We're not very far away from the arrival of the NHS Commissioning Board now.

This leads me to wonder where the really big problems that the new NHS system is going to face over the next several years of flat (at best) real-terms financial growth (as thought likely by the economists of the Kings Fund, the Nuffield Trust and Richard Douglas).

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Are the really big problems going to be in commissioning? Or solved by commissioning?

That looks like the assumption on which the NHS Commissioning Board has been founded.

The previous Commons Health Select Committee was not mightily impressed by commissioning in the NHS to date; nor was the new one.

The Smith, Curry, Mays and Dixon 2010 Nuffield Trust paper also offers an experienced perspective of what commissioning has and has not achieved.

And in 2011, the Kings Fund ran a 'Windmill'-type simulation based on what was known then of the new system, which ended with some rather interesting (if predictable) behaviours being modelled.

Civitas' last real report on health, co-written with Professor Kieran Walshe of Manchester Business School, 'Does Size Matter?' (fnarr, fnarr) found that "data on the performance of commissioning organisations in the NHS (CQC Annual Health Check & DH World Class Commissioning regime) show little or no relationship between size of commissioners and their performance. This may be because there is no relationship, or because none is revealed due to there being little heterogeneity in organisational size; repeated reorganisations masking performance differences; and measures of performance lacking discriminatory power. Similar results are in evidence in the academic literature on commissioning in the NHS.

"In 10 European countries analysed, seven have seen a consolidation of commissioning organisations over the past 15 to 20 years, two have seen no change. In only one country (Spain, due to devolution) has the number of commissioning organisations increased. In all countries apart from Switzerland the average population coverage of a commissioner is above 300,000 people".

Mmmmm.

So will one more push do it?

It's too early to judge commissioning in the new world, let alone write its obituary. As HSJ's study of the last World-Class Commissioning Assessment revealed, PCTs were improving as commissioners just as they started on the road to abolition.

And it is a plausible hypothesis that clinicians in primary care who are engaged in commissioning will start to care more about their underperforming colleagues in primary care (where they may be able to exert some peer pressure) and in secondary care (where their influencing ability may be more mixed). Time will tell, we may hope.

But most of the delivery of the Nicholson Challenge so far has come about by capital underspending, freezing wages and sacking some managers.

None of which had anything to do with commissioning.

All of which were centrally-driven and provider-oriented reforms.

Ahead lies the political firewalk of provider reconfiguration, about which I wrote here.

There is the list of twenty probably financially unviable providers.

There is not-too-funky-looking FT pipeline, over which the NHS Trust Development Authority looms like a big, loomy top-down sort of thing. Except we don't do top-down any more. Do we?

There is the possibility of FT acquisitions and mergers - oh no, hang on, not that easily there isn't, it seems! (HSJ again).

There is also the need to improve the co-operation and co-ordination of patient care between primary and secondary care - in a completely non-anti-competitive way, naturally.

In a blog I wrote in September 2011, I quoted businessman Gerry Robinson on BBC Panorama, who said, "what worries me, and what I do not think will work in the long run is to use outside providers because they appear cheaper in the short term - but that are not part of a properly managed, strategically planned system of care. I think there is a place for outside providers but it needs to be very carefully managed ... Who is going to be managing that big picture? Unless somebody really does grab this thing at the centre and has the courage to make unpopular but right decisions, then I fear this could spell the end of the NHS".

What a bitter irony it would be if the reforms were to fail because of the lack of an NHS Provision Board.