The struggle for the soul of the reforms is intensifying as the outline shape of the new landscape clarifies.

At a national level, senior Department of Health sources talk about their “best intelligence” suggesting there will be around 200 consortia - a broadly sensible number. At a local level, the number of straws in the wind is increasing. Some primary care trusts are reimagining themselves as commissioning support organisations, either within the NHS or as social enterprises. Many others are allocating staff and responsibilities to fledging consortia, not all of whom are being welcomed.

Management consultants and commissioning support organisations report approaches from GPs keen and/or anxious about getting a better grip on new responsibilities. The Royal College of GPs asked for 50 members to come forward to offer advice to new commissioners, it had 200 volunteers.

Lest HSJ be criticised for donning rose coloured glasses, let us make it clear that confusion is still the dominant attitude in the NHS towards the reform process. But in any such NHS upheaval there comes a tipping point, when the service starts to focus on implementing rather than resisting. That tipping point is still months away, but it is on the horizon.

Only a perfect storm of financial meltdown and, perhaps as a result, political U-turn, will mean that GP consortia are not ruling the roost in two years. But there should be no assumption that they will behave exactly as set out in the white paper.

The strategy for the development of consortia is being driven by the government, but what consortia actually do will be driven by the culture created within those new organisations and, as any good management textbook will tell you, “culture eats strategy for breakfast.”

The strategic priority for government is to use GPs’ understanding of patient need to improve the commissioning of NHS services. The cultural inclination of GPs asked to take a greater role in running the NHS will be to seek a larger role in providing services. Commissioning will be seen as a means to that end by many, maybe most, GPs.

The new RCGP chair Clare Gerada makes this point and also, rightly, raises the dangers of a conflict of interest if a clear divide is not drawn between commissioning and provision. Her answer to this dilemma is for GP consortia to be responsible for a large enough population to ensure commissioning decisions are made “as far away as possible” from GP surgeries. The white paper, of course, makes a merit of commissioning decisions being made as close as practical to the “front line”.

If the government sticks to its line of not determining the number or size of consortia this can only be a tension that is played out during the reform’s implementation.

Competition is another example of the fluidity of reform implementation. The government’s view is that competition is essential to driving service improvement and patient choice. The majority GP opinion appears to be that it is, at best, a last resort. Two things, therefore, might happen in the implementation of the reforms.

The first is enshrined in the belief of policy makers that once GPs fully understand the challenge of commissioning they will embrace competition as an essential tool. The second is that other mechanisms will need to be found to create a competitive market, which can then be presented to GP commissioners as a fait accompli. It is interesting, in this context, to see the DH moving rapidly to appoint a chair of the new NHS economic regulator.

The NHS reform programme may have only one natural father in health secretary Andrew Lansley, but the battle for long term custody is only just beginning.