One of the major planks of the reforms are for the abolition of primary care trusts - the local(ish) level of bureaucracy which commissions services from GPs and local and general hospitals as well as other health providers.
In their place will come local commissioning groups which were meant to be led by GPs. With actual doctors on the ground being in charge, the hope was that there would be additional expertise and commissioning based on local knowledge and needs, not the target driven culture of the last government.
This week we have seen the amalgamation of two of the three Cornish commissioning groups as the smaller mid Cornwall organisation joined forces with the very large mid and west Cornwall group. The other organisation is the East Cornwall group which covers mainly the area of Cornwall that looks east to Derriford, Exeter and North Devon hospitals. The effect of this is that, rather than having lots of small local commissioning groups as was hoped, we have large organisations which could be remote from local needs and unaccountable to local people.
The big challenge though has been how to involve working GPs in the decision making. Nationally, it appears that many have chosen to withdraw as this survey by Pulse Magazine has found. The reason for their withdrawal appear to be the time commitment. As one former enthusiast for change told Pulse:
"When commissioning was announced it sounded like GPs would be able to do what they thought was right. But it has shifted to us being accountable here and accountable there and a whole lot of management speak. You never seem to be making any progress."But the new commissioning groups will still exist, so who is going to run them? Step forward the bureaucrats who have, until now, been running the Primary Care Trusts and other bits of the NHS that have been abolished.
Whilst the ambition of this part of the NHS reforms - to make commissioning more expert and accountable - was laudable, it appears to be falling apart already in some areas.