HSJ readers will be familiar with the tensions inherent in the government’s reforms which are now beginning to leak into the public ken.

Nick Timmins, public policy editor of the Financial Times and number 20 in last month’s HSJ100 list of the most influential people in health, has taken to reciting a naval tale to sum up the developing scenario.

A US battleship was on manoeuvres in thick fog. A lookout reported, “Light on the starboard bow.”

The captain, seeing the two ships were on collision course, ordered a signal sent to the other vessel: “Change course 20 degrees.” The reply said simply: “Negative, suggest you change course 20 degrees.”

After the same exchange was repeated a couple of times, the captain exploded: “Tell him I’m a battleship!”

Back came the reply: “I’m a lighthouse.”

HSJ suggests the lighthouse in this case is Cabinet Office minister Oliver Letwin, whose policy spotlight has finally settled on the health reforms - one of the reasons why he was number 2 in the HSJ100. However, HSJ understands that Treasury chief secretary Danny Alexander is also providing much of the impetus to the review now being undertaken of health secretary Andrew Lansley’s reforms. Social care minister Paul Burstow is another wandering out of his brief to challenge the detail of commissioning changes.

However, these rising tensions will not sink the reforms in the House of Commons. The legislation will contain many discretionary powers, but not much that is compulsory or linked to a particular date. There will be few opportunities for political opponents to rally enough support.

Once again, for the real action, we must turn to the Department of Health and its twin track policy implementation. On one hand we have the desire of battleship Lansley and his close advisers to engender a “bottom-up revolution” by setting broad policy objectives and letting GPs and others determine the detail. On the other, is the inclination of the DH’s top officials to find a way to frame the new landscape. Mr Lansley refuses to say how many commissioning consortia there should be, meanwhile the DH’s top brass deduce what number would constitute the most financially stable set-up and drive the system towards that conclusion.

Those championing the purity of the policy insist GPs can draw their commissioning support from wherever they like, the pragmatists - mindful of costs, concerns of the new commissioners and the need to “grip” the new system - are finding ways to make primary care trust staff the default option.

The strategic goal is the same - but it is being approached with two distinct philosophies.

Nearly all these tensions are focused on the future of commissioning. The situation with provider reform is very different: PCT provider arms are all heading for their new homes; most reconfigurations are going ahead as planned; the foundation trust pipeline is flowing, while merger or grouping plans are developed for those that cannot win independence; the DH is driving forward to find the leadership of the economic regulator, just as it stalls on doing the same for the commissioning board.

All of this is happening with remarkably little controversy and reasonably rapidly. Encouraging news, as the majority of the initial efficiency savings must come from secondary care. However, there is a real danger that commissioning and provider reforms slip out of sync and that, as result, a more stable hospital sector will dominate emerging consortia.

The last government allowed a similar situation to emerge by failing to drive commissioning reform early enough. Mr Lansley was determined not to repeat that mistake, so he set sail as soon as he took command. But then the mist rolled in and the foghorns began to moan.

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