I appointed myself as NHS Chief Inspector Of Chief Inspectors last year, in the wake of the post-Francis appointments frenzy.
The organisational politics of this were fascinating: a textbook example of what 'Yes, Minister' defined as The Politician's Syllogism:
1. Something must be done.
2. This is something.
3. Therefore this must be done.

A wry smile has played around the corners of my well-chiselled features this year, as the NHS's two main independent inspectorates paraded their need for my CIOCI services.

Independent economic regulator Monitor issued their guidance to my colleagues at Health Service Journal on when and how competition should best be used as regards mergers and failure.

Alas, it really isn't up to Monitor on mergers, but to the OFT/Competition Commission. Nor can Monitor regulate failures: as we saw with Lewisham, the failure regime under the 2012 Act requires clarification via the Care Bill currently before Parliament, but it's sweet that they went to the effort.

And independent quality regulator Care Quality Commission chair David Prior this weekend wrote in the Telegraph that “we need to change the culture … We need the Government to change the way it holds the NHS to account: an end to trusts being blindsided by waiting targets that miss the point, skew priorities and have unintended consequences … (and) to radically alter the relationship between NHS staff and management. In far too many hospitals, there is a ‘them and us’, with those few clinicians who go into management branded as ‘going over to the dark side’ … clinicians need to take a leading role in changing the culture of the NHS”.

Mmmm.

The political likelihood of an end to targets under a Health Secretary who had weekly meetings with system leaders and who phoned provider chief executives whose trusts breached the four-hour waiting standard and a Prime Minister who summoned the leaders of the regulators to Number 10 to talk winter seems slim.

Nor is the analysis of cultural problems and a clinician-manager divide a new one. For one thing, without a deeper diagnosis about why this arises, the public policy prescription of a culture change is (as incoming Nuffield Trust CE Nigel Edwards rightly observed) simply a synonym for ‘and now a miracle happens’.

Prior’s suggested reforms range from the well-intentioned but beyond CQC’s direct remit (“stronger clinical leadership and a workplace that encourages learning, openness and respect”) to the blatantly unlikely on the grounds of being anti-competitive (“successful hospitals taking over failing hospitals and community services” – see also Monitor’s intervention above).

Oh, and of course “we need more competition to drive up standards of care; more entrants into the market from private-sector companies, the voluntary sector and other care providers”. Unless, that is, we found that introducing more competition might work against Prior’s goal for providers becoming workplaces that “encourage learning, openness and respect”.

The Browning breakfast
You probably already know the two key quotes about culture: “When I hear the word culture ... I release the safety catch on my Browning!”. And from the walls of the Ford 'War Room', ”culture eats strategy for breakfast … culture is unspoken, but powerful. It develops over time - difficult to change”.

On the subject of culture in NHSland, my fellow-blogger Roy Lilley nailed a truly good point on Twitter, observing that ”you gotta change the climate before you can change the culture”.

So these interventions by the independent regulators seemed slightly divorced from the reality on the ground, where the climate is the cash, and the only way you can see what’s happening is to follow the money.

One of the more pertinent recent documents was the latest instalment of the Kings Fund's survey of finance directors found that while performance is holding up (partly due to not too wintry a winter), the financial pressure is beginning to bite deeper. This echoes the NHS Confederation’s findings about cuts in social care funding leading to delays in discharges.

We know about the tight finances (compounded by the underspend). Realism about their enduring nature, through what has been identified by centrist Labour blogger Hopi Sen as 'the long ugly' and by Flip Chart Rick as the Venn diagram overlap of 'La-La Land', is not in short supply among informed policy watchers.

If reconfiguring provision and moving to seven-day working will drive cost-savings, then we need to acknowledge that this involves planning on a fairly massive scale. And the emphasis on competitive quasi-market dynamics in the 2012 Act makes this very problematic.

More to the point, there is a sizable ‘if’ over the assumption that reconfiguration will save money. Where is the evidence that the 4% annual cost-efficiencies to date have been delivered, other than by bungs and specialist commissioning tricks and flicks?

Flat real funding and rising demand put the NHS under massive pressure. Its front-line staff are taking on a mighty task: many are performing brilliantly and deserve our praise and thanks. Policymakers and system leaders will do a public service if they can reality-check their rules and rhetoric.

To this end, I have decided to appoint myself to an extra role: president of the Society for Post-Equine-exit Stable-door Closure: SPESC. Nominations will be accepted for a regular SPESCious Award for the daftest and least relevant policy initiative or intervention, in the hope of raising NHS staff morale.

Spoofing Mark Britnell
I would also like to use this opportunity to congratulate the Photoshop-savvy Health Policy Insight reader who emailed in this spoof mock-up of a newspaper piece on Mark Britnell.

As satire goes, this is a nice effort: Mark will no doubt not only be amused, but feel flattered that someone actually went to all that trouble. (However, they should probably have spelled his surname correctly.)