The grand old health secretary risks getting the new consortia stuck on the hill, unless a change in strategy to push them higher up the slope of success is attempted.

Oh, the grand old Duke of York,

He had ten thousand men;

He marched them up to the top of the hill,

And he marched them down again.

And when they were up, they were up,

And when they were down, they were down,

And when they were only half-way up,

They were neither up nor down.

The nursery rhyme is believed to refer to the Battle of Wakefield in 1460. The Duke of York took up a defensive position and, in a moment of hubris, marched his army “down again”. The government may unwittingly face a similar scenario after its Health Bill has eventually passed through Parliament.

When scores were released after the first round of world class commissioning, there was a debate about what they meant. The process had gone well, given the short timescale, but concerns that it had been too paperwork heavy were acknowledged.

The second round of world class commissioning scores demonstrated progress with some health gains which had been locally determined, not nationally mandated. Financial and access targets had been achieved and there was optimism that - as per the original aims - sustainable progress could be achieved over a five year period.

Practice based commissioning was far too variable, but it was not considered politically feasible to give GPs hard cash, as this would have been perceived as fundholding in all but name. As a result, many GPs felt very frustrated with the “heavy hand” of PCT bureaucracy.

There was doubt that 152 PCTs could ever become first class. Governance, finance, strategy and competency scores were too variable. Good working relationships with clinicians appeared to be the exception. A smaller number - about 30 - of bigger commissioners plus active local fund management by enthusiastic GPs was the next evolutionary step. Such tough decisions were side-stepped partly because of the impending general election and partly because NHS culture continued to promote the idea that it is better to muddle through (it’s then easier to blame the politicians when structural change happens).

Dumb waiter

It is ironic that we might now end up in a similar position. Strategic health authorities and PCTs will be abolished and commissioning consortia introduced. However, implementation of the new system will take place in the context of increasing central control as the government wrestles with financial balance and waiting list targets.

In practice, the NHS Commissioning Board will probably have created about 50 PCT clusters which - while they will have boards until 2013 - will be centrally directed by the board. They will be given limited objectives including finance, access, outcomes, GP development plus acting as a sort of “dumb waiter” in the process of consortium authorisation, which will be centrally directed.

The authorisation process itself will drive quality, innovation, productivity and prevention deep into consortia and simultaneously standardise and nationalise the way they set about commissioning. About 40 per cent of commissioning consortia will pass the first rigorous authorisation test and the government will then have to decide whether or not to direct the board to be more tolerant and flexible.

The result will either be political pressure to let more consortia “under the gate” or, conversely, to maintain a smallish rump of enthusiasts who will actively bring to life the current board’s vision.

Meanwhile, the board will be in a position to negotiate contracts with all tertiary and specialist hospitals and it will be able to protect or promote true clinical service excellence or mediocrity. If foundation trusts fear “death by 500 GP pea-shooters”, they should be equally exercised by the board’s “bazooka”.

So, if the end point of these changes looks familiar, what can be done to make sure implementation is better and the NHS does not remain gripped by the status quo? First, much more money, time and effort needs to be given to developing consortia.

Second, leading ideas from different countries need to be introduced to consortia from creation, particularly integrated care with secondary care clinicians.

Third, clusters need to be supported by third parties that can change their modus operandi.

Fourth, the authorisation process for consortia must not be watered down and the Commissioning Board must be given autonomy and independence.

Finally, if the new system does not focus on clinical outcomes at the very beginning it will never achieve improvements in this area because the system is wedded to targets and incremental improvement. A true focus on outcomes will enable consortia to contract for outcomes and this will create supply-side innovation that works for patients and taxpayers alike.

So, are we halfway up or down?