The new government's plans are genuinely distinctive in their intention to give general practices almost all of the responsibility for commissioning as primary care trusts are phased out. To persuade general practitioners to take on this challenge, the government will have to negotiate a revised contract with the British Medical Association (BMA), and this will take time. The need to reassure the Treasury on how GPs will be held to account for the use of budgets may be a further brake on progress.
Previous reforms have relied on general managers to act as the shock troops of change, most notably in the internal market introduced by the Thatcher and Major governments in the 1990s. The coalition government's distrust of managers and its commitment to significantly reduce management costs mean that this option is not available this time round. Ministers have placed enormous faith in the ability of entrepreneurial GPs to make change happen and it remains to be seen whether this is justified.
So while the health White Paper has set out a clear direction of travel, it is far from a done deal. The history of NHS reform is littered with examples of bold government plans that have been amended and compromised by the politics of health care and the difficulty of implementation. Often, it has been the power of doctors, both nationally through the BMA and locally through their role in influencing change, that has limited the impact of policies in practice.
The next thousand days will determine the fate of the government's plans and their effect on patient care. Ministers and their officials will need to exercise consummate skill to negotiate the political and policy minefields that lie ahead as the hard work of implementation and delivery now begin.