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Since the NHS spends most on pay, it's clear that the main way to reduce recurring expenditure is to reduce the head-count.

It is also a truism that there is always scope for increased efficiency - but that the tricky part is doing this in a rational way [rather than an across-the-board percentage reduction that is anything but 'efficient'].

The key is clinical engagement - insightful clinicians can identify many activities that happen in their departments that are a waste of time. There has been little incentive to realise these savings though, with the suspicion being that the money is really going to subsidise X specialism 'who we all know never controls their costs" [or so it seems].

Service Line Management offers some hope for both clinical engagement and financial efficiency. Can it be implemented quickly enough though? As a general rule all change in a large organisation takes longer to implement than you think. There are few short-cuts to understanding the actual costs within service lines - and at the same time service leaders need management skills. That's going to take investment.

WCC has promised much - and now is the time to deliver. The reality of commissioners talking directly to Service Leaders as 'adults to adults', of commissioners engaging with clinicians, remains to be tested in most of the country. If the culture is right, it might unlock a lot of potential for efficiencies and quality improvements.

Finally - is it possible that the report has been leaked to provide an apocalyptic vision so that, if in fact the reality is only, say, a 3% reduction in workforce then that 3% suddenly looks like quite a cheery number?