The biggest ambition implicit in the NHS plan is its wish to change the service's very culture - the values, attitudes, beliefs and behaviour of those working within it - summed up in the intention that it be 'redesigned around the needs of the patient'. Without that cultural shift, many of the plan's noble aspirations will never see the light of day. That remains its major weakness: for such change cannot simply be ordained from above. It comes slowly, at great cost in terms of management time as well as money, and is always patchy in its impact. To some places it may never come at all, whatever the effort expended.
Should ministers, carried away by heady political rhetoric, need any reminder of this they would do well to read our feature on the progress of clinical governance (see pages 30-32). It is now three years since the government launched its quality reforms in the health service, yet the authors conclude from their study of 47 trusts: 'It is too early to discern much real impact from the NHS quality reforms in general, or from clinical governance in particular'.
That is not to say there has been no progress: there has. Encouragingly - if cautiously - the authors report that quality problems are now 'less likely to be allowed to persist'. After much hard slog, systems and processes are in place. But that is the easy part. The research found few signs that the 'cultural transition' was starting to take place, even after three years. Clinical governance has a vital role in the new NHS, and its progress is an indicator of how the rest of the plan may fare. It is safe to assume that the resistance to cultural change, which it has encountered so far, will be writ large for the plan as a whole, however many of its aims have generally wide support.