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Re Frank's comment : the layer of CSU is essential for 3 reasons . Firstly GPs, who function at the gut instinct level, do not know how to behave as responsible public servants and require the leadership of officers to pull them into line with CB expectations ; secondly CSUs are surely an effective channel for national policy and acceptable codes of behaviour and are large enough to promote a culture of compliant behaviour; thirdly, CSGs have shed much of the PCT know-how, and have to start again to learn how to commission and procure safely. I guess the whole thing is a bit like using steel buttresses to secure a badly designed building - it is inevitable once the foul deed is done.