A first glimpse at what the intermediary primary care landscape might look like before commissioning consortia are sworn in emerged this week after the Health Services Journal published details on the primary care trust clusters charged with overseeing the transition.

According to the publication, the biggest cluster of PCTs is most likely to be in Greater Manchester, which be made up of about 10 trusts covering a population of more than 2.6 million, while that in Tees is expected to be the smallest with four trusts covering just 560,000 people.

The formation of 38 different clusters across England is on the cards, the HSJ says, but notes that seven of the particularly large PCTs - namely Cumbria, North Yorkshire and York, Norfolk, Suffolk, Surrey, Lincolnshire and Hertfordshire - could well carry on as standalone groups until the envisaged reforms are in place in 2013.

Guidance on the establishment of PCT clusters - which are essentially designed to merge management capacity and save cash - was issued by the Department of Health last week, which is keen to prevent the current system from crumbling before its new primary care structure is fully operational. 

As NHS chief executive David Nicholson explained in an accompanying letter to NHS leaders, the formation of clusters "will also create space for emerging GP consortia, the number of which is growing rapidly with 141 pathfinder consortia now identified".

And while these new clusters are not statutory bodies or permanent features of the incoming structure, they are necessary to sustain PCT capability and enable the creation of the new system, the DH said. The move will, however, undoubtedly cause problems as managers vie for positions on the new teams.  

The government has charged strategic health authorities with leading the process of establishing the new clusters in 2011/12, after which the NHS Commissioning Board oversee their operations throughout the proposed destruction of PCTs in March 2013. A single chief executive will be accountable for quality, finance, performance, QIPP and the development of commissioning functions across the whole of the cluster area, with support by a single executive team.

A spokesperson for the Department of Health refused to comment on the reported establishment of clusters, but did confirm that they are scheduled to be finalised by June this year.

Under fire

Meanwhile, as the government pushes on with its fast-paced healthcare reforms, objections are gathering force. 

The British Medical Association is arguing that certain developments under the proposals are already taking place despite the fact that the Health Bill has not been passed by parliament, and has issued MPs with a list of its issues with the plans.

"The BMA believes that potentially positive elements of the reforms - giving clinicians greater responsibility for commissioning and shaping local health services, increasing public and patient involvement, and putting a greater focus on improving public health - are threatened by other aspects, particularly those that seek to increase competition", it said, and argued that, while the government claims the cost of the reforms will be £1.2 billion, independent academics estimates are much higher at £3 billion.

Amongst other things, it also voiced "significant concerns" over the phasing out of PCTs before consortia are properly established, and said that the formation of sub-regional PCT clusters goes only some way to addressing its concerns. 

Elsewhere, eight leading health charities claim that the government's reforms of the health service could water down patient power rather than strengthen it. Writing in The Times, the groups warned of a 'democratic deficit' under the plans, arguing that patients are insufficiently represented on the very organisations established charged with protecting their interests.