By the time you read this Andy Burnham will be Prime Minister. At that stage we may learn more about his plans for health and care, as well as who he will put in charge.
Whoever gets the call will likely feel some ambivalence. It is a high-profile job with responsibility for the Labour Party's most proud achievement. But there is also an intimidating in-tray, including a less than coherent reform agenda, financial challenges and manifesto targets that will be tough to achieve. And that is not to forget an uninspiring but tricky Health Bill meandering through Parliament.
Any conversation about reform of the NHS must start with money. The leftward and preventative shifts outlined in former health secretary Wes Streeting's 10-year plan are widely supported, both as ways of improving care, and of achieving financial sustainability. But, the international evidence is clear that system-level transformation cannot be delivered without some double running of services. That costs money.
If this reality is accepted, other important things follow.
First, transformation will have to be pursued at different paces in different parts of England. The Government has not much more than two years to prove that radical change is possible and potentially popular. What might be possible in London with its impressive assets and workforce, or in Greater Manchester or South Yorkshire with strong local leadership and collaboration, will be out of reach in other places.
A twin-track approach would see the centre using its considerable assets and skills to support change in leading areas, while retaining the capacity to intervene in places where enlightened crisis management remains the only real option.
Second, if leading systems are to be given transformation funds – even if in the form of a social finance type repayable investment – they need to demonstrate capability and commitment. That means a robust and credible model of governance and accountability.
It is widely assumed that a Burnham Government will not only get behind the concept of integrated care boards (ICBs) as strategic commissioners, but also insist that local government is holding one side of the commissioning steering wheel.
Previous attempts to use commissioning to drive change have lacked support from ministers when the going got tough, just as ICBs suffered under Wes Streeting. A Burnham Government needs to learn from those mistakes.
The route to strong, collaborative commissioning is easier in some places than others. So, the centre needs to be clear about what is expected from system models in terms of partnership, outcomes, accountability and assurance, but relatively flexible about specific arrangements.
The acute sector, which accounts for more than half of local NHS spending, is usually the most expensive setting for care and much of its activity is ‘failure demand' that could have been avoided through better intervention elsewhere.
In many systems, for example, the ICB will be a high-level commissioner leaving the work of contract development and pathway transformation to trust collaboratives and/or place bodies.
The real test of governance is whether it can make and implement difficult decisions. The case for the left shift is not only that patients should be treated earlier and closer to home, but also that this should be more financially efficient.
The acute sector, which accounts for more than half of local NHS spending, is usually the most expensive setting for care and much of its activity is ‘failure demand' that could have been avoided through better intervention elsewhere.
But moving money from acutes is incredibly hard. Even the most sensible reconfigurations of services, like consolidating fragile specialisms or closing clearly non-viable A&E or maternity departments, is liable to cause local unrest.
Even when the willing is there, the sunk investment of hospitals, for example in buildings, means that costs remain sticky, even when services move.
The much-vaunted neighbourhood health service has to show it can stem acute demand. There is evidence it can, but without a plan to use acute funding better and shift more of it to community and primary services, no system will be able to convince a sceptical Treasury to back extra investment.
Beyond this, many of the NHS leaders I used to represent may be hoping for other green shoots. One would be a Department of Health and Social Care change model that is less about micro-management and blame allocation and more about enabling and empowering. As local government knows, the best learning is peer-to-peer not top-down. We could also do with many fewer targets and a much clearer account of priorities.
That, in turn, would benefit from a more honest conversation with the public, hosted by a PM skilled in communication, about the role we all have in helping the NHS survive and thrive.
Matthew Taylor is former chief executive of the NHS Alliance and former adviser to Tony Blair
