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Editor’s blog Thursday 15 July 2010: Solid foundations; bad architect’s plans. Good builders needed.

You may have noticed that the White Paper has not gone down too well here. Clearly it would be churlish to suggest that a terrible typo took place, and that the ‘W’ should have been an ‘S’.

But I’ve felt a degree of unease about responding negatively to it, and yesterday I realised why. The underlying ideas – the foundations – are correct.

Clinicians do need to be involved in commissioning, if is to become effective.

Information on NHS-funded performance does need to be more open.

Everybody’s focus does need to be on outcomes (they missed unacceptable variation, but you can’t have everything – as your commissioning consortia will soon tell you).

That much, they have got right. I wouldn’t try to build anything without a decent foundation, and the above list represents one.

They have also, for the time being, dodged a bullet in terms of making up the numbers. The whole concept of needing c. 80,000-100,000 population for reinsurance purposes is the right response to completely the wrong question. It should be a piece of cake to cerate a reinsurance system for catastrophically costly patients (of whom by definition there are few) in a single-payer tax-funded system.

New age architecture
The fundamental problem with this White Paper’s equity-excellence-liberation theology is that in presenting such an unformed vision, it offers an architecture of power without the comfort of structure.

NHS restructuring – in Alan Maynard’s classic phrase, “redisorganisation” - has a long and inglorious pedigree, and think-tank Civitas recently highlighted its proven opportunity costs. It fundamentally misunderstands the first rule of good design – form should follow function.

The irony of co-production
There is a terrible irony in the document’s espousing the principle of nothing about me without me for patients, but signally failing to live this value with the people who will staff the New Age system of NHS 2.0. As La Rouchefoucauld observed, “hypocrisy is the homage that vice pays to virtue”.

Because while structure is not the solution to the problems identified above – the ‘foundation’ issues - it matters. A lot.

Literally and metaphorically, we live and work in structures. Co-producing new structures with the people who need to work in them and make them work would have been the single most sensible idea that could have informed the White Paper.

Instead, a bunch of people went into a little room and came up with what has been presented.

Where the architect’s drawing for the new system is not actually bad, it is blank on key details. HSJ editor Alastair McLellan’s latest editorial aptly quotes US General David Petraeus’ metaphor about redesigning the Afghan counter-insurgency as “Building an advanced aircraft while it is in flight, while it is being designed and while it is being shot at.”

This is going to need some very good builders indeed. Who understand what bits of the old architecture should be salvaged, and what new materials and construction techniques are needed. While saving £4 billion a year. And taking out 45% of management costs by 2015.