If past behaviour in the NHS is an accurate guide to its future conduct then Simon Stevens, its reforming CEO, has a few sleepless nights ahead of him.
Stevens' recent Five Year Forward Plan was met with deserved support from virtually all quarters, including many in local government.
In it he said, in plain English, that the NHS will need to change beyond recognition in a very short time if it is to avoid being both unfit-for-purpose and bankrupt. It will also, he added , need a lot more Government money to add the final planks of sustainability, once all the planned efficiencies were all in.
So far so good. The problem is that Stevens, on face-value at least, is backing the NHS to reshape itself to the grand new designs set out in this strategy.
And, this is where it all starts to stretch the imagination a bit. Because the essence of Stevens' plan is the same repatterning of hospital resources away from expensive interventions into primary and preventative care (including better social care where this can be shown to keep people healthy) that the NHS has found ways of avoiding for many years.
So let's assume Stevens is hoping to take on the vested interests. His timing couldn't be worse. He is punting a huge re-purposing of the NHS (including hospital-shrinkage) at a time when health professionals can claim, with some justification, that current resources have never been in greater demand.
Allied to the BMA and GP ,self-preserving behaviour that has been the signature of the NHS bodies since 1948 and you have a severe mismatch between the aspirations set out by Stevens and the means at his disposal to execute the change.
Other things are puzzling about Stevens' report. The most curious omission is the role of other sectors beyond the NHS, charities. His is very quiet about local government, even though his whole mission depends on councils' strategic leadership of the health agenda locally and their participation in new multipurpose providers.
Likewise, the role of independent providers, be these mutuals or the large private companies Stevens once ran is barely discussed. Perhaps most conspicuous is Stevens' silence on the role of markets in health beyond the development of personal budgets for people with long-term conditions.
These omissions are particularly stark when you think about just how all of Stevens' new-style, integrated NHS provision is going to brought quickly on-stream ahead of the closure of whole or parts of acute hospitals.
It is likely to be necessary that both preventative and curative approaches are funded to cope with the time-lag between, let's say, a new council-led diabetes-reduction scheme reduced flow of diabetics into local GP surgeries and A&E Departments.
The big question falling out of the Stevens review, then, is 'Who is going to pay for crucial investment in new models of health care ahead of any savings being felt by the system?' Councils can't. And new layers of fresh public investment are for the birds.
So, the government - and local councils- will need other sectors to fill the investment-gap, possibly based on outcome–funding or capitated funding which rewards health and social care providers for reducing spend on the most expensive types of care for the 15% of the population who get through 70% of NHS resources.
The scale of the investment requirement is immense. Prevention relies on industrial-scale roll-out tele-care and other tech that enables self-management of health. The effects of this are long-term but the costs immediate.
And if the government is broke, then place-leaders, including NHS Trust and councils, will need to go elsewhere - to the market, to investors and large healthcare providers - for the money. This is inevitable, it is right and it will help to get us there.
So why doesn't Stevens come out and say this all of this? He is, of course, too smart a politican himself to say such a thing at this time in the cycle -particularly when he needs all of the parties to converge around his agenda and bid each other up ahead of the General Election.
But here is the truth: Whatever Stevens is saying today about the NHS driving its own reform, his vision depends both on the creation of a more diverse, multi-player health and social care marketplace in which both councils have a larger role and in which private and social investment has a legitimate role. .
I wish he would just say this.
Craig Dearden-Phillips is managing director of Stepping Out Ltd
