Much of my week-by-week work has me visiting various places and looking at ways of developing GP commissioning. I usually work with a PCT that wants to be proactive in helping GPs to build their expertise and the organisation.
This means that there is goodwill and energy from both the PCT and the GPs in the room.
The problem is that the way in which both groups think about the world is very different. Most of the senior managers of PCTs have spent their careers working in large organisations.
Over the next month, I will visit several PCTs and they are all big establishments with numerous offices.
I too have spent most of my life working in big organisations and I am completely at home with the feel of them.
People with that background tend to talk in very large scale with a strategic sweep, but with not as much attention to detail as necessary.
Most GPs have spent much of their working lives running much smaller organisations. They are responsible for running the organisations and delivering services to the public.
They are interested in developing those services and want to do so with speed and attention to detail.
What's interesting to me is that now that I run my own small business, I can understand this a lot better.
It's important for the future of GP-led commissioning that these two ways of working can meet together - but this is going to be difficult.
For example, at the moment the PCTs will talk to GPs about the importance of commissioning as a large organisation.
Striking the best bargain
There is a lot of sense in this and it's important to recognise that small commissioners who negotiate with large hospitals don't strike the best of bargains for their patients.
But for those GPs who are interested in commissioning, what matters is how they can use commissioning in their day-to-day practice to improve patient outcomes. If they believe that the only way they can do this is by being part of something with a population base of half a million, many will lose motivation.
What the PCT has to be aware of is that it cannot simply expect the lessons it has learnt over the past five years to be obvious to people who have only worked in much smaller organisations.
With those PCTs that want to help, they will have to recognise that the organisations will only be built from the small upwards to the big - not the other way round.
- Paul Corrigan is a management consultant and former special adviser to Tony Blair. More at www.pauldcorrigan.com