Four years ago I participated in scenario planning. The document that emerged is as relevant today as it was then – perhaps because it was looking “Over the Horizon,” taking a ten year view and considering plausible alternative futures for health care. We envisaged four scenarios: Fools Gold, Swimming Upstream, Red Arrows,  and A Tale of Two Citizens. The document gives the detail and you can probably guess what Fool’s Gold and a Tale of Two Citizens encompass. Swimming Upstream and Red Arrows envisaged differing levels of professional and public engagement in improving health and care. It was a fascinating exercise which taught me a lot about reading signals in the constant noise that surrounds us.

We are leaving an era of Fools Gold behind since the average 7% growth year on year has ceased – abruptly.  The economy needs us to deliver Swimming Upstream or, best of all, Red Arrows ( there was a Lincolnshire influence!). Alternatively we could end up with a Tale of Two Citizens.  It really feels as if we are at a crossroad and have choices to make.

Being of an optimistic nature I see an opportunity in the way the system is emerging “post pause” that could, given the right behaviours and mindset from the multiple players involved, take us towards Red Arrows. It will require a coherent narrative from the centre about supporting the development and comprehensive involvement of professionals in delivering innovation, productivity, and contributing to prevention if quality is to be maintained or improved. It will require professionals to accept accountability for the best use of resources whilst ceding real influence to the public and patients. It will require strong partnership working between the NHS and those who influence and control resources in communities so that both sides align their investments to promote health.

This will not be easy and there are some crucial signals which the centre will send out in the next few weeks and months which will indicate how likely it is that such alignment will be achieved. The first of these will be the announcement of “running costs” for Clinical Commissioning Groups. As Dr Casalino points out in the lessons learnt from the experience of Independent Physician Associations (IPAs) in the USA, underinvestment in management was a significant factor in the failure of IPAs. If the centre truly value clinical commissioning, then the level of running costs which they allow will be important. The other will be the “grip” exerted from the centre on commissioning groups. I am reading Tim Harford’s excellent book Adapt. The message I take from it is that if we really want the NHS to flourish and adapt to meet the challenges ahead, the centre will have to embrace difference and allow some failure. Too tight a grip will choke innovation. As Chris Ham asked recently, “will Clinical Senates be on tap or on top of commissioning groups?” Will networks guide or command commissioning groups?  Ultimately, as Edwards and Fulop point out, “it will be the nature of relationships, how people behave, and how they navigate a new and uncertain environment that will really make a difference.”

If we focus on structures and governance, but do not value or invest in relationships and changing mindsets and behaviours, then these reforms may bring about that scenario which they were, I believe, intended to avoid.

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.