Picture this. It is June 2011. Health secretary Andrew Lansley meets with chancellor George Osborne and the prime minister. The health secretary explains that his decision to give GP commissioners the right to sign off reconfiguration plans means that efficiencies are taking longer to find than hoped. The chancellor, already alerted by officials to the dangers of placing £60bn in the hands of reluctant and uncontrollable GPs, stresses the NHS has already had more than its fair share of public money.

David Cameron, remembering his commitment to dealing with the deficit while not “cutting the NHS”, will demand immediate action before the situation gets out of control.

When the economy is profoundly challenged, the only question that matters is “who controls the money?”

How did it come to this, he may also ask? The answer may well be traced back to the decision to strip primary care trusts of the majority of their commissioning powers.

From April 2012 local managerial influence over the bulk of commissioning is set to be dramatically reduced. Mr Lansley’s radical vision will effectively transform PCTs into regional public health offices, debating forums for local opinion and a useful repository for “residual” services.

All these roles have value - but at a time when the economy is profoundly challenged, the only question that matters is “who controls the money?”

In the NHS, the bulk of the budget is tied up in providing relatively few areas of treatment. If you are able, for example, to use commissioning powers to influence the care of those with chronic obstructive pulmonary disease you hold the key to significant savings.

“Control” of NHS spending will therefore be played out in the tension between the Department of Health’s independent board and around 500 GP consortia.

As a streamlined contracting regime, the new approach seems to fit the spirit of the age. No intervening bureaucracies to slow the radical and rapid change needed. It also aligns neatly with GPs’ new role as reconfiguration gatekeepers.

Why then do so few people - many actually involved in shaping and delivering the policy - believe that it will work? Readers are likely to have their own answers to that question. HSJ believes two stand out. The first is that of accountability.

PCTs’ last act as commissioning agents will be to ready an army of GP consortia, the majority of which do not exist yet. They will be coming to commissioning with little or no experience and will need some persuading to shoulder responsibility.

At a national level, the DH will be attempting to renegotiate the GP contract with the British Medical Association, while working out where the statutory duty to ensure high quality health services will lie.

Even assuming PCTs are successful in creating the critical mass of consortia, GPs could be taking up spending responsibilities at a time when the “locally representative” PCT boards come into place.

Elected representatives tend to assume they have the right to exercise power. GPs will see this potential clash coming and attempt to avoid anything that might tarnish their reputation and position as the patient’s champion.

The second major question about the wisdom of placing so much power in the hands of GPs is how quickly change can be delivered.

Even with the most ingenious implementation plan and an enthusiastic response from GPs, it will be half a decade before this new system is delivering real results across the system. Does anything you have heard from the new government suggest that it thinks the UK can wait this long to re-engineer the cost base of its public services?

The only trouble is that, having placed so much faith in GPs and with the best SHA and PCT managerial staff already lining up top jobs with GP consortia, the government may soon find the ability to control the direction of the NHS has slipped through its fingers.

Our hypothetical meeting between the PM, chancellor and health secretary may end in an uneasy silence and accusatory looks.

Dangers of putting GPs in charge outweigh the rewards