Besieged by change, senior managers in the NHS are adept at resisting it while apparently leading it.

They divert attention to "middle managers" should anyone notice that while all targets have been met, nothing has actually changed.

The latest threat to the status quo is world class commissioning. This initiative sets out a clear vision not only to improve health (the familiar commitment to add "years to life") but, more radically, to be concerned about the quality of those extra years ("life to years"). Furthermore, it seeks to leverage the relatively universal and comprehensive coverage offered by the NHS to demonstrate that wise investment by public bodies can have a greater, more rapid impact on health outcomes at reduced cost than fragmented, demand-led systems.

The hypothesis that commissioning could drive improvement in service responsiveness, cost and effectiveness and innovations in delivery is challenging for a service founded on the power and influence of acute provision of medical care. The golden pathway of NHS management has always been bound by the walls of the large hospital, and most of the highest positions have been earned by delivering more activity on reduced expenditure in acute settings. This is an important but rather different skill set from commissioning's concern with population intelligence, return on investment and stakeholder facilitation.

Those concerned that this new initiative could seriously disrupt established power relationships and divert money into new areas need not be unduly concerned. There are several ways the system can quickly reassert business as usual.

First way: "it's the money, stupid" - as long as we continue to spend the money in the same old pattern, nothing will change. A continuing emphasis on access at the expense of relevance or effectiveness will undermine any attempt to introduce the concept of investment into commissioning practice.

Or try diverting organisational attention into transactional tasks - 75 per cent of the population are "sensing" in style. "S" people like to build up information from external sources, paying attention to local detail. This trait will drive us into a concern with the technicalities of procurement, compliance and research standards of evidence. It should cut some costs. But if we are merely becoming more efficient at doing the wrong things, we will only increase inappropriate activity and thus spend in the system.

Another approach is to develop "the specialty". The NHS likes to develop specialisms: historically this has been the route to status and inflated salaries. We are likely to see an explosion of commissioning courses and degrees, which will take out the limited numbers of people in the system for weeks, just when we need them most.

Here is a further ploy. "Do, buy, share" offers a challenge to primary care trusts to be honest about internal strengths, opportunities for collaboration and the need to buy in expertise where it does not exist. This excellent discipline can be readily undermined by only concentrating on one option rather than exercising all three. PCTs are likely to swing wildly between do and buy, avoiding the too-close-to-home sensation of share. Strategic health authorities are, conversely, more likely to assume that the best answer in all cases is share, enabling them to assume a commissioning role "on behalf of" PCTs in the name of efficiency. The DH has negotiated a lot of external contracts with commercial providers so is likely to see buy as a default option.

Some change resisters will go for prioritising internal relationships over customers - PCTs have primary care designed into structures as a core element of a 2000 deal with GP fundholders that they would retain control in the move to the new organisations. Their notion is that commissioning is something we do to hospitals. The shift from administration of a national GP contract to the challenge of applying world class commissioning competencies to investment in primary care and our own community provision will seriously test relationships. So long as our first loyalty is to our contractors rather than to patients, nothing will change.

Others may favour asserting "rights" over "responsibilities". The current emphasis on patient rights should ensure we spend an ever increasing proportion of public money on ever fewer people for ever diminishing returns. Without being equally concerned with responsibilities, we shall be driven by unreasoning demand and the law of the common good, which states that no one values that which appears to be free, particularly when visibly abused by others.

Assurance over development offers another way to keep change at bay. Our system is all too familiar with performance management and we should not doubt that the opportunity to demonstrate how consistently PCTs fail world class comparators will be avidly pursued.

Or you could make it just about PCT development - the work on development to date has been exciting, participative and embraced by PCTs. It has also revealed that world class commissioning will require new skills and behaviours throughout the system to succeed.

Another way: structural change is the most established and successful tactic for drawing commissioning leadership attention into internal competition, strategic uncertainty, pensions and employment law, and away from tackling inequalities and service improvement.

Finally, when all else fails, laugh - otherwise known as the Star Trek defence; even the most frightening alien can be defeated by consistent loud jeering.

If you are in a PCT, of course, you may by now be crying.