The current NHS landscape, polar ice sheets and tall buildings all have one thing in common. When they start to collapse, they seem to move at first slowly; then massively and fast.
Simon Stevens' speech to the Kings Fund's Integrating Care conference this morning confirmed the completion of what HPI identified as a longstanding shift in the Conservatives offshoring political power over the health service.
No job titles will actually change, but in reality Simon is now the Secretary Of State For Health. And Virgin toilet misuser Jeremy Hunt is now the NHS national director for safety, patients and the public.
Stevens told delegates that "if we lose control of our finances, we lose control of our destiny": a warning without ambiguity. 80% of the provider sector and an unknown proportion of commissioners have done just this.
He diagnosed "the cause of provider overspends not as unexpected emergency demand (whose rise moderated below commissioners' prudent expectations, according to NHS England's Q1 data), but on increased costs in workforce. Hospitals' incomes have risen 2.1% but staff costs are up 4.7%, due to agency spend and the Better Care Fund.
"At the heart of this problem is decisions made on nurse training five years ago, and providers' views of safe staffing levels to meet CQC requirements. NHS Improvement will announce new action on converting agency staff to permanent roles.
"And we must sort out the immigration issue regarding NHS staffing. We also need to be smarter: with modular training, and new and extended roles. Also important is our constancy as system leaders with the Five-Year Forward View's vision, and for us to create a safe space for change. 'To will the end is to will the means!'"
A personal view ex cathedra
Offered as a personal view, The Sun King of NHS England declared "this is the moment to call time on the FT pipeline: the notion these organisations can pass the regulators' tests in the current financial climate is not tenable.
"And we should stop the acquisition process in many areas: I find too many parts of the country where deep seated problems are stalemated in flawed so-called ‘acquisition processes’ that drag on for years, cost oodles in management consultancy spend and deliver slightly less than diddly-squat".
He emphasised the triple integration of the Five-Year Forward View, outlining the next six months' priorities as being moving care from hospital settings into strengthened primary care; and the three new cancer Vanguards, who will be paid on a non-tariff, non-fee-per-item basis.
The big reveal
Stevens continued, "any money that we hope might be unlocked in November's Spending Review will only be available to organisations who plan collaboratively on a population health-orientated geographically-based partnerships, making four-year plans with delivery milestones from 2016 to 2020. The spending review announcement is an opportunity to move away from from transactional payment approaches, and get organisations to plan in health economies to 2020".
A man as smart as Simon Stevens is saying this for one of two reasons. Either he knows there will be more money coming in the Spending Review, or he thinks he can bluff the NHS into commitments that he can take to George Osborne's Treasury team.
The implication is clear: NHS England reinforces control over the system with control of this de facto Transformation Fund.
Simon's in charge.
It is also the platonically ideal NHS redisorganisation: one without legislation, or indeed any blueprint of organisational change. There will be organisational change, of course. But it'll be local, and dissimilar between areas.
And this is the pilot step of the move to funding by accountable care organisation-type geographical population-based funding, and away from the national tariff and fee-for-service expectation.
This complete re-plumbing of the NHS financial system will pretty clearly be led by NHS England.
Simon's in charge.
Warning that there is "too much friction between organisations", Stevens cited duplicative and under-using waste of property in a community hospital in the Cumbrian 'success regime': "we need to end these silos. We need and I want to use this moment of extreme pressure to argue for a well-funded NHS, but also to address the genuinely difficult, longstanding system issues. When people's backs are to the wall, they can be up for real change".
Asked by The Guardian's Polly Toynbee about the fit of his proposal for funding geographical regions with the Lansley market vision and prospect of challenge from providers, Le Roi Soleil responded "we'll have to be pragmatic. I don't detect any appetite for primary legislation; in fact I detect a broad consensus on this direction of travel from all the main political parties, the NHS and system leaders. As I've said, 'to will the end is to will the means'!"
Responding to debate that this announcement should in proper procedure have been Jeremy Hunt's to make, IPSO chief executive and long-time NHS expert Matt Tee tweeted, "Saying it's not Simon's announcement like saying it's against the law. Only matters if challenged. Which it won't be."
Matt's right. Indeed it won't be challenged.
Simon's in charge.
Versailles, here we come.