NHS owned support units may be asked to step in to help unauthorised clinical commissioning groups (CCGs).
In an exclusive interview, the chair of the NHS Commissioning Board (NHS CB) Professor Malcolm Grant said those CCGs that have difficulty receiving full authorisation can be helped "in other ways" than the board taking control.
Grant said "different relationships" with commissioning support units (CSUs) and neighbouring CCGs may emerge to "secure" the "struggling" CCG.
Dr Charles Alessi, chair of the National Association of Primary Care (NAPC) and interim chair of the NHS Clinical Commissioners said he is "anxious" about CSUs having the ability to stop CCGs "acting autonomously" and said it would be "appalling" if they were to have some sort of control over CCGs.
Chair of the Royal College of GPs (RCGP) Dr Clare Gerada also responded to the comments saying: "I don't know what system we have anymore. It started with GPs leading organisations but it has become so far removed from that and it is becoming clear that CSUs will be the engine rooms and powerhouse behind the reforms. Unless CCGs merge, the power will lie with CSUs".
David Stout, managing director of Essex CSU and Hertfordshire CSU, said "imposing external input" onto the CCG would make for an "uneasy relationship" with the CSU and would be something the organisation "would be wary of".
"Under the Health Act, the CCG cannot delegate authority for commissioning decisions," said Stout.
"I will be very surprised if CSUs are allowed to take on that role."
Dr Sarah Pinto-Duschinsky, head of authorisation at the NHS CB, said the board will consider whether a shadow CCG's functions can be provided by a neighbouring CCG or whether a "support package" from the local CSU can be put in "before the board directly steps in to handle local commissioning functions".