When the prime minister makes two major interventions in the NHS in the space of a week, it is a sure sign that the problems of the NHS have reached the top of the government's agenda. In the second of these interventions, a speech to the New Health Network Clinician Forum, Tony Blair rehearsed the progress made in improving the performance of the NHS and argued that a “crunch point” had been reached in its reform.

The crunch point has arisen, in his words, as part of the transition from the application of “necessarily crude and blunt instruments of centralised performance management and targets” to the use of market-like incentives “to make reform self sustaining.”1 In recognition of the challenges involved in making this transition, the prime minister's message was that he and his government intend to hold their nerve and see the process of change through, even if this means bearing the short term political costs.

To many NHS staff struggling to deal with financial deficits and to implement …