Editorial Thursday 3 April 2014: Fantasy reform scenario planning with Dylan or The Dame?

In 'Stuck Outside Of Mobile With The Memphis Blues Again',  Bob Dylan wrote "And here I sit so patiently, waiting to find what price/You have to pay to get out of going through all these things twice". It's a good line.

However, Dylan also later wrote "Wiggle, wiggle, wiggle like a bowl of soup", which cancelled the former line out, and proves that you can't trust Bob Dylan as a seer.

His starting work formally as NHS England's CE on Monday marked The Feast Of Stevens. Simon's first speech was a solid exposition of the challenges that lie ahead. "Think like a patient, act like a taxpayer' is a nice inversion of 'think global, act local'.

What lies ahead is the unknown. This is exciting territory. It would be a more foolish person than I who would predict Stevens'  actions.

Nonetheless, it might be a bit of fun to have a good, wild speculate about how a theoretical system leader of the whole NHS (if there were one), starting from here, could approach the challenges. (Other than just running away, as fast as they could.)

One possibility would be to do a King Lear: divide the kingdom into three realms (London can bloody well run itself) and give each to a successor to rule while the Dear Leader can "unburden'd crawl towards death". Complete vertical integration or rabid competition: let the best third win, Darwin-style.  This gives you scale, but does interesting things to innovation and might, just possibly, be a teeny bit anti-competitive in the vertical integration version.

The next move would be to move to locally closed systems on a CCG footprint. Maybe they could be Organisations Accountable for Care. You could call them the Kaiser Chiefs.  Bigger providers could affiliate or offer choice; smaller providers could be locked in if geography suggested. This approach invests heroic faith in commissioning, and heroic faith is commonly associated with martyrdom.

Another move would be to nationalise absolutely everything. You could call this The Nicholson Health Service. GPs would clearly love being government employees. This is mildly unlikely.

Trying to  picture a metanarrative of this kind  is not a serious endeavour. The point of writing this is to demonstrate such folly. It is more than slightly dubious that a Grand Unified Theory Of Everything for the NHS is in existence.

Complexity and uncertainty aren't going anywhere: we will have to get used to them and remain used to them. A strongman with a moustache may have been the preferred solution of the West to leadership in the Arab world, but it isn't going to work here.

Besides, Even Stevens doesn't have a moustache.

No, for lyrical words of wisdom on the next bit, we need to look to The Dame: David Bowie. Not 'The Man Who Sold The World', but certainly 'Changes'. Hopefully, some 'Rebel, Rebel': the system is going to need a few of those 'Under Pressure'.  There's a fair bit of 'Quicksand' about, and it could well be that "we've got five years" or Golden Years ahead. Time will tell, in her familiar voice.