Last week’s leader explored the risks of giving GPs a central role in commissioning.

It received two distinctly different types of response. On hsj.co.uk most visitors seemed to be sympathetic to our concerns over accountability and whether the move would hamper the drive to achieve the necessary efficiencies in the short term.

Two of the leading (medically dominated) primary care organisations objected strongly. The leaders of both the NHS Alliance and the National Association for Primary Care took HSJ to task for its pessimism (see box).

For the NHS Alliance we were “providing excuses for doing nothing”. For the NAPC, our crime was to ignore the “spectacular” failure of primary care trusts to develop “clinical commissioning”.

The NHS Alliance claim misunderstands HSJ’s view. We believe in reform, probably too much for some readers. We believe the NHS will prosper by continuously examining its performance and looking to improve it.

We also believe in a greater role for clinicians in management. The most effective health organisations all demonstrate that characteristic. We believe in GPs having a greater role in commissioning.

What we will not do is ignore the dangers in rapidly placing the bulk of the NHS budget with any group whose understanding of the broad sweep of the challenges facing the health service is still developing.

This point speaks to the NAPC’s claim about the inefficiency of PCTs. Few informed NHS staff or observers would say PCTs have been a runaway success. But the number that have crashed and burned is similar to the proportion of GPs who have demonstrated the humility and courage needed to take responsibility for the tough resourcing decisions ahead.

But there are points of agreement between HSJ and the champions of GP commissioning. The NHS Alliance talks of managers and clinicians “working as equals” - a message we hope they transmit to the new health secretary. The NAPC says the establishment of effective GP commissioning would be a “legacy” for PCTs “to be proud of”. We concur, although we believe commissioning guided by the appropriate range of healthcare professionals is a better model than one “led” by a particular discipline.

Letters from the NHS Alliance and the National Association for Primary Care

Do GPs justice

Why have the government’s plans to put GPs in charge of commissioning brought so much ill feeling (leader, page 3, 10 June)? Surely this is not simply a case of vested interest and the establishment calling for the status quo?

With the NHS facing one of its greatest management and financial challenges, it is crucial that those who commit the vast bulk of health service spending are fully and actively engaged in taking decisions about how patient services are designed, delivered and transformed.

In answer to the two main concerns raised last week - accountability and how quickly GPs can deliver change - we need a robust system which not only ensures GPs are clear about their commissioning responsibility, but which is also clear about reward, remuneration, accountability, risk and reinvestment.

In terms of delivering change quickly, if things are done properly, we will start to see the results soon.

The transfer of services from secondary to primary care has been too slow, productivity has fallen and the solutions that primary care can offer have been ignored by a centralist, managerial dominated (rather than managers and clinicians working as equals) and secondary care centric system. HSJ should aim higher than providing excuses for doing nothing.

Dr Michael Dixon, chair, NHS Alliance

Spectacular failure

In order to address the economic, health and social challenges, the NHS needs to transform at an alarming pace. If such change is risk free then it will not be transformational and is doomed to failure (leader, page 3, 10 June). Primary care trusts have had the past five years to develop practice based commissioning and align clinical and financial accountability within general practice. With the exception of a valiant few, their failure has been spectacular, due in no small part to their risk averse nature.

GP commissioning cannot address all the challenges alone. Fortunately they will not have to rely solely on PCTs for support and staff but be able to draw on a much wider source of commissioning knowledge and support.

In the transition period it will be the best PCTs that leave behind effective GP commissioners and high quality services. If GP commissioning goes on to deliver real results across the system in the first half of this decade that would be a significant improvement on NHS commissioning in the last half of the previous decade and a lasting legacy for PCTs to be proud of.

Dr Jonathan Marshall, chair, National Association of Primary Care

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