The unlikeliest and, perhaps, most powerful alliance affecting the delivery of the NHS reforms is between Royal College of GPs chair Dr Clare Gerada and what some might term the “old guard” of NHS managers who have wielded the greatest influence over the last decade.

One management leading light told HSJ that Dr Gerada is convinced she is engaged in a battle to “save the NHS” – something confirmed by her comments in our interview about how the reforms will lead to an insurance-funded system. Few of the old guard agree – finding her analysis naive and simplistic – but they warm to her unabashed love for the service and her ability to chuck spanners into a reform process they have significant doubts about.

Dr Gerada for her part places an enormous amount of faith in NHS chief executive Sir David Nicholson. When HSJ asked how Sir David and senior NHS colleagues were reacting to her opposition, she replied: “I have a lot of people ringing me up in confidence – including very senior people in high places who are anxious about the Health Bill but can’t say it in public because they are frightened for their jobs.”

Dr Gerada is proving a highly effective politician and will seek to maximise any impression that reform is being resisted in “high places”, as well as on the ground. However, HSJ has spoken to many of those same people and knows there are concerns aplenty.

Little wonder, therefore, that old rivals the NHS Alliance and the National Association of Primary Care have formed a coalition to try and maintain what momentum remains behind GP commissioning and to resist what they see as the danger of smothering centralisation.

It will be interesting to see how they respond to Dr Gerada’s latest upping of the stakes by raising the spectre of GPs falling foul of the General Medical Council should they become complicit in commissioning decisions which “conflict” with their duty to patient care.

The introduction of clinical commissioning creates no new fundamental principle or risk that is not already covered by GMC guidance. However, if the government is successful in rolling out the commissioning reforms it is a risk that will be borne by many more medics on a much more regular basis.

The GMC will no doubt explore the implications of this during the imminent review of its guidance. However, the steps needed to systematically protect GP commissioners from the risk could yet prove another stumbling block for the implementation of the reforms.

But what of Dr Gerada’s central point that GPs should not become involved in “rationing”? The answer to that question, of course, depends on what you mean by rationing. Responding to Dr Gerada’s interview on, many readers commented that GPs already “rationed” care through referral decisions and that, if the NHS was to live within its restricted means, medics would have to take greater responsibility for the use of NHS resources.

Her challenge exposes the fault line that runs through the NHS – and has since its birth. Public funding has allowed clinicians to be removed from most of the financial implications of their decisions. Indeed, many would see it as a strength of our system. Dr Gerada believes that more money should be spent on healthcare, calling for a repeat of the Wanless review which provided the intellectual ballast for the 2002 NHS budget bonanza.

However, given that another step change in NHS funding seems near impossible in the foreseeable future, the “rationing” issue is not going to disappear. The medical profession is still going to have to decide whether it leaves those decisions to others or shoulders the professional and reputational risks of getting its hands dirty.