Have the tone of messages from the NHS chief executive and health secretary ever been as different as those emerging from Sir David Nicholson and Andrew Lansley? At last week’s health questions in the House of Commons, ministers got stuck into “pen pushers”. Contrast this language with Sir David’s latest letter to the service.

He writes that NHS managers “have a very strong track record of delivering” and should be “rightly proud of their achievements”. All of which “underlines to me the excellence of the public service managers we are lucky to have”. Note the “to me”.

Is this simply General Nicholson pepping up the troops as Field Marshall Lansley orders them over the top? No doubt. But HSJ also suspects Sir David’s extensive NHS network tells him that resentment over the government’s plans is reaching boiling point - and that some influential figures are rapidly reaching the conclusion they can only take so much.

This smouldering revolution may, of course, fizzle out. However, it could also ignite into an internal resistance movement to the reforms and may do real damage during these delicate early stages.

Sir David also stresses in his letter how much has not changed. Mr Lansley trumpeted the end of the 18 week waiting target, Sir David chooses to specifically remind NHS chief executives that it “remains a constitutional right” and commissioners have “a responsibility to ensure that commitment is met”.

In bold type he warns that work on “designing the new system” must not “distract us from the major operational challenges we continue to face”.

Sir David has also turned the volume up on the need to take that design work steadily - again a sharp contrast with ministers who are happy to leave the impression that GPs will be taking over the NHS tomorrow, rather than in two and half years.

The union-inspired judicial review into the reforms has clearly instilled some caution into the government plans, but just as influential will have been the nervousness being expressed by GPs.

This caution is underlined by the British Medical Association’s observations on GP consortia commissioning.

The document is full of statements that would sit very easily in Sir David’s letter, for example, a warning that primary care trusts should not “select a consortium leadership team”.

But there is one statement which should send a chill down both Mr Lansley and chancellor George Osborne’s backs - and makes Sir David’s plea to focus on the cost saving challenges of the here and now all the more sage.

Faced with the need to slow growth in spending, the health secretary has rightly suggested that more effective commissioning is the best way to drive efficiencies. He has also suggested that GPs are best placed to spot potential savings.

The BMA begs to disagree. “There should be no expectation that an effective commissioning process will generate freed-up resources on a regular basis,” it says.

Let us hope this is simply a negotiating position, otherwise the NHS is heading for a very painful reckoning.

Provider changes

HSJ is pleased the Department of Health has taken up its suggestion to establish “a national reference group” of provider trust chief executives to feed into the transition process. Manchester’s Mike Deegan, although not our original suggestion, is an excellent choice as chair.

As Sir David points out, the NHS is facing fierce challenges from the rise in emergency activity and other cost pressures - which the forthcoming comprehensive spending review will accentuate. Moving to an all foundation trust future in this environment is best handled by the people meeting those challenges day to day.