The signs so far from the local election results are that in England, the Lib Dems have taken a not-unexpected beating; Labour have some gains; and the Conservatives have held up better (if not much better) than expected.

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The NHS needs to pay serious attention to what looks as if it may be an outright SNP victory in Scotland, which would mean that a referendum on full Scottish independence should come towards the end of the Holyrood Parliament. Labour's campaign in Scotland has had poor results.

Labour may take some comfort from its greater success in Wales, where it may gain overall control of the Assembly. Where, of course, the NHS is facing real-terms budget cuts.

The political impact of the Lib Dems' English massacre will be very significant on health policy for the NHS in England. If as predicted by the opinion polls, they have also lost the AV referendum, it will increase the tensions between those Lib Dem MPs who broadly support the Lansley reforms and those who have greater reservations.

The conversations ahead will be crunchy ones - particularly with Conservative backbenchers buoyed by their party's success in local elections and anticipating that the 'No To AV' campaign will have won.

It is early in the anticipated five-year life of the Coalition - not even a year since the Agreement. There is a lot of road ahead. But the politics of the AV referendum and the local government massacre of Lib Dem activists will alter the dynamic of the Coalition.

The health policy change at the Lib Dem Spring Conference, and its consequences, will now move centre-stage as the hearing-but-not-listening pause continues.