"If we want things to stay as they are, things will have to change."
(The Leopard, Giuseppe Tomasi di Lampedusa)

Two letters have defined the past few weeks in NHS policy.

They are not F and U – not yet. No, the latest waiting figures from the DH proved that the NHS is maintaining its good performance on getting down the number of very long waiters, and is also broadly meeting its targets for 18 weeks and 4 hours in A&E. This is some testament to the NHS staff in providers - and more impressively, the many still unsure of their future on the commissioning side. Hats off.

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No: both of the two letters were, paradoxically, sent by a currently-powerful individual whose position in the new system remains to be confirmed.

The first of the two is by none other than Our Saviour And Liberator Andrew Lansley. The Secretary Of State’s letter was also ironically mis-addressed.

Its ostensible recipient was the NHS Commissioning Board’s Chairman Mal – Professor Malcolm Grant. Chairman Mal gave his first public speech on NHS reform at the recent NHS Clinical Commissioners (the working title for the NHS Alliance-NAPC will-they-won’t-they nuptials) conference.

And it was a strong performance – Grant’s line and tone were well-judged. He is a class act, who stands a fair chance of keeping Comrade-In-Chief Sir David ‘Challenge’ Nicholson on his prehensile-gripping toes.

Professor Grant told CCG leaders-in-waiting that “I see CCGs as absolutely the engine room of new NHS … The NHS can function better outwith the day-to-day operational control of politicians; and also not under day-to-day operational control of the NHSCB – the NHS will be in a variety of hands; of which yours, as CCG leaders, are the most important”.

Chairman Mal continued, “The NHSCB’s head office will not be called ‘HQ‘; the Board will have national, regional and local support components. The word ‘support’ implies different behaviours to those to which we’ve become accustomed in the system; the shared responsibility with CCGs means that the Board’s role is about support and co-development”.

So, although Chairman Mal was the addressed recipient of Mr Lansley’s letter on ‘The Government’s strategic objectives for the NHS Commissioning Board Authority’, it is highly evident that Professor Grant ‘gets it’ – at least, in words.

The most cursory of reads of Mr Lansley’s text immediately shows that, albeit addressed to Chairman Mal, the letter was squarely aimed at Comrade-In-Chief Nicholson ...

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