This report looks at how changes to the NHS in England over the past decade have created greater risks of abuses of power, and how reforms to local commissioning are exacerbating them. Since 2012, membership organisations made up of General Practitioners (GPs), called Clinical Commissioning Groups (CCGs), have managed most of the NHS’ budget in England. They are responsible for purchasing £78 billion of healthcare services on behalf of the NHS. At the same time, these same GPs are independent contractors to the NHS and are in receipt of around £8.5 billion of NHS funding each year.