The Coalition's proposed reforms offer the best opportunity to change the managerial culture of the NHS but more so for providers than commissioners. Strengthening local leadership will always be limited because of the strong history of hierarchical management overlaid by political control. And given this history, the exhortation for leaders to 'look out, not up' and become more self-reliant would always be more of an aspiration than a reality. 


But all this should positively change with the reforms. For providers, breaking away to a market-based, regulated system will generate much greater managerial independence. The test for FT leadership is rising to the challenge that this freedom will offer.


The same may not be true for commissioners however. The maintenance of a strong hierarchy from the national commissioning board through some form of intermediate tier to local commissioning groups may not bode well for creating a new culture for commissioning. But the new kids on the block, in the shape of GP leaders, will bring a different dynamic that is likely to act as an effective counterweight to central control.  GPs should stand a better chance of being able to flex their muscles and demand greater independence for local commissioning.  


The creation of these two distinct cultures will result in diverging demands for future organisation, leadership and skills development. At a simple level providers will want to hone their business, M&A, organisational performance and strategy skills in the context of competing with new, private and third sector, market entrants.


Commissioners, on the other hand, will want to develop their analytical skills, partnership development, citizen engagement and processes for complex decision-making as the basis for more effective commissioning. 


The argument for a coherent, national approach to commissioning development is much stronger than for provider development. Whilst commissioners may continue to look to the centre for their development, providers are likely to see themselves aligning more with private sector practices, for example perhaps by creating their own trade organisation.   


There's little doubt that the current, centrally driven development approach will come under pressure to change and new paradigms will have to emerge for developing commissioners and providers.