In an effort to legitimise their policies and secure public support, various bodies are rallying to show they can deliver what the public wants and the NHS needs

The delegates leaving the NHS Confederation conference in 2012 had one question running through their minds: “Who is in charge?” Now the new system is in place and half a dozen voices are all crying: “We are!”

In the words of one system leader at this year’s conference, a range of new organisations – or old ones with new roles – are trying hard to determine their own “alternative legitimacies”. A battle royal is raging for the mantle of the public’s champion.

NHS England hopes its 10-year strategy will be the vision over which political parties fight to demonstrate the closest alignment with their own plans. The organisation’s new strategy director is already building on his chief executive’s wish to threaten a herd of health policy sacred cows.

Meanwhile consultation will soon begin on the second Department of Health mandate to NHS England. The tension between these two parallel processes is rising along with the summer temperatures.

‘There is a real danger that wrestling with difficult questions recent reforms have done little to address will become a battle for supremacy’

But there is also a welter of consultations and guidance being generated by Monitor and the Care Quality Commission. These are more technocratic but they are still allied to developing an approach perceived to be central to underpinning the public interest in healthcare.

It is no bad thing to have so many clever people wrestling with difficult questions that recent reforms have done little to address. But there is a real danger – especially between NHS England and the DH – that it becomes, primarily, a battle for supremacy.

A service sick with reform fatigue and struggling with myriad day to day concerns will look for a rapid and clear consensus about where the service is going and how it might best get there.