recent annual conference of the NHS confederation are to be believed, David Nicholson, the larger than life CEO of the NHS gave an inspiring final day speech - a kind of colonel Tim Collins effort and the troops were dispatched in fine spirits. A comment from the speech that was quoted by, amongst many Mark Newbold, medic, NHS Trust CEO and all round good egg was that change in the NHS will be driven by providers. This view struck me as curious. IMHO, from my vantage point on the increasingly lowly shop floor, changes over the past 5-10 years have occurred in response to dictats and targets set by commissioners - some of them sensible and an equal number nonsensical. Maybe the beast of Doncaster does not trust the medic dominated newbies, the CCGs, to be so demanding or discriminating or even so careful with the pennies. It is surely a sign of the developing tension between the 2 axes in the new NHS, the clinical commissioning groups and National Commissioning Board, a tension that will form a major part of the narrative for the NHS over the next few years.