The passing of the health and social care bill was trumpeted in some quarters (including, apparently, the Cabinet room) as a hard-won victory for Andrew Lansley and his plans to "liberate the NHS".
For the battalion of health service managers, however, the campaign has now begun in earnest. It is they who have to take the legislation, translate its complex clauses into practical plans, and determine how far Lansley's hopes will be realised and the fears of his detractors proven or not.
NHS managers have been here before. Reorganising the service forms a core part of the person specification for any NHS management post, because every four years or so, they can be pretty sure to find themselves charged with implementing the latest grand plan of their political masters.
However, the latest reforms are of a different order, entailing change at every level: Department of Health (splits to form a new NHS commissioning board); strategic health authorities (to be abolished in 2013); primary care trusts (again, abolished in 2013); hospitals (if not already a foundation trust, must be by 2016); public health (off into local government); and general practice (to be organised into 250 clinical commissioning groups by 2013).
The managers responsible for all this could be forgiven for feeling beleaguered. While waiting nearly two years to find out if the NHS white paper would be passed into legislation, they were instructed by the Department of Health to get on with implementing the reforms, which is why primary care trusts are already a thing of the past, clinical commissioning groups are up and running, the NHS commissioning board has a top team in place, and strategic health authorities are down from 10 to four.
What is more, managers have obeyed orders, knowing that cuts to the administrative budget of 45% over four years are coming in the name of cutting bureaucracy, although the NHS is one of the most lightly managed – some would say under-managed – health systems in the world.
This structural change is, however, a sideshow. The biggest challenge is not the implementation of these legislative changes. What keeps senior NHS managers awake at night is how on earth they are going to make 4% efficiency savings each year until 2015 (and probably for several years beyond that) and make sure that local services stay safe and viable.
They know they need to make radical changes to how hospitals and general practice work in the future, and that mergers and other difficult decisions will be required. Managers are also painfully aware of the signs of strain in the NHS, as witnessed by reports of shockingly awful care of older people, cancelled operations and sub-optimal maternity and other services.
What managers want more than anything is for politicians to provide them with the equipment (ie, political leadership and support) with which to fight the most important battle facing the NHS: that of doing more with less.
The main salvo of 2012 has yet to be fired into the NHS. Robert Francis QC is busy writing his report of the public inquiry into the scandal of Stafford hospital. This is likely to provide shock and awe for NHS managers, doctors and nurses, asking how the NHS allowed itself to become enmeshed in such a complicated system of oversight and performance management that it could not see what mattered most: the suffering of frail and vulnerable patients.
As NHS managers concentrate on implementing this latest, and most complicated, reorganisation, they need to think hard about how the new system they create will look when the Francis report casts its piercing light over the service. Most critically, who will notice if there is a serious failing in a hospital or practice, and who will be responsible for taking action?
Judith Smith is head of policy at the Nuffield Trust, a healthcare thinktank Guardian Professional.
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