It's good to start with something I haven't felt able to say for the last few weeks: I am looking forward to the 10-Year Plan. In part, this reflects the greater confidence among national leaders. Chair of NHS England Dr Penny Dash, who has been working around the clock on the document, told our NHS ConfedExpo conference this month she was ‘very happy' with where things have reached.  

The main concern now is that as the plan is subject to a Whitehall write-round it could come up against concerns from Downing Street, HMT or other departments such as the Ministry of Housing, Communities and Local Government. I'm told that worry over leaks of the plan mean that, ministers and senior officials will - like people who have looked at earlier drafts - only have access to numbered hard copies to be returned when read. Those subject to the cloak and dagger might point out how much of the plan was trailed by health secretary Wes Streeting to a packed auditorium during our highly successful NHS ConfedExpo conference. 

As the secretary of state told the conference, the CSR was both generous to health given the overall fiscal picture, but also not enough to make combining recovery and reform easy. There is little or no scope for ‘double-running'. 

Indeed, one of the three key narratives than ran across speeches was the service needed to focus not on the 3% extra over the next few years but the 100% of spending. The other two were the NHS faces an existential crisis if it doesn't quickly improve and a repeated reassertion of the centre's commitment to be leaner and less controlling. Putting what  Streeting said alongside other comments at meetings open and closed, there seems to have been progress towards clarity on some of the knottier issues the team working on the plan have been trying to resolve: 

Old ICBs are dead, long live new ICBs 

ICBs will be portrayed as central to the 10-Year Plan in strategic commissioning but also provider market-making, particularly in terms of neighbourhood health. 

Freedoms for integration  

There has been a tension between the ‘Milburnite' agenda of trust autonomy and competition and the integrative logic of the left shift. The result seems to be the offer of new freedoms for foundation trusts but only on the condition that they demonstrate a capacity to collaborate and integrate. 

Acutes preferred but other solutions available  

The question of which organisation should be in the lead in relation to place level provider architecture remains ambiguous. The scale and capacity of acutes may make them the default, but there will be scope for other ways of organising integration and neighbourhoods. On the latter, if primary care can demonstrate a willingness and capacity to operate at scale it will be well placed to lead.  

Left shift - this time it's serious  

The plan will launch some radical and relatively swift change programmes which ensure that the left shift (which the centre strongly believes can achieve major productivity gains) is not just an aspiration. This may involve a stretching target to reduce hospital-based outpatient activity. 

It was good to hear a more consistent acknowledgement from the secretary of state of the role of local government at system, place and neighbourhood level, but this needs more clarity.  

In a tech heavy document, the precise nature of what can be promised may be subject to critical HMT scrutiny (both on grounds of cost and credibility). There are also questions about access to capital, including private capital (for which the door was opened – particularly in relation to primary/neighbourhoods - in the CSR). 

Then there are some questions about the overall document which we will only know the answers to when it is published. 

Will it hang together? 

Earlier iterations were critiqued for feeling like 10 different plans – from life science innovation to neighbourhood operating model – somewhat arbitrarily combined. 

How credible and bold will the theory of change be? 

Delivery is everything and somehow the plan needs to combine a compelling medium-term vision, realism about what is affordable in the short term and confidence-building first steps. 

What is the core message to the public? 

I have argued this needs to be more than a vision and some retail offers. How can the plan generate a stronger sense that the public's buy in and engagement is central to a new model of care. 

There may yet be another twist in the tail for the 10-Year Plan, but the feeling I gleaned from the thousands at our conference is an impatience to get going with the changes that we all know are needed.