'This is an historic day '

The death of the directorates of health and social care looks like the end of regional structures in the NHS for the first time since its foundation.

One strategic health authority chief executive said: 'It is the disappearance of the last vestige of regional structures. All sorts of powerful people wanted to abolish them and nobody was successful. From 1948 to the mid-1990s there were very powerful regional offices. This is an historic day.' He added: 'The SHAs will now be the top level of contact with the Department of Health. That almost inevitably means that some of the work done by the directorates will be done by us, and we will have direct contact with the DoH.'

York University professor of health economics Alan Maynard said the focus would now be on the SHAs.He said: 'You could say the regions are being splintered into [the 28] SHAs. The regions are dead, long live the regions!

SHAs are a classic sort of organisation trying to seek a role. The money lies with primary care trusts, the activity lies with hospitals, and the SHAs are supposed to manage the capacity plans.'

Dr Charles Webster, author of the official history of the NHS, agreed there were problems with the SHAs. He said: 'You could say the SHAs are anachronisms and they do not fit into any logical and constitutional structures, and could too be targets for abolition.

'My general view is that one of the lessons of the early NHS was that it is impossible to administer all the multifarious bits from one central point.

'You need some intermediate entity between central government and the locality, and the early National Health Service hit upon the regions as being the right level.

'Things such as disaster planning need to be looked at on that basis; emergency planning and specialist care planning needs to be looked at on a regional basis.'

And he added: 'The PCTs are really evolving into embryonic health authorities. I could see that the purchaser/provider split will come to an end and PCTs will take on secondary care facilities.

'What this shows is the government is not operating according to a settled blueprint which is being rolled out on a logical basis over time. Everything is being done on the basis of crisis management and creating the instability and destabilisation in the NHS workforce.'

'They say: 'We are going to put everything back to the frontline', and then do things that put things back to the centre.'

NHS Confederation policy director Nigel Edwards said he expected directorate functions to be widely distributed. He said: 'The SHAs are going to be delegated a lot of stuff and the Commission for Healthcare Audit and Inspection is going to be given a lot of departmental stuff.'

He said he thought responsibility for public health could end up being transferred to the nine regional government offices. Already, directors of public health are based there, although they are parts of the health and social care directorates.

Of the possible extension to the role of CHAI, one government source said: 'I guess the question would come around performance management.

What happens after CHAI has inspected? Who keeps an eye [open] to see if the action plan is being followed up?'

Despite the fact that the changes were intended to support devolution of power to the front line, a source in primary care said he was concerned that the effects of the next round of changes might work against primary care trusts.

'I have a concern that primary care is going to be sidelined.

The biggest danger is [that] the delivery unit is going to concentrate on targets, and the only (primary care) target is access. A lot of policy around may seem a lot less important.'