Policy-wise, today’s announcements could be among the most politically significant for the NHS since a certain third party leader stormed the first of the three televised ‘leaders’ debates.

The NHS is central to the UK’s political narrative. That is an interesting place for healthcare to be. Money and power are the meat and drink of politics, and they make it interesting to watch.

Health Secretary Andrew Lansley has made a high-stakes gamble in applying homeopathic principles to reforming NHS management: diluting it in order to increase its potency.

There is evident tension between SoS Lansley and NHS chief executive Sir David Nicholson, as we have noted.

Nicholson recently told last month’s NHS Alliance conference that the White Paper reforms to the NHS constitute "a change management programme so big you could probably see it from space".

Nicholson repeated this line to the recent Healthcare Financial Managers Association conference, adding that this was “the biggest change management programme anyone could think of”. (It seems odd that the fall of Soviet Communism slipped the mind of this former Communist.)

Nicholson also told the NHS Alliance that we must “beware GPs with maps and pens” - i.e. avoid the structuring of consortia by simply drawing lines on a map.

This is ironic, since that is exactly what is to happen to PCTs. By February 2011, the current 151 PCTs are to follow the London model and be clustered. At one stage, it appeared that a really radical scale of consolidation to just 35 organisations. It now seems that the clustering process will reduce them to around 60.

The influence that ‘super’-PCTs will have on the development of GP commissioning consortia will be significant. Herein lies the risk. If the centralists run the super-PCTs without actively working with GP commissioning enthusiasts, then the same dynamic that hobbled GP practice-based commissioning will be repeated and financially speaking, the system will blow up very swiftly.

And no amount of good ideas from the RCGP’s clinical commissioning champions, or good ideas from the NHS Confederation’s Clinical Responses To the Downturn, will make any difference.

There is no way that we will get through the next few financially-challenged years without making the clinicians co-pilots. They know where the system is inefficient.

If they are involved, then we will start to have a series of difficult conversations about underperforming individuals, practices, teams and services; about closing things and doing differently. This will be politically noisy and risky.

The signal-to-noise ratio generated by today's announcements will determine whether the NHS starts playing a new tune or we get a storm of screaming feedback.