The single thing that really concerns me is the capability (actually the lack of it) of the NHS to rapidly implement best practice, productivity reforms, movement to community and home, and all the other things they know they have to do before the 15 and 20 billion black hole hits in a couple of years. They currently seem incapable of getting out comparatively simple tenders. Where is the inspirational leadership delivering the change and innovation needed? Many people at the top know what is needed (I have just been with Lord Darzi at Arab Health) but the delivery mechanisms seem so disparate. All I can foresee are pockets of change and innovation, but huge areas where waiting lists grow and cuts occur.