Good morning from Manchester, where the NHS Alliance's 12th annual conference kicks off - and let's hope it does. As mentioned in my interview with Alliance chief executive Michael Sobanja, the event has an honorable history of straight talking. (And it's interesting to compare the agenda for 2009 with this interview from this time last year, with Alliance chair Michael Dixon. It's also a bit depressing that the key issues have seen little change in the past year.)

At senior management levels, the NHS remains as much a National Hospitals Service as ever. The oncoming financial storm (be it tepid, cold or arctic) is going to require behaviour change from those who commit most of the discretionary spending in the NHS. That means primary care.

The NHS is looking to deliver 'better care closer to home' and 'healthcare outside hospitals' -remember them? That means primary care.

Equally, it is straightforward - indeed, too easy - for people in primary care to simply moan about the heavy hand of the centre. It would be nice to hear about good practice and delivery on the promise of primary care. As Andrew Donald of top-rated commissioning PCT Birmingham East and North lamented recently, “I can get an idea taken up more quickly on the other side of the world than anywhere else in the NHS. I’m sick of going to conferences where someone explains a good scheme, and then people from elsewhere in the NHS explain why it wouldn’t work in their locality, or that they do something different which works just as well if not better … the NHS is bad at learning from itself; let alone anyone else”.

An interesting morning
Ummm. That was a proper curate's egg of a morning. Very amusing chairing from the excellent Phil Hammond, making mischief of Boy Burnham's absence "he only goes to one primary care conference a year, and he's doing the RCGP".

Michael Dixon's speech mixed up attacks on DH centralism and clinical disengagement with a passionate call to arms to reconsider how the market is used - criticising is as both "too weak and too overbearing". In particular, he re-emphasised the need for urgent action on Payment by Results, warning that tariff must become a maximum price.

Dixon attacked the disconnections between centre and front-line, between primary and secondary care and between manager and clinician. He located the start of the rot with the creation of general management following the Griffiths report.

He highlighted two Alliance projects - their new report 'Sustaining The Vision', which sets out a range of principles for NHs response to the financial straitening ahead, and a joint project with the Nuffield Trust on how the NHS can develop local services that will, in effect, be clinically-led and owned mutuals. The paper will be out in November.

Survival tactics
Dr Peter Brambleby then gave an energetic and funny session on navigating an uncertain future, warning delegates of the Darwinian need to adapt or become extinct.

Brambleby focused on the impiortance of professional motivation, offering the following checklist for survival
1. keep a positive attitude (what do I want to spend £1 bn on, not where must I cut £0.5 mn; why is my glass more than half the capacity I require)
2. find common purpose in reducing unacceptable variations in clinical practice
3. focus on responsible stewardship of public’s finances and trust
4. keep it simple (the system is currently too complex with too many rules, elaborate regulations processes, can we please dumb it down?)

David Nicholson - laconic in content
Here is what David Nicholson said.

There. Did you enjoy that?

There was one wonderful Freudian slip when he warned of the risk of "beer traps" (corrceting quickly to "bear traps"), but basically, there was no strong message. The closest we came was a move towards "something must be done" (part one of the Political Syllogism) about PbR, but he didn't actually say it. He said he was taking the criticisms of PbR from speakers and delegates in questions "on the chin".

Watch out for money ... more careful handovers and navigation needed at interfaces ... change the culture (which is all up to you, and DH and SHAs can't do it to you.

Yes, it was at that sort of level.

The absence of new policy is fine in so far as continuity is somewhat radical. Yet the absence of comment on commissioning, and in particular PBC following the David Colin-Thome comments, was surprising.

Whose NHS is it anyway?
Dr Brian Fisher launched a new online debate about the type of service people want from "their NHS". Whose NHS is it anyway is an effort to stimulate debate and discussion, and promises to hold radical, contradictory and controversial views for discussion.

If it doesn't get hijacked by interest groups, it could be really quite interesting. See you there.

Norman Lamb - time for localism
The consensus among several delegates overheard was that the Lib Dem health spokesman is probably offering many of the better top-level ideas in his promises of increased localism and reduced bureaucratic overload. Regular readers of HPI have already had the chance to see this.

Inevitably, in 20 minutes the scope for detail was not there, but Lamb continues to impress. He gave the best speech of the health spokesfolk at the recent party conferences, and many of his instincts - locally elected health boards, liberating staff energies, capitated budgets for multidisciplinary clinical teams - are good ones. He is also a quick learner on policy, and seems to have good instincts for the NHS.

Bloody hell, I'm being nice about a politician.

Zenna Atkins was funny, often accurate and intermittently ridiculous about regulation, and Alan Maynard of this parish gave a masterclass on the future of the "toothless bulldogs" of PC Ts, quoting the brilliant anecdote from Archie Cochrane about the happy crematorium worker who explained his job satisfaction deriving from seeing how much goes in and how little comes out.