“NICE is accountable to the public,” Lord Crisp - the former NHS chief executive - advised Parliament last week. “What we don’t need is to import American style private sector rationing where individuals find themselves the victims of decisions made in private by individual insurance companies where nobody is accountable.”

He is right. Exposed to the open health insurance market, many of us would be as lambs to the slaughter.

Lord Crisp’s call is for transparency and regulation, likening health insurance cover to “a private healthcare lottery”.

But health insurance is not a lottery. It is a game of poker, against an expert.

The nature of the insurance business is to attract the customer, take the premium, then work hard to retain it. Multinational health insurers are ruthlessly efficient when it comes to rationing. They work hard to impose care protocols; step outside the protocol and you don’t get paid.

Hospital doctors in the US hate the protocol approach. It restricts clinical freedom; learning and development is limited; you become more like a hired hand on a production line. But inexperienced GP commissioners may find offers of “support” from the insurers irresistible.

Actually, their involvement may already be a tacit requirement, the suits reassuring the Treasury the NHS budget is in safe hands because the insurance sector is giving GPs the benefit of their business acumen.

And consortia that choose to work with the big insurers may soon rue the day, for the protocol approach begins in primary care.

Far from being the commissioners, GPs may soon find they are being commissioned.

Noel Plumridge is an independent consultant and former NHS finance director, noelplumridge@aol.com