The Health Bill remains silent about the 20 or so organisations that are to “support” NHS commissioning in England, but we should underestimate their significance.

Clinical commissioning groups assume commissioning support services (CSSs) will provide administrative support, taking on the donkey-work of contracting. Some, however, are beginning to worry about their competence and apparent lack of respect for their “customers”; they mutter about CSSs’ lack of accountability. And cynics suspect that CSSs, which are to become “free-standing enterprises” by 2016, are a temporary device to trim the redundancy costs arising from PCT abolition?

But the true role of a CSS is likely to be different; far from being the GP’s servant, they may soon define what NHS commissioners may and may not do. For CSSs are the ideal vehicle through which to impose controls and limitations on commissioners - including prescribing - and monitor their compliance.

It always seemed naïve to suppose that the Treasury would tolerate the transfer of £60bn of public funds to numerous loosely-defined new organisations, some still barely extant and led by a profession known for its vigorous independence, without insisting on a control regime. The spirit of the bill, and of the white paper that preceded it, is laissez faire; but in Whitehall the ability to hold to account and apportion blame is paramount.

Financial caution sits alongside two other dynamics; one is the desire, in recessionary times, to eliminate the variations in practice – in length of stay, re-admission rates, staffing skill mix – that lie beneath cost differentials.

The other is the political difficulty of handling the commissioning “postcode lottery”. As financial limits bite, more NHS commissioners are openly rationing their populations’ access to care. “Fat and fags” are becoming common barriers: no IVF for smokers, no joint replacement surgery for obese patients.

Such restrictions are thought of as deeply divisive, even amongst GPs. “I think it’s discriminatory,” Clare Gerada, chair of the Royal College of GPs, commented last week. “The government should determine what should be applied universally” she concluded. 

Dr Gerada, your wish may be granted via national restrictions policed by the CCGs’ own “support” organisations. And your colleagues won’t like it one bit.