I set off on holiday in early July. Part of the trip included a visit to a volcanic island. It is awe-inspiring to see how central eruptions from the volcanic crater would, intermittently, over the years send out huge streams of lava which completely reshaped the landscape. Trying to predict what will happen when an eruption occurs seems nigh on impossible. The consequences can be slight or radical.

Then I came home to Equity and Excellence: Liberating the NHS. I returned to a landscape, as yet unchanged, but with every indication that it is about to be reshaped in a way which no one can predict. There appear to be few certainties. General practice is to be integrated into management of the health system. Primary care trusts will be abolished. The “what” is apparent, the “how” remains unclear.

What is certain is that getting the “how” right will determine how radical these reforms turn out to be. I launched back into work with gusto. The NHS requires innovation and the deconstruction of a system which served us well in the 20th century but which has not adapted enough to meet  changes in demographics and disease patterns, nor taken full advantage of developments in informatics, technology, and therapeutics.

A quote that has stuck in my mind is, “changing behaviour does not change a system, but changing a system changes behaviours.” Already, since I returned to work, I have noticed a distinct change in attitude towards PCT staff from colleagues in General Practice. No longer is it “why?” but more, a growing sense of, “how?” The “how” to manage a health system, the “how” will all GP practices be engaged and most importantly “how” will this impact on me personally. Everyone is trying to gauge “how radical is this all going to be?”

My sense is that there are two critically important changes to the system that could accelerate really radical reform; one in a direction aligned with the values and ethos of the NHS with which we have grown up and a second that will have rapid and tsunami like consequences.

The first is whether consortia of practices will be given freedoms to provide new services. There are a few clinicians who are interested in commissioning. Most clinicians are interested in provision. If those freedoms to be innovative and truly reshape the provider landscape are given to consortia then my sense is that the reforms will deliver radical changes quite quickly.

The second is the sale of goodwill. The new contract in 2004 started to change attitudes to partnerships.  Given the opportunity to reap a financial reward and divest themselves of responsibility for the business of general practice a lot of partners would do it. I would predict that, if sale of goodwill were allowed, even the BMA would be unable to stop a transformation of the general practice landscape on the scale of Krakatoa.

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.