Good evening. As the temperature drops again, and autumn leaves carpet the gutters, a few things are becoming clearer through the November fog.

Some of this came from sources at the HSJ 100 launch last week; other material from the NHS Alliance conference. In the instances where I can't give a name, I'm not relying on a single source.

1. Health Secretary Lansley is known to be in trouble
This is motivated by no desire to add to the problems of a man who has just lost a parent. Nevertheless, it’s become abundantly clear in a variety of conversations over the past week that concern about both the practicalities and the reception of Mr Lansley's White Paper have firmly lodged in both Number 10 and the Treasury.

One source described a policy of "dual man-marking" by PM David Cameron's Cabinet Office policy director Oliver Letwin and health select committee chair Stephen Dorrell.

Several sources described the increasing concerns of the Treasury. The concerns of both Numbers 10 and 11 Downing Street have reached the influential radar of PoliticsHome editor Paul Waugh.

So what would happen? One person, well-networked in Conservative influencing circles, suggested that a ‘defenestration strategy’ would be deemed too extreme. She said “what you’d see would be more likely to be the arrival of new special advisers – and almost certainly some new ministers. That would be the way they will want to proceed. To keep it un-dramatic. Unless events demand a more dramatic response”.

2A. Commissioning enthusiasts are also enthusiasts for integration of care …
Dr Phil Hammond pulled a straw poll of delegates at the NHS Alliance conference plenary on Thursday morning as to who favoured integrated organisations and who preferred GP commissioning consortia.

One hand was raised for GP commissioning consortia. Around eight hundred favoured integrated organisations.

2B. ... which means Any Willing Provider and competition may have a smaller role than anticipated
One of the dominant, repeated themes of the NHS Alliance conference was the tension between integration of care and the competitive, any willing provider approach – on which the White Paper goes very long.

Sir David ‘£15-20 Billion Challenge’ Nicholson and Dame Barbara Hakin both took the line that it was not ‘either / or’ but ‘and’. Hakin told delegates that “choice, competition, collaboration / coalition … it’s a combination of all three”.

Nicholson described the NHS attitude to opposed concepts as “a bit bipolar”.

But the dominant comments came from Earl Howe, in response to a question about any willing provider competition problematising successful integration of care in Cumbria: ”The drive to competition and ‘any willing provider’ is a shorthand away of saying that Monitor is there to police unfairness in competition; not to drum up artificial competition where there is none.

“I don’t see competition and integration as opposed – you can have both, integrating care pathways, and elements of competitive as appropriate along the pathway. Our published response to the White Paper consultation will give a better sense in what we say about how this will be rolled and fleshed out. I think we’re on the same side”.

Integration was also on the agenda of KPMG global health honcho Mark Britnell, saying that ”the power of £80 billion a year should be used to integrate … clinically-based decision-making … using better integration and pathway redesign ... can produce 20% efficiency gains - but more strikingly, the time to benefit is two if not three years”.

Britnell also told delegates, ”the issue about healthcare integration becomes the most important for the next 10 years, and I’m not sure we yet have all the policy and structure levers to ensure we reshape services”. One could always read that as a job application. But for which vacancy?

If there is to be a step away from market fundamentalism, it will add fascinating new dynamics to the proposed reforms. By cutting out their philosophical core.

It will also be fascinating to see whether there is any public rearguard action from the private sector in response to both Michale Dixon’s call for “open book transparency” among providers from any sector, and its warm reception by Earl Howe.

3. David Nicholson seems demob-happy about something
Demob-happiness seems like a reasonable response to demobilisation. Since demobilisation is not apparently imminent for the £15-20 Billion-Pound Man, then his extraordinarily Vicky Pollard ‘not bovvered’ performance at the NHS Alliance conference indicated either that he thinks 1. above may progress promptly, or that if he never spends any more time in the company of primary care enthusiasts for NHS management and commissioning, it will be a millennia or two too soon.

The anti-Lansley thesis gains credence from Nicholson’s extraordinarily frank words about the idea of a major redisorganisation in the midst of having to save £15-20 billion in productivity gain by 2014-15 - ”If you’d asked me back in May if this was a good time for a major NHS reorganisation I’d have said, ‘don’t bother’ … it has added significant risk to the system”.

This of course builds on the evident, renascent tension between the two men - which we discussed the week before last.

4. Inherited debt forgiveness is on the agenda
NHS South West has apparently already guaranteed that its underspends as a health economy will be vired hither and thither such that the commissioning consortia will not inherit PCT debt. And the comments of both Jim Easton and Earl Howe – implict and explicit – clarify the fact that some form of plan is under way.

Easton said, "We’re trying to think through though how to create the right starting point for people in consortia; between not saddling people with impossible legacies and not pretending they don’t exist. The Secretary of State is minded to act, but we shouldn’t pretend that some people have nothing to do with historical debts, it would be wrong to pretend that, because it’s not the case".

Howe went further: ”We understand the need to address the concerns that consortia will inherit PCTs deficits. We are working with SHAs to straighten this out, and we'll say more in the new NHS Operating Framework later this year”.

5. There were more candidates for ‘Line Of The Week’ than usual
Rear Admiral Jarvis (on any advice for NHS reform): “Thank goodness all I’ve got to do is run a war in Afghanistan!”
Phil Hammond to Rear Admiral Jarvis: `”We’ve got to get us some of those uniforms”
Chris Ham to Phil Hammond: “Well, it is called ‘Liberating The NHS!”

Cynthia Bower, CQC’s CE on the DH’s obstacle-making against use of CQC enforcement powers: “maybe they thought we’d have a wing full of NHS managers in Pentonville!”