Michael White: who's the one to watch?

But no. Cameron’s luck held again. As you may know the culprit was Mark Britnell, much fast-tracked NHS veteran turned top health honcho at consultants KPMG, which was quick to insist that his remarks were made in New York last autumn and taken out of context.

OK if you say so. But talking about showing the NHS “no mercy” and it being reduced to “a state insurance provider, not a state deliverer” is not exactly ambiguous and not helpful to Number 10 as Dave seeks to reassure voters. The sentiments were also in the brochure. Perhaps he means US investors rescuing the struggling Southern Cross care homes group? Ho, ho.

In any case, Britnell is a smoothie, not exactly a conference novice, isn’t he? Lord (Nigel) Crisp’s protégé was admired as a can-do man by Labour ministers, despite being blamed by some for the spotty finances of University Hospitals Birmingham Foundation Trust on his watch (2000-06), although others say he was just caught “holding the parcel.”

More to the point, Britnell had hopes of getting his mentor’s job as permanent secretary/chief executive of the NHS and was miffed, friends say, when he was elbowed aside by David Nicholson. No love lost there, I imagine. Cameron’s luck held this week because Britnell’s is not exactly a household name whereas Steve Field is a medic, not a suit. The man calling Andrew Lansley’s current competition model “unworkable” in the Guardian is also chairman of Number 10’s own NHS Future Forum.

Lots of partisans are sounding off during the Cameron review, including health committee chair Stephen Dorrell. But who knows what the outcome will be? No one yet, not even David Cameron or Andrew Lansley, who has sensibly gone quiet. Note the contrast with Liam Fox who has botched defence cuts (no surprise to those who knew him on the health brief?) but thinks it smart to fight Number 10 in public. Bye bye, Liam?

When I got to Cameron’s speech I thought it the most workmanlike one he has made on the NHS, one which confirms what free market pressure groups like Reform interpreted  as “diluting” the coalition’s commitment to a competitive model. Too soon to say that too, but you can see why they’re nervous.

Cameron love-bombed the NHS but said he loves it so much he needs it to become more efficient, more integrated (Dorrell’s emphasis too), more flexible, less top-down, more local; the familiar agenda which is intended to make the system affordable in the face of sharp-rising costs. “Evolution, not revolution,” pure Dorrellism. No “space-age institution,” it will still be the dear old NHS.

Reading it reminded me of The Leopard, that great Italian novel (set in Lampedusa where Libyan refugees land), whose aristo-hero famously says: “Everything must change so that everything can stay the same.” There’s an irony just below the surface there, but there are also signs of Cameron’s familiar wishful thinking which alarms both left and right.

It’s fine to attack the NHS postcode lottery, but the Lansley model seriously risks exacerbating it. It’s fine to urge better lifestyle choices on citizens, but not when you are taking benefits away from poor people. You could say the same about bombing Gaddafi. Fine if we can afford the bombs.

What was most conspicuous in the speech was the bit that wasn’t there: how will Monitor’s regulatory role emerge? Amid minor and cosmetic concessions (a training levy on private providers?), Monitor’s the one to watch. Yes?