Alison Chisholm wrote her PhD on the transition from Primary Care Groups (PCGs) to Primary Care Trusts (PCTs) and worked for the Picker Institute for four years. I sought her views on the ConDem proposals for NHS commissioning. She writes (and I post with permission): Well I've not had my finger on the pulse very recently so I don't know about the World Class Commissioning stuff, but I can't see that the mandatory involvement of all GP practices in commissioning is anything other than complete nonsense. For one thing, the transaction costs of individual practices or small consortia of practices commissioning services from secondary care or social care have to be huge compared to PCTs. Apart from the time each practice/consortium has to put into it, and the consultants they'll have to pay to help them with it, how can, for example, the local hospital (here a major regional teaching hospital) respond to one local GP practice commissioning one sort of care for their stroke patients while another local GP practice commissions a different sort of care for their patients? For another, most GPs will lack the expertise needed for effective commissioning (not to mention the inclination to get heavily involved in the bureaucratic mire) – and they already complain that they have to squeeze their patients into too tight appointment slots and have to make them sometimes wait too long for appointments. If they spend a chunk of time 'doing commissioning', that has to eat into their patient time (which is what they are trained to do). And for another, if PCTs have made "Insufficient progress … on implementing the Carter Review of specialised commissioning for rare diseases and conditions" with the collective resources they have, how are GP practices or small consortia going to have the expertise to commission care for rare conditions they may come across once in a blue moon, or never? I don't claim to be an expert, but it looks as if the health secretary has no understanding of the history of commissioning in the NHS – which may well be the case. Bonkers!