Nigel Edwards – in his masterly analysis of the Health Act – declares that “the real level of autonomy available to clinical commissioning groups is likely to be determined by the behaviour of the NHS Commissioning Board… rather than by the legislation.”

He adds: “The act does little to safeguard the system from top-down recidivism in the board.”

In that light, Andrew Lansley’s letter to board chair Malcolm Grant commanding that CCGs are to have “assumed liberty” appears significant. Its message is in tune with fierce lobbying by those champions of clinical commissioning, the NHS Alliance and National Association of Primary Care and it might be thought they have forced a U-turn from the government.

In the middle of last year, the Department of Health responded to the House of Commons health committee report on the commissioning reforms. It noted the committee’s approval of a “change from the principle of ‘assumed liberty’ to one where commissioners will earn autonomy” during the authorisation phase. It said the process of CCG authorisation “will be undertaken in line with… the principle of ‘earned autonomy’.”

However, in truth, the debate is a continuation of the dance performed by the government ever since it revealed its plans for GP-led commissioning. To attract enough GPs to the commissioning table it had to promise them relative freedom. GPs, after all, have a day job they can return to should they feel their influence is being constrained. On the other hand, the government had to reassure a whole range of stakeholders that these new GP organisations would not be allowed to do whatever they liked.

Witness the debate over clinical senates. Revealed with some fanfare in response to hospital doctors’ concern that GPs would rule the roost, a few months later the government was busy briefing how senates would fulfil a purely advisory role.

This dance is set to continue as the new system develops. Professor Grant, in his first ever interview, tells HSJ that CCGs can expect the board’s grip to remain relatively tight during the transition.

On one level, this tension is simply created by the desire of any new organisation to have freedom of action – witness the ongoing birth pangs of the foundation trust sector – and the need for the centre, where blame eventually, and inevitably, arrives – to reduce its pain.

But there are other, almost subconscious, forces at work. Significant among them is the fear of CCG leaders of being labelled “bureaucrats” – something the government wants to avoid as well.

The holy grail of these reforms is for the wave of reconfigurations and service redesign which must sweep through the NHS to be perceived by the public as led by professionals who care only for patients. To give this vision power – and justify the upheaval reform has caused – it has been regularly contrasted with the approach it replaces, in which decisions were, supposedly, made by “faceless bureaucrats”.  

To maintain this construct, CCGs must not be perceived as acting in a bureaucratic manner, making decisions which feel distant from the needs of patients. Since this is impossible to achieve consistently in a system of the NHS’s scale, having someone to blame can be handy.

A commissioning board perceived as overly officious may actually play to the advantage of CCGs in establishing their freshness.

This is not cynicism, simply a recognition of the ever-present dynamic between the NHS’s centre and its local manifestations.

More significant will be what CCGs do with their “liberty” and how the centre reacts when and if that freedom ends in “failure”.