When it comes to the reconfiguration of unsustainable services, it seems clinical commissioning groups are not to be fully trusted to grasp the nettle.

That is the underlying motive behind the proposed change to the Health Bill which would see Monitor publish annual lists of services it believes cannot maintain clinical quality and/or financial robustness, effectively requiring their commissioners to take action to remedy the situation.

At last week’s policy summit organised by the Nuffield Trust think tank, its chief economist Anita Charlesworth said that, contrary to the conventional wisdom, it was not demographic change and growth in chronic disease that would endanger the sustainability of NHS services. These were manageable, even on the 2 per cent real terms growth she predicted the NHS would have to learn to live on in the medium to long term. The real risk was the NHS’s lack of success in controlling “pay and prices” and its reliance on outdated, costly models of care.

In other words, it is not what the NHS is being asked to do that is the problem, but the way it is going about meeting the challenge.

There was little confidence at the summit – and elsewhere – that CCGs in general would have the desire or, in some cases the courage, to tackle this structural issue.

Instead, Monitor will be relied on to highlight weaknesses within health economies, creating the possibility of intervention by the commissioning board or the Department of Health if CCGs fail to act.

But how will these lists of unsustainable services be produced? Will it really be about services and not organisations – or will it prove impossible to separate the two? How will services provided, in part or whole, by private or third sector organisations be treated? How will failure be judged? What, for example, would Monitor have to say about the service supplied by Peterborough and Stamford Hospitals Foundation Trust with its £56m projected deficit and no obvious alternative supplier?

The biggest question is what will happen if CCGs are deemed to be taking inadequate action and the centre takes the lead? How will we avoid the danger inherent in the current system of fear of political embarrassment skewing the logic of decisions?