Managers' leaders have voiced serious concerns about new guidance giving GPs a dominant role on primary care group boards.
The long-awaited guidance emerged in a letter from health minister Alan Milburn to the British Medical Association's GP negotiators last week.
It says that at levels one and two, PCG boards should be established as committees of health authorities and include four to seven GPs, one or two nurses, one social services nominee, one lay member, one HA non-executive and the PCG's chief executive. GPs will be allowed to decide locally 'whether they wish to hold the chair'.
John Chisholm, chair of the BMA's general medical services committee, said this was enough to meet its demand that GPs should have a majority on PCG boards.
The GMSC last month threatened to ballot GPs on unspecified action if ministers did not concede this point and another six 'key' demands on the structure and funding of PCGs.
Dr Chisholm said Mr Milburn's letter was a 'satisfactory basis for GPs to enter PCGs'. A ballot was therefore 'redundant'.
But the Royal College of Nursing immediately expressed its disappointment with the arrangements. General secretary Christine Hancock said the RCN would 'expect' boards to include two nurses, and 'it should be up to a PCG board as a whole to nominate a chair'.
The director of the Institute of Health Services Management, Karen Caines, claimed: 'There is a real danger that this letter is trying to address the concerns of just one set of stakeholders.
'Chief executives of HAs could be asked to be personally accountable for the actions of PCGs but have no stake in the management of the groups, ' she added. 'It is unclear how proper accountability can be exercised.'
Jaki Meekings, chair of the Healthcare Financial Management Association, also questioned how the arrangements could 'square with the responsibility of HA chief executives to work within their budgets each year'.
'There seems to be nobody responsible for financial control, ' she said.
'That is a real omission.'
Stephen Thornton, chief executive of the NHS Confederation, said it was 'important. . . to get GPs engaged in the new process', but expressed disappointment that doctors could chair the new groups when 'the opportunities for local public involvement in PCGs seem weak enough as it is'.
But Dr Chisholm told HSJ that managers should not be 'upset' about governance arrangements unless 'they hoped to get in and manage them'.
Ken Jarrold, chief executive of County Durham HA and former NHS human resources director, also argued:
'I think it is important that HAs are not on the boards of these groups. They will only work if there is local ownership.'
But he added: 'It means holding them to account through the health improvement programme.'
Mr Jarrold also backed calls from the HFMA for further guidance on PCGs' financial arrangements to be issued urgently.
Milburn's concessions Protection for GPs' independent contractor status.
A guarantee of 'clinical freedom to prescribe and refer in the best interest of patients', with PCG overspends 'managed within the funds made available to HAs and the NHS more widely'.
Ring-fencing for primary care infrastructure cash by creating 'floors' for funding premises, computer and staff costs at HA and PCG level.
New legislation to ensure local medical committees represent all GPs.