Puzzling it out

Health authority delegates to this year's conference may wonder what Mr Blair thinks 'major upheaval' is, if having to establish a new commissioning system by next April avoids it.

The first step, agreeing primary care group boundaries, has to be taken by the end of the month. So how is the establishment of perhaps 500 PCGs in England going?

Michael Sobanja, chief officer of the NHS Primary Care Group Alliance, says: 'It has been amazingly patchy.'

Maggie Marum of the National Association of Fundholding Practices agrees. 'In some areas, it has been top-down and there has been a lot of distress. In other places it has worked properly and the approach has been bottom- up.'

Stephen Thornton, chief executive of the NHS Confederation, says much the same thing - with a slightly different emphasis. 'There are places where GPs have rushed in and got involved, and others where they have waited for HAs to do everything - with everything in between,' he says.

Three weeks ago, the British Medical Association's GP negotiators were still threatening to ballot members on unspecified action if health minister Alan Milburn did not meet seven demands on the control and financing of PCGs.

Family doctors in various parts of the country took an equally strong line. 'There was concern in Birmingham, as there was nationally, about who was going to run these things and where the money was coming from,' says Steve Coneys, assistant to the chief executive of Birmingham HA.

'We took the view that these were national issues. Now national agreement has been reached, that has largely calmed down.'

He pays tribute to the 'realism' of GPs in the city, which has 50 per cent fundholding. 'They realised that this was government policy and it was going to go live,' he says.

'They also realised that they needed to get over these difficulties sooner rather than later. There is still a huge implementation agenda ahead.'

The old divides created by fundholding have not gone away, however. And trying to find 'natural communities' of 'about 100,000 people' that tie in with parliamentary constituencies and local authority boundaries - without straddling rivers and roads that local residents do not cross - has caused endless headaches in cities.

Steve Gillam, director of primary care at the King's Fund, says: 'I think there are real problems with the guidance on what PCGs are supposed to cover. I cannot see that people are going to stop being preoccupied with the 'who is in and who is out' stuff for some time. Nor is it clear what the arbitration mechanism will be.'

Mr Thornton comments: 'It has become clear that there are going to be a whole range of population sizes covered by PCGs, from the very, very small to the very large. The original idea of having populations of 100,000 has gone.'

Dr Gillam says other issues to emerge include a lack of public involvement - 'to most people, this stuff is just arcane detail' - and the exclusion of other stakeholders.

Clare Gerada, a GP working in Lambeth, Southwark and Lewisham, told a recent conference in London that a wide range of groups in Lambeth were initially included in discussions about PCG boundaries.

Stakeholders were invited to a conference and asked to vote on options produced by the HA by sticking red dots on sheets pinned on a wall.

The majority voted for a single Lambeth-wide PCG, but primary care professionals wanted two PCGs. 'The local medical committee took the view that since this is supposed to be a primary care-led NHS, it should recommend two PCGs,' says Dr Gerada.

'That is a perfect example of how difficult nurses and other professionals have found it to become involved,' says Dr Gillam. 'And it is bound to cause problems in future.'

While the loose ends are tied up, managers' and doctors' leaders are becoming increasingly anxious for guidance on the details of how to run and finance the new groups.

'The first question is how long regional offices will take to agree the boundaries,' says Mr Sobanja. 'Another contracting round is coming up very fast. PCGs must have time to deal with it.

'We also need to know when guidance will be issued. It does not help anyone if guidance is promised and then fails to come out or if things are left to local discretion and then swamped by guidance that suddenly appears.

'Officially, we do not even know yet whether people will be able to go in at levels three and four next year,' he adds.

'I do not see how they can get the legislation through in time, but it would be nice if someone would start saying things like that.'