1. Create a compelling narrative about why the reforms matter in order to engage patients, the public and staff in the enterprise. This is particularly important when you consider the scale and complexity of the programme as well as the challenging financial environment. This might be better it were not created by Government, but it is needed.  

2. Address the significant cultural and behavioural changes required and develop capacity and capability. GPs will retain their role as a patient advocate with a focus on individuals, but will also have to take a population viewpoint with responsibility for decisions in areas like rationing and reconfiguration. Some of this help can be provided by external agencies. There are similar challenges for local government and providers. The professions have the opportunity to tak a leadership role in helping to lead improvement and identify where change is needed.

3. Recognise that low GP involvement is among the biggest threats to success. The NHS in some areas could be overwhelmed by demand if GP involvement is low or if consortia either carry on with the current model of commissioning or cone themselves to micro issues.

4. Ensure hospitals operating in a market-based system can reconfigure services and organise multi-faceted  specialist care.  Markets work best when suppliers can quickly adjust costs or what they supply, but this can be difficult in the NHS where many services are interdependent. Measures to make this easier are required.

5. Realise the benefits of the market in terms of improving quality and efficiency by creating space for new entrants.  This will not happen naturally when, as in the case of the NHS, the size of the total market is not increasing.  Closure of existing services will be necessary.

6. Learn the lessons of the past when driving change through payment mechanisms such as the NHS tariff.  This means pursuing a limited number of objectives, continually adjusting and refining the approach, and ensuring tariffs send clear signals that are worth responding to.

7. Clarify weak arrangements for oversight and accountability, particularly those relating to the quality of care. New accountability arrangements contain potential for misunderstanding and conflict – this at a time when the financial environment will put pressure on quality. 

8. Carry out further work in three areas:

• The reforms ignore the need to improve primary care, in particular in relation to enabling the best GP practices to help those in less well performing areas.
• There is a need to integrate primary and secondary care, as well as health and social care, but the reforms may not achieve this and could push them further apart.
• There are insufficient practical measures to empower patients, encourage choice, and bolster shared decision making – despite strong rhetoric in this area.

9. Help the new relationship between GP consortia and local government to work well in practise. Consortia will need access to public health professionals. Health and well-being boards will need to help provide strategic leadership. These are new bodies so building relationships will not be easy.

10. Recognise that removing politicians from the day-to-day running of the NHS may prove difficult. Local commissioners will be making difficult decisions and providers will be outside of state control. History suggests politicians will struggle to resist pressure to intervene.

11. Address the biggest risk: transition. This means: getting consortia into action more quickly; acting now on long-standing hospital reconfigurations; ensuring well-developed back office support for consortia; avoiding devaluing those responsible for driving change; setting up as soon as possible the new organisations such as the economic regulator and NHS Commissioning Board.

12. Be realistic and recognise taht the reforms will take some time to deliver. GP commissioning is likey to produce some early results but big improvements will take time and it will take even longer for the public to recognise them.