'The conundrum is simply how to devolve day-to-day responsibility to an independent board with the benefits of efficient delivery, local decisions and avoidance of political interference'

The shifting sands in Westminster herald changing times ahead for the National Health Service.

Several forces have come together at the same time and even the most seasoned commentators would be hard-pressed to predict political fortunes through the summer. The shift in the Blair-Brown axis has produced the platitudes for 10 years of investment and market-orientated reforms. But it has taken a long time to come full circle and both money and time have been wasted on the journey. Waiting times are down and new institutions like NICE and the Healthcare Commission are certainly here to stay.

Let's also not forget that according to Polly Toynbee the Conservatives have held the lead on health since November 2006. You can get odds of 26/1 on Patricia Hewitt becoming the deputy leader of the Labour Party; a long shot but departure from Richmond House seems likely.

A reconfigured top team to create a strategic distance has also been enacted by David Nicholson. And at last some good advice on public health and the chief medical officer has been heeded with enhanced billing for both.

The challenge ahead

The real question lies with independence, an initial test of whether Gordon Brown will be able to deliver on his promises. There is no doubt this idea has been looked at by both sides - the devil is in the detail.

The conundrum is simply how to devolve day-to-day responsibility to an independent board with the benefits of efficient delivery, local decisions and avoidance of political interference. The challenge is to make this meaningful without creating a branch office of McKinsey and disconnecting any levers that might work from the secretary of state for health.

Benefits to independence

Independence has a number of appeals for some, with an end to politically motivated targets and enabling professional autonomy. We might even see a shift in local priority setting and patient choice. The private sector would consider longer term financial planning if the business cases were right. But most attractive of all would be an independent overview in resource allocation and service planning.

We would still see ministers determining overall resources, setting strategic objectives, concentrating governmental effort on public health and determining accountability. The final piece of the puzzle for me is that an independent board would probably have to determine or have determined for them the boundaries to NHS provision. Without this piece the argument would have already carried the day.

The next Prime Minister must recognise that in a European single payment model, commissioning and productivity are keys to NHS survival. The principles of 'full engagement' certainly include self care, health education and targeting chronic disease risk factors. Local accountability and engaging professionals in new models of working using informational technology will also matter.

So it was interesting to see Mr Brown pull back from independence and suggest walk-in centres instead as the cure for all ills. The accelerator pedal of reform is certainly about to receive a different applied pressure, the question is whether the magical 'delivery on promises' will be associated with a new era.