Last week Sir David Nicholson summoned the 51 primary care trust cluster chief executives to a meeting at which he set out how they should address the challenges ahead. The audience listened dutifully, but the tension in the room was palpable.

Later, one very senior figure present told HSJ that Sir David was speaking with the knowledge “that half the people in the room don’t believe in the reforms they’re being asked to implement”.

The scepticism, and in some cases anger, means the need to set out a vision for the future of commissioning support is badly needed. This week HSJ was the first to reveal the draft version of that vision, the Department of Health’s Towards Service Excellence.

The document was immediately attacked as being a blueprint for the wholesale privatisation of the commissioning support sector – which is unlikely – or for reflecting the confused nature of the reforms – for which it can hardly be blamed.

In fact, the guidance is perhaps the first positive news those working in PCTs have received for years – setting out, as it does, a pathway to a potentially robust structure for a wide range of key functions. It states that commissioning support organisations will “work closely with commissioners” on a “day to day” and “long term” basis.

However, the guidance raises many questions. Perhaps the most significant is the role of the NHS Commissioning Board.

The guidance says: “The changes set in train are complex, involve a great many staff carrying out work that has a high monetary and operational value, yet must be implemented rapidly and with precision. This requires the commissioning board to set a very clear direction during the transition in order that these critical changes are delivered properly first time.”

In other words – “we didn’t create this mess, but we’ll make sure it doesn’t spiral out of control”. Sir David could have summed up the paragraph in one of his favourite words: “grip”.

A focus for that “grip” will be on ensuring that PCT redundancy costs are minimised along with the commissioning talent drain. Those two reasons, as well as allowing emergent clinical commissioning groups to “focus” on their apparent “strengths” of providing “clinical” and “community” insight, are the drivers behind the guidance.

The board will be in the unusual and conflicted position of being the biggest customer of commissioning support (it will, after all, be by far the biggest commissioner), the biggest supplier of support and the organisation responsible for developing the commissioning support market.

It is meant to exit the commissioning support space by “2016 at the latest”. That, of course, is a year after the next election, by which time health policy may be very different. Sir David, a man whose “wallet starts to itch” at the mention of private commissioning support, knows this and will make the appropriate judgements in what he believes are the interests of the NHS.

Private sector input can enhance commissioning support, but businesses are likely to need more certainty about the scale of the opportunity, the cash CCGs will have to spend and the procurement process before investing in capacity.

The guidance makes reference to “framework call-off arrangements” for some support areas. The underwhelming impact of 2007’s framework for procuring external support for commissioners suggests this will be easier said than delivered.

But perhaps the most present danger is set out on page 14 of the guidance. “PCT clusters and commissioning support organisations will continue to be under pressure to reduce operating costs.” Hardly an encouraging message to receive when embarking on a “complex”, “rapid” and “precise” change programme with a “high monetary and operational value”.