On paper the idea of practice based commissioning, a major plank of the government's modernisation programme for the NHS in England, seems to be a remarkably simple proposal, with few risks and potentially many gains.

The theory is that if general practices are given control of their own budgets for commissioning secondary care and community health services, the number of referrals to hospitals will fall, cutting hospitals' running costs along the way. With greater autonomy, GPs will also gain the freedom to exercise their entrepreneurial and clinical skills for the good of their patients by developing community services according to local needs.

And by providing expert care closer to patients' homes through “super clinics” in the community, GPs get to keep patients within their sights, delivering true follow-up of care and reaping professional fulfilment.

So what could possibly go so wrong? Why did Hamish Meldrum, chairman of the BMA's General Practitioners Committee, last week declare the scheme a “shambles”?

The Department of Health launched practice based commissioning in 2004 as part of the NHS improvement plan to “put people at the heart of public services,” and GPs were able to take part in the scheme from April 2005.

Despite its uncanny resemblance to fund holding—the system that the Tories introduced in the 1990s to increase GPs' financial responsibility for referral and prescribing but that was scrapped soon after …