The announcement of a pause in the progress of the legislative process has been serendipitous for me. It coincided with a series of events where I could listen to a variety of interesting people offering their take on the reforms.

The rap, which thousands have watched, even in America, was referenced on numerous occasions. It demonstrates the potential of social media to powerfully convey a message which traditional media fails to do, and it is difficult to counter.
One person wondered whether the real purpose of the pause was predominantly to secure third party endorsement of the principles of the reforms; to try and change perceptions of the reforms being about radical change to a set of proposals which are evolutionary.

At one event I was struck by an analysis of how much of what is being proposed is evolutionary and how much revolutionary. Foundation Trusts, regulation, clinical commissioning, evidence based quality standards, public information, targets (now to be known as outcomes), use of the private sector, are all part and parcel of the system I work in and am familiar with. The proposals about these parts of the system are evolutionary. The revolutionary aspects of the reforms relate to public health and the system of governance. The changes being proposed to public health are not evolutionary. The changes being proposed to the governance structures of the NHS are fundamental. Maybe it is this latter, revolutionary set of changes to governance that is causing so much ill defined dis-ease across the system. The wholesale removal of SHAs and PCTs creates a vacuum in the traditional wiring diagram of the NHS. It leaves people who have been accustomed and used to working within such a system uncertain. It would require a massive change in attitude and behaviour to make the new system work in the way it is intended.  The natural instinct is to transmit this anxiety, but because it is difficult to encapsulate it is mutated into a set of concerns that people can relate to e.g. cuts, privatisation, and loss of financial control.

Everyone, and I do mean everyone, thought the greatest opportunity that the reforms presented was to realise the potential of clinical leadership and engagement in making the system work better. Allied to that is the opportunity to harness the potential of primary care, but to do so requires a meteoric evolutionary change in the way primary care works.  The worry is that by restoring the traditional modes of governance everyone is familiar with, the changes required will be lost, as they were with primary care groups and practice based commissioning.

Finally I had my preference for evolution versus revolution reframed by the effervescent Nigel Edwards who pointed out that evolution might sound nicer than revolution unless you look at it from the viewpoint of a Neanderthal.

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.