Despite the controversy over Oxfordshire Clinical Commissioning Group’s outcomes based contracting plans, it was ultimately not the local providers that forced Dr Richards out – it was a vote by local GPs who may have been voting on any number of local or personal issues.

Nevertheless, his departure, combined with the compromises the CCG has agreed to its radical outcomes based commissioning plans, form a critical development for outcomes based contracting – and has wider political significance.

Dr Richards’ attempt to introduce integrated care through large scale contracts was seen as a test case because it was early and ambitious. Bedfordshire CCG might have gone to market earlier to find a lead provider for musculoskeletal services, but the Oxfordshire plans account for up to 40 per cent of the CCG’s entire £612m commissioning budget.

The main lesson here is that, as many suspected, CCGs might have the power to go to market and bring in new providers, but that does not mean they have ultimate power over their health economies. Put another way: integration is not something that one part of the system can enforce on another part through commercial activity.

Provider incumbency counts. Strategically important trusts will now assume that they will be entitled to take part in the design process from the outset. Where they judge local plans to be unworkable, they will expect their concerns to be accommodated.

The Oxfordshire episode is not only a setback for outcomes based contracting – it is a blow for clinical commissioning in general – and therefore for the reforms of former health secretary Andrew Lansley. It is now clear that even when a CCG is large and willing to use competition to enact radical change, it will not get its own way if it does not win the confidence of its providers.

Attention will now shift to Cambridgeshire and Peterborough and Croydon to see if they can succeed in implementing big, ambitious outcomes based contracts. With large influential providers such as University Hospitals Birmingham setting out their own vision for integrated care, the CCG sector needs to show it can be the driver of large scale service change. Otherwise, what will have been the point of the 2012 Health Act?

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