Mike Farrar, the chief executive of the NHS Confed recently warned that the current health reforms represent a potentially fatal distraction from the real tasks facing the NHS in managing the money and tackling the desperate need to strengthen care provided in the community.

Given the mood in debate amongst directors of adult care we say amen to that which shows the integration of the professional associations sought by the Future Forum! More worryingly, it also highlights the potential for the implementation of the current reforms to create systems and ways of working that undermine the goals we share.

Local government has welcomed the new powers conferred on it in the small part of the Health and Social Care Bill that gives it  new roles. The new statutory duty to reduce health inequality is a long overdue reform to drive up the quality and length of life. Health and wellbeing boards have been welcomed by all as a vital part of the new dialogue between clinicians, politicians, professionals and citizens about driving up health and care outcomes in a place. As part of this landscape the appetite of local government for integration across commissioning, provision and planning has been strong.

While that conversation has gone on in local government, the NHS has set about its new commissioning landscape, in which very large commissioning support organisations are beginning to appear. The need for assurance of the capacity and capability of the clinical commissioning groups is running alongside this design. These are driven in part by a response to the money worries expressed by Mike there is little doubt that they will control spend. As directors we are sitting through a lot of discussion in our places about the design of these large commissioning vehicles.

But the question how and what will they commission with us? is going unanswered. Commissioning without us undermines the very integration that has been sought. Commissioning away from localities and people is technocratic science, omitting the art of blending science  with imaginative responses to need and implementing innovation. Councils that already have large joint commissioning budgets and services report that they have assurance on retaining what is working but that this still leaves good local practice outside the loop of development.

We want to strengthen community-based care, yet the question of how to design links with the care systems and councils as the lead in shaping that system seems to be low down the design criteria. The final twist is that clinical commissioning groups eager to make progress seem equally uncertain about where the traction is for more integrated commissioning.

This might just be a stage in the design of the structural changes within the NHS. Our worry is that it potentially undermines the shared aspirations for integrated responses in localities that were so much a part of the thinking of the NHS Future Forum, and so strongly supported as a meaningful response to meeting the challenges of tight resources and rising demand that face us.

We have heard many calls for better integration between health and care from many politicians over recent months. We continue to share the frustration at the current state of integration and havent weakened in our aspirations to improve the situation. As our early questions on the design of the commissioning landscape of the future are raising our anxiety levels, ADASS calls for a greater level of debate on how we reach our shared ambition of strengthened and better care in our communities and a health care system that drives out the inequalities in outcomes that the Bill rightly challenges.