing financial difficulties it is a perilous decision for commissioners as to how far they can go in making changes.

If falling foul of competition law and risking bankrupting the local hospital has not unnerved them, there is always the fear of breaching conflict of interest rules.

Even articulating their vision for the local health service is tough. The mantra is “commission for outcomes not processes,” but defining those outcomes in a legally binding document is proving hard.

NHS Clinical Commissioners (NHSCC)—the membership organisation for clinical commissioning groups (CCGs)—is determined to reinvigorate commissioning by keeping GPs focused on what they are trying to achieve and encouraging them not to be distracted by the regulations and processes.

Its briefing document The Rules Are Not Your Enemy, launched today, drives home that CCGs have to be bold in changing the health system because of the stark facts contained in the Fiscal Sustainability Report published by the Office for Budget Responsibility in July. Bluntly, unless there is a sharp improvement in healthcare productivity, public sector net debt will spiral over the next five decades. Clinical commissioners have to take decisive action, which means taking significant risks.

Psychology is central to getting CCGs back on track. The GPs need to accept themselves, and convince their providers, that there is no risk greater than maintaining the status quo. Big changes are needed, and that has to come through major disruption to existing patterns of care.

But the message from the NHSCC is that this does not have to mean disrupting the whole supply chain, but making changes such as increasing integration between different providers and bringing in new services at particular points along the care pathway.

Competition law cannot be avoided, but it can be managed and shaped. When deciding whether to put a service out to tender, CCGs cannot ignore the market, but they can decide after an objective assessment of the evidence not to use it. By demonstrating they have considered all the options and are acting in the interests of patients, commissioners can help establish how the legislation is interpreted.

Nonetheless, the competition rules in the Health and Social Care Act are too prescriptive, certainly in comparison with the way competition law operates in other EU countries. In the closing stages of the parliamentary debate on the legislation health minister Lord Howe gave firm commitments that commissioners would determine when and how competition was used. The NHSCC wants ministers to firm up this position—if necessary through legislation.

For GPs, this is their only chance to lead the NHS. If they are unable to demonstrate they have made a substantive difference a future government will strip them of their commissioning powers.

Richard Vize is a journalist and communications consultant specialising in health and local government. He was the editor of the HSJ 2007-2010.