'I recently chaired a conference where it was put to me that I would be neither a poacher nor a gamekeeper but rather the pheasant!'

The reaction to my appointment as chief executive of the new South Central strategic health authority (extending from Milton Keynes to the Isle of Wight) has been interesting.

Some of my foundation colleagues see it as a demotion while others think it is great that, finally, a poacher in the modern NHS has become a gamekeeper in a reforming health service.

Some primary care trust friends see it as a promotion while I view the move as a natural step in a different direction after eight happy years at a successful teaching hospital that has finally secured a new private finance initiative hospital after decades of high hopes and dashed dreams.

Some people have warned me that the job is fragile as the intermediate tier will be re-arranged again within three years and, in any event, will not be given freedom in a system that still believes control and command is the best way to get things done. Indeed

I recently chaired a conference where it was put to me that I would be neither a poacher nor a gamekeeper but rather the pheasant!

Naturally, I do not share these pessimistic views and believe the new SHAs to be pivotally important to the future wellbeing of the NHS ? we are leaders of the NHS in our respective regions and not solely chief executives of SHAs. However, if the new SHAs are to succeed they should look to the future. While old SHAs did a good job in performance-managing key national targets, we will still teeter on the edge of the system reform. An old mentor of mine used to say there were three ways of thinking of doing things ? not doing them, doing them and faking it.

The time for faking, in my opinion, is over and the system has to shift fundamentally in the next two years while hitting access targets and, above all else, restoring financial balance. This year is going to be a tough and thankless year, but financial deficits (still the minority for most NHS organisations as 70 per cent of deficits reside in 10 per cent of NHS trusts) must be systematically and unswervingly addressed. It is difficult to reform a system if the underlying financial position is brittle.

To my mind, there needs to be a new kind of honesty and courage between employers, employees and colleges and unions about what the future holds. In many other industries, quality improvement and cost efficiency are seen as two sides of the same coin, not two warring factions seeking to claim hegemony over the 'true' historic values of the NHS. The sooner organisations realise that this is the new reality, the better. New, dynamic forms of staff appraisal and development will be needed if organisations are to understand and direct the hopes and fears of individuals working at a clinical level.

The ultimate purpose for a new SHA is to improve the health of the nation and alleviate the causes of poor health for the benefit of patients, public and taxpayers alike. SHA chief executives are the leaders of the NHS in their particular regions. There will clearly be a strong performance-management role of the new PCTs (and some of them look very impressive on paper), but the first short to medium-term task for the new SHAs will be to conceptualise, and then operationally execute

first-class commissioning for the populations we serve.

There has been quite a bit of theory applied to commissioning, purchasing, procurement and contracting, but we should be clear that these functions are all different. Once this is realised, we can plan and organise in a new fashion and be humble enough to accept that we can learn from other people where skills are lacking. The development of a commissioning movement is a central task for the new SHAs and time will not wait while we try to learn without external stimulation.

Equally, there is a very strong agenda for a radical public health function that more systematically makes alliances with those that can reduce health inequalities and areas of poor health. I think private sector techniques can be brought into this portfolio to refine and focus

our activities while we should never underestimate the role regeneration can have on wealth and health creation. Regeneration and research often go hand in hand and we should actively contribute to the knowledge economy of UK plc.

Clinical informatics and clinical quality should be at the heart of the new SHA. Intelligent clinical informatics can be used for commissioners and providers alike. New techniques can help NHS organisations reconcile and improve the clinical quality and cost efficiency agenda. Where appropriate, clinical configuration issues need to be addressed as lean thinking begins to question spare or redundant capacity.

Furthermore, there is scope for a much more radical approach to workforce and organisation development. We should concentrate on delivering high-class services to organisations that will secure better productivity, increased staff motivation and improved sustainable skills through a changing health service. New clinical and general management leadership pools need

to be created and talent and succession planned. Turnaround skills should be everywhere.

How will all of this (and much more) actually come about? It will not be dogmatically commanded from the Department of Health or the SHA but energetically directed and facilitated from a regional vantage point that seeks to liberate commissioning and provider organisations alike.

NHS provider and commissioner boards must take both responsibility and accountability for their future. If they both do their jobs properly, the 'intermediate tier' will indeed have served its purpose, as it will have created a self-improving system with light-touch regulation all arranged for the benefit of patient care.

Mark Britnell was chief executive of University Hospital Birmingham foundation trust and is now chief executive of South Central SHA.