Managing demand will be a major issue this year and also a major test of the maturity of relationships between acute and primary care trusts. Variability is an acknowledged reality but poor access to and grasp of information means that it too often remains amorphous.

Managing demand will be a major issue this year and also a major test of the maturity of relationships between acute and primary care trusts. Variability is an acknowledged reality but poor access to and grasp of information means that it too often remains amorphous.

As we report exclusively this week, a survey from the London Health Observatory shows that the capital's NHS could save up to almost£100m a year by stopping a range of unnecessary treatments ( click here)

It argues that the evidence base for treatment is being applied with great variation in different parts of the NHS - but also that the best primary care trusts are working to manage referrals to address it.

Analysis by itself, however interesting, does not aid action. As Don Berwick of the Institute for Healthcare Improvement will argue in HSJnext week, a transformation in performance begins first with the will to do it. That might sound an obvious point except that improvement is held back in this, as in so many other areas, by an acceptance of the status quo - often a current situation that would be unacceptable if arrived at suddenly.

The application in patient safety is an obvious one. As we report this week, there is a huge challenge facing trusts this year in tackling growing levels of Clostridium difficile- by some measures four times as deadly and harder to eradicate than MRSA.

And yet as our last Barometer survey of acute chief executives revealed, nine out of 10 trusts had not set their own local C difficiletarget yet.

Local targets will begin to reveal another aspect of variability - and also another lesson from Dr Berwick's work. Namely that transforming performance also entails first acknowledging that the problem is worse than historically admitted, both internally and, crucially, to patients and the public.