'It could be kindly argued that, by general lack of enthusiasm, a third of the country is yet to churn out any meaningful health activity data, yet alone customise or dynamise it to specific local goals. Perhaps more telling is that two-thirds have yet to even put together a simple budget concentrating on core activity.'

Commissioning is the buzzword in health systems across the western world. Reformists (a badge I am happy to wear) suggest that modern commissioning frameworks will be the only route to balanced budgets and successful targeting of health spending to specified outcomes.

The current rule set known as practice-based commissioning was originally launched in December 2004 with a fanfare and general feelings of heightened expectation. The policy model remains sound but clearly the implementation has been less than spectacular. Many commentators, including GPs and primary care trusts,.are happy to stand up and talk about commissioning but I am yet to come across anyone who is fully engaged in a model for even a minute portion of health spending that would be recognised as true commissioning across a disease cycle, yet alone reinvesting freed resources to target quality outcomes.

So what has hampered the delivery of a policy that market economists and traditional believers in public services all recognise as important? Wearing my GP badge you may expect me to make wild accusations of lack of incentives in the system, but this is simply untrue. Commissioning structures need to be successful and part of eventual productivity will be the need to invest in clinician time to run local clusters or new services. The absence of pump-primed funds means that reinvesting efficiency gains are implicit in the policy and can only happen if local health economies are free standing.

The slogan 'good management' should be music to most readers' ears. Yet the whole reason for institutional inertia lies with the core set of management delivery. PBC came so far down the task list in the old PCTs that, for argument's sake, it never happened. It seemed to outsiders as an unwelcome bolt-on to many managerial portfolios that meant it fell well below the notions of tidying up the office, filing a mileage claim and renewing the annual insurance for the dog.

It could be kindly argued that, by general lack of enthusiasm, a third of the country is yet to churn out any meaningful health activity data, yet alone customise or dynamise it to specific local goals. Perhaps more telling is that two-thirds have yet to even put together a simple budget concentrating on core activity. So it is not surprising that most GPs have yet to drum up any enthusiasm for this new venture.

More unkindly it could be argued that a general low-level PCT conspiracy was in place. Organisations are only being reconfigured by the fitness for purpose exercise, redrawn boundaries and shuffling of appropriately screened chief executives. Surely it was no accident that after two years only a third of PCTs had implemented key pieces to the jigsaw and by and large many of these were not well-stratified models predicting future spending.

To transform health delivery and standards we need to break down costs for diseases across a disease level, for example considering the community and primary care costs, acute hospitalisation needs and wider social care needs for things like stroke. Only then with targeted outcomes and considering the disease across the spectrum of the condition will expensive interventions comparable with international standards become the norm. Only then will CT scanning stroke patients at 3am seem like good value, using international evidence to support better patient outcomes and hence justify new commissioning.

I don't really think there is a conspiracy afoot to prevent data and budgets being handed to GPs. Most GPs don't seem to be bothered either but the NHS is going to have to think whether the status quo is ever going to leap frog us up the OECD league tables.