Challenges to neurosurgery service delivery. Who moved my cheese?

The change programme in the National Health Service has moved the Acute Trusts providing neurosurgical services to very different ways of delivering healthcare. The process of reform has been supported by investment but the next few years will see far less additional money, and success and failure of services will be dependent upon the approach to those reforms. The 'payment by results' system of funding through tariff, the 'plurality of providers' policy of forcing commissioners to purchase activity from independent providers, the 'patient choice' process of encouraging patients to select treatment from a number of providers, and the '18-week wait' target of bringing down referral to treatment times are all major shifts in the way services are delivered and developed. The reforms have not been made with neurosurgery in mind, how will they affect the way this small specialty is delivered?