Published: 17/03/2005, Volume II5, No. 5947 Page 3

There is a huge contrast between the NHS depicted in the media this week - even the sober Daily Telegraph screeched about 'control-freak managers' - and the one set out in the latest NHS delivery plan.

In it, NHS chief executive Sir Nigel Crisp sees the service progressing logically from the big target era of 2000's NHS plan and 2002's Delivering the NHS Plan to the choice-driven, devolved period signalled by last year's NHS Improvement Plan and its 'delivery' companion published this week (news, pages 5-7).

The paper attempts to give a stronger sense of coherence to NHS reform in which pace of change makes it hard to perceive how the pieces fit together.

However, in his HSJ interview Sir Nigel admits that real incoherence has crept into parts of reform. The move to end volume contracts with independent treatment centres is a sign that government is willing to act when it knows it is wrong, although the clash between choice and primary care trusts 'directing' patients to providers was such an obvious clanger that it should never have been dropped.

But the cornerstone of the document is PCT development. If reform follows the set path, many commissioning decisions will move to practices; back office functions, including contracting, will be outsourced - not necessarily to the private sector; and PCTs will concentrate on the shape of services (as choice changes patient flows) and public health. Many will merge, confederate or linkup, providing a critical mass of expertise focused on a more manageable agenda. If they can maintain clinical engagement through the transition, PCTs will have found a more sustainable role.

The most welcome message is the intention that reform should be led by developing best practice at local level. Sir Nigel is very clear that the inspiration for the proposed contracting reforms came from the service, not Richmond House.

He also says he wants this significant change to the way the relationships between organisations are managed to be led and developed by the NHS.

The proposed reforms will throw up issues and problems of their own and cynics will suggest the lack of detail is down to confusion at the centre rather than a willingness to devolve. But all in all, Delivering the NHS Improvement Plan is an encouraging document which does suggest a growing, if belated, coherence to policy implementation and a further loosening of central control.

So courage mes braves. Line the budgie cage with Telegraph editorials and keep your head down for the next six weeks.

Better times are ahead.