A fierce debate about the future shape of health services throughout the North West has been launched by the regional office.
A discussion document, Fit for Purpose, outlines a wide range of options for NHS bodies in the region, from merging all 16 health authorities to creating a single 'super trust' across Greater Manchester.
But with just a fortnight to go before the 15 October deadline for responses, managers in HAs, trusts and primary care groups are still digesting the implications.
Dr Adrian Mercer, chief executive of South Manchester PCG, which has applied to be a trust, described the paper as 'wonderfully complex'.
'It is a useful starting point but it needs to be made clear how the decisions will be made.'
And Eddie Kinsella, chief executive of South Cheshire HA, said: 'Many people are weary of repeated organisational change but given the government's agenda the status quo is not really an option.'
A regional office spokesperson denied that the region had an agenda of its own. 'There is no direction from here - this is just a discussion document.'