Couple of reasons. Firstly, arguably the most strategic leader the RCGP has ever had said so this week. Secondly researchers from Durham pointed out that “multimorbidity” will be the norm and finally because I say we can’t go on like this.

The politicians, researchers and frontline GPs can all agree we need to change, but it’s not just the commissioning function that needs to change a la the Silver Fox. If, and it’s a big if, we are to improve the efficiency of the NHS then a transformational change is required.

Specialists will need to come out of the ivory towers, GPs will need to stop treating snot, and patients will have to realise that we have a finite budget.

So what’s the chances that practices will adopt new ways of working, create “new deals” with the patients, radically rewrite the way we deliver care? I don’t know the answer, but I know the cost if we can’t change our ways.

New entrants into the GP space will not carry our baggage of “the way things used to be”. New entrants will look at the way things are, see opportunities to provide solutions in ways that are cost effective and suited to our times and technology.

They will survive and, save for a few innovative champions, we will find ourselves painted as money grabbing Luddites, uninterested in patient care and that’s not true is it?

A new referral from for routine ENT services has appeared on behalf of the cluster. Basically it follows a “heuristic web” which reminds me of those childrens games where you put in a marble at the top and it bounces off pegs before arriving at the bottom in a random position, acquiring a particular score.

In this case the patient will ping pong through the system, possibly being assessed by a clinician other than me, possibly being investigated and finally coming to rest having collected a number of points.

Apparently it’s all agreed.

The other game on offer is a revised PLCP or rationing pathway. We will be getting patients engaged in the system thanks to my practice mangers skilful re-labelling of a monopoly board. Patients landing on symptoms can choose to pay for their operation, or roll again in the hope that they land on a cheaper hospital. Her best idea was to include Health and Wellbeing board cards instead of “chance”.

The final game on offer is lotto. Any of our cohort who want to enter can apparently apply for a “ticket” to be an accountable officer. If they are unlucky they could end up winning what must be the ultimate prize in CCG land- entry into the game of jeopardy.

I used to be in a golf club, but when I changed my car I had to leave. That club was a loose affiliation meeting in a pub putting the world to rights by decrying the rise of far eastern automobiles cloning traditional European car manufacturing techniques.

I was once in a proper club, but following an incident with a loose canapé my membership was lapsed and I left clubland behind.

I suppose I should not have worried, since we’re all in the club now, not the pudding club, but the GP CCG Club which Old Nick has thrust upon us.

If you get the chance, or indeed suffer from insomnia or day/night inversion as part of your ongoing psychotic delusion that the NHS will be okay, then you might want to read the resources on the NHS Commissioning Board website.

Here it details the car parking spaces, dress code, rules about bringing in strangers and the generally accepted standards required for a ‘members organisation’.

I appreciate you might not have wanted to join this club, but you don’t have any choice. I suppose it might be the way they do things in politics – the House of Commons is after all a very expensive club – so it might be a matter of political ideology to herd us into clubs.

In my case I tend towards Marx on this matter because as Groucho once said: ‘I don’t want to belong to any club that will accept people like me as a member’.

Speaking to him recently, he passed comment on a meeting he’d been invited to by a local trust. He’d attended thinking it was an educational meeting, but came away thinking he’d been given the hard sell by double glazing people.

‘They want me to send stuff to them,’ he said, ‘They want me to recommend the service to colleagues,’ and ‘They said there’s no reason why we can’t use them rather than our local hospital’.

Finally he wanted to know ‘why did they think they had to sell to me?’ The answer is really straightforward.

All local trusts feel the wind of change blowing. All fear the unforseen shift in commissioning. All feel the potentially chilly fingers of a reduction in referrals and all are worried. Some are seeking to convince GPs (their new commissioners) that they are the experts of choice.

The rhetoric of shifts to primary care is becoming a reality. The trusts are adopting one of two positions; either a willing partner in the devolution of near patient care, or a desperate man digging fingernails into the floor boards to avoid being pulled into a new world of patient centred commissioned care.

Those desperate men will tell us that as GPs we can’t possibly deliver expert services without them. They are right, but it will need to be on our basis, in our frameworks, on our terms. We will decide who the experts really are.

All in all, its beginning to feel a bit like a puppet show. There is a script, written by the Silver Fox, but it is the puppet master who brings the characters to life, who causes them to act in accordance with his wishes.

If GPs are lucky we will be marionettes all sorts of strings attached to ensure we work in the right way, but the audience is able to see the strings and recognise the futility of the task. If we are unlucky we will end up as glove puppets, with the master puppeteer invisible, away in the NHS Commissioning Board, the audience believing that we have autonomy and a responsible for the tough decisions ahead.

So just make sure you and your colleagues can see the strings, otherwise you may be shouting “that’s the way to do it” in a diffent voice than your own.

In fact it is very safe, those people who used to run the NHS will still be running it. The NHS commissioning board will appoint people to help GPs run CCGs. The NHS Commissioning Board will decide whether GPs are fit to take on the responsibility and the ability to commission. The NHS commissioning Board will define those outcome measures that must be achieved in order to deliver safe health care.

There is a lot riding on the NHS Commissioning board. The good news is that the board all have great experience of running the NHS, good pace setting and command and control style and are already running the NHS.

The same team who fired the starting pistol and most of the PCT staff with it are the same team now lining up the NHS Commissioning Board local leaders.

We will shortly be sent the HR framework for establishment of the local offices of the NHSCB. Already insiders know that those jobs will be ‘lift and shift’ for existing expensive directors deposed from PCTs.

There is a thin veneer of ‘this time it will be clinically led’ but always accompanied with a knowing look, an arched brow and a caveat of ‘when appropriate’.

The NHS will be in safe hands, whilst GPs will be left taking care of the new generation of healthcare problems, or perhaps just holding the baby.

I suppose by many peoples standards I’m quite good looking. Ok perhaps that’s a bit much, but I’m definitely not ugly, but all this week my patients have been telling me I’m striking.

I realised early on this was not a compliment, simply an observation of the news and internet stories surrounding the BMA position on how we should deliver industrial action.

The trouble is most of my patients and a lot of managerial colleagues see the issue as too much, too late. We are now likely to take industrial action in a way that will have the public believe that personal financial gain is our sole concern.

After all we didn’t strike over the biggest shake up of the NHS since its inception, we’re just striking over our pensions.

Many of our patients will have believed that handing GPs the money to run the NHS would see profiteering by some GPs and now I fear those patients who were undecided will see evidence which might just convince them it is only about the money.

As it is we’re going to stop doing routine work and provide an emergency only service. I have to say that some days it seems that’s exactly the service I do provide, so no change in a strike for me.

Is there a solution?

I don’t know. Perhaps disengaging form CCGs would be a better industrial action, the throbbing red of the risk register would be visible from space if we did that.

One thing he does possess is perspicacity, by the barrow full. I believe the saying goes ‘able to see through a brick further than most’.  Admittedly not a saying I hear a lot, but one he’s used.

Our local cluster medical director and his chum/rival, the former PEC chair, have had a great idea. As leaders of the system they will call together the first senate. In fact it’s already met. There were apparently eight GPs present.

Just the eight.

No nurses, no consultants, no ‘takeholder’ representatives.

Just the eight.

My friend attended the meeting, believing it to be a multi-professional senate as endorsed by the NHSCB. When challenged by him as to why the absence of consultants etc the answer was that as guidance is lacking at present and they ‘thought it better just to crack on with GPs and invite the others later’.

Obviously there might be some explaining later on as to how the paraphernalia of meetings was already sorted out, the terms of reference etc, when the ‘others’ eventually arrive. At least I assume they will eventually be engaged.

My friend was not keen to contribute under the circumstances and in the absence of any minutes he summed up the meeting thus – ‘Senate,  seen eight, thought say nowt’.

I don’t just mean the usual Friday ‘it’s been a long week ‘ feeling, but a total growing disinterest in the media debate about how bad the bill is, how the RCGP is playing Hokey Cokey, how we’re only upset because of our pensions, the list goes on and on.

The latest hacking point is the idea of industrial action. Industrial action that doesn’t involve impact on our patients, ie. the very thing we’re hired to do, the industry we provide.

We really should be very clear, we’re committed to the patients, not the Bill. So why aren’t we just disengaging from the authorisation process? Why aren’t we just sitting in the room as GPs working with fellow clinicians rather than as CCGs commissioning them?

We can easily prove our contempt for the bill – just don’t play the game, after all it’s not in our contract or law yet.

I’d be happier with that than a strike involving slower paperwork or not answering the phones with a cheery hello.

In effect what is being suggested by the BMA is industrial inaction. I’m not convinced that would be anymore effective than cheap toilet paper – it seems a nice idea but one white paper won’t be enough to stop us getting our hands covered.

Last week our brightest and best CCG leads from the SHA footprint were gathered in a hotel conveniently placed for motorway access and, aside from the deep breathing, asked to imagine what the world had in store if the Bill was somehow blocked.

Those who attended seemed to be given the impression that Plan B was rapidly becoming Plan A, especially in the minds of those who are currently running the show.

The managers who are now overseeing all the uncertainty, chaos and confusion, had either chosen to stay put and wait for redundancy or were unable to find alternate employment. Mixed in with them are a smaller number who despite personal uncertainty decided to hang in there for the good of the patients.

Perhaps it’s cynical of me, but that means if – and it’s a big if – the Bill falls at the final hurdle, our commissioning support will be run by inept ne’er do wells, or idealistic idiots. Those with ability, skills in demand, and common sense have already left the building.

Is it that bad locally? Let’s just say that those currently in the Cluster needed the CCG chairs to work out what happens when the parliamentary poop hits the Lordly fan. Need I say more?