The NHS is in a state of flux. Primary care groups arrived as players - and are already exiting stage left. Primary care trusts have been performing for a year - but specialist mental health trusts are muscling in on their territory.
The only way to satisfy the expansion plans of some acute trusts would be to let them take over a small country - yet many community trusts must be wondering if they will be left with anything to do.
For health service managers, the agenda is both exciting and unsettling.Which is why this year's HSJManagement Challenge is set in the fictitious city of Birdon, newly emerging from 'a major organisational reconfiguration of services'.
Jeanne Hardacre, a fellow at Birmingham University's health services management centre, says the teams will be expected to cope with new structures while 'proactively addressing the modernisation agenda for the local health economy'.
That, of course, translates as: providing better healthcare for patients while wading through the alphabet soup of recent government initiatives from CHI to SaFFs via NSFs.
Managers who are already doing just that in real life may wonder why they should bother. But previous management challenges have proved their worth: 'Lots of comments from last time were about how much value teams gained from just one day out, ' says Ms Hardacre.
'It is also worth stressing how current this year's issues are. The scenario is one that may crop up within six to 12 months.'
HSJ and the centre have been running the Management Challenge for three years. Teams which enrol for this year's event - which will take place at Aston Villa football club from 9am on 24 May - will find themselves transported to the borough of Shotton in Birdon.
Birdon has an HA, a PCT, one large teaching trust, two neighbouring acute trusts and a specialist mental health trust.
Despite the recent reorganisations, they inevitably fail to share the same boundaries. And it would make things just too easy if they were coterminous with the local authority.
Teams will be assessed against five key elements of successful modernisation:
developing modernisation strategies through innovation;
creating and leading supportive organisations;
working in partnership;
building high-performance teams;
handling public relations and communications.
In previous years, handling public relations has been the wild card. Two years ago, the 36 teams in the first management challenge were just coping with a spiralling deficit and an 'alarming' millennium compliance audit when news broke of a non-executive with wandering hands. And then someone set light to a local psychiatric ward.
Last year, the 50 teams involved were more or less coping with a£15m deficit that 'just emerged from nowhere', when a psychiatric patient opened up with a handgun in the local council offices.
Extreme? Of course. But not that extreme.
Imagine dealing with the news that the police are exhuming the patients of a local GP, or that the hospital basement is full of children's body parts.
We couldn't have invented those - could we?
The Management Challenge has always had superb support from some of the top chief executives in the country.
Pam Charlwood, chief executive of Avon HA, says dealing with bad news is just part of the job.
'When you get the call from regional office, who have just had a call from Downing Street, sometimes you just have to deal with it, regardless of its place in the wider scheme, ' she said in assessing the 1999 challenge. The real value of the challenge, however, lies in giving teams the chance to develop skills.
Last year one team said they enjoyed 'being a different person, doing a different job, in a different organisation and thinking outside their boxes'.
Did they really? The 'outstanding performance' winners of the 1999 challenge were West Hertfordshire HA.Anne Walker, director of commissioning (acute services), said one of the key lessons of the day had been perseverance:
'Partnership can be hard work, ' she said.
'You have to be prepared to work at different paces with different people.And you have got to work all the time at fostering relationships.'
Every event has its downside, however. And the big downside of the Management Challenge may be the effect it has on participants'waistlines.
Teams have been known to arrive early to set up files, flip charts and in-trays and get to work on those morale-boosting mission statements.
But by the end of the day gin, sweets, gin, chocolate, gin and cuddly toys are the things people most wish they had brought - or were glad they had.
'We had to keep our sugar levels up, 'Ms Walker admitted in 1999.