Keir Starmer will land in Ankara this week carrying a title he will not hold for much longer and a mandate that expired the moment Andy Burnham won his seat back in Westminster. Whitehall officials worry he could be sidelined by Donald Trump, and they are right to worry, but the more interesting sidelining is happening at home. The incoming prime minister is negotiating with the civil service over what he will inherit, including a defence spending plan that Starmer is alleged to have left £5 billion short, while the departing prime minister quarrels about shared responsibility and the 3.5 percent objective. That gap will not stay contained to defence. Every pound found for Nato commitments in the next spending review is a pound that has to be argued for against a health budget that is already stretched thin, and the argument will be made by a government that does not yet exist in any settled form.

This matters for the NHS in a way that goes beyond the usual grumbling about crowding out. With NHS England being shut down, integrated care boards being merged from 42 to 26, and Jim Mackey promoting a kind of responsibility that depends on suppliers believing the rules will remain in effect in six months, the service is halfway through the biggest structural change in a generation. Reform of that kind survives on continuity of political attention. It does not survive well on a change of prime minister, a probable reshuffle of the health secretary's office, and a summer recess in which the leadership contest is meant to conclude. James Murray inherited the health brief from Wes Streeting only weeks ago; he may find himself explaining Mackey's reforms to a new prime minister's team before he has fully explained them to himself.

The Ankara trip is a reminder of how thin the machinery of continuity actually is. Starmer is going because a Nato summit does not wait for a leadership timetable, and because someone has to sit in the room while the succession is settled elsewhere. But every hour spent managing Trump's irritation over defence spending is an hour not spent handing over the detail that keeps a reform programme moving: which trusts are being given real financial autonomy under Mackey's contract, which ICBs are still fighting their mergers, what happens to the digital investment programme once new ministers start asking whether £10bn was the right number in the first place. None of that pauses just because the person accountable for it is on a plane to Turkey, but the political bandwidth to defend it does, and that is the more consequential kind of neglect.

There is also a blunter fiscal point. Downing Street insists defence spending will rise to 2.7 per cent of GDP by 2027-28 without a firm commitment on the 3 per cent interim benchmark, which suggests a Treasury still trying to avoid choosing between the armed forces and public services in public. Burnham inherits that unresolved choice along with everything else, at the exact moment his government will be judged on whether it has a serious answer for waiting lists and staff morale. A prime minister who arrives promising stability cannot for long avoid saying which promises get funded first.

None of this means the Ankara summit is irrelevant to health policy in some direct, causal sense. It is not. Its relevance is structural and cautionary: it exposes how easily reform can drift while political authority is between two hands, and how a fiscal argument conducted in a foreign capital will eventually be settled at home, in a spending review that touches every integrated care board in the country. The NHS needs Burnham's government, whenever it finally exists, to inherit a defence bill it can afford without quietly deciding that health can wait another year to find out.