"The headquarters of the NHS will not be in the Department of Health or the new NHS Commissioning Board but instead, power will be given to the front-line clinicians and patients. The headquarters will be in the consulting room and clinic." So proclaimed the health white paper a year ago.
The strategy paper from NHS chief executive Sir David Nicholson on developing the NHS Commissioning Board shows health secretary Andrew Lansley was misinformed - the board is unquestionably the new NHS headquarters.
The National Commissioning Board oversees the local 'clinical commissioning groups' who will be buying health services for local people. The way the board is set up matters because it will determine whether Lansley's dream of making commissioning locally based and largely free of central control will survive the rewriting of his reform plans.
Nicholson's strategy is awash with evidence of how Lansley's flawed plan to hand commissioning power to family doctors has backfired to recreate a heavily centralised command and control health service. While MPs and peers are busy abolishing strategic health authorities and primary care trusts through the Health and Social Care Bill, structures which bear a remarkable similarity to them are being re-established as the regional and local arms of the commissioning board, with a staff of 3,500.
As Lansley's initial plans have unravelled the tone of the commissioning board's role has changed from supporting, overseeing and holding to account to controlling and directing. The section on working with local government betrays the centralising culture the board is imposing on the healthcare system.
It could have said the board will work closely with local government to ensure the work of clinical commissioning groups meets the specific health needs of the local area and secures effective integration with social services and other local partners, while also meeting national standards and priorities.
What it actually says is that "[elected] Local government... will need to work closely with the [unelected] board to ensure there is strategic coherence and alignment in how the Board seeks to deliver its priorities". So you help us, we don't help you.
The great tension in the new healthcare system is the conflict between upwards accountability to the National Commissioning Board and the horizontal, local accountability - meeting local health needs and collaborating with local government. For NHS staff and GPs it is not difficult to work out whose priorities will win if these forces are pulling in different directions.